Every finding on record at Silverstone Place

Based on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #2's medication to Resident #1 which resulted in Resident #1 glucose levels fall below the healthy range. The facility census was 86.The administrator was notified on 11/20/25 of past Non-Compliance, which occurred on 8/13/25 when staff administered the wrong medication to the incorrect resident. Staff assessed the resident, notified the residents physician, monitored the resident, and in-serviced nursing staff on medication administration. Staff corrected the deficient practice on 8/13/2025.1. Review of the facility Medication Administration General Guidelines Policy, revised 5/2022, showed medications are administered as prescribed in accordance with manufacturers specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after having familiarized themselves with the medication. Residents are identified before medication is administered. Explain to the resident the type of medication being administered and the procedure. Medications supplied for a resident are never administered to another resident.2. Review of the facility investigation, dated 8/13/25, showed Certified Medication Technician (CMT) B administered Resident #2's medication to Resident #1 because Resident #1 and Resident #2 have similar names. Staff documented CMT B is unfamiliar with residents. Review showed nursing staff in-serviced on proper medication administration on 8/13/25.3. Review of Resident #1's quarterly minimum data set (MDS), a federally mandated assessment tool, dated 11/5/25, showed staff assessed the resident as cognitively intact with a diagnosis of diabetes.Review of the resident's physician order sheet (POS), dated August 2025, did not contain a physician's order for Novolog insulin (a rapid-acting insulin to control blood sugar levels).Review of the resident's progress notes, dated 8/13/25 at 4:45 P.M., showed Registered Nurse (RN) A documented at 5:55 P.M., Certified Medication Technician (CMT) B administered Novolog insulin 24 units to the resident, and blood sugar was 153. Review showed the physician notified immediately, received orders to administer glucose gel, take vitals and blood glucose every hour for the next 10 hours, order for glucagon IM if resident to become unconscious. Physician declines need to send resident to ER at this time but with frequent monitoring as described. Resident has consumed 760mL of orange juice, two glucose gels, and 50% of dinner meal. Blood glucose at 160 at 17:27. Resident able to make needs known, speech clear and easily understood, reporting at this time he/she currently feels no different than normal.During an interview on 9/25/25 at 8:19 A.M., CMT B said he/she was responsible for a medication error on 08/13/25. He/She said he/she gave Resident #2's Novolog insulin 24 units to Resident #1. CMT B said he/she immediately reported the medication error to the Director of Nursing (DON). He/She said staff contacted the physician and was told to check the residents blood sugar every hour. He/She said the resident did not suffer any adverse effects from receiving the medication. CMT B said he/she did not know how he/she made the error. CMT B said he/she did not know if he/she was rushing or how the error occurred. He/She said staff are directed to check the Electronic Medical Administration Record verses the resident and the medication. He/She said he/she should have verified the resident's last name and date of birth prior to administering the insulin. CMT B said he/she did not ask the resident's last name and knew he/she should have asked. He/She said the two residents had just been admitted to the facility.During an interview on 11/20/24 at 8:28 A.M., Resident #1 said staff did give her the wrong medication, he/she said he/she does not know a lot of details, but staff scrambled to get him/her sugar because the insulin took his/her sugar too low. He/She said staff checked on him/her constantly. He/She said he/she is a diabetic, but he/she does not take insulin just metformin. He/She said the medication error was scary, but staff handled it well.During an interview on 11/20/25 at 8:55 A.M., the administrator said CMT B gave Resident #1 Resident #2's insulin, when resident #1 does not receive insulin for his/her diabetes diagnoses. He/She said the residents have the same first name and were admitted about the same time and across the hall from each other. He/She said CMT B states she verified the residents name, and the resident said yes. He/She said the resident refused to go to the hospital. He/She said the resident was given sugar and was place on one-on-one monitoring for over 24 hours. He/She said there was a full investigation into the medication error and staff were in serviced on insulin administration and the seven rights of medication administration.During an interview on 11/20/25 at 9:45 A.M., The DON said he/she expects all staff administering medication to follow the seven rights of medication administration, and if they have questions they need to verify further. He/She said the medication error was not intentional, Resident #1 and Resident #2 share the same first name and the CMT was confused. He/She educated staff for insulin administration and the seven rights of medication administration.2626672

Based on interview, and record review, facility staff failed to report an allegation of abuse for one resident (Resident #1) out of five sampled residents, within in two hours to the administrator and the state agency (Department of Health and Senior Services). The facility census was 65.1.Review of the facility's Abuse policy, dated 01/10/2024, showed time period to report allegations of abuse and neglect establishes two-time limits for the reporting of reasonable suspicion of a crime, depending on the seriousness.-Serious Bodily Injury-two-hour limit: If the events first cause the reasonable suspicion result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but not later than two hours after forming the suspicion.-All others-Within 24 hours: If the events that cause the reasonable suspicion do not result in serious bodily injury to a resident, the covered individual shall report the suspicion not later than 24 hours after forming suspicion.3. Review Resident #1's Face Sheet, dated 07/09/25, showed staff assessed the resident with a history of falling, cardiac pacemaker, muscle weakness, reduced mobility and Chronic Obstructive Pulmonary Disease (COPD). Review of the Facility's Investigation titled Investigation on Incident R/T Staff Vs. Resident #1, dated 07/16/25, showed the Director of Nursing (DON) documented he/she spoke with staff and residents regarding allegations of abuse on the early morning hours of 07/16/25. The investigation included the written statements of staff present during the incident as follows -On 07/16/25 Certified Medication Technician (CMT) E documented he/she witnessed CMT C and Certified Nurse Aide (CNA) B physically restrain the resident to take the resident back to his/her room. The CNA held the resident's arms down and the CMT held the resident's legs together and up, so CNA D could propel the resident in his/her wheelchair, back to his/her room. CMT E and CNA B picked the resident up and threw the resident on his/her bed. -On 07/16/25 CNA D documented he/she observed CNA B hold the resident's hands down and the resident said let me go, I'm not going to hit you. CNA B then said he/she was not going to let the resident go and told the resident, Try to get lose Motherfucker. CMT C then bent down and said to the resident, Now go ahead and punch me Motherfucker. CNA D documented he/she observed CNA B and CMT C pick the resident up under his/her arms, where his/her feet were off the ground and throw the resident into his/her bed. Review showed the investigation did not contain documentation the facility notified the Department of Health & Senior Services about this allegation of abuse within the required two hours. During an interview on 07/23/25 at 12:35 P.M., Registered Nurse (RN) A said he/she went to the resident's room to talk to him/her the morning of the incident. RN A said the resident told him/her, he/she had been cussing at the staff and the staff were cussing at him/her. RN A said if staff cussed at the resident, it would be abuse. RN A said he/she reported to the DON and administrator that the resident said staff cussed at him/her. He/She said the facility has two hours to report abuse, or allegations of abuse to the state. RN A said he/she thought the state had been notified. During an interview on 07/24/25 at 8:02 A.M., CNA D said he/she saw both CNA B and CMT C call the resident a Motherfucker and was holding the resident down against his/her will. CNA D said RN F was right outside the resident's room. CNA D said he/she exited the resident's room and told RN F what he/she observed. CNA D said RN F reported the incident to the Assistant Director of Nursing (ADON) when he/she came in. CNA D said he/she told RN F he/she felt it was abuse and RN F agreed it was abuse, he/she would have to report to management, and they would have to report it to state. What time was that? During an interview on 07/24/25 at 8:28 A.M., CMT E said he/she went into the resident's room and observed CNA B and CMT C pick the resident up where his/her feet were off the ground and threw the resident down on his/her bed, because his/her bed had already been lowered all the way to the ground. CMT E said he/she also heard the resident report to RN A the staff had cussed at him. During an interview on 07/24/25 at 8:43 A.M., RN F said CNA D reported to him/her that CNA B and CMT C called the resident Motherfucker and threw the resident into bed. RN F said he/she reported to the ADON and the ADON said he/she would report it to state. During an interview on 07/24/25 at 11:10 A.M., the ADON said he/she would say CNA D's witness statement alleges abuse. The ADON said he/she forwarded the CNA D's statement to the administrator. The ADON said he/she did not know that all allegations of abuse had to be reported to the state health agency within two hours. The ADON said CNA D later asked if it had been reported to the state, so he/she contacted the DON, and the DON said the incident had been investigated and handled appropriately. During an interview on 07/24/25 at 1:04 P.M., the DON said when he/she arrived at the facility, the administrator had taken all the statements. The DON said he/she then read the statement. The DON said he/she would consider it abuse if a staff cussed at a resident. The DON said he/she spoke with ownership and the administrator and because our investigation showed it was unsubstantiated, we decided it did not have to be reported to state. The DON said he/she was not aware allegations of abuse had to be reported to state within two hours, if the facility already unsubstantiated the allegation of abuse in its investigation. During an interview on 07/24/25 at 2:05 P.M., the administrator said he/she considers staff cussing at a resident to be abuse. The administrator said the ADON told him/her a staff member alleged abuse. The administrator said he/she had two hours to complete the investigation. The administrator said he/she did not report it to state, because his/her investigation did not show abuse. The administrator said he/she was halfway aware to report to state, like he/she has reported things in the past, he/she knew were not factually accurate. Incident #2570225

Based on observation, interview and record review, facility staff failed to preform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. Facility staff also failed to wash, rinse and sanitize mechanically washed dishes in a manner to prevent cross-contamination and allow cleansed dishes to air dry before they were stacked in storage or used to prevent the growth of foodborne pathogens. These failures have the potential to affect all residents. The facility census was 77. 1. Review of the facility's policy titled Hand Washing, dated 03/21/18, showed the policy directed staff to wash their hands whenever visibly soiled and before, during and after food preparations. Review showed the policy directed staff to lather and scrub their hands for 10 to 15 seconds, rinse thoroughly under warm running water, dry with a single-service paper towel and turn off the faucet with a paper towel; the whole process should take 25 seconds. Observation on 06/04/25 at 6:21 A.M., showed, when the cook washed his/her hands, he/she scrubbed his/her hands with soap for five seconds and then rinsed his/her hands. Observation showed, after the cook dried his/her hands, he/she continued to prepare food items for service to the residents. Observation on 06/04/25 at 6:31 A.M., showed, when Dietary Aide (DA) A washed his/her hands, he/she scrubbed his/her hands with soap under running water from the faucet and then turned the faucet off with his/her bare hands. Observation showed, after the DA dried his/her hands, he/she then placed rolls of silverware and cups on a service cart for resident use at breakfast. Observation on 06/04/25 at 6:47 A.M., showed, when DA A washed his/her hands at the handwashing sink, he/she scrubbed his/her hands with soap under running water from the faucet and then turned the faucet off with his/her bare hands. Observation showed after the DA dried his/her hands, he/she then prepared thickened beverages for service to residents at breakfast. Observations on 06/04/25 at 7:04 A.M. and 7:18 A.M., showed, when DA A washed his/her hands at the handwashing sink, he/she scrubbed his/her hands with soap under running water from the faucet for three seconds and turned the faucet off with his/her bare hand. Observation showed after the DA dried his/her hands, he/she served food to residents from the steamtable. During an interview on 06/04/25 at 7:18 A.M., DA A said staff trained him/her on hand hygiene upon hire. The DA said staff trained him/her to scrub his/her hands, out of the water, with soap for a full minute and turn the faucet off with a paper towel so his/her hands would not get dirty again. The DA said he/she thought he/she scrubbed his/her hands with soap for a full minute when he/she washed his/her hands, but just forgot to turn the faucet off with a paper towel. During an interview on 06/04/25 at 7:38 A.M., the administrator said staff should perform hand hygiene after they touch anything dirty. The administrator said staff should scrub their hands with soap, out of the water, for at least 30 seconds and turn the faucet off with a paper towel because the faucet is dirty. The administrator said staff are trained on proper hand hygiene procedures upon hire and routinely throughout the year. Observation showed on 06/05/25 at 8:27 A.M., showed DA B washed soiled pans at the mechanical dishwashing station. Observation showed, without preforming hand hygiene, the DA removed a cleansed cutting board from the dishwasher and placed it in a rack on the clean side of the station. Observation on 06/05/25 at 8:37 A.M., showed DA B washed soiled dishes at the mechanical dishwashing station. Observation showed the DA washed his/her hands at the handwashing sink, turned the faucet off with a paper towel, and then used the same paper towel to dry his/her hands. Observation showed the DA then put away cleansed dishes from the clean side of the station. During an interview on 06/05/25 at 8:40 A.M., DA B said staff trained him/her on hand hygiene upon hire. The DA said staff should wash their hands between dirty and clean dishes and he/she should have washed his/her hands before he/she took the cutting board out of the dishwasher, but he/she forgot to do so. The DA said staff should turn the faucet off with a paper towel when they wash their hands, so they do not make their hands dirty again, and using the same paper towel to turn the faucet off and dry hands would make the hands dirty again. The DA said he/she just did not think about the towel making his/her hands dirty again. During an interview on 06/05/25 at 8:56 A.M., the Dietary Manager (DM) said staff should perform hand hygiene after they touch anything dirty. The DM said when staff wash their hands they should scrub their hands with soap, out of the water, for at least 20 seconds and turn the faucet off with a paper towel so they do not contaminate their hands. The DM said staff should not use the same paper towel to dry their hands that they used to turn the faucet off because it will contaminate their hands. The DM said staff are trained on proper hand hygiene procedures upon hire, routinely as part as the facility's infection control program, and during in-services. 2. Review of the facility's policy titled Sanitation-Warewashing, revised January 2019, showed: -Dinnerware and supplies shall be washed and sanitized according to food safety practices and regulatory guidelines; -The dish machine, if low temp, shall use a detergent, a rinse drying agent and a sanitizer; -The sanitizing temperature for a low temperature machine shall be above 120 degrees or at an appropriate temperature to activate the sanitizer per manufacturer's instructions. Review of the manufacturer's instructions posted on the mechanical dishwasher showed instruction for the minimum water temperature for the wash and rinse cycles to be 120 degrees Fahrenheit (dF). Observation on 06/02/25 at 10:20 A.M., showed staff washed soiled dishes in the mechanical dishwasher. Observation showed the water temperature of the wash cycle measured 100 (dF) and the rinse cycle measured 106 dF. Observation on 06/04/25 at 6:35 A.M., showed staff washed soiled dishes in the mechanical dishwasher. Observation showed the water temperature of the wash cycle measured 106 dF and the rinse cycle measured 118 dF. Review of the product label for the dishwasher's detergent, showed the ideal wash temperatures for this product range from 140 dF to 160 dF, but wash temperatures as low as 120 dF would produce acceptable results, although slower drying times would occur. Observation on 06/04/25 at 9:56 A.M., showed DA C washed soiled dishes in the mechanical dishwasher. Observation showed the water temperature of the wash cycle measured 101 dF and the rinse cycle measured 110 dF. During an interview on 06/04/25 at 9:58 A.M., DA C said the water temperature of the dishwasher usually runs about 115 dF to 120 dF, staff check the water temperature of the machine every day and document the temperatures on the log. The DA said he/she had not read the instructions for use on the dishwasher's chemicals but was told the chemicals would work at any temperature, even if the water temperature in the dishwasher ran low. The DA said he/she did not check the dishwasher water temperature before he/she washed dishes, because he/she worked in the back dining room and whoever is the first person to wash dishes is responsible to check the temperature. Review of the Dishmachine-Warewashing Logs, dated March 2025 through 06/04/25, showed the logs directed staff to contact the service provider of temperatures below 120 dF and staff documented the water temperatures below 120 dF for the dates of 03/01/25 through 04/28/25 and 04/30/25 through 06/03/25. Review showed staff did not document the water temperature of the dishwasher on 06/04/25. During an interview on 06/04/25 at 10:20 A.M., the DM said he/she knew of the low temperatures staff documented on the dishwasher logs. The DM said they have had the thermostat replaced on the dishwasher twice and when maintenance checked the water going into the dishwasher with a thermometer before it measured 120 dF. The DM said he/she did not know the actual water temperature in the dishwasher was under 120 dF. Review of the facility provided work invoices from the facility's contracted dishwasher service provider, showed on 05/21/24 the technician documented the water temperature of the wash cycle at 118 dF. Review showed on 04/03/25, the technician documented he/she replaced the thermostat, and the sanitizer concentration measured 50 parts per million. Review showed the technician did not document the water temperature of the dishwasher's wash and rinse cycles on 04/03/25. Observation on 06/04/25 at 10:21 A.M., showed DA C continued to wash soiled dishes in the mechanical dishwasher. Observation showed the water temperature of the wash cycle measured 106 dF and the rinse cycle measured 112 dF. During an interview on 06/04/25 at 10:43 A.M., the DM said staff should check the water temperature of the dishwasher in the morning and document the results on the log and he/she also checks the temperature periodically. The DM said staff are trained to notify him/her or the maintenance director if the water temperature is below 120 dF. The DM said staff had not told him/her about the low water temperatures every day they documented below 120 dF. The DM said staff should probably not use the dishwasher to wash dishes if the water temperature is below 120 dF, but he/she had not directed staff not to use the dishwasher when the temperature was below 120 dF and they continued to wash dishes in the machine. During an interview on 06/04/25 at 11:50 A.M., the maintenance director said they had been having problems regulating the water temperatures for the kitchen and when they increase the temperature of the water for the kitchen, the water temperatures for the other rooms also increase because they are supplied by the same water heaters. The maintenance director said they have had the contracted service provider for the dishwasher come to try to resolve the water temperature issues, but he/she had not contacted any other service providers to see if the problem could be resolved elsewhere in the building and he/she did not know what else to do about it. Observation on 06/05/25 at 8:34 A.M., showed DA B washed soiled dishes in the mechanical dishwasher. Observation showed the water temperature of the wash cycle measured 108 dF and the rinse cycle measured 113 dF. Review of the Dishmachine-Warewashing Log, dated 06/05/25, showed staff documented the water temperature of the wash cycle measured 80 dF and the rinse cycle measured 85 dF. During an interview on 06/05/25 at 9:22 A.M., the administrator said the water temperature of the dishwasher should be 120 dF and the person who runs the dishwasher in the morning should test and document the temperatures. The administrator said if the water temperature is not correct, staff should notify management and wash dishes by hand instead of in the dishwasher. The administrator said he/she did not know staff had documented the water temperatures for the dishwasher below 120 dF since March 2025. 3. Review of the facility's policy titled Sanitation-Warewashing, revised January 2019, showed the policy directed staff to air dry dinnerware and supplies before they are put into storage after they are washed. Observation on 06/04/25 at 7:03 A.M., showed 12 plastic plate covers and three steamtable pans stacked together wet on the storage shelves near the steamtable. Observation on 06/04/25 at 10:21 A.M., showed DA C removed cleansed plates and bowls from the clean side of the mechanical dishwashing station, stacked them together while wet and placed them on a utility cart. Observation on 06/04/25 at 10:33 A.M., showed 11 plastic plate covers and 24 plastic juice glasses stacked together wet on storage shelves near the steamtable. Observation on 06/04/25 at 10:34 A.M., showed the cook removed the cleansed food processor from the dishwasher while wet, placed it on its base and used it to puree cooked California blend mixed vegetables for service at the lunch meal. During an interview on 06/04/25 at 10:43 A.M., the DM said staff are trained to allow clean dishes to air dry before they are put away or used. Observation on 06/04/25 at 10:49 A.M., showed DA D removed cleansed plastic glasses from the clean side of the mechanical dishwashing station, stacked them together while wet and put the stacks on a utility cart. During an interview 06/04/25 at 10:51 A.M., DA D said the dishes on the utility cart were clean and they were put on the cart so they could be put away on the storage racks later all at one time. The DA said dishes should be dry before they are put away and he/she just thought the dishes were dry enough. The DA said dry enough would not mean the same thing as dry. During an interview on 06/05/25 at 9:22 A.M., the administrator said staff are trained to allow clean dishes to air dry before they are put away or used.

