Every finding on record at St Elizabeth Care Center

Based on observation, interview and record review, the facility staff failed to provide meals which were palatable, attractive and served at a safe and appetizing temperature. Facility staff also failed to maintain the internal temperatures of hot food items at 120 degrees Fahrenheit (F) or higher when served to residents. The facility census was 59.1. Review of the facility's Dietary Food Preparation policy, revised 07/05/23, showed: -The cook or Dietary Manager (DM) will taste food before serving;-Food will be served at the proper temperature to ensure food safety;-Acceptable serving temperature for hot foods including hot pureed foods is 135 degrees Fahrenheit (F) but preferably 160-175;-Each food item, served separately in the regular diet, is pureed and served separately for the pureed diet according to the pureed recipes. 2. Observation on 02/25/26 at 11:30 A.M., showed the 200 hall residents ate lunch in the 200-hall dining room. Observation showed multiple residents used mustard, sugar packets and individual sauce packets to season their food. Observation showed when staff cleared the resident tables after the residents were done eating multiple plates contained cauliflower and rice which was discarded in the trash. 3. Observation on 02/25/26 at 12:20 P.M., showed Resident #25 received his/her lunch tray with white rice, white cauliflower and white chicken on a white plate. The meal did not appear or smell appetizing. Observation at 12:35 P.M., showed the resident ate approximately 10% of his/her food, placed a napkin over the food and pushed his/her plate away. During an interview on 02/25/26 at 12:35 P.M., the resident said he/she did not eat much, because the food did not taste good and did not have flavor. 4. Observation on 02/25/26 at 12:25 P.M., showed Resident #3 brought four containers of personal seasoning from his/her room and sat them on the dining room table. The resident received a white plate, with white rice, white chicken and white cauliflower. The resident's meal did not appear or smell appetizing. During an interview on 02/25/26 at 12:25 P.M., the resident said he/she brings his/her personal sauces and seasoning because the staff makes the food plain and bland. He/She said he/she uses his/her own seasonings so he/she can taste the food. Observation on 02/25/26 at 12:33 PM, showed the resident lifted his/her white plate with white chicken, white rice, and white cauliflower, and pointed to his/her seasonings and said this is why he/she needs the seasonings. 5. Observation on 02/25/26 at 12:28 P.M., showed Resident #49 received his/her lunch tray. All the items on the plate as well as the plate were white. The meal did not appear or smell appetizing. At 12:42 P.M. the resident asked an unknown staff member for seasoning. The unknown staff went to Resident #3 and asked if Resident #49 could use some of his/her personal seasonings. During an interview on 02/25/26 at 2:52 P.M., the resident said he/she has to ask resident #3 for his/her seasoning for his/her food, because the food does not have flavor. 6. During an interview on 02/25/26 at 1:41 P.M., Resident #1 said the food is bland and he/she needs to buy his/her own seasonings to make it taste good. During an interview on 02/25/26 at 3:32 P.M., Resident #43 said the food is not good and is very bland with no seasonings. During an interview on 02/26/26 at 9:07 A.M., Resident # 18 said the quality of the food is not good. The resident said the food does not have flavor and some of it does not even look edible. During an interview on 02/26/26 at 9:20 A.M., Resident #9 said the flavor of the food is gross. 7. During an interview on 02/25/26 at 12:25 P.M., [NAME] G said he/she prepared the rice and cauliflower, but he/she did not season the food according to the recipes. [NAME] G said he/she knew where the recipes were located but he/she did not follow them. [NAME] G said he/she did not taste the food but did not say why. 8. Observation on 02/25/26 at 12:35 P.M., showed the DM prepared pureed chicken, rice and cauliflower for one resident. Observation showed the temperature of the pureed chicken was 106 degrees F and the pureed cauliflower was 114 degrees F as the items were placed on a service cart and about to be served to the resident. 9. During an interview on 02/26/26 at 9:20 A.M., Resident #9 said he/she always eats in his/her room and the food is always cold.Observation on 02/26/26 at 11:27 A.M., showed Resident #9 received his/her lunch tray in his/her room. Observation showed the temperature of the resident's pork chop was 95.7 degrees F and the green beans were 108.9 degrees F.10. Observation on 02/26/26 at 11:16 A.M., showed Resident #15 received his/her lunch tray in the dining room. Observation showed the temperature of the resident's pork chop was 99.2 degrees F.11. During an interview on 02/26/26 at 9:07 A.M., Resident #18 said his/her food is usallay not hot when staff gets it to his/her room.Observation on 02/26/26 at 11:30 A.M., showed the resident received his/her lunch tray in his/her room. Observation showed the temperature of the pork chop was 95.7 degrees F and the green beans were 109 degrees F.12. During an interview on 02/27/26 at 9:33 A.M., the DM said he/she expected staff to follow the recipes. The DM said he/she had not been keeping up with training and monitoring new staff. The DM said he/she did not know staff were not following the recipes. The DM said he/she knew the residents requested additional sauces and seasonings but did not think about it. The DM said he/she did not taste the food. The DM said pureed items should be reheated to 165 degrees F or according to the recipe. The DM said hot food should be served at 120 degrees F or higher.During an interview on 02/27/2026 at 1:23 P.M., the administrator said the DM and kitchen staff were responsible for following standard recipes. The administrator said he/she did not know kitchen staff were not following the recipes. The administrator said he/she was not aware of how many residents did not like the food.

Based on observation, interview and record review, facility staff failed to clean and maintain equipment in a manner to prevent potential contamination. Facility staff failed to store food in a manner to prevent potential contamination and outdated use. Facility staff failed to maintain and serve food items at temperatures adequate to prevent food borne illness. Facility staff failed to maintain an ice machine air gap. These failures have the potential to affect all residents. The facility census was 59.1. Review of the facility's policy titled Dietary - Equipment Operations, Infection Control and Sanitation, revised 02/02/24, showed staff were directed to: -Place food waste in covered garbage and trash cans;-Wash and sanitize the meat slicer blade and all parts after each use;-Thoroughly wash walls and ceilings at least twice a year. Observation on 02/25/26 at 9:00 A.M., during the initial kitchen tour showed: -Two trash cans in the kitchen were uncovered and were not in use;-A scoop stored in flour, which was in a large, covered bin;-The back side of the meat slicer contained an accumulation of grease and small pieces of meat;-The dry goods storage area contained a large bin of breadcrumbs which was not dated;-The area behind the ice machine contained a large amount of black material. Observations on 02/25/26 at 11:30 A.M. and 12:20 P.M., showed two trash cans in the kitchen were uncovered and were not in use. During an interview on 02/27/2026 at 9:33 A.M., the Dietary Manager (DM) said he/she was responsible for kitchen cleanliness and food storage. The DM said trash cans should be covered when not in use. The DM said scoops should not be stored in bins and foods in bulk bins should be dated. The DM said he/she never really looked behind the ice machine and he/she did not know who was responsible to do so. The DM said he/she was responsible for the meat slicer since he/she is the only one who used it. 2. Review ow the facility's Dietary Food Preparation policy, revised 07/05/23, showed: -Standardized recipes will be used for all products prepared. The DM will monitor and check routinely the cook's use of recipes;-Food will be served at the proper temperature to ensure food safety;-Acceptable serving temperatures for hot foods including hot pureed foods is 135 degrees Fahrenheit (F) but preferably 160-175;-Each food item, served separately in the regular diet, is pureed and served separately for the pureed diet according to the pureed recipes. Observation on 02/25/26 at 12:35 P.M., showed the DM prepared pureed chicken in a food processor and placed an unmeasured portion on a divided plate. The DM washed the food processor and prepared pureed rice and added an unmeasured portion to the divided plate with the chicken. The DM washed the food processor and prepared pureed cauli flower and added an unmeasured portion to the divided plate with the chicken and rice. Observation showed the divided plate was placed in a warming cabinet after each item was prepared. Observation showed the DM did not reheat the three items after they were pureed. Observation showed the temperature of the pureed chicken was 106 degrees F and the pureed cauliflower was 114 degrees F as the items were placed on a service cart and about to be served to the resident. During an interview on 02/25/26 at 12:35 P.M., the DM said he/she prepared the pureed items for Resident #8 because the original items were too thin. The DM said he/she did not reheat the pureed items or check the temperature and did not measure the portions before placing the items on the plate. The DM said pureed items should be reheated to 165 degrees F or according to the recipe. The DM said he/she was in a hurry to get the resident's food back to him/her. The DM said all hot food should be served at 120 degrees F or higher. 3. Observation on 02/26/26 at 11:16 A.M., showed Resident #15 received his/her lunch tray in the dining room. At time of service the temperature of the resident's pork chop was 99.2 degrees F. 4. During an interview on 02/26/26 at 9:20 A.M., Resident #9 said he/she always eats in his/her room and the food is always cold. Observation on 02/26/26 at 11:27 A.M., showed the resident received his/her lunch tray in his/her room. At time of service the temperature of the resident's pork chop was 95.7 degrees F and the temperature of the green beans was 108.9 degrees F. 5. During an interview on 02/26/26 at 9:07 A.M., Resident #18 said his/her food is usually not hot when staff gets it to his/her room.Observation on 02/26/26 at 11:30 A.M., showed Resident #18 received his/her lunch tray in his/her room. At time of service the temperature of the resident's pork chop was 95.7 degrees F and the temperature of the green beans was 109 degrees F. During an interview on 02/27/2026 at 9:33 A.M., the Dietary Manager (DM) hot food should be served at above 120 degrees F. The DM said he/she did not know food was being served cold since he/she had not done random tray checks in a while. 6. Review of the facility's policy titled Dietary - Equipment Operations, Infection Control and Sanitation, revised 02/02/24, showed the policy did not contain guidance related to ice machine air gaps. Observation on 02/26/26 during the Life Safety Code tour showed the ice machine contained a small drain covered by a dried washcloth. Observation showed when the maintenance director removed the washcloth the ice machine drain led to a larger white plastic drain and did not contain an air gap. Observation showed the larger drain contained a large accumulation of black and brown slimy material. Observation showed the floor at the rear of the ice machine contained a dish bin and a sump pump type device. Observation showed the floor, the bin and the pump contained large amounts of a black substance. During an interview on 02/26/26 at 9:10 A.M., the maintenance director said he/she was not sure what an air gap was and did not know the ice machine drain required an air gap. The maintenance director said the rag was placed over the ice machine drain about three months ago when a contracted plumber used pressurized water to clean a drain which is connected to the ice machine drain. The maintenance director said he/she did not routinely inspect behind the ice machine, so he/she did not know about the accumulation of black material. During an interview on 02/27/2026 at 1:23 P.M., the administrator said the DM and kitchen staff are responsible for ensuring the kitchen is kept clean, trash cans are covered, and food is served at proper temperatures. The administrator said the maintenance director is responsible for the area behind the ice machine. The administrator said he/she did not know about the ice machine drain air gap requirement. The administrator said he/she did not know of any kitchen issues.

Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease, a serious type of pneumonia caused by Legionella bacteria. Facility staffs' failure to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. The facility census was 59 with a capacity of 63. 1. Review of the Centers for Medicare and Medicaid Services (CMS), QSO-17-30, dated 06/02/17 and revised 07/06/18, showed: -CMS expects Medicare and Medicare/Medicaid certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems;-Facilities must have water management plans and documentation that, at a minimum, ensure each facility:--Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system;--Develops and implements a water management program that considers the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) industry standard and the CDC toolkit;--Specifies testing protocols and acceptable ranges for control measures and document the results of testing and corrective actions taken when control limits are not maintained;--Maintains compliance with other applicable Federal, State and local requirements;--Note: CMS does not require water cultures for Legionella or other opportunistic water borne pathogens. Testing protocols are at the discretion of the provider. Review of the facility's Water Management Plan, undated, showed the documentation did not contain: -A facility specific risk assessment;-Control measures related to identified risk areas;-Corrective actions to take if control measures are not within specified ranges;-Documentation of ten annual water samples completed during water system testing. Review of the facility's Legionella sampling plan showed testing of the building's hot and cold-water distribution systems must be performed at least annually. Review showed water samples from at least five outlets on the hot water system and at least five outlets on the cold-water system should be taken for each annual testing cycle. Review of the facility's inspection, testing and maintenance records for the period of February 2025 through February 2026 showed the records contained a single Legionella test which was performed by the maintenance director on 01/09/26. 2. Observation on 02/26/26 during the Life Safety Code tour showed the ice machine contained a small drain covered by a dried washcloth. Observation showed when the maintenance director removed the washcloth the ice machine drain led to a larger white plastic drain and did not contain an air gap. Observation showed the larger drain contained a large accumulation of black and brown slimy material. Observation showed the floor at the rear of the ice machine contained a dish bin and a sump pump type device. Observation showed the floor, the bin and the pump contained large amounts of a black substance. During an interview on 02/26/26 at 9:10 A.M., the maintenance director said he/she was not sure what an air gap was and did not know the ice machine drain required an air gap. The maintenance director said he/she did not routinely inspect behind the ice machine, so he/she did not know about the accumulation of black material. During an interview on 02/27/2026 at 11:29 A.M., the maintenance director said he/she is familiar with the water management plan. The maintenance director said he/she is part of the water management team but there are not any formal team meetings. The maintenance director said he/she was not familiar with a facility specific risk assessment, but facility risk areas would probably include hot water storage tanks, water lines not in regular use and the tub on the 200 hall since the water is turned off. The maintenance director said he/she did not perform any routine water flushes or system checks. The maintenance director said corporate staff had a water test kit sent to the facility and he/she tested on e water sample by dipstick. During an interview on 02/27/2026 at 1:23 P.M., the administrator said the maintenance director is responsible for the water management plan. The administrator said the facility's water management plan is written by corporate staff and was received by the facility this week. The administrator said he/she should be familiar with the plan, but he/she is not. The administrator said he/she thought facility risk areas would include the ice machine. The administrator send he/she knew the maintenance director completed one water sample in January. The administrator said he/she did not know the water plan directed staff to test ten water samples since corporate staff wrote the plan and sent the sample testing materials.

Based on interview and record review, facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment instrument) when staff did not accurately code Section F for activities of interest, for eight residents (Residents #1, #4, #9, #18, #34, #41, #43, and #44) of 41 sampled residents. The facility census was 59. 1. Review of the facility's MDS 3.0 Care Assessment Summary and Individualized Care Plans policy, dated 11/06/23, showed the MDS 3.0 Section F is to be completed by the Activity Director which allows the resident to determine his or her own preferences for daily activities. 2. Review of Resident #1's Annual MDS, dated [DATE], showed staff documented the resident as cognitively intact. Review showed staff completed section F of the resident's assessment and documented no response or non-responsive to all interview questions.Review of the resident's Activity Interest Survey, dated 01/05/2025, showed staff documented the resident's activities of interest as shopping, coloring, crafts, smoking, reading, socials, going out to eat, going to the movie theater, parties, cook outs, and scenic drives. 3. Review of Resident #4's Annual MDS, dated [DATE], showed staff documented the resident as cognitively intact. Review showed staff completed section F of the resident's assessment and documented no response or non-responsive to all interview questions.Review of the resident's Activity Interest Survey, dated 07/07/25, showed staff documented the resident's activities of interest as music, shopping, dance, exercise, manicures, socials, going out to eat, walking, going to movie theater, concerts, and going on scenic drives.4. Review of Resident #9's Annual MDS, dated [DATE], showed staff documented the resident as cognitively intact. Review showed staff completed section F of the resident's assessment and documented no response or non-responsive to all interview questions.Review of the resident's Activity Interest Survey, dated 10/31/25, showed staff documented the resident's activities of interest as sports, watching comedy and horror movies, smoking, rock and roll music, attending social events and going on scenic drives. 5. Review of Resident #18's Annual MDS, dated [DATE], showed staff did not document an interview for activities of interest, due to resident rarely understood. Review of the resident's Activity Interest Survey, dated 04/22/25, showed staff documented the resident's activities of interest as baseball, football, cannabis, rock and roll music, action and comedy movies, magazine, social events, going out to eat, walking, going to movie theater, parties, bar-b-q cook outs, arts and culture outings, and scenic drives. During an interview on 02/27/26 at 2:48 P.M., the Social Services Designee (SSD) said the resident is interviewable. The SSD said the MDS Coordinator documented the resident as not interviewable. 6. Review of Resident #34's Annual MDS, dated [DATE], showed staff documented the resident as cognitively intact. Review showed staff completed section F of the resident's assessment and documented no response or non-responsive to all interview questions.Review of the resident's Activity Interest Survey, dated 07/25/25, showed staff documented the resident's activities of interest as crafts, bible study, church, journaling, music, adventure movies, going to social events, shopping, going out to eat, walks, parties, cook outs, art and culture outings and scenic drives, enjoys reading materials. 7. Review of Resident #41's Annual MDS, dated [DATE], showed staff documented the resident as cognitively intact. Review showed staff completed section F of the resident's assessment and documented no response or non-responsive to all interview questions.Review of the resident's Activity Interest Survey, dated 12/08/25, showed staff documented the resident's activities of interest as cosmetics, music, shopping, bingo, volunteering, dress-up, manicures, social events, going out to eat, walks, parties, cook outs, art and culture outings and scenic drives, and enjoys magazines and the bible.8. Review of Resident #43's Annual MDS, dated [DATE], showed staff documented the resident as moderately cognitively impaired. Review showed staff completed section F of the resident's assessment and documented no response or non-responsive to all interview questions.Review of the resident's Activity Interest Survey, dated 05/29/25, showed staff documented the resident's activities of interest as animals, bingo, smoking, reading picture books, going out to eat, shopping, socials, scenic drives, cook outs, and going to movie theater. 9. Review of Resident #44's Annual MDS, dated [DATE], showed staff documented the resident as cognitively intact. Review showed staff completed section F of the resident's assessment and documented no response or non-responsive to all interview questions.Review of the resident's Activity Interest Survey, dated 04/11/25, showed staff documented the resident's activities of interest as music, bible study, manicures, social events, shopping, going out to eat, walks, parties, cook outs, art and culture outings and scenic drives, enjoys magazines and the bible. 10. During an interview on 02/27/26 at 11:32 A.M., the activity director said he/she does not complete section F/the activity portion of the MDS. He/She said the facility had an MDS coordinator in the building at one time, but now a regional person completes the MDS's. During an interview on 02/27/26 at 1:11 P.M., the Assistant Director of Nursing (ADON) said Residents #1, #4, #9, #18, #34, #41, #44, and #43 are all interviewable and should have been interviewed for Section F of the MDS. He/She said the corporation took over the MDS position and the facility has had several different MDS coordinators who have not been to the facility or interviewed the residents. During an interview on 02/27/26 at 2:02 P.M., the Director of Nursing (DON) said the facility has a new regional MDS Coordinator, and he/she has only seen him/her once. The DON said if a resident is interviewable, the resident should be interviewed for cognition and for activity preferences. The DON said he/she did not know the interviews were not being completed. The DON said to his/her knowledge the regional MDS Coordinator is responsible for the activity portion/Section F of the MDS. The DON said he/she doesn't know what the policy directs staff to do. The DON said he/she would think staff are supposed to follow their policy and does not know why they are not. The DON said it has been quite a while since a nurse has been to the facility to complete MDSs. During an interview on 02/27/2026 at 2:32 P.M., the administrator said the facility has had a corporate MDS Coordinator since September of 2025. The administrator said today was the first time he/she met the MDS Coordinator. The administrator said he/she doesn't know how the MDS Coordinator is completing resident interviews, he/she doesn't know of the MDS Coordinator calling to speak with the residents. The administrator said if the resident is interviewable, the resident should be interviewed. The administrator said he/she is ultimately responsible for making sure the MDS assessments are completed accurately, and he/she did not know staff were not following the facility policy. During an interview on 03/05/26 at 11:30 A.M., the MDS Coordinator said he/she started completing MDS assessments for the facility in September 2025. The MDS Coordinator said he/she covers five facilities, and she visits each one monthly. The MDS coordinator said he/she does not complete section F/the activity portion because he/she was told not to. The MDS Coordinator said all residents should be interviewed for section F, or at least an attempt should be made.

