Every finding on record at Stonewall Living Center

Based on interviews and record reviews, the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of 13 of 16 residents (13 confidential residents) in that: The facility failed to ensure staff were not on their personal cell phones while providing Resident care. This could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings include: During an interview with confidential residents at an undisclosed date and time thirteen confidential residents stated the use of cell phones by nurses and CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned the nurses and CNAs could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. During an interview thirteen confidential residents stated the use of cell phones by nurses and CNAs occurred on every shift. Confidential residents also stated staff utilize their cell phones while feeding residents during meals; residents stated the use of the cell phones while feeding residents forces those residents to have significant wait times between bites. During an interview thirteen confidential residents stated they did not know the names of the nurses and CNAs who utilized their cell phones while performing care. The confidential residents stated cell phone usage by nurses and CNAs while performing care happened in the facility so often, they said every nurse and CNA in the facility utilized their cell phone while performing care. The Residents stated most of the cellular use was via earbuds. During an interview on 02/12/26 at 1:35pm, the ADM stated residents should be provided with privacy during resident care. She stated all staff were trained on privacy, resident rights, dignity, and cell phone usage during orientation and through continuous education by department heads and the ADM. She stated staff were monitored by making rounds and correcting any issues found, and by addressing complaints. She stated cell phones should never be used in resident rooms, hallways, or nurses' stations. She stated the potential negative outcome could be mistakes and HIPAA violations. During an interview on 2/12/2026 at 2:35pm, the DON stated cell phones usage is not acceptable while performing Resident Care. The DON stated direct Resident care is a priority. The DON stated nurses and CNA are trained on resident rights, dignity, privacy, and cell phone usage during the hiring process, quarterly continuous education, and in services. The DON stated department heads are responsible for training their staff on cell phone usage in the facility. The DON stated she monitors staff for cell phone usage by performing rounds and providing continuous training. The DON stated cell phones should not be used in resident rooms, hallways, and the nurses' station. The DON the potential negative outcome of cell phone usage while performing resident care could be affecting the dignity of residents, violating their privacy and the potential for mistakes. Record review of the undated facility policy titled Resident Rights revealed the following: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and ImplementationFederal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a dignified existence to be treated with respect, kindness, and dignityt. privacy and confidentiality

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed for food safety. The facility failed to ensure food items in the refrigerator (x1), and freezers (x5), were labeled and stored in accordance with the professional standards for food service. These failures could place residents at risk for food-borne illness and cross contamination.Findings included: During kitchen tour observations on 2/10/26 that began at 11:08 a.m. and concluded at 11:59 a.m., revealed the following: Reach-in refrigerator revealed the following: What resembled pecan pie (undated, unlabeled), chocolate cake (undated, unlabeled), and [NAME] cake (no use by date) in different clear plastic bags. Reach-in freezer #1 revealed the following: What resembled sausages (undated), hamburger patties, hot dogs, double chocolate cookies, omelets, and french fries in different clear plastic bags with no use by date. Reach-in freezer #2 revealed the following: What resembled cookies (undated, unlabeled), waffles (undated, unlabeled), and pancakes (no use by date) in different clear plastic bags. Reach-in freezer #3 revealed the following:What resembled chocolate chips (unlabeled), sweet potatoes, corn flakes, and Italian style vegetable in different clear plastic bags with no use by date. Reach-in freezer #4 revealed the following:What resembled diced onion (unlabeled), organic multicolor rice, corn flakes, and cauliflower in different clear plastic bags with no use by date. Reach-in freezer #5 revealed the following:What resembled purple onion, and beef in different clear plastic bags with no use by date. During an interview on 2/12/2026 at 1:43 p.m., regarding kitchen observations, the DM stated, it is the cook's responsibility for dating and labelling of all food items whenever the truck comes in, and I jump in to help them. The DM further stated that the food items should have been labelled and dated, I really feel that this is an isolated event, we were short staffed, the truck came in on Monday - 02/9/26, I was not here so the kitchen staff were making sure to get the truck unloaded, cook breakfast and then serve the residents. When asked about who is responsible for monitoring the dating and labelling of the food items she stated, that is my responsibility, that is what I meant by if my staff misses something, I am the one to catch it. She further stated that she has the kitchen policy and been trained to label and date food items. The DM stated, numerous things like food borne illness, and residents might not like to eat the food resulting to weight loss, when asked the potential negative outcome serving residents meals not labelled /dated. During an interview on 2/12/2026 at 2:20 p.m., with [NAME] A regarding kitchen observations, she stated everyone in the kitchen were responsible for dating and labelling all food items, that everything was supposed to be labelled and dated, and that the DM was responsible for monitoring that. When asked about the kitchen policy she stated, I have come across the policy. She further stated that not dating /labelling of the food items will potentially cause food borne illnesses because we don't know how long the food items have been there. During a phone interview on 2/12/2026 at 2:29 p.m., with the RD, regarding kitchen observations, she stated, all the kitchen staff were responsible for dating and labelling the food items. When asked if the staff have been trained on such tasks, the RD stated, yes, I believe so. She further stated that everything was supposed to be labelled /dated. When asked about who is responsible for monitoring the dating and labelling of the food items she stated, I think all the staff should, but on a daily work shift should be the DM. The RD stated that food items not labeled or dated would potentially cause food borne illness to the residents or not tasty food because it is old or spoiled, resulting in resident's weight loss. She further stated, the kitchen staff were supposed to be using the 'fifo method', first in, first out. During an interview on 2/12/2026 at 3:14 p.m., with the ADM regarding kitchen observations, she stated, all kitchen staff were responsible for ensuring food was stored and dated properly, and they were all trained on that. When asked why the food items were not labelled/dated, she stated, I can't say why they missed it. She further stated, the DM is responsible for monitoring the dating/labelling of the food items. The ADM stated the potential negative outcomes to the residents was, using or serving expired food on those residents could be potentially harmful to the residents. Record review of the facility's policy and procedure titled, Food Storage, dated March 2021, reflected the following: Policy: Refrigerators and freezers will be kept clean and sanitized. The procedures to maintain the proper temperatures for storing cold foods will be strictly followed to prevent food borne illness. Procedure:6. Food must be stored in a properly covered container with a date and label identifying what is in the container. Foods may remain in the [NAME] box as long as content and dates are easily visible on the box. Any foods removed from the [NAME] box must be dated and labeled. 15. All of the following terms will be considered expiration dates for cold food products: Expires by date Best Used by date Use by date Sell by date.

Based on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents. The facility failed to ensure CNA A and CNA B implemented the appropriate amount of assistance when they transferred Resident #1 themselves instead of using a mechanical lift, as was care planned. The Failure resulted in staff having to assist Resident #1 to the flor, and required her to be sent to the hospital where she was ultimately diagnosed with a fractured right femur. The noncompliance was identified as PNC. The IJ began on 06/14/25 and ended on 6/17/25. The facility had corrected the noncompliance before the survey began This failure could place residents at risk for physical harm, pain, mental anguish, emotional distress and serious injury. Findings include: Record review of Resident #1's face sheet, dated 6/19/25, revealed a [AGE] year-old-female who was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], Resident #1 had diagnoses which included muscle weakness, difficulty walking and congestive heart failure (chronic heart condition) Record review of Resident #1's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact. Section GG Functional Abilities did not indicate Resident #1 used a mechanical lift. Section V Care Area Assessment (CAA) Summary: CAA Results: 11. Falls Record review of Resident #1's Weight Summary, revealed the following: 6/02/25 202.2 lbs. Record review of Resident #1's progress notes, dated 3/19/25- 6/19/25, revealed: LVN C documented on 6/14/25 at 1:45 PM: Resident #1 was being transferred from her bed to the shower chair, and was lowered to the floor slowly by 2 CNA's (CNA A and B) and Family Member D at bedside. Provider E notified, and gave an order to send to hospital via transportation to ER for evaluation. The DON and Family Member D notified. LVN C documented on 6/14/25 at 2:39 PM: Notified EMS for transport-to-transport patient to ER for evaluation. LVN C documented on 6/14/25 at 2:40 PM: Transport called back and said they would have an ambulance come from a nearby city d/t unavailability of a backup ambulance. Resident #1 said she was ok and may just need some Tylenol, Tylenol administered as ordered. LVN C documented on 6/14/25 at 3:00 PM: LVN C asked if the Resident #1 was comfortable, Resident #1 was in bed and stated yes, she did not want to go to hospital and voiced concern to Family Member D that she wanted to stay at the facility, nurse encouraged patient that it was important to just go to the ER to get evaluated. Resident #1 agreed, Family Member D told patient she would go to the ER with her. LVN C documented on 6/14/25 at 3:18 PM: Called EMS to get an ETA on their arrival, dispatch stated they should be pulling up. LVN C documented on 6/14/25 at 3:28 PM: EMS got Resident #1 loaded into Ambulance and transported to the local hospital. LVN C documented on 6/14/25 at 4:18 PM: Nurse (Unknown) called from hospital and spoke with RN F and asked what exactly the patient was being sent over for observation for, nurse supervisor gave patient report. LVN C documented on 6/14/25 at 6:15 PM: RN F called the hospital and spoke with NP G and received results on Resident #1 that x ray and CT showed a Right Distal Femur FX, Family Member D and DON notified. LVN C documented on 6/15/25 at 6:10 PM: Resident #1 returned to the facility via EMS transport, Family Member D and Family Member H were with her, patient was smiling and stated she was so glad to be back in her bed. Brace/immobilizer to right LE in place. Resident #1 denied pain at this time. Provider E notified. Record review of Resident #1's care plan, dated 5/07/25, revealed: Focus: Resident #1 had an ADL self-care performance deficit r/t to CHF and weakness. (Initiated: 5/03/24 and revised 6/04/24) Goal: Resident #1 will maintain current level of function in ADL's. (Initiated 5/3/24 and Revised 11/11/24) Intervention(s): Transfer: Resident #1 required Mechanical lift with two staff assistance for transfers. (Initiated 8/21/24) Record review of Resident #1's incident report, dated 6/14/25, revealed Resident #1 was being transferred from her bed to the shower chair, and was lowered to the floor slowly by 2 CNAs (CNA A and CNA B) and Family Member D was at bedside. Provider E was notified and gave the order to send to the hospital via transportation to the ER for evaluation. The resident description revealed she had CNAs (CNA A and CNA B) on each side of her and her family member at bedside and the CNAs assisted to a standing position and after she stood with their assistance, her right leg started giving out on her and she told the aides she couldn't stand up no more and the CNAs assisted her to the floor softly. Resident #1 stated she did not have pain at the time. The immediate action taken was the CNA (specific CNA not identified ) came to get the nurse (Specific nurse not identified). Nurse assessed Resident #1, took vitals and assessed for pain and discomfort (No additional details listed). Resident #1 was oriented to person, situation, place and time. No pain level was indicated. Record review of Family Member D's witness statement, dated 6/14/25, revealed two CNAs (unidentified in the statement) came to get Resident #1 up from her bed to go the shower. The CNAs were able to ger her (Resident #1) on the side of the bed to transfer her from the bedside to the shower chair. One CNA got on each side of Resident #1. Resident #1's legs began to fold under her. They (CNAs) lowered her to her knees, and they were unable to get her lifted, so they eased Resident #1 to her bum. Resident #1's right leg was bent under her to the side, but the staff were able to get it straightened out. The staff went to grab the mechanical lift to get her off the floor and into the shower chair. Record review of CNA B's witness statement, dated 6/14/25, revealed she and her partner (unidentified) went to transfer Resident #1 to the shower chair. When they realized they could not complete the transfer they set her (Resident #1) on the floor. She (CNA B) went to get the nurse while CNA A stayed with Resident #1. Record review of CNA A's witness statement, dated 6/14/25, revealed she and CNA B were transferring Resident #1 to the shower chair. Resident #1 started to pull down and they were unable to lift her (Resident #1) high enough to get her on the shower chair, so they lowered her (Resident #1) to her knees. Record review of Resident #1's medical record, dated 6/15/25 , revealed: Resident #1's reason for the visit was to address pain post fall. Imaging of the right lower extremity was conducted and revealed an acute traumatic fracture medial distal femur. There was no significant displacement. Resident #1 did not appear to be in any obvious distress. Resident #1 was pleasant and welled groomed. Record review of the facility's incident/accident report, dated 06/18/25, revealed Resident #1 had a witnessed fall on 06/14/25 at 1:30 PM. Record review of the facility's Form 3613 (Provider Investigation Report), dated 6/18/25, revealed CNA A and CNA B were the alleged perpetrators. Family Member D was a witness to the incident . Form 3613 indicated LVN C conducted an assessment on Resident #1. Form 3613 indicated the ADM was notified of the fall on 06/14/24 (Time not indicated) that involved Resident #1. CNA A and CNA B were preparing Resident #1 for a shower. The two CNAs performed a 2-person transfer. Resident #1 stood up and the right leg failed to support the weight of Resident #1. Resident #1 was guided to the floor by CNA A and CNA B. Resident #1 complained of knee pain. CNAs (CNA A and CNA B) alerted charge nurse about the incident. The DON interviewed both CNAs (CNA A and CNA B). There was no reason given by either CNA why they chose not to follow the care indicator instructions. Care indicators were posted and had been in-serviced to staff. The DON suspended both CNAs immediately pending the outcome of the investigation. Record review of the facility's admission discharge report, dated 6/23/25, revealed Resident #1 discharged from the facility on 06/14/25 and returned to the facility on [DATE]. An observation was made on 06/18/25 at 3:01 PM of two pictures next to her room name plate of a mechanical lift and a picture of two people. During an interview on 06/18/25 at 3:01 PM, Resident #1 stated she fractured her leg. She stated she was the only one in the room when it happened. She stated she sat up on the side of the bed and when she stood up her legs gave out. She stated no one was in the room with her. She denied CNA A and CNA B being in the room with her. She denied Family member D being in the room with her. She stated she was all alone. She could not recollect the time when the fall occurred and stated she could not remember how she got off the floor and who helped her. She stated the staff used the mechanical lift but there was a time when she could help staff transfer herself, but she was too weak to do it on her own. She stated she felt safe at the facility and did not have any concerns. She stated she was not in pain at the time of the interview and if she was in pain she could get pain medication if she wanted it. During an interview on 6/18/25 at 10:53 AM the ADM stated regarding Resident #1 and her fall it was reported to her that the staff (unspecified) was getting Resident #1 ready for her shower. She stated that her initial report to state was that the incident occurred in the shower room but later confirmed that the incident took place in Resident #1's room. She Resident #1 was sent to the hospital and came back the next day with a small fracture. She stated she suspended both CNAs. At the time of the interview, she did not have the CNAs name but stated the DON would know their names. She stated during her investigation she identified Resident #1 was supposed to have the mechanical lift for transfers. She stated the DON conducted the interviews and would defer to her for what was said in those interviews. She stated she was familiar with the facility policy on using the correct lift for the residents. She stated the system to monitor staff and resident transfers was they had icons (pictures) on the outside of each resident's door that required a specialized transfer. She stated nursing staff will round and ensure that the CNAs are using the appropriate transfer. She stated that there is cheat sheet or care indicator form that is kept at the nurses' station and it also has pertinent information about each resident to include their appropriate transfer. She stated this system was in place at the time that the CNAs transferred Resident #1. She stated the purpose of conducting appropriate transfers was for resident and staff safety. She stated the potential negative outcome if the improper transfer was used was injury to the staff and residents. She stated she or the DON was unaware that CNAs were using the incorrect transfer for Resident #1. The ADM stated she had been trained regarding using the appropriate lift for residents and her staff had also been trained. She stated she expected her staff to use the appropriate transfer for each resident when providing care. She stated the staff should be following the resident's care plan. The ADM stated the staff are responsible for the care that they provide and are responsible for using the appropriate transfer for the resident's which should prevent incidents and accidents. She stated there was no reason that was given to her as to why the CNAs used the inappropriate transfer when transferring Resident #1 on 06/14/25. The ADM stated because of the incident involving Resident #1 the staff were immediately inserviced on ANE, care indicators, and following the resident's care plan. The ADM stated CNA A and CNA B have not worked since the date (6/14/25) that they used the incorrect transfer. She stated CNA A would be terminated and CNA B who worked for the temporary staffing agency would be placed on a list that indicated that she could no longer work at the facility. During an interview on 6/18/25 at 10:54 AM the DON stated regarding Resident #1 her care indicators that show staff what transfer to use is posted outside the door and have been even on 6/14/25 when CNA A and CNA B performed the incorrect transfer on Resident #1. She stated on 06/14/25 Family Member D was in the room when the incident occurred. She stated a discussion was had regarding getting Resident #1 up for a shower. She stated CNA A and CNA B conducted a two person transfer and during the transfer Resident #2 stated one of her legs gave out and both CNAs assisted Resident #1 down to the floor. She stated Resident #2 complained of pain and the nurse (unspecified at this time) conducted an assessment. She stated Resident #2 was transferred to the hospital for further evaluation. The DON stated after consultation with orthopedics it was determined that Resident #2 was not a candidate for surgery and would return to the facility with an immobilizer. The DON stated her diagnosis given was a mildly displaced femur fracture. The DON stated she spoke with Family Member D, and she (Family Member D) stated she had instructed the CNAs to give Resident #1 a shower. She stated Family Member D did not instruct the CNAs which transfer to use. The DON stated she was familiar with the facility policy regarding safe transfers and incident and accident prevention. She stated the purpose of having and following the facility policy was to prevent injury to staff and residents. She stated failure to follow the policy could cause injury to the staff or residents. She stated she was unaware at the time of the incident that CNA A and CNA B were performing the incorrect transfer but was made aware when the charge nurse reported the incident to her. The DON stated she knew automatically that the wrong transfer was used because she knew Resident #1 and knew that the mechanical lift should have been used. She stated they had a total of three mechanical lifts, and all are operational. She stated the system to monitor that staff were using the appropriate transfer was through staff training. She stated training occurred upon hire and annually. The DON stated she had been trained on the use of appropriate transfers and all her staff had also been trained on using the proper transfer for residents in the facility. She stated she had provided the staff inservice training on ANE (preventing abuse), the care indicators (located on the outside of the door), where to find the information regarding resident transfers and the importance of using the appropriate transfer for each resident. She stated the care indicator system located outside of the door was in place at the time CNA A and CNA B transferred Resident #1 on 6/14/25. She stated they had trained all staff that had worked since the incident. She stated that she expected all her staff to use the appropriate transfer for each resident to prevent incidents and accidents. She stated when she interviewed CNA A and CNA B there was no reason given why the incorrect transfer was