Based on interview and record review facility staff failed to ensure one resident (Resident #1) remained free from significant medication errors when staff administered Resident #2's Fentanyl (an copied drug used in the treatment of severe pain) patch to Resident #1. The facility census was 85. The administrator was notified on 3/12/25 of past Non-Compliance, which occurred on 2/27/25 when staff administered the wrong medication to the incorrect resident. Staff assessed the resident, notified the residents physician, sent the resident to the hospital, and in-serviced nursing staff on medication administration. Staff corrected the deficient practice on 3/10/25. 1. Review of the facility's Medication administration general guidelines policy, undated, showed staff are to verify medication is correct three times before administering the medication. Residents are identified before medication is administered. Medications supplied for resident are never administered to another resident. Review of the facility's Medication error policy, undated, showed staff are to report the administration of the wrong medication being administered to a resident. Medications should be administered per physician's orders. When a medication error has occurred update the physician and responsible party immediately via telephone with the medication error. Follow all new physician orders in regards to the medication error. Obtain a set of vital signs immediately. Staff are to complete a medication error report and turn into the Director of Nursing (DON) office. Review of the facility's Performing the five rights policy, undated, showed staff are to, for safety, check the five rights three times. Take out the patient's medication drawer or bin and place it alongside the medication administration record (MAR) sheet containing the drug orders. Verify that the patient name on the drawer corresponds to the name on the MAR sheet. Count the number of medications to be administered at the particular time. The five rights for medication administration are right drug, right dose, right route, right time, and right patient. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/21/25, showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of Congestive Heart Failure; -Received a scheduled pain regimen; -Had pain occasionally. Review of the residents care plan, dated March 2025, showed the resident was at risk for pain and utilized acetaminophen related to a history of pain. Staff are directed to give the medication as ordered. Review of the resident's Physician's Order Sheet (POS), dated March 2025, showed the POS did not contain an order for a Fentanyl patch. Review of the resident's nurses note, dated 2/27/25 at 12:17 P.M., showed staff documented they found Resident #2's fentanyl patch on the resident. Staff assessed the resident, removed the Fentanyl patch, and filled out a medication error report for placement of a Fentanyl patch to the incorrect resident. Staff contacted the physician and received orders to remove the Fentanyl patch and monitor the resident's vitals signs every 15 minutes for two hours. During an interview on 3/12/25 at 11:41 A.M. the DON said nurses are responsible for administering Fentanyl patches. If a nurse has a medication error they are expected to assess the resident and call the doctor. He/She said they are also responsible for contacting the resident's family. The nurse is expected to follow the doctors orders and make a nurses note. He/She said the nurse made a medication error by administering Resident #2's Fentanyl patch to Resident #1. The nurse noticed the error after about 30 minutes and removed the patch and reported to the him/her immediately. The DON said he/she contacted the doctor and was told to do 15 minutes checks with vital signs for two hours. He/She said LPN D filled out a medication error report and made a nurses note. He/She said LPN D was educated on the spot about medication administration and the five rights He/She said all staff were inserviced on 3/10/25. During an interview on 3/12/25 at 2:32 P.M., the physician said staff contacted his/her office and let them know about the medication error. During an interview on 3/18/25 at 7:50 A.M., LPN D said he/she normally works nights but worked a day shift that day. He/She said he/she was not used to the fast past of day shift and was trying to keep up. He/She said he/she made a to do list which included the fentanyl patch for Resident #2. He/She went to Resident #1's room and applied the patch and said he/she did not find the existing patch and though it may have fallen off. He/She said it wasn't until about 30 minutes later when he/she went to chart he/she realized the medication error. He/She said he/she immediately let the DON know and went down to remove the patch and assess the resident. He/She said the doctor was called and instructed to do 15 minute checks for two hours. He/She said he/she notified family of the error and made progress notes in the resident's chart. He/She was educated on the five rights of medication and medication administration. MO00250265

Based on observation, interview, and record review, facility staff failed to ensure dietary staff had the appropriate competencies and skills to safely and effectively carry out the functions of food and nutrition services. Facility staff failed to provide effective training to dietary staff related to kitchen ware washing/sanitation. The facility census was 87. 1. Review of the facility's Food Service policy, undated, showed dishwashing machines use either heat or chemical sanitization methods. Manufacturer's instructions must always be followed. Review of the manufacturer's label which was affixed to the front of the dish machine showed wash and rinse temperatures 120 degrees Fahrenheit (F), minimum. Review of the low temperature dish machine operation guidelines, which were mounted on the wall on the clean side of the dish machine showed: -Water temperature should be between 120 and 140 degrees F; -Special notes when using this machine; -Wash minimum temperature, 120 degrees F; -Final rinse temperature minimum, 140 degrees F. Observation on 05/14/24 at 9:55 A.M., showed DA B ran a load of dishes through the dish machine. Observation showed the machine thermometer indicated a temperature of 110 degrees F during the rinse cycle. Observation on 05/14/24 at 10:23 A.M., showed DA B washed a sheet pan in the dish machine. Observation showed the rinse temperature was 115 degrees F. Observation on 05/14/24 at 1:18 P.M., showed DA T ran a load of dishes through the dish machine. Observation showed the highest temperature indicated on the machine thermometer was 112 degrees F. Observation on 05/14/24 at 1:57 P.M., showed Cook R ran two table steam pans through the dish machine. Observation showed the highest temperature indicated on the machine thermometer was 110 degrees F. During an interview on 05/14/24 at 10:20 A.M., DA B said he/she did not check the dish machine temperature before or during use. DA B said he/she only paid attention to the temperature if it was not hot enough. DA B said the water was hot enough. DA B said he/she was not sure what the dish machine water temperature should be. During an interview on 05/14/24 at 10:26 A.M., DA B said the dietary manager told him/her facility chemicals were made to work at any temperature, but the dietary manager liked the machine temperature to be at 120 or above. During an interview on 05/14/24 at 1:18 P.M., DA T said he/she did not know what temperature the dish machine should reach. During an interview on 05/14/24 at 1:57 P.M., Cook R said he/she did not know what the dish machine temperature was supposed to be. Cook R said he/she was trained by another cook within the past month and his/her training did not cover the dish machine temperature. 2. Review of the facility's Food Service policy, undated, showed clean and sanitize work surfaces, including cutting boards and food-contact equipment (e.g., food processors, blenders, preparation tables, knife blades, can openers and slicer's) between uses and consistent with applicable code. Review of the three compartment sink procedures, which were mounted on the wall above the three-compartment sink showed users were instructed to allow items to soak for two minutes. Review of the sanitizer directions for use showed: -Clean the equipment in the normal manner; -Immerse equipment in the sanitizing solution for at least two minutes and allow the sanitizer to drain. Observation on 05/14/24 at 9:54 A.M., showed the sanitizer compartment of the three-compartment sink contained two large tubes of ground meat submerged in water. Observation on 05/14/24 at 10:03 A.M., showed Cook R hand washed a large steam table pan, a plastic pitcher, a sheet pan, and a food processor bowl and blade in the first compartment of a three-compartment sink. Cook R dipped the items in the rinse sink and placed them on a drain board on the clean side dish machine. Cook R did not soak the items in sanitizer. Observation on 05/14/24 at 10:05 A.M., showed Cook R added soap to the first compartment of the three-compartment sink. Cook R cleaned two steam table pans and rinsed the pans in the second sink. Cook R placed the pans on the clean side of the dish machine and did not soak the items in sanitizer. Observation on 05/14/24 at 11:56 A.M., showed DA Q added sanitizer to the third compartment of the three compartment sink. DA Q washed a large pot, two steam pans, a pair of tongs, and a large plastic pitcher in the first sink compartment. DA Q dipped the items in the rinse sink and then dipped the items in the sanitizer. The items were placed on a drain board on the clean side dish machine. DA Q did not soak the items in sanitizer. Observation on 05/14/24 at 2:01 P.M., showed Cook R washed two pans in sink one of a three compartment sink, rinsed the pans in sink two, then placed the pans in the sanitizer sink for less than one minute and placed the pans on a drain board on the clean side dish machine. Observation showed Cook R then hand washed a food processor blade, lid and steam pan, and rinsed the items. Cook R dipped the items in the sanitizer sink and rotated them before he/she removed the items and placed them on a drain board on the clean side dish machine. Cook R did not allow the items to remain submerged in the sanitizer solution for two minutes. During an interview on 05/14/24 at 11:52 A.M., Cook R said he/she washed dishes in the first sink, rinsed in the second sink and dipped dishes in sanitizer sink. Cook R said he/she did not let the dishes soak in sanitizer. Cook R said he/she skipped the sanitizer because there was meat in the sanitizer sink. Cook R said he/she started about a month ago and never had training or in-services on how to use the three-compartment sink. During an interview on 05/14/24 at 11:56 A.M., DA Q said he/she knew how to use the three-compartment sink and sanitizer and he/she was sanitizing items correctly. During an interview on 05/14/24 at 1:45 P.M., Cook S said he/she was trained on the three compartment sink when he/she started about four years ago. Cook S said staff were to wash pots and pans in soap of first sink, rinse in second sink and then let items set for 10 seconds in the third sink During an interview on 5/15/24 at 10:12 A.M., Human Resources staff said he/she did not maintain any kitchen staff competency paperwork. He/She said the DM was responsible for kitchen staff competency. During an interview on 5/15/24 at 10:16 A.M., the DM. said he/she put new staff one on one with another kitchen staff member for training. The DM said he/she did not document kitchen staff training. The DM said he/she conducted verbal reviews with new staff and asked if they had questions. The DM said the verbal reviews did not follow a schedule or structure. During an interview on 05/15/24 at 10:21 A.M., the administrator said the DM was responsible for kitchen staff competency. The administrator said dietary aides should look at the dish machine temperature to make sure it's working correctly and the DM should monitor. The administrator said kitchen wares should soak in the sanitizer but he/she could not remember how long.