Based on observation, interview, and record review, facility staff failed to develop measurable goals and interventions for comprehensive care plans and update existing care plans to reflect care needs for seven residents (Residents #1, #2, #5, #8, #18, #43, and #44) out of 21 sampled residents. The facility census was 59.1. Review of the facility's policy titled Comprehensive Care Plans, dated 10/31/24, showed: -The facility is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs; -The Comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment; -The individualized care services plan, (also called the bedside care plan) will be updated with pertinent information needed for nursing staff on the floor to provide the needed care for residents. 2. Review of Resident #1's Activity Interest Survey, dated 01/05/25, showed staff documented the resident's activities of interest as shopping, coloring, crafts, smoking, reading, socials, going out to eat, going to movie theater, parties, BBQ/Cook outs, and scenic drives. Review of the resident's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 12/17/25, showed staff documented the resident had intact cognition, should not be interviewed for Section F (activity preferences), and did not document activities of interest. Review of the resident's care plan, dated 02/23/26, showed staff did not document the resident's activity preferences or interests. During an interview on 02/27/26 at 1:39 P.M., the Assistant Director of Nursing (ADON) said the resident is alert, oriented, and able to communicate his/her interests and the resident's activity preferences should be on the care plan. During an interview on 02/27/26 at 2:02 P.M., the Director of Nursing (DON) said he/she was not familiar with the activity survey preferences and thinks that activities identified on the survey should be on the care plan, and he/she does not know why it is not on the care plan. The DON said he/she did not know the activity survey existed so would not have known to add it to the care plan. The DON said himself/herself and the ADON are responsible for updating the care plans. 3. Review of Resident #2's Significant Change in Status Assessment (SCSA), dated 12/18/25, showed staff documented the resident as moderately cognitively impaired with a diagnosis of dementia. Review of the resident's care plan, dated 01/22/26, showed staff did not document the resident's diagnosis of dementia or interventions. During an interview on 02/27/26 at 1:14 P.M., Certified Nurse Aide (CNA) C said he/she thinks a diagnosis of dementia should be on the care plan, so staff know the appropriate care to provide the resident. During an interview on 02/27/26 at 1:22 P.M., Registered Nurse (RN) B said dementia should be on the care plan, so staff know how to care for the resident. During an interview on 02/27/26 at 1:39 P.M., the ADON said dementia should be on the care plan, and he/she did not know the diagnosis was not addressed on the resident's care plan. He/she said himself/herself and the DON are responsible for updating the care plans. During an interview on 2/27/26 at 2:02 P.M., the DON said dementia with behaviors should be on the care plan, and he/she did not know the diagnosis not addressed on the resident's care plan. During an interview on 2/27/26 at 2:32 P.M., the administrator said the ADON and DON are responsible for completing the care plans, and ultimately, he/she is responsible for ensuring it is done. The Administrator said dementia should be on the care plan, so staff know the type of care to provide the resident. 4. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff documented the resident as moderately cognitively impaired and frequently incontinent of urine and stool. Review of the resident's Physician Order Sheet (POS), dated February 2026, showed the following orders: -02/18/26: Cephalexin (antibiotic) 500 milligrams (mg), daily for prophylaxis; -02/23/26: Macrobid (antibiotic) 100 mg, give two times a day for Urinary Tract Infection (UTI) for seven days; -02/27/26: Cranberry 450 mg daily for frequent UTI. Review of the resident's History and Physical, dated 02/12/26, showed a history of recurrent UTIs and urinary retention, on prophylactic antibiotic for recurrent UTI per urology (urinary specialty). Review of the resident's care plan, dated 02/16/26, showed staff did not document the resident's history of UTIs or use of prophylactic antibiotics and supplements. During an interview on 02/27/26 at 1:14 P.M., CNA C said he/she thinks UTIs should be on the care plan to let him/her know the care the resident requires. During an interview on 02/27/26 at 1:22 P.M., RN B said if a resident has chronic UTIs it should be on the care plan, so staff know what interventions need to be in place to help prevent the UTIs. He/she did not know this was not on the resident's care plan, and he/she does not update the care plans. During an interview on 02/27/26 at 1:39 P.M., the ADON said the resident's chronic UTIs should be on the care plan, so staff know what to do and are able to track the UTIs and treatments. During an interview on 02/27/26 at 2:02 P.M., the DON said the resident's care plan should address the UTI's as he/she has had them for 20 years, and it does not fully go away, so staff should be aware to know what they need to do. During an interview on 02/27/26 at 2:32 P.M., the administrator said the resident's chronic UTIs should be on the care plan so staff know what interventions they should be doing. He/she said he/she did not know the care plan did not address the UTIs. 5. Review of Resident #8's Quarterly MDS, dated [DATE], showed staff documented the resident as moderately cognitively impaired, and did not receive hospice services. Review of the resident's POS, dated February 2026, showed the resident was admitted to hospice on 02/04/26. Review of the resident's care plan, dated 01/22/26, showed staff did not document the resident's hospice status. During an interview on 02/27/26 at 1:14 P.M., CNA C said if a resident received hospice, he/she would expect to see it on the care plan. During an interview on 02/27/226 at 1:22 P.M., RN B said he/she would expect hospice to be on the care plan. The RN said the resident went on hospice recently, but that hospice should be on the care plan. During an interview on 02/27/26 at 1:39 P.M., the ADON said the care plan should be updated when a resident goes on hospice, or if they come off hospice. The ADON said he/she did not realize the care plan was not updated with the change in status for the resident. During an interview on 02/27/26 at 2:02 P.M., the DON said when a resident goes on hospice it should be updated on the care plan, and he/she is still learning care plans. During an interview on 02/27/26 at 2:32 P.M., the administrator said hospice should be on the resident's care plan, so staff know what to do for the resident, and he/she did not know it was not updated. 6. Review of Resident 18's Annual MDS, dated [DATE], showed staff documented an interview for cognition and interview for activities of interest had not been completed, due to the resident assessed as rarely understood. Review of the resident's Activity Interest Survey, dated 04/22/25, showed staff documented the resident's activities of interest as baseball, football, cannabis, rock and roll music, action and comedy movies, magazine, social events, going out to eat, walking, going to movie theater, parties, bar-b-q cook outs, arts and culture outings, and scenic drives. Review of the resident's care plan, dated 12/18/25, showed staff did not care plan the resident's activities of interest identified on his/her Activity Interest Survey. During an interview on 02/27/26 at 10:35 A.M., Nurse Aide (NA) F resident specific activities of interest should be on the care plan. During an interview on 02/27/26 at 11:18 A.M., RN B said he/she would think a resident's activities of interest should be on their care plan. During an interview on 02/27/2026 at 1:11 P.M., the ADON said he/she doesn't know why the activities had not been care planned, they should have been. During an interview on 02/27/26 at 2:02 P.M., the DON said the activities of interest should be on the care plan most the time. The DON said he/she doesn't know why they are not. During an interview on 02/27/2026 at 2:32 P.M., the administrator said activities of interest should be identified on the care plan if staff has the information. 7. Review of Resident #43's Annual MDS, dated [DATE], showed staff documented the resident as moderately cognitively impaired, marked resident should not be interviewed in Section F/activities. Review of the resident's Activity Interest Survey, dated 05/29/25, showed staff documented the resident's activities of interest as animals, bingo, smoking, reading picture books, going out to eat, shopping, socials, scenic drives, cook outs, and going to movie theater. During an interview on 02/27/26 at 1:39 P.M., the ADON said the resident is alert, oriented and able to communicate his/her interests and the resident's activity preferences should be on the care plan. During an interview on 2/27/26 at 2:02 P.M., the DON said resident activities of interest should be on the care plan. 8. Review of Resident #44's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively Intact; -Active diagnoses of Anxiety disorder, Schizophrenia, and Post Traumatic Stress Disorder (PTSD); -Received antipsychotic medication. Review of the resident's care plan, revised 02/09/26, showed the care plan did not contain direction or guidance for Anxiety disorder, Schizophrenia, PTSD, and antipsychotic medication. During an interview on 02/27/26 at 11:37 P.M., Registered Nurse (RN) B said care plans are important to guide the care for the resident, so staff know how to care for each resident. He/She said he/she does not do anything with care plans and said the Assistant Director of Nursing (ADON) and Director of Nursing (DON) does care plans. During an interview on 02/27/26 at 1:20 P.M., the ADON said Schizophrenia, anxiety, and PTSD should be on the resident's care plan and he/she is not sure why it's not. He/She said the care plans tell the resident's story and guide staff care. During an interview on 02/27/26 at 2:15 P.M., the DON said Schizophenria, anxiety, and PTSD should be included on the care plan. He/She said care plans are important for staff to be able to provide care to the residents. During an interview on 02/27/26 at 2:40 P.M., the administrator said he/she expects diagnoses to be included on the care plans with interventions. He/She said care plans are how staff know what's going on with the residents and how to care for them.

Based on interview and record review, facility staff failed to provide an ongoing activity program designed to meet the residents' interest, mental, and psychosocial well-being on the weekends for eleven residents (Resident #59, #44, #41, #4, #1, #3, #34, #29, #43, #18, and #9) out of 21 sampled residents. The facility census was 59.1. Review of the facility's policy titled Activity, dated 07/19/23, showed the purpose is to ensure all residents in the facility are provided an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, their interests and their physical, mental and psychosocial well-being. 2. Review of the facility's Activity Calendar, dated January 2026, showed: -Saturdays, 01/03, 01/10, 01/17, 01/24, 01/31/26, at 9 A.M., Sit and Be Fit at 2 P.M., Deep Clean Room and 6 P.M., and Journal Prompt;-Sundays, 01/04, 01/11, 01/18, 01/25 at 9 A.M., Sit and Be Fit at 2 P.M., Bible Study and 5 P.M., Journal Prompt. Review of the facility's Activity Calendar, dated February 2026, showed: -Saturdays, 02/07, 02/14, 02/21, and 02/28/26 at 9 A.M., Sit and Be Fit, at 2 P.M., Deep Clean Room and 6 P. M. Journal Prompt;-Sundays, 02/01, 02/08, 02/15, and 02/22/26 at 9 A.M., Sit and Be Fit at 2 P.M., Bible Study and 5 P.M. Journal Prompt. During an interview on 02/25/26 at 10:03 A.M., Resident #59 said activities are not offered on the weekends, and he/she would attend the activities if offered. He/She said he/she colors on the weekends. During an interview on 02/25/26 at 11:34 A.M., Resident #44 said activities are not offered on the weekends. He/She said the second Sunday of the month a church group will come in. He/She said he/she tries to keep busy by reading books and watching television. The resident said he/she would like more activities on the weekends.During an interview on 02/25/26 at 11:47 A.M., Resident #41 said he/she likes to go to all activities and really enjoys bowling. The resident said he/she wished activities were offered on the weekends. During an interview on 02/25/26 at 12:07 P.M., Resident #4 said the only activities offered on the weekends involved cleaning and watching television. The resident said he/she would attend actual activities if offered on the weekends. During an interview on 02/25/26 at 1:41 P.M., Resident #1 said there are not any activities offered on the weekends, and he/she usually stayed in his/her room and colored. He/She said staff do not offer activities on the weekends.During an interview on 02/25/26 at 2:24 P.M., Resident #3 said staff do not offer activities on the weekends, and there is not anything to do other than watch television. During an interview on 02/25/26 at 3:14 P.M., Resident #34 said staff do not offer activities on the weekends. The resident said the residents watch television on the weekends. The resident said he/she would like for there to be activities on the weekend. During an interview on 02/25/26 at 3:22 P.M., Resident #29 said he/she has been told there is not staff led activities on the weekends because the activity director (AD) is not available. The resident said he/she would like activities on the weekends because all he/she does is watch television. During an interview on 02/25/26 at 3:32 P.M., Resident #43 said activities are not offered on the weekends and that he/she wished there were some as he/she may participate. The resident said he/she just stays in his/her room on the weekends or watches television because there is nothing to do. During an interview on 02/26/26 at 9:04 A.M., Resident #18 said activities are not offered on the weekends, but if there was, he/she would participate. During an interview on 02/26/26 at 9:25 A.M., Resident #9 said there is not activities on the weekends, and he/she gets bored. During an interview on 02/26/26 at 1:45 P.M., Nurse Aide (NA) E said sometimes when he/she works on the weekends he/she will try and play games with the residents if he/she has the chance. He/She said staff provide coloring pages for the residents to color. He/She said there are not any staff led activities on the weekends. During an interview on 02/26/26 at 2:25 P.M., the AD said on the weekends the residents have coloring pages and if the aides have time they can play games with them. He/She said there is sit and be fit, journal prompting, and cleaning up but those are pretty much on the residents own time. He/She said there is not any group lead activities offered on the weekends. The AD said he/she does not work on the weekends, and it is hard to depend on others to do activities. During an interview on 02/27/26 at 10:35 A.M., NA F said he/she does work some weekends. The NA said there is not scheduled activities on the weekend. The NA said he/she is unsure if anyone is assigned to complete activities with residents on the weekends. During an interview on 02/27/26 at 11:18 A.M., Registered Nurse (RN) B said he/she has worked some weekends. The RN said the activity on weekends is usually church. The RN said staff does not facilitate activities for residents who do not go to church. The RN said there is not a staff member scheduled, or responsible for completing activities with residents on the weekends. During an interview on 02/27/26 at 1:38 P.M., the Assistant Director of Nursing (ADON) said sometimes a church will come in on Sundays. He/She said there are games and books available for the residents. He/She said if aides have time they can play a game with the residents. During an interview on 02/27/26 at 2:15 P.M., the Director of Nursing (DON) said there are coloring sheets and sometimes resident lead bible studies on the weekends. He/She said a church will come in sometimes and residents choose if they want to attend. He/She said he/she is not aware of activities for residents who do not attend church. He/She said there is not scheduled staff lead activities on the weekends. During an interview on 02/27/26 at 2:40 P.M., the administrator said there are not staff lead activities on the weekends. He/She said there should be activities on the weekends. He/She was not aware staff should lead activities on the weekends.