used. She stated Resident #1 used the mechanical lift because she is bed and wheelchair bound. She stated Resident #2's transfer was already in place. She stated physical therapy did not evaluate her recently for her transfer, but that Resident #1 has always used the mechanical lift. She stated that Resident #1 had used the mechanical lift for a long time. Interviews conducted on 6/18/25 between 1:32 PM-1:44 PM, revealed that staff (CNA W, NA X) had been trained on the use of mechanical lift and appropriate transfers for residents. They stated the mechanical lifts at the facility are operational. They were able to report that there was never a reason they would use an inappropriate transfer. During an Interview on 06/18/25 at 1:58 AM CNA A stated that she had been trained on the facility's system for appropriate transfers for residents. She stated she had been trained on the use of the mechanical lift. She stated that she was trained that there was never a reason that she should deviate from the appropriate transfer for any resident. She stated she received the training before 6/14/25 when the incident that occurred on 6/14/25 involving Resident #1 being lowered to the floor after she and CNA B had used the incorrect transfer. She stated on 06/14/25 she was instructed by RN F to shower Resident #1 and to get someone to help her. She stated he got CNA B to help her. She and CNA B were transferring Resident #1 into the shower chair. CNA A stated she did not look at the pictures/icons on the outside of the door when she first went in. She stated when they attempted the 2-person transfer Resident #1 dropped her weight. She stated she and CNA B had to sit Resident #1 down on her knees. She stated they continued and lowered her slowly down on her butt. She stated that once they got Resident #1 down the pulled her legs gently out from under her. She stated Family member D was present in the room. She stated Family Member D did not stop them or instruct them to do the 2 person transfer on Resident #1. She stated she or CNA B did not realize that Resident #1 used the mechanical lift. She stated Resident #1 usually receives her shower at night. CNA A stated she normally would look at the resident door before she transferred a resident but in the case with Resident #1, she did not. She stated when Resident firs was admitted she did not use the mechanical lift, but it had been a long time since she had worked directly with Resident #1. CNA A stated she could not give the exact time she and CNA B conducted the transfer but that she did not uses a mechanical lift. CNA A stated Resident #1 did not necessarily fall in her opinion because she and CNA B sat her down on her bottom very slowly. CNA A stated they did not sit her down hard. She stated that Resident #1 was not in pain but later complained of pain in her leg. She stated she could not be for sure, but it may have been 5 minutes or so after the incident. She stated they got the nurse. She stated LVN C and RN F came in. She stated they were told at that time that Resident #1 was supposed to use the mechanical lift. She stated from that point they used the mechanical lift to get Resident #1 from the floor, shower and returned her to bed. She stated Resident #1 had to get x-rays because she was in pain. She stated she did not work any additional shifts because she was suspended pending investigation. She stated the potential negative outcome of not using the appropriate transfer was the residents could get injured or receive a fractured bone. She stated they ran the risk of dropping Resident #1 or pulling her limbs too hard. During an interview on 6/18/25 at 2:25 PM CNA B stated that she had been trained on the facility's system for appropriate transfers for residents. She stated she had been trained on the use of the mechanical lift. She stated that she was trained that there was never a reason that she should deviate from the appropriate transfer for any resident. She stated she received the training before 6/14/25 when the incident that occurred on 6/14/25 involving Resident #1 being lowered to the floor after she and another cna (unspecified during the interview) had used the incorrect transfer. She stated she had used a 2 person transfer with Resident #1 before with another staff that she could not remember her name. She explained it was a long time ago but could not be sure of the period. CNA B stated on 6/14/25 the shower girl asked if she (CNA B) could help her transfer Resident #1. She stated she did not know the other can's name. CNA B stated it was her mistake for not checking the door before she went into Resident #2's room. CNA B stated she did not realize Resident #1 used the mechanical lift. She stated Family Member D was in the room when they conducted the transfer. CNA B stated when they conducted the two-person transfer Resident #1's right leg gave out from under her, and they had to sit Resident #1 down slowly. CNA B stated Resident #1 did not go down hard. She stated they pulled her right leg out from under her gently. She stated that Family Member D was in the room with them and did not stop them from conducting the two person transfer but Family Member D did not instruct them to do the 2-person transfer either. She stated Resident #1 was a larger resident and that was how they knew to at least have 2 people. She stated she was in a hurry on 6/14/25 and she thought that it would be like every other time she had ever conducted a 2-person transfer on a resident. She stated Resident #2 does not typically shower during the day, but Family Member D requested that Resident #1 be showered during the day. CNA B stated she was fully aware of the icons/pictures on the outside of the door, and she should have looked for them. She stated when the incident happened, she left to get a nurse and left the other cna with Resident #2. She stated that she grabbed a sling on the way back. She stated once Resident #2 was assessed they got her up using the mechanical lift. She stated they proceeded to take her to the shower. She stated Resident #1 did not complain of pain. She stated she later heard after the incident complained of pain but was not present. She stated that she was suspended pending the investigation and has not worked a shift since the incident on 6/14/25. She stated she had a shift scheduled after, but it was cancelled. During an interview on 6/18/25 at 3:16 PM Resident #3 stated there were no additional concerns with resident transfers or failure to use the mechanical lift when appropriate. She stated there was always two staff that used the mechanical lift when they transferred her. She stated no had ever tried to use any other transfer on her while she has resided at the facility. During an interview on 6/18/25 at 7:00 PM Family Member D stated that she was present in the room when the two aides transferred Resident #1. She stated she did not know the two aides' names. Family Member D stated that she had asked that Resident #1 have a shower. She stated the two aides did 2-person stand pivot. She stated that Resident right leg gave out and the two aides lowered Resident #1 to the floor. She stated they lowered Resident #1 very slowly but that they lowered her on top of her knee first and then to her bottom. She stated that the aide pulled her right leg out from under her. She stated the aides were gentle with Resident #1. She stated that Resident did report her knee hurt but was not complaining really bad. She stated that she had never observed any staff do a 2-person transfer with Resident #1 before. She stated she had always observed staff use the mechanical lift. Family Member D stated that she should have stopped them, but she thought that about how it would make her feel if someone came to her place of work and told her how to do her job. She stated that she did not have any complaints about the facility, and they take really good care of Resident #1. She stated Resident #1 sometimes does get confused and she (Family Member D) was not surprised that Resident #1 did not fully remember what happened. She stated the same day when they went to the hospital on [DATE] Resident #1 could not give a full of count of what happened, and she (Family Member D) had to assist in telling the doctors what happened. During an interview on 6/18/25 at 5:15 PM The DON stated she would provide updated inservices on 06/19/25. She confirmed that all staff on leave, PRN, and agency would be inserviced prior to being able to work their shift. During interviews conducted on 06/19/25 from 10:56 AM-11:40 AM, staff that worked the day time shift (LVN I, LVN L, LVN O CNA K,CNA M, CNA N, CNA P, CNA Q, CNA R, CNA Y, CNA Z ) were able to report that that since 6/14/25 they had been trained/reeducated on the facility's abuse policy. They stated they had been trained that ANE not only included reporting but prevention. They were able to report that using the proper transfer for residents was a way to prevent incidents, accidents, and neglect. They were able to report that they would never use an inappropriate transfer for a resident. They were able to report that they had been trained/reeducated on the facility system on the posted icons/pictures outside of the resident's door. They stated even if they had provided care to a resident in the past they would check the door, care indicator sheet at the nurse's station, care plan and or ask a charge nurse for clarification. They all stated they felt comfortable and confident in their role regarding resident transfers, ANE policy, and preventing incident and accidents. During an interview on 6/19/25 at 2:15 PM RN F stated she worked on 6/14/25 at the facility. She stated that she could not remember the two cna's names, but that Family Member D requested that Resident #1 be showered. She stated she instructed the aides to shower her. RN F stated she was not in the room when the aides transferred her. She stated she was told by staff (not specified) that the aides did a 2-person transfer to place Resident #2 in the shower and Resident #2's leg buckled under her. The aides eased Resident #1 to the floor. Resident #1's right leg was under her, and the aides pulled her leg out. Family Member D reported to her that Resident #1 was fine. She stated Resident #1 was assessed and reported to be fine and not in any pain. She stated after Resident #1 took her shower and was placed bed with the mechanical lift that was when the resident complained of pain. RN F stated the pain was not tremendous. RN F stated Resident #1 did not initially want to go to the hospital but after encouraging from staff and Family Member D she agreed to go. Once Resident #1 made it to the hospital that was when they received the x-ray that Resident #1 had a fracture. RN F stated Resident #1 received Tylenol while she waited for EMS transport. RN F stated she was not told why the aides did not use the mechanical lift and they may have told LVN C. RN F stated the signs of the appropriate transfer is posted outside of the residents' room and was posted outside of Resident #2's room on 6/14/25. During an interview on 6/19/25 at 2:21 PM LVN C stated she was not in the room when CNA A and CNA B transferred Resident #1 on 6/14/25 but that she was the nurse in charge of Resident #1 on that day. She stated when the transfer happened one of the cna's came to get her, but she could not remember which one. She stated she was told that they did a 2-person transfer on Resident #1 and when they stood Resident #1 up to pivot with her, her right leg gave out. She stated the staff reported to her that they lowered her to the floor. She stated as soon as she (LVN C) was notified she ran in there and started her assessment. She stated she immediately explained to the aides that Resident #2 required the mechanical lift. She stated she asked the aides if they saw the sign on Resident #2's door. She stated before they could answer Family Member D interjected, apologized and explained that she was the one who told them to get Resident #1 up. LVN C stated she explained to Family Member D that it was not her fault, and the staff knew what they were supposed to do. LVN C stated she knew that both aides knew to check the door and knew where to go check for transfer information because they had worked at the facility even before she started. She stated Resident #1 did not want to go to the hospital, but they encouraged her. She stated Family Member D convinced Resident #1 to go. She stated she assessed Resident #1 and there were no concerns. She stated she administered Tylenol to Resident #1 but Resident #1 did not complain of excruciating pain. During an interview on 6/19/25 at 3:52 PM CNA M stated she had been trained how to use the mechanical lift. She stated all mechanical lifts (x3) were operational. She was able to describe how she would use the mechanical lift to include ensuring that the wheels are locked during the ascending and descending process. She stated that the mechanical lift was not used for transport but only for transfer. She stated that before she would use the mechanical lift she would inspect the machine to include the sling and that they only use the mechanical lift with two staff at all times. During an interview on 6/19/25 at 3:55 PM CNA K stated she had been trained how to use the mechanical lift. She stated all mechanical lifts (x3) were operational. She was able to describe how she would use the mechanical lift to include ensuring that the wheels are locked during the ascending and descending process. She stated that the mechanical lift was not used for transport but only for transfer. She stated that before she would use the mechanical lift she would inspect the machine to include the sling and that they only use the mechanical lift with two staff at all times. Record review of CNA A's course completion report, dated 6/18/25, revealed CNA A completed Fall Prevention for Older Adults on 08/7/24. CNA A completed preventing, identifying, and responding to abuse and neglect on 08/11/24. Record review of CNA B's Required credentials, dated 6/18/25, revealed that her abuse, neglect and exploitation was valid and did not expire until December of 2025. Record review of the CNA B's Acute CNA Assessment, undated, revealed CNA B passed the assessment with the required 70 or above. Patient Safety and Patient Mobility and transfers were areas covered in the assessment. Record review of the facility's inservice sheet, dated 6/10/25 revealed 30 staff had been inserviced on the facility's fall policy and ANE policy. Record review of the facility's inservice sheet, dated 6/14/25 revealed 26 staff had been inserviced on the facility's care indicators system located on the resident's doors, Patient centered care, ANE policy and Resident lifting. Record review of the facility's care indicator legend, undated, revealed 8 pictures and the corresponding indicator to include whether a person was a high fall risk, 2 person assist, 2 person transfer and mechanical lift. Record review of the Resident Care Guide, undated, revealed Resident #1 was on hall 2 and required a mechanical lift with 2 people. Record review of the facility's policy, Assessing Falls and Their Causes, Revised March 2018, revealed: Purpose: The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Record review of the facility policy, Safety and Supervision of Residents, Revised December 2007, revealed: Policy: Our facility strives to make the environment as free from accident hazards as possible. Residents' safety and supervision and assistance to prevent accidents are facility wide priorities. Resident-Oriented Approach to Safety: Staff shall use various sources to identify risk factors for residents, including the information obtained from medical history, physical exam, observation of the resident, and the MDS. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accidents hazards or risk for that resident. The care team shall target interventions to reduce the potential for accidents. Implementing interventions to reduce accident risks and hazards shall include the following: Assigning responsibility for carrying out interventions. Providing Necessary training Ensuring that interventions are implemented Monitoring the effectiveness of interventions shall include the following: Ensuring the interventions are implemented correctly and consistently Resident Risks and Environmental Hazards: Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated [TRUNCATED]

Based on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 7 residents (Resident #2) reviewed for medication. The facility failed to prevent Resident #2's Methocarbamol 500 MG medication from being accounted for, between April 2025-June 2025. This failure could place residents at risk for not receiving prescribed medication for specified diagnosis. Findings include: Record review of Resident #2's face sheet, dated 6/19/25, revealed a [AGE] year-old-female who was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #2 had diagnoses which included dementia (memory loss) and pain in left knee. Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was cognitively intact. Section I Active Diagnosis: Pain in Left Knee Section J Health Conditions: Resident #2 was on a pain medication regimen, received PRN pain medications. Section V CAA did not reveal Resident #2 should be care planned for pain. Record review of Resident #2's Order Summary Report, dated 6/19/25, revealed: Methocarbamol Oral Tablet 500 mg (1 tablet by mouth every 8 hours as needed for muscle pain/spasms related to low back pain (Ordered and Started 9/12/24) Record review of Resident #2's MAR for March 2025 revealed: Methocarbamol 500 mg was administered a total 8 times (three times on 3/14, 3/15, 3/17, 3/26, 3/30 and 4/31) Record review of Resident #2's MAR for April 2025 revealed: Methocarbamol 500 mg was administered a total 6 times (4/1, 4/14, 4/16, 4/22, 4/23, and twice on 4/24 Record review of Resident #2's MAR for May 2025 revealed: Methocarbamol 500 mg was administered a total 3 times (5/1, 5/2, and 5/24) Record review of Resident #2's MAR for June 2025 revealed: Methocarbamol 500 mg was administered a total 2 times (6/4 and 6/15) Record review of Resident #2's care plan, dated 3/31/25, revealed: Focus: Resident #2 is on pain medication therapy r/t low back pain. (Initiated 9/16/24 and revised on 10/4/24) Goal: Resident #2 will be free of any discomfort or adverse side effects from pain medication. (Initiated 9/23/24 and revised 1/6/25) Intervention(s): Monitor/Document/Report PRN adverse reactions to analgesic therapy: altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, and urinary retention. Record review of the facility's Form 3613 (Provider Investigation Report), dates 6/11/25, revealed on 06/05/25 the DON was notified of an inconsistent medication count on Resident #2's 500 MG Methocarbamol. The inconsistent count was noted as order too early. The DON conducted an investigation regarding count and re-order request. It was determined 23 pills were not accounted for. The DON contacted the nurses (not specified). The DON reviewed/ in-serviced on medication administration and documentation protocols. Nurses acknowledged the in-service. The DON requested the pharmacy to replace the medication, and bill was charged to the facility. The DON noted the resident did not experience any negative impact. The DON initiated muscle relaxers should be counted along with the controlled medications. Record review of the facility pharmacy orders, dated 3/4/25, revealed Resident #2's 500 MG Methocarbamol was ordered. Record review of the facility pharmacy orders, dated 4/15/25, revealed Resident #2's 500 MG Methocarbamol was ordered. Record review of the facility pharmacy orders, dated 4/29/25, revealed Resident #2's 500 MG Methocarbamol was ordered. Record review of the facility pharmacy orders, dated 5/27/25, revealed Resident #2's 500 MG Methocarbamol was ordered. Record review of the facility's pharmacy sheet, dated 3/04/25, revealed Resident #2 received a medication card that included 30 500 MG Methocarbamol on 03/03/25. Record review of the facility's pharmacy sheet, dated 4/15/25, revealed Resident #2 received a medication card that included 30 500 MG Methocarbamol on 4/15/25. Record review of the facility's pharmacy sheet, dated 4/30/25, revealed Resident #2 received a medication card that included 30 500 MG Methocarbamol on 4/30/25. Record review of the facility's pharmacy sheet, dated 6/05/25, revealed Resident #2 received a medication card that included 30 500 MG Methocarbamol on 06/05/25. An observation was made of the medication administration card (Methocarbamol Oral Tablet 500 mg) and the Medication Count sheet. The Medication Administration card and count sheet were accurate reflecting 3 pills in one card and on the corresponding sheet and 30 pills in the second card and on the corresponding count sheet. During an interview with Resident #2 on 06/18/25 at 3:20 PM, she stated she received her medications when prescribed. She stated she did not know the exact names of the medications, but she received them when she asked for them. She stated there had never been a time where she was in pain, asked for medication and it was unavailable. She stated she mostly had pain in her knees. She stated she was unaware if she had any missing medications. During an interview on 6/18/25 at 10:53 AM, the ADM stated regarding Resident #2's missing muscle relaxer they (ADM and DON) were alerted by the Pharmacy Consultant it was too early to order Resident #2's muscle relaxer. She stated it was reported to her by the DON there were 23 missing muscle relaxers that had not been accounted for. She stated the facility paid for the replacement. She stated during her investigation she found there was no uncontrolled pain or needs not met for Resident #2. She stated she determined this through record review and interviewing Resident #2. She stated Resident #2 still had medication if she needed a dose. She stated a full cart count was conducted. She stated because of the incident they decided to place the muscle relaxers on a count sheet like the controlled medication to alleviate future errors. She stated she did not have a date of when the medication would have come up missing because as a rule, they did not count muscle relaxers. She stated in her PIR she determined the incident involving Resident #2 and her missing medications unfounded because it was determined to be a documentation error. During an interview on 6/18/25 at 10:54 AM, the DON stated Resident #2 was the only resident in the facility on muscle relaxers. She stated during her investigation of the missing documentation it was determined the muscle relaxers were not missing and it was a documentation error. She stated she would now conduct administration checks of the medication. The DON stated she was now placing the muscle relaxers on a count sheet like the narcotic medications. She sated because the muscle relaxers were not counted the error was not caught. She stated they were alerted to inconsistencies because the Pharmacy Consultant stated when the medication was reordered it was told to them it was too early to re-order. The DON stated she found there was a discrepancy in what was in the EMR and what was documented. She stated there was at least four times documented the medication was refilled, and it did not coincide with the EMR. She stated without the medication being signed out it would be difficult to determine what was missing. She stated before the muscle relaxer would have been