Based on observation, interview and record review, facility staff failed to thaw frozen food in a manner to prevent potential contamination. Facility staff failed to store frozen food in a manner to prevent potential contamination. Facility staff failed to allow cleansed dishes to air-dry prior to stacking in storage to prevent the growth of food-borne pathogens. These failures have the potential to affect all residents. The facility census was 87. 1. Review of the facility's Food Service policy, undated, showed thawing some foods at room temperature may not be acceptable because it may be within the danger zone for rapid bacterial proliferation. Recommended methods to safely thaw frozen foods include: -Thawing in the refrigerator, in a drip proof container, and in a manner that prevents cross-contamination; -Completely submerging the item under cold water (at a temperature of 70 degrees F or below) that is running fast enough to agitate and float off loose ice particles. Observation on 05/14/24 at 9:54 A.M., showed the sanitizer compartment of the three-compartment sink contained two large tubes of ground meat submerged in standing water. Observation showed the water temperature was 108 degrees F when checked with a calibrated metal stem thermometer. Observation on 05/14/24 at 11:11 A.M., showed the sanitizer compartment of the three-compartment sink contained two large tubes of ground meat. Observation showed the water was running over one tube of the meat, which was not completely submerged. Observation on 05/14/24 at 11:34 A.M., showed the sanitizer compartment of the three-compartment sink contained two large tubes of ground meat. Observation showed the water was running over one tube of the meat which was not completely submerged. Observation on 05/14/24 at 11:55 A.M., showed Cook S removed two large tubes of meat from the sanitizer sink and placed the meat on the prep counter at room temperature. Observation on 05/14/24 at 12:12 P.M., showed Cook S opened the tubes of meat and added the meat to a pan on the stove top for meal service. During an interview on 05/14/24 at 11:49 A.M., Cook S said his/her boss just told him/her not to thaw meat by soaking. Cook S said ground meat should be thawed under running cold water. Cook S said he/she put the meat in water earlier and he/she thought the water was cold. During an interview on 05/14/24 at 2:52 P.M., the DM said meat should be thawed under cold running water in a tub, not in the sanitizer sink. The DM said meat should not be thawed in warm standing water. During an interview on 05/15/24 at 10:21 A.M., the administrator said the DM was responsible for ensuring kitchen staff handled food correctly. The administrator said the cook was responsible for meat thawing meat correctly. The administrator said meat should not be thawed in warm water or in the sanitizer sink. The administrator said meat should thaw in the refrigerator, or in a pan under cold running water. 2. Review of the facility's Food Service policy, undated, showed frozen foods must be maintained at a temperature to keep the food frozen solid. Practices to maintain safe refrigerated storage include monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation. Review of the facility's Refrigeration Temperature Record form showed the form contained a column for recording walk in freezer temperatures but the form did not contain a column to record reach in freezer temperatures. Observation on 05/13/24 at 10:25 A.M., showed the double door reach in freezer contained an internal thermometer which indicated a temperature of 20 degrees F. Observation on 05/14/24 at 9:46 A.M., showed the exterior digital gauge on the reach in freezer indicated a temperature of 10 degrees F. Observation showed the thermometer inside the freezer indicated a temperature of 23 degrees F. Observation on 05/14/24 at 9:57 A.M., showed the interior freezer thermometer indicated a temperature of 24 degrees F. Observation showed the freezer was not opened between 9:46 A.M. and 9:57 A.M Observation on 05/14/24 at 9:57 A.M., showed the reach in freezer contained bread sticks which were soft to firm pressure. Observation on 05/14/24 at 10:06 A.M., showed the reach in freezer temperature was 24 degrees F with a calibrated metal stem thermometer. Observation showed the reach in freezer was not opened between 9:57 A.M. and 10:06 A.M. Observation on 05/14/24 at 1:15 P.M., showed the interior freezer thermometer indicated a temperature of 22 degrees F. Observation on 05/14/24 at 1:57 P.M., showed the exterior digital gauge on the reach in freezer indicated a temperature of 9 degrees F. Observation showed the thermometer inside the freezer indicated a temperature of 22 degrees F. Observation on 05/15/24 at 7:53 A.M., showed the exterior digital gauge on the reach in freezer indicated a temperature of 8 degrees F. Observation showed the thermometer inside the freezer indicated a temperature of 22 degrees F. Observation showed the reach in freezer contained bread sticks which were soft to firm pressure. During an interview on 05/14/24 at 1:15 P.M., DA T said he/she did not know if kitchen staff kept a freezer temperature log. DA T said the reach in freezer outside gauge should be negative and the inside thermometer should be less than zero. DA T said he/she did not know who was responsible for checking the freezer temperature. During an interview on 05/14/24 at 1:45 P.M., Cook S said the freezer temperature should be negative 20 on the exterior gauge and he/she did not know what the inside temperature should be. Cook S said the dietary aides or maintenance were responsible for keeping the freezer at the correct temperature. During an interview on 05/14/24 at 2:14 P.M., the DM said the reach in freezer should be between 30 degrees F and negative. The DM said the temperature needed to be less than 30 degrees F. The DM said the cook was responsible for maintaining the freezer temperature log. The DM said he/she could not locate the May 2024 reach in freeer temperature log. The DM said he/she did not know the freezer temperature logs did not include the reach in freezer. During an interview on 05/15/24 at 10:21 A.M., the administrator said the cook was responsible for checking the reach in freezer temperatures daily. The administrator said he/she did not know if kitchen staff had a log for freezer temperatures. The administrator said the DM was responsible for ensuring any kitchen logs were being completed. The administrator said freezer temperatures should be at zero degrees F or less. 3. Review of the low temperature dish machine procedures, which were mounted on the wall on the clean side of the dish machine, showed users were instructed to place racks of dishes in a clean, dry area and allow to air dry. Review of the three compartment sink procedures, which were mounted on the wall above the three-compartment sink, showed users were instructed to place items to air dry and not rinse or towel dry. Observation on 05/13/24 at 10:32 A.M., showed eight steam table pans on metal storage shelving were stacked wet. Observation showed three of the pans contained dried food debris. Observation on 05/14/24 at 10:08 A.M., showed the metal storage shelving contained one stack of three pans and two stacks of five pans, which were stacked wet. Observation on 05/14/24 at 2:01 P.M., showed Cook R removed clean pans from the dish machine racks and stacked on a service cart, while still wet. Cook R wheeled the service cart full of pans to the storage area and placed the pans on the metal storage shelves, while wet. During an interview on 05/14/24 at 1:23 P.M., DA T said kitchen items should not be stacked wet. DA T said the person washing and stacking kitchen items was responsible for making sure items were dry before being put away. During an interview on 05/14/24 at 2:02 P.M., Cook R said the pans were not soaking wet and he/she could get a towel and dry the pans. Cook R said he/she just cleaned his/her pots and pans and put them away. Cook R said he/she started working in the kitchen about a month ago and nobody ever told him/her about air drying kitchen items. During an interview on 05/14/24 at 2:14 P.M., the DM said kitchen items should air dry and staff should not be putting items away wet. During an interview on 05/15/24 at 10:21 A.M., the administrator said whoever put kitchen items away was responsible for making sure the items were dry. The administrator said the DM was responsible for training and monitoring kitchen staff.

Based on interview and record review, facility staff failed to perform Criminal Background Checks (CBC), and Employee Disqualification List (EDL) checks in accordance with facility policy for six (Licensed Practical Nurse (LPN) M, Nursing Assistant (NA) N, Certified Nursing Assistant Technicain (CMT) O, Laundry Aid U, Dietary Aid R, Dietarty Aid T) out of ten sampled staff. The facility census was 87. 1. Review of the facility CBC policy, undated, showed: -All applicants for employment must have a CBC submitted a minimum of two days prior to date of hire, -All offers of employment are contingent on a satisfactory report, -No applicant may be offered a position prior to checking the State EDL. 2. Review of LPN M's personnel record showed a hire date of 6/9/2023. Review showed the facility requested and received the CBC results on 6/30/2023 (21 days after hire). Review showed staff documented the EDL check on 6/29/2023 (20 days after hire). 3. Review of NA N's personnel record showed a hired date of 4/20/2024. Review showed the facility requested and received the CBC results on 5/15/2024 (25 days after hire). The EDL check was performed on 5/15/2024 (25 days after hire). 4. Review of CMT O's personnel record showed a hire date of 1/3/2024. The record showed a CBC was requested and received on 5/15/2024 (133 days after hire). 5. Review of Laundry Aid U's personnel record showed a hire date of 4/1/2024. The record showed a CBC was requested and received on 5/15/2024 (45 days after hire). The EDL check was performed on 5/15/2024 (45 days after hire). 6. Review of Dietary Aid R's personnel record showed a hire date of 2/20/2024. The record showed a CBC was requested and received on 5/15/2024. The EDL check was performed on 2/23/2024. 7. Review of Dietary Aid T's personnel record showed a hire date of 6/21/2023. The record showed a CBC was requested and received on 5/15/2024 (329 days after hire). The EDL check was performed on 8/23/2023 (63 days after hire) During an interview on 5/16/2024 at 1:55 P.M., the Human Resources Manager said there is a lot of documentation missing for the CBC's. He/She apologized and said he/she has looked everywhere and cannot find them. He/she said he/she realizes policy had not been followed. He/she is onboarding a new HR Manager and will ensure he/she is trained in the process according to policy. During an interview on 5/16/2024 at 2:00 P.M., the Corporate Administrator said he/she does not have the policy memorized but can look it up. He/She said he expects staff to follow the policy. During an interview on 5/16/2024 at 2:04 P.M. the administrator said he/she expects staff to follow the policy.

48982 Based on interview and record review, facility staff failed to notify the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of resident transfers to the hospital for five residents (Resident #4, #47, #61, #77 and #84) of 22 sampled. The facility census was 87. The facility did not provide a policy for Ombudsman notification of resident transfers to the hospital. 1. Review of Resident #4's medical record showed the resident transferred to acute care for pneumonia on 04/12/24. The record did not contain documentation staff notified the Ombudsman of the resident's transfer and readmitted on [DATE]. 2. Review of Resident #47's medical record showed the resident: -Transferred to the hospital on 04/04/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer; -Transferred to the hospital on 04/30/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer; -Transferred to the hospital on 05/03/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer. Review of the facility's monthly resident transfer log sent to the Ombudsman showed the log did not contain documentation of staff notification to the Ombudsman of the resident transfer for the dates of: -04/04/24 through 04/05/24; -04/30/24 through 05/01/24; -05/03/24 through 05/08/24. 3. Review of Resident #61's medical record showed the resident: -Transferred to the hospital on 03/24/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer; -Transferred to the hospital on 05/15/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the Ombudsman of the resident's transfer. Review of the facility's monthly resident transfer log sent to the Ombudsman showed the log did not contain documentation of staff notification to the Ombudsman of the resident transfer for the dates of: -03/24/24 through 03/28/24; -05/15/24 through 05/15/24. Review of the facility's notification to the Ombudsman showed did not contain documentation March 2024 logs were sent to the Ombudsman; 4. Review of Resident #77's medical record showed the resident: -Transferred to the hospital on 03/03/24 for a fracture or possibility of a fracture. The record did not contain documentation staff notified the Ombudsman of the resident's transfer; -Transferred to on 03/29/24 for a head injury. The record did not contain documentation staff notified the Ombudsman of the resident's transfer. 5. Review of #84's medical record showed the resident transferred to the hospital on 4/4/24 for changes in mental status and aggressive behavior. The record did not contain documentation staff notified the Ombudsman of the resident's transfer. 6. During an interview on 05/15/24 at 11:46 A.M., the Director of Nursing (DON) said he/she is not sure who does the written notification to the Ombudsman when a resident is discharged or transferred from the facility. During an interview on 05/15/24 at 10:00 A.M., the Social Service Director (SSD) said he/she does not notify the Ombudsman when a resident is sent out that day. The SSD said he/she sends a monthly log to the Ombudsman either by fax or email at the end of the month. The SSD said he/she thought the requirement was for the notification to be monthly. During an interview on 05/15/24 at 1:49 P.M., the administrator said he/she does not have written notices to the Ombudsman and the SSD is responsible to do this. During an interview on 05/16/24 at 8:55 A.M., Registered Nurse (RN) U said he/she is not sure who is responsible to notify the Ombudsman when a resident is discharged or transferred from the facility. During an interview on 05/16/24 at 2:45 P.M., the administrator said the SSD is responsible to complete written notification to the Ombudsman when a resident is discharged or transferred from the facility. The Administrator said notification should be given to the Ombudsman with each resident discharge or transfer. 50432

37131 48982 Based on observation, interview, and record review, facility staff failed to provide written information to resident's and/or the responsible party of the bed hold policy at the time of transfer to the hospital on eight residents (Resident #2, #4, #47, #61, #76, #77, #84, and #340) out of 22 sampled residents. The facility census was 87. 1. Review of the facility's policy titled Hospital Transfer and Bed Hold Policy, undated, showed if the physician orders his/her patient to be transferred to the hospital, the family or responsible part will be notified and arrangements made. In the event a resident is transferred to a hospital, a copy of the policy with be sent with them. 2. Review of Resident #2's Discharge/Return Anticipated Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/15/24, showed the resident discharged to the hospital. Review of the resident's medical record, showed the resident returned to the facility on [DATE]. Review showed the medical record did not contain a bed hold agreement. Review of the resident's Discharge/Return Anticipated MDS, dated [DATE], showed the resident discharged to the hospital. Review of the resident's medical record, showed the resident returned to the facility on [DATE]. Review showed the medical record did not contain a bed hold agreement. 3. Review of Resident #4's Discharge MDS, dated [DATE], showed the resident transferred to acute care for pneumonia on 04/12/2024 as an unplanned discharge with return anticipated. Review of the residents Quarterly MDS, dated [DATE], showed the resident readmitted on [DATE]. Review of the resident's medical record showed the record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy. 4. Review of Resident #47 Annual MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment. Review of the resident's medical record showed the resident: -Transferred to the hospital on 04/04/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy; -Transferred to the hospital on 04/30/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy; -Transferred to the hospital on 05/03/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy. 5. Review of Resident #61's Significant Change MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment. Review of the resident's medical record showed the resident was: -Transferred to the hospital on 03/24/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy; -Transferred to the hospital on 05/15/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy. 6. Review of Resident #76's Discharge/Return Anticipated MDS, dated [DATE], showed the resident discharged to the hospital. Review of the resident's medical record showed the resident returned to the facility on [DATE]. Review showed the record did not contain a bed hold agreement. 7. Review of Resident #77 Admission MDS, dated [DATE], showed staff assessed the resident as cognitively independent. Review of the resident's medical record showed the resident: -Transferred to the hospital on 03/03/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy; -Transferred to the hospital on 03/29/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy. 8. Review of #84's Significant Change MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the medical record showed this resident transferred on 04/04/2024 to the hospital for mental status changes and aggressive behavior. Review showed the record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy. 9. Review of Resident #340's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's medical record showed the resident was transferred to the hospital on 04/26/24 and returned to the facility on [DATE]. The record did not contain documentation staff notified the resident or responsible party of the facility's bed hold policy. 10. During an interview on 05/15/24 at 10:00 A.M., the Social Service Director (SSD) said he/she does not do the bed holds and thinks the Director of Nursing (DON) takes care of those. During an interview on 05/15/24 at 11:46 A.M., the DON said when a resident is transferred or discharged the nursing staff give them a copy of the bed hold policy, but they do not get it signed or keep a copy of this. During an interview on 05/15/24 at 1:49 P.M., the administrator said he/she does not have any signed bed holds and nursing staff are responsible to do this. During an interview on 05/16/24 at 8:55 A.M., Registered Nurse (RN) U said he/she is not sure who completes the bed holds when a resident is discharged or transferred from the facility. During an interview on 05/16/24 at 10:37 A.M., the DON said nursing only sends a copy of the bed hold policy with the resident upon discharge or transfer. The DON said the SSD is responsible to complete a written notification to the Ombudsman. The DON said he/she is not sure the facility has any signed bed holds and he/she is not sure who is responsible to do that. The DON said a bed hold should be done with every discharge or transfer from the facility. During an interview on 05/16/24 at 2:45 P.M., the administrator said nursing staff are responsible to complete a bed hold when a resident is discharged or transferred. The Administrator said he/she was not sure if the facility kept a signed copy of the bed holds given to the resident. During an interview on 05/16/24 at 2:45 P.M., the corporate administrator said the facility should have a signed copy of a bed hold given. He/She said a resident should have the opportunity to sign a bed hold with any discharge or transfer from the facility. The corporate administrator said he/she is not sure why the facility does not have signed copies of the bed holds given. 50432