Based on observation, interview and record review, the facility staff failed to serve and prepare food in accordance with the nutritionally calculated recipes and menus to all residents. The facility census was 59.1. Review ow the facility's Dietary Food Preparation policy, revised 07/05/23, showed:-Standardized recipes will be used for all products prepared. The dietary manager will monitor and check routinely the cook's use of recipes;-Uniform food portions shall be established for each diet and served to all residents;-The dietary manager will monitor the cooks and their use of portion control utensils on tray line;-Food will be served at proper temperature to ensure food safety;-Acceptable serving temperatures for hot foods including hot pureed foods, 135 degrees Fahrenheit (F) but preferably 160-175;-Each food item, served separately in the regular diet, is pureed and served separately for the pureed diet according to the pureed recipes. Review of the facility's Week Four, Day 25 lunch menu showed residents who received pureed meals were to receive a #6 (five and one third ounces) scoop of pureed chicken, a #8 (four ounces) scoop of mushroom rice, a #12 (two and two thirds ounces) scoop of au gratin cauliflower and a #10 (3.2 ounces) scoop of frosted cake. 2. Observation on 02/25/26 at 12:20 P.M., showed Resident #8 sat in the dining during the noon meal. Observation showed three off white, pureed food items in a divided plate set in front of the resident. Observation showed the pureed items were thin in consistency and contained visible liquid. Observation showed the Dietary Manager (DM) removed the plate from the resident. During an interview on 02/25/26 at 12:25 P.M., [NAME] G said he/she did not follow the standardized recipe when he/she prepared the pureed items. [NAME] G said he/she did not really know how to prepare pureed food items. Observation on 02/25/26 at 12:35 P.M., showed the DM prepared pureed chicken in a food processor and placed an unmeasured portion on a divided plate. The DM washed the food processor and prepared pureed rice and added an unmeasured portion to the divided plate with the chicken. The DM washed the food processor and prepared pureed cauliflower and added an unmeasured portion to the divided plate with the chicken and rice. Observation showed the divided plate was placed in a warming cabinet after each item was prepared. Observation showed the DM did not reheat the three items after they were pureed. Observation showed the temperature of the pureed chicken was 106 degrees F and the pureed cauliflower was 114 degrees F as the items were placed on a service cart and about to be served to the resident. During an interview on 02/25/26 at 12:35 P.M., the DM said he/she prepared the pureed items for Resident #8 because the original items were too thin. The DM said he/she did not reheat the pureed items or check the temperature and did not measure the portions before the items were placed on the plate. The DM said pureed items should be reheated to 165 degrees F or according to the recipe. The DM said hot food should be served at 120 degrees F or higher. The DM said he/she was in a hurry to get the resident's food back to him/her. 3. Review of the facility's standardized recipe for 55 servings of mushroom rice showed the recipe included two quarts of mushrooms. Observation on 02/25/26 at 12:00 P.M. showed kitchen staff served rice at the noon meal and the rice did not contain mushrooms. 4. Review of the facility's standardized recipe for 55 servings of cauliflower au gratin showed the recipe included one pound, two ounces of shredded cheddar cheese and a topping of two and three quarter cups of breadcrumbs. Observation on 02/25/26 at 12:00 P.M. showed kitchen staff served cauliflower at the noon meal and the cauliflower did not contain cheese or a bread crumb topping. During an interview on 02/25/26 at 12:25 P.M., [NAME] G said he/she prepared the rice with butter and salt and did not add mushrooms. [NAME] G said he/she did not season the cauliflower or add cheese or the bread crumb topping. [NAME] G said he/she knew where the recipes were located but he/she did not follow them and did not say why. During an interview on 02/27/26 at 9:33 A.M., the DM said he/she expected staff to follow recipes including portion size. The DM said he/she had not been keeping up with training and monitoring new staff. The DM said he/she did not know staff were not following the recipes. During an interview on 02/27/2026 at 1:23 P.M., the administrator said the DM and kitchen staff were responsible for following standard recipes including portion sizes and temperatures. The administrator said he/she did not know the pureed foods temperature requirements and did not know kitchen staff were not following the recipes.

Based on interview and record review, facility staff failed to ensure residents received their mail on Saturdays. The facility census was 52. Review of the facility's policy titled, Resident Rights, revised July 2023, showed residents have the right to privacy in written communications including the right to send and promptly receive mail that is unopened. During the resident group meeting on 02/05/25 at 10:07 A.M., the residents said staff does not deliver their mail on Saturdays. During an interview on 02/06/25 at 1:54 P.M., Licensed Practical Nurse (LPN) E said the activities department is in charge of and distributes the mail. The LPN said he/she did not know who delivered the mail on Saturdays. During an interview on 02/06/25 2:59 P.M., the activity director said the administrator gets the mail and hands it out. The activity director typically just takes care of packages. The activity director said the residents do not get mail on the weekends because a department head has to be present to make sure the mail is not contraband. During an interview on 02/06/25 03:52 P.M., the administrator said mail is not delivered to the residents on the weekends. The Administrator said he/she never thought about it but the registered nurse (RN) on duty could pass the mail out to the residents. The administrator said he/she prefers the department head to go through the packages with the residents due to contraband.

Based on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's needs for seven residents (Resident #4, #31, #34, #40, #42, #48 and #55) out of seven sampled residents. The facility census was 52. 1. Review of the facility's policy titled Care Plan Policy, revised 5/18/24 showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the facility's policy titled Coordination of Hospice Services, revised 05/18/24, showed the facility and hospice provider will coordinate a Plan of Care and will implement interventions in accordance with the resident's needs, goals, and recognized standards of practice in consultation with the resident's attending physician/practitioner and resident's representative, to the extent possible. The Plan of Care will identify the care and services each entity will provide in order to meet the needs of the resident and his/her expressed desire for hospice care. The Plan of Care will include directives for managing pain and other uncomfortable symptoms and will be revised and updated as necessary. Review of the facility's policy titled Proper Use of Bedrails, revised 06/26/24 showed the facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices. This should be evidenced in the resident's records, including their care plan. 2. Review of the Resident #4's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/26/24, showed staff assessed the resident as: -Cognitively intact; -Required setup or cleanup assistance for showers; -Required setup or cleanup assistance for personal hygiene. Review of the resident's medical record showed staff documented the resident has diagnoses of drug induced subacute dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk); extrapyramidal and movement disorder, unspecified (EMDU) (a medical term used to describe a group of disorders characterized by involuntary, abnormal movements that are not caused by damage to the pyramidal tract of the brain); orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down which can cause dizziness or loss of consciousness); and Post-Traumatic Stress Disorder (PTSD), (a disorder that makes a person feel in danger even though the danger is past, especially when there are triggers). Review showed staff documented the resident fell on [DATE]. Review of the resident's Care Plan, revised 08/12/24, showed the care plan did not address the residents specific PTSD triggers, the type of assistance the resident required for showers, personal hygiene, his/her unsteadiness and dizziness or his/her fall 02/02/25. Observation on 02/03/25 at 11:53 A.M., showed the resident unsteady as he/she stood up from his/her bed. Observation on 02/04/25 at 10:50 A.M., showed the resident stood by his/her dresser and had involuntary movements of his/her lower extremities, tremors, and unsteadiness. During an interview on 02/04/25 at 10:50 A.M., the resident said he/she experienced dizziness while standing. Observation on 02/06/25 at 10:30 A.M., showed the resident unsteady as he/she walked in his/her room. 3. Review of Resdient # 31's Quarterly MDS, dated [DATE] showed staff assessed the resident as cognitively intact and did not use bed rails. Review of the care plan, revised 01/31/25, showed the care plam did not address the use of bed rails. Observation 02/03/25 10:45 A.M., showed a bed rail up on the right side of the resident's bed. Observation 02/04/25 10:59 A.M., showed a bed rail up on the right side of the resident's bed. During an interview on 02/03/25 at 10:45 A.M., the resident said he/she uses the rail when he/she needs to get out of bed because he/she is large and his/her legs are very swollen. 4. Review of Resident # 34's Five Day MDS, dated [DATE] showed staff assessed the resident as: -Cognitively impaired; -Ostomy (a prosthetic device that collects waste from a surgically created opening in the abdomen). -Did not receive hospice care. Review of the care plan, last revised on 12/27/24 showed the care plan did not address hospice care or ostomy care. Review of the medical record showed staff documented hospice care had been initiated for the resident on 01/30/25. Review of the Physician Order Summary (POS), dated 02/02/25 showed an order for hospice care. 5. Review of Resident #40's Quarterly MDS, dated [DATE], shows staff assessed the resident as cognitively intact and did not have dental issues. Review of the resident's care plan, revised 09/23/24, showed the care plan did not address the resident's dental issues. During an interview on 02/03/25 at 11:00 A.M., the resident said he/she has had dental issues since August. During an interview on 02/05/25 at 5:05 P.M., the Social Services Director (SSD) said the resident has seen a dentist several times and had a tooth extracted in January. The SSD did not know the resident's dental issues were not on the care plan and said it should be. 6. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as severe cognitive impairment and did not receive hospice care. Review of the resident's medical record showed staff documented the resident discharged to an acute care hospital on 01/20/25 and returned to the facility on [DATE] on hospice care. Review of the resident's care plan, revised 12/01/24, showed the care plan did not address the resident's hospice care. 7. Review of Resident #48's Significant Change MDS, dated [DATE], showed staff assessed the resident as cognitively intact and did not receive hospice care. Review of the resident's Care Plan, revised 08/07/24, showed the care plan did not address the resident's hospice care. 8. Review of Resident #55's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment and did not receive hospice care. Review of the resident's medical record showed staff documented the resident discharged to an acute care hospital on 12/14/24 and returned to the facility on [DATE] on hospice care. Review of the resident's care plan, dated 08/01/24, showed the care plan did not address the resident's hospice care. 9. During an interview on 02/06/25 at 1:24 P.M., Certified Nurse Aide (CNA) B said when he/she is unfamiliar with a resident he/she will ask what type of care the resident requires. The CNA said he/she did not know about care plans, or how to find the care information. During an interview on 02/06/25 at 1:54 P.M., the MDS Coordinator said care plans should be updated with all information, including the type and amount of assistance needed, and if the resident receives hospice care. LPN E said care plans should be used to properly care for the resident. The MDS Coordinator said he/she is new to the position and still getting caught up. During an interview on 02/06/25 at 3:24 P.M., the Director of Nursing (DON) said the MDS Coordinator is responsible to ensure care plans are completed. The DON said all topics related to the resident's care should be covered including the type of assistance needed for ADL's such as showers and personal hygiene, as well as if the resident receives hospice care. The DON said care plans should guide the care a resident receives. The DON said he/she did not know the care plans were not up to date. He/She said he/started in the position in July and is still getting up to speed. During an interview on 02/06/25 at 3:52 P.M., the administrator said the MDS Coordinator is responsible for updating care plans. The staff has quarterly care plan meetings where goals and the residents' issues are covered. The administrator said he/she would expect the care plan to reflect all care issues including ADL's, dental issues, and hospice care. The administrator said he/she did not know care plans were not being updated. 42484 50432