stored on the medication cart. She stated the nurses were the only ones who gave medications and had access to the medications for residents. She stated the night nurses were the nurses who reordered the medication. She stated the night nurse was trained if the medication had 7 or less medication that it was time to reorder the medication. She stated when the night nurse reordered it was a routine order. She stated she determined 23 muscle relaxers were missing because the last refill was made on 4/30 for a total of 30 pills. She stated when she looked at the EMR only 3 doses were charted. She stated this would have left 23 doses not documented. She stated there would have been 4 or 5 pills still left on the card. She stated at least 3-4 times a week she checked the narcotics and checked the muscle relaxers for Resident #2. The DON stated she did not think anyone took the medications or there was a drug diversion because there were no missing controlled medications. The DON stated she felt it was a documentation error. She stated she believed the medication was being administered but not documented . She stated when she interviewed the nurses they stated in general they sometimes forgot to document when they administered PRN medications. She stated all nurses were placed on a PIP . She stated she did not have any written statements from any of the nurses she interviewed. She stated she did not identify any inconsistencies overall in PRN medications. During an interview on 6/18/25 at 2:41 PM, the Pharmacy Consultant stated the day after Memorial Day the facility staff (unspecified) requested a refill on Resident #2's muscle relaxers (Methocarbamol 500 MG). She stated a part of the routine with PRN medications she would check to see if the resident was taking the medication regularly to see if they needed to refer the resident to the physician. The Pharmacy Consultant stated she did not fill the requested medication because it was too early. She stated it was reported Resident #2 had 5 pills on site. The Pharmacy Consultant stated when she checked Resident #2's EMR she had only seen 3-4 pills were administered. The Pharmacy Consultant stated as a rule narcotics were the only medication that would be counted. She stated she suggested to the facility that the muscle relaxers be locked up and accounted for. She stated she emailed the facility Resident #2's MAR that she reviewed and contacted the ADM and the DON about the medication. She stated Resident #2 was not consistent in taking the PRN muscle relaxer. She stated she could not be sure without the paperwork in front of her but the medication was ordered at least three times between the end of May and June. She stated without counting the medication it could not have been prevented but in the past before the new management team they counted muscle relaxers but with the new management team they no longer counted muscle relaxers. She stated she was unaware why this had changed. She stated she felt an audit needed to be conducted by someone other than the facility staff. The Pharmacy Consultant stated the Monday after she identified the problem she went to the facility and offered and was prepared to conduct an audit but was told by the DON it was her (DON) job to conduct an audit . The Pharmacy Consultant stated this disturbed her. The Pharmacy Consultant stated she did not look at any of the controlled medications sheets. She stated without being able to conduct and audit it would be difficult to get an accurate number. She stated if the facility stated there were 23 pills unaccounted for that would lead her to believe the medication were taken. She stated 23 missing pills was a lot for a documentation error . During an interview on 06/19/25 at 10:56 AM, LVN I stated she was a nurse at the facility. She stated nurses were the only staff to administer medications. She stated she did not have any information about any missing muscle relaxers, but it was reported to her the muscle relaxers were not being documented when they were administered. She stated as a result of this error they now must count the muscle relaxers like they did the narcotics. She stated before they did not count muscle relaxers. She stated in the past she administered the muscle relaxer to Resident #2, but never forgot to document the medication. She stated Resident #2 typically would receive her muscle relaxer in the evening. She stated she heard through staff talking there were 23 of the muscle relaxers not documented. She stated Resident #2 was the only resident in the facility who took muscle relaxers. During an interview on 6/19/25 at 11:21 AM, LVN L stated she was a nurse at the facility. She stated nurses were the only staff to administered medications. She stated she did not have any information regarding the muscle relaxers that were unaccounted for. She stated she heard about it here and there. She stated she was surprised when she worked and saw the muscle relaxers were in the locked box with the narcotics. She stated they normally did not keep them there and did not count them. She stated because she worked at night she did the ordering of medications. She stated she heard the Pharmacy Consultant stated the medication was ordered before it should have been. She stated she heard about it when she came to work one night. She was unsure of the exact date and time and who notified her. She stated she was not necessarily questioned about it but was told the medication was not being documented. She stated she never administered the medication to Resident #2. She stated the only reason she ordered the medication was because it was low. She stated she was trained to order the medication when medications got down to 7 or 8 pills. During an interview on 6/19/25 at 11:57 AM, LVN O stated she was a nurse at the facility. She stated nurses were the only staff to administered medications. She stated she did not have any information regarding Resident #2's muscle relaxers that were not accounted for. She stated she did not work with Resident #2. She stated she had never administered any muscle relaxers to Resident #2. She stated no one on her hall took muscle relaxers. During an interview on 6/19/25 at 12:26 PM, LVN S stated she was a nurse at the facility. She stated nurses were the only staff to administered medications. She stated she did not have any firsthand information on Resident #2's muscle relaxers. She stated she normally worked the opposite hall Resident #2 resided and never administered any muscle relaxers to Resident #2. She stated because of the documentation error with Resident #2, they were told they would have to count muscle relaxers, but this did not apply to her since no one on her hall took muscle relaxers. She stated she was not questioned about the muscle relaxers but heard about it in passing. During an interview on 6/19/25 at 12:42 PM, LVN T stated she was a nurse at the facility. She stated nurses were the only staff to administer medications, but she never administered medications at the facility. She stated she only consulted with the staff for MDS purposes. During an interview on 6/19/25 at 12:48 PM, LVN BB stated she was a nurse at the facility and was PRN. She stated nurses were the only staff to administer medications at the facility. LVN BB stated she had only been to the facility twice. She stated the last time she worked at the facility would have been the previous Thursday (6/12/25). She stated she knew muscle relaxers were now in the lock box with the narcotics. She stated they received an in-service as to why they were locked up. She stated she was told the medications were not being locked up. She stated she did not know how the facility determined the situation was a documentation error, but she had administer the medication. She stated the DON went over the in-service with her. During an interview on 6/19/25 at 12:54 PM, LVN CC stated she was a nurse at the facility. She stated nurses were the only staff to administer medications. She stated she did not administer medications but she only was available if there were concerns regarding the MDS. During an interview on 6/19/25 at 1:00 PM, RN U stated she was a nurse at the facility. She stated nurses were the only staff to administer medications. She stated she administered medications at the facility but never administered any PRN muscle relaxers to Resident #2. She stated if she had administered the medication, she would have documented it. She sated as a result Resident #2's undocumented PRN medication, they now had count the muscle relaxers. She stated it was told to her in passing the issue was not being documented. During an interview on 6/19/25 at 1:02 PM, RN V stated she was a nurse at the facility. She stated nurses were the only staff to administer medications. She stated she received an in-service about ensuring all PRN medications were documented. She stated she provided care to Resident #2 the previous Tuesday (6/17/25) and she did not administer any PRN muscle relaxers to her. She stated she never administered any PRN muscle relaxers to Resident #2. During an interview on 6/19/25 at 2:15 PM, RN F stated she was a nurse at the facility. She stated nurses were the only staff to administer medications at the facility. She stated she did not have any firsthand information regarding Resident #2's PRN muscle relaxers. She stated she rarely administered medications. She stated she would assist if needed. She stated she provided supervision and observation of staff and residents when she was on shift. She stated she was uncertain if the medication was taken from the facility or if there was an issue with documentation. During an interview on 6/19/25 at 2:21 PM, LVN C stated she was a nurse at the facility. She stated nurses were the only staff to administer medications. She stated she did not have any firsthand knowledge regarding Resident #2's muscle relaxers. She stated Resident #2 did go home sometimes. She stated the medications went home with her. She stated Resident #2 went home for Easter, Mother's Day weekend and around graduation time . She stated they do count Resident #2 medications such as narcotics but never the muscle relaxers. She stated she never noticed a significant amount of the muscle relaxers gone when she returned from being on pass with her family. LVN C stated she administered the PRN medication to Resident #2 but stated she documented every time. She stated she never administered the medication and did not document. She stated she administered at least 2 PRN doses since the medication was moved to the lock box. She stated prior to the undocumented PRN muscle relaxers they never counted the muscle relaxers but now they must count them along with the narcotics. She stated there were no other residents who took muscle relaxers. During an interview on 6/19/25 at 2:35 PM, Family Member DD stated she was notified by the facility staff Resident #2's medication was off. She stated she was not for sure which medication. She stated when Resident #2 went home on pass the facility gave her Resident #2's medication. She stated if it were prescribed, she would administer the medication. She stated Resident #2 only came home once a month and it would only be for three days at a time because the facility policy only allowed her to be out of the facility for 72 hours at a time. She stated there was one month Resident #2 went home with her twice in one month. She stated even at the rate of coming once a month and recently two times in one month she would not have administered any medication 23 times. She stated when she was sent home with medications the nurses would count the medications before she left and when she came back. She stated she never had an instance when any medication counts were not accurate. She stated she hoped the medications were not taken. She stated she trusted the facility staff and they took excellent care of Resident #2. During an interview on 6/19/25 at 3:31 PM, the ADM stated it was the facility's responsibility to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. She stated she was familiar with the facility's pharmacy program and their policies. She stated if medication was missing or accounted for this could place the resident at risk of not having the medication available placing the resident at risk for uncontrolled pain. The ADM stated nothing was 100 percent and she could not say if there was a documentation error or if the medications was taken. The ADM stated the nurses who were interviewed admitted they failed to document PRN medications but not specifically regarding Resident #2. The ADM stated she was not aware about 23 undocumented muscle relaxers until the Pharmacy Consultant notified them. She stated the system the facility used to monitor resident medication was the DON and management team verified the medication and documentation matched. She stated this was discussed daily if there was an issue. She stated she was trained on the facility's pharmacy services. She stated she expected resident medication to be administered and documented appropriately. She stated the DON was responsible for the facility pharmacy and pharmaceutical services. She stated the reason the muscle relaxers were not accounted for was there was a system failure in documentation on the facility nurse's behalf. During an interview on 6/19/25 at 3:37 PM, the DON stated it was the facility's responsibility to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. She stated she was familiar with the facility's pharmacy program and their policies. She stated if the medication was missing or unaccounted for there was a risk the medication would be unavailable for the resident. She stated the potential negative outcome was the resident could be in pain. The DON stated she could not 100 percent prove the medication was not taken but she did have evidence to support it was a documentation error with other residents but not with Resident #2. She stated documenting PRN medications was an issue with her nurses since December 2024 . She stated she had been addressing the issue with her nurses through in-services. The DON stated no nurses specifically admitted they failed to document Resident #2's PRN muscle relaxer. She stated she was unaware there were 23 muscle relaxers unaccounted for until the Pharmacy Consultant brought it to her attention and ever since she started counting them with the narcotics. She stated she was trained regarding the facility's pharmacy services. She stated she expected for resident medications to be administered appropriately per policy and documented. She stated if there was a way to account for the medication then staff should be making sure the medication was accounted for. She stated she was responsible for the facility pharmacy service program in the facility. She stated she did not have a reason as to why the PRN muscle relaxers for Resident #2 were not accounted for. She stated there was no chance Resident #2's PRN muscle relaxers could have been given to another resident as there were no other residents in the facility who took muscle relaxers. During an interview on 6/23/25, the Pharmacy Consultant stated the facility received the refills (30 pills) of the Methocarbamol on 3/03/25, 5/15/25, 4/30/25 and 6/05/25. She stated she had signature logs that were faxed back to the pharmacy, and she would send those to the state surveyor (They were not sent). During an interview with the DON on 6/24/25 at 8:51 AM, she stated the 23 missing/undocumented muscle relaxers came from the Pharmacy Consultant when she identified the inconsistency between Resident #2's medical record. She stated she did not look at the past 90 days of the medication refill orders. She stated it appeared all ordered was received. She stated the muscle relaxers that were ordered ere received on 3/03/25, 4/15/25, 4/30/25, and on 06/05/25 and they were signed for by LVN L . She stated now she would be the staff who would retrieve the facility's medication order from the pharmacist when it was ready. She stated the medication was administered 8 times in March, 6 times in April, 3 times in May and 2 times in June as the muscle relaxer was a PRN medication and was only given when requested. She stated she was unaware the total of undocumented/missing medications was 71 not 23. She stated she understood how the state surveyor could come up with that number by taking the total amount of muscle relaxer refills from March 2025-April 2025 (90 500 MG Methocarbamol) and subtracting the total amount administered according to Resident #2's MARs from March 2025-June 2025 (19 500 MG Methocarbamol) equaling 71 pills not accounted for. She stated she still believed it was a documentation error and the pills were given and not documented. She stated when she interviewed Resident #2, she was able to state she was receiving the medication when she asked for it . During an interview with the DON on 6/24/25 at 8:55 AM, she stated the 23 missing/undocumented muscle relaxers came from the Pharmacy Consultant when she identified the inconsistency between Resident #2's medical record . She stated she looked at all the documentation that was given to the state surveyor. She stated the medication was refilled on 3/03/25, 4/15/25, 4/30/25, and 6/05/25 per the DONs documentation. During an interview with the ADM on 6/24/25 at 8:56 AM, she stated according to Resident #2's MAR the medications were administered 8 times in March 2025, 6 times in April 2025, 3 times in May 2025 and 2 times in June 2025. She stated she was unaware the total unaccounted for was 71 undocumented/missing 500 MG Methocarbamol. Attempted to interview with LVN J on 6/19/25 at 12:40 PM. She did not answer. A text message was sent requesting a return call. Record review of The Pharmacy Consultant's statement, dated 6/25/25, revealed the following: 12/11/24: the Pharmacy Consultant stated she received a refill request for Resident #2 for Methocarbamol 500 mg and reorder sheet stated she had 6 left. The Prescription was last filled 11/21/24 for 30 tablets (ordered 3 times daily). There were 3 doses charted from 11/21 until 12/11. One dose charted on 12/14. Prescription refill was sent 12/13/24. 1/15/25 I visited once again with the DON and ADM. The DON told The Pharmacy Consultant there was no discrepancy issue, this was a charting issue that had been addressed in an inservice on 12/19/24. The ADM agreed with the DON. The DON asked the Pharmacy Consultant if she (The Pharmacy Consultant) had reviewed the chart sheets since then and The Pharmacy consultant had not. The Pharmacy Consultant stated she would go to Provider E and see what he wanted to do if there was a continued problem. Record review of a performance Improvement Plan, dated 6/5/25, revealed the plan was not specified for a particular staff but for the nursing department. The plan addressed proper documentation for PRN medication administration. The plan stated per the facility policy it was required that the nurse administering the medication will record the dose in the residents EMR. The date, time, dosage, route and results achieved should be documented. Record review of the facility policy, Storage of medications, revised April 2017, revealed: Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Record review of the facility's policy, Accepting Delivery of Medications, dated April 2007, revealed: Policy Statement: All staff shall follow a consistent procedure in accepting medications. Any errors noted in receiving medications shall be brought to the attention of the pharmacist and DON. Policy Interpretation and Implementation: The dispensing pharmacy, consultant pharmacist, and DON shall be notified of medication errors.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services., in that: 1. Dietary director failed to wash hands properly. 2. [NAME] A failed to wash hands properly and change gloves. These failures could place residents at risk for food contamination and foodborne illness. The findings included: During an observation on 11/13/24 at 11:55 AM observed the Dietary Director washed her hands; she used the used paper towel to turn off water. During an observation on 11/13/24 at 12:04 PM observed [NAME] A wash her hands and turned water off with bare hands. During an observation on 11/13/24 at 12:12 PM observed [NAME] A picked up a piece of paper off the floor with her gloved hand. [NAME] A threw away the paper and continued temping food on the steam table. No observation of glove changes or hand washing. During an observation on 11/13/24 at 12:21 PM observed [NAME] A carrying a pan to dishwash area with gloves on and returned to food prep area to puree veggies with the same gloves on. No observation of [NAME] A changing gloves or washing hands. During an observation on 11/13/24 at 12:30 PM observed [NAME] A walking to dishwash area and returned to food prep area with same gloves on. No observation of [NAME] A changing gloves or washing hands. During an interview on 11/14/24 at 03:15 PM with [NAME] A, she stated after washing and drying her hands she should have used a clean paper towel to turn off the water. She stated she was trained to change gloves and wash hands any time she left the food prep area. She stated she just got nervous and forgot. She stated she had been trained on handwashing and glove changes. She stated the potential negative outcome could be spread of germs. During an interview on 11/15/24 at 09:57 AM with the Dietary Director, she stated she should have used a clean paper towel to turn the water off. She stated all staff have been trained on proper glove usage and handwashing. She stated [NAME] A should have changed her gloves and washed hands before entering the food prep area. She stated the shift leader and herself were responsible for monitoring staff for compliance. She stated the potential negative outcome could be food contamination and a resident becoming sick. During an interview on 11/15/24 at 11:00 AM with the ADM, she stated the dietary director was responsible for monitoring all kitchen staff for compliance with handwashing and glove usage. She stated water should be turned off using a clean paper towel. She stated gloves should be changed anytime you leave the food prep area. She stated all staff have been trained. She stated her expectations were for staff to follow policy and understand the reasoning. She stated the potential negative outcome was infection control. Record review of the facility policy, titled Handwashing, dated March 2021 reflected the following: Policy: Employees are to wash hands: . Between handling of dirty and clean dishes, equipment/utensils, and food . After touching objects that may be a source of contamination if the next contact with the hands is food or food contact surfaces . Procedure: . 2h. Use another paper towel to turn off water and to avoid contamination of hands . 4. The use of gloves or the use of hand sanitizer does not replace handwashing. Record review of the facility policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices dated March 2021 reflected the following: Policy: Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Procedure: . 6. Employees must wash their hands: . d) Before coming in contact with any food surfaces; . f) After handling soiled equipment or utensil. g) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h) After engaging in other activities that contaminate the hands . 9. Foodservice employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. 10. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing .

Based on observations, interviews, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 7 of 24 confidential residents. The facility failed to ensure 7 of 24 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, access to the Grievance forms, information of who the facility's grievance official was and their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings included: Interviews during Resident Council on, 11/14/2024 at 10:00 AM, attendees 7 of 24 confidential residents stated they did not know about the grievance process. They also stated they did not know where to obtain or submit a grievance form. They stated they did not know they could file a Grievance anonymously. They stated the Grievance procedure had never been discussed in Resident Council. They also stated they had not observed a posting of the Grievance procedure in prominent locations. Residents attending the group meeting did not know how to file a grievance. Residents did not know where to obtain a grievance form, who to turn the form into, and what should happen once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. Seven Residents attended the meeting, and the seven Residents in attendance had all been Residents of the facility for 6 months or longer. Observation and interview on 11/14/2024 at 11:30 AM: there was no visible signage or area designated for grievance forms with instructions informing residents of how/where to file a grievance. During an interview with the DON, the DON was unable to locate blank grievance forms available to residents and could not identify the location residents could have turned in an anonymous grievance form. In an interview with the DON on 11/14/2024 at 3:10 PM; the DON stated the facility planned to add an area for grievance forms near the foyer of the facility with a box to allow residents to file anonymous grievances. The DON stated there was not a previous system in place to file anonymous grievances. The DON stated there used to be grievance forms near the foyer for residents to access, but they were moved, and she was not sure when or why. The DON stated, on this day, grievance forms were not available for residents. The DON stated the ADM was responsible for grievance forms and for ensuring grievances were followed up on. The DON stated, to her knowledge, grievances were discussed during resident council and the activities director relayed any concerns voiced by the residents. In an interview with the AD on 11/15/2024 at 9:43 AM; the AD stated she discussed concerns and complaints during resident council and if the residents had any concerns she relayed them to the ADM for resolution. The AD stated she did not recall a process that would have allowed a resident to file an anonymous grievance, and she was unsure of where the grievance forms were kept. The AD stated the ADM was responsible for resolving grievances. In an interview with the ADM on 11/15/2024 at 9:30 AM; the ADM stated grievance forms had been at the front of the facility and available to residents, but at some point they had been moved and she was not sure when or why. The ADM stated there was not a previous system in place allowing a resident to file an anonymous grievance. The ADM stated the facility was working on adding a location at the front of the facility for residents to find grievance forms and to file them anonymously. The ADM stated grievances were usually voiced during resident council and the AD would relay the concerns. The ADM stated it was her responsibility to ensure grievances were resolved. The ADM stated when grievances were reported to her, she would gather additional information and try to resolve the grievance as soon as possible. The ADM stated this process involved speaking to residents, family, and staff to find a resolution. The ADM stated the previous system was completed via a verbal process, mostly. The ADM stated not having a written process in place could have left out residents who did not feel comfortable voicing their grievance verbally. The ADM stated it was her expectation to resolve grievances and acknowledge a resident's concern immediately or work to find a resolution as soon as possible. The ADM stated it was every staff's responsibility to report a resident's complaint or concern, but it was ultimately her responsibility to ensure grievances were resolved. The ADM stated if a resident could not file a grievance, a concern could go unseen and unresolved because the facility was not made aware of it. Record Review of the undated document titled PATIENT COMPLAINT AND GRIEVANCE PROCESS , revealed the following: PURPOSE: To provide guidance to staff in handling patient complaints or grievances DEFINITIONS: o Grievance: A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP) or accrediting organization standards, or a Medicare beneficiary billing complaint related to rights and limitations. o How Received: E-mail and faxed complaints are accepted and subject to the same process. Information obtained from satisfaction surveys will be handled in the same manner if patient identifiable information is provided. Any verbal communication from a patient or his/her legal representative in which he/she requests investigation or requests a response is handled per this process. PROCEDURE: Information provided to the patient upon request shall include: o Whom the patient contacts to file a grievance (Patient Advocate, Grievance Coordinator) and the contact information o How to reach the Patient Advocate or Grievance Coordinator o The form in which a grievance may be filed; verbal or written o Brief description of the patient complaint/grievance process o The reasons for submitting a grievance, i.e., quality of care concerns or premature discharge perception NOTE: The Joint Commission has a patient complaint service. The Department of Health in several states requires posting of complaint contact information. Medicare beneficiaries must be provided with information about filing a complaint.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1) The facility failed to ensure foods were processed and pureed under sanitary conditions. 2) The facility failed to ensure dietary staff ensured food and non-food contact surfaces were clean. and 3) The facility failed to ensure foods were stored in a manner to prevent contamination. These failures could place residents at risk for food contamination and foodborne illness. The findings included : - The following observations were conducted during a kitchen tour beginning on 10/10/23 at 11:03 AM and concluded at 12:15 PM: In refrigerator #4 there were two unshielded lightbulbs. Freezer #3 had a heavy buildup of ice and frost on one of two sides. The lower shelf of the prep table near the stove was soiled with gummy grease . In the walk-in refrigerator, there was a box of garlic bread that was opened and uncovered which exposed it to contaminants. There was a large plastic bag of thawed raw stew meat stored in the same bin next to two fully cooked boneless hams. The ice scoop handle was dirty, in the ice machine. The handle had a yellow brown buildup on the handle grooves. Dietary staff A placed slices of bread and apple juice in the processor and pureed the food. She then took the processor to the dishwasher to wash. After she washed the processor, the Surveyor observed that there was a large area (approximately 2) of pureed bread and food debris on the interior of the processor pot and lid. The Surveyor intervened and pointed out to Dietary staff A that the processor pot and lid was still soiled with food. Dietary staff A then took the parts to the dishwasher and ran them through the dishwasher. The processor was still wet and there was food debris in the lid after washing. Dietary staff A washed the processor parts in the dishwasher again two more times due to food debris remaining on the parts. After the last washing, Dietary staff A was observed placing the blade in the processor pot and it was still wet after coming out of the dishwasher. She then used her bare hands and wiped the water off the blade and lid interior. She then placed broccoli in the processor and pureed it. - The following observations were conducted during a kitchen tour beginning on 10/10/23 at 5:29 PM and concluded at 5:55 PM: There was heavy ice buildup inside of freezer #1 There was heavy ice buildup in freezer #3 (1 of 2 haves). Refrigerator #4 had two of two interior lights that were not shielded. In the walk-in refrigerator, there was still a bag of thawed bloody stew meat in a bin stored with 2 cook hams. Dietary staff B made the pureed foods for evening meal . She pureed potatoes, then zucchini. After that, the Dietary Manager sent the processor parts through the dishwasher and then wiped the interior of the pot and blade with a paper towel. She did not allow them to air dry. After that, Dietary staff B then pureed meat in the processor. Dietary staff C was observed putting her foot on the lower shelf of the prep table near the stove. There were jugs of oil stored on the shelf. - The following observations and interviews were conducted during a kitchen tour beginning on 10/11/23 at 9:25 AM and concluded at 9:55 AM: On 10/11/23 at 9:28 AM an interview and observation were conducted with Dietary staff A. There were two cooked hams on a cart in a bin in the kitchen. Regarding where she obtained the two cooked hams that were on the kitchen cart, she stated, she got them from the bin where the thawed raw stew meat was stored in the walk-in She stated she was aware raw and cooked foods should not be stored in the same container. She added she had looked for another bin at the time, and that bin with the raw meat was the only place to store the cooked hams. On 10/11/23 at 9:40 AM an interview was conducted with Dietary staff A regarding what could result from raw and cook foods being stored in the same container. She stated someone could get sick. Two of two lights were unshielded in refrigerator #4. - The following observations and interviews were conducted during a kitchen tour beginning on 10/11/23 at 2:51 PM and concluded at 3:33 PM: Refrigerator #4 had two of two unshielded lights. The ice scoop in the ice machine still had a yellow brown substance along the crevices on the ice scooper handle. The underside of the stove's upper shelf had a buildup of splatter, grease and food. On 10/11/23 at 2:53 PM interview and observation were conducted with the Dietary Manager regarding dietary sanitation issues in the facility. She stated the hospital was going to get a company to check the refrigerator lights and freezer ice buildup and the gaskets had been changed previously on the freezers. She stated she was not aware that the lights in the refrigerator were not shielded. She stated she did not know the shields were needed. Regarding why the processor pot was dried with a paper towel instead of allowing it to air dry, she stated, staff were told paper towels could be used to dry equipment. Observation of the Low Temperature Dishwasher Sanitizer, connected to the dishwasher, revealed the following, .Sanitation. Tableware Sanitizer and Destainer for Mechanical Spray Warewashing Machines. Air dry or follow with a potable water rinse. Regarding the storage of the ready to eat foods with raw meat, she stated produce should be on the other side of the walk-in refrigerator away from raw meat. She further stated that raw and cooked food should not have been stored together. At that time , observation in the walk-in , there was a bin of raw cabbage observed on a shelf with bins of thawed raw meat. She stated the issues were unacceptable, and the department was shorthanded. She added sometimes staff forgot to do things and staff were moving too fast. Regarding what she expected staff to have done, she stated she started in January 2023 as the assistant Dietary Manager and was appointed October 1 (2023) as the Dietary Manager. She stated she wished staff would have slowed down and paid attention. Regarding whom was responsible for ensuring that dietary sanitation procedures were correct in the kitchen, she stated the Dietary Manager and staff. Regarding what could result from the issues observed related to dietary sanitation, she stated residents could get deathly sick. On 10/12/23 at 9:51 AM an interview was conducted with the Administrator. Regarding why the dietary sanitation issues occurred, he stated staff were not following proper steps they were trained on. He stated staff should have done what they were trained to do. He stated each staff member and the Dietary Manager were responsible for ensuring that dietary sanitation functions were carried out correctly. Regarding what could result from dietary sanitation procedures not being carried out correctly he stated contaminated food, items not sanitized and shattered lightbulbs. On 10/12/23 at 11:36 AM an interview was conducted with Dietary staff A. Regarding why she did not allow the processor pot, lid and blade to air dry when she made the pureed foods, she stated she usually allowed the equipment to dry, and she was in a hurry. Regarding what could result from not allowing equipment to air dry as required, she stated that was not good because the equipment could have soap in it. She added residents could become ill. Record review of the In-Service Training Report dated 8/14/23 revealed a Subject title: Cleaning/Sanitation., Summary of Meeting revealed the following, Keeping dietary clean and sanitize. Dietary staff A and B attended the in-service. Record review of the In-Service Training Report dated 9/18/23 revealed, Subject: Dietary policies and procedures., The Summary of Meeting revealed the following, Dietary policies and procedures. Dietary staff A and B attended the in-service. Record review of a facility policy titled Policy: Equipment Sanitation. Department: Dietary. Effective: March 2021, Policy Number: 4.03, revealed the following documentation, Policy: Kitchen equipment will be cleaned and sanitized between uses to prevent cross-contamination and foodborne illness. Procedure: 1. All equipment must be thoroughly washed, and sanitized between uses and different food preparation tasks (e.g., Salad preparation, raw meat cutting, and cooked meat cutting). All items will be sanitized by one of the following methods: a. Washed and sanitized through use of the dish machine with 50 to 100 ppm chlorine bleach solution e. All items washed and sanitize will be air dried. 5. Blender, mixer, and food processor bowls should be washed and sanitize, and inverted to air dry on shelves with vented slots to allow for adequate air circulation. Record review of the facility policy titled Policy: Cleaning Schedules. Department: Dietary. Effective: March 2021, Policy Number: 4.04, revealed the following documentation, Policy: The dietary services department and all equipment in the kitchen will be cleaned on a regularly scheduled basis, following the cleaning schedules, provided for daily, weekly and monthly tasks Record review of the facility policy titled Policy: Food Safety. Department: Dietary. Effective: March 2021, Policy Number: 4.19, revealed the following documentation, Policy: It is the policy of this home that food will be handled in a safe and sanitary method to prevent contamination and foodborne illness. Procedure. 7. The ice scoop is to be washed and sanitized daily Record review of the facility policy titled Policy: Handling Potentially Hazardous Foods. Department: Dietary. Effective: March 2021, Policy Number: 4.20, revealed the following documentation, Policy: It is the policy of this home to establish safe and sanitary methods of handling potentially hazardous foods (PHF). A potentially hazardous food (PHF) is a food that consists in part of milk or milk products, meat, poultry, fish, eggs, shellfish, low acid canned items, fresh melons, and other ingredients in a form capable of supporting rapid progressive growth of microorganisms. Procedure. 2. Meat, Poultry, and Fish. d. Avoid cross-contamination between raw and cooked foods. Record review of the facility policy titled Policy: Food Storage - Refrigerated and Frozen Foods. Department: Dietary. Effective: March 2021, Policy Number: 4.21, revealed the following documentation, Policy: Refrigerators and freezers will be kept clean and sanitized. The procedures to maintain the proper temperature for storing cold foods will be strictly followed to prevent foodborne illness. Procedure. 4. Storage refrigerators and freezers shall be kept clean and organized . 11. Store ready to eat and cooked foods above raw meat, poultry, and fish to prevent raw food juices from dripping into ready to eat or cooked food that can cause foodborne illness. 14. Freezer should be defrosted regularly so that they will operate more effectively

Based on observation, interview and record review, the facility failed to ensure personnel stored linens so as to prevent the spread of infection in 2 of 4 baths (Hall 100 (large) and Hall 200 (large)), in that: The facility failed to store clean linens in a sanitary manner in 2 of 4 common baths (Hall 100 (large) and Hall 200 (large)). This failure could result in the spread of resident infections. The findings include: Observation on 10/10/23 at 4:54 PM revealed the large bath on hall 100 had large amounts of towels and wash cloths stored on open uncovered metal racks in the bath. There were approximately, 105 towels and 125 washcloths. On 10/10/23 at 5:04 PM o hall 200 large bath was observed. There was a large amount of towels and washcloths on open, uncovered metal racks in the bath. There were approximately 100 towels and 125 washcloths on the open rack that were unprotected. There was also a covered soiled linen cart present in the bath. On 10/11/23 at 10:10 AM Laundry staff A was observed stocking the hall 200 large bath with linens. On 10/11/23 at 10:12 AM an interview and observation were conducted with Laundry staff A. Regarding the amount of towels and washcloths in the laundry, she stated she checked the linen supply in the baths one time a day or three times a week to restock. She stated besides stacking clean linens on the metal racks, she stacked linens on top of a chest of drawers located in the bath. Observation of the linen rack at this time revealed that there were approximately 200 towels, and 200 washcloths on the metal racks in the hall 200 large bath. Next to the racks were shower shoes/boots that were stored nearest the lowest shelf that contained linens. On 10/11/23 at 10:26 PM an observation was made of the large 100 hall bath. There was a soiled linen barrel present, which was covered and 3/4 full. There was a trash bin present, which was covered and contained gloves/briefs that were soiled. There was approximately 150 towels and 100 washcloths, clean and stored on the open metal rack in the bath. The soiled linen barrel, and trash bin were approximately 10 feet away from the clean linens. The air in the bath was humid. The shower stall was wet. Next to the racks of linens, was the whirlpool, which was dusty, and had some bits of debris. There were cleaning brushes on the walls hanging next to and above the rack of clean linens. The restroom door was also open in the room. CNA A was in the bath at this time cleaning and preparing for the next bath. On 10/11/23 at 10:35 AM CNA A was observed wheeling a resident into the hall 100 large bath. The clean linens, soiled linen barrel and trash bin were still present and full. On 10/11/23 at 11:59 AM observation in the large 100 hall bath revealed there was still racks of clean linens present, and the soiled linen barrel was present. CNA A was in the bath cleaning. On 10/11/23 at 12:22 PM an observation was made of the large bath on hall 100. There were racks of clean linens, towels and wash cloths on the open metal racks, and there were approximately 200 towels, and 150 washcloths present. The barrel was full of soiled towels and the room was humid with no active showers being conducted. The trashcan was filled with soiled gloves. The soiled linen barrel and trashcan were covered. The whirlpool was dusty with debris. There was a bariatric shower chair present near the towel racks, and there was a wheelchair present in the corner. On 10/11/23 at 1:01 PM an interview was conducted with CNA A regarding the clean linens being stored in the bath. She stated she had worked in the facility six months and that was the way the clean linens towels and washcloths had been stored since working there. She added the soiled barrels were taken out of the baths every day to empty and the soiled barrel was always stored there in the bath. She also stated that she normally gave 13 to 15 baths a day. She added she gave seven or eight on hall 100 today (10/11/23) so far. Regarding what could result from leaving clean linens in a soiled area, she stated if a resident was sick, it could spread infections and illness could spread easily. On 10/12/23 at 9:37 AM interview was conducted with Infection Control Preventionist/ADON regarding linen infection control situations in the facility. She stated initially she did not think of the current linen storage issue as an infection control situation. Regarding why the situation occurred, she stated the linens were in the baths due to storage space. She stated there was a lack of space and there was more available in the baths. Regarding what she expected staff to have done, she stated initially when residents moved in the facility the linens were stored in a clean linen closet. Regarding whom was responsible for ensuring that linens were stored in a sanitary manner, she stated the laundry department. During this interview, the BOM stated she previously worked in central supply and recalled the laundry department did not request to store the linens in the baths. Regarding what could result from storing the clean linens in a soiled area, the ADON stated contamination due to splash, body fluids, feces and humidity. She added that she had not conducted any in-services related to storage of clean and soiled linens. She added that new hires were told that clean linens were to be stored away from their bodies, soiled linens should be bagged, and soiled linens should be taken out twice a shift. She stated staff were shown where linens were stored, but storage of linens in baths was not addressed. She further stated staff would need to be re-educated on linen storage. Regarding how long she had been the Infection Control Preventionist, she stated a little over a year. On 10/12/23 at 9:51 AM an interview was conducted with the Administrator. Regarding why the linen storage situation occurred, he stated that was something the facility had not considered; storage was taken where it was available. Regarding what he expected staff to have done, he stated it was the staffs job to catch the situation; staff were operating the way they were supposed to. Regarding whom was responsible for ensuring that clean linens were stored in a sanitary manner, he stated he Administrator and Infection Control. Regarding what could result from the storage of clean linens in a soiled area, he stated, infection transmission could occur. On 10/12/23 at 10:51 AM an interview was conducted with the DON. Regarding what could result from clean linens being stored in the soiled area, he stated it could lead to infection and cross contamination. He stated he was not sure if in-services had been conducted on linen storage. Regarding why he felt the situation happened, he stated the facility had initially stored linens in the supply room, and then there was an overflow problem. He added the facility did not have room in the storage rooms, so clean linens were moved to the showers. Record review of the facility policy, titled Departmental (Environmental Services) - Laundry and Linen, Level 1, Revised January 2014, revealed the following documentation, Purpose. The purpose of this procedure is to provide a process for the safe and aseptic handling, washing and storage of linen. General Guidelines . Washing linen and other soiled items. 6. Keep soiled and clean linen, in their respective hampers and laundry carts, separate at all times. 7. Clean linen will remain hygienically, clean, (free of pathogens, in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts.

Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 5 of 5 residents (Residents #2, #19, #25, #26 and #142) reviewed for nutrition services; in that: The facility failed to provide food that was in a form to meet resident needs for Residents #2, #19, #25, #26 and #142 who had orders for pureed diets. This failure could place residents at risk of decreased food intake and choking. The findings include: Resident #2: Record review of the Order Summary Report dated 10/11/23 for female Resident #2 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of abnormality of albumin (chemical imbalance related to protein), chronic kidney disease, unspecified, pain, unspecified, abnormal weight loss, unspecified, dementia, unspecified severity with other behavioral disturbance (cognitive impairment). Further record review revealed that the resident had the diet order, reflected , regular diet, puree texture, regular consistency, order date 1/18/23, start date 1/19/23. Record review of the annual MDS assessment dated [DATE] revealed Resident #2 had a BIMS score of five which indicated that the resident had cognitive impairment. The MDS further reflected the resident had loss of liquid/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals. Resident #19: Record review of the Order Summary Report dated 10/11/23 revealed that female Resident #19 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance (cognitive impairment), Vitamin D, deficiency, unspecified, abnormal weight loss, Further record review revealed that the resident had the diet order, regular diet, p puree texture, regular consistency, order date, 8/30/21, start date, 8/30/21. Record review of the Quarterly MDS assessment for a Resident #19 dated 7/25/23 revealed that the resident had a BIMS score of two indicating that the resident was cognitively impaired. Further record review of the MDS revealed that the resident had loss of liquids/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals. Further review revealed that the resident had missing teeth or tooth fragments . Resident #25: Record review of the Order Summary Report for female Resident #25 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Hemiplegia and hemiparesis following cerebral infarction , affecting unspecified side (paralysis from stroke), dysphagia, unspecified (swallowing disorder), abnormal weight loss, and psychotic disorder with hallucinations due to known physiological condition (psychiatric issue). Further record review revealed that the resident had the diet order, regular diet, puree texture, regular consistency, order date 8/27/21, start date 8/27/21. Record review of the Quarterly MDS assessment dated [DATE] revealed that Resident #25 had a BIMS score of 10 indicating mild cognitive impairment. Further record review revealed the resident had loss of liquids/solids from mouth when eating or drinking and holding food in mouth/cheeks or residual food in mouth after meals . Resident #26: Record review of the Order Summary Report for female Resident #26 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of abnormal weight loss, Parkinson's disease (neurological disorder), and unspecified, dementia, unspecified severity, with agitation (cognitive impairment). Further record review revealed the resident had the diet order, regular diet, puree texture, nectar consistency, order date 11/10/22,start date 11/10/22. Record review of the Quarterly MDS assessment for Resident #26 revealed that the resident had a BIMS score of two indicating the resident was cognitively impaired. Further review revealed the resident had loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals and coughing, or choking during meals or when swallowing medications . Resident #142: Record review of the Order Summary Report for female Resident #142 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of abnormal weight loss, mild cognitive impairment of uncertain or unknown ideology, and unspecified kidney failure. It was further revealed that the resident had the diet order, regular diet puree texture, regular consistency, order date 9/20/23 start date 9/20/23. Record review of the Quarterly MDS assessment dated [DATE] revealed Resident #142 had a BIMS score of seven indicating moderate cognitive impairment. Further record review revealed the resident had no swallowing issues. Record review of the Nutritional Follow Up Note dated 9/20/23 for Resident #142 revealed the following, . Resident is status post surgery with wound VAC. Diet: regular puree with house shakes . (added 9/16/23). Diet texture changed to puree today, due to trouble chewing/swallowing. Dietitian - The following observations were conducted during a kitchen tour beginning on 10/10/23 at 11:03 AM and concluded at 12:15 PM: Observations were made of Dietary staff A pureeing foods. She placed chicken fried steaks and broth in the processor and pureed the mixture. The appearance of the puree was very coarse. Dietary staff A, then placed cooked broccoli/cauliflower in the processor and pureed it. The appearance of the puree was very coarse. Observation on 10/10/23 at 12:13 PM, the Surveyor sampled the pureed chicken fried steak and the pureed broccoli and cauliflower with the following results: Puree, chicken fried steak - very coarse grainy with bits of gristle. Pureed, broccoli/cauliflower - very coarse and grainy. Observation on 10/10/23 at 12:16 PM another Surveyor also sampled the pureed broccoli and cauliflower and pureed chicken fried steak with the following results: Pureed chicken fried steak - required chewing to be consumed. Pureed broccoli and cauliflower - chunky/coarse. On 10/10/23 at 12:27 PM an observation was made in the dining room of residents who were served puree diets. Resident #26 was observed in a specialized high back wheelchair and was fed a pureed diet by staff. Her tray card reflected Level 4 diet. The resident had some coughing during the meal. The resident was served puree bread, puree chicken fried steak that was coarse in appearance, puree broccoli cauliflower was coarse in appearance, thickened water, thickened tea and pudding. On 10/10/23 at 12:28 PM Resident #2 was observed in the dining room and was being fed by staff a pureed diet. The resident was obese, used oxygen and was in a Geri chair. The resident was served tea, water, pudding, and pureed broccoli cauliflower and pureed chicken fried steak that were very coarse in appearance. Resident #2 also received pureed bread and mashed potatoes. The resident was observed coughing during the meal. Her tray card reflected Level 4 diet. On 10/10/23 at 12:30 PM Resident #142 was observed in the dining room being fed by staff a pureed diet. The tray card reflected at Level 4 diet. The pureed broccoli/cauliflower and pureed chicken fried steak were very coarse in appearance. The resident received puree bread, pudding, mashed potatoes and water . On 10/10/23 at 12:33 PM Resident #19 was observed in the dining room being fed by staff a pureed diet. Her tray card reflected Level 4 diet. She was served pureed broccoli and cauliflower, pureed chicken fried steak and both were coarse in appearance. She received pureed bread, pudding, mashed potatoes, and water . On 10/10/23 at 12:34 PM an observation was made of Resident #25 in the dining room, and she fed herself. The resident received a pureed diet which consisted of puree broccoli and cauliflower and pureed chicken fried steak, which were both coarse in appearance. She also was served pudding, pureed bread, mashed potatoes. - The following observations were conducted during a kitchen tour beginning on 10/10/23 at 5:29 PM and concluded at 5:55 PM: Meal service started on 10/10/23 at 5:45 PM and on the steam table were potatoes, zucchini, carrots, roast beef, pureed potatoes, pureed zucchini, pureed roast beef and pureed carrots. The pureed carrots and pureed roast beef had a coarse appearance. The pureed foods were prepared by Dietary staff B. On 10/10/23 at 5:47 PM the meal tray for Resident #2 was observed prepared and the resident was served applesauce, pureed carrots, pureed zucchini, pureed potatoes, and pureed roast beef. The pureed carrots had a coarse appearance as did the roast beef which was more of a stringy lean coarseness . On 10/10/23 at 5:51 PM, the Surveyor sampled the pureed roast beef, carrots, potatoes and zucchini. The results were as follows: Pureed zucchini - OK, texture was correct Pureed carrots - grainy Pureed roast beef - stringy and needed to be chewed to be consumed. Pureed potatoes - grainy texture. On 10/11/23 at 9:38 AM an interview was conducted with the Dietary Manager regarding pureed diets. She stated the meal software was what they used as guidance and that they went by the IDDSI Level 4 definition for pureed diets. She added that the consistency of a pureed diet would be like baby food. Regarding if she had conducted any training related to pureed foods, she stated yes. She added, the IDDSI guide info was given to employees regarding purees. She stated that she had an in-service in June related to purees. On 10/11/23 at 9:43 AM the Dietary Manager was interviewed regarding training new employees and related to the coarse texture of the puree. She stated that new employees were also trained regarding pureed diet. She added, the Dietitian had come in the past, and there was a problem with their purees being too thin. She stated she would conduct a refresher training on purees. She added she should have caught the errors with the puree consistency. Regarding why the issues occurred with the puree diets, she stated with a chicken fried steak, the issue was the breading; it thickened after setting. She added purees were served at the end of the meal service, and they should have checked them again. She stated they should have cooked the vegetables longer and it was the same with the potatoes. She stated October 1, 2023 she was appointed dietary manager and stated the responsibility was on her for ensuring foods were in the correct form. She added the dietary department was shorthanded. Regarding what she expected staff to have done related to pureed diets, she stated the beef should have been pureed longer and the vegetables should have been pureed more. The vegetables should have been cooked longer. Regarding what could result from the pureed foods was not being in the correct form, she stated resident aspiration. On 10/11/23 at 2:51 PM an interview was conducted with Dietary staff B regarding the coarseness of the purees she prepared for the evening meal on 10/10/23. Regarding why the puree was coarse, she stated she had an emergency and that was why it happened . On 10/11/23 3:53 PM an interview was conducted with LVN A regarding why the following residents were on purees diets, she stated Resident #26 had swallowing issues; Resident #2 had difficulty chewing; Resident #142 had a change after she was hospitalized and declined; Resident #19 had swallowing issues and Resident #25 did not chew or swallow well. On 10/12/23 at 9:51 AM an interview was conducted with the Administrator. Regarding food form and why the issues with pureed diets occurred, he stated he assumed staff were not knowledgeable or lacked the ability to have pureed the foods correctly. He stated staff should have pureed Tweethe foods correctly and produced the proper texture. He stated the cook and Dietary Manager were responsible for ensuring foods were in the correct form. He stated a choking hazard, aspiration, and having difficulty swallowing could result from foods not being in the required form. On 10/12/23 at 11:36 AM an interview was conducted with Dietary staff A regarding the puree she produced for the noon meal on 10/10/23, she was asked why the puree was coarse, and she stated when she placed it on the steam table, it got thick. Regarding what could result from purees not being in a pureed form, she stated residents could choke. Record review of the In-Service Training Report document dated 6/12/23 revealed that an in-service with the Subject: Puree diets. Summary of Meeting reflected, Explained the proper technique and importance of proper pureed texture diets. Reviewed IDDSI guidelines . Dietary staff A and B attended the in-service. Record review of the facility's current guidelines titled IDDSI, International Dysphagia Diet Standardization Initiative, . 4 PUREED, dated January 2019 revealed the following, Level 4 Pureed Food for Adults. What is this food texture level? Level 4 - Pureed Foods: -Are usually eaten with a spoon -Do not require chewing. -Have a smooth texture with no lumps. -Hold shape on a spoon -Fall off a spoon in a single spoonful when tilted -Are not sticky? -Liquid (like sauces) must not separate from solids. Why is this food texture level use for adults? Level 4 - Pureed food may be used if you are not able to bite or chew food or if your tongue control is reduced. Record review of the facility policy, titled Policy: Consistency Modification of Foods. Department: Dietary. Effective: March 2021, Policy Number: 5.10, revealed the following, Policy: It is the policy of this home that dietary services will provide modified consistency (modified texture) food to meet the individual needs of the residents as recommended by the SLP and ordered by the physician. Standardize recipes are to be followed for menu adherence . Procedure 1. Orders for texture or consistency. Modification must be added to the resident's therapeutic diet order. These orders are generally used to address swallowing and/or chewing problems and are based on the individual resident's needs. d. Pureed foods are regular menu items, with some exceptions, that are prepared with a food processor to form a cohesive and homogeneous bolus. The desired consistency of pureed foods is mashed potatoes to pudding; however, applesauce and other pureed fruit may be appropriate in texture to meet the needs of a resident therefore the use of a thickener is not indicated. Pureed meats should be served with gravy and sauces for enhancing flavor of foods. Water is never to be added as a liquid to puree a food; the cook should refer to the pureed standardized recipe for the correct liquid to add for the menu item Record review of the facility policy titled Policy: Diet Conversion List. Department: Dietary. Effective: March 2023, Policy Number: 5.01A, revealed the following, Policy: Diet order should be liberalized to the extent that meets the residents, nutritional needs and/or expectations. Procedure: Per menu and diet extensions the facility uses the following diets are what are available to order and use. Diet order with different names will be changed to diet and diet extensions that are available in the dietary department. Diet Conversion List. Diet Ordered. Puree. Use This Diet Order. IDDSI 4. Record review of the facility policy titled Policy: Preparation of Food. Department: Dietary. Effective Date: March 2021, Policy Number: 2.01, revealed the following, Policy: It is the policy of this home is food to be prepared by methods that conserve nutritive value, flavor and appearance under sanitary conditions. Procedure. 2. All foods . will be . in a consistency (form) to meet the individual needs of the resident. 5. Food and beverages will be modified to meet individual needs of the resident and served according to the diet orders and current menu cycle.

Based on observation, interview and record review the facility failed to ensure resident rooms were designed or equipped to assure full visual privacy for each resident in 23 of 23 identified semi-private resident rooms reviewed (Rooms 101 - 116, 202, 204, 206, 208, 210, 212 and 214), in that: The facility failed to ensure semi-private resident rooms provided full visual privacy at the window area beds. This failure could place residents at risk of being exposed while receiving personal care. The findings include: Observation on 10/10/23 at 4:35 PM revealed room [ROOM NUMBER] had one privacy curtain that surrounded the bed at the door but there was no privacy curtain at the foot of the bed for the bed nearest the window. If an individual in the door bed went to their chest of drawers, they would be able to view the resident in the window area bed receiving care. Observations on 10/10/23 at 4:38 PM and 10/11/23 at 12:07 PM revealed room [ROOM NUMBER] had one privacy curtain that surrounded the bed at the door but there was no privacy curtain at the foot of the bed for the bed nearest the window. An individual standing at the door area chest of drawers could view the resident in the window area bed. The window bed was occupied by Resident #16, and the door bed was occupied by Resident #1. Observation on 10/10/23 at 4:44 PM revealed room [ROOM NUMBER] had one privacy curtain that surrounded the bed at the door but there was no privacy curtain at the foot of the bed for the bed nearest the window. An individual standing at the door area chest of drawers could view the resident in the window area bed. Observations on 10/10/23 at 4:47 PM, 10/11/23 at 10:08 AM and 10/11/23 at 12:13 PM revealed room [ROOM NUMBER] had one privacy curtain that surrounded the bed at the door but there was no privacy curtain for the bed nearest the window. An individual standing at the door area chest of drawers could view the resident in the window area bed. The residents in the rooms were Resident #17 and Resident #8. Resident #8 was in the window area bed and Resident #17 was in the door area bed. Observation on 10/10/23 at 4:50 PM and 10/11/23 at 12:20 PM revealed room [ROOM NUMBER] had one privacy curtain that surrounded the bed at the door but there was no privacy curtain at the foot of the bed for the bed nearest the window. An individual standing at the door area chest of drawers could view the resident in the window area bed. Residents #27 and #15 resided in the room and Resident #15 occupied the bed nearest the window. On 10/11/23 3:53 PM an interview was conducted with LVN A. She stated the following regarding the incontinent status of these residents and need for assistance: -Resident #8 was occasionally incontinent. -Resident #17 was occasionally incontinent. -Resident #1 was mostly incontinent. -Resident #16 was incontinent and needed assistance with incontinent care. -Resident #15 and Resident #27 were continent. On 10/12/23 at 9:14 AM an interview was conducted with LVN B regarding mobility of the following residents. She stated the following: -Resident #17 could transfer, stand and walks in her room, and she self-propelled in her wheelchair. -Resident #27 could stand and walk. She could wheel herself to the dining room and walked in her room. -Resident #1 could walk independently. On 10/12/23 at 9:17 AM observation in room [ROOM NUMBER] revealed the distance from the center privacy curtain to the window was approximately 8 feet. There was no privacy curtain that was ceiling suspended at the window bed. On 10/12/23 at 9:20 AM observation in room [ROOM NUMBER] revealed the center privacy curtain was approximately 8 feet from the window and there was no ceiling suspended privacy curtain at the of the window bed. On 10/12/23 at 9:22 AM observation in room [ROOM NUMBER] revealed the center privacy curtain was approximately 8 feet away from the window wall and there were no ceiling suspended privacy curtains at the window bed side. On 10/12/23 at 9:24 AM observations in room [ROOM NUMBER] revealed Resident #41's bed was at the door, and Resident #2's was at the window. Resident #41 was confused, wandered and walked. Resident #2, who was by the window was in bed, used oxygen, had a catheter , and was confused. Further observation of the room revealed that it was designed in the same manner as rooms 104, 106, 108, 110 and 112. The center privacy curtain was approximately 8 feet from the window wall and there were no ceiling suspended privacy curtains on the window side bed. The Surveyor stood at the door area chest of drawers and could fully view Resident #2 in the window area bed. On 10/12/23 at 9:32 AM observations were made of the 200 hall rooms and checked which rooms had two beds (and currently considered semi-private) with no privacy curtain at the window bed that was ceiling suspended to provide full visual privacy. The following rooms designed in this manner were 202, 204, 206, 208, 210, 212 and 214. On 10/12/23 at 9:34 AM an observation was made of hall 100 rooms regarding those that had two beds and had no ceiling suspended privacy curtains at the window bed. The following rooms were 101 through rooms 116 (currently considered semi-private); 16 rooms. On 10/12/23 at 9:51 AM an interview was conducted with the Administrator regarding the missing ceiling suspended privacy curtains at the window area bed in semi-private rooms. He stated that was the first time the privacy curtain issue had come up. Regarding why the situation occurred, he stated it had not been brought to the facility's attention initially. He further stated the hospital had privacy screens but was unsure if there was enough of them for each room. Regarding what he expected staff to have done, he stated there was nothing told to them about the missing privacy curtains by the architects. He stated that he expected the inspection personnel to have mentioned that also. Regarding whom was responsible for ensuring that the privacy curtains were installed as required, he stated the building contractors. Regarding what could result from not having the ceiling suspended privacy curtains at the window area bed, he stated residents would not be provided the dignity deserved if someone peeked around the curtain. On 10/18/23 at 8:41 AM and interview was conducted with the Administrator. He stated that residents were moved from the old facility to the current facility on 6/10/20. He added that there was no waiver regarding ceiling suspended privacy curtains. Record review of the facility's Salesforce Account revealed the following, Bed Notes. EFF (effective) 05/21/2020 [Previous Name of Facility] CONSTRUCTED A NEW BUILDING AT [address] . LSC WAS APPROVED ON 05/21/2020 FOR A CAPACITY OF 53 BEDS, 38 SNF/NF; 15 SNF Record review of the current undated facility policy titled Subject: Resident Rights to Privacy and Confidentiality. Policy LTC11011, Department: Long-Term Care, revealed the following documentation, Policy: facility staff shall observe and respect resident's rights to privacy and confidentiality. This includes all employees, consultants, contractors, volunteers, and other caregivers who provide care and services to residents on behalf of the long-term care facility. Every nursing home resident has the right to personal privacy of not only his/her own physical body, but also of his/her personal space, including accommodations, and personal care. Administrator shall be responsible for providing ongoing oversight, and supervision to ensure staff are not engaging in activities that violate the resident's rights of privacy and confidentiality.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, which included measurable objectives and timeframes to meet the a residents medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 9 of 14 residents (Residents #9, #11, #25,#26, #27, #30, #37, #41, and #93) reviewed for care plans. 1. The facility failed to develop a care plan for [CONDITION(S)], cognitive loss, [CONDITION(S)] drug use, and DNR for Resident #5. 2. The facility failed to develop a care plan for cognitive loss, urinary, falls, nutritional, pressure ulcer and [CONDITION(S)] drug use for Resident #9. 3. The facility failed to develop a care plan for cognitive loss, communication, activities of daily living, urinary, falls, nutrition and pressure ulcer for Resident #11. 4. The facility failed to develop a care plan for cognitive loss, communication, nutrition, pressure ulcers and [CONDITION(S)] drug use for Resident #25. 5. The facility failed to develop a care plan for [CONDITION(S)], cognitive loss, activities of daily living, urinary, nutrition, pressure ulcers and [CONDITION(S)] drug use for Resident #26. 6. The facility failed to develop a care plan for cognitive loss, urinary falls, nutritional and pressure ulcer for Resident #27. 7. The facility failed to develop a care plan for DNR for Resident #30. 8. The facility failed to develop a care plan for [CONDITION(S)], cognitive loss, falls, pressure ulcer and [CONDITION(S)] drug use for Resident #37. 