Based on observation, interviews and record review, staff failed to maintain a professional standard of care, when facility staff failed to document the dosage of insulin administered to three residents (Resident #2, #59 and #71) of 22 sampled residents. The facility census was 87. 1. Review of the facility's Eight Rights of Medication policy, dated 05/2023, showed staff are instructed to ensure when staff administer medications: -Right individual; -Right medication; -Right dosage; -Right route; -Right time; -Right documentation; -Right reason; -Right to refuse. 2. Review of the facility's Medication Administration policy, undated, showed staff should ensure the correct medication doses administered to the resident. 3. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/25/24, showed staff assessed the resident as follows: -Insulin injections seven days of the seven day look back period; -Diagnosis of Diabetes. Review of the resident's Physician Order Sheet (POS), dated May 2024, showed an order directed staff to administer Lispro (insulin) 100 unit (u)/milliliters (mL) subcutaneous pen, one unit subcutaneous (insertion of medications beneath the skin either by injection or infusion) three times per day, inject insulin lispro blood sugar divided by 30 minus 3 for insulin dosage. Do not give if resident eats less then 50% of meal. Review of the resident Medication Administration Record (MAR), dated May 2024, showed staff documented they administered Insulin Lispro and did not document the dosage they administered on: -May 1st at 6:30 A.M., 11:30 A.M. and 4:30 P.M.; -May 2nd at 6:30 A.M., 11:30 A.M. and 4:30 P.M.; -May 7th at 6:30 A.M., 11:30 A.M. and 4:30 P.M.; -May 8th at 6:30 A.M., 11:30 A.M. and 4:30 P.M.; -May 9th at 6:30 A.M., 11:30 A.M. and 4:30 P.M.; -May 14th at 6:30 A.M., 11:30 A.M. and 4:30 P.M.; 4. Review of Resident #59's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Insulin injections seven days of the seven day look back period; - Diagnosis of diabetes. Review of the resident's POS, dated May 2024, showed: - Insulin Lispro (U-100) Insulin 100 unit/mL pen, 12 units subcutaneous before meals; - Insulin glargine (U-100) 100 unit/mL pen, 25 units subcutaneous daily at bedtime. Review of the resident's MAR, dated May 2024, showed staff document they administered the residents Insulin Lispro and did not document the dosage of insulin they administered for: - May 1st at 6:30 A.M., 11:30 A.M., and 4:30 P.M.; - May 2nd at 6:30 A.M., 11:30 A.M., and 4:30 P.M.; - May 3rd at 11:30 A.M., and 4:30 P.M.; - May 4th at 11:30 A.M., and 4:30 P.M.; - May 5th at 11:30 A.M., and 4:30 P.M.; - May 6th at 6:30 A.M., and 11:30 A.M.; - May 7th at 6:30 A.M., 11:30 A.M., and 4:30 P.M.; - May 8th at 6:30 A.M., 11:30 A.M., and 4:30 P.M.; - May 9th at 6:30 A.M., 11:30 A.M., and 4:30 P.M.; - May 10th at 6:30 A.M., and 4:30 P.M.; - May 11th at 11:30 A.M., and 4:30 P.M.; - May 12th at 4:30 P.M.; - May 13th at 4:30 P.M.; - May 14th at 6:30 A.M., 11:30 A.M., and 4:30 P.M.; - May 15th at 6:30 A.M., and 11:30 A.M. Review of the resident's MAR, dated May 2024, showed staff document they administered the Insulin glargine and did not document the dosage they administered for: - May 1st at 8:00 P.M.; - May 2nd at 8:00 P.M.; - May 3rd at 8:00 P.M.; - May 4th at 8:00 P.M.; - May 5th at 8:00 P.M.; - May 6th at 8:00 P.M.; - May 8th at 8:00 P.M.; - May 9th at 8:00 P.M.; - May 10th at 8:00 P.M.; - May 11th at 8:00 P.M.; - May 12th at 8:00 P.M.; - May 13th at 8:00 P.M.; - May 14th at 8:00 P.M. 5. Review of Resident #71's Significant Change MDS, dated [DATE], showed staff assessed the resident as follows: -Insulin injections six days of the seven day look back period; -Diagnosis of Diabetes. Review of the resident's POS, dated May 2024, showed: -Insulin Lispro 100 unit/mL subcutaneous pen, one unit subcutaneous three times per day, inject insulin lispro blood sugar divided by 30 minus 3 for insulin dosage. Do not give if resident eats less then 50% of meal. Review of the resident's MAR, dated May 2024, showed staff documented they administered the residents Lispro Insulin and did not document the dosage they administered for: -May 1st at 7 A.M. and 11 A.M.; -May 2nd at 11 A.M.; -May 3rd at 7 A.M. and 11 A.M.; -May 5th at 7 A.M. and 11 A.M.; -May 6th at 7 A.M. and 11 A.M.; -May 7th at 7 A.M.; -May 8th at 7 A.M. and 11 A.M.; -May 9th at 7 A.M., 11 A.M. and 4 P.M.; -May 10th at 7 A.M. and 11 A.M.; -May 11th at 7 A.M.; -May 12th at 7 A.M.; -May 13th at 7 A.M. and 4 P.M.; -May 14th at 7 A.M. and 4 P.M. Review showed the MAR did not contain documentation of the dosage of insulin administered to the resident for the 23 administrations documented. 6. During an interview on 05/15/24 at 10:38 A.M., the Director of Nursing (DON) said staff do not document the amount of insulin given, the orders are put in the system and it calculates how much to give based off the resident's physician's order. Staff do not document in the computer actual units given, just that staff gave what the calculator said to give. The DON said he/she does not know how to see the dosage administered to the residents. The DON said there is no way to print the dosage of insulin administered to the residents. The DON said corporate said the medication program has a place to add the dosage of insulin administered, but it had not been set up on the facility's program. During an interview on 05/15/24 at 11:15 A.M., Certified Medication Technician (CMT) E said there is no spot on the MAR for how many units are given for sliding scale insulin, for set doses it says to give the amount and shows administered in the chart, but there is no place to document the number that was actually given. CMT E said this can lead to numerous things, the resident's blood sugars could bottom out, or they could be given too much; and if they are sent out to the hospital we would not be able to easily tell them how much insulin they received. During an interview on 05/15/24 at 11:15 A.M., Licensed Practical Nurse (LPN) G said there is no place to chart units given in the chart, it could lead to medication errors, or blood sugar issues if staff can not tell how many units were given or not, and we would not be able to track if the right amount was actually given. During an interview on 05/15/24 at 11:46 A.M., Assistant Director of Nursing (ADON) said staff should write down the amount of insulin given. Staff should make sure the resident's name, medication, date, route, time and dosage is documented at administration. The ADON said staff should have documented the dosage they gave, without documenting the dosage given, there is no way to tell if there is medication errors. During an interview on 05/16/24 at 12:07 P.M., CMT H said he/she did not the document insulin dosages he/she administered to residents on the computer, until yesterday. The CMT said he/she can not look back to the MAR and see what dosage of insulin had been given, just that it had been given. During an interview on 05/16/24 at 1:53 P.M., the DON said he/she does expect staff to document the amount of insulin they administer to residents. 45489

Based on observation and interview, facility staff failed to properly maintain the temperature of hot foods at or above 120 degrees Fahrenheit ( F) at the time staff served hall trays to six residents (Residents #13, #45, #75, #59, #42 and #77) of 22 sampled residents. Facility staff failed to maintain hold temperatures of 135 F, while on the steam table, during food service. Failure to maintain hold temperatures on steam table has the potential to affect all residents served in the main dining room. The facility census was 87. 1. Review of the facility's Food Service policy, undated, showed: -Avoid holding foods in danger zone temperatures which are between 41 F and 135 F; -Cooking Fresh, Frozen, or canned fruits and vegetables to a hot holding temperature of 135 F prevents the growth of pathogenic bacteria that may be present in, or on these foods; -Does not identify the expectation of temperature for food at time of service. 2. Observation on 05/14/24 at 11:53 A.M., showed Dietary Aide (DA) B served Resident #13 a hall tray. At the time of service, the resident's broccoli was at 108 F. Observation showed the DA failed to offer to reheat the resident's tray. During an interview on 05/14/24 at 10:42 A.M., the resident said he/she always eats in his/her room and the food is always cold. The resident said the facility used to have a heat cart for the hall trays, but it broke and the facility never got a new one. 3. Observation on 05/14/24 at 12:06 P.M., showed DA B delivered Resident #45 a hall tray. The temperature of the food at time of service was, pork loin 113 F and broccoli 111 F. Observation showed the DA failed to offer to reheat the resident's tray. 4. Observation on 05/14/24 at 12:07 P.M., showed DA B delivered Resident #75 a hall tray. The temperature of food at time of service was, pork loin 118 F, cornbread 117 F and broccoli 101 F. Observation showed the DA failed to offer to reheat the resident's tray. 5. Observation on 05/14/24 at 12:33 P.M., showed DA B delivered Resident #59 a hall tray. The temperature of the food at time of service was, cornbread 116 F and broccoli 116 F. Observation showed the DA failed to offer to reheat the resident's tray. 6. Observation on 05/14/24 at 12:47 P.M., showed DA B delivered Resident #42 a hall tray. The temperature of food at time of service is, cornbread 112 F and broccoli 119 F. Further observation showed the DA failed to offer, to reheat resident's tray. 7. Observation on 05/14/24 at 12:49 P.M., showed DA B delivered Resident #77 a hall tray. The temperature of food at time of service was, cornbread 109 F. Further observation showed the DA failed to offer to reheat the resident's tray. 8. During an interview on 05/13/24 at 2:12 P.M., Resident #2 said he/she eats in his/her room and his/her food is not cold sometimes, it is cold all the time. During an interview on 05/14/24 on 10:03 A.M., Resident #71 said he/she always eats in his/her room. The residents said the food is always cold when he/she gets it. During an interview on 5/15/24 at 10:21 A.M., the administrator said food on room trays should be served at 120 F. During an interview on 05/16/24 at 10:17 A.M., Nurse Aide (NA) F said a few residents have complained about the hall trays being cool. The NA said he/she usually brings the tray back to dietary and dietary warms the tray up, or fixes the resident a fresh tray. During an interview on 05/16/24 at 10:26 A.M., the Wound Nurse said he/she has heard residents complain about the food being cold. The Wound Nurse said staff should reheat a resident's food, if it is cold. During an interview on 05/16/24 at 11:00 A.M., the Dietary Manager (DM) said he/she has had complaints about hall trays being cold. The DM said food has to be 120 F, or above at the time it is served to resident. The DM said he/she had received some complaints from residents about cold food. The DM said he/she usually addresses these concerns in the morning meetings with department heads, but they have not been having morning meetings this week. 9. Observation on 05/13/24 at 12:06 P.M., showed DA B served lunch to residents in the main dining room. The temperatures taken from the steam table showed, beef stroganoff was 120 F, green beans were 122 F, pureed beef stroganoff was 120 F, pureed green beans were120 F. Observation showed the DA served six more residents from the steam table through 12:30 P.M., after the temperatures were taken by the DA at 12:06 P.M. During an interview on 05/13/24 at 12:30 P.M., DA B said he/she does not normally serve the food from the steam table, a cook did not come in today and that is why he/she is serving the food off the steam table. 10. Observation on 5/14/24 at 12:48 P.M., showed Cook R served residents pork with gravy, sweet potatoes, broccoli and corn bread with butter. Observation showed the temperature of the pork was 124 F, broccoli was 126 F, and sweet potatoes were 132 F on the steam table. During an interview on 5/14/24 at 12:54 P.M., Cook R said he/she did not check food temperatures before or during the lunch meal service. The cook said he/she thought food should be held at 175 degrees, but that was just a guess. The cook said he/she did not know the holding temperature for food, since no one ever told him/her. Cook R said he/she received some training from another cook but the training was not good. During an interview on 5/14/24 at 1:45 P.M., DA S said food temperatures on the serving line should be 160 degrees and if anything was below 130 degrees he/she would tell someone. DA S said he/she did not know how kitchen staff made sure residents who received room trays were getting warm food. During an interview on 5/14/24 at 2:14 P.M., the DM said foods on the serving line should be held at 120 degrees F. The DM said kitchen staff serve food from the steam table to room trays as quickly as they can and it usually took less than 20 minutes to pass room trays. The DM said three residents complain about cold food regularly but there were no food complaints at the last resident council meeting. The DM said new cooks were trained by other kitchen staff. The DM said he/she did not document new staff training. During an interview on 5/15/24 at 10:21 A.M., the administrator said the DM was responsible for kitchen functions. The administrator said the cook was responsible for making sure food temperatures were maintained. The administrator said he/she could not remember what temperature food needed to be held at during meal service. 45564