Based on observation, interview and record review, facility staff failed to maintain professional standards of care when staff failed to transcribe accurate and complete physician's orders for five residents (Resident #10, #20, #34, #42 & #55) out of five sampled residents. The facility census was 52. 1. Review of the facility's policy titled Medications Order, dated 05/18/24, showed: -The order should be recorded in the physician orders in the electronic health records, which will add the order to the Medication Administration Record (MAR); -Clarify the order; -If using electronic medication records, input the medication order according to the electronic health record (EHR) instructions and facility policy; -Call or fax the medication order to the provider pharmacy if EHR states to; -Ensure the order is in the electronic MAR (eMAR); -When an order changes the dosage of a previously prescribed medication, discontinue the order as per the electronic software instructions and retype the new order; -Ensure the new order is in the eMAR. 2. Review of Resident #10's Physician Order Summary (POS), dated 02/25, showed a physicain order for Divalproex Sodium Direct Release ((DR) seizures) 500 milligrams (mg). Take one tablet every morning. Review showed Divalproex DR 250 mg, take 3 tablets (750 mg) twice a day, and one tablet in the afternoon discontinued on 08/04/24. Review of the resident's eMAR, dated 02/04/25, showed staff did not discontinue the Divalproex DR 250 mg, take 3 tablets (750 mg) twice a day, and one tablet in the afternoon as ordered on 08/04/24. Review of the resident's medication card showed the medication pack label instructed staff to administer Divalproex DR 250 mg 3 tablets (750 mg) by mouth twice a day and take one tablet daily in the afternoon. Observation showed additional instruction to administer Divalproex DR 500 mg every morning. During an interview on 02/04/25 at 8:52 A.M. CMT D said the nurse told him/her to administer and select the 500 mg instructions in the eMAR. The CMT said he/she crossed out the discontinued instructions on the medication labels in stock from the pharmacy that included both orders. During an interview on 02/04/25 2:00 P.M. Licensed Practical Nurse (LPN) A said the pharmacy did not discontinue the order on their end and continues to send packets with both orders on the label. LPN A said he/she did not know why the discrepancy had not been resolved earlier. The LPN said staff should not strike through anything on the medication label. During an interview on 02/06/25 10:32 A.M. the Director of Nursing (DON) said the eMAR shows the Divalproex DR 750 mg as an active order. The DON said he/she thinks the pharmacy removes the orders from the eMAR. During an interview on 02/06/25 1:45 P.M., the DON said it is ultimately his/her responsibility to ensure the eMAR is correct. It is important so residents receive the correct medication. During an interview on 02/06/25 02:00 P.M., the administrator said it is not acceptable for a resident to have a discontinued order on the eMAR since August 2024. The administrator said it should have been addressed in a timely manner. The DON is responsible for ensuring the accuracy of the eMARS. 3. Review of the facility's policy titled Medication Orders, revised 05/18/24, showed an element of a medication order is route of administration. Review of the manufacturer's instructions for Nystatin 100,000 units/milliliter (ml) Oral Suspension (Ready-Mixed), dated 07/23, showed always take this medicine exactly as prescribed. Check with physician or pharmacist if unsure. 4. Review of Resident #20's POS, dated February, 2025, showed an order for Nystatin oral suspension 100,000 unit/ml 5 mls four times a day for thrush (a fungal infection). The order did not contain the route of adminstration. During an interview on 02/04/25 at 9:22 A.M., CMT D stated he/she did not know if the medication should be swallowed or spit out by the resident. During an interview on 02/04/25 at 9:50 A.M., LPN A said the order does not state whether the resident should swallow or spit the medication. LPN A said spit and swallow are different modes of administration. The nurse taking the order is responsible for the accuracy of the orders and contacting the physician for clarification. During an interview on 02/06/25 3:25 P.M. the DON said it is the responsibility of the nurse taking the order to ensure instructions are complete. Missing or incomplete orders should be clarified with the physician so medications are taken correctly. The DON said it is ultimately his/her responsibility orders are correct. During an interview on 02/06/25 at 3:49 P.M., the administrator said it is the DON's responsibility to ensure orders are complete and accurate. He/she said staff should contact they physician or DON if something is missing or unclear. 5. Review of the facility's policy titled Coordination of Hospice Services, revised 05/24, showed when a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being. The policy did not contain direction for staff to obtain a physician's order for hospice care. Review of the facility's policy titled Oxygen Administration, revised 05/18/24, instructed staff to administer oxygen under orders of a physician. 6. Review of Resident #34's Prospective Payment System (PPS) Five Day Scheduled Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/10/25, showed staff assessed the resident as: -Severe cognitive impairment; -Continuous oxygen use; -Did not receive hospice services. Review of the resident's medical record showed staff documented hospice services initiated on 01/30/25. Review of the POS, dated 02/25, showed an order oxygen without the rate of oxygen to be adninistered. Review showed the POS did not contain the hospice order. Observation on 02/03/25 at 11:15 A.M., showed the resident wore oxygen at three liters per minute. During an interview on 02/03/25 at 11:15 A.M., the resident said he/she receives one liter of oxygen during the day and three liters at night. Observation on 02/04/25 at 11:03 A.M., showed the resident wore oxygen at three liters per minute. Observation on 02/05/25 at 12:23 P.M., showed the resident wore oxygen at three liters per minute. During an interview on 02/06/25 at 2:49 P.M., LPN A said he/she did not know the resident's oxygen order did not have a flow rate. 7. Review of Resident #42's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely impaired cognition and did not receive hospice services. Review of the resident's medical record showed staff documented the resident discharged to an acute care hospital on 01/20/25 and returned to the facility on [DATE] with hospice services. Review of the resident's POS, dated February 2025, showed it did not contain an order for hospice services. 8. Review of Resident #55's Quarterly MDS, dated [DATE], showed staff assessed the resident as -Moderate cognitive impairment; -Independent for all mobility; -Diagnoses of pneumonia, stroke, and depression; Review of the resident's medical record showed staff documented the resident discharged to an acute care hospital on 12/14/24 and returned to the facility on [DATE] with hospice services. Review of the resident's POS, dated 12/24, showed it did not contain an order for hospice services. 9. During an interview on 02/06/25 at 1:54 P.M., Licensed Practical Nurse (LPN) E said residents who receive hospice services should have a physicians order on their POS. LPN E said he/she did not know how the orders were missed. During an interview on 02/06/25 at 3:24 P.M., the Director of Nursing (DON) said the nurses are responsible for transcribing orders from the hospital paperwork. If clarification is needed, or an order has been omitted, the charge nurse is responsible to get clarification from the physician. 50432

Based on observation, interview, and record review, facility staff failed to obtain consent for the use of bed rails for two residents (Resident #31 and #48) of two sampled residents. The facility census was 52. 1. Review of the facility's policy titled Proper Use of Bed Rails, dated February 2025, showed informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion. The information that the facility should provide to the resident, or resident representative includes, but is not limited to: the resident's risk from the use of bed rails and likelihood of the benefits, and the risks from the use of bed rails an how these risk will be mitigated. 2. Review of Resident #31's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/31/24, showed staff assessed the resident as: -Cognitively intact; -Independent with Activities of Daily Living (ADL's); -Diagnoses of traumatic brain injury (TBI), anxiety, depression, psychotic disorder, and schizophrenia; -Bed rails not used. Review of the resident's care plan, revised 02/03/25, showed staff documented the resident at risk for falls due to multiple medication use. Review showed the care plan did not include bed rail use. Review of the resident's medical record did not contain an informed consent for bed rail use. Observation on 02/03/25 10:45 A.M. showed the resident in bed with his/her right quarter bed rail up. Observation on 02/04/25 10:59 A.M. showed the resident in bed with his/her right quarter bed rail up. During an interview on 02/04/25 at 10:59 A.M., the resident said he/she asked for the bed rail to help him/her move in bed and get up. The resident said he/she does not remember if staff talked to him/her about the risk and benefits of bed rail use. 3. Review of Resident #48's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent with ADL's; -Diagnoses of heart failure, hypertension, stroke, depression, and respiratory failure; -Bed rails not used. Review of the resident's care plan, revised 02/04/25, showed staff documented the resident has problems positioning self in bed, has grab/positional bars in place on bilateral sides of bed to help turn from side to side. Review of the resident's medical record did not contain an informed consent for bed rail use. Observation on 02/03/25 at 10:10 A.M., showed the resident in bed with the grab bars up on both sides. Observation on 02/06/25 09:55 A.M., showed the resident used his/her grab bars to reposition. During an interview on 02/06/25 at 10:15 A.M., the resident said he/she requested the bed rails to help him/her reposition and get out of the bed. 4. During an interview on 02/06/25 at 3:15 P.M., the Director of Nursing (DON) said the residents asked for the bed rails to assist with mobility. The residents or the residents representatives should sign a consent for bed rail use. He/She does not know why this had not been completed. During an interview on 02/06/25 at 3:49 P.M., the Administrator said bed rail consents should be signed before the bed rails are installed. He/She did not know the residents did not have a consent in the their medical records. 50432

Based on observation, interview, and record review, facility staff failed to follow infection control practices when staff did not properly sanitize the blood glucose monitor for four residents (Resident #53, #7, #6 and #20) out of four sampled residents. The facility census was 52. 1. Review of the facility's policy titled Glucometer Disinfection, dated February 2025 showed the facility will ensure glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The glucometers will be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA), an independent agency of the United States government tasked with environmental protection matters, registered healthcare disinfectant that is effective against Human Immunodeficiency Virus (HIV), Hepatitis C and Hepatitis B virus. -Procedural steps include: -retrieve two disinfectant wipes from container; -Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer; -After cleaning, use the second wipe to disinfect the glucometer with the disinfectant wipe following the manufacturer's instructions. Allow the glucometer to air dry; Review of the MicroKill One Medline Germicide Alcohol wipes manufacturer instructions, showed to use one or more wipes as necessary to wet surface sufficiently and to thoroughly disinfect hard nonporous surface. Clean the surface: use one or more wipes as necessary to thoroughly wet the surface to be treated. Treated surface must remain visibly wet for one minute to achieve complete disinfection of all pathogens listed on this label. Observation on 02/04/25 at 11:39 A.M. showed Certified Medication Technician (CMT) D checked Resident #53's blood glucose, and loosely wrapped the glucometer with a disinfectant wipe. The wipe did not cover the collection strip insertion site for the required one minute. Observation on 02/04/25 at 11:50 A.M. showed CMT D checked Resident #7's blood glucose, and loosely wrapped the glucometer with a disinfectant wipe. The wipe did not cover the collection strip insertion site for the required one minute. Observation on 02/04/25 at 12:06 P.M. showed CMT D checked Resident #6's blood glucose, and loosely wrapped the glucometer with a disinfectant wipe. The wipe did not cover the collection strip insertion site for the required one minute. Observation on 02/04/25 at 12:15 P.M., showed CMT D checked Resident #20's blood glucose, and placed the glucometer in the medication cart drawer. The CMT did not disinfect the glucometer. During an interview on 02/04/25 at 12:17 P.M., CMT D said the most contaminated portion of the glucometer is where the test strip is inserted. The CMT said the way he/she cleansed the glucometer would not be sufficient because it did not cleanse the strip insertion site. The CMT said he/she received training in regard to cleansing the glucometer. CMT D said he/she did not realize he/she had not cleansed the glucometer after checking Resident #20's blood glucose. The CMT said the glucometer is used for multiple residents. During an interview on 02/06/25 at 3:15 P.M., the Director of Nursing (DON) said he/she expects staff to thoroughly cleanse the glucometer between each resident to prevent cross contamination. He/She said all staff who pass medications have received training on disinfecting glucometers. During an interview on 02/06/25 at 3:49 P.M., the administrator said he/she expects staff to follow the facility's glucometer disinfection policy. It is the DON's responsibility to ensure staff are trained and performing thorough disinfection to prevent harm to the residents.