9. The facility failed to develop a care plan for [CONDITION(S)], pressure ulcer and DNR for Resident #41. These failures could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings include: 1. Record review of Resident #5's face sheet, dated 08/09/22, documented a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #5's comprehensive admission MDS (Minimum Data Set) assessment, dated 07/15/22, documented the following: Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 04 which indicated severely impaired cognitively (never/rarely made decisions). Section C - [CONDITION(S)] C1310 Signs and Symptoms of [CONDITION(S)] B. Inattention 2 Behavior present/fluctuates (comes and goes/changes in severity) C. Disorganized thinking 2 Behavior present/ fluctuates (comes and goes/changes in severity) Section N Medications N0410. Medications Received within the last 7 days: Antidepressant N0450. Antipsychotic Medication Review No - Antipsychotics were not received Section Q Participation in Assessment and Goal Setting Q0100 Participation in Assessment A. Resident Participated in assessment 1 Yes B. Family or significant other participated in assessment 1 Yes Section V - Care Area Assessment Summary (1) [CONDITION(S)] (2) Cognitive Loss (17) [CONDITION(S)] Drug use Record review of Resident #5's Order Summary report reflected the following: DNR (Do Not Resuscitate) - Order start date: 05/16/22. Palliative Care - Order start date: 05/16/22 [MEDICATION(S)] 7.5 mg Give 1 tablet by mouth at bedtime for increase appetite Record review of Resident #5's Out of Hospital Do not Resuscitate (OOH-DNR) Order signed and dated by Resident #5 on 07/08/21 and the Resident's physician on 07/08/21 revealed the document was complete. Record review of Resident #5's ,undated, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #5's, undated, Care Plan revealed the following: A care plan for [CONDITION(S)] was not present. A care plan for Cognitive loss was not present. A care plan for [CONDITION(S)] drug use was not present. A care plan for Hospice (palliative care) was not present. A care plan for Advanced Directives (DNR) was not present. 2. Record review of Resident 9's face sheet, dated 08/09/22, documented an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #9's comprehensive annual MDS (Minimum Data Set) assessment, dated 04/22/22, documented the following: Section B - Hearing, Speech, and Vision B0600. Speech Clarity 1. Unclear Speech Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 6, which indicated severely impaired cognition (Alert and Oriented x time, place, person). Section H Bladder and Bowel H0300. Urinary Continence Always incontinent H0400 Bowel Continence Always incontinent Section J Health Conditions None of the sections pertaining to falls not completed. Section K Swallowing/ Nutritional Status K0100 Swallowing Disorder (A) Loss of liquids/solids from mouth when eating or drinking (B) Holding food in mouth/ cheeks or residual food in mouth after meals K0510. Nutritional Approaches Mechanically altered diet Therapeutic Diet Section M Skin Conditions M0150. Risk of Pressure Ulcer/ Injuries Yes Section N Medications N0410. Medications Received within the last 7 days: Antipsychotic, Antianxiety, Antidepressant, and Hypnotic N0450. Antipsychotic Medication Review Yes- Antipsychotics were received on a routine basis only Section Q Participation in Assessment and Goal Setting Q0100 Participation in Assessment A. Resident participated in assessment 1 Yes B. Family or significant other participated in assessment 1 Yes Section V - Care Area Assessment Summary (2) Cognitive Loss (6) Urinary (11) Falls (12) Nutritional (16) Pressure Ulcer (17) [CONDITION(S)] Drug Use Record review of Resident #9 Order Summary report, dated 08/10/22, reflected the following: Resident was on low concentrated sweets diet, mechanical soft texture; Resident was to receive two house shakes daily; Resident #9 was on the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] tablet 10 mg 2 tablets one time a day for major depressive disorder. [MEDICATION(S)] tablet 1 mg at bedtime physiological condition [MEDICATION(S)] tablet 15 mg 1 tablet at bedtime for [CONDITION(S)] [MEDICATION(S)] tablet 10 mg two times daily for anxiety. Record review of Resident #9's Care Plan, dated 1/21/22, revealed the following: A cognitive care plan initiated 03/09/22 did not reflect any interventions for the triggered area; A care plan for urinary was not present; A fall care plan initiated 03/09/22 did not reflect any goals or interventions for the triggered area; A nutritional care plan initiated 03/09/22 did not reflect any interventions; A pressure ulcer care plan initiated 03/09/22 did not reflect any goals or interventions for the triggered area; A care plan for [CONDITION(S)] medications was not present. 3. Record review of Resident #11's face sheet, dated 08/09/22, documented a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #11's comprehensive admission MDS (Minimum Data Set) assessment, dated 04/27/22, documented the following: Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 10, which indicated moderately impaired cognition (Alert and Oriented x time, place, person). Section G - Functional Status - G0110 Activities of Daily Living (ADL) Assistance A. Bed Mobility 4. Total Dependence - full staff performance every time during entire 7-day period B. Transfer 3. Extensive assistance - resident involved in activity, staff provide weight-bearing support C. Walk in room 8. Activity did not occur D. Walk in corridor 8. Activity did not occur E. Locomotion on Unit 4. Total Dependence F. Locomotion off Unit 4. Total Dependence G. Dressing 4. Total Dependence H. Eating 4. Total Dependence I. Toilet Use 4. Total Dependence J. Personal hygiene 4. Total Dependence Section H - Bladder and Bowel H0300 - Urinary Continence 3. Always incontinent Section K - Swallowing/Nutritional Status K0100 - Swallowing Disorder A. Loss of liquids/solids from mouth when eating or drinking B. Holding food in mouth/cheeks or residual food in mouth after meals K0510 - Nutritional Approaches C. Mechanically Altered Diet Section M - Skin Conditions M0150 - Risk of Pressure Ulcer/Injury 1. Yes Section Q Participation in Assessment and Goal Setting Q0100 Participation in Assessment A. Resident Participated in assessment 1. Yes B. Family or significant other participated in assessment 1. Yes Section V - Care Area Assessment Summary (2) Cognitive Loss (4) Communication (5) Activities of Daily Living (6) Urinary (11) Falls (12) Nutrition (16) Pressure Ulcer Record review of Resident #11's Order Summary report reflected the following: Regular Diet/Pureed texture/Nectar consistency, no bread. - Order Start date: 04/26/22. Record Review of Resident #11's, undated, Care Plan revealed the following: A care plan for Cognitive Loss was incomplete with no goals and no interventions documented; A care plan for Communication was incomplete and not specific to Resident #11; A care plan for Activities of Daily Living was incomplete and not specific to Resident #11; A care plan for Urinary Incontinence was incomplete, not specific to Resident #11 and had no interventions documented; A care plan for falls was incomplete and not specific to Resident #11; A care plan for nutrition was incomplete and not specific to Resident #11 and no interventions were documented; A care plan for Pressure Ulcer risk was incomplete with no goals and no interventions documented. 4. Record review of Resident #25's face sheet , dated 08/09/22, documented an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #25's comprehensive admission MDS (Minimum Data Set) assessment, dated 11/22/21, documented the following: Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 09, which indicated moderately impaired cognition (Alert and Oriented x time, place, person). Section L - Dental - L0200 B. No natural teeth or tooth fragments (edentulous) Section M - Skin Conditions M0150 Risk of Pressure Ulcers/Injuries 1. Yes M0210 Unhealed Pressure Ulcers/Injuries 1. Yes Section N - Medications N0410 Medications Received B. Antianxiety C. Antidepressant Section O - Special Treatments, Procedures and Programs O0100 Special Treatments, Procedures, Programs C. Oxygen Therapy Section Q Participation in Assessment and Goal Setting Q0100 Participation in Assessment A. Resident Participated in assessment 1 Yes Section V - Care Area Assessment Summary (2) Cognitive Loss (4) Communication (12) Nutrition (16) Pressure ulcers (17) [CONDITION(S)] Drug Use Record review of Resident #25's Order Summary report reflected the following: -Continuous O2@ 3L via NC. r/t [CONDITION(S)]. Order start date 06/23/22. -DNR. Order Start Date: 08/27/21 -[MEDICATION(S)] 10 mg Give 1 tablet by mouth two times a day related to anxiety disorder -[MEDICATION(S)] 40 mg Give 1 capsule by mouth one time a day for depression. Record review of Resident #25's Out of Hospital Do not Resuscitate (OOH-DNR) Order signed and dated by the Resident's responsible party on 11/23/20 and the Resident's physician on 11/23/20 revealed the document was complete. Record review of Resident #25's, undated, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] 10 mg [MEDICATION(S)] 40 mg Record Review of Resident #25's, undated, Care Plan revealed the following: A care plan for Cognitive Loss was not present; A care plan for Communication was not present; A care plan for Nutrition was incomplete and not specific to Resident #25; A care plan for Pressure Ulcers was incomplete and not specific to Resident #25; A care plan for [CONDITION(S)] Drug Use was not present; A care plan for Oxygen Use was incomplete and not specific to Resident #25; A care plan for Advanced Directives DNR status was not present. 5. Record review of Resident #26's face sheet, dated 08/09/22, documented a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #26's comprehensive admission MDS (Minimum Data Set) assessment, dated 11/28/21, documented the following: Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 07, which indicated moderately impaired cognition (Alert and Oriented x time, place, person). Section G - Functional Status G0110 ADL assistance A. Bed Mobility 3. Extensive assistance B. Transfer 3. Extensive assistance C. Walk in room 8. Activity did not occur D. Walk in corridor 8. Activity did not occur E. Locomotion on unit 3. Extensive assistance F. Locomotion off unit 3. Extensive assistance G. Dressing 4. Total Dependence H. Eating 1. Supervision I. Toilet use 3. Extensive assistance J. Personal Hygiene 4. Total dependence Section H - Bladder and Bowel - H0300 - Urinary Incontinence 3. Always incontinent Section K - Swallowing/Nutritional Status K0100 - Swallowing Disorder A. Loss of liquids/solids from mouth when eating or drinking C. Coughing or choking during meals or when swallowing medications K0510 - Nutritional Approaches C. Mechanically Altered Diet Section M - Skin Conditions M0150 Risk of Pressure Ulcers/Injuries 1. Yes Section N - Medications N0410 Medications Received A. Antipsychotic C. Antidepressant Section Q Participation in Assessment and Goal Setting Q0100 Participation in Assessment A. Resident Participated in assessment 1 Yes Section V - Care Area Assessment Summary (1) [CONDITION(S)] (2) Cognitive Loss (5) Activities of Daily Living (6) Urinary (12) Nutrition (16) Pressure ulcers (17) [CONDITION(S)] Drug Use Record review of Resident #26's Order Summary report reflected the following: -Regular diet, pureed texture, regular consistency. Order start date: 08/27/21 -DNR. Order Start date: 08/27/21 -[MEDICATION(S)] 125 mg Give 1 capsule by mouth two times a day related to psychotic disorder. Order start date: 03/24/22 -[MEDICATION(S)] 1 mg Give 1 tablet by mouth in the morning related to psychotic disorder. Order start date: 12/22/21 -[MEDICATION(S)] 1 mg Give 2 tablets by mouth at bedtime related to psychotic disorder. Order start date: 12/21/21 -[MEDICATION(S)] 50 mg Give 1 tablet by mouth at bedtime related to [CONDITION(S)]. -[MEDICATION(S)] 225 mg by mouth one time a day related to major depressive disorder. Record review of Resident #26's Out of Hospital Do not Resuscitate (OOH-DNR) Order signed and dated by the Resident's responsible party on 02/21/20 and the Resident's physician on 02/21/20 revealed the document was complete. Record review of Resident #25's, undated, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #26's, undated, Care Plan (undated) revealed the following: -A care plan for [CONDITION(S)] was not present. -A care plan for Cognitive Loss was incomplete and not specific to Resident #26. -A care plan for ADL's was incomplete and not specific to Resident #26. -A care plan for Urinary Incontinence was incomplete and not specific to Resident #26. -A care plan for Nutrition was incomplete and not specific to Resident #25. -A care plan for Pressure Ulcers was incomplete and not specific to Resident #25. -A care plan for [CONDITION(S)] Drug Use was not present. -A care plan for Advanced Directives DNR status was not present. 6. Record review of Resident 27's face sheet dated 08/09/22, documented a [AGE] year-old female admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #27's comprehensive admission MDS (Minimum Data Set) assessment dated [DATE] documented the following: Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 4 severely impaired cognitively (Alert and Oriented x time, place, person). Section H Bladder and Bowel Section H was not completed. Section J Health Conditions J1700 Fall History on Admission No Falls on Admission J1800. Any Falls Since Admission/ Entry or Reentry or Prior Assessment No Falls since Admission Section K Swallowing/ Nutritional Status K0510. Nutritional Approaches Therapeutic Diet Section M Skin Conditions M0150. Risk of Pressure Ulcer/ Injuries Did not reflect any risks for pressure ulcers. Q0100 Participation in Assessment A. Resident participated in assessment 1 Yes B. Family or significant other participated in assessment 1 Yes Section V - Care Area Assessment Summary (2) Cognitive loss (6) Urinary (11) Falls (12) Nutritional (16) Pressure Ulcer Record Review of Resident #27's Care Plan dated 05/19/22 revealed the following: A cognitive care plan initiated 08/09/22 did not reflect interventions for the triggered area. A care plan for urinary was not present. A fall care plan initiated 06/21/22 did not reflect goals or interventions for the triggered area. A nutritional care plan initiated 08/09/22 did not reflect interventions for the triggered area. A care plan for pressure ulcers was not present. 7. Record review of Resident 30's face sheet , dated 08/09/22, documented an [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #30's comprehensive admission MDS (Minimum Data Set) assessment, dated 12/8/21, documented the following: Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 7 which indicated severely impaired cognition (Alert and Oriented x time, place, person). Section Q Participation in Assessment and Goal Setting Q0100 Participation in Assessment A. Resident participated in assessment 1 Yes B. Family or significant other participated in assessment 1 Yes Section V - Care Area Assessment Summary DNR Record review of Resident #30's Order Summary report, dated 08/10/22, reflected the following: DNR (Do Not Resuscitate) - Order start date: 12/21/21. Record review of Resident #30's Out of Hospital Do Not Resuscitate (OOH-DNR) Order signed and dated by the resident's responsible party on 11/23/21 and the Resident's physician (undated) revealed the document was complete. Record Review of Resident #30's Care Plan, dated 1/3/22, revealed the following: A care plan for DNR was not present. 8. Record review of Resident 37's face sheet, dated 08/09/22, documented a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #37's comprehensive admission MDS (Minimum Data Set) assessment, dated 06/19/22, documented the following: Section B - Hearing, Speech, and Vision B0200. Hearing Moderate Difficulty Speaker has to increase volume and speak distinctly B0300. Hearing Aid Yes B0600. Speech Clarity Unclear Speech B0700. Makes self Understood Sometimes understood B0800. Ability to Understand Others Sometimes understands Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 9, which indicated moderately impaired cognition (Alert and Oriented x time, place, person). [CONDITION(S)] C1310. Signs and Symptoms of [CONDITION(S)] A. Acute Onset Mental Status Change Resident had present or fluctuating behavior of the following: Inattention and disorganized thinking. Section J Health Conditions J1700 Fall History on Admission Yes J1800. Any Falls Since Admission/ Entry or Reentry or Prior Assessment Yes Section M Skin Conditions M0150. Risk of Pressure Ulcer/ Injuries Yes M0210. Unhealed Pressure Ulcer/Injuries Section N Medications N0410. Medications Received within the last 7 days: Antidepressant Section Q Participation in Assessment and Goal Setting Q0100 Participation in Assessment A. Resident participated in assessment 1 Yes B. Family or significant other participated in assessment 1 Yes Section V - Care Area Assessment Summary (3) [CONDITION(S)] (2) Cognitive Loss (9) Behavior (11) Falls (16) Pressure Ulcer (17) [CONDITION(S)] Drug Use Record review of Resident #37's Order Summary, dated 08/10/22, report reflected the following: -DNR (Do Not Resuscitate) - Order start date: 06/14/22. -Resident #37 was on the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] tablet one time daily for depression Record review of Resident #37's Out of Hospital Do not Resuscitate (OOH-DNR) Order signed and dated by the Resident's responsible party on 06/13/22 and the Resident's physician signed 06/13/22 revealed the document was complete. Record Review of Resident #37's Care Plan, dated 08/9/22, revealed the following: -A care plan for [CONDITION(S)] was not present. -A cognitive loss care plan initiated 08/09/22 did not reflect any interventions for the triggered area. -A fall care plan initiated 08/09/22 did not reflect any goals or interventions for the triggered area. -A pressure ulcer care plan initiated 08/09/22 did not reflect any goals for the triggered area. -A care plan for [CONDITION(S)] was not present. -A care plan for DNR was not present. 9. Record review of Resident #41's face sheet, dated 08/09/22, documented a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #41's comprehensive admission MDS (Minimum Data Set) assessment, dated 01/08/22, documented the following: Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 03, which indicated severely impaired cognition. Section C - [CONDITION(S)] C1310 Signs and Symptoms of [CONDITION(S)] B. Inattention 2 Behavior present/fluctuates (comes and goes/changes in severity) C. Disorganized thinking 2 Behavior present/ fluctuates (comes and goes/changes in severity) Section M - Skin Conditions M0150 Risk of Pressure Ulcers/Injuries 1. Yes Section V - Care Area Assessment Summary (1) [CONDITION(S)] (16) Pressure Ulcers Record review of Resident #41's Order Summary report reflected the following: DNR - Order start date: 08/27/21 Record review of Resident #41's Out of Hospital Do not Resuscitate (OOH-DNR) Order signed and dated by Resident #41 on 07/14/16 and the Resident's physician on 08/09/16 revealed the document was complete. Record Review of Resident #41's, undated, Care Plan revealed the following: -A care plan for [CONDITION(S)] was not present. -A care plan for Pressure ulcers was incomplete and not specific to Resident #41. -A care plan for Advanced Directives DNR status was not present. Interview on 08/10/22 at 11:00 AM, the MDS (Minimum Data Set) Nurse stated she was in charge of creating care plans. She stated she had been trained in care plans and was expected to follow the facility policy. She stated she received comprehensive training ten years ago and kept up with her Resident Assessment Coordinator training annually. She said in the annual training, she received training on MDS updates and skilled nursing services. She stated the comprehensive care plan was important because the facility nurses and certified nursing aids (CNA) use it to provide care to the residents. She stated care plans were important because it informed the staff of what type of care the resident needed and if multiple staff were needed to carry out care. She stated she had not completed care plans because she had recently been working the floor, and the facility had been short-staffed. She stated the electronic medical record they were using was new, and she was not as familiar with the program; this also made it challenging to complete care plans on time. She stated she was not aware of any processes in place used to ensure care plans were being done. She stated they had the new electronic medical record since January 2022. She stated she would write notes to remind herself when things needed to be completed. She stated failure to complete care plans for residents could affect their quality of care. She stated if a resident took [CONDITION(S)] medications, the facility staff could not correctly monitor for side effects, and the drug regimen may not accurately be followed. She stated gradual dose reductions might not be completed, which could cause the resident to be on medications too long. She stated residents with behaviors might not be handled appropriately because staff would not know how to avoid triggers or appropriate responses to address behaviors. She stated failure to list OOH-DNR on the care plan would place the resident at risk of receiving chest compressions against their wishes. She stated residents that triggered for [CONDITION(S)] could be at risks for falls or increased behaviors. She said if cognitive loss triggered then the resident was at risks for entering another residents room. She said if a resident triggered for visual the staff may not properly address the residents with their visual needs such as wearing glasses. She said if a resident triggered for activities of daily living the staff could fail to have the appropriate amount of staff to carry out the residents care. She said if a resident triggered for urinary a resident would be at risk for pressure ulcers and urinary tract infections. She said mood, behaviors and psychosocial well-being could place residents at risk because staff would not know how to avoid things that may trigger the resident. This could cause an increase in behaviors and a change in mood and emotions for the resident. Nutritional triggers not being care planned could place the resident at risks as they might receive the wrong diet texture and this could cause weight loss. She said if a resident triggered for pain then the person could continue to be in pain or have increased pain untreated. She said if a resident was at risk for falls then the resident could have an increase in falls and could suffer injuries. She said residents who triggered for pressure ulcers could be at risk for worsened pressure ulcers or developing new ones and this could have created infections. (When observing the electronic medical record on 08/10/22, it was noted that multiple resident care plans had been updated after state surveyor entrance into the facility). She stated she completed multiple care plans on this date as she needed to do them. When asked about the plans she corrected on 08/09/22, she stated she was able to change the plans easier because of practice. When asked about the involvement of the facility staff, residents, and responsible parties in care plan meetings, she reported according to the facility policy, it was a team effort. She stated she did not include anyone in the team when she changed care plans on 08/09/22. She stated no one reviewed her care plans to ensure they were completed. Interview on 8/11/22 at 09:47 AM, the DON (Directors of Nurses) stated the MDS Coordinator was overseeing care plans. He stated the MDS coordinator was responsible for completing MDS assessments, baseline care plans and care plans. He stated he had not been trained regarding care plans or MDS's. He said he had been the DON since 05/20/22 and was still learning all of his duties. He stated he signed off on the care plans but had not been ensuring they were completed or reviewed. He stated he had been aware she was behind on care plans, and this was because they had an increase in the census and a shortage in staff. He stated the facility had utilized agency staff, which helped some. He stated he was aware the MDS Coordinator was behind