Based on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for three residents (Resident #27, #47, and #61) out of 22 sampled residents. The facility census was 87. 1. Review of the facility's policy titled Care Planning Policy and Procedure, revised 01/17/18, directed staff to: -Ensure the resident and family participate in the resident's care quarterly and annually to ensure there is continuity of care; -Care plan will be developed upon admission, updated quarterly, annually, with any significant change, and in accordance with the individual's needs; -Care plan will be updated as needed. Review of the facility's policy titled Falls, revised 10/05/23, directed staff to: -Care plans with individualized interventions post fall; -The Interdisciplinary Team (IDT) will evaluate the fall prevention plan of care for residents at risk for falls; -Following a resident fall appropriate interventions are implemented, and the care plan updated. 2. Review of Resident #27 Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/05/24, showed staff assessed the resident as: -Cognitively intact; -Depended on staff for transfers; -Requires maximum assistance with bed mobility; -Uses a wheelchair; -No falls since the prior assessment. Review of the resident's Physician's Orders Sheet (POS), dated 05/13/24 showed: -May have overhead trapeze to aide in repositioning with a start date of 04/02/23; -Air mattress to bed with a start date of 04/09/24. Review of the resident's nurse note, dated 04/09/24, showed the resident fell out of bed at 3:00 P.M. when his/her leg slipped off the bed. New intervention for bilateral floor mats beside his/her bed placed. Review of the resident's nurses note, dated 05/10/24, showed the resident rolled out of bed at 7:50 A.M. Observation on 05/13/24 at 10:48 A.M., showed the resident in bed on a low air loss mattress with a trapeze over head. Observation on 05/14/24 at 8:29 A.M., showed the resident in bed without floor mats next to the bed. Observation on 05/14/24 at 10:42 A.M., showed the resident in bedwithout floor mats next to the bed. He/She moved himself/herself in his/her bed with the trapeze bar. Observation on 05/14/24 at 2:14 P.M., showed the resident in bed. Observation showed there were not fall mats on the floor next to the bed. Observation on 05/15/24 at 7:41 A.M., showed the resident in bed on a low air loss mattress with an overhead trapeze and without floor mats next to the bed. Observation on 05/15/24 at 9:30 A.M. showed Certified Nurse Assistant (CNA) I, CNA K, and CNA/Restorative Aide (RA) J performed a mechanical lift transfer on the resident. Review of the resident's care plan, revised 02/22/24, showed the care plan did not contain direction for trapeze use, mechanical lift transfer, and fall interventions placed. During an interview on 05/13/24 at 2:20 P.M., the resident said he/she had a fall from bed a month ago when his/her leg slipped off the bed. During an interview on 05/16/24 at 10:37 A.M., the Director of Nursing (DON) said he/she was aware of the intervention discussed for fall mats to be placed on 04/09/24 but the resident and family member refused. The DON said he/she did not have a note about the refusal and should have documented that. 3. Review of Resident #47's Annual MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Dependent on staff for ADL's and transfers; -Not able to ambulate; -Not at risk for pressure ulcers. Review of the resident's POS, dated 05/13/24 showed an order for air mattress to bed with a start date of 04/09/24. Observation on 05/13/24 at 11:40 A.M., showed the resident in his/her wheelchair with a mechanical lift pad under him/her. Observation on 05/14/24 at 8:31 A.M. and 2:14 P.M., showed the resident in his/her wheelchair with a mechanical lift pad under him/her. Observation on 05/15/24 at 7:38 A.M., showed the resident in his/her wheelchair with a mechanical lift pad under him/her. Observation on 05/16/24 at 8:44 A.M., showed the resident in his/her wheelchair with a mechanical lift pad under him/her. Review of the residents care plan, revised 04/25/24, showed the resident care plan did not contain direction for the use of low air loss mattress or mechanical lift. 4. Review of Resident #61's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Diagnosis of a seizure (uncontrolled movements of the body) disorder. Review of the resident's face sheet, undated, showed an admitted [DATE] with a diagnosis of unspecified convulsions. Review of the resident's POS, dated 05/13/24, showed staff were directed to administer: -Keppra (a medication given to treat seizures) 750 milligrams (mg) twice a day for seizures; -Naloxone (a lifesaving medication) 4mg per nares as needed for low blood pressure with convulsions/seizures. Review of the resident's care plan, revised 03/27/24, showed it did not contain directions for seizures/convulsions. 5. During an interview on 05/16/24 at 8:47 A.M., CNA I said he/she does not have access to the computer to look at the care plans. CNA I said he/she talks to the Care Plan Coordinator (CPC) or the charge nurse with questions regarding a resident's care. CNA I said he/she would expect a care plan to be individualized for each resident. During an interview on 05/16/24 at 8:47 A.M., CNA K said he/she does not have access to the computer to look at the care plans. CNA I said he/she talks to the CPC or the charge nurse with questions regarding a resident's care. CNA K said he/she would expect a care plan to be individualized for each resident. During an interview on 05/16/24 at 8:47 A.M., CNA J said he/she has access to the computer to look at the care plans as he/she works in therapy. CNA J said he/she would expect a care plan to be individualized for each resident. CNA J said he/she would expect a care plan tocontain a low air loss mattress, trapeze, how much assistance a resident need, how they transfer such as using a mechanical lift, if the resident walks or uses a wheelchair. He/She said the care plan should direct staff on how to care for each resident. During an interview on 05/16/24 at 8:54 A.M., CNA I said the administrator told him/her there were printed care plans in a binder at the nurse's station. CNA I said he/she was not aware of this. During an interview on 05/16/24 at 8:55 A.M., Registered Nurse (RN) U said care plans are printed and kept in binders at the nurse's station. RN U said the CPC is responsible for updating them and the staff do not do updates. RN U said a resident's care plan should be individualized to show staff how to take care of a resident. RN U said he/she would expect the care plan to address low air loss mattress', trapeze, mechanical lift to transfer, certain medications, and diagnosis that are relevant such as seizures. During an interview on 05/16/24 at 9:00 A.M., Certified Medication Technician (CMT) E said the CPC is responsible for updating the care plans. CMT E said he/she was not sure if he/she had access on the computer to look at care plans. CMT E said he/she was not aware there were printed copies at the nurse's station. CMT E said care plans should be individualized for each resident. CMT E said resident care plans should address how much assistance a resident need for care, how the resident transfers, if the resident needs a mechanical lift, and special equipment such as a trapeze or low air loss mattress, and any diagnosis such as seizures staff need to be aware of. During an interview on 05/16/24 at 9:07 A.M., the CPC said he/she is responsible to complete and update the care plans but does not do the MDS's. The CPC said he/she is the only one who updates care plans. The CPC said he/she did not get any training on care plans and has learned on his/her own. The CPC said care plans are updated quarterly, annually, and as needed with a change in condition. The CPC said when a new order is obtained that should be on the care plan, he/she relies on the nurse who got the order to tell him/her verbally. The CPC said he/she does not have a report he/she can pull from the computer to look for new orders. The CPC said the facility staff have a meeting each morning as well where they discuss resident changes, and he/she updates the care plan accordingly. The CPC said once he/she updates the care plan in the computer he/she prints a new copy and replaces the old one in the binders at the nurse's station. The CPC said care plans should be individualized and accurate as they direct the resident's care. The CPC said a care plan should have how much assistance a resident needs. The CPC said a care plan should also have certain medications such as antidepressants, antipsychotics, antianxiety, and anticoagulants. He/She said the care plan should also have certain diagnosis that place a resident at risks staff may need to know about such as seizures, and falls. The CPC said if a resident has a fall a new intervention should be placed and the care plan updated with that intervention. During an interview on 05/16/24 at 10:37 A.M., the DON said the CPC is responsible to complete and update all of the care plans. The DON said care plans should be completed upon admission and updated quarterly, annually, and with any changes as needed. He/She said the nursing staff are responsible to verbally communicate or leave a note regarding any new orders to the CPC so he/she can update the care plan as needed. The DON said the facility staff also have a meeting each morning to discuss resident changes and the CPC should update the care plans accordingly with thing they discuss. The DON said once the CPC updates the care plan then the CPC should print a new copy and place in the binders at the nurse's station for the staff. The DON said a care plan should be accurate, individualized, and able to direct the staff on how to care for a resident. The DON said he/she would expect thing such as a mechanical lift transfer, trapeze, wheelchair, walker, low air loss mattress, the amount of assistance a resident needs, any fall interventions put in place, certain at risk meds, and diagnosis such as seizures on the care plan. During an interview on 05/16/24 at 2:45 P.M., the administrator said the CPC is responsible to update the care plans on each resident. The Administrator said he/she is not sure what training the CPC has had, but he/she has access to online seminars from their company, a corporate consultant, and Quality Improvement Program for Missouri (QUIPMO) if he/she has questions. The administrator said care plans should be updated quarterly, annually, and as needed with changes. The administrator said care plans should be accurate and individualized for each resident. The administrator said the care plans serves as a guide for staff on how to care for the resident. The administrator said all staff have access to a paper copy of the care plan in the binders at the nurse's station. The administrator said he/she was not aware not all the staff knew they had paper copies, and he/she plans to educate them. The administrator said care plans should have things on them such as mechanical lift transfer, oxygen, trapeze, wheelchair, walker, low air loss mattress, the amount of assistance a resident needs for any care, any fall interventions put in place, certain at risk meds, and diagnosis such as seizures.

