Every finding on record at Stonebridge Owensville

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 72.1. Review of the facility's policy titled Food Services Manager, updated 09/28/22, showed the Food Services Manager may serve as the Director of Food and Nutrition Services who must at a minimum meet one of the following qualifications:-A certified dietary manager (CDM), or;-A certified food service manager, or;-Has similar national certification for food service management and safety from a national certifying body, or;-Has an associates (or higher) degree in food service management or hospitality, if the course includes food service or restaurant management from an accredited institution, and;-Has two or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023. Review of the dietary manager's (DM) Food Protection Manager on-line course enrollment showed the DM enrolled in the course on 02/02/26 and started the course on 02/20/26. Review showed, as of 03/24/26, the DM had not completed the course. During an interview on 03/24/26 at 1:52 P.M., the DM said he/she had worked as a cook in the facility for a little over two years and took over the DM position about a month ago. The DM said he/she had never been a DM before, was not certified, and did not have a degree in food service management or hospitality. The DM said the facility's registered dietician only worked for the facility part-time and the facility did not have any other clinically qualified nutrition staff who worked at the facility full-time. The DM said he/she was enrolled in a food manager certification course, but he/she had not had time to complete the course due to a staffing shortage and no one gave him/her a timeline to complete the course. During an interview on 03/26/26 at 2:01 P.M., the administrator said he/she knew the DM was not qualified for the position, but he/she promoted him/her to the position because he/she could not find a qualified DM to hire. The administrator said the facility did not have any clinically qualified nutrition staff employed at the facility full-time. The administrator said the DM was enrolled in an appropriate course for certification, but the kitchen had experienced a large amount of staff turnover so the DM had not been able to complete the course.

Based on observation, interview and record review, the facility staff failed to ensure the mechanical dishwasher operated according to manufacturer's instructions in a manner adequate to prevent cross-contamination of kitchen wares. This failure has the potential to affect all residents. The facility census was 72.1. Review of the facility's policy titled Dishwashing Machine Use, revised March 2010, showed: -The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in facility approved log;-The operator will monitor the gauge frequently during the dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately;-The supervisor will check the calibration of the gauge weekly by running a secondary thermometer through the machine or using commercial temperature test strips using manufacturer's instructions;-If hot water temperatures do not meet requirements, cease use of dishwashing machine immediately until temperatures are adjusted. Review of the manufacturer's specifications posted on the facility's mechanical heat-sanitizing dishwasher showed instruction for the wash temperature to measure a minimum of 155 degrees Fahrenheit (dF) and the rinse temperature to measure a minimum of 180 dF. Review of the facility's Dish Machine - High Temperature Sanitizing Log dated February 2026, showed: -Staff did not document dishwasher temperatures for the period of 02/01/26 through 02/19/26 an 02/25/26 through 02/28/26;-Staff documented morning and afternoon wash temperatures of 110 dF with a rinse temperature of 170 dF on 02/20/26;-Staff documented an afternoon wash temperature of 110 dF with a rinse temperature of 160 dF. Review of the facility's Dish Machine - High Temperature Sanitizing Log, dated 03/01/26 through the morning of 03/24/26, showed staff recorded morning and afternoon wash and rinse temperatures each day. Review showed staff documented the morning and afternoon wash temperatures below 155 dF each day. Review also showed staff last documented the rinse temperature of the dishwasher at or above 180 dF in the morning on 03/06/26 and in the afternoon on 03/11/26. Observation on 03/23/26 at 10:29 A.M., showed Dietary Aide BB ran a load of kitchen wares through the dishwasher. Observation showed the wash temperature measured 110 dF and the rinse temperature measured 166 dF. Observation on 03/24/26 at 11:08 A.M., showed an unidentified staff member ran a load of kitchen wares through the dishwasher. Observation showed the wash temperature measured 108 dF and the rinse temperature measured 176 dF. Observation on 03/24/26 at 1:58 P.M., showed the dietary manager (DM) ran an empty dish rack through the dishwasher and the wash temperature measured 110 dF. During an interview on 03/24/26 at 1:58 P.M., the DM said the wash temperature of the dishwasher should be at least 155 dF and the rinse temperature should be at least 180 dF. The DM said he/she became the DM about one month ago and was not very familiar with the dishwasher, but when he/she thought the dishwasher was not reaching the correct wash temperature for at least one week, he/she notified the maintenance director. The DM said the maintenance came and checked the dishwasher and told him/her it was working okay. The DM said the maintenance director and assistant told him/her if the end temperature reached 180 dF, it should be fine. The DM said he/she had not reviewed what staff documented on the Dish Machine - High Temperature Sanitizing Logs and did not know there was an issue with the dishwasher temperatures. During an interview on 03/26/26 at 12:32 P.M., the maintenance director said he/she is responsible for the maintenance of the dishwasher. The maintenance director said he/she believed the dishwasher temperatures issues were caused by a water softener that broke down about one month ago. The maintenance director said he/she replaced the water softener but the dishwasher still did not reach the correct wash cycle temperature, but he/she thought the rinse cycle temperatures were adequate. The maintenance director said he/she replaced the booster heater yesterday, but the dishwasher still did not reach the correct operating temperatures. During an interview on 03/26/26 at 2:01 P.M., the administrator said he/she would expect the DM to follow facility policy related to operation of the dishwasher and dietary staff should report any equipment issues to the DM and/or maintenance staff. The administrator said he/she did not know about any issues with the dishwasher until yesterday.

Based on observation, interview and record review, facility staff failed to properly clean and maintain wheelchairs for three residents (Resident #41, #45 and #37) of a sampled of 20 residents. The facility census was 72. 1. Review of the Facility's policy titled, Wheelchair Cleaning Procedure, undated, showed staff are to make sure no visible dirt, foot, etc. on any part of the wheelchair. Provides wheelchair cleaning schedule to cover all wheelchairs in the facility to be cleaned once a week. 2. Review of the Facility's policy titled, Creating a New Work Order in Technology Efficiency Life Safety and Services (TELS), undated, showed staff are directed how to place a work order for maintenance, when staff observe items needing to be repaired. 3. Review of Resident #41's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 03/23/26, showed staff assessed the resident as follows:-Severe cognitive impairment;-Maximal assistance from staff member with eating;-Dependent on staff member for transfers;-Wheelchair.Observation on 03/23/2026 at 3:06 P.M., showed the resident in his/her wheelchair, both armrest on the resident's wheelchair cracked and missing vinyl, and exposed yellow foam. Observation on 03/24/26 at 11:35 A.M., showed the resident in his/her wheelchair with dried food debris on the frame of the wheelchair, and both armrest cracked and missing vinyl. Observation on 03/25/26 at 1:21 P.M., showed the resident in his/her wheelchair. The resident's wheelchair had dried food debris built up on both foot pedals, and both arm rest had cracked and torn vinyl, with exposed yellow foam. 4. Review of Resident #45's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment;-Moderate assistance from staff member with eating;-Dependent on staff member for transfers;-Wheelchair. Observation on 03/23/26 at 3:50 P.M., showed the resident in his/her wheelchair. The wheelchair's left armrest vinyl cracked. The wheelchairs wheels and tires had dried food debris on them. Observation on 03/24/26 at 11:35 A.M., showed resident in his/her wheelchair. The wheelchair wheels had dried food debris on them. The left armrest vinyl cracked and damaged. Observation on 03/25/26 at 8:00 A.M., showed resident in his/her wheelchair, in the dining room for breakfast. Observation showed his/her wheelchair with dried food debris and splatter on the wheels and tires. Observation showed the left armrest cracked and peeled vinyl. 5. Review of Resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows:-Severe cognitive impairment;-Supervision, or touching assistance from staff member with eating;-Dependent on staff members for all transfers. Observation on 03/23/26 at 4:02 P.M., showed the resident in his/her mechanical chair, with dried food debris and splatter on the chair's armrest, wheels and seat. Observation on 03/24/26 at 9:52 A.M., the resident in his/her mechanical chair in the community day room. Observation showed the armrest and wheels of the mechanical chair with dried, and splattered food debris on them. Observation on 03/25/26 at 7:57 A.M., showed the resident in mechanical chair in dining room. Observation showed the armrest and wheels of the mechanical chair with dried, and splattered food debris on them. 6. During an interview on 03/26/26 at 1:23 P.M., Certified Nurse Aide (CNA) G said CNAs are supposed to clean food off resident's wheelchairs after meals, and the wheelchairs should be cleaned at least once a week by the overnight CNAs. The CNA said there is a schedule to clean the resident's wheelchairs at the nurse's station. The CNA said the resident's wheelchairs are not getting cleaned. The CNA said cracked armrest on wheelchairs are a safety issue, and staff should put a work order in the TELS system immediately for maintenance to fix, but nothing changes. During an interview on 03/26/26 at 1:38 P.M., Licensed Practical Nurse (LPN) H said nightshift CNAs clean wheelchairs, but he/she tells the aides on his/her shift, to clean food off chairs, if the aides see it when transferring the residents. The LPN said he/she doesn't know why the wheelchairs are not getting cleaned, because he/she knows the aides have a schedule they are supposed to go by. The LPN said the nightshift charge nurse is responsible to ensure the nightshift aides are doing those duties. The LPN said cracked armrest are supposed to be put in the TELS system. The LPN said the cracked vinyl on armrest can cause skin tears. The LPN said bacteria lives inside the cracked areas of armrest, and if the armrest is cracked, it can't be cleaned appropriately. During an interview on 03/26/26 at 2:46 P.M., the Maintenance Director said he/she is responsible for maintaining wheelchairs. The Maintenance Director said staff are supposed to put in TELS, when the resident's armrest are cracked and peeling. The Maintenance Director said cracked armrest could cause abrasions on the resident's arms. The Maintenance Director said he/she is not sure why the staff have not reported the cracked armrest to him/her. During an interview on 03/26/26 at 3:23 P.M., the Director of Nursing (DON) said CNAs are responsible for cleaning wheelchairs per schedule, on nights. The DON said the nurses and himself/herself are supposed to make the sure the aides are cleaning the wheelchair per schedule. The DON said he/she had a complete turnover in staffing for the night shift recently, and himself/herself and the Assistant Director of Nursing (ADON) had been covering the night shift. The DON said if there is dried food debris on the wheelchairs, he/she expects staff to clean it immediately. The DON said staff are supposed to report cracked arm rest in the TELS system, so maintenance can follow up on it. The DON said residents can get wounds, infections and skin tears from cracked vinyl on the arm rest. The DON said he/she does not know why staff are not reporting the cracked armrest. During an interview 03/26/26 at 4:41 P.M., the administrator said night shift CNAs have cleaning wheelchairs on their task list. The administrator said the ADON, DON and charge nurses are supposed to monitor the aides, to make sure they complete the task list. The administrator said he/she does not know why the wheelchairs are not getting cleaned, the night shift probably needs someone in there to train them correctly on a routine. The administrator said he/she would expect the aides to do a visual scan of residents and their wheelchairs after meals, to make sure there is not food debris on them, before staff take the residents out of the dining room. The administrator said he/she would expect staff to put vinyl tares on armrest of wheelchairs in the TELS system. The administrator said staff have a bad habit of telling the Maintenance Director about things in passing and he/she can't remember everything. The administrator said torn vinyl on the armrest can affect residents skin integrity.

Based on interview and record review, facility staff failed to screen eight employees (Registered Nurse (RN) AA, Laundry Aide Z, Laundry Aide X, Dietary Aide Y, Certified Nurse Aide (CNA) S, [NAME] V, Nurse Aide (NA) T and Licensed Practical Nurse (LPN) U) out of ten new employees prior to employment to determine if the employees had indicators on the CNA Registry, Family Care Safety Registry (FCSR), Criminal Background Check (CBC) and/or Employee Disqualification List (EDL). The facility census was 72. 1. Review of the Facility's policy titled, Background Screening Investigations, dated March of 2019, showed the facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants. For purposes of this policy direct access employee means any individual who has access to a resident or patient of a long-term care (LTC) facility or provider through employment or through a and has duties that involve (or may involve) one-on-one contact with a patient or resident of the facility or provider, as determined by the state for purposes of the national background check program. The director of personnel, or designee, conducts background checks, reference checks and criminal conviction checks on all employees. Background and criminal checks are initiated within two days of an offer of employment or agreement and completed prior to employment. Should the background investigation disclose any misrepresentation on the application form or information indicating that the individual has been convicted of abuse, neglect, mistreatment of individuals, and/or misappropriation of property, the applicant is not eligible for employment. 2. Review of RN AA's personnel record showed:-Hire date of 06/02/25;-FCSR check on 06/13/25;-EDL check on 06/03/25:-CNA Registry check without a date. 3. Review of Laundry Aide Z's personnel record showed:-Hire date of 06/30/25;-CBC on 07/29/25;-EDL check on 03/25/26;-CNA Registry check on 07/09/25. 4. Review of Laundry Aide X's personnel record showed:-Hired date of 08/06/25;-FCSR checked on 08/13/25; -CNA Registry check without a date. 5. Review of Dietary Aide Y's personnel record showed:-Hire date of 10/27/25;-CBC and EDL check dated 11/04/25;-CNA Registry check without a date. 6. Review of CNA S's personnel record showed:-Hire date of 12/17/25;-FCSR checked on 12/30/25;-CNA Registry check without a date. 7. Review of [NAME] V's personnel record showed:-Hire date of 12/31/25;-CBC dated 01/08/26;-EDL check dated 01/29/26;-CNA Registry check without a date. 8. Review of NA T's personnel record showed:-Hire date of 02/11/26;-CBC and EDL check dated 03/25/26;-CNA Registry check without a date. 9. Review of LPN U's personnel record showed:-Hire date of 02/18/26;-CBC and EDL check dated 03/25/26;-FCSR dated 03/24/26;-CNA Registry check without a date.10. During an interview on 03/26/26 at 9:56 A.M., the Business Office Manager (BOM) said he/she is responsible to complete the pre-employment screening for staff. The BOM said the employee's pre-employment screenings were not completed prior to them starting, because the Director of Nursing (DON) and Assistant Director of Nursing (ADON) needed the staff bad on overnights and were having to cover those shifts. The BOM said the kitchen staff were started before checks, because there was only one cook, and he/she was in dire need of help. The BOM said he/she is aware he/she is supposed to check the FCSR, EDL, CBC and CNA Registry before the staff start working in the facility. The BOM said the employees hire date is their first date in the building, they spend the first day in the office with him/her doing paperwork and the then work on the floor day two through five, working on competency checks. During an interview on 03/26/26 at 4:41 P.M., the administrator said CBC, EDL, FCSR and CNA Registry checks are supposed to be ran on all staff, before the staff can start in the building. The administrator said the BOM is responsible to ensure all the checks are completed before staff start in the building. The administrator said he/she responsible to make sure the BOM gets the checks done, before the staff start in the building.