Based on interview and record review, facility staff failed to educate and offer the Coronavirus disease (COVID-19) vaccination for five residents (#14, #31, #34, 40 and #51) out of five sampled residents. The facility census was 52. 1. The Center's for Disease Control COVID-19 Vaccination Long Term Care guidelines, dated August 2024, recommends everyone ages 5-[AGE] years, including people who live and work in long-term care (LTC) settings, get one dose of a 2024-2025 COVID-19 vaccine; and everyone ages [AGE] years and older, including people who live and work in LTC settings, get two doses of a 2024-2025 COVID-19 vaccine 6 months apart. 2. Review of Resident #14's medical record showed: -The resident is under age 65; -admitted on [DATE]; -The record did not contain a COVID-19 vaccination consent or declination form; -The record did not contain documentation the resident received or refused the COVID-19 vaccine. 3. Review of Resident #31's medical record showed: -The resident is under age 65; -admitted on [DATE]; -The record did not contain a COVID-19 vaccination consent or declination form; -The record did not contain documentation the resident received or refused the COVID-19 vaccine. 4. Review of Resident #34's medical record showed: -The resident is under age 65; -admitted on [DATE]; -The record did not contain a COVID-19 vaccination sent or declination form; -The record did not contain documentation the resident received or refused the COVID-19 vaccine. 5. Review of Resident #40's medical record showed: -The resident is over age 65; -admitted on [DATE]; -The record did not contain a COVID-19 vaccination consent or declination form; -The record did not contain documentation the resident received or refused the COVID-19 vaccine. 6. Review of Resident #51's medical record showed: -The resident is under age 65; -admitted on [DATE]; -The record did not contain a COVID-19 vaccination consent or declination form; -The record did not contain documentation the resident received or refused the COVID-19 vaccine. 7. During an interview, on 02/03/25 at 2:10 P.M., the Infection Preventionist said he/she started in the position in July of 2024 after his/her predecessor quit abruptly. The Infection Preventionist said he/she did not believe the COVID-19 education or vaccine had been provided to the residents because the facility is remote, and they do not have local access to the vaccine. The Infection Preventionist said he/she could not locate a policy in regard to COVID-19 vaccinations for residents. During an interview on 02/06/25 03:49 P.M., the administrator said the facility does not provide education in regard to the COVID-19 vaccine to the residents and does not provide the vaccine. The administrator said he/she started in the position in July of 2024, and there is not a policy.

Based on interview and record review, facility staff failed to ensure one resident (Resident #2) remained free from verbal and emotional abuse, when Certified Nurse Aid (CNA) E threatened to take the resident to the floor, blocked and refused to leave the resident's room after repeated requests made by the resident. The facility census was 58. 1. Review of the facility's policy titled Abuse and Neglect , dated 06/12/24, showed abuse is the willful infliction, injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. Verbal abuse includes speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Mental abuse includes humiliation, harassment, threats of punishment or deprivation, or abuse that is facilitated or caused by nursing home staff. Verbal abuse includes the use of verbal conduct by staff to cause the resident to experience agitation. This includes hovering over a resident with the intent to intimidate, threatening and isolating the resident. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/31/24, showed staff assessed the resident as: -Intact cognition; -Rejection of care not exhibited; -Behaviors not exhibited; -Received antipsychotic medication seven days out of the seven day look back period; -Post Traumatic Stress Disorder (PTSD), anxiety and flashbacks triggered by traumatic event, Bipolar disorder and Depression. Review of the resident's care plan, revised 09/17/24, showed staff documented the resident as: -Emotional distress is triggered by overwhelming emotions, feelings, or memories; -Poor impulse control with restlessness and increased anxiety, agitation and aggressive behavior; -History of PTSD, encourage resident to express emotions in a safe environment; -A safe environment should be free from actual or perceived judgement and physical or perceived danger; -Listen to what the resident is saying and establish trust with the resident; -Behave in a calm manner around the resident, especially when the resident has a high level of anxiety; -Resident is triggered by people being to close and gets angry when people don't listen; -Residents with PTSD are often fearful, providing a calm and relaxing environment can help lessen, or relieve anxiety and promote a feeling of safety; -May often have difficulty communicating due to racing thought or inability to concentrate; -Avoid rushing the resident and allow them more time to answer, or respond to promote security; -Do not argue, or become defensive with the resident; -Do not get into a power struggle with the resident. 2. Review of the facility's investigation, dated 11/02/24, showed the resident notified the Director of Nursing (DON) on 11/1/24 Certified Nurse Aide (CNA) E abused him/her when CNA E would not leave the resident's room after being asked to leave multiple times, and blocked the doorway from the resident. Review showed Nurse Aide (NA) C statement showed he/she witnessed CNA E and resident yelling at each other and CNA E would not leave after the Licensed Practical Nurse told CNA E to leave. Review showed LPN D documented he/she heard yelling from the resident and CNA E. LPN D asked CNA E to leave the resident's room multiple times and instructed CNA E to go behind the unit doors. LPN documented CNA E left the room but not the unit. LPN D documented the resident left his/her room and CNA E approached the resident and stood abdomen to abdomen. The LPN notified the DON on 11/2/24 at. Review showed the DON notified the administrator on 11/2/24. During an interview on 11/06/24 at 11:03 A.M., the resident said the incident happened on 11/02/24 he/she thinks. The resident said he/she asked CNA E to please get out of his/her room. The resident said CNA E said no, he/she is not leaving. The resident said he/she asked CNA E to leave his/her room approximately eight times. The resident said CNA E had his/her arms spread across the door frame and said he/she can do this for 12 more hours and smiled at him/her. The resident said he/she became frustrated and told CNA E to get out of his/her room, or he/she will put CNA E out of his/her room. The resident said CNA E then said he/she would put the resident on the floor. The resident said he/she became more agitated, and grabbed hot sauce packets and threw them in the hall and the CNA stood in the door frame and blocked him/her from leaving the room. The resident said Licensed Practical Nurse (LPN) D and Nurse Aide (NA) C came to his/her room. The resident said LPN D told CNA E to get out of the resident's room several times and CNA E would not leave the resident's room. The resident said after this incident CNA E continued to walk past his/her room and smile at him/her to frustrate him/her. The resident said he/she walked down the hall, yelled at CNA E and the CNA turned around walked back up to him/her and got face to face. During an interview on 11/06/24 at 12:45 P.M., CNA E the resident yelled he/she was going to beat the CNA's ass and for the CNA to leave the room. The CNA said LPN D told him/her to get out of the resident's room and he/she told LPN D he/she couldn't because the resident had him/her pinned. The CNA said he/she stayed in the resident's room, after the resident told him/her to leave, because he/she tried to calm the resident down. During an interview on 11/06/24 at 1:23 P.M., NA C said he/she and LPN D were at the nurse's station and heard yelling coming from the resident's room. NA C said he/she and LPN D went to the resident's room. NA C said when he/she got to the room CNA E and the resident were face to face and abdomen to abdomen. NA C said LPN D told CNA E to walk away several times and CNA E wouldn't. NA C said CNA E yelled several times that he/she could do this for 12 hours and smiled at the resident. During an interview on 11/06/24 at 2:00 P.M., the resident said when CNA E would not leave his/her room and had blocked his/her door, it made him/her feel trapped and unsafe, Like I was a prisoner in my own room. The resident said it made him/her really agitated and upset, because he/she couldn't get out of his/her room and CNA E would not leave the room. During an interview on 11/06/24 at 2:26 P.M., the DON said LPN D called him/her on 11/01/24 and said the resident yelled that he/she was going to beat the shit out of the CNA. The DON said LPN D called him/her again and said the resident left his/her room and went after the CNA. The DON said he/she took statements the next day and the staff statements were different from what he/she had been told over the phone. The DON said CNA E should have respected the resident's wishes and left the room. The DON said CNA E should have removed himself/herself from the situation. The DON did not say whether or not CNA E abused the resident. During an interview on 11/06/24 at 2:54 P.M., the administrator he/she investigated the resident's behavior and he/she should have investigated it as abuse. The administrator said he/she terminated CNA E because he/she would not listen to LPN D and stood in the resident's room to continually agitate the resident. The administrator said what CNA E did could increase the resident's agitation and cause further behaviors. The Administrator did not say whether or not CNA E abused the resident. During an interview on 11/07/24 at 7:45 A.M., LPN D said CNA E went into the resident's room and that is when he/she heard the resident yell get out, get out. LPN D said he/she heard CNA E say, I will take you to the floor. LPN D said the resident told CNA E to get out of his/her room several times but CNA E would not leave the room. LPN D said he/she told CNA E to leave the resident's room and CNA E would not leave the room. LPN D said CNA E stayed face to face with the resident. LPN D said CNA E could have left the room at any time. MO00244704

Based on interviews and record review, facility staff failed to report an allegation of employee to resident emotional abuse to the Department of Health and Senior Services (DHSS) within the two hour timeframe for one resident (Resident ##2) who reported an allegation of abuse. The facility census was 58. 1. Review of the facility's policy titled Abuse and Neglect , dated 06/12/24, showed the licensed nurse will protect the resident from further incident and remove the accused employee from resident care areas. The nurse will then notify the administrator or designee. Should the incident be a reportable event, the administrator should notify appropriate agencies immediately, as soon as possible, but no later that 24 hours after the discovery of the incident. In case of serious bodily injury, no later than two hours after discovery or forming the suspicion. 2. Review of the facility's investigation, dated 11/02/24, showed the resident notified staff on 11/1/24 that Certified Nurse Aide (CNA) E abused him/her when CNA E would not leave the resident's room after being asked to leave multiple times, and blocked the doorway from the resident. Review of Nurse Aide (NA) C's statement showed he/she witnessed CNA E and the resident yelling at each other and CNA E would not leave after the Licensed Practical Nurse (LPN) D told CNA E to leave the resident's room. Review showed LPN D documented he/she heard yelling from the resident and CNA E. LPN D asked CNA E to leave the resident's room multiple times and instructed CNA E to go behind the unit doors. LPN D documented CNA E left the room but not the unit. LPN D documented the resident left his/her room and CNA E approached the resident and stood abdomen to abdomen. The LPN notified the DON on 11/2/24. Review showed the DON notified the administrator on 11/2/24. Review showed facility staff did not notify the state agency with in the two hour timeframe as required. During an interview on 11/06/24 at 1:23 P.M., NA C said when he/she got to the resident's room CNA E and the resident were face to face. NA C said he/she knows there is a two hour timeframe for reporting allegations of abuse. The NA said he/she is not aware if it was reported to the state. During an interview on 11/06/24 at 2:26 P.M., the DON said he/she did not know he/she is supposed to call state, he/she said he/she called the administrator on 11/2/24, and the administrator takes care of reporting. The DON said it was reported to him/her the staff shoved the resident. The DON said he/she did not know the timeframes. During an interview on 11/06/24 at 2:54 P.M., the administrator said he/she investigated the resident's behavior and he/she should have investigated it as abuse. The administrator said he/she considers what CNA E did as trying to get a rise out of the resident and staff should not be doing that, as it could increase the resident's agitation and cause behaviors. The administrator said he/she contacted his/her regional administrator and told the regional administrator. The regional administrator told him/her to get statements and go from there. The administrator said he/she got statements and called the regional administrator and left a voicemail and did not receive a call back. The administrator said he/she knows now that he/she should have called state. During an interview on 11/07/24 at 7:45 A.M., LPN D said he/she heard the resident yell get out, get out. LPN D said he/she heard CNA E say, I will take you to the floor. LPN D said the resident continued to tell CNA E get out of my room and CNA E would not leave the room. LPN D said he/she told CNA E to leave the resident's room and CNA E would not leave the room, CNA E stayed face to face with the resident. LPN D said staff have two hours to report abuse allegations to state. LPN D said the DON told him/her they needed to ask corporate if they had to report it. LPN D said he/she is not aware if it was reported to state. LPN D said the resident reported to him/her that CNA E shovedhim/her. MO00244704