Based on observation, interviews, and record reviews, the facility staff failed to protect, label, and date stored food to prevent cross contamination and outdated use; to ensure the ice machine drained through an air gap; and to perform hand hygiene as often as necessary. Facility staff also failed to test the sanitizing solution according to facility policy and to protect stored dishes, silverware, and plastic ware to prevent contamination. This failure had the potential to affect all facility occupants. The census was 82. 1. Review of the facility's Purchasing and Storage: Facility and Resident Food and Supplies policy, undated, showed the policy did not address the storage of food in the kitchen. Observation on [DATE] at 10:05 A.M., of the refrigerator in the kitchenette of the main dining room, showed: - Open package of cream cheese in a zipper storage bag, undated; - Open container of grape jelly, undated; - Three pitchers of juice, not labeled and undated; - Open jar of dill pickles, undated; - Open five pound container of cottage cheese, undated; - Open loaf of bread, undated; - Open package of hamburger buns, undated; - Open container of orange juice, undated. Observation on [DATE] at 10:10 A.M., of the pantry in the kitchenette of the main dining room, showed: - One bottle, which contained a brown liquid, not labeled and undated; - Open five pound container of peanut butter, undated; - Six open bags of cereal, undated. Observation on [DATE] at 10:35 A.M., of the spice rack, showed: - Open container of coffee creamer, undated; - Open box of corn starch, unprotected and undated; - Open box of salt, unprotected and undated; - Open box of baking soda, unprotected and undated; - Open container of parsley flakes, undated; - Open bottle of browning seasoning, undated; - Open bottle of [NAME] cooking wine, undated; - Open bottle of Worcestershire sauce, undated; - Open bottle of vanilla, undated; - Open bottle of lemon extract, undated; - Open container of thyme, undated; - Open container of seasoning blend, undated; - Open container of chili powder, undated; - Open container of bay leaves, undated; - Open container of garlic powder, undated; - Open container of ground mustard, undated; - Open container of ground basil, undated; - Open container of onion powder, undated; - Open container of Italian seasoning, undated; - Open container of ground nutmeg, undated; - Open container of rubbed sage, undated; - Open container of cinnamon, undated; - Open container of garden seasoning, undated; - Open container of poultry seasoning, undated; - Open container of garlic [NAME] sprinkle, undated; - Open container of ground black pepper, undated. Observation on [DATE] at 10:50 A.M., of the dry goods storage area, showed: - Bulk granulated sugar with scoop stored in the sugar; - Bulk flour with scoop stored in the flour; - Open bag of brown sugar stored in zip bag, undated; - Open bag of white cake mix stored in zipper storage bag, undated; - Open bag of croutons stored in zipper storage bag, undated; - Five open bags of cereal stored in zipper storage bag, undated; - Open box of farina, not protected and undated; - Open one gallon container of butter flavored oil, undated; - Open one gallon bottle of white vinegar, undated. Observation on [DATE] at 11:00 A.M., of the walk-in refrigerator, showed: - Open loaf of bread, undated; - Three open packs of hamburger buns, undated; - One zipper storage bag of sliced tomatoes, undated; - Open 32 ounce package of sliced turkey breast, undated; - One zipper storage bag of lettuce, undated; - Open 10 pound container of macaroni salad with the lid partially opened, undated; - Open container of potato salad, undated; - Open bag of breaded chicken patties, dated [DATE], unprotected; - Open container of grape jelly, undated; - A zipper storage bag contained round sliced meat, not labeled and undated; - Open gallon of milk, with best by date [DATE], not dated; - A zipper storage bag of bacon, undated. Observation on [DATE] at 10:45 A.M., of the pantry, showed an open five pound container of peanut butter, undated. Observation on [DATE] at 10:47 A.M., of dry goods storage area, showed: - Bulk granulated sugar with scoop stored in the sugar; - Bulk flour with scoop stored in the flour; - Open bag of brown sugar, undated; - Open bag of white cake mix, undated; - Two open bags of croutons, undated; - Four individual bowls of cereal, undated. Observation on [DATE] at 11:10 A.M., of the walk-in refrigerator, showed: - Two small Styrofoam bowls with lids, which contained a yellow substance, not labeled and undated; - One small Styrofoam bowl with lid, which contained a yellow substance, unlabeled; - Open bag of sliced lunch meat, not labeled and undated; - Open block of white sliced cheese, not labeled and undated; - Open bag of white meat chunks, not labeled and undated; - One gallon ziplock bag with bacon slices, undated; - Open bag of bread slices, undated; - Open bag of hamburger buns, undated; - Open bag of hotdog buns, undated. Observation on [DATE] at 11:25 A.M., of the pantry in the kitchenette of the main dining room, showed: - Open bag of corn chips undated; - Three open bags of cereal, undated. Observation on [DATE] at 12:55 P.M., of the walk-in freezer, showed: - Bag of brown patties, not labeled and undated; - Bag of pork chops, undated; - Bag of meat dated [DATE], unlabeled; - Bag of white meat, not labeled and undated; - Bag of broccoli, undated. Observation on [DATE] at 1:00 P.M., of the pantry, showed: - Open bag of spaghetti noodles, not protected and undated; - Open container of broccoli and cheese soup mix, undated; - Open 50 pound bag of long grain rice, undated; - Two open bags of corn chips, undated. During an interview on [DATE] at 2:19 P.M., the dietary manager said she is responsible to ensure dietary staff follow kitchen policy and procedures regarding food storage. She said the scoops for bulk food should be stored on a hook on the outside of the storage bin. The scoop should not be stored on top of the food product, because it can contaminate the food. She said food in storage should be protected, labeled, and dated to protect it from contamination and outdated use. The dietary manager said the cooks check the food storage areas daily to make sure food is stored properly, and she checks food storage every once in a while when she is doing inventory. The dietary manager said the facility has a policy for food storage, and the dietary staff have been trained on the policy. During an interview on [DATE] at 3:02 P.M., the administrator said the dietary manager is responsible to ensure food is stored correctly. The administrator said the facility has a policy on food storage, and the staff have been trained on the policy. The administrator said it is expected the cooks would check food storage every day and correct any items that are not stored according to policy. The administrator said all stored food should be protected, labeled, and dated, and the scoops for bulk food should be stored protected outside the storage container. 2. Review of the facility's policies and procedures showed the facility did not have a policy regarding the ice machine. Observation on [DATE] at 11:10 A.M., showed an ice machine, located in the kitchenette off the main dining room, contained a black substance on the top inside of the ice storage bin door. Observation on [DATE] at 10:11:30 A.M., showed the ice machine, located in the kitchenette off the main dining room, did not drain through an air gap. Observation of the ice storage bin inside the ice machine showed a black substance along roof of the storage bin. Observation also showed an accumulation of trash under the ice machine drain pipe which prevented the ice machine from draining properly. Further observation showed a clear sludge type substance hung out of the pipe and onto the trash, and the bottom ,d+[DATE] inch of the pipe covered with a black substance. During an interview on [DATE] at 2:19 P.M., the dietary manager said the facility does not have a policy regarding the ice machine. She said the dietary staff clean the outside of the ice machine and sweep the floor under the machine daily. An outside company cleans the inside and performs maintenance on the machine, but she does not know how often. The dietary manager said the ice machine is used for the residents, and it should drain through an air gap. During an interview on [DATE] at 3:02 P.M., the administrator and the maintenance director said maintenance director is responsible to ensure the ice machine is inspected and maintained according to code. The maintenance director checks the ice machine every two months and cleans the filer and coils. He does not check to ensure the air gap is maintained. The administrator and the maintenance director said the facility does not have a policy for the ice machine, but the machine should drain through an air gap according to regulations. 3. Review of the facility's handwashing policy, dated [DATE], showed employees are to wash their hands after touching body parts, handling soiled equipment, when changing tasks, before donning gloves, after engaging in any activity or task which contaminates their hands, and as much as possible during food preparation to remove soil and contamination and to prevent cross contamination. Observation on [DATE] at 9:55 A.M., showed Cook X prepared food for the resident's lunch. The cook touched his/her facemask with his/her bare hand to the front of the facemask and then touched various food related items. Cook X did not wash his/her hands after he/she touched his/her facemask and before he/she touched food related items. Observation on [DATE] at 10:18 A.M., showed the activity director (AD) entered the kitchen, touched the ice scoop and sink faucet handle. The AD did not wash his/her hands after he/she entered the kitchen and before he/she touched various kitchen equipment. Further observation showed various dietary staff touched the unsanitized ice scoop and faucet handle. Observation on [DATE] at 10:27 A.M., showed Volunteer Y touched his/her hair with his/her bare hands. Further observation showed the volunteer touched the ice scoop and the mouth area of resident cups. The volunteer did not perform hand hygiene after he/she touched his/her hair and before he/she touched the ice scoop and the resident cups. During an interview on [DATE] at 2:19 P.M., the dietary manager said the facility has a policy regarding handwashing in the kitchen, and the staff have been trained on the policy. She said it is expected staff would perform hand washing when they enter the kitchen and after touching their hair or face masks. The dietary manager said dietary staff should remind other staff and volunteers to wash their hands as often as necessary. During an interview on [DATE] at 3:02 P.M., the administrator said it is expected staff would wash their hands when they enter the kitchen and after they touch their body, to include their hair and face mask. He said the facility has a policy for hand washing in the kitchen, and the staff have been trained on the policy. 4. Review of the facility's Warewashing and Storage policy, dated [DATE], showed: - All dinnerware, utensils, preparation, and service supplies shall be washed and sanitized according to food safety practices and regulatory guidelines; - The dish machine, if low temperature, shall use a detergent, a rinse drying agent, and sanitizer; - Test strips shall be available for the pot sink and low temp dish machine sanitizer. Results shall be checked and recorded daily. Observation on [DATE] at 10:30 A.M., showed the dishwasher sanitizer test strips expired in 2022, and the three compartment sink sanitizer test strips expired in ,d+[DATE]. Observation on [DATE] at 10:00 A.M., showed the dish washing machine used low temperature and sanitizing agent to clean and sanitize the dishes. The manufacturer's instruction label on the dishwashing machine read wash temperature 120 Fahrenheit (F), rinse temperature 120 F, and chlorine sanitizer at 50 parts per million (ppm). Further observations showed the dishwashing area did not contain any sanitizer test strips. During an interview on [DATE] at 2:19 P.M., the dietary manager said the dishwashing machine used low temperatures and a sanitizing agent to clean and sanitize the dishes. She said the facility had expired test strips, and they threw them away. She called the outside dishwasher service company, but they have not brought any sanitizing strips to the facility. The dietary manager said she ordered some from the food vendor, but the test strips will not arrive until the next food delivery in a couple days. She said it is expected the staff test the sanitizing solution daily, but they cannot do it without the strips. The facility has a policy for the dishwasher, and the staff have been trained on the policy. During an interview on [DATE] at 3:02 P.M., the administrator said the dishwasher uses low temperatures and a sanitizing solution, and the staff should use test strips to test the solution daily. The administrator said the dietary manager should monitor the test strips and order them as needed. He said he was not aware the facility did not have any test strips. The administrator said it is expected staff would tell him, because the test strips can be bought locally. 5. Review of the facility's Warewashing and Storage policy, dated [DATE], showed the policy did not address protecting stored dishes, silverware, and plastic ware. Observation on [DATE] at 11:00 A.M., showed: - Two stacks of small plates, two stacks of clear bowls, one stack of small white bowls, and one stack of medium white bowls stored on the bottom shelf of the steam table, not inverted and unprotected; - Plastic ware and silverware stored unprotected on a table near the pantry. During an interview on [DATE] at 2:19 P.M., the dietary manager said plates and bowls should be covered when not in use. Silverware should be stored with the handles up, and the bag which contains plastic ware should be closed when not in use. She said the facility had a policy, and the staff have been trained on the policy. During an interview on [DATE] at 3:02 P.M., the administrator said the dietary manager is responsible to ensure the dishes are stored in a manner that prevents contamination. He said the facility has a policy, and the staff are trained on the policy. The administrator said it is expected plates, bowls, and silver/plastic ware are stored inverted and protected. 45564

43327 Based on observation, interview, and record review, the facility staff failed to maintain a clean blood glucose meter (device used to obtain a blood sugar reading) between two residents (Resident #49 and #195) and failed to use hand hygiene, change gloves, and wiped multiple times with the same area of a wipe/gauze during perineal care and wound care in a manner to reduce the risk of infection for one resident (Resident #23). Additionally, staff failed to ensure all employees were screened for Tuberculosis (TB), a potentially serious infectious bacterial disease that mainly affects the lungs), when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) was completed and documented as per the facility policy for ten out of ten sampled employees (Dietary Aide (DA) G, Certified Nurse Assistant (CNA) H, CNA I, Activities Director, CNA J, Activity Aide (AA) K, DA L, Maintenance Director, Licensed Practical Nurse (LPN) M, and DA N). Facility staff failed to follow infection control protocols, for Coronavirus Disease 2019 (COVID-19), when staff failed to wear facemasks that covered the nose and mouth, failed to implement an infection surveillance program that included tracking of organisms responsible for infections, and failed to review their Infection Prevention and Control Program (IPCP) on an annual basis. The facility census was 82. 1. Review of the Centers for Disease Control and Prevention (CDC) Infection Prevention during Blood Glucose Monitoring and Insulin Administration dated 2/6/13 provided by the facility, showed: -Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared; -An underappreciated risk of blood glucose testing is the opportunity for exposure to blood borne viruses through contaminated equipment and supplies if devices used for testing are shared; -Unsafe practices during assisted monitoring of blood glucose that have contributed to transmission of virus's or have put persons at risk for infection include using a blood glucose meter for more than one person without cleaning and disinfecting it between uses. Review of the facility's Sanitizing Multi-Use Equipment and Surface Area's policy, undated showed: -Sani-cloth (purple top) multi-purpose cleaner and sanitizer will be used for sanitizing multi-use equipment and surface areas; -Sani-cloth will be used per instructions on the packaging; -Sani-cloth is effective on all surface areas, and may be used on equipment including but not limited to lifts, gait belts, tables, medication carts, etc. Review of the G2 glucometer manual, dated 2017, showed: -Cleaning and disinfecting your meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface; -Inspect for blood, debris, dust, or lint anywhere on the meter or lancing device; -To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port; -Do not use glass or household cleaners on the meter or the lancing device; -Wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use; -Wipe meter dry or allow to air dry. Review of the Sani-cloth General Guidelines for Use, dated 2022, showed: -Use a wipe to remove visible soil prior to disinfecting; -Unfold a clean wipe and thoroughly wet surface; -Allow treated surface to remain wet for two minutes and let air dry. Observation on 3/7/23 at 7:56 A.M., showed Certified Medication Technician (CMT) F took the blood glucose meter, finger stick device, and alcohol pad into Resident #49's room and placed them on the resident's over bed table. He/She washed his/her hands and placed the glucose meter on the resident's lap. He/She obtained the blood sample and returned the meter to the resident's lap while he/she cleaned the resident's finger of residual blood. The CMT placed the glucose meter on top of the sink in the resident's room, washed his/her hands, placed the glucose meter on top of the medication cart and did not clean the glucose meter. Observation on 3/7/23 at 8:31 A.M., showed CMT F took the same glucose meter from the top of the medication cart, a finger stick device, and alcohol pad into Resident #195's room and placed them on the resident's over bed table. He/She washed his/her hands and placed the glucose meter on the resident's bed. The CMT obtained the blood sample, then placed the blood glucose meter on the over bed table. He/She washed his/her hands, placed the meter on top of the medication cart and did not clean the glucometer. During an interview on 3/7/23 at 9:06 A.M., CMT F said he/she should wipe the meter down with a disinfecting wipe then let it set in the wipe for 30 seconds. He/She said the meter should air dry before using on another resident to decrease risk of infections and he/she was nervous. During an interview on 3/9/23 at 9:14 A.M., CMT B said staff are encouraged to use two glucometers, one to use and one to air dry. He/She said staff are directed to use a disinfecting wipe on the blood glucose meters when finished obtaining a reading and before taking another from a different resident. CMT B said if staff does not clean the blood glucose meters, there is a risk of spreading infection. During an interview on 3/9/23 at 9:51 A.M., the Minimum Data Set (MDS) nurse said glucometers (blood glucose meters) should be cleansed after each resident and before the next resident using a disinfectant wipe and air dry for at least one minute. He/She said failure to clean the glucometer could result in spreading of germs. During an interview on 3/9/23 at 10:24 A.M., LPN C said glucometer's should be cleaned between residents using a disinfectant wipe and air dried at least 30 seconds, then wipe it with a dry cloth. He/She said it would be better if staff would use two meters, one to use and one to air dry. During an interview on 3/9/23 at 11:03 A.M., the Director of Nursing (DON) said glucometer's should be cleansed between residents by the person checking the blood. He/She said disinfectant wipes should be used and the meter air dried before using or risk the spread of infection or germs. 2. Review of the facility's Infection Control and Prevention policy, undated showed: -Observe standard precautions; -Wash hands before and after procedures; -Wash hands before and after resident contact; -Maintain sterility or cleanliness of equipment and working field as necessary; -Wash hands before and after resident contact (i.e. meds, treatments, care) and whenever visibly soiled; -Wash hands or perform hand hygiene after gloves are removed. Review of the facility's Infection Prevention and Control Program, dated August 2021, showed: -Staff must provide hand hygiene before and after contact with resident; -Before performing an aseptic task; -After contact with blood, bodily fluids, visibly contaminated surfaces or after contact with objects in the resident's room; -After removing personal protective equipment (PPE) (e.g. gloves, gown, facemask); -Gloves are to be worn before and after contact with blood or body fluid, mucous membranes, or non-intact skin; -Gloves are to be changed and hand hygiene performed before moving from a contaminated-body site to a clean-body site during resident care; -Gloves are to be discarded followed by hand hygiene before leaving a resident's room. Review of the facility's Handwashing/Perineal Care/Incontinent Care in-service training, dated December 2022, showed: -Wash hands, apply gloves and follow standard precautions; -Wash genital area, moving front to back, while using a clean area of the washcloth for each stroke; -Using a clean washcloth, rinse soap from genital area, moving from front to back, using a clean area of the cloth for each stroke; -Do not touch any clean linen with soiled gloves; -Remove gloves and wash hands. Review of the facility's Pericare policy, dated January 2017, showed: -Wipe the genital area from front to back, rotating disposable wipe between each wipe; -Remove gloves and wash hands; -Wipe the rectal area from front to back, rotating disposable wipe between each wipe; -Remove gloves, wash hands, reapply gloves; -Apply barrier cream and assist to comfortable position; -Remove gloves and wash hands. Review of the facility's Prevention of wounds and wound care policy, dated November 2019, showed it did not contain direction for wound care or wound care protocol. Observation on 3/6/23 at 8:11 A.M., showed CNA O and CMT F entered Resident #23's room to provide care. CNA O did not perform hand hygiene or change his/her gloves after he/she transferred the resident to bed with a mechanical lift or before he/she provided perineal care. He/She did not change the position of the wipe with each swipe when he/she cleaned around the resident's buttock dressing. With the same gloves, CNA O rolled the resident to his/her back, grabbed a foam wedge cushion, and handed it to CMT F who placed it behind the resident's back, placed a pillow on the opposite side of the resident, cleaned the resident's inner thighs and genitals and did not use a clean area of the wipe for each stroke. CNA O hooked the catheter to the bed and lowered the bed to the floor. CNA O and CMT F removed their gloves. CMT F gathered the soiled linens and trash and left the room and did not wash his/her hands. During an interview on 3/6/23 at 8:22 A.M., CNA O said he/she should have washed his/her hands after putting the resident to bed, when taking his/her gloves off, and after perineal care. He/She said he/she did not think about it and was taught when providing perineal care to rub the same area multiple times with a wipe. Observation on 3/6/23 at 8:53 A.M., showed LPN M and CNA O entered the room to provide wound care on Resident #23. LPN M did not wash his/her hands before he/she applied gloves. He/She removed the dressing from the resident's left toe, left inner ankle, and right shin, discarded the old dressings, removed his/her gloves and applied new gloves and did not perform hand hygiene between glove changes. He/She cleansed the right shin with wound cleanser and gauze pad, discarded the gauze pad. The LPN cleansed the left toe and left inner ankle with the same gauze pad. The LPN did not change his/her gloves after he/she provided wound care or before he/she applied the new dressings to the left toe, left inner ankle and right shin. He/She removed his/her gloves gathered the trash and left the room for more supplies and did not perform hand hygiene. The MDS nurse and LPN entered the room and did not wash their hands before they applied gloves. LPN M placed the supplies at the foot of the bed while CNA O and the MDS nurse positioned the resident exposing the right hip. LPN M removed the right hip dressing, removed his/her gloves and applied new gloves and did not perform hand hygiene between glove changes. He/She cleansed the wound with the same area on and inside the wound. He/She did not change his/her gloves or perform hand hygiene before he/she applied a new hip dressing. LPN M sprayed wound cleanser directly into the coccyx (tailbone) wound and patted dry with a gauze pad multiple times with the same area of the gauze pad, removed his/her gloves and applied new gloves and did not perform hand hygiene. He/She applied the dressing to the wound, removed his/her gloves, and took leftover supplies to the treatment cart outside the resident room and did not perform hand hygiene. CNA O positioned the resident and lowered the bed to the floor. During an interview on 3/6/23 at 8:51 A.M., LPN M said staff are directed to change gloves and wash hands from dirty to clean areas, between glove changes and before and after care is given. He/She said they were trying to hurry due to the resident has history of restlessness and agitation when he/she is messed with much. During an interview on 3/9/23 at 11:03 A.M., the DON said staff are directed to wash their hand between glove changes, before and after care of the resident, between clean and dirty tasks. 3. Review of the facility's policy Purified Protein Derivative (PPD-used in a skin test to help diagnose tuberculosis infection in persons at increased risk of developing active disease) Administration-Employees, dated December 18, 2015, showed the following: - When an employee accepts a position with the facility they must be brought to a licensed Clinical Manager or the Clinical Manager Coordinator to have a tuberculosis (TB) test administered. This is step 1 of Tuberculin Skin Test (TST). The employee must have the results read within 48-72 hours of receiving the TB test. The employee may not work until 1st step has been completed. Within 1-3 weeks of employee receiving the 1st step TST, a 2nd step TST must be completed and read within 48-72 hours. Current employees who have a step 2 on file will receive the annual TST in January. Review of DA G's employee file showed the following: - Hire date of 1/13/20; - Staff did not document they administered any PPD. Review of CNA H's employee file showed the following: - Hire date of 7/21/22; - Staff did not document they administered any PPD. Review of CNA I's employee file showed the following: - Hire date of 9/16/21; - Staff did not document they administered any PPD. Review of the Activity Director's employee file showed the following: - Hire date of 5/20/21; - Staff did not document they administered any PPD. Review of CNA J's employee file showed the following: - Hire date of 5/5/22; -Staff did not document they administered any PPD. Review of AA K's employee file showed the following: - Hire date of 8/17/22; -Staff did not document they administered any PPD. Review of DA L's employee file showed the following: - Hire date of 12/2/22; -Staff did not document they administered any PPD. Review of the Maintenance Director employee file showed the following: - Hire date of 9/27/22; -Staff did not document they administered any PPD. Review of LPN M's employee file showed the following: - Hire date of 12/31/22; -Staff did not document they administered any PPD. Review of DA N's employee file showed the following: - Hire date of 3/24/22; -Staff did not document they administered any PPD. During an interview on 3/9/22 at 10:00 A.M., the Medical Records Director said he/she was aware of the requirement for employee testing, but did not know where the results were for testing prior to their employment. During an interview on 3/9/22 at 10:15 A.M., the administrator said a past employee that was responsible for the documentation of employee testing misplaced the records. The administrator added that he/she was aware of the requirement to test new employees in a timely manner. 4. Record review of the CDC website, updated 09/23/2022, showed the following: -When SARS-CoV-2 Community Transmission levels are high, source control (use of well-fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing) is recommended for everyone in a healthcare setting when they are in areas of the healthcare facility where they could encounter patients. Review of the facility's Infection Prevention and Control Program, dated August 2021, showed when not experiencing an outbreak, it's recommended for all staff and visitors to wear surgical masks or equivalent when in areas of the facility when in resident contact. Further review showed the policy did not direct staff on how to wear the facemask. Review of the facility's community transmission level showed the level was high. Observation on 3/5/23 at 9:30 A.M., showed Nurse Aide (NA) D answered the front door, walked past residents in the hall, resident rooms that had the door open, and to the dining area with his/her mask off. Observation on 3/5/23 at 9:36 A.M., showed the Assistant Director of Nursing (ADON)'s face mask did not cover his/her nose during medication administration to an unknown resident. Observation on 3/5/23 at 11:17 A.M., showed CNA A entered Resident #45's room to provide care to the resident with his/her mask under his/her nose. Observation on 3/5/23 at 11:49 A.M., showed NA D wheeled an unidentified resident to the dining room and his/her mask did not cover their nose. Observation on 3/5/23 at 12:07 A.M., showed CNA A entered the dining room and sat down with two residents with his/her mask under his/her nose. Observation showed the CNA A pull the mask below his/her the chin to talk to Resident #23 within a 6 foot distance, then put the mask up below the nose. Observation on 3/5/23 at 12:16 P.M., showed CNA A pull his/her mask down below his/her chin to talk to another staff member while he/she fed a resident. He/She returned the mask over the his/her mouth, but under the nose. Observation on 3/5/23 at 1:49 P.M., showed Housekeeper P enter resident room [ROOM NUMBER] with his/her mask under his/her nose. Observation on 3/6/23 at 12:14 P.M., showed the DON sat with Resident #56 at the dining room table. The DON pulled down the facemask under his/her chin to talk to resident. Observation on 3/9/23 at 8:18 A.M., showed CNA A sat at the dining room table with his/her mask under his/her nose and chin while he/she fed an unidentified resident. Observation on 3/9/23 at 10:22 A.M., showed CNA A in Resident #45's room with his/her mask under his/her chin to provide care. During an interview on 3/9/23 at 8:30 A.M., CNA A said staff should always wear a mask. He/She said occasionally they need to pull the mask down because they have difficulty breathing. CNA A said it is policy, so we need to wear them to decrease spread of bacteria and germs. During an interview on 3/9/23 at 9:14 A.M., CMT B said staff should always keep a mask on so disease is not spread from one person to another and should cover the nose and mouth. During an interview on 3/9/23 at 10:24 A.M., LPN C said all staff should be wearing a surgical mask unless the facility is in outbreak for COVID-19, then an N95 mask or respirator is required. He/She said the mask should cover the nose and mouth to decrease risk of spreading germs and bacteria to other residents, staff and/or visitors. During an interview on 3/9/23 at 11:03 A.M., the DON said staff are to wear surgical masks at all times except when on break. He/She said the masks should cover the nose and mouth to decrease spread of bacteria. 5. Review of the facility's Infection Prevention and Control Program, revised 8/18/21, showed: -The facility will maintain an infection prevention and control program in order to maintain a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections; -The infection prevention and control program follows national standards and guidelines and contains a system for preventing, identifying, reporting, investigating and controlling infections and communicable diseases for all residents, staff and visitors; -Data analysis, documentation, and reporting: The facility will gather and analyze data to properly identify communicable diseases or infections to reduce/eliminate the spread of communicable diseases/infections; -The facility will conduct an annual review of its IPCP and update their program, as necessary, in order to ensure effectiveness and that they are in accordance with current standards of practice for preventing and controlling infections; -The facility did not document they updated the IPCP on an annual basis. During an interview on 3/08/23 at 10:28 A.M., the Infection Preventionist (IP) said he/she started as the IP in January and kept track of infection types, but did not track bacterial sources of infections. The IP said infection related lab reports were faxed to the doctor and placed in the residents' records and he/she did not always see them. The IP also said he/she did not receive monthly lab reports summarizing bacteria types in the facility. The IP did not know how many residents in the facility had active infections. During an interview on 3/08/23 at 9:55 A.M., the DON said the IP is responsible for ensuring the Infection Prevention and Control Program meets standards and is reviewed when required. During an interview on 3/09/23 at 8:55 A.M., the Administrator said the IP should be tracking bacteria types and sources within the facility. He/She also said the IP is responsible for tracking antibiotic use. 45564