Based on observation, interview, and record review, facility staff failed to use proper hand hygiene and provide perineal care in a manner to reduce the risk of infection for one resident (Resident #32) out of three sampled residents, facility staff failed to use Enhanced Barrier Precautions (EBP) (an infection control practice that requires staff to wear personal protective equipment (PPE) (protective equipment such as gowns, gloves, goggles, and masks used to prevent or minimize exposure to hazards) for one resident (Resident #66) out of three sampled residents; and facility staff failed to implement appropriate infection control procedures to prevent the spread of communicable diseases when staff failed to screen five staff (Registered Nurse (RN) AA, Certified Nurse Aide (CNA) S, [NAME] V, Nurse Aide (NA) T, and Licensed Practical Nurse (LPN) U) out of ten staff for tuberculosis (TB), a contagious, air-borne bacterial infection primarily affecting the lungs, in accordance with facility policy. The facility census was 72. 1. Review of the facility's policy titled Hand Hygiene, dated 2021, showed hands should be washed with soap and water under the following conditions: -Before and after handling clean or soiled dressings, linens; -After handling items potentially contaminated with blood, body fluids, secretions, or excretions; -When, during resident care, moving from a contaminated body site to a clean body site. 2. Review of Resident #32's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/25/26, showed staff assessed the resident as: -Had an indwelling urinary catheter; -Always incontinent of bowel; -One pressure ulcer. Observation on 03/25/26 at 10:51 A.M., showed LPN H and the Assistant Director of Nursing (ADON) entered the resident's room to provide wound care. The ADON and LPN applied gowns, washed hands and then applied gloves. The LPN removed the resident's personal items from his/her bedside table, left dried food debris on the table, placed a washcloth and put wound supplies on the washcloth. With the same soiled gloves, the LPN picked up the bed remote and adjusted the head of the bed. The ADON removed the resident's right sock and revealed a bandage on the resident's right heel saturated with blood. The LPN provided wound care, changed gloves and placed the same sock back on resident's foot over the new bandage. The ADON took the dirty foam wedge from under the resident's leg and placed it on the chair. With the same soiled gloves, the LPN removed the wound dressing over the resident's face wound. The LPN sprayed wound cleanser on the resident's face wound, walked away from the resident to perform hand hygiene, the resident's face started to bleed, the ADON continued to wear the same soiled gloves and placed clean gauze on the wound to the resident's face. The LPN returned to the resident and removed the dirty gauze from the resident's face and performed the wound treatment. Observation showed the LPN removed the resident's soiled brief with bowel movement and the bandage from the resident's coccyx wound. The LPN wiped bowel into the resident's wound several times. At this time, the ADON told the LPN, he/she needed to use a new wipe each time because the wipes were visibly soiled. The LPN continued to wear visibly soiled gloves picked up the resident's clean brief and placed it on the resident's bed. The LPN provided wound care to the resident's coccyx wound and placed the brief on the resident he/she had touched with visibly soiled gloves on and picked up the bed remote and removed the wound treatment supplies from the resident's room and placed the supplies back on the treatment cart. During an interview on 03/26/26 at 10:42 A.M., LPN H said he/she should have changed his/her gloves and washed his/her hands after touching the bed remote and dirty bedside table. The LPN said he/she didn't, because he/she was nervous. The LPN said during the care the ADON should have removed gloves, washed hands and placed new gloves before he/she touched the clean gauze and applied it to open area on the resident's face, and after he/she had touched the dirty foam wedge that was under the resident's leg. The LPN said since the ADON touched the gauze with soiled gloves, he/she should have changed gloves and washed hands after removing the gauze from wound and should have applied clean gloves before he/she changed the dressing to the resident's face. The LPN said the resident had been incontinent of bowel, and he/she should have avoided touching the wound with feces, because it increases the risk of infection, but was not certain how to with the placement of the wound. The LPN said he/she should not have picked up the resident's clean brief with soiled gloves on. The LPN said they should not have placed that brief on the resident after cleaning him/her as it is now soiled. The LPN said after the treatments, when he/she touched the residents dirty bedside table with his/her bare hands, he/she should have washed hands, before picking up the wound care supplies for multiple residents. During an interview on 03/26/26 at 11:30 A.M., the ADON said when the LPN removed items from the bedside table, he/she should have made sure the table was clean and sanitized. The ADON said the LPN should have removed gloves, washed hands and applied clean gloves after he/she touched the dirty table. The LPN's gloves were not clean, and he/she risked introducing bacteria, or infection to the resident's wound. The ADON said he/she should have changed gloves and washed his/her hands before he/she put the clean gauze on the resident's face especially after he/she touched the dirty foam wedge. The ADON said the LPN should have removed gloves and washed hands after he/she touched the gauze on the resident's face. The ADON said when the LPN wiped bowel into the resident's open wound on his/her coccyx he/she introduced bacteria to the wound. The LPN should have removed his/her soiled gloves and washed hands before he/she touched the resident's clean brief. The ADON said the LPN should have washed hands after he/she handled the bedside table again, and before handling the wound supplies used for several residents. During an interview on 03/26/26 at 3:23 P.M., the Director of Nursing (DON) said when staff move from clean to dirty tasks when providing care. The staff should wash hands, apply gloves and gowns in room prior to providing care. The DON said staff should not touch clean items with soiled gloves on. The DON said if staff have dirty gloves, the staff should not place clean gauze on an open wound. The DON said after touching drawer handles, staff should remove gloves, and wash hands. The DON said staff should not wipe bowel over an open wound, it creates a cross contamination and infection risk. The DON said staff should not touch a bedside table with food debris on it, during wound care, if they do touch it, staff should remove their gloves, wash their hands and apply clean gloves and a new barrier. The DON said staff should not touch the wound supplies with dirty gloves on. 3. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP), dated September 2022, showed EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organisms (MDRO) as well as those at increased risk of MDRO acquisition like residents with wounds or indwelling medical devices for dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care. The gown and gloves will be outside the resident room for the staff to apply before entering the room and staff will remove inside the room before exiting. 4. Review of Resident #66's Quarterly MDS, dated [DATE], showed staff assessed the resident as one pressure ulcer. Observation on 03/24/26 at 9:43 A.M., showed an EBP sign posted by the door frame, at the entrance to the resident's room. Personal Protective Equipment can be observed in a three drawer, plastic bin, inside the door to the resident's room. Observation showed NA L, Certified Medication Technician (CMT) N and CNA K did not wear gowns as they assisted the resident with a shower. Observation showed the resident's mid- calf surgical wound unwrapped. Observation on 03/25/26 at 10:49 A.M., CNA R and CNA P entered the resident's room and provided incontinence care to the resident and did not wear PPE. During an interview on 03/25/26 at 12:05 P.M., CNA R said he/she provided incontinence care for the resident. The CNA said the resident was incontinent of urine and bowel. The CNA said he/she did not use a gown during the care, it slipped his/her mind. During an interview on 03/25/26 at 12:08 P.M., CNA P said the resident was incontinent of bowel and bladder. The CNA said he/she did not wear a gown, as he/she provided the incontinence care to the resident. The CNA said he/she didn't pay attention to the precautions. During an interview on 03/26/26 at 1:05 P.M., the Infection Preventionist (IP) said staff should follow EBP when they are providing direct care with residents. The IP said staff should wear gowns and gloves, when they provide incontinence care and showers for residents on EBP. The IP said he/she doesn't know why staff are not wearing gowns. The IP said he/she is responsible to make sure staff are following the precautions for EBP, and the floor nurse should be following up with staff on the floor. During an interview on 03/26/26 at 1:23 P.M., CNA G said EBP should be used anytime a resident has a wound or a catheter. The CNA said staff should wear a gown when providing a resident on EBP with a shower or incontinence care. During an interview on 03/26/26 at 1:38 P.M., LPN H said EBP, such as gown and gloves, should be used for residents with wounds and/or catheters. The LPN said staff should wear a gown if giving a resident with a wound a shower and with incontinence care. The LPN said he/she does not know why aides are not wearing gowns. The LPN said the charge nurse is responsible to make sure aides are wearing gowns with the cares, for residents on EBP. During an interview on 03/26/26 at 3:23 P.M., the DON said residents with chronic wounds, or internal medical devices should be on EBP. The DON said gowns and gloves should be used with transfers, or direct care of residents on EBP. The DON said staff should wear gowns with showers and incontinence care. The DON said he/she and the IP are responsible to make sure staff are wearing the correct PPE, when providing care to residents on EBP. 5. Review of the facility's policy titled Employee Tuberculosis Screening, dated December 2016, showed All employees shall be screened for tuberculosis (TB) infection and disease, using a two-step tuberculin skin test (TST) or blood assay for Mycobacterium tuberculosis (BAMT) and symptom screening, prior to beginning employment. Each newly hired employee will be screened for TB infection and disease after an employment offer has been made but prior to the employee's duty assignment. 6. Review of RN AA's personnel records showed a hire date of 06/02/25, with a first date worked in the facility of 06/02/25. The resident's personnel records showed he/she received his/her step one of the two step TB screening administered on 06/02/25 and read on 06/04/25. 7. Review of CNA S's personnel records showed a hire date of 12/17/25, with a first date worked in the facility of 12/17/25. The resident's personnel records showed he/she received his/her step one of the two step TB screening administered on 12/17/25 and read on 12/19/25. 8. Review of [NAME] V's personnel records showed a hire date of 12/31/25, with a first date worked in the facility of 12/31/25. The resident's personnel records showed he/she received his/her step one of the two step TB screening administered on 12/31/25 and read on 01/03/26. 9. Review of NA T's personnel records showed a hire date of 02/11/26, with a first date worked in the facility of 02/11/26. The resident's personnel records showed he/she received his/her step one of the two step TB screening administered on 02/11/26 and read on 02/13/26. 10. Review of LPN U's personnel records showed a hire date of 02/18/26, with a first date worked in the facility of 02/18/26. The resident's personnel records showed he/she received his/her step one of the two step TB screening administered on 02/18/26 and read on 02/20/26. During an interview on 03/26/2026 at 9:56 A.M., the Business Office Manager (BOM) said the Infection Preventionist (IP) does the TB screenings for new hires and keeps a binder. The BOM said on the new hire's first day in the building, the staff are in the office with him/her completing paperwork and then day two through five, staff are on the floor. During an interview on 03/26/26 at 1:05 P.M., the IP said when the BOM does orientation with new staff, a nurse here gives the first TB. The IP said the new staff's first day of orientation is with the BOM in office, the next five days the staff complete orientation on the floor. The IP said the first TB must be read, before the staff work on the floor. The IP said he/she is not in charge of the schedule anymore; it is whatever department head the new staff falls under. The IP said when he/she completed the schedule, he/she made sure the first TB was read before the new staff worked on the floor. During an interview on 03/26/26 at 3:23 P.M., the DON said the new staff come in and do orientation. The DON said the new staff work the first day in the business office and their second day, the staff are out on the floor. The DON said the corporation told him/her staff could work the floor before their first step TB is read.