43327 Based on interview and record review, the facility staff failed to develop and implement policies and procedures for the inspection, testing, and maintenance of the facility water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD). The facility census was 49. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification (S&C) letter 17-30, dated 06/02/17 and revised on 06/09/17; showed: -The bacterium Legionella can cause a serious type of pneumonia called LD in persons at risk. Those at risk include persons who are at least [AGE] years old, smokers, or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as shower heads, cooking towers, hot tubs, and decorative fountains; -Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water; -CMS expects Medicare certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. An industry standard calling for the development and implementation of water management programs in large or complex building water systems to reduce the risk of legionellosis was published in 2015 by American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE). In 2016, the CDC and its partners developed a toolkit to facilitate implementation of this ASHRAE Standard(https://www.cdc.gov/legionella/maintenance/wmp-toolkit.html). Environmental, clinical, and epidemiological considerations for healthcare facilities are described in this toolkit; -Surveyors will review policies, procedures, and reports documenting water management implementation results to verify that facilities: -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; -Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; -Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. -Utilize tools provided by the CDC and ASHRAE industry standard as guidance in development, implementation, and ongoing evaluation of program to limit Legionella and other waterborne germs from growing and spreading; -Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathoges could grow and spread in the facility water system; -Identify areas where Legionella could grow and spread by completing an analysis of the current building water system; -Complete a written description and process flow diagram. Identify waster sources, flow, temperature, stagnation, disinfection, conditions for bacteria spread, special considerations, and external hazards; -Put control measures into place and how to monitor them utilizing indicators identified on the process flow diagram; -Establish ways to intervene when control limits are not met; -Make sure the program is running as designed and is efective. Review of the facility's inspection, testing and maintenance records showed the records contained a Legionella Disease policy, revised 6/29/2023. Further review showed the policy was a corporate template and did not contain any facility specific information related to an active water management program. During an interview on 10/19/23 at 11:50 A.M., the maintenance director said he/she did not have a water management program. During an interview on 10/19/23 at 3:45 P.M., the administrator said the facility did not have an active water management program. The administrator said he/she started at the facility two months ago and did not have a chance to get the program started yet. 45564

Based on record review and interview, the facility staff failed to maintain an accurate accounting system that assured the resident fund bank statement matched the reconciliation for the same month from 09/01/22 through 03/31/23. This had the potential to affect all residents that had funds entrusted to the facility on the residents' behalf. The facility census was 49. 1. Review of the Facility's Resident Trust policy, dated 9/17/21, showed: -The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed; -A reconciliation of the bank statements, checkbook and trust funds must be completed monthly. 2. Review of the facility's Bank Statement dated 09/30/22 showed: -A beginning balance of $6,699.59; -An ending balance of $5,138.51. Review of the facility's Reconciliation dated 09/01/22 through 09/30/22, showed the bank with: -A beginning balance of $15,003.88; -An ending balance of $14,631.56. 3. Review of the facility's Bank Statement dated 10/31/22 showed: -A beginning balance of $5,661.87; -An ending balance of $6,126.24. Review of the facility's Reconciliation dated 10/01/22 through 10/31/22 showed the bank with: -A beginning balance of $14,631.56; -An ending balance of $15,324.47. 4. Review of the facility's Bank Statement dated 11/30/22 showed: -A beginning balance of $6,126.24; -An ending balance of 3,671.01. Review of the facility's Reconciliation dated 11/01/22 through 11/30/22 showed the bank with: -A beginning balance of $15,234.47; -An ending balance of $12,894.24. 5. Review of the facility's Bank Statement dated 12/31/22 showed: -A beginning balance of $3,671.01; -An ending balance of $6,756.32. Review of the facility's Reconciliation dated 12/01/22 through 12/31/22 showed the bank with: -A beginning balance of $12,779.24; -An ending balance of $16,096.71. 6. Review of the facility's Bank Statement dated 01/31/23 showed: -A beginning balance of $6,756.32; -An ending balance of $4,207.01. Review of the facility's Reconciliation dated 01/01/23 through 01/31/23 showed the bank with: -A beginning balance of $16,096.71; -An ending balance of $13,763.40. 7. Review of the facility's Bank Statement dated 02/28/23 showed: -A beginning balance of $4,207.01; -An ending balance of $3,552.47. Review of the facility's Reconciliation dated 02/01/23 through 02/28/23 showed the bank with: -A beginning balance of $13,763.40; -An ending balance of $13,324.86. 8. Review of the facility's Bank Statement dated 03/31/23 showed: -A beginning balance of $3,552.47; -An ending balance of $2,127.78. Review of the facility's Reconciliation dated 03/01/23 through 03/31/23 showed the bank with: -A beginning balance of $13,324.86; -An ending balance of $7,116.17. 9. During an interview on 10/19/23 at 10:23 A.M., the Administrator and the Corporate Liaison said the newly hired business office manager is out on a family emergency and the Corporate business office manager is not in town. The Corporate Liaison was trying to find out why the reconciliation did not match the bank statements. During an interview on 10/20/23 at 10:54 A.M., the Administrator and Corporate Liaison said there had been no word from the Corporate office on the reason for the discrepancies with the resident fund accounts. During an interview on 10/20/23 at 01:01 P.M., the Administrator said he/she was responsible to review the end of month resident funds to ensure they were accurate and then signed off on them. He/She said there had been a lot of staff changes and all department leaders were new and learning their roles.

Based on interview and record review, the facility failed to provide refunds of personal funds to residents from the facility operating account in a timely manner for four residents (Resident #1, #2, #3, #4, and #8) discharged from the facility. The facility census was 49. 1. Review of the Facility's Resident Trust policy, dated [DATE], showed: -Upon the discharge of a resident, the facility shall provide an up-to-date accounting of the resident trust account balance; -The resident shall be issued a check for all remaining personal funds in his/her account within five (5) days of discharge along with a complete accounting record of the funds; -Checks received after a resident is discharged should be either forwarded to the resident or returned to the sender; -If the facility is Representative Payee, any unspent Social Security or Social Security Income (SSI) funds that are held on behalf of a beneficiary belong to that beneficiary; -Upon the death of a resident who had received aid or assistance from the Department of Social Services, the facility will submit in writing a complete accounting of the resident's remaining personal funds within 30 days from the date of the resident's death. Funeral expenses may be paid from a resident's personal funds held by a facility if no other funds are available to cover the cost. If funds are used for this purpose, this fact and the amount used shall be noted on the account report submitted to the department and documentation of payment shall be attached; -Upon the death of a resident who had not received aid or assistance from the Department of Social Services or the Department has not made claim to the funds, the facility must provide the fiduciary of the resident's estate, at his/her request, all personal possessions and funds along with their complete accounting records within 30 days from the date of the resident's death; -Checks received after a resident has expired must be returned to the sender with written explanation. Review of the facility's maintained Accounts Receivable Report for the period [DATE] through [DATE], showed the following residents with personal funds held in the facility operating account:. Resident Amount Held in Operating Account discharge date #1 $1,606.00 [DATE] #2 $ 260.00 [DATE] #3 $5,364.00 [DATE] #4 $1,903.00 [DATE] #8 $ 873.56 [DATE] Total $10,006.56 During an interview on [DATE] at 10:23 A.M., the Administrator and the Corporate Liaison said the facility recently hired a person to review the aging and clean up the credits but is out on a family emergency. The Corporate Liaison said that the business office works with the corporate office to ensure credits are refunded timely During an interview on [DATE] at 10:54 A.M., the Administrator and the Corporate Liaison said they have not heard from the corporate office on why the credits exist on the accounts receivable report. During an interview on [DATE] at 1:01 P.M., the Administrator said patient fund credits should be refunded within 30 days of discharge from the facility. He/She said that it is the responsibility of the business office staff with guidance of the corporate office to ensure refunds are issued within 30 days.

Based on observation and interview, the facility staff failed to ensure complete privacy for residents by failing to close an exterior curtain for one resident whose abdomen was exposed during an insulin injection (Resident #27), close an exterior curtain for one resident who was being assisted to bed (Resident #30), and to close a privacy curtain between two residents who shared a room during assistance to bed (Resident #30 and #34) and failed to ensure resident's personal information was protected when they left the Medication Administration Records (MARs) open and unattended in public hallways. The facility census was 49. 1. Review of the facility's Resident Rights Policy, dated 7/5/23, showed: -The resident has the right to personal privacy and confidentiality of his or her personal and clinical records; -Personal privacy includes personal care and accommodations. Review of the facility's Medication Administration and Monitoring policy, dated 09/2023 showed it did not contain direction on privacy during medication administration. 2. Observation on 10/17/23 at 01:44 P.M., showed Nurse Aide (NA) Q and the Director of Nursing (DON) entered the room to assist Resident #30 to bed. Resident #34, the roommate, was in the room and the exterior curtain was open. NA Q and the DON transferred Resident #30 to bed without pulling the curtain between the two residents or the exterior curtain. The resident's brief was exposed during the transfer. The view out the exterior window was the employee break area with two employees present. 3. Observation on 10/18/23 at 2:33 P.M., showed Certified Medication Technician (CMT) F entered Resident #27's room to administer his/her insulin and left the Electronic Health Record screen open showing the resident's information including his/her medication list. CMT F raised the resident's shirt to expose his/her abdomen and did not close the exterior window curtain. Additionally, two visitors were seen coming into the building from the open window. 4. During an interview on 10/17/23 at 10:51 A.M., NA Q said he/she was still in training but knew to pull the curtains for resident privacy. He/She did not know why the curtain was not pulled during the transfer for Resident #30. During an interview on 10/20/23 at 09:34 A.M., Licensed Practical Nurse (LPN) C said staff are instructed to make sure the screen on the medication cart is hidden when stepping away from the cart to ensure resident privacy is maintained. He/She said when providing care, including administration of insulin and during transfers and/or patient care, all the room curtains should be closed so the staff maintain the resident's privacy. During an interview on 10/20/23 at 01:01 P.M., the Administrator and DON said staff were expected to maintain the resident's privacy at all times by keeping medication screens locked or minimized when stepping away and keeping doors closed, exterior curtains closed, and privacy curtains pulled between residents during care. The DON said he/she should have pulled the curtain between resident #30 and #34 when laying resident #30 down for a nap to maintain his/her privacy.