Based on observation, interview and record review, facility staff failed to maintain resident dignity, when staff failed to cover two residents' (Resident #23 and #36) catheter drainage bags (bag that collects urine from the bladder), failed to assist one resident (Resident #39) with dressing in a timely manner resulting in the resident sitting in his/her doorway without clothing on, posted resident care data on the closet doors in view of the hallway for one resident (Resident #37), and staff used the over-head paging system to ask staff to come to the dining room to assist the feeders. The facility census was 82. 1. Review of the facility's Resident Rights policy, dated January 2017, showed: -The facility protects and promotes the rights of each resident in order to provide a dignified life; -The right to be treated with dignity and respect; -The right to personal privacy and confidentiality of his/her personal and medical records. Review of the facility's Abuse Policy and Procedures, dated December 2018, showed: -Each resident has the right to privacy and confidentiality for all aspects of care and services; -Each resident must be provided individualized care with dignity and respect. 2. Review of the facility's Catheter Care policy, dated August 2017, showed it did not contain direction to maintain resident dignity or drainage bag placement on the wheelchair. 3. Review of Resident #23's Significant Change Minimum Date Set (MDS), a federally mandated assessment tool, dated 1/23/23, showed staff assessed the resident as: -Cognitively impaired; -Has an indwelling catheter (tube that drains the bladder). Observation on 3/5/23 at 11:58 A.M., showed the resident sat in the dining room in a reclining wheelchair. Further observation showed his/her catheter urine collection bag hung on the wheelchair uncovered with urine visible to the residents, staff, and visitors in the dining room. 4. Review of Resident #36's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Did not have an indwelling catheter. Observation on 03/6/23 7:50 A.M., showed the resident sat in a reclining wheelchair in the television area. Further observation showed he/she had a catheter drainage bag that hung on the wheelchair with urine visible. Observation on 3/6/23 at 11:25 A.M., showed the resident in a reclining wheelchair in the television area. Further observation showed his/her catheter drainage bag hung on the wheelchair with urine visible. 5. During an interview 3/9/23 at 8:14 A.M, Nurse Aide (NA) E said he/she is not sure what the facility policy is regarding catheter positioning. During an interview on 3/9/23 at 8:30 A.M., Certified Nurse Assistant (CNA) A said catheters should be covered to hide the urine because it is not dignified. During an interview on 3/9/23 at 9:14 A.M., Certified Medication Technician (CMT) B said catheter drainage bags should always be covered when the resident is in the bed and in the wheelchair. He/She said the facility has dignity bags to put the catheters in and not sure why Resident #23 or #36 did not have one in use. He/She said if the catheter bags are not covered then other residents could see the urine and point it out to others. During an interview on 3/9/23 at 11:03 A.M., the Director of Nursing (DON) said catheter drainage bags should be kept in dignity bags to keep the urine covered. He/She said dignity bags over the catheter bags will help maintain the resident's dignity. During an interview on 3/15/23 at 11:08 A.M., the Administrator said catheter drainage bags should be kept in dignity bags to help maintain the resident's dignity. 6. Review of Resident #39's annual MDS, dated [DATE] showed staff assessed the resident as follows: -Required limited assistance from one person with dressing; -Required extensive assistance from one person with mobility, transfers, toileting and personal hygiene; -Impairment one side lower extremity; -Used a wheelchair. Observation on 3/7/23 at 8:28 A.M., showed the resident initiated their call light at 8:06 A.M Further observation showed the resident sat in a wheelchair in the doorway of his/her room without his/her pants on and held their pants in their hand. During an interview on 3/7/23 at 8:30 A.M., the resident said he/she just needed help getting his/her pants on after using the restroom and nobody had come to help. 7. Observation on 3/7/23 at 10:56 AM showed Resident #37's undated Resident Care Status sheet posted on the exterior of the closet door visible to the hallway. Further observation showed the care sheet contained activity of daily living assistance needed, bladder and bowel status, cognition, diet, mobility devices, skin care, communication needs, and fall risk status. During an interview on 3/15/23 at 11:08 A.M., the Administrator said resident care sheets should not be located in view of the hallway and kept behind a closet door to maintain the resident's privacy. 8. Observation on 3/9/23 at 8:03 A.M., showed the facility staff announced on the over-head paging system for staff to come to the dining room to assist the feeders. During an interview on 3/15/23 at 11:08 A.M., the Administrator said staff should never refer to resident's as feeders. He/She said it is undignified. 45564

Based on interview and record review, facility staff failed to keep eight residents (Residents #7, #33, #35, #46, #193, #289, #290 and #291) from going into a negative balance, which allowed the residents to spend another resident's money without written authorization. The facility also failed to obtain written authorization before donating Resident #193's funds to MO Healthnet. The facility census was 82. 1. Review of the facility's policies showed staff did not provide a policy for managing the Resident Trust Account. 2. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 2/28/23 Resident #7's account had a negative balance of $-5.91. 3. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 2/28/23 Resident #33's account had a negative balance of $-11.13. 4. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 1/31/23 Resident #35's account had a negative balance of $-7.37. 5. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 8/31/22 Resident #46's account had a negative balance of $-28.55. 6. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed Resident #193's account had a negative balance on the following dates: -On 10/31/22 the balance was $-24.05; -On 08/31/22 the balance was $-24.03 7. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed Resident #289's account had a negative balance on the following dates: -On 2/28/23 the balance was $-998.00; -On 01/31/23 the balance was $-998.00; -On 12/31/22 the balance was $-998.00; -On 11/30/22 the balance was $-998.00; -On 10/31/22 the balance was $-998.00; -On 09/30/22 the balance was $-998.00; -On 08/31/22 the balance was $-499.00; -On 07/31/22 the balance was $-499.00; -On 06/30/22 the balance was $-499.00; -On 05/31/22 the balance was $-499.00; -On 04/30/22 the balance was $-499.00; -On 03/31/22 the balance was $-499.00. 8. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 10/31/22 Resident #290's account had a negative balance of $-42.80. 9. Review of the facility's maintained Trust Fund Balance Reports for the period 03/01/22 through 02/28/23, showed on 3/31/22 Resident #291's account had a negative balance of $-1,281.00. During an interview on 3/08/23 at 1:55 P.M., the Business Office Manager (BOM) said he/she managed the resident petty cash and posted payments. The BOM said he/she did not review bank statements or trust fund balance reports. During a teleconference on 3/08/23 at 2:05 P.M., the Corporate Controller, administrator and BOM all stated they were not not responsible for reviewing the monthly trust fund balance reports. None of the three could say who was responsible. 10. Review of the Resident Trust Fund Audit Report for the period 1/01/23 through 1/31/23 showed Resident #193 had $19,256.00 transferred to his/her trust account on 1/19/23 and a numbered facility check for $14,440.79 was disbursed on 1/20/23. During an interview on 3/09/23 at 9:22 A.M., the administrator said the resident got a large sum of money and it was supposed to be returned to Social Security. The administrator could not provide any more details. During an interview on 3/09/23 at 11:21 A.M., the BOM said the check for $14,440.79 listed as personal use in the audit report was a check sent to MO HealthNet to keep the resident from exceeding the Supplemental Security Income (SSI) resource limit. The BOM said corporate staff asked her to send the funds to MO HealthNet and he/she did not get authorization from the resident. During an interview on 3/09/23 at 2:42 P.M., the Corporate Controller (CC) said the resident had a Social Security back payment of approximately $40,000 but they should not have paid that much. The CC said the resident received about $19,000 after Social Security recouped overpayment and after paying bills. The CC also said he/she asked facility staff to voluntarily send the money to MO HealthNet and write on the check voluntary payment. During an interview on 3/09/23 at 3:28 P.M., the BOM said he/she did not believe the resident signed a written authorization to send funds to MO HealthNet. The BOM said he/she received an e-mail from the CC asking him/her to send funds to MO HealthNet and was never told he/she needed written authorization from the resident.