Based on observation, interview and record review, facility staff failed to document a complete and accurate Minimum Data Set (MDS) assessment (a federally mandated assessment tool), when they did not accurately code anticoagulant use for two residents (Resident #5 and #6), oxygen and/or Continuous Positive Airway Pressure (CPAP - Machine that keeps the airways open during sleep for persons with sleep apnea) use for two residents (Resident #1 and #4), falls with injury for one resident (Resident #3), and a psychiatric diagnosis for one resident (Resident #41) out of 20 sampled residents. The facility census was 72. 1. Review of the facility policy titled, MDS Completion and Submission Timeframes, dated July 2017, showed the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted in accordance with current federal and state guidelines. The policy did not address the accuracy of MDS assessments. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's manual, dated October 2023, showed an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. Information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during the observation period) by the Interdisciplinary Team (IDT) completing the assessment. 2. Review of Resident #5's Significant Change MDS, dated [DATE], showed staff assessed the resident as cognitively intact and taking an anticoagulant. Review of the resident's Physician Order Sheet (POS), dated March 2026, did not show an order for an anticoagulant. 3. Review of Resident #6's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and received an anticoagulant. Review of the resident's POS, dated March 2026, did not show an order for an anticoagulant. During an interview on 03/26/26 at 2:54 P.M., the MDS Coordinator said he/she uses physician orders and the Medication Administration Record (MAR) for coding of medications. He/She thought Resident #5 and Resident #6 received anticoagulants, but it must have been an error. He/She said if they are not on an anticoagulant then the MDS should have been marked no. During an interview on 03/26/26 at 3:22 P.M., the Director of Nursing (DON) said the MDS Coordinator is responsible for coding the assessment correctly and would expect medications to be coded correctly on MDS. The DON said he/she was not aware Resident #5 and Resident #6 were coded for anticoagulants but was not currently taking an anticoagulant. The DON said he/she believes there is a corporate person who oversees the MDS assessments are being completed. During an interview on 03/26/26 at 4:41 P.M., the administrator said the MDS Coordinator is responsible for completing the assessments. The administrator said he/she expects all medications to be coded correctly on MDS assessment. 4. Review of Resident #1's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact, did not use non-invasive mechanical ventilation/CPAP, with diagnoses of atrial fibrillation (a common, often rapid, and irregular heart rhythm), heart failure, high blood pressure, and pneumonia. Review of the resident's POS, dated March 2026, did not show an order for use of CPAP. Review of the resident's care plan, dated 03/17/26, showed a diagnosis of sleep apnea, unspecified, and staff did not document the resident's use of a CPAP. Observation on 03/23/26 at 11:03 A.M. and 3:29 P.M., showed the resident's CPAP on his/her nightstand. Observation on 03/24/26 at 9:15 A.M., showed the resident's CPAP on his/her nightstand. Observation on 03/25/26 at 8:41 A.M., showed the resident's CPAP on his/her nightstand. During an interview on 03/23/26 at 3:29 P.M., the resident said he/she has used his/her CPAP for many years now and uses it at night. During an interview on 03/26/26 at 2:54 P.M., the MDS Coordinator said he/she uses physician orders and the MAR for coding of medications and treatments. He/she said if a resident uses a CPAP it should be coded on the MDS correctly, and he/she would not have known to code it without the physician orders. During an interview on 03/26/26 at 3:22 P.M., the DON said the MDS Coordinator is responsible for coding the assessment correctly and would expect if a resident was using a CPAP it should be on the assessment. The DON said he/she believes there is a corporate person who oversees the MDS assessments are being completed. During an interview on 03/26/26 at 4:41 P.M., the administrator said the resident's use of CPAP should be coded correctly on the MDS assessment. He/she said the MDS Coordinator is responsible for completing the assessments. The administrator said he/she did not know the resident was admitted with a CPAP. 5. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact, did not use non-invasive mechanical ventilation/CPAP or oxygen therapy, with diagnosis of asthma, Chronic Obstructive Pulmonary Disease (COPD), or chronic lung disease, and respiratory failure. Review of Resident's POS, dated March 2026, showed the following orders: -CPAP at 4/20 with 2 liters (L) of oxygen at bedtime; -Oxygen 2 Liters via nasal cannula for oxygen saturation below 90% or short of breath (SOB); -Change tubing and humidifier bottle, change once weekly on Sunday, and date both tubing and bottle. Review of the resident's care plan, dated 03/25/26, showed a diagnosis of COPD and staff did not document the resident's use of a CPAP or oxygen. Observation on 03/23/26 at 10:59 A.M., showed the resident in his/her recliner on 4L of oxygen via nasal cannula and a CPAP machine on the table next to the recliner. Observation on 03/23/26 at 11:23 A.M., showed the resident wheeled himself/herself in his/her wheelchair down the with oxygen on via nasal cannula. Observation on 03/24/26 at 9:35 A.M., showed the resident in his/her wheelchair in the activity room with his/her oxygen on via nasal cannula. Observation on 03/26/26 at 8:30 A.M., showed the resident in his/her recliner on 4L of oxygen via nasal cannula and a CPAP machine on the table next to the recliner. During an interview on 03/26/26 at 8:30 A.M., the resident said he/she uses oxygen continuously when in the room and when in the wheelchair outside of his/her room. He/She said he/she uses CPAP machine at bedtime and has since he/she has been at the facility. During an interview on 03/26/26 at 2:54 P.M., the MDS Coordinator said that he/she uses physician orders and the MAR for coding of medications and treatments. He/she said that if a resident uses a CPAP and oxygen it should be coded on the MDS correctly. During an interview on 03/26/26 at 3:22 P.M., the DON said the MDS Coordinator is responsible for coding the assessment correctly and would expect if a resident was using a CPAP or oxygen it should be on the assessment. The DON said he/she believes there is a corporate person who oversees the MDS assessments are being completed. During an interview on 03/26/26 at 4:41 P.M., the administrator said the resident's use of CPAP and Oxygen should be coded correctly on the MDS assessment. He/she said the MDS Coordinator is responsible for completing the assessments. 6. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff assessed the resident as unable to assess cognition, with short/long-term memory problems, had no falls since the prior assessment, and diagnosis of Alzheimer's Disease. Review of the resident's MDS assessments showed the previous assessment was a Significant Change in Status Assessment, dated 01/07/26. Review of the resident's progress notes showed the resident had falls on the following dates: - 01/10/26 fall with injury; - 02/05/26 fall with injury; - 02/23/26 fall with injury. During an interview on 03/26/26 at 2:54 P.M., the MDS Coordinator said he/she reviews resident's progress notes, fall assessments and related documentation such as care plans to see if the resident has had any falls since the prior assessment. The MDS Coordinator said falls are reviewed at the morning meeting, and he/she did not know how he/she missed that. He/she said it should be coded correctly on the MDS assessment. During an interview on 03/26/26 at 3:22 P.M., the DON said the MDS Coordinator is responsible for coding the assessment correctly and would expect if a resident had falls or falls with injury it should be on the assessment. The DON said he/she believes there is a corporate person who oversees the MDS assessments are being completed. During an interview on 03/26/26 at 4:41 P.M., the administrator said falls should be coded correctly on the MDS assessment and he/she did not know that it was not done for the resident. 7. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident as received antipsychotic medication and did not check the resident had a psychotic Disorder. Review of the resident's POS, dated March 2026, showed an order for Olazapine 2.5 Milligram (MG) (Antipsychotic) with Diagnosis of Psychotic Disorder. During an interview on 03/26/26 at 2:54 P.M., the MDS Coordinator said when he/she completes MDS section N for medications, he/she gets those medications from MARS and POS. The MDS Coordinator said he/she find the diagnosis under the medical diagnosis tab. The MDS Coordinator said he/she does not know what the nurses do, when a resident gets a new diagnosis. The MDS Coordinator said the MDS for the resident would not be accurate, and he/she would need to do the modification and resubmit the MDS. During an interview on 03/26/26 at 3:23 P.M., The DON said the MDS Coordinator is responsible for accurate MDS assessments. The DON said the administrator is responsible to make sure the MDS Coordinator is completing MDS accurately. The DON said if a resident's POS says antipsychotic for Psychotic disorder, psychotic disorder should be identified on the MDS. During an interview on 03/26/26 at 4:41 P.M., the administrator said if a resident has a diagnosis of Psychotic Disorder on POS, the diagnosis should be on MDS.

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 four residents (Residents #4, #11, #23, and #41) out of 20 sampled residents. The facility census was 72.1. Review of the facility's policy titled Comprehensive Care Plans, dated 09/22, showed the care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care; -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; -The residents' goals for admission, desired outcomes, and preferences for future discharge; -The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 2. Review of Resident # 4's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/30/25, showed staff documented the resident as: -Cognitively intact; -Very Important to listen to music, and go outside for fresh air; -Somewhat important to do things with groups of people, do favorite activities, and participate in religious services; -Did not use Continuous Positive Airway Pressure (CPAP), a machine that keeps the airways open during sleep for persons with sleep apnea) or oxygen therapy -Diagnoses of asthma, Chronic Obstructive Pulmonary Disease (COPD), or chronic lung disease, and respiratory failure. Review of the Resident's POS, dated March 2026, showed the following orders: -CPAP at 4/20 with two liters (L) of oxygen at bedtime; -Oxygen two Liters via nasal cannula for oxygen saturation below 90% or shortness of breath; -Change tubing and humidifier bottle weekly on Sunday. Review of the resident's care plan, dated 03/25/26, showed staff did not document the resident's activities preferences, oxygen therapy, or CPAP usage. Observation on 03/23/26 at 10:59 A.M., showed the resident in his/her room with his/her oxygen on at 4 liters via nasal cannula and the CPAP machine on a table. Observation on 03/23/26 at 11:23 A.M., showed the resident wheeled down the hallway in his/her wheelchair with his/her oxygen on. Observation on 03/24/26 at 9:35 A.M., showed the resident in an activity with his/her oxygen on. Observation on 03/26/26 at 8:30 A.M showed the resident in his/her room with his/her oxygen on via nasal cannula and the CPAP machine on a table. During an interview on 03/26/26 at 8:30 A.M., the resident said he/she uses oxygen continuously. He/She said he/she uses the CPAP machine at bedtime and has since he/she has been at the facility. He/She said he/she enjoys going to activities and tries to attend them all. 3. Review of Resident #11's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Moderate Cognitive Impairment; -Diagnosis of diabetes; -Received seven Insulin injections in the last seven days; -Receives a hypoglycemic medication (used to lower blood sugar). Review of the resident's care plan, revised 03/17/26, showed staff did not document the resident's diagnosis of diabetes or interventions. 4. Review of Resident #23's Comprehensive MDS, dated [DATE], showed staff assessed the resident as cognitively intact and very important to listen to music, keep up with the news, do things with groups of people, do favorite activity, go outside to get fresh air, and participate in religious services. Review of the resident's care plan, dated 02/13/26, showed staff did not document the resident's activity preferences or interests. During an interview on 03/25/26 at 8:17 A.M., the resident said he/she enjoys going to activities. During an interview on 03/26/26 at 1:32 P.M., Licensed Practical Nurse (LPN) F said if a resident receives Oxygen or uses a CPAP that information should be on the residents' care plan. He/She said a diagnosis like diabetes and activity preferences should also be the care plans. He/She said care plans guide staff on how to care for that resident. He/She said if a nurse notices something is not on the care plan, they should let the MDS coordinator know. During an interview on 03/26/26 at 2:55 P.M., the MDS Coordinator said he/she uses physician orders, progress notes, meetings, and assessment documentation for updating care plans. He/she said if a resident uses a CPAP, Oxygen, and has a diagnosis of diabetes that should be included on the care plan. He/She activity preferences are asked about upon admission and should be on care plan, so staff know what the resident likes. Care plans shape what the staff should be doing for the residents and lets staff know how to care for residents. During an interview on 03/26/26 at 3:22 P.M., the Director of Nursing (DON) said oxygen use and CPAPs should be on the care plan along with a diagnosis of diabetes and residents' activity preferences. He/She said the MDS coordinator updates the care plans. He/She said care plans are important, so staff know how to care for that resident. During an interview on 03/26/26 at 4:41 P.M., the administrator said he/she expects CPAP's, oxygen therapy, a diagnosis of diabetes, and activity preferences to be on the care plan. He/She said care plans are important to identify all needs and its communication, so all staff know the individual and how to care for them. 5. Review of Resident #41's Quarterly MDS, dated [DATE], showed staff assessed the resident requires a mechanically altered diet. Review of the resident's Dietary Slip, dated 03/23/26, showed pureed texture for the resident. Observation on 03/23/26 at 12:37 P.M., showed the resident ate a lunch meat sandwich in the dining room. Review of the resident's Dietary Slip, dated 03/24/26, showed pureed texture for the resident. Observation on 03/23/26 at 12:02 P.M., showed the resident ate a lunch meat sandwich in the dining room. Review of the resident's care plan, dated 01/29/26, showed staff documented the resident receives a regular diet with pureed texture. Staff did not document the resident may have exceptions to the diet for comfort. During an interview on 03/26/26 at 1:23 P.M., Certified Nursing Assistant (CNA) G said the resident should receive Pureed food. The CNA said he/she doesn't know why the resident is getting sandwiches, unless an aide is going to get the resident a sandwich, because the resident is asking for it. The CNA said if the resident can have comfort foods, it should be on the resident's care plan, so staff knows. During an interview on 03/26/26 at 1:38 P.M., LPN H said he/she believes the resident should receive a pureed diet. The LPN said he/she was not under the impression the resident received sandwiches, his/her diet order does not indicate he/she can have that. The LPN said sometimes residents can have pleasure foods, if the resident and family are educated of the risk. The LPN said if sandwiches are for comfort purposes, it should be on the resident's care plan. The LPN said he/she would assume it is not on the care plan. During an interview on 03/26/26 at 2:54 P.M., the MDS Coordinator said a resident's diet consistency should be on the care plan. The MDS Coordinator said if a resident has exceptions to consistency, like comfort food, it should be on care plan. During an interview on 03/26/26 at 4:41 P.M., the administrator said if a resident is on a pureed diet, it should be on the resident's care plan. The administrator said exceptions to the diet, like comfort food, should be identified on the care plan.