Based on observation, interview and record review, the facility staff failed to provide a clean, homelike and comfortable environment when staff failed to clean and maintain resident rooms. The facility census was 49. 1. Review of the facility's policy Environmental Rounds, dated 6/09/23, showed staff were directed as follows: -Environmental rounds are to be done daily by department heads using the environmental rounds form; -The department head should be inspecting the rooms for potentially hazardous items and any areas that may not be in compliance of state and federal regulations. Review of the facility's policy Work Order Policy, dated 12/21/22, showed staff were directed as follows: -The facility maintenance department's function is to provide material and labor to maintain the buildings, equipment and grounds; -Work order forms should be submitted for any issues that an employee observes which need the attention of facility maintenance. 2. Observation on 10/17/23 at 10:05 A.M., showed the floors of the kitchen area, pantry, and kitchen passages with yellow, brown, and black stains, cracks, gouges in the tiles, and missing tiles. Observation on 10/17/23 at 10:30 A.M., showed the dining room had two doors off the kitchen area with missing veneer and gouges. Vinyl was ripped on the seat of an arm chair, and white paint dried on two dining room chairs. The dining room floor had yellow stains throughout the room. Observation on 10/17/23 at 10:39 A.M., showed a handrail loose on 100 hallway across from room [ROOM NUMBER]. Observation on 10/17/23 at 10:53 A.M., showed room [ROOM NUMBER] had areas on the wall with chipped paint, the floor with dark stains near bed one, a dark stain between the beds, a cracked tile near the foot of bed one, and black stains surrounded each individual tile. The toilet area was stained with brown stains in the bowl and the sink had a crack and brown stains. The door for the toilet area had veneer scraped off with raw unfinished wood exposed. Observation on 10/17/23 at 10:58 A.M., showed room [ROOM NUMBER] with the toilet area with multiple spots of gray paint on the floor and walls, the toilet bowl with brown spots on back and brown stains inside the entire bowl area. The drain in the shower was rusty and chipped tile left rough edges around the drain. Observation on 10/17/23 at 11:15 A.M, showed room [ROOM NUMBER] had damaged walls behind the bed and sitting chair in the room. Paint missing, tears and gouges in the sheetrock. Wall trim between the flooring and walls is missing with damaged sheetrock exposed. Further observation showed the flooring in the bathroom was ripped and raised up. Observation on 10/17/23 at 11:21 A.M., showed room [ROOM NUMBER] with dark brown stains on the outside of the toilet bowl and the top of the inside of the toilet bowl, and a tan stain in the bottom area of the toilet bowl. Observation on 10/19/23 at 3:17 P.M., showed the grab bar at the end of 100 hall was missing the corner trim piece. Under the missing trim were sharp metal mounting edges. Observation on 10/20/23 at 8:53 A.M., showed room [ROOM NUMBER] contained broken wall corner trim, gouged sheetrock, and torn paint. The flooring was separated and had a raised edge between the bathroom and sink area. Observation on 10/20/23 at 9:15 A.M., showed the bathroom sink in room [ROOM NUMBER] had cracks in it around the drain area that leaked when used. Observation on 10/20/23 at 9:30 A.M., showed room [ROOM NUMBER] had multiple dead insects in the corner of room in a pile. Observation on 10/20/23 at 9:38 A, M. showed room [ROOM NUMBER] had damaged and missing wall corner trim and the sink had deep cracks in it around the drain. Observation on 10/20/23 at 10:00 A.M., showed the 100 hall shower had a large pile of small dead insects in a corner between a wall and a storage cabinet. 3. During an interview on 10/18/23 at 10:12 A.M., the resident of room [ROOM NUMBER] said the chipped paint, worn sinks and floors bothered him/her. During an interview on 10/20/23 at 8:49 A.M., Certified Medication Technician F said there were forms staff filled out to tell Maintenance what needed to be repaired. During an interview on 10/20/23 at 9:03 A.M., the Activity Director said staff told the maintenance supervisor if they found broken items in a resident's room. During an interview on 10//20/23 at 9:10 A.M., the housekeeping supervisor said he/she told the maintenance supervisor when he/she saw a broken item in a resident's room and there was a form they could fill out with repair requests. During an interview on 10/20/23 at 10:07 A.M., Nurse Aid Q and Certified Nurse Aid J said they told the charge nurse when a broken item was found and there was a maintenance from staff could fill out. During an interview on 10/20/23 at 10:40 A.M., the Maintenance Supervisor said he/she got a work order from staff and they were going to a computer based repair system for work orders soon. Some staff tell him/her about needed repairs directly. They have replacement parts coming but there were not all here. They were attempting to fix the flooring or replace it. A pest control company came biweekly. During an interview on 10/20/23 at 1:08 P.M., the Director of Nursing and the Administrator said damaged or broken items could be put into their computer system to be tracked now. There was also a paper report that maintenance could use to know what needed to be fixed. The maintenance director was responsible for fixing items as well as all staff. If needed repairs cost over $1000 dollars, they had to request approval from their corporate office. 42484 43327

Based on interview and record review, Registered Nurse (RN) F failed to assess and monitor one resident (Resident #2) in accordance with the resident plan of care, with a change in condition consistent with a previous seizure activity. RN F instructed staff to turn lights off and close the resident's door and did not notify the resident' physician with the change in condition. RN F failed to assess the resident from approxiamely 5:40 P.M., to 6:00 P.M. when shift change occurred. RN G immediately assessed the resident during rounds with RN F, notified the resident's physician who ordered they send the resident to the hospital for evaulation and treatment of the change in condition. The facility census was 46. 1. Review of the facility's Abuse and Neglect policy, revised 01/05/23, showed the purpose of this policy is to outline procedures for reporting and investigating complaints of abuse, neglect and misuse of funds and property and to define terms of abuse, neglect, and misappropriation. Review showed class I neglect is defined as the failure of an employee to provide reasonable and necessary services to maintain the physical and mental health of any resident when that failure presents either imminent danger to the health, safety or welfare of a resident, or a substantial probability that death or physical injury would result. Review showed Class II neglect is defined as a failure of an employee to provide reasonable or necessary services to a resident according to the individualized treatment/habilitations plan, if feasible, or according to acceptable standards of care. 2. Review of the Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/08/23, showed staff assessed the resident as: -Severely cognitive impaired; -Active diagnoses of medically complex conditions, stroke, dementia, hemiplegia, seizure disorder, anxiety and depression; -Always incontinent of bowel and bladder; -Wheelchair use; -Required extensive two person physical assistance for personal hygiene, toilet use, dressing, locomotion on and off the unit, transfers and bed mobility. Review of the resident's plan of care, dated 12/13/22, showed staff documented the resident with a seizure disorder. Review showed staff are instructed to not leave the resident alone during a seizure. Review of the resident's progress notes, dated 08/06/23, showed RN F documented the resident's blood pressure (BP) 142/82 and pulse 78. The resident began staring off which is normal for him/her, was tapping his/her feet during supper. The RN documented the resident had been alert and talkative all day and in a good mood. The resident did not have muscle twitches at this time. Nurse Aide (NA) I was asked to lie down resident in his/her chair as he/she seemed tired from being awake all day. RN F documented report given to oncoming nurse at 5:55 P.M., then both RN and oncoming nurse went to see the resident. The resident was staring off and having some minor twitches in her right hand. Oncoming nurse made decision to send resident out. Review of the resident's progress notes, dated 08/06/23, showed RN G documented the resident in his/her recliner in his/her room with head turned to the right and not responding to staff. BP 172/96 and Pulse 102. Resident had slight tremor to right hand and eyes were twitching. Spoke with the resident's guardian and reported resident's condition. Called on-call doctor with the hospital and reported resident's condition. Resident had a history of seizure activity and resident was not responding to staff and eyes were twitching. The Physician assistant on call directed staff to send the resident to emergency room for evaluation and treatment. Review of the resident's admission hospital records, dated 08/06/23, showed the resident arrived to the hospital intubated (a tube placed through a person's mouth or nose, then down into their trachea to maintain an airway) and admitted with status epilepticus (a seizure that lasts longer than five minutes, or having more than one seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes) and urinary tract infection. During an interview on 08/08/23 at 9:15 A.M, the administrator said emergency medical services took over an hour to get to the facility. Staff believed the resident was having a stroke. They life flighted him/her and he/she was not back yet. The administrator said the resident was in the intensive care unit, intubated. RN F was in charge when the symptoms occurred. During an interview on 08/08/23 at 09:25 A.M., RN F said the resident started staring off and not responding while in the dining room, which he/she has done in the past. He/She believed the resident might have been having a seizure and instructed staff to take the resident into his/her room to be away from stimuli like light and noise and to rest. At approximately 05:45 P.M., he/she was with RN G in the resident's room for visual rounds and RN G said he/she was going to send the resident out. He/She said the resident was stable when he/she left the building around 06:20 P.M., they have sent the resident out before thinking he/she was having a stroke and they always send her back and it was a seizure, all his/her medications were given that day . RN F said it was his/her anniversary and he/she wanted to put his/her family over her work. He/She did not notify the administrator, DON, EMS, physician or guardian of change in condition. During an interview on 08/08/23 at 09:44 A.M., the interim director of nursing said RN G called him/her around 6:30 P.M. on 08/06/23 very upset due to the resident change in condition, concerned it was not a seizure and the resident blood pressure was very high and his/her eyes were twitching back and forth. The resident had a history of stroke and seizures and never should have been left alone, the physician and EMS should have been notified sooner and RN F should have never left in the middle of an emergency. During an interview on 08/08/23 at 10:02 A.M., the resident care coordinator said some days the resident was alert and some days he/she was not. He/She did often stare into space and you could tell when the resident was going to have a seizure. They usually sent the resident out due to the severity of his/her seizures, and they mimic strokes. In the past, staff had removed her from stimuli to see if the resident can come out of it, but staff needed to stay with the resident at all times. It is best not to assume a (seizure vs. stroke) because it could be either. The resident had a history of both seizure and stroke. During an interview on 08/08/23 at 10:43 A.M., CNA H said the resident often stares off but this was different then his/her normal state. The CNA said RN F had the other aides take the resident to his/her room to relax. No staff stayed with the resident. During an interview on 08/08/23 at 10:50 A.M., Nurse Aide I said the resident's status changed at dinner and RN F said he/she might have had a seizure. The resident's hand was clenched and very stiff, his/her eyes were darting left and right and his/her foot started tapping on the floor. He/She was instructed to put the resident in his/he room to relax because RN F was convinced the seizure had passed. He/She said the resident was put back in his/her room around 5:40 P.M. and at 6:00 P.M., shift change occurred where he/she gave visual report to oncoming aides. The resident's head was turned to the right with eyes still moving left to right. During an interview on 08/08/23 at 11:10 A.M., CNA J said the day shift aide and him/her were doing rounds and the aide reported the resident had a seizure at dinner and they put the resident in his/her recliner to relax and decrease stimuli. The resident was awake but not normal. When the resident has had a seizure in the past his/her body got stiff. They alerted the nurse and stayed with him/her until EMS got there. It was abnormal they did not send the resident out when it happened. During an interview on 08/08/23 at 11:36 A.M., CNA K said he/she got the facility around 5:45 P.M., and RN F was outside smoking and told him/her that the resident had a seizure and put him/her in his/her room. He/She said they did visual walking rounds around 6:00 P.M., and could tell something was off with the resident. He/She stayed with the resident until the nurses came in for report. RN G told RN F he/she was sending the resident out and RN F said there was no need because the hospital would just send him/her back and it was his/her anniversary and he/she needed to go. The resident has a history of seizures but this one seemed worse. His/Her good hand was tensed, he/she was crying and his/her eyes were darting back and forth. They usually sent the resident out with these symptoms. During an interview on 08/08/23 at 11:48 A.M., the director of operations said he/she believed this happened because of shift change and that was a concern to him/her. He/She said the resident was never left alone. He/She would expect the physician to be contacted to see if there were any new orders and if the physician wanted the resident sent out. During an interview on 08/08/23 at 03:07 P.M., NA L said he/she arrived for his/her shift around 5:50 P.M. and said RN F was outside. The aides did walking rounds and the resident was alone in his/her room, the other staff said he/she had a seizure at dinner. The resident did not appear normal. His/Her eyes were bobbling left to right, the resident seemed scared and it was not a normal seizure for the resident. During an interview on 08/08/23 at 04:28 P.M., RN G said he/she arrived around 6:00 P.M. and RN F was outside smoking. He/She got report the resident had a seizure at dinner. The RN said during rounds he/she knew something was wrong with the resident and called the physician. The physician, EMS, guardian, DON and administrator had not been notified before RN G came on shift. The resident has a history of seizures but he/she has not witnessed one before. He/she knew the resident did not usually convulse but his/her head was turned to the right, the resident was not responsive and his/her eyes were twitching. When he/she told RN F that he/she was sending the resident out because he/she needed a higher level of care, he/she said well you can, but I have to go, it's my anniversary. Upon EMS arrival, they believed it could be a stroke and called for a helicopter. When the resident did not respond to stroke medication they believed the resident may have a brain bleed. During an interview on 08/08/23 at 4:44 P.M., the resident's guardian said the resident did have a history of seizures but since getting his/her medications under control he/she had not had one since 3/1/23. The guardian said EMS should have been called sooner because he/she cannot remember a time when the resident's seizures did not result in hospitalization due to the severity. During an interview on 08/22/23 at 04:28 P.M., EMS staff D and E said when they arrived on scene no one was in the room with the resident. The resident was unresponsive, head stuck to the right, arm buckled and foot pointed downward. EMS staff E thought the resident might be having a stroke due to symptoms and longevity of symptoms and they called for the helicopter. EMS staff said the timeframes for the facility to call EMS abnormally long whether a stroke, seizure or another medical emergency, the resident needed a higher level of care. As of 8/24/23, the resident's physician had not responded to request for interview. MO00222611