Based on interview and record review, the facility failed to provide notification when the resident's trust account reached $200 less than the Supplemental Security Income (SSI) resource limit of $5,301.85 for three residents (Residents #13, #49 and #292). The census was 82. 1. Review of the facility's policies showed staff did not provide a policy covering Medicaid resource limit. 2. Review of the Resident Trust Fund Balance Reports for the period of March 2022 through February 2023 showed Resident #13 had a trust fund balance in excess of the SSI threshold on the following dates: -On 2/28/23 the balance was $5,725.55; -On 1/31/23 the balance was $5,744.30; -On 12/31/22 the balance was $5,563.00; -On 11/30/22 the balance was $5,695.72; -On 10/31/22 the balance was $5,788.10; -On 9/30/22 the balance was $5,720.81; -On 8/31/22 the balance was $5,723.31; -On 7/31/22 the balance was $5,656.02; -On 6/30/22 the balance was $5,598.72; -On 5/31/22 the balance was $5,541.46; -On 4/30/22 the balance was $5,484.11. 3. Review of the Resident Trust Fund Balance Reports for the period of March 2022 through February 2023 showed Resident #49 had a trust fund balance in excess of the SSI threshold on the following dates: -On 2/28/23 the balance was $5,398.62; -On 1/31/23 the balance was $5,269.38; -On 12/31/22 the balance was $5,115.09; -On 11/30/22 the balance was $5,792.32; -On 10/31/22 the balance was $5,661.03. 4. Review of the Resident Trust Fund Balance Reports for the period of March 2022 through February 2023 showed Resident #292 had a trust fund balance in excess of the SSI threshold on the following dates: -On 9/30/22 the balance was $11,714.37; -On 8/31/22 the balance was $8,707.82; -On 7/31/22 the balance was $7,931.99; -On 6/30/22 the balance was $6,975.62; -On 5/31/22 the balance was $6,119.69; -On 4/30/22 the balance was $23,584.71; -On 3/31/22 the balance was $21,617.21; During an interview on 3/08/23 at 1:35 P.M., the Business Office Manager (BOM) said he/she handles resident petty cash and bill posting but corporate staff manages the resident trust fund. The BOM, said corporate staff sent letters to residents or their representatives when a resident was within 200 dollars of the SSI threshold. The BOM said he/she did not have any of the letters on file. During an interview on 3/08/23 at 2:05 P.M., the administrator said there should be copies of SSI resource limit letters on file in the business office.

Based on interview and record review the facility staff failed to maintain an approved surety bond sufficient to ensure protection of all resident funds. The facility census was 82. 1. Review of the facility's Resident Trust Surety Bond Policy, revised 4/7/17, showed: -The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the secretary to assure the security of all personal funds of residents deposited with the facility; -The facility will maintain a non-canceling escrow agreement which has been filed with and approved by the state to cover the amount of coverage needed for the trust account. Review of the Department of Health and Senior Services bond approved list showed a surety bond and escrow amounts that totaled $78,500. Review of facility's records showed trust fund security as follows: -Bond - $70,000 -Escrow with a current value of $1,062.59 -Escrow with a current value of $2,584.39 -Escrow with a current value of $5,259.14 -Total of current bond and escrow values showed the facility had security coverage totaling $78,906.12. Review of the resident trust account for March 2022 through [DATE], showed an average monthly balance of $ 70,945.65 which requires a surety bond of $106,500.00. The current trust fund ledger amount was $57,294.01. During an interview on on 3/08/23 at 1:35 P.M., the Business Office Manager (BOM) said the trust fund security bond is handled by corporate staff. During an interview on 3/08/23 at 2:05 P.M., the administrator said he/she was actively working with corporate staff to increase the amount of the resident trust fund bond.

Based on observation, interview, and record review, the facility staff failed to serve meals on plates with silverware to residents who received hall trays. The census was 82. 1. Review of the facility policies showed the facility did not have a policy regarding the use of plates and silverware for resident meals served as hall trays. Review of the resident meal tickets, showed 42 residents received their lunch meal as a hall tray. Observation on 3/5/23 at 11:30 A.M., showed dietary aide (DA) AA and DA BB prepare resident lunches for hall tray service. The DAs prepared the meals in disposable Styrofoam containers with plastic ware. The DA also provided drinks for resident lunches in disposable Styrofoam cups with plastic lids. Further observation showed the facility had forty plates and sufficient silverware and cups available for use for the hall tray service. During an interview on 3/8/23 at 2:19 P.M., the dietary manager (DM) said the facility has been using disposable containers, cups, and plastic ware for hall tray service since the beginning of the pandemic. She said the facility does not currently have any residents on precautions, and there is enough plates and silverware to use for the hall tray service. The DM said there is no reason why staff continue to use disposable containers and plastic ware for hall tray service. They should use the plates, cups, and silverware, because it makes the meal nicer and more homelike. During an interview on 3/8/23 at 3:02 P.M., the administrator said the DM is responsible to ensure the meals are served in an appropriate manner that is homelike. He said the facility does not currently have any resident on precautions, but the staff may continue to use the containers to keep the food warm during service. The administrator said it is preferred the residents are served meals with real plates, cups, and silverware.

Based on interview and record review, the facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for six sampled residents (Residents #1, #9, #21, #58, #80, and #193). The facility census was 86. 1. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI OBRA-required Assessment Summary showed assessment time frames as follows: -Entry MDS completion date no later than the 7th calendar day from the resident's entry into the facility and submitted no later than 14 days from the date of entry into the facility; -Admission (Comprehensive) MDS completion date no later than 14th calendar day of the resident's admission and submitted no later than 14 calendar days from the care plan completion date; -Quarterly (Non-Comprehensive) MDS completion date not later than ARD + 14 calendar days; -Quarterly assessment for a resident must be completed at least every 92 days following the previous OBRA assessment of any type; -Discharge Assessment for a resident must be completed no later than 14 days from the date of discharge and submitted by the MDS completion date plus 14 calendar days. -A significant change in status assessment (SCSA) is appropriate when there is a determination that significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent quarterly assessments and the resident's condition is not expected to return to baseline in two weeks; -A significant change is any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment and does not reflect normal fluctuations in that individual's functioning; -A significant change assessment must be completed within 14 days a determination has been made that a significant change in status has occurred and submitted within 14 days of the care plan completion date. Review of the facility's MDS policy, undated, showed: -The facility will, in accordance with state guidelines, complete MDS Assessments; -MDS Assessments will consist of admission comprehensive assessments with Care Area Assessments (CAA) areas, quarterly assessments, and annual assessments for long term residents; -All assessments will be completed on time, per guidelines; -All residents admitting to facility will have an admission assessment completed and all residents discharging from facility will have a discharge assessment submitted. 2. Review of Resident #1's closed medical record showed the resident admitted to the facility on [DATE] and discharged from the facility on 11/9/22. Review of the resident's MDS record dated 11/9/22 to 11/23/22 showed the record did not contain a completed or submitted discharge assessment within the required time frame. 3. Review of Resident #9's closed medical record showed the resident admitted to the facility on [DATE] and discharged from the facility on 11/21/22. Review of the resident's MDS record dated 11/21/22 to 12/5/23 showed the record did not contain a completed or submitted discharge assessment within the required time frame. 4. Review of Resident #21's closed medical record showed the resident admitted to the facility on [DATE] and discharged from the facility on 11/21/22. Review of the resident's MDS record dated 11/21/22 to 12/5/22 showed the record did not contain a completed or submitted discharge assessment within the required time frame. 5. Review of Resident #58's closed medical record showed the resident admitted to the facility on [DATE] and discharged from the facility on 10/25/22. Review of the resident's MDS record dated 10/25/22 to 11/8/22 showed the record did not contain a completed or submitted discharge assessment within the required time frame. 6. Review of Resident #80's closed medical record showed the resident: -admitted to the facility on [DATE] and discharged from the facility on 9/12/22 and; -admitted to the facility on [DATE] and discharged from the facility on 11/18/22. Review of the resident's MDS record dated 9/12/22 to 9/26/22 and 11/18/22 to 12/2/22 showed the record did not contain a completed or submitted discharge assessment within the required time frame for either stay at the facility. 7. Review of Resident #193's medical record showed the resident was discharged with return anticipated on 10/31/22. Further review showed the resident returned to the facility on [DATE]. Review of the resident's MDS record showed the record did not contain a completed or submitted entry tracking record within the required time frame. 8. During an interview on 3/9/23 at 9:51 A.M., the MDS nurse said he/she is responsible to complete MDS assessments and has been with the facility doing MDS since September of 2022. He/She said residents admitted to the facility should have an entry, admission and quarterly assessments completed and residents discharged from the facility should have a discharge assessment completed. He/She thought the discharge from Medicare assessment counted as the discharge from facility assessment and is still learning the position requirements. He/She will complete the assessments and submit them as required. During an interview on 3/9/23 at 11:03 A.M., the Director of Nursing (DON) said the MDS nurse is responsible to complete the MDS assessments timely and accurately. Since the MDS nurse is an LPN, the DON signs as completed. He/She was not aware of any late assessments.

Based on observation, interview, and record review, facility staff failed to provide care and services in a manner to meet professional standards of quality when staff did not document they assessed, monitored, or provided treatment for [REDACTED].#1) resulting in an infection. The facility census was 95. 1. Review of the facility's policy for Peripheral Intravenous (IV) Access, therapy and Maintenance, dated 9/6/18, showed: -Maintenance of IV site. Only competent and qualified personal may maintain IV access. -Maintenance of IV site will occur as directed by physician; -Monitor site every shift and as needed. Ensure area is not [MEDICAL CONDITION] (swollen with an excessive accumulation of fluid) or redden and warm to touch; -Redress if needed; -Document procedure in clinical record 2. Review of Resident #1's nursing notes, dated 4/26/19 at 8:11 P.M., showed staff documented the resident was admitted with a right upper chest [MEDICAL CONDITION]/plasma port with a clear dressing in place. Pressure bandage on the left upper anterior chest from central line. Review of the resident's plan of care, dated 6/13/19, showed staff identified the resident at risk for/actual skin breakdown. Review showed staff were directed to monitor the condition of each area of skin breakdown and to documented with every treatment and/or dressing change. Inspect skin by completion of head to toe assessment every week and document results, inspect skin daily with care and bathing, and report any changes to charge nurse. Review showed staff are to notify the physician of any worsening of skin breakdown and to complete treatments and dressings as ordered per physician. Additional review of the care plan showed it did not contain intervention for the resident's Hickman catheter. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument, dated 8/12/19, showed staff assessed the resident as: -Cognitive; -No Behavioral issues or rejection of care; -Required extensive assistance of two with transfers; -Total dependence of two for bed mobility and dressing; -Total dependence of one for eating, personal hygiene, and bathing; -Non-ambulatory; -Bowel and bladder incontinence; -At risk for pressure ulcers; -Surgical wound. Review of the resident's physician order [REDACTED]. Review ot the resident's Treatment Administration Record (TAR), dated from admission to Sepember 2019, did not contain documention staff provided care or treatment of [REDACTED]. Review ot the resident's Medication Administration Record(MAR) dated from admission to Sepember 2019, did not contain documention staff provided care or treatment of [REDACTED]. Review of resident's nurses notes, dated 9/28/19 at 7:30 [NAME]M., showed staff documented at 12:55 [NAME]M. a Certified Nursing Assistant (CNA) notified the nurse the resident had vomited. Review showed staff documented the resident had a temperature of 104.8, alert and oriented times two, having trouble getting words out. Review showed staff notified the physician who directed staff to send the resident to the emergency room . They send the resident by ambulance at approximately 1:20 [NAME]M. Review of the resident's hospital progress notes, dated 09/28/19, showed the primary [DIAGNOSES REDACTED]. Additional review of the progress note showed hospital staff assessed the following: -Sepsis likely from resident's Hickman catheter; -Poor management of the catheter and there is evidence of [MEDICAL CONDITION] discharge (fluid containing mucus and pus) around the insertion point; -Blood cultures have been drawn and antibiotics started; -Temperature was 105 degrees at the nursing home. During an interview on 10/3/19 at 3:20 P.M., the resident said he/she did have a clear dressing covering the Hickman catheter prior to his/her hospital admission. The resident's said the dressing had not been changed since April. The resident said he/she asked about it and was told they don't mess with these IVs here. The resident said he/she had noticed the area itching or feeling painful to touch prior to hospitalization , but didn't say anything. During an interview on 10/4/19 at 12:55 P.M., emergency room Register Nurse (RN) said the resident was admitted with a clear dressing, clearly dated 4/15/19. The RN said the area under the dressing was dirty and appeared infected. The RN said normal protocol is for the dressing to be changed weekly. During an interview on 10/3/19 at 3:38 P.M., the resident's physician/facility medical director said he/she did not know what the protocol was for monitoring and care of the Hickman catheter. The physician said said he/she believed it was a nursing function to determine monitoring and care of catheter. The physician said he/she had not been notified of any care or monitoring concerns. During an interview on 10/3/19 at 3:45 P.M., the Director of Nursing (DON) said she could not believe a dressing was on the resident for six months and not changed. The DON said she would have expected bath aides or nurses to have questioned it and brought it to their attention. The DON said she was not aware of a facility policy and procedure specifically for the care of a Hickman catheter as the facility does not have the RN coverage required to utilize the port, which the resident was not utilizing while at the facility. During an interview on 8/28/19 at 1:05 P.M., the Assistant Director of Nursing(ADON)/Infection specialist said he/she would expect the site to be monitored for signs of infection. He/She is not sure what protocol was on a Hickman catheter, but would expect the site to be assessed and documented during weekly nursing skin assessments, and would expect nursing staff to notify him/her or the DON if a dressing was clearly outdated for further evaluation. MO 335