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 three residents (Resident #4, #23, and #28) out of 20 sampled residents. The facility census was 72.1. Review of the facility's policy titled, Life Enrichment Program, dated 10/2017, showed facility-sponsored group and individual activities and independent activities will be designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, as well as encourage both independence and interaction within the community. 2. Review of the facility's Activity Calendar, dated February 2026, showed: -Saturdays, 02/07, 02/14, 02/21, 02/28 Games/Puzzles;-Sundays, 02/01, 02/15 Games/Puzzles;-Sunday, 02/08 Superbowl Sunday 5 P.M. Wear your Colors;-Sunday, 02/22 Church everyone. Review of the facility's Activity Calendar, dated March 2026, showed: -Saturdays, 03/07, 03/14, 03/21, 03/28 Games, Puzzles, Read a book;-Sundays, 03/01, 03/08, 03/15, 03/22 TV, Church, Games, Puzzles;-Sunday, 03/29 Church, All Welcomed. During an interview on 03/24/26 at 12:22 P.M., Resident #4 said he/she tries to go to all activities. He/She said there are no weekend activities. He/She said, I feel kind of lost on the weekends without activities, I wish there was activities on the weekends. During an interview on 03/25/26 at 8:17 A.M., Resident #23 said he/she enjoys going to activities. He/She said there are no activities on the weekends. He/She said he/she wishes there was activities on the weekends, he/she said I'm bored when there are no activities. During an interview on 03/26/26 at 10:43 A.M., Resident #28 said I love going to activities, I go to all of them. He/She said there are no weekend activities. Resident said without weekend activities, It leaves me just laying here, I wish they had activities on the weekends. During an interview on 03/26/26 at 1:29 P.M., Certified Nurse Assistant (CNA) J said on the weekends the aides can do some activities like puzzles or a movie if they have time. He/She said a lot of residents enjoy doing cross word puzzles on weekends. He/She said there are no staff led activities on the weekends. During an interview on 03/26/26 at 1:32 P.M., Licensed Practical Nurse (LPN) F said some residents go to church and once a month a church comes into facility on a Sunday. He/She said the residents can watch a movie in the activity room or do Puzzles. He/She said there are no staff led activities on the weekends. During an interview on 03/26/26 at 1:22 P.M., the activities director said on the weekends the residents have puzzles, books, and movies in the activity room they can do. He/She said, the weekends are kind of down time for the residents. He/She said there are no staff led activities on the weekends. He/She said he/she was not aware they needed staff-led activities on the weekends. During an interview on 03/26/26 at 3:22 P.M., the Director of Nursing (DON) said on the weekends there are puzzles, movies, books, and music playing. He/She said activities are not scheduled on the weekends. He/She said he/she was not aware of regulation and staff led activities on the weekends. During an interview on 03/26/26 at 4:41 P.M., the administrator said on the weekends the residents have board games, movies, and church on Sunday. He/She said there are no staff led activities on the weekends. He/She said he/she was aware of regulation, he/she said they recently hired an assistant to help with activities but need to see if they can come in on the weekends to do activities.

Based on observation, interview and record review, facility staff failed to provide care and services to meet professional standards in regard to the use of a Continuous Positive Airway Pressure (CPAP) device, the standard treatment for obstructive sleep apnea using a mask and gentle air pressure to keep airways open during sleep, when facility staff failed to obtain an order for the use of the CPAP, and include the use of CPAP on the resident's care plan, for one resident (Resident #1) of two sampled residents. The facility census was 72. 1. Review of the facility policy titled CPAP/Bi-level positive airway pressure (BiPAP) Support, dated March 2025, showed the following: -Review the physician's order to determine the oxygen concentration and flow, and the Positive End-Expiratory Pressure (PEEP) pressure for the machine; -Wipe machine with warm, soapy water and rinse at least once a week and as needed; -Humidifier: use clean, distilled water only in the humidifier chamber, clean humidifier weekly and air dry; to disinfect, place vinegar-water solution (1:3) in a clean humidifier, soak for 30 minutes and rinse thoroughly; -Filter cleaning: rinse washable filter under running water once a week to remove dust and debris, replace disposable filters monthly; -Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for five minutes, mild dish detergent is recommended, rinse with warm water and allow to air dry between uses; -Document the following in the resident's medical record:-General assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure; -Time CPAP was started and duration of the therapy; -Mode and settings for the CPAP; -How the resident tolerated the procedure; -Oxygen saturation during therapy. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/25/26, showed staff assessed the resident as cognitively intact, did not use non-invasive mechanical ventilation/CPAP, with diagnoses of atrial fibrillation (irregular heart rhythm), heart failure, high blood pressure, and pneumonia. Review of the resident's care plan, dated 03/17/26, showed staff documented a diagnosis of sleep apnea, unspecified, and the care plan did not contain guidance or information for CPAP use.Review of the resident's Physician Order Sheet (POS), dated March 2026, showed the orders did not contain use of CPAP with the required information for the type of unit, pressure settings, frequency of therapy and cleaning schedule. Review of the resident's medical record showed staff did not document a resident assessment regarding the resident's use of CPAP including time and duration of therapy, mode and settings, how the resident tolerated CPAP use or the oxygen saturation during therapy. Observation on 03/23/26 at 11:03 A.M., showed the resident's CPAP on his/her nightstand. Observation on 03/24/26 at 9:15 A.M., showed the resident's CPAP on his/her nightstand. Observation on 03/25/26 at 8:41 A.M., showed the resident's CPAP on his/her nightstand. Observation on 03/26/26 at 8:22 A.M., showed the resident's CPAP on his/her nightstand. During an interview on 03/23/26 at 3:29 P.M., the resident said he/she had used his/her CPAP for years, and staff forgets to put water in the CPAP, which causes his/her mouth to become dry and his/her nose to burn. During an interview on 03/26/26 at 8:22 A.M., the resident said staff must put the water in the machine and then press the button to turn it on, but he/she can usually take the mask off and on. The resident said he/she was not sure what the settings were for the CPAP, but he/she can tell when it is not blowing enough air and will ask staff to adjust the settings. He/she said a night or so ago, it did not feel like it was working right, so staff adjusted the settings. The resident said he/she was not sure how staff would know the settings, he/she just tells them when it does not feel right, but he/she does not believe the CPAP has auto settings, where it would self-adjust. The resident said he/she has not seen staff clean the CPAP mask, tubing or machine. During an interview on 03/26/26 at 1:07 P.M., Certified Nurse Aide/Certified Medication Technician (CNA/CMT) G said CPAPs should be on a resident care plan, so staff know when it should be on, what to watch out for if the resident has sleep apnea, when it needs to be cleaned or if water needs to be added. During an interview on 03/26/26 at 1:11 P.M., Licensed Practical Nurse (LPN) H said there should be orders for CPAP and it is important to have the orders because it helps the resident breathe at night. He/She said the order should include the settings, when to clean it, when it should be put on and taken off, and if water is required. The LPN said he/she would think it needs to be cleaned every day. LPN H said the CPAP should be on the care plan because it lets staff know when it needs to be cleaned, when it should be put on and when the resident uses it. LPN H said he/she did not know the resident did not have orders for the CPAP. LPN H said usually the admitting nurse gets the orders from the physician and enters them in the computer system. During an interview on 03/26/26 at 2:54 P.M., the MDS Coordinator said if a resident uses a CPAP, it should be on the care plan, and that he/she is responsible for updating the care plans. The MDS Coordinator said he/she did not know that the resident used a CPAP as there were no orders, and the CPAP was not on the MDS assessment, which would trigger him/her to add it to the care plan. During an interview on 03/26/26 at 3:22 P.M., the Director of Nursing (DON) said there should be orders for CPAP use, with the settings and cleaning schedule and use of distilled water. He/she said the admitting nurse is responsible for putting the CPAP orders in, and then he/she or the Assistant Director of Nursing (ADON) follow through if something has been missed. The DON said he/she did not know the resident had CPAP. He/She said those kinds of things are usually talked about weekly on Tuesday morning, and it would be important to make sure it is used correctly. The DON said CPAP use should be on the care plan, and the MDS Coordinator is responsible for updating the care plans. He/she believes there is a corporate staff that oversees the facility's MDS Coordinator. The DON did not know why the orders were missing.During an interview on 03/26/26 at 4:41 P.M., the Administrator said it is important to have orders for CPAP use, to know the settings, to make sure infection control is being followed, and for cleaning directions. The administrator said CPAP use should be on the resident's care plan, because care plans identify all resident care needs, so that all departments and staff know the individual care for that specific resident. The administrator said he/she did not know the resident was admitted with CPAP, he/she has a spreadsheet with all special equipment that residents use, like CPAP, BiPAP and nebulizers, and he/she goes over it every Tuesday at the weekly meeting and it was not listed. The administrator said the admitting or charge nurse is responsible for entering the necessary orders, and the DON and ADON are responsible for overseeing the charge nurse.

Based on observation, interview, and record review, facility staff failed to complete entrapment assessments for five residents (Resident #11, #32, #63, #66, and #70) who used bed rails out of 20 sampled residents. The facility census was 72. 1. Review of the facility's policy titled Proper Use of Side Rails, dated 09/2022, showed:-The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself;-Inspecting and regularly checking the mattress and bed rails for areas of possible entrapment;-Ensuring the bed frame, bed rail, and mattress do not leave a gap wide enough to entrap a resident's head of body, regardless of mattress width, length, and/or depth;-The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule of all bed frames, mattresses, and bed rails.2. Review of Resident #11's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 03/25/26, showed staff assessed the resident as moderate cognitive impairment and restraints not used.Review of the resident's care plan, revised 03/20/26, showed staff documented assist bar on the upper left side of bed.Review of the resident's medical record showed the record did not contain an entrapment assessment.Observation on 03/23/26 at 1:14 P.M., showed resident in bed with the left grab bar in upright position on the bed.Observation on 03/24/26 at 08:36 A.M., showed resident in bed with left grab bar in upright position on the bed.Observation on 03/25/26 at 11:01 A.M., showed resident in bed with left grab bar in upright position on the bed.Observation on 03/26/26 at 10:45 A.M., showed resident in bed with left grab bar in upright position on the bed.3. Review of Resident #32's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment and restraints not used.Review of the resident's medical record showed the record did not contain an entrapment assessment.Observation on 03/23/26 at 11:32 A.M., showed the resident in bed with grab bars in upright position on both sides of the bed. Observation on 03/25/26 at 10:37 A.M., showed the resident in bed with grab bars in upright position on both sides of the bed. Observation on 03/26/26 at 9:25 A.M., showed the resident in bed with grab bars in the upright position on both sides of the bed. 4. Review of Resident #63's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact and restraints not used.Review of the resident's care plan, revised 03/10/26, showed staff documented bilateral assist rails.Review of the resident's medical record showed the record did not contain an entrapment assessment. Observation on 03/23/26 at 1:01 P.M., showed the resident in bed with bilateral grab bars in upright position on the bed.Observation on 03/24/26 at 1:32 P.M., showed the resident in bed with bilateral grab bars in upright position on the bed.Observation on 03/25/26 at 8:52 A.M., showed the resident in bed with bilateral grab bars in upright position on the bed.Observation on 03/26/26 at 10:30 A.M., showed the resident in bed with bilateral grab bars in upright position on the bed.5. Review of Resident #66's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderate cognitive impairment and restraints not used.Review of the resident's medical record showed the record did not contain an entrapment assessment.Observation on 03/25/26 at 10:49 A.M., showed the resident in bed with a grab bar in the upright position, on left side of the bed.Observation on 03/26/26 at 9:23 A.M., showed the resident in bed with a grab bar in the upright position, on left side of the bed.6. Review of Resident #70's Annual MDS, dated [DATE], showed staff assessed the resident as intact cognition and restraints not used.Review of the resident's medical record showed the record did not contain an entrapment assessment.Observation on 03/23/26 at 12:02 P.M., showed the resident in bed with quarter siderails in the upright position on both sides of the bed.Observation on 03/26/26 at 9:21 A.M., showed the resident in bed with quarter siderails in the upright position on both sides of the bed.7. During an interview on 03/25/26 at 4:32 P.M., the maintenance director said he/she only installs the bedrails after the MDS coordinator says the assessment is completed. He/She said he/she only installs the bedrails. He/She said he/she thinks the MDS coordinator does the measurements after he installs them. During an interview on 03/26/26 at 8:44 A.M., the MDS coordinator said he/she only does the bed rail assessments. He/She said he/she does not do anything with measuring bed rails for entrapment. He/She said he/she thought maintenance does the measurements. He/She said he/she tells maintenance what rails to put on the bed and they have the form to fill out with measurements that they keep.During an interview on 03/26/26 at 2:36 P.M., the maintenance director said after the bed rail assessment is completed, he/she will go put the assist bar on the bed. He/She said he/she does not do any type of measurements when he/she puts the assist bars on the bed, he/she said he/she was never informed to do entrapment measurements. He/She said he/she was never instructed to go back and do any measurements with a mattress change or quarterly. He/She said entrapment assessments are important, so the resident's arm or neck does not get entrapped in the bed rail.During an interview on 03/26/26 at 3:22 P.M., the Director of Nursing (DON) said the MDS Coordinator and him/herself perform the bed rail assessment and inform maintenance to put the assist bars on the bed. He/She said maintenance is supposed to be doing entrapment measurements when he/she puts them on the bed. He/She said he/she was not aware maintenance was not doing entrapment measurements. The Administrator is responsible for ensuring that it is being completed. He/She said the importance of entrapment assessment is, so the resident does not get trapped or cause an injury. During an interview on 03/26/26 at 1:22 P.M., the administrator said he/she believes there was miscommunication about who is responsible for entrapment assessments. He/She said the MDS coordinator does the bed rail assessment, then maintenance is supposed to be doing the entrapment measurements when the rails are put on the bed. He/She said he/she was not aware that it was not being done. He/She said entrapment assessments are important to prevent rolling off the bed and injury.

Based on observation, interview, and record review, facility staff failed to safely transfer one resident (Resident #1) out of two sampled residents in a manner to prevent accidents when staff failed to use a gait belt during a transfer which resulted in a fracture. The facility's census was 73. The administrator was notified on 11/26/25 of past Non-Compliance which occurred on 11/16/25 when the administrator implemented new policies and procedures to ensure the nursing staff safely transferred residents. Staff were in-serviced on 11/16/25 regarding how to safely transfer a resident.1. Review of the facility's Safe Lifting and Movement of Residents policy, dated 07/2017, showed to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate decisions regarding the safe lifting and moving of residents. Manual lifting of residents shall be eliminated when feasible. The policy did not contain direction for staff regarding when to use a gait belt.Review of the facility's Educational Guide for Caregivers for Safe Transfers policy, undated, showed staff are directed to always use a gait belt for staff and patient's safety. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/16/25, showed staff assessed the resident as moderately cognitively intact and required substantial to maximal assistance from staff with transferring to and from a bed to a chair (or wheelchair). Review of the resident's care plan, dated 11/24/25, showed staff documented the resident required substantial to maximum assistance from staff with transfers. The care plan did not contain documentation to direct staff on gait belt use with transfers. Review of the facility's fall incident report, dated 11/16/25, showed staff documented the resident had a fall with injury and was sent to the hospital. Staff documented Certified Nurse Aide (CNA) A and Nurse Aide (NA) D had attempted to lift the resident under his/her arms and heard a popping noise. Staff assessed the resident with a possible hip fracture after a fall. CNA A and NA D were counseled for n ot following fall protocol and resulted in a resident injury. Review of the resident's hospital discharge paperwork, dated 11/16/25, showed a diagnosis of a closed fracture of the left femur.During an interview on 11/26/25 at 10:42 A.M., CNA A said staff went into the resident's room and found the resident was partially on the bed with his/her upper half on the bed face down. He/She said NA D was trying to get the resident to an upright position on the floor. He/She said NA D had grabbed the resident under her arm pits and was beginning to move him/her on to the floor, when the resident turned, they heard a popping noise. He/She said neither staff member used a gait belt during the transfer. He/She said he/she did not know if staff were required to use a gait belt with the resident. He/She said the resident required a one person assist, but two staff members always transferred the resident. He/She said two staff would lift the resident with one hand under the arm on each side and another hand on the brief and pants. He/She said the concern with not using a gait belt when transferring the resident is the potential for injury. He/She said they should not have moved the resident without a gait belt, but they were worried about the resident safety and didn't think about it. He/She said he/she did not recall having an in-service on safely transferring residents, including during orientation.During an interview on 11/26/25 at 12:45 P M, Licensed Practical Nurse (LPN) B said to transfer a resident safely, staff are directed to use a gait belt and the appropriate number of staff. He/She said the resident was a two person assist. He/She said the concern with not using a gait belt while transferring the resident is the possibility of a fall. During an interview on 11/26/25 at 12:52 P.M., CNA C said staff were directed to use a gait belt when transferring a resident. He/She said the resident could potentially fall or hurt themselves if not safely holding on to the resident.During an interview on 11/26/25 at 1:16 P.M., the Director of Nursing (DON) [NAME] said staff are directed to use a gait belt or other type of transferring equipment. He/She said the resident was a one person assist with a gait belt. He/She said the concern with not using a gait belt while transferring a resident is the potential for injury due to fall. He/She said he/she did not think the staff used a gait belt during a transfer of the resident, which is why staff were in-serviced on safe transfers. 2669281

Based on interview and record review, facility staff failed to administer medications as ordered by the physician when Licensed Practical Nurse (LPN) D prepared insulin for Resident #2, and the Assistant Director of Nursing (ADON) administered the insulin to Resident #1 and facility staff failed to document a medication error in the resident's medical record. The facility census was 78. 1. Review of the facility's medication administration policy, dated December 2024, showed the individual administering the medication must check the label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall document appropriately in the clinical chart. 2. Review of Resident #1's Minimum Data Set (MDS), a federal mandated assessment tool, dated 5/23/25, showed the staff assessed the resident as: -Cognitively intact; -Diagnoses of Alzheimer's, hypothyroidism, congestive heart failure, schizophrenia, and diabetes mellitus type II. Review of the Physicians Order Sheet (POS), dated June 2025, showed the POS did not contain a physician order for insulin. Review of the resident's progress notes, dated June 2025, showed the nurses notes did not contain documentation the resident received another resident's insulin on 6/7/25. During an interview on 6/16/25 at 12:04 P.M., the physician's nurse said the doctor was notified on 6/10/25 when the resident received another resident's insulin on 6/7/25. During an interview on 6/16/25 at 12:10 P.M., the Director of Nursing (DON) said he/she was unaware of a medication error and the resident being given insulin. He/She said it is the expectation of the staff to document if there is a medication error in Point Click Care (PCC) (an electronic Medical Record system) in the progress notes. He/She said one staff should not prepare the medications while another one gives them. During an interview on 6/16/25 at 12:15 P.M., the ADON said he/she had to come in to work because the medication technician went home. He/She said he/she was aware of the medication error which occurred on 6/7/25. He/She said Licensed Practical Nurse (LPN) D was more familiar with the residents to pass medications, so they prepped the insulin and gave it to him/her to administer to the resident. He/She said he/she checked the resident's blood glucose and administered the insulin in conjunction with the insulin sliding scale. He/She said the family was with the resident asked when the resident started taking insulin. He/She said this is when they discovered the medication error and LPN D called the on-call doctor. He/She said staff are not to prepare medication and another staff administer. He/she said staff should document errors in PCC. He/She said he/she just went along with this system of LPN D preparing the insulin and he/she administering it because they have been short of staff, and he/she came in halfway through the medication pass. During an interview on 6/16/25 at 12:23 P.M., LPN D said they had a medication technician go home early during medication pass. He/She said he/she prepared insulin and the glucometer for Resident #2 when the ADON came up and said he/she would take care of it. He/She said the ADON realized his/her mistake after the insulin had been given to Resident #1 and said he/she would take care of notification and charting of the medication error. During an interview on 6/16/25 at 12:31 P.M., the administrator said he/she was made aware of the medication error and started an investigation. He/She said the ADON had to come in on 6/7/25 due to a medication technician going home. The ADON said LPN D handed him/her the insulin pen and glucometer. He/She said staff are expected to notify the doctor, the family and himself/herself if an error occurs with medications, and all of this should be documented in PCC. Staff are not expected to prepare medication and another staff administer the medication. MO00255687 MO00256185

Based on interview and record review facility staff failed to ensure one resident (Resident #1) remained free from accidents when staff failed to prevent Resident #1 from ingesting Resident #2's medications. The facility census was 83. The administrator was notified on 04/08/25 of past Non-Compliance which occurred on 03/29/25. when Resident #1 ingested Resident #2's medications. Staff assessed the resident, and notified the required parties and agencies. The administrator immediately in-serviced all nursing staff in-serviced nursing staff on medication administration. Staff corrected the deficient practice on 4/02/25. 1. Review of the facility's Administering Medications Policy, updated 12/2012, showed staff are to verify the resident's identity three times before administering the medication. Review showed staff are to check the medication label to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Review showed, during medication administration, no medications are kept on top of the cart, the cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Review of the facility's Adverse Consequences and Medication Errors policy, updated 4/2017, showed in the event of a significant medication related error, staff are to notify the attending Physician, implement the Physician's orders, monitor the resident closely for 24 to 72 hours or as directed, describe the incident on shift change to alert staff for the need to monitor the resident, document the incident, and forward the report to the Director of Nursing (DON), Quality Assurance Nurse, Medical Director, and Consultant Pharmacist. 2. Review of the facility's investigation, dated 3/29/25, showed staff documented Resident #1 approached the medication cart requested his/her night medications. Certified Medication Technician (CMT) C set aside the cup of medications he/she had prepared for Resident #2, and prepared Resident #1's Atorvastatin (a cholesterol reducing medication) 40 milligrams (mg), along with a cup of water, and handed the medication to Resident #1. Licensed Practical Nurse (LPN) D stood to the right of the medication cart, and requested CMT C check his/her blood glucose level. CMT C performed the blood glucose level on LPN D, after taking his/her own medication, Resident #1 reached in front of CMT C, picked up the cup containing Resident #2's medications, and ingested the medications. Review showed Resident #1 ingested one 5mg tablet of Haloperidol (an antipsychotic medication), one 20 mg tablet of Atorvastatin Calcium, and one 400 mg tablet of Clozaril (an antipsychotic). 3. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/07/25, showed staff assessed the resident as cognitively intact and independent with ambulation. Review of the resident's plan of care plan, dated 3/14/25, showed staff were directed to give medications as ordered. Review of the resident's Physician's Order Sheet (POS), dated March 2025, showed the POS did not contain an order for Haloperidol, Atorvastatin Calcium 20 mg, or Clozaril 400 mg. Review of the resident's nurses' note, dated 3/29/25 at 6:49 P.M., showed LPN D documented he/she stood at the medication cart when CMT C handed Resident #1 his/her medications, turned to check LPN D's blood glucose level, and when he/she looked down, Resident #1 had taken his/her own medication, then set the cup down and took Resident #2's medication. Staff assessed Resident #1 and notified the on-call Nurse Practitioner. Staff obtained an order to monitor Resident #1's vitals signs every shift. Review of the resident's nurses' note, dated 3/30/25 at 4:58 A.M., showed Registered Nurse (RN) E documented at 4:50 A.M., resident's oxygen saturation level measured 89 percent with a heart rate in the 40's. RN E documented the resident's family member gave permission to send the resident to the Emergency Department. RN E documented, Audible wheezing could be heard down the hall two doors down. Skin greyish in color at this time and gurgling is clearly heard with only the ears. During an interview on 4/07/25 at 2:50 P.M., the DON said staff are directed to administer medications, or lock medications in the medication cart if they are unable to administer the medications immediately. The DON said he/she in-serviced staff regarding completing one task before performing another task, and to not interrupt staff if they are administering medications. He/She said the on-call Nurse Practitioner directed staff to monitor the resident every shift. He/She said staff were monitoring the resident at least every two hours. During an interview on 4/07/25 at 11:36 A.M., the physician said staff contacted his/her office and notified him/her about the medication error. The physician said he/she could not say for sure if the medication error led to the resident's death, but he/she had been notified. During an interview on 4/07/25 at 3:29 P.M., LPN D said he/she approached CMT C as CMT C was giving Resident #1 his/her medications, and requested CMT C check LPN D's blood glucose level. LPN D said as Resident #1 was finishing his/her cup of water, CMT C pivoted his/her body to perform a fingerstick on LPN D. LPN D said while CMT C was performing the fingerstick on LPN D, Resident #1 reached in front of CMT C, picked up the cup containing Resident #2's medications, and ingested the medications. LPN D said he/she and CMT C immediately assessed the resident's vital signs, took the resident to his/her room, and notified the on-call Nurse Practitioner, DON, and Administrator. During an interview on 4/07/25 at 3:40 P.M., CMT C said as he/she was preparing Resident #2's medications, Resident #1 approached him/her and requested his/her medication. CMT C said he/she placed Resident #2's cup of medications on top of the medication cart, and prepared Resident #1's medication.CMT C said he/she handed Resident #1 his/her medication and a cup of water. He/She said as the resident finished the water, LPN D approached him/her and requested he/she check LPN D's blood glucose level. While CMT C was performing the fingerstick on LPN D, Resident #1 reached in front of CMT C, picked up the cup containing Resident #2's medications, and ingested the medications. CMT C said he/she and LPN D immediately assessed the resident's vital signs, took the resident to his/her room, and notified the on-call Nurse Practitioner, DON, and Administrator. MO00251947 and MO00252178

Based on interview and record review, facility staff failed to prevent misappropriation of one residents (Resident #1's) out of four sampled residents when Licensed Practical Nurse (LPN) A misappropriated the resident's Oxycodone (an Opioid analgesic) and Lorazepam (an antianxiety medication). The facility census was 83. The administrator was notified on 04/08/25 of past Non-Compliance which occurred on 03/07/25. Staff immediately suspended LPN A, conducted an investigation, and notified the required parties and agencies. The administrator immediately in-serviced all staff on facility's policy regarding counting narcotics and accounting for medications upon a resident's discharge, and abuse, neglect and misappropriation. The deficiency was corrected on 03/11/25. 1. Review of the facility's Abuse, Neglect, and Exploitation Program Responsibilities Policy, dated 9/2022, showed staff are directed as follows: -Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation, including the freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms, injury of unknown origin, or theft of belongings; -Residents must not be subject to abuse by anyone, including, but not limited to: facility staff, other residents, consultant contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 2. Review of Resident #1's Discharge Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/07/25, showed staff assessed the resident as cognitively intact. Review showed staff documented the resident with occasional pain with an intensity level of seven, and received opioid and antianxiety medications. Review of the resident's physician order sheet (POS), dated 2/01/25, showed an order for Oxycodone-Acetaminophen (Apap) 10-325 mg, one tablet every six hours for chronic pain. Review showed the resident's POS did not contain an order for Lorazepam. Review of the pharmacy Packing Slip Proof of Delivery, dated 2/28/25, showed the pharmacy delivered four Oxycodone filled bubble cards of 30 tablets each for a total of 120 tablets. Review of the resident's Medication Release Form, dated 3/07/25, showed staff documented the staff released to the resident 49 tablets of Oxycodone-APAP 10-325 mg and 25 tablets of Lorazepam .5 mg. Review of the facility's investigation, dated 3/11/25, showed staff documented on 3/11/25, staff reported the resident medications from his/her discharge on [DATE] missing to the Director of Nursing (DON). Staff documented the pharmacy delivered 120 tablets of Oxycodone on 2/28/25. Review showed staff discharged the resident with 19 tablets of Oxycodone and three cards of 30 tablets of Oxycodone, which the resident reported missing. Upon review of video footage, staff observed LPN A in the medication room pull three medication cards from the locked narcotic box, and place the three cards into the top drawer of the medication cart. LPN A took one of the cards from the locked narcotic box, placed the three cards in the top of the medication cart, and took one of the cards and the medication sign out sheet from the top of the cart, and left the medication room, and walked down the hallway. Upon returning into the video screen he/she disposed of something in the shred bin and something in the trash. Review of the local police department's incident report, dated 3/20/25, showed on 3/11/25 the investigator documented video from the facility showed LPN A handling the missing medications for the resident. The three cards, according to the administrator were one full card of 30 Oxycodone (Percocet), one partial card of 20 tablets of Oxycodone (Percocet), and a card containing 25 tablets of Lorazepam. In the video, LPN A is seen pulling the three cards from a locked box, only to place two cards back and leave the medication room with a full card and medication sign-out sheet. After less than five minutes LPN A is seen coming back up to the office where he/she is seen disposing of something in a shred bin and something else into the trash. The administrator watched the video, went through the shred bin, and located the top of the medication card, matching the resident's missing prescription. The administrator said there would have been no reason at that time for the resident to even have used up a full card, suggesting that LPN A was seen in the video leaving with a full card of Oxycodone only to dispose of the packaging without accounting for the medication. During an interview on 3/25/25, at 11:09 A.M., the DON said the resident's spouse notified the facility on 3/11/25, to inform them resident was missing medications from his/her discharged medications on 3/07/25. The DON said during the investigation, staff reviewed video of the medication room and nurse's station, and observed LPN A pull three cards from the locked box, take a card and sign out sheet down the hall, and discard something in the trash, and something in the shred bin. During an interview, on 3/25/25 at 11:50 A.M,. the Administrator said he/she reviewed the video footage of LPN A pulling three cards from the locked box in the medication room, walking down the hall with a card and sign out sheet, then returning to the nurse's station, and discarding something in the trash, and something in the shred bin. The Administrator said she and the DON found the top of the resident's medication card in the shred bin, and empty medication card in the trash. The administrator said he/she notified the local police department and state agency. MO00250892

Based on observation, interview, and record review, facility staff failed to provide a clean barrier for wound supplies during wound care for two residents (Resident #2 and #3) and failed to perform approved hand hygiene during incontinence care for two residents (Resident #3 and #64) out of 25 sampled residents. Facility staff failed to ensure dietary staff performed hand hygiene as often as necessary using approved techniques to prevent cross-contamination during food preparation and service. The facility census was 71. 1. Review of the facility's policy titled, Dressings, Dry/Clean, dated September 2013, showed staff are directed to do: -Clean bedside stand; -Establish a clean field; -Place clean equipment on the clean field. 2. Observation on 08/29/24 at 9:20 A.M., showed LPN (Licensed Practical Nurse) S entered Resident #2's room with wound care supplies and placed the supplies directly on the end of the resident's bed. The LPN did not provide a clean field for the wound care supplies prior to wound care. 3. Observation on 08/29/24 at 8:20 A.M., showed LPN S entered Resident #3's room with wound care supplies and placed the supplies directly on the resident's urine soaked bed. The LPN did not provide a clean field for the wound care supplies prior to wound care. During an interview on 08/29/24 at 9:21 A.M., LPN S said wound care supplies should be placed on a clean surface such as the bed or bedside table. LPN S said the residents' bedside tables are preferred but are usually in use and cluttered. He/She said the bed is the easiest accessible location for supplies to be placed. During an interview on 08/29/24 at 12:45 P.M., The Director of Nursing (DON) said wound care supplies should always be placed on a clean barrier, such as a towel, when taken into a residents' room. During an interview on 08/29/24 at 2:10 P.M., the administrator said staff should always place care supplies on a clean barrier when in a residents' room. 4. Review of the facility's policy titled, Infection Control- Preventing Spread of Infection- Hand Hygiene, undated, showed staff are directed: -Hand hygiene should be completed before and after direct resident contact; -Before and after changing a dressing; -Before and after assisting resident with toileting; -After coming in contact with a residents body fluids. Review of the facility's policy titled Perineal Care Procedure, undated, showed the policy directed staff to perform hand hygiene after providing perineal care. 5. Observation on 08/29/24 at 8:20 A.M., showed LPN S entered Resident #3's room to provide wound care to the resident's sacral (near the lower back) wound. Observation showed the LPN did not wash his/her hands or change his/her gloves and provided perineal care. With the same soiled gloves on, the LPN put a clean brief on the resident and turned the resident. During an interview on 08/29/24 at 9:21 A.M., LPN S said staff should perform hand hygiene before and after they touch a resident, any time gloves are visibly soiled, and when moving from dirty to clean tasks. During an interview on 08/29/24 at 12:45 P.M., the DON said staff should perform hand hygiene at the start of their shift, before and after cares, and from dirty to cleans tasks. The DON said if staff fail to perform proper hand hygiene it could result in infections or the spread of infections. 6. Observation on 08/28/24 at 9:45 A.M., showed Certified Nurse Aide (CNA) J entered Resident #64's room, washed his/her hands and applied gloves. Observation showed the CNA removed the resident's soiled brief, moved the resident to his/her right side, and wiped the resident's urine soaked back and perineal area. With the same soiled gloves, the CNA rolled the resident to his/her left side, removed the soiled sheets from the bed, and then touched the resident's clean sheets, and clean brief. Observation showed the CNA removed his/her gloves, did not wash his/her hands, touched three pillows in the resident's room and repositioned the resident. During an interview on 08/28/24 at 9:55 A.M., CNA J said he/she is supposed to change gloves and wash hands when moving from dirty to clean tasks. The CNA said he/she should have changed gloves and washed hands between touching soiled linens and clean linens. The CNA said he/she should have change his/her gloves, he/she just tried to get the resident back where he/she should be, quickly. During an interview on 08/29/24 at 1:24 P.M., the DON said staff should wash their hands and put gloves on before providing care, and should remove their soiled gloves and wash their hands before they touch anything clean. The DON said he/she did not know why the staff did not change their gloves and wash their hands during care. During an interview on 08/28/24 at 2:10 P.M., the administrator said staff should wash their hands between gloves changes, from dirty to clean tasks, and before and after care. The administrator said staff should not wear the same gloves during the whole process. 7. Review of the facility's policy titled Hand Hygiene, undated, showed: -Hand hygiene is a general term that applies to either handwashing or the use of an antiseptic hand rub, also know as alcohol-based hand rub (ABHR); -Hand hygiene technique when using soap and water: a. Wet hands with water. b. Apply enough soap to cover all hand surfaces. c. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers; d. Rinse hands with water. e. Dry thoroughly with a single-use towel. f. Use towel to turn off the faucet. -The use of gloves does not replace hand washing. Wash hands after removing gloves. Review showed the policy did not include any additional direction to staff on when hand hygiene should be performed. Observation on 08/26/24 at 11:27 A.M., showed, Dietary Aide (DA) C washed his/her hands at the sink in the dining room food service station. The DA scrubbed his/her hands with soap for two seconds, rinsed his/her hands and turned the faucet off with his/her wet bare hand. Observation showed the DA then served plates of food to residents. Observation on 08/26/24 at 11:49 A.M., [NAME] A served food to residents in the dining room food service station with gloved hands. Observation showed the cook removed his/her soiled gloves and washed his/her hands at the sink in the station by scrubbing his/her hands with soap for five seconds. Observation showed, after the cook washed his/her hands, he/she donned new gloves and continued to serve food to the residents. Observation on 08/26/24 at 11:53 A.M., showed, when DA C washed his/her hands at the sink in the dining room food service station, the DA scrubbed his/her hands with soap for two seconds, rinsed his/her hands and turned the faucet off with his/her wet bare hand. Observation showed, after the DA washed his/her hands, he/she then entered the kitchen, obtained cartons of milk from the refrigerator, placed the cartons of milk on a tray, brought the tray of milk to the dining room and put the tray on top of a food cart that contained trays of food for service to the residents. Observation showed the DA delivered the food cart to the unit for the lunch meal service. Observation on 08/26/24 at 12:04 P.M. showed, when DA B washed his/her hands at the sink in the dining room food service station, the DA scrubbed his/hands with soap for five seconds, rinsed his/her hands and turned the faucet off with his/her wet bare hands. Observation showed the DA then served drinks to the residents in dining room. During an interview on 08/26/24 at 12:06 P.M., DA B said he/she had worked at the facility about a month and he/she got trained on how to wash his/her hands upon hire. The DA said he/she was trained to scrub his/her hands with soap for 20 seconds and to turn the faucet off with a towel. The DA said he/she just got in a hurry and did not think about how he/she washed his/her hands. Observation on 08/26/24 at 12:08 P.M., showed, when [NAME] A washed his/her hands at the sink in dining room food service station, the cook scrubbed his/her hands with soap for one second out of the water and then scrubbed his/her hands in the running water. Observation showed, after the cook washed his/her hands, he/she donned gloves and continued to serve food to residents. During an interview on 08/26/24 at 12:09 P.M., [NAME] A said he/she had worked at the facility since October 2023 and he/she got trained on how to wash his/her hands. The DA said he/she was not sure how long he/she should scrub his/her hands with soap and he/she should probably wash his/her hands longer that he/she had, but at least he/she washes his/her hands often. The DA said hands should be scrubbed with soap out of the water, not under running water, during handwashing. Observation on 08/26/24 at 1:26 P.M., showed [NAME] A used his/her cell phone, put the phone back in his/her pocket and, without performing hand hygiene, obtained two sanitized metal food preparation/service pans from the storage shelf and set the pans on the countertop. Observation showed the cook then obtained two cans of sliced apples from the pantry and placed the cans on the countertop next to the pans. Observation showed the cook used his/her bare hand to wipe his/her mouth, used the can opener on the countertop to open the cans of sliced apples and pour the apples in to the pans. During an interview on 08/28/24 at 12:11 P.M., the Certified Dietary Manager (CDM) said staff should wash their hands when they change gloves, between tasks and anytime their hands become contaminated. The CDM said when staff wash their hands, they should scrub their hands with soap for 20 seconds out of the water, not under running water, and turn the faucet off with a paper towel. The CDM said staff are trained on hand hygiene upon hire and routinely during the year. During an interview on 08/28/24 at 12:22 P.M., the administrator said staff should perform hand hygiene when they after they enter and before they exit the kitchen, between tasks, after glove use and after they touch anything dirty. The administrator said when staff wash their hands, they should scrub their hands with soap for 30 seconds out of the water, not under running water, and turn the faucet off with a towel. The administrator said staff are trained on hand hygiene upon hire and as needed. 37131 50361

Based on record review and interview, facility staff failed to complete a baseline care plan within 48 hours of admission for five residents (Resident #1, #2, #6, #28, and #65) out of a sample of 25 residents. The facility census was 71. 1. Review of the facility's policy titled Care plans - Baseline, dated December 2016, showed staff were directed: -A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission; -The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan; -The resident and their representative will be provided a summary of the baseline care plan. 2. Review of Resident #1's medical record showed staff documented the resident admitted to the facility on [DATE]. The record did not contain a baseline care plan. 3. Review of Resident #2's medical record showed staff documented the resident admitted to the facility on [DATE]. The record did not contain a baseline care plan. 4. Review of Resident #6's medical record showed staff documented the resident admitted to the facility on [DATE]. The record did not contain a baseline care plan. 5. Review of Resident #28's medical record showed staff documented the resident admitted to the facility on [DATE]. The record did not contain a baseline care plan. 6. Review of Resident #65's medical record showed staff documented the resident admitted to the facility on [DATE]. The record did not contain a baseline care plan. 7. During an interview on 08/29/24 at 1:30 P.M., the Director of Nursing (DON) said baseline care plans should be completed within 48 hours of admission by the nursing staff as part of the admission process. The DON said the Assistant Director of Nursing (ADON) complete chart reviews but has been unable to recently. The admitting nurse should complete the baseline care plan, and he/she does not know the care plans are not complete. During an interview on 08/29/24 at 2:00 P.M., Licensed Practical Nurse (LPN) S said baseline care plans are completed on a routine basis, and reviewed with the medical chart or primary care and family. LPN S said the care plan should address how the resident participates with care, their preferences, and should be completed within 24 hours of admission. LPN S said he/she does not know who is responsible. The LPN said the admitting nurse tries to get most of it completed, and he/she did not know the baseline care plans were not done. During an interview on 08/29/24 at 2:10 P.M., the administrator said baseline care plans should be completed on admission and within 48 hours by the admitting nurse. The admitting nurse is responsible for completing the care plan, and then nursing leadership should ensure the care plans are complete. The administrator said he/she did not know the baseline care plans were missing and has only been at the facility for five months. 50361

Based on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan addressing oxygen use for one resident (Resident #14), limited range of motion for one resident (Resident #64), Post Traumatic Stress Disorder (PTSD), a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event, for four residents (Resident #66, #71, #1, and #17), urinary catheter (tube placed directly in the bladder) care for one resident (Resident #2), and Activities of Daily Living (ADL)/transfer needs for one resident (Resident #65) out of 25 sampled residents. The facility census was 71. 1. Review of the facility's policy titled, Comprehensive Care Plans, dated October 2022, showed staff were directed to do the following: -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 timeframes 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 be developed within seven days after the completion of the comprehensive Minimum Data Set (MDS), a federally mandated assessment tool to be completed by staff, assessment; -The comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma; trigger specific interventions will be used to identify ways to decrease a resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident; -The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment; -Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. 2. Review of Resident #14's Annual MDS, dated [DATE], showed staff assessed resident as follows: -Cognitively intact; -Did not receive oxygen; -Diagnoses of Respiratory Failure and Chronic Obstructive Pulmonary Disease (COPD), a lung disease that restricts airflow. Review of the resident's Physician Order Sheet (POS), dated 08/24, showed an order dated 09/17/22 for Oxygen two Liters Per Minute (LPM), as needed with the goal to maintain oxygen saturation at 88% or higher and for shortness of air. Review of the resident's care plan, dated 06/10/24, showed it did not address the resident's respiratory failure, or the intervention of oxygen use. Observation on 08/27/24 at 11:21 A.M., showed the resident in bed with an oxygen concentrator at his/her bedside. The oxygen concentrator is on and the nasal cannula is on the floor. Observation on 08/28/24 at 8:58 A.M., showed the resident in bed with an oxygen concentrator at his/her bedside. The oxygen concentrator is on and the nasal cannula is hung over the concentrator. During an interview on 08/28/24 at 8:58 A.M., the resident said he/she mainly uses the oxygen at night when he/she sleeps. During an interview on 08/29/24 at 11:25 A.M., Certified Nurse Aide (CNA) M said the resident is supposed to wear oxygen at all times, but he/she wears it off and on during the day and most of the night. The CNA said oxygen should be addressed on the care plan and he/she has no idea why it is not on the care plan. During an interview on 08/29/24 at 11:37 A.M., Licensed Practical Nurse (LPN) K said oxygen therapy should be on a resident's care plan. During an interview on 08/29/24 at 1:24 P.M., the Director of Nursing (DON) said Respiratory Failure with Hypoxia and oxygen therapy should be on a resident's care plan. The DON said he/she does not know why it is not. During an interview on 08/29/24 at 2:10 P.M., The MDS Coordinator said oxygen should be on a resident's care plan, if the resident wears it during the look back period. Staff are not documenting that the resident is wearing oxygen on the Treatment Administration Record (TAR). The MDS Coordinator said he/she is responsible for ensuring the care plans reflect the care the resident wants and requires. During and interview on 08/29/24 at 2:39 P.M., LPN I said the resident wears oxygen when he/she wants to. The LPN said the resident takes the oxygen off and throws it on the floor. The LPN said the resident does wear the oxygen every day. The LPN said he/she is pretty sure the oxygen is on the resident's care plan. 3. Review of the Resident #64's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Moderately impaired cognition; -ROM impairment of upper extremities; -ROM impairment of lower extremities; -Diagnoses of Stroke and paralysis of one side of the body. Review of the resident's care plan, dated 07/26/24, showed staff did not document the resident's contractures, goals or interventions. Observation on 08/26/24 at 2:52 P.M., showed the resident in bed. The resident's left hand is contracted closed. Observation on 08/27/24 at 2:22 P.M., showed the resident in bed. The resident's left hand is contracted closed. The resident attempted to open his/her left hand with his/her right hand. The resident grimaced and could not open his/her left hand. During an interview on 08/27/24 at 2:22 P.M., the resident said it hurts when he/she tries to open his/her left hand. During an interview on 08/29/24 at 11:25 A.M., CNA M said if a resident has a contracture it should be on the care plan. During an interview on 08/29/24 at 11:37 A.M., LPN K said care plans should direct resident care. The LPN said the resident's contracture should be in his/her care plan. During an interview on 08/29/24 at 1:24 P.M., the DON said he/she would imagine the contracture should be care planned, he/she doesn't know why it is not. During an interview on 08/29/24 at 2:10 P.M., The MDS Coordinator said the resident's contracture should be in the care plan. The MDS Coordinator said he/she did not see the contracture on the resident's hospital discharge paperwork and it is not on the resident's diagnosis list. 4. Review of Resident #66's Quarterly MDS, dated [DATE], showed the staff assessed the resident as follows: -Moderate cognitive impairment; -Mood interview showed the resident feels down, depressed or hopeless, has trouble falling asleep/staying asleep; feels bad about self; moves, or speaks slowly and has trouble concentrating on things nearly everyday; Was this addressed? Yes -Diagnosis of PTSD. Review of the resident's care plan, dated 08/13/24, showed it did not address the resident's PTSD diagnosis with interventions. 5. Review of Resident #71's Quarterly MDS, dated [DATE], showed the staff assessed the resident as follows: -Moderate cognitive impairment; -Diagnosis of PTSD. Review of the resident's care plan, dated 06/18/24, showed it did not address the resident's PTSD diagnosis with interventions. During an interview on 08/26/24 at 11:21 A.M., the resident cried as he/she talked. The resident said he/she does not want to be at the facility. During an interview on 08/26/24 at 11:28 A.M., The DON said the resident sometimes has crying spells. 6. Review of Resident #1's Admission MDS, dated [DATE], showed staff assessed the resident as follows: -Moderate cognitive impairment; -Mood interview showed little interest/pleasure in doing things; feels down, depressed or hopeless; had trouble falling asleep/staying asleep; feels tired/has little energy; poor appetite or overeats; and has trouble concentrating on things nearly everyday; -Social isolation often; -Diagnosis of PTSD. Review of the resident's care plan, dated 06/07/24, showed it did not address the resident's PTSD diagnosis with interventions. During an interview on 08/27/24 at 8:53 A.M., the resident said the SSD knows about his/her PTSD. The resident said he/she does like to be in large crowds, and said certain pictures or sounds can trigger him/her. During an interview on 08/29/24 at 10:10 A.M., CNA M said he/she has not noticed any certain behaviors from Resident #1, but would not know what to look for specifically. During an interview on 08/29/24 at 11:28 A.M., the SSD said said Resident #1 has refused outside treatment, and has asked if she has a flare up if she can talk to the SSD. He/she said the only trigger he/she is aware of is the resident does not like to be in large group settings or activities like going to Wal-Mart. During an interview on 08/29/24 at 2:00 P.M., LPN S said he/she does know Resident #1 has PTSD but is not aware of any specific triggers. LPN S said triggers should be found in the care plan, and signs of the resident's PTSD such as abnormal behaviors, or increased anxiety. He/she did not know PTSD is not on the care plan. 7. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Mood interview showed little interest/pleasure in doing things; fees down, depressed or hopeless; trouble falling asleep/staying asleep; feels tired/has little energy; poor appetite or overeats; and trouble concentrating on things nearly everyday; -Social isolation often; -Diagnosis of PTSD. Review of the resident's care plan, dated 07/26/24, showed it did not address the resident's PTSD diagnosis with interventions. During an interview on 08/29/24 at 10:10 A.M., CNA M said Resident #17 does have some behaviors and does not come out of his/her room a lot. During an interview on 08/29/24 at 11:28 A.M., the SSD said Resident #17 is seeing his/her own psychiatrist and refuses to discuss his/her triggers with staff. The SSD said PTSD should be on the care plan to identify any triggers or behaviors that would indicate a flare up of the PTSD. During an interview on 08/29/24 at 2:00 P.M., LPN S said she is aware that resident #17 has some mental health diagnoses but did not know if he/she had PTSD. 8. During an interview on 08/29/24 at 10:10 A.M., CNA M said he/she not did not know of any residents on his/her with PTSD, but he/she had not asked. CNA M said it is very important to know what the resident's triggers are because they could shut down or have behaviors, and it would be good to know what the triggers are so we can treat them how they need to be treated. He/she said it should be found in the care plan or computer system, and he/she would expect to see PTSD on the care plan. During an interview on 08/29/24 at 10:17 A.M., CMT/CNA T said he/she does not now if any residents on his/her hall have PTSD. He/she said it would be important to watch for behaviors, as some can get violent, and it would be helpful to know what their triggers are, to know what to look for. CMT/CNA T said he/she would expect to find that information in the care plan. During an interview on 08/29/24 at 1:30 P.M., the DON said the SSD works with each resident to figure out their PTSD triggers, and psychiatry comes to the building for residents who agree to be seen. The DON said the SSD relays the information regarding the resident's PTSD to the rest of the team. He/she said PTSD needs to be on the care plan, and he/she does not know why it is not care planned. The DON said the triggers and potential behaviors to look for should be on the care plan, and if triggers are unknown then behaviors to watch for should be on the care plan. During an interview on 08/29/24 at 2:00 P.M., LPN S said PTSD triggers should be found in the care plan, and signs of the residents' PTSD such as abnormal behaviors, or increased anxiety. He/she did not know that PTSD is not on the care plan. He/she said if staff does not know what the triggers are the resident could be triggered and it could make the situation worse, with behaviors such as exit seeking, erratic behaviors, or anything off the resident's baseline behaviors. During an interview on 08/29/24 at 2:10 P.M., The MDS Coordinator said PTSD should be identified on the care plans. The MDS Coordinator said he/she gets PTSD information from the resident's diagnosis list. The MDS Coordinator said he/she did not know it had not been care planned. The MDS Coordinator said there is four residents with PTSD and he/she added it to all four of their care plans this morning. During an interview on 08/29/24 at 2:10 P.M., the Administrator said PTSD should be on the care plan with known triggers and behaviors to watch for. He/she does not know why PTSD is not on the care plan for the residents, and if staff does not know what the triggers for a resident are then the resident could be triggered or have an exacerbation of their PTSD. The Administrator said he/she has only been at the facility for five months. 9. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident had an indwelling urinary catheter. Review of the resident's care plan showed staff documented: -Resident has a urinary catheter; -Check tubing for kinks with cares, monitor/document for pain/discomfort due to catheter, and monitor/record/report to medical doctor (MD) for signs or symptoms of Urinary Tract Infection (UTI), an infection of the urinary tract system; -Resident has an ADL self-care performance deficit with interventions to provide supervision with toileting hygiene. -The care plan did not address the resident's urinary catheter care. During an interview on 08/27/24 at 9:54 A.M., the resident said staff does not clean his/her catheter. The resident said he/she needs assistance from staff to clean his/her perineal area. During an interview on 08/29/24 at 10:22 A.M., CNA M said staff provide perineal and catheter care for the resident. The CNA said the resident uses his/her call light when he/she needs to use the bathroom, and staff provides the care at this time. Usually, it is once or twice a day. The CNA said the resident's care plan should contain instruction for catheter care so staff are aware it should be completed on a regular basis. During an interview on 08/29/24 at 10:45 A.M., RN (Registered Nurse) W said CNAs sometimes provide perineal care for the resident. RN M said the resident will sometimes toilet himself/herself. RN M said there should be a task in the charting system to prompt CNAs to perform catheter care. RN M said the tasks are assigned in the chart by the MDS coordinator and there is a task in his/her chart to perform catheter care. RN M said there is not care plan documentation for catheter care for resident. During an interview on 08/29/24 at 12:49 P.M., the DON said catheter care should be on listed on the resident's care plan. The DON said CNA tasks should be generated from the care plan. During an interview on 08/29/24 at 2:10 P.M., the Administrator said catheters and the required care should be on the care plans. He/she did not know catheter care is not on the care plan for the resident. 10. Review of Resident #65's Admission MDS, dated [DATE], showed staff assessed the resident is at risk for developing pressure ulcers. Review of resident's Discharge MDS, dated [DATE], showed staff assessed the resident as: -Has one unhealed, unstageable pressure injury; -Dependent on staff for sit to stand transfer and chair-bed-to-chair transfer; -Toilet transfer, tub/chair transfer, and car transfer not attempted due to medical condition/safety concern; -Walk 10 feet not attempted due to medical condition/ safety concern; -Resident is dependent on staff to wheel 50 feet. Review of the resident's care plan, 07/11/24 showed resident has a potential for pressure ulcer development related to immobility. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of the care plan showed it did not address pressure relief interventions, transfer/weight bearing status, or use of an external fixator to the right knee. Observation on 08/27/2024 at 8:36 A.M., showed the resident in bed with an external fixator on his/her right leg. Observation on 08/27/2024 at 12:22 P.M., showed the resident in his/her recliner with legs propped up and an external fixator on the right leg. During an interview on 08/29/24 at 10:19 A.M., CNA M said the resident is toe touch weight bearing on one leg and is a pivot transfer with a gait belt. The CNA said this is documented through the therapy department and he/she knows this information from going to therapy to ask them to transfer the resident with him/her, so he/she knows how to do it properly. The CNA said this information should be on the resident's care plan. The CNA said he/she also receives this information through shift report. The CNA said there should be documentation in the residents care plan about the external fixator to ensure they knew how to properly care for the resident in regard to the medical device. During an interview on 08/29/24 at 10:38 A.M., RN W said therapy usually meets with staff to go through the residents' transfer needs, abilities, and weight bearing statuses. RN W said this should be documented in the resident's therapy notes and weight bearing status and restrictions should be pulled over in the orders. The RN said he/she would expect the resident's transfer needs to be in their care plan and be updated as their needs and capabilities change with therapy progression. The RN said most care plans are not specific about resident wounds and related interventions. The RN said the facility policies and procedures cover floating heels and off loading as well as standing orders. The RN said if this is not in the care plan it would have to be verbally communicated to the care staff from a nurse. During an interview on 08/29/24 at 12:40 P.M., the DON said transfer needs should be in the resident's care plan. The DON said he/she did not think the resident's external fixator was mentioned in the care plan. The DON said the physician orders has the residents weight bearing status, device use, and pin sights. The DON said there should be person centered interventions in resident care plans about wound care needs. The DON said there should be more detail and clarification about the residents wound and their specific needs. During an interview on 08/29/24 at 2:10 P.M., the Administrator said pressure ulcer prevention and interventions should be on the care plan, as well as any assistance and cares needed for Resident #65's external fixator (a device used to keep fractured bones stabilized and in alignment). The Administrator said the care plan should address how staff are to take care of the external fixator and how the resident should transfer with the external fixator. 45489 50361

Based on interview and record review, facility staff failed to document the administration of medications for five residents (Residents #2, #12, #23, #64 and #65) of 25 sampled residents, on the residents Medication Administration Record (MAR). The facility census was 71. 1. Review of the facility's Documentation of Medication Administration policy, dated April 2007, showed the facility shall maintain a medication administration record to document all medications administered. A Nurse or Medication Medication Aide shall document all medications administered to each resident on the resident's MAR. Administration of medication must be documented immediately after it is given. The documentation must include signature and title of the person administering the medication. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/16/24 showed staff documented the resident has a diagnosis of osteomyelitis (an infection of the bone). Review of the resident's Physician Order Sheet (POS) showed an order for Ceftazidime (an antibiotic) Intravenous Solution two grams (gm) intravenously (IV) three time a day for osteomyelitis for six weeks with a start date of 07/05/24 and stop date of 08/16/24. Review of the resident's MAR, dated August 2024, showed staff did not document they administered the resident's Ceftazidime on: -08/02/24 at 6:30 A.M., -08/10/24 at 2:30 P.M., -08/11/24 at 6:30 A.M. 3. Review of Resident #12's Annual MDS, dated [DATE], showed staff assessed the resident as: -Frequent pain; -Pain frequently disrupts sleep; -Pain occasionally interferes with day-to-day activities; -Diagnosis of arthritis. Review of the resident's POS, dated 05/13/24, showed an order for Norco (a narcotic medication used for pain relief) 7.5-325 milligrams (mg) three times a day for pain. Review of the resident's MAR, dated August 2024, showed staff did not document they administered the resident's Norco on: -08/03/24 at 2:23 P.M., -08/04/24 at 2:30 P.M., -08/09/24 at 6:30 A.M., -08/09/24 at 2:30 P.M., -08/13/24 at 2:30 P.M., -08/16/24 at 6:30 A.M., -08/20/24 at 6:30 A.M., -08/23/24 at 2:30 P.M. 4. Review of the Resident #23's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Received scheduled pain medication; -Received opioid medication seven out of the seven days in the look back period. Review of the resident's POS, dated August 2024, showed an order for Norco Oral Tablet 5-325 MG before meals and at bedtime for pain. Review of the resident's MAR, dated August 2024, showed staff did not document they administered the resident's Norco on: -08/03/24 before lunch; -08/03/24 before dinner; -08/13/24 before lunch; -08/13/24 before dinner; -08/23/24 before dinner; -08/25/24 before dinner. 5. Review of the Resident #64's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Had a feeding tube; -Received a mechanically altered diet; -Diagnoses of Stroke and Hemiplegia (paralysis of of one side of the body). Review of the resident's POS, dated August 2024, showed an order for Glucerna 1.5 Cal 240 milliliters (ml) with a 60 ml water flush four times a day. Review of the resident's MAR, dated August 2024, showed showed staff did not document they administered the resident's Glucerna or water flush on: -08/04/24 at 6:30 A.M.; -08/10/24 at 6:30 A.M.; -08/13/24 at 4:30 P.M.; -08/23/24 at 6:30 A.M.; -08/25/24 at 4:30 P.M. 6. Review of Resident #65's POS, dated August 2024, showed an order for Piperacillin Sod-Tazobactam (a antibiotic) 3-0.375 gm IV every six hours for infection of the knee for 42 days with a start date of 07/29/24 and a stop date of 08/26/24 and Piperacillin Sod-Tazobactam 3-0.375 gm IV every six hours with a start date of 08/26/24 and stop date of 09/7/24. Review of the resident's MAR dated August 2024showed staff did not document they administered the resident's Pipercillin Sod-Tazobactam on: -08/05/24 at 6:00 P.M., -08/19/24 at 6:00 P.M., -08/25/24 at 6:00 P.M. -08/26/24 at 6:00 P.M., -08/28/24 at 6:00 P.M. 7. During an interview on 08/29/24 at 11:34 A.M., Certified Medication Technician (CMT) P said staff should sign the MAR after they give the medication to the resident. The CMT said if the MAR is not signed it was probably was not given. During an interview on 08/29/24 at 11:37 A.M., Licensed Practical Nurse (LPN) K said staff should sign the MAR when they give the medication or treatment. The LPN said if the MAR is not signed, it means it was not given, or staff did not sign it out. The LPN said if staff give the medication and do not sign the MAR, the resident could get a double dose of the medication. During an interview on 08/29/24 at 1:24 P.M., the Director of Nursing (DON) said staff should sign the MAR after the medication or treatment is administered. The DON said no signature means it's not administered, and this could lead to the resident receiving the wrong dose of medication. 50361

Based on observation, interview, and record review, facility staff failed to remove and destroy expired medications and biologicals in two of four sampled medication carts, and one of two medication rooms. The facility census was 71. 1. Review of the facility's policy titled Storage of Medications, dated April 2007, showed the facility staff shall store all drugs and biologicals in a safe, secure, and orderly manner. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 2. Observation on 08/27/24 at 8:45 A.M., showed the charge nurse's medication cart contained liquid pain relief acetaminophen 160 milligrams (mg)/5 milliliters (ml), 16 fluid (fl) ounces (oz), 473 (ml), expired 04/24. 3. Observation on 08/27/24 at 9:03 A.M., showed the 400 hall medication cart contained the following expired medications: -Refresh lubricant eye gel 0.5 fl oz bottle, expired 04/24; -Bottle of Nitroglycerin 0.4 MG, expired 08/14/24; -10 ml bottle of fecal occult blood test developing solution, expired 04/30/24; -5 MG box of laxative tablet, expired 02/24; -One dressing change kit with statlock, expired 01/14/24. 3. Observation on 08/27/24 at 9:53 A.M., showed the medication storage room contained the following expired medications: -Novolog (insulin)Flex Pen, expired 12/18/23; -28 doses of 0.7 mL prefilled syringes of Influenza Vaccine, Fluzone High-Dose Quadrivalent, expired 06/2024; -25 doses of prefilled syringes 0.5 mL influenza vaccine, Flulaval Quadrivalent, expired 6/30/24. 4. During an interview on 08/27/24 at 9:03 A.M., Certified Medication Technician (CMT) R said someone from the pharmacy used to come in and check the medication carts and medication room for expired medications, but they don't come anymore. The CMT said if he/she sees an expired medication he/she removes it from the medication cart. During an interview on 08/29/24 at 11:37 A.M., Licensed Practical Nurse (LPN) K said the nurses and CMT's look through the medication carts and medication room weekly for expired medications. The LPN said he/she did not know of any expired medications in the medication carts or the medication room. The LPN said he/she believes he/she checks the nurse's medication cart and the CMTs check their medication carts. During an interview on 08/29/24 at 1:24 P.M., the Director of Nursing (DON) said the pharmacist comes monthly and completes cart audits. The DON said he/she normally checks the medication storage rooms for expired medications. The DON said any nurse that sees expired medications, can throw it away. The DON said he/she did not there were expired medications in the medications in the medication carts and medication rooms. The DON said she checked the medication storage room last week and he/she did not know why the expired vaccines were in the medication room.

Based on observation, interview, and record review, facility staff failed to provide appropriate treatment and services to prevent further decrease in range of motion (ROM), movement of a joint, for one resident (Resident #64), with a contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the left hand out of 25 sampled residents. The facility census was 71. 1. Review of the facility's Resident Mobility and ROM policy, dated July 2017, showed residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. As part of the resident's comprehensive assessment, the nurse will identify the resident's current ROM of his/her joints and current mobility status. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility to include contractures. The care plan will be developed by the interdisciplinary team based on comprehensive assessment and will be revised as needed. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. The care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. Review of the facility's Functional Impairment-Clinical Protocol policy, dated September 2012, showed the physician and staff will evaluate the resident for complications secondary to functional decline and/or immobility, such as contractures. The physician and staff will review the results and implications of these evaluations and use them to guide subsequent care planning. 2. Review of Resident #64's hospital discharge documentation, dated 03/29/24, given to the facility upon admission, showed hospital staff documented, anticipate ongoing Occupational Therapy (OT) with the the specific focus to include the use of left upper extremity and contracture prevention. Review of the resident's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 07/18/24, showed: -Moderately impaired cognition; -ROM impairment of upper extremities; -ROM impairment of lower extremities; -Diagnosis of Stroke and paralysis of one side of the body. Review of the resident's care plan, dated 07/26/24, did not contain documention of the resident's contractures, goals or interventions. Observation on 08/26/24 at 2:52 P.M. showed the resident in bed and his/her left hand contracted close. Observation on 08/27/24 at 2:22 P.M., showed the resident in bed and his/her left hand contracted close. The resident attempted to open his/her left hand with his/her right hand. The resident grimaced and could not open his/her left hand. During an interview on 08/27/24 at 2:22 P.M., the resident said it hurts when he/she tries to open his/her left hand. The resident said he/she does not have any braces. The resident said staff put a rolled up wash cloth in his/her hand, but there is not one now. The resident said his/her hand feels better when staff put the rolled up wash cloth in it. The resident said he/she could not remember if he/she told staff the wash cloth helped. The resident said hopefully, he/she will start physical therapy. Observation on 08/27/24 at 4:25 P.M., showed Licensed Practical Nurse (LPN) I entered the resident's room to provide care. The resident's left hand contracted and did not have anything in it. The LPN left the room after he/she provided care and did not provide an intervention to the resident's contracted left hand. Observation on 08/28/24 at 9:51 A.M., showed the resident in bed and his/her left hand contracted close. Certified Nurse Aide (CNA) J entered the resident's room. The CNA provided care, and repositioned the resident. The CNA left the room and did not provide an intervention for the resident's contracted left hand. Observation on 08/29/24 at 8:44 A.M., showed CNA J provided care and repositioned the resident. The CNA left the resident's room and did not provide an intervention for the resident's contracted left hand. During an interview on 08/29/24 at 8:47 A.M., CNA J said the resident's left hand is contracted and staff have to work hard to get his/her left hand open to clean it. The CNA said he/she is not aware of anything staff do for the resident's contracted hand, and the resident is not receiving therapy. The CNA said he/she does not perform ROM with the resident. The CNA said the facility has two Restorative Aides (RA). During an interview on 08/29/24 at 9:00 A.M., LPN K said he/she the resident's left hand is contracted. The LPN said he/she is not sure if physical therapy had seen the resident for his/her hand contracture. The LPN said staff were putting folded washcloths in the resident's hand and he/she does not know why staff have not put the washcloth in the resident's hand this week. The LPN said care plans should direct the resident's care. The LPN said the contracture should be on the resident's care plan. During an interview on 08/29/24 at 10:06 A.M., RA L said he/she provides restorative therapy after an order is received and the Director of Nursing (DON) puts it on the Medication Administration Record (MAR). The RA said he/she had not noticed the resident's contracted hand. The RA said he/she had not received an order for passive ROM with the resident. The RA said he/she has not done restorative therapy with the resident's hand. The RA said he/she doesn't think he/she had looked at the resident's care plan. The RA said if the resident had a contracture he/she would think the contracture would be care planned. During an interview on 08/29/24 at 11:25 A.M., CNA M he/she is aware the resident has a contracture of his/her left hand. The CNA said when he/she is on the resident's hall, he/she puts a washcloth in the resident's hand, but he/she is not on the resident's hall all the time. The CNA said if a resident has a contracture it should be on the care plan. The CNA said he/she has some experience, so he/she puts a washcloth in the resident's hand, but some of these aides are new and don't have the experience. During an interview on 08/29/24 at 1:24 P.M., the DON said he/she is aware of the resident's left hand contracture. The DON said the contracture should be care planned and he/she does not know why it is not. The DON said he/she does not know why staff is not putting a washcloth in the resident's hand anymore. He/She said it should be communicated with the nurse and in the resident's care plan. The DON said it is the charge nurses responsibility to document the resident contracture and ensure information is communicated to the MDS Coordinator so it can be put in the care plan. The DON said physical therapy determines who receives restorative services.

Based on observation, interview and record review staff failed to transfer one resident (Resident#2) appropriately. The facility census was 86. 1. Record review of Resident #2's comprehensive Minimum Data Set(MDS), a federally mandated assessment tool, dated 08/15/11 showed staff assessed the resident with the following: - Confusion; - Past stroke; - Limited range of motion in all extremities including his/her legs; - Did not walk; - Required extensive assistance of staff for his/her Activities of Daily Living and required two staff to assist with transfers. - Wheelchair for locomotion with extensive assistance of staff. Review of the resident's electronic charting fall documentation dated 10/03/11 at 8:35 P.M., showed staff recorded one staff member assisted the resident to transfer into his/her bed when the resident's legs "gave out" resulting in a fall during the staff-assisted transfer. Additional review showed the resident complained of pain in his/her right knee after the incident. Review of the resident's radiology report dated 10/03/11 showed the resident fractured his/her right knee. Review of the resident's care plans updated 10/10/11 showed staff recorded the resident was to be transferred with two staff assistance with a Hoyer (mechanical device for transferring residents) lift. Observation on 10/19/11 at 9:05 A.M., showed the resident sat in his/her wheelchair in his/her room. Additional observation showed Certified Nurse Assistant (CNA) F and CNA H transferred the resident from his/her wheelchair to his/her bed with a Hoyer lift. During an interview on 10/19/11 at 9:05 A.M., CNA F said before the resident broke his/her leg, the resident required assistance to transfer with two staff members utilizing a gait belt. During an interview on 10/19/10 at 9:40 A.M., Licensed Practical Nurse (LPN) I said the resident required one staff person, depending on his/her strength, using a gait belt to assist him/her to transfer. LPN I said the resident can be alert on some days and not so much on others. LPN I said the resident is alert to self and place. Review of the resident's medical record showed he/she was readmitted back into the facility on [DATE]. During an interview on 10/19/11 at 10:25 A.M., the resident said his/her legs "gave out" while one staff member tried to transfer him/her from his/her wheelchair to his/her bed without using a gait belt. The resident said the staff member seemed to be "rushed or in a hurry." The resident said it took two people to assist him/her to transfer. During an interview on 10/19/11 at 11:00 A.M., the Director of Nursing (DON) said the facility's policy directed staff to use gait belts during transfers and ambulation. The DON said the CNA who transferred the resident on 10/03/11, which resulted in the resident suffering a fractured right knee, did so by him/herself, and also did not use a gait belt. MO 482