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 of 14 residents (Resident #93) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was developed for Resident #93 within 48 hours of the resident's admission. This failure could place residents at risk for insufficient immediate care needs being met and maintained. Findings include: Record review of Resident 93's face sheet, dated 08/09/22, documented a [AGE] year-old female admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #93's electronic medical record revealed there was not a care plan documented under the care plan section of Resident 93's electronic medical record and Record review of Resident #93's electronic medical record revealed there was not a baseline care plan or assessment documented under the assessment section of Resident 93's electronic medical record. Record review of Resident #93's Brief Interview for Mental Status evaluation, dated 07/21/22, revealed BIMS Summary Score of 14, which indicated the resident was cognitively intact (Alert and Oriented x time, place, person). Record review of Resident #93 Order Summary dated 08/10/22 revealed the following: The resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The Resident took the following antipsychotics: [MEDICATION(S)] 20 mg for depression, [MEDICATION(S)] 25 mg three times a day for anxiety, and [MEDICATION(S)] 0.5 mg by mouth for depression. The Resident had the following behaviors: itching (picking at skin), restlessness (agitation), hitting, increase in complaints, biting, kicking, spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, [CONDITION(S)], regression and refusing care. Record review of Resident #93's, undated, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 20 mg for depression, [MEDICATION(S)] 25 mg three times a day for anxiety, and [MEDICATION(S)] 0.5 mg by mouth for depression Interview on 08/09/22 at 11:13 AM, Resident #93 stated she was new to the facility. She was able to explain she came from the hospital due to having COVID-19. She stated she had not participated in any meetings since she had been at the facility. Interview on 08/10/22 at 11:00 AM, the MDS (Minimum Data Set) Nurse stated she was in charge of creating baseline care plans. She stated she had been trained in baseline care plans and expected to follow the facility policy of completing the baseline care plan within the first 48 hours. She stated she received comprehensive training ten years ago and kept up with her Resident Assessment Coordinator training annually. She said that in the annual training, she receives training on MDS updates and skilled nursing services. She stated the baseline care plan, like the comprehensive care plan was important because the facility nurses and certified nursing aids (CNA) used it to provide care to the residents. She stated baseline care plans were important because it was the initial plan before a comprehensive care plan could be completed that informed the staff of what type of care the Resident needed and if multiple staff were needed to carry out care. She stated she had not completed Resident #93 baseline care plan because she had recently been working the floor, and the facility has been short-staffed. She stated the electronic medical record they used was new, and she was not as familiar with the program; this also made it challenging to complete baseline care plans and care plans on time. She stated she was not aware of any processes in place that were used to ensure baseline care plans were being done. She stated they had the new electronic medical record since January 2022. She stated she would write notes to remind herself when things needed to be completed. She stated failure to complete baseline care plans for residents could affect their quality of care. She stated if a resident took [CONDITION(S)] medications, the facility staff could not correctly monitor for side effects, and the drug regimen may not accurately be followed. She stated gradual dose reductions might not be completed, which could cause the resident to be on medications too long. She stated residents with behaviors might not be handled appropriately because staff would not know how to avoid triggers or appropriate responses to address behaviors. She stated OOH-DNR would be listed on the baseline care plan, and failure to list this preference on the baseline care plan would place the resident at risk of receiving chest compressions against their wishes. When observing the electronic medical record on 08/10/22, it was noted that Resident #93 baseline care plan had been completed. She stated she completed the baseline care plan after the state surveyor intervention. She stated she completed multiple care plans on 08/09/22 as she needed to do them. When asked about the plans she corrected on 08/09/22, she stated she although she was not familiar with the electronic medical record program she was able to change them quickly because as she completed them it became easier. When asked about the involvement of the facility staff, residents, and responsible parties in care plan meetings, she reported according to the facility policy, it was a team effort. She stated she did not include anyone in the team when she changed care plans on 08/09/22. She stated no one reviewed her care plans to ensure they were completed. Interview on 8/11/22 at 09:47 AM, the DON (Directors of Nurses) stated the MDS Coordinator was overseeing care plans. He stated the MDS coordinator was responsible for completing MDS assessments, baseline care plans and care plans. He stated he had not been trained regarding care plans or MDS's. He said he had been the DON since 05/20/22 and was still learning all of his duties. He stated he signed off on the care plans but had not been ensuring they were completed or reviewed. He stated he had been aware that the MDS Coordinator was behind on care plans, and this was because they had an increase in the census and a shortage in staff. He stated the facility utilized agency staff, which helped some. He stated he was aware the MDS coordinator was behind for the past 2-4 weeks. He stated the only effort made to get caught up on care plans was attempting to find staff for the floor. He stated he expected baseline care plans be completed within 48 hours according to facility policy. He said with his limited knowledge, he expected any care areas triggered from the MDS assessment to be included in the Resident's care plan. He stated the Resident could be at risk of receiving improper care if a care plan was incomplete or missing. He stated depending on the care area, the Resident was at risk for decline. He stated he expected the residents' care plan to be tailored to their needs, and all portions of the care plan, including baseline care plans, should be completed. He stated he did expect non-triggered items such as DNR status to be included in baseline care plans. He stated the facility had the electronic medical record since November of 2021. He stated before the new electronic medical record implementation, he and the administrator received virtual training. He stated it was also his expectation the care plan for the individual should include goals and interventions for the identified problems. He stated the care plan meetings included himself, the Administrator, the MDS coordinator, the Nurse Practitioner or the Physician, and the Resident or family member. He stated it was not standard practice to change care plans without the team. Interview on 8/11/22 at 9:59 AM, the Administrator stated the MDS coordinator was responsible for overall care plans, which included baseline care plans. He stated he was aware she was behind and they tried to address this by addressing the staffing issues they were having. He stated he was unaware care plans or baseline care plans had been updated since surveyors had entered the building for the full book survey. He stated he knew she would try and get caught up but was unsure how many had been updated. He stated it was not the facility practice to update the resident's care plan without a care plan meeting. He stated the purpose of having the meeting was to ensure changes were not made that were not warranted. He stated he was unfamiliar with care plans and MDS's as they were more clinical, and he did not cover much of them or clinical areas as an administrator. He stated he expected the facility to follow clinical practices, which baseline and care plans, according to facility policy. He stated he expected the care plans to be fully completed, individualized and customized to resident needs. He stated he was unsure if his DON knew MDS, baseline care plans and care plans. He stated the failure to develop baseline care plans and care plans could affect residents' care. He stated the resident might not receive the care they needed or wanted. He stated the baseline care plans and care plans were not completed because of the COVID-19 outbreak they experienced in July and an increase in the census of residents. He stated the efforts made to address the systemic issues of baseline care plans and care plans not being completed were not directly addressed but indirectly addressed through trying to find coverage so the MDS coordinator could be in the office completing care plans. He stated the importance of the baseline care plan was to generate a baseline of care until the MDS coordinator had the opportunity to develop a more comprehensive care plan. He stated he expected baseline care plans to be completed within 48 hours and meet the need of the resident. Interview on 8/12/22 at 12:15 PM, the Resident's Responsible Party stated he was not invited or had not participated in any meetings since the admission of Resident #93. He stated he did not live in Texas, but if he had been invited to a meeting about Resident #93, he would have participated by telephone. Record review of the MDS coordinator Resident Assessment Coordinator- Certified (RAC-CT) revealed the MDS coordinator received certification on 06/22/21 with an expiration date of 07/01/23. Record review of the facility resident listing report provided by the MDS coordinator indicated by yellow highlighting. Resident #93 was one of the corrected care plans. Record review of the facility policy Care Plans- Baseline, Comprehensive Person-Centered, Revised December 2016, revealed the following documentation: Policy Statement: A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. Policy Interpretation and Implementation (1) To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident admission. (2) The interdisciplinary team will review the healthcare practitioner's orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a baseline care plan to meet the resident's immediate care needs including but not limited to: a. Initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] b. Physician orders; c. Dietary orders; d. Therapy services e. Social Services; and f. PASARR recommendation; if applicable

Based on observation, interview and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for 29 of 29 residents who consumed foods orally. 1. The facility failed to ensure foods were served which were palatable and at an appetizing temperature for residents. These failures could place residents at risk of decreased food intake and unwanted weight loss. The findings include: On 06/08/21 at 03:19 PM In a confidential resident group meeting in the dining room the residents were asked to rate the food palatability/taste satisfaction of their meals over the last three to four weeks on scale of one to ten from bad to excellent taste. Six of seven members rated the overall average as four (indicating below average). There were five of seven residents who said, vegetables are overcooked and mushy and without seasoning. Two residents said, Rice is usually undercooked and has hard kernels sometimes. There were 6 of seven residents who said the pork chops are tough and hard to eat. Three of six individual residents confidentially interviewed voiced concerns related to the palatability of foods served. One Resident stated, Food is terrible. It is cold and taste bad. Another resident stated they did not like the food. A third resident stated they were not satisfied with the food. Record review of the Resident Council meeting notes dated 3/16/21 revealed the following, .The pork chops were hard to chew that were served . This was listed under comments related to food service. On 6/8/21 at 11:41 AM a kitchen observation was made and concluded at 12:20 PM. Observation of the service line revealed the following foods: Zucchini squash was mushy and over cooked Puréed pork chop had a dry thick more ground appearance. During the preparation of the ground pork chop by Dietary Staff A sharp periods of grinding with the blender could be heard. The sound was like the blade struck something solid. At that time, she stopped the processor and stated that she was searching for bones. She found two bone pieces in the ground pork chop. On 6/8/21 at 12:57 PM an observation was made of Resident #9 in the dining room. She was served a regular diabetic diet. She was served a pork chop, potatoes, squash, a slice of bread and a packaged snack cake. She only ate the snack cake which was 20% of her meal. The pork chop was hard, dark, thin and dry. She ate none of the pork, potatoes, zucchini squash, or slice of bread. On 6/9/21 at 11:23 AM a test tray was requested. On 6/9/21 at 11:46 AM a kitchen tour was conducted. Observation of the service line revealed the following: Beef tips were setting in a large amount of water. Broccoli was tan colored and overcooked appearance . Puréed beef tips had a very dry and coarse appearance The hall tray service started on 6/9/21 at 11:59 AM with the tray prep. Resident trays were completed at 12:08 PM. The test trays were prepped at 12:09 PM. The hall cart left the kitchen at 12:15 PM with one CNA delivering trays. Hall tray delivery was completed at 12:41 PM. The test trays arrived in the conference room at 12:44 PM and testing began at 12:46 PM with the following results: Beef tips and rice - tough beef tips and hard to chew Broccoli - mushy/overcooked and bland Ground beef with brown rice - tough beef and lukewarm (not a palatable temperature) Puréed beef with gravy - coarse and not in a puréed form Purée broccoli - very poor flavor. No definitive broccoli flavor Puréed rice - bland, sweet, coarse, thick and had bits of whole rice and a hard seed. Purée bread - too sweet Marinated Carrot salad - bitter, overwhelming onion flavor, no definite carrot flavor Eight of 11 foods tested had palatability concerns with flavor, texture and temperature. Record review of the current Diet Roster dated 6/08/21 revealed that there were 3 food forms served in the facility; regular, ground and pureed. These eight foods affected three of three food forms served in the facility (regular, ground and pureed). On 6/9/21 at 1:05 PM Dietary staff B was interviewed regarding the palatability of the test tray foods. She was told that the beef tips were tough and hard to chew. She stated, They never come out. I've tried (cooking) them in the oven too. When told about the broccoli being overcooked she stated, It was frozen broccoli. I'm used to fresh. When asked about the brown rice sweetness she stated, It was just minute rice. They probably use the apple juice in it. When asked about the overwhelming onion taste of the carrot salad she stated, It was made last night. It was made with vinaigrette, carrots and onions. On 6/10/21 at 8:38 AM a kitchen observation was made. At that time Dietary staff A was asked when she first started cooking the beef tips from yesterday. She stated, I put them on to cook at about 8:30 AM. Some was frozen in the middle. On 6/10/21 at 8:40 AM an interview was conducted with the Dietary Manager. She was asked if she ever spoke with residents and asked them their opinion of the food. She stated, Dietary staff B usually asks residents. She does it a lot. Dietary staff D is a cook and asks. When asked how often they asked residents about food she stated, Random. There's no regularity to it. She added, They (residents) complained about the broccoli being too hard so I think that's why she (Dietary staff B) cooked it more. The Dietary Manager was asked why the puréed meat was dry. She stated, They're not adding enough liquid. The dietitian went over it with her (Dietary staff A) and she was doing better. She was asked why the puréed bread was sweet. She stated, They added honey to the puréed bread. She was also asked why the puréed rice was sweet. She stated, I am unsure what they added to the puréed rice to make it sweet. At that time Dietary staff A added, I added apple juice to the puréed rice. Record review of the facility policy titled Food and Nutrition Services Staff, Revised October 2017, revealed the following documentation, Policy Statement. The food services department is staffed by food and nutrition services personnel who have demonstrated the skills and competency to carry out the functions of the department. Policy Interpretation and Implementation. 1. The food and nutrition services staff, under the supervision of the dietitian and/or the food and nutrition services manager, will safely and effectively carry out the functions of the food and nutrition services department . 4. Food will be palatable, attractive, and served in a timely manner at proper temperatures .

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 29 of 29 residents who consumed food from the facility's only kitchen; in that: 1) Dietary staff (staff A and D) failed to ensure foods were protected from possible contamination during processing and allowed to air dry (puree processing, dishware). 2) In use foods were expired and not in sound condition (moldy/rotting celery and jalapenos and expired packets of sliced ham and turkey breast). 3) The facility failed to ensure chemicals were stored in a manner to prevent contamination of foods and food contact equipment. 4) Dietary staff (B and C) failed to use good hygienic practices during dietary duties (touching clothing and masks during food and dishware handling) These failures could place residents at risk of foodborne illness. The findings include: 1. The following observations were made during a kitchen observation tour beginning on [DATE] at 11:41 AM and concluded at 12:20 PM: Dietary staff A was observed washing the food processor in the three compartment sink. She then took the dripping wet processor and assembling the blade in the processor with her bare hands. The interior of the processor and blade were also soiled with bits of food and wet. She washed her hands and donned gloves. The surveyor asked to see the blade in the processor and it was wet. She then placed pork chops in the processor, puréed it and then placed the purée on the steam table. Next she took the processor to the three compartment sink, washed it and then put it on the drain table at 11:50 AM. She then washed her hands and then assembled the blade in processor pot at 11:51 AM. She assembled this with her bare hands and the processor was dripping wet and the interior and blade were wet. She donned gloves and placed zucchini squash in the processor and then puréed it. At that time the Dietary Manager was asked to test the quaternary sanitizer concentration in a three compartment sink and it tested at 200 ppm (active liquid sanitizerwhich could be left in the wet processor). Dietary staff A then took the processor to the three compartment sink and washed it at 11:55 AM. She placed it on the drain table, washed her hands and then came back and assembled the processor which was still wet on the interior at 11:56 AM. She donned gloves and the surveyor intervened and told the Dietary Manager of the food being pureed in the wet processor. On [DATE] at 12:00 PM the Dietary Manager stated, We ordered another (processor) and blade. It came in today (processor pot and lid). When mentioned that the processor should have air dried before use she stated, They say it has to dry for five minutes. At that time Dietary staff A took the same wet blade she had washed and the new processor pot and lid and puréed potatoes. On [DATE] at 10:40 AM an interview was conducted with the Dietary Manager. She was asked why the dietary staff had puréed food in processors that were wet with sanitizer. She stated, I think she was rushed. We were told to let it dry five minutes. The following observations were made during a kitchen observation tour beginning on [DATE] at 9:41 AM and concluded at 9:50 AM: Clean glasses were stacked wet in the dish machine and kitchen areas. On [DATE] at 1:50 PM kitchen observation was made. Dietary staff C was observed stacking and storing clean wet glasses from the dishwasher. Record review of the dietary department In-Service Training Report dated [DATE] revealed that the subject covered was . sanitation. Record review of the facility policy titled Dishwashing Machine Used, Revised [DATE], revealed the following documentation, Policy Statement. Food service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Policy Interpretation and Implementation. 1. The following guidelines will be followed when dishwashing . j. After running items through entire cycle, allowed to air dry . Record review the facility policy titled Sanitization, Revised [DATE], revealed the following documentation, Policy Statement. The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation. 1. All kitchen, kitchen areas and dining areas shall be kept clean, free from litter and rubbish 2. All utensils, counters, shelves and equipment shall be kept clean . 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions . 10. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical . 2. The following observations were made during a kitchen observation tour beginning on [DATE] at 10:39 AM and concluded at 11:12 AM: Observation of the walk-in refrigerator revealed that there were two 32 ounce packages of Smoked Ham Extra Lean Fully Cooked that was labeled, Use by [DATE]. Also, in the walk-in refrigerator was five 32 ounce packages of Oven Roasted Turkey Breast Extra Lean that was labeled, Use by [DATE]. There were three large Ziploc bags of cut celery sticks that were yellowed and rotted. There was also a large Ziploc bag of small jalapeño peppers that were moldy. ~ The following observations were made during a kitchen observation tour beginning on [DATE] at 5:05 PM and concluded at 5:30 PM: Observation of the walk-in refrigerator revealed that the same rotted/moldy jalapeños and expired packages of smoked ham and oven rest roasted turkey were present. There were also the same three bags of rotted brown celery sticks present. ~ The following observations were made during a kitchen observation tour beginning on [DATE] 9:41 AM and concluded at 9:50 AM: Observation of the walk-in refrigerator revealed that the same bags of rotted celery and moldy jalapeños were present. The same expired ham and oven roasted turkey was present. On [DATE] at 10:40 AM an interview was conducted with the Dietary Manager . At that time, she was shown the expired foods and spoiled foods in the walk-in refrigerator. She stated, I don't know why it's past the date. Everybody should be checking. There's no one in particular that checks it. She was then asked about the bag of moldy peppers and the marking on it was ,d+[DATE]. She stated Yes it came in on ,d+[DATE]. She was then asked why spoiled and expired foods were present in the walk-in refrigerator with in use foods. She stated, They (staff) are not checking. Also, at this time the brown celery was still in the walk-in refrigerator. Record review of the facility policy titled Refrigerators and Freezers, Revised [DATE], revealed the following documentation, Policies Statement. This facility will ensure a safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation . 7. All food shall be appropriately dated to ensure proper rotation by expiration dates . Expiration dates on unopened food will be observed and use by dates indicated once food is open. 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or passed parish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes . 3. The following observations were made during a kitchen observation tour beginning on [DATE] at 10:39 AM and concluded at 11:12 AM: There was an uncovered red bucket of quaternary sanitizer stored on the lower prep table shelf next to pots. There was also an open container of antibacterial wipes on the shelf. There was an uncovered red bucket of quaternary sanitizer and a large pump container of Germ Attack 70% Alcohol Hand Sanitizer Gel stored on a lower shelf at the front of the kitchen. These chemicals were stored next to eating utensil packets. Observation and record review of the bottle of Germ Attack 70% Alcohol Hand Sanitizer Gel revealed the following documentation, . Warnings. Flammable . For external use only. When using this product do not use in eyes. In case of contact with eyes, rinse with water . If swallowed get medical help promptly . The following observations were made during a kitchen observation tour beginning on [DATE] at 5:05 PM and concluded at 5:30 PM: There was a pump bottle of Germ X hand sanitizer stored on top of the microwave and next to a bin of French vanilla creamer packets and a pump bottle of Coffeemate creamer. The hand sanitizer was labeled Flammable . On [DATE] at 8:38 AM a kitchen observation was made. There was a large pump bottle of Germ Attack 70% Alcohol Hand Sanitizer Gel on the lower front shelving next to wrapped eating utensils in paper napkins. On [DATE] at 8:40 AM an interview was conducted with the Dietary Manager. She stated that the dietitian had not mentioned anything to them about the storage of hand sanitizer next to food and food contact surfaces. 4. The following observations were made during a kitchen observation tour beginning on [DATE] at 11:46 AM and concluded at 12:15 PM: Dietary staff B was observed putting on a pair of gloves then pulling up/adjusting her pants. She then picked up a bag of bread. Dietary staff C had her nose uncovered from her mask. She repeatedly touched the front of her mask with her gloved hands. She then placed plates and bowls of food on the meal trays and put them in the service cart. ~ On [DATE] at 1:50 PM a kitchen observation was made. Dietary staff C was observed touching the front of her facemask in the mouth area and then removed clean silverware from the dishwasher. Record review of the dietary In-Service Training Report dated [DATE] revealed that there was an in-service with the subject of glove use . Dietary Staff B and C had not attended this in-service. Record review of the facility policy titled Preventing Foodborne Illness - Food Handling, Revised [DATE], revealed the following documentation, Policy Statement. Food will be stored, prepared, handled and serve so that the risk of foodborne illness is minimized. Policy interpretation and implementation. 1. This facility recognizes that the critical factors implicated in foodborne illness are: a. Poor personal hygiene food service employees; . c. Contaminated equipment; and d. unsafe food sources. 2. With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents. 3. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents .

Based on observation, interview and record review, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection in that: - CNA A failed to maintain appropriate infection prevention and control practices to prevent the contamination of clean objects with soiled gloves while providing incontinent care to Resident # 27. - CNA B failed to maintain appropriate infection prevention and control practices to prevent the contamination of clean objects by not performing hand hygiene between dirty and clean care while providing incontinent care to Resident #26. - Housekeeping Staff A and CNA C failed to perform appropriate infection prevention and control practices to prevent contamination of non-quarantined areas by doffing contaminated PPE outside of patient room and placing contaminated PPE in open trash container attached to housekeeping cart and in a trash bin used for resident common area. - The facility failed to maintain appropriate infection prevention and control practices to prevent contamination of clean laundry by not storing laundry under negative air pressure. These failures have the potential to affect residents by placing them at an increased and unnecessary risk for infection. Findings include: During an observation on 06/08/21 at 3:39 PM CNA A, with the assistance of CNA B, performed peri-care on Resident #27. CNA A failed to change gloves and perform hand hygiene after wiping residents bottom area and before placing clean brief under resident and handling resident's clean linens. During an interview on 06/08/21 at 4:03 PM, CNA A stated that she is supposed to change gloves and perform hand hygiene between dirty and clean care. She has been trained on how to correctly perform peri-care; they receive training yearly. During an observation on 06/08/21 at 3:49 PM, CNA B, with assistance of CNA A, performed peri-care on Resident #26. CNA B failed to perform hand hygiene after removing gloves between dirty care and clean care. During an interview on 06/08/21 at 4:04 PM, CNA B stated that she is supposed to perform hand hygiene between gloves changes when going from dirty to clean care. She has been trained on how to correctly perform peri-care; they receive training yearly. Stated that some risks to the resident if hand hygiene is not performed appropriately during peri-care are C-Diff and urinary tract infections. During an interview on 06/08/21 at 4:23 PM, DON stated that she expects her staff to perform all areas of peri-care correctly every time they perform care. She provides yearly training to staff with follow-up observations by her and the ADON. Some risks to the resident if peri-care is not performed correctly is skin breakdown and infection. On 6/8/21 at 11:15 AM a resident tour was conducted with LVN A. The LVN stated that Resident #79 was a new admit with falls and dementia. She added the resident was quarantined because she was not vaccinated for COVID-19. Observation of the resident's room revealed it had posters outside of the door stating it was a yellow zone and the resident was in quarantine. Start date was 6/2/21 and the end date was 6/16/21. Test date was 6/9/21. There were CDC guidelines for donning and doffing PPE posted on top of the PPE cabinet outside the room. Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the physician telephone order for Resident #79 dated 6/2/21 revealed the following documentation, Resident to be on 14 day quarantine upon admission per COVID-19 precautions. May COVID-19 test resident on day eight and remove off quarantine if negative per facility/CMS guidelines. Record review of the facility undated document titled Resident Testing revealed that Resident #79 was not tested for COVID-19 until 6/9/21 and was of unknown COVID status until that date. During an observation on 06/08/21 at 1:51 PM Housekeeper staff A was observed coming out of quarantined room [ROOM NUMBER] wearing a gown, gloves, and N95 mask. She mopped up area of the floor in the corridor outside of the room and then doffed her gloves and gown in the corridor and placed them in the open housekeeping cart garbage bin. She used hand sanitizer and then disposed of her N95 mask in the open trash bin on the housekeeping cart. Then she donned gloves and a regular face mask and left down the hall. During an observation and interview on 06/08/21 at 6:07 PM CNA C delivered a meal tray to Resident #79 in quarantined room [ROOM NUMBER]. She donned gloves and a gown and took the meal into the room. She doffed PPE in the corridor at the meal cart container and then put her gloves and gown in one of the three bin containers in the community disposal cart in the hall near the hall 100 bath. At that time, she was interviewed about her actions and she stated, They usually have a trash barrel in the restroom. We put trash in there. When in quarantine we have a barrel for linen and one for trash in the room. I didn't see one in there. I put it in my regular trash here. She's almost off quarantine. Observation of the three-barrel area revealed that there were bin sections for dirty linen trash and personal items. CNA C was then asked if she kept on the same surgical mask what she was wearing when she went into the quarantined room. She stated, yes. On 6/8/21 at 6:11 PM CNA C was observed in the dining room assisting Residents #26 with their meal and wearing the same mask. During an interview on 06/08/21 at 6:20 PM with DON about staff entering the quarantine room and what their instructions have been she stated, Staff are to don PPE and announce themselves. Use hand sanitizer before entering and exiting, and then dispose of the PPE. There should be barrels in the restroom to dispose of the PPE. We have barrels for linen and trash. She was then asked what constituted for PPE. She stated, A mask, gloves, and gown. Staff are to change mask after exiting room. If it's a Covid positive resident we use an N95. We will Covid test Resident #79 in the morning. She was then asked what had happened to the barrels that should've been in the residence room. She stated, I'm not sure. We will put them back. On 6/10/21 at 9:57 AM an interview was conducted with the DON. She was asked the consequences of staff doffing and disposing of the PPE in a public area. She stated, . It could cause the spread of infections. Record review of the facility document titled Personal Protective Equipment Competency Validation. Donning and Doffing for Reuse During Pandemic revealed that Housekeeper A passed the competency on donning and doffing PPE on 12/30/20 and CNA C passed on 1/05/21. During an observation on 06/09/21 at 2:35 PM of the laundry room, surveyor stood on a step stool and held a pole with a tissue attached to the end and placed it near the ceiling vent. The tissue did not stick to the vent, therefore demonstrating no negative air pressure. During an interview on 06/09/21 at 2:40 PM Laundry Supervisor stated she did not know anything about the exhaust vent, and we should talk to the Maintenance Supervisor. She said she did know there was supposed to be an exhaust vent in the soiled side of the laundry for infection control purposes from working in other long term care facility laundries, but did not know why there was not one in this laundry room. During an interview and observation on 06/10/21 at 10:05 AM of the laundry room the Maintenance Supervisor looked at the ceiling air vent and demonstrated to himself and surveyor with climbing up on a step stool holding a tissue attached to the end of a pole that the tissues did not stick to the air vent. The Maintenance Supervisor stated, This is not a return air vent, it is an air conditioning vent. When asked what the consequences were of not having an exhaust vent in the laundry, he stated, There was nowhere for the bacteria to leave the laundry to the outside air. During an observation on 06/10/21 at 10:15 AM Laundry Staff A brought a basket of soiled resident clothing from the facility into the laundry area and began the washing process. During an interview on 06/10/21 at 11:03 AM, ADON, who is the Infection Control Preventionist, was asked what the consequences of not having a return air vent in the laundry area were, he stated, There would be nowhere for the infectious air/bacteria to escape out of the laundry. Record review of facility provided policy titled Infection Control Guidelines for All Nursing Procedures, revised August 2012, reflected in part: General Guidelines: 3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: c. After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; d. After removing gloves; e. After handling items potentially contaminated with blood, body fluids, or secretions; Record review of facility provided policy titled Departmental (Environmental Services)-Laundry and Linen, revised January 2014, reflected in part: Purpose: The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Washing Linen and other Soiled Items: 7. Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts. Record review of facility provided CDC guidelines on doffing PPE titled Sequence for removing personal protective equipment (PPE) no revision date noted, reflected in part: Except for respirator remove PPE at doorway or in anteroom. Remove respirator after leaving patient room and closing door. Record review of article on CDC website titled Healthcare Providers, revised January 2021, reflected in part: When to Perform Hand Hygiene: - Before moving from a soiled body site to a clean body site on the same patient When and How to Wear Gloves: - Wear gloves and perform hand hygiene during patient care, if: Moving from work on a soiled body site to a clean body site on the same patient of if another clinical indication for hand hygiene occurs References: Centers for Disease Control (2021, January 08). Healthcare providers. Retrieved June 14, 2021, from https://www.cdc.gov/handhygiene/providers/index.html

Based on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, in 2 of 2 baths (Hall 100 and 200), 7 of 20 resident rooms (102, 104, 106, 107, 112, 201 and 204), 2 of 2 shower rooms (100 and 200), soiled utility room, beauty salon, lobby and 2 of 2 corridors (100 and 200), in that: 1)Resident use hot water was not maintained at comfortable and safe temperatures (2 of 2 baths (Hall 100 and 200), 7 of 20 resident rooms (102, 104, 106, 107, 112, 201 and 204), 2 of 2 shower rooms (100 and 200)) , 2) Chemicals were not stored in a manner that was inaccessible to residents (soiled utility room, beauty salon, lobby and 2 of 2 corridors (100 and 200)). 3) Resident use and resident area equipment were not maintained in a clean manner (2 of 2 showers (100 and 200)), These failures could lead to resident chemical and hot water injuries and cause the facility to have an unsightly appearance. The findings include: 1.The following resident rooms had hot water that was not at safe and comfortable temperatures on 6/08/21: 12:27 PM - room 107 was 114.4°F 12:32 PM - room 104 was 120.2°F 12:35 PM - room 106 was 122.5°F 12:39 PM - room 204 was 114.8°F 12:41 PM - room 201 was 114.9°F On 6/8/21 at 12:46 PM the Administrator was informed of the elevated hot water in the facility. At that time the surveyor checked her digital thermometer in ice water to establish accuracy and the temperature was registered at 33.1°F (within + 2 degree variance) . Also at that time the temperature was taken of the hot water in room 112 and it was 114.4°F. On 6/8/21 at 12:47 PM the Administrator stated regarding the resident area water heater, They replaced it (recirculating pump) twice. It's a digital system. On 6/8/21 at 12:48 PM the hot water was checked in room 102 with the Administrator and the temperature was 123.1°F. On 6/8/21 at 12:50 PM the hot water was tested in room 106 and it was 115.2°F. The Administrator was present. On 6/8/21 at 1:13 PM an observation was made of the resident area water heater with the Administrator. The digital temperature display on the heater stated that it was 117°F. The Administrator stated, The (installing) company has to come out with a specialized computer to adjust the temperature. We have to call the company to adjust it stated the Maintenance staff A. Maintenance staff A stated, We were not aware of this issue that it (hot water) was up so high. He was then asked the procedure for monitoring hot water in the facility. He stated, We picked a couple of rooms and used a digital thermometer. He was asked what time of day they checked the water temperatures. He stated, It's random. He was then asked how often these rooms were checked. He stated, It's when we can get free. Normally it's early in the morning or late afternoon. We try to keep on a schedule. Maintenance staff A stated that they had replaced the recirculating pump for the water heater one time due to the freeze. On 6/8/21 at 1:20 PM Maintenance staff A was asked again to clarify the water monitoring routine for resident rooms. He stated, We check four rooms one time a month. Record review of the facility's current undated document titled Maintenance Schedule revealed the following documentation that water temperatures were checked monthly; Monthly - water temperature check . Record review of the facility documents titled Water Temperature Log revealed resident water temperatures were taken one day a month. The documentation for March 2021 - May 2021 was as follows: March 2021 log documented that four resident areas were tested for water temperatures on 3/9/21 beginning at 11:45 AM and ending at 12:08 PM. The areas tested were shower one, room 107, room 209 and room 204. The temperatures documented for these areas range from 109°F to 110°F. The document further stated, Temperature must be between 100 - 110°. April 2021 log document revealed that water temperatures were taken in four resident areas on 4/14/21 at 9 AM until 9:05 AM. The areas tested were shower 2, room 203, 201 and 106. The temperatures range from these areas was 108° through 110°F. May 2021 log revealed that water temperatures were taken in the facility in four resident areas on 5/11/21 beginning at 1:00 PM through 1:06 PM. The areas tested were rooms 110, 109, 210 and 209. The temperature range for these areas was 109° to 110°F. On 6/8/21 at 1:40 PM an observation was made of the hall 100 bath and the water at the hand sink was 115.9°F. On 6/8/21 at 1:43 PM the hall 100 shower had hand sink hot water at 115.5°F. On 6/8/21 at 1:55 PM an observation was made of the hall 200 bath and the hot water was 114.8°F. On 6/8/21 at 1:56 PM an observation was made at the hall 200 shower room and the hot water was 114.8°F. [The facility shut off the resident use hot water in response to the elevated temperatures after surveyor intervention] On 6/8/21 at 2:03 PM Maintenance staff A presented the thermometers that they used to take water temperatures in the facility. He and Maintenance Supervisor stated that these three thermometers were the ones they had been issued for taking water temperatures of water. Observation of the thermometers revealed that they were infrared thermometers and were labeled, Non-Contact Forehead Thermometer. When asked how long they have been using these thermometers to test water temperature they stated they had used them for the last nine months. This was since the opening of the new building. Also at that time the infrared thermometers were checked in comparison with the surveyor's digital thermometer. The temperature of the hot water was checked in the hall 200 shower again. At this time and the surveyor's thermometer read 121°F compared to the infrared thermometer number one which read 109°F. When the surveyor thermometer read 120.4° it was compared to the number two infrared thermometer that had just been taken out of the package and it read 103°F. The water continued to run and the surveyor's thermometer read 117.1° and it was compared to the number three infrared thermometer that had just been taken out of the package and it read 107°F. The Maintenance Supervisor stated the number one infrared thermometer was the one that they have been using for the past nine months. On 6/10/21 at 10:08 AM an interview was conducted with the Maintenance Supervisor regarding any training related to taking water temperatures. He was asking if any training had been provided to staff related to taking water temperatures in the facility. He stated, No (training in taking temperatures). Review of the current American Burn Association Scald Injury Prevention Educator's Guide provided the following information. The basis of the information is from research conducted by [NAME], AR, Herriques, FC Jr. Studies of thermal injuries: II The relative importance of time and surface temperature in the causation of cutaneous [CONDITION(S)]. M J Pathol 1947; 23:695-720. and Stone, M, [NAME] J, [NAME] J. The continuing risk of domestic hot water scalds to the elderly. [CONDITION(S)] 2000; 26:347-350.: .although scald [CONDITION(S)] can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper [CONDITION(S)] with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person's perception, memory, judgment or awareness may hinder the person's ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 127 degrees F. caused third degree [CONDITION(S)] in 1 minute and water at 133 degrees F. caused third degree [CONDITION(S)] within 15 seconds. Water temperatures at 140 degrees F. caused third degree [CONDITION(S)] within 5 seconds. Water temperatures at 148 degrees F. caused third degree [CONDITION(S)] within 2 seconds and Water temperatures at 155 degrees F. caused third degree [CONDITION(S)] within 1 second. Record review of the facility policy titled Water Temperatures, Safety Of, Revised December 2009, revealed the following documentation, Policy Statement. Tapwater in the facility shall be kept within a temperature range to prevent scolding of residents. Policy Interpretation and Implementation. 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110° or the maximum allowable temperature per state regulations. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks and a maintenance log . 2. On 6/8/21 at 11:15 AM a resident tour was conducted on hall 100. In the corridor outside Room 110 there was a large pump bottle of Germ Attack 70% Alcohol Hand Sanitizer Gel on top of the PPE cabinet. This bottle was within reach of residents in wheelchairs. There was also a large pump bottle of this hand sanitizer in the lobby area and within reach of residents in wheel chairs. Observation and record review of the bottle of Germ Attack 70% Alcohol Hand Sanitizer Gel revealed the following documentation, . Warnings. Flammable . For external use only. When using this product do not use in eyes. In case of contact with eyes, rinse with water . If swallowed get medical help promptly . Confused independently ambulatory residents wandered the corridors and lobby such as Resident #22 on 6/08/21 at 4:57 PM and 6/10/21 at 3:00 PM. During an interview with the Administrator on 6/16/21 at 2:32 PM he stated that they had previously ordered wall hand sanitizer dispensers that did not have the appropriate concentration of alcohol. So they changed to the pump containers. He added that they planned to replace the pump bottles with a higher concentration alcohol solution for the wall dispenser units. On 6/8/21 at 1:05 PM a housekeeping cart was parked in the corridor near room 104. Housekeeper A was inside the room and cleaning. The cart had the key left in the cabinet door and unlocked. The cabinet door was facing the corridor. Residents were wandering in the corridor at the time. Inside the cart cabinet was AF Ultra which was an acid free total bathroom cleaner, Re-act Mal Odor [MEDICATION(S)], Effer San disinfectant tablets which were diluted in a spray bottle. There was also [NAME] Disinfectant Spray Q which was labeled, Causes moderate eye irritation. Also in the cabinet was Bio Conqueror 105 which was labeled, Harmful if swallowed. Record review of the safety data sheet for AF Ultra, Acid Free Disinfectant and Total Bathroom Cleaner, revealed the following documentation, . Handling and storage. Handling: ensure adequate ventilation. Wear personal protective equipment is required based on a risk assessment. Do not get in eyes, on skin, or on clothing. Do not breathe vapors or spray mist. Remove and wash contaminated clothing before reuse. Washed thoroughly after handling . Record review of the safety data sheet for Re- Act Thai Mango, Malodor [MEDICATION(S)], revealed the following documentation, . Hazard identification . Hazard statements . Combustible liquid . May be fatal if swallowed and enter airways . On 6/8/21 at 1:25 PM an observation was made of the facility beauty salon and it was unlocked and unattended. There was an unlocked cabinet which contained an unlabeled blue liquid in a spray bottle and then an unlabeled yellow bottle with liquid in it. There was an aerosol can of [NAME] Disinfectant Spray Q which was labeled, Causes moderate irritation . Avoid contact with skin in clothing . Flammable On 6/8/21 at 1:37 PM Housekeeper A was observed inside room 110 cleaning. The housekeeper cart was in the corridor and the cabinet door was ajar with the key in the lock of the cabinet. The same chemicals were still present in the housekeeping cart cabinet. On 6/8/21 at 2:53 PM an observation was made of the Housekeeping Laundry Supervisor cleaning in room 207 and the key was in the lock of her housekeeping cart cabinet and the cabinet door was ajar. The housekeeping cart was unlocked and unattended in the corridor. On the inside of the cabinet there was a container of Total Housekeeping Disinfectant which was labeled, Causes substantial but temporary eye damage . Flammable . On 6/8/21 at 3:01 PM an interview was conducted with the Housekeeping Laundry Supervisor. She stated, I usually lock it (housekeeping cart cabinet). It slipped my mind. She was asked if she had received any training related to ensuring chemical security. She stated, They mentioned it when I first got trained. That was two years ago. There was also a pump bottle of Germ X hand sanitizer on top of the cart unattended and accessible that was labeled Flammable . On 6/8/21 at 3:03 PM an observation was made of the soiled utility room. There was a sign on the door that stated, Make Sure to Keep This Door Locked At All Times. The door was unlocked and the room was unattended. There was a housekeeping cart inside that had the cabinet unlocked. This was the cart that Housekeeper A had used. The cabinet containing the same chemicals as mentioned before. In this room there was also a hand sink cabinet that was not lockable. There were two jars of Effer San [MEDICATION(S)] Tabs Disinfectant Sanitizer Cleaner. These jars were labeled, Danger. Corrosive There was also a spray bottle of Clorox All Purpose Cleaner Disinfectant that was labeled, Causes moderate eye irritation . On 6/10/21 at 10:01 AM an interview was conducted with the Housekeeping Laundry Supervisor regarding any employee training on chemical security. She stated, We do training. It (securing the chemicals) slipped our minds. I do remind them (to lock housekeeping cart chemical cabinet). She was then asked what the consequences would be if staff continue to leave their chemical cabinet unlocked in resident areas. She stated, They (residents) can get in the chemical and ingest it and die. 3. On 6/8/21 at 1:43 PM the hall 100 shower had one of three in use shower chairs (large blue) with a heavy accumulation of brown residue/BM on the underside of the seat. The mesh back of the shower chair had a heavy accumulation of residue and dirt. On 6/8/21 at 1:56 PM an observation was made at the hall 200 shower room. The underside of the shower chair had BM along the frame at the foot area. On 6/9/21 at 11:30 AM an observation was made of the hall 200 shower. Two of three in use shower chairs were dirty. The large blue shower chair still was soiled with a build up a BM on the underside frame. One of two smaller blue shower chairs had BM on the frame on the front foot rail area. The large blue shower chair also had a buildup of dirt on the mesh back. On 6/9/21 at 11:35 AM an observation was made of the hall 100 shower. One of two in use shower chairs (pink) had dried BM on the underside of the seat. On 6/9/21 at 11:37 AM an interview was conducted with CNA E regarding CNA cleaning duties in the shower. She stated, The shower aides disinfect the shower chairs. Housekeeping goes in and cleans the room. The shower aid she does showers for everyone. On 6/9/21 at 11:41 AM an interview was conducted with the Housekeeping Laundry Supervisor relating to cleaning duties in the baths. She stated, We clean and spray down. We wipe down with Effer San. We clean shower chairs. We spray it (Effer San) on and then rinse it off. I think the night aids do deep cleaning and shower chairs. On 6/9/21 at 11:42 AM an interview was conducted with CNA F, shower aide, regarding cleaning duties in the bath. She stated, I disinfect for 10 minutes and then rinse it off and dry off. After that's done I ask housekeeping to disinfect all of the baths. I clean up BM. I do some turning them (shower chairs) over and scrubbing. The night aids clean the wheelchairs. On 6/9/21 at 3:53 PM an interview was conducted with the DON regarding shower cleaning duties for CNAs. She stated, Mostly the shower aid is responsible for shower chairs. CNA F works Monday through Friday and the floor CNA does it on the weekends. They clean (shower chairs) between residents. They spray the chair and wait for 10 minutes and rinse. They clean thoroughly between uses. The night CNAs clean wheelchairs and shower chairs and do more deep cleaning. Record review of the facility policy titled Cleaning and Disinfection of Resident Care Items and Equipment, Revised July 2014, revealed the following documentation, Policy Statement. Resident care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA blood-borne pathogen standard. Policy Interpretation and Implementation . 3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 4. Reusable resident care equipment will be decontaminated and/or sterilize between residents according to manufacturer's instructions .

Based on interview and record review the facility failed to designate a person to serve as the director of food and nutrition services who met the required qualifications for 29 of 29 residents who consumed food orally. 1)The facility failed to designate a person to serve as the director of food and nutrition services who met federal and state specific Dietary Manager requirements. This failure could place residents at risk to the spread of foodborne illness and residents not having their nutritional need met. The findings include: Record review of the personnel file for the dietary manager revealed that she had a date of hire of 6/24/10. Further record review of the personnel file revealed that there was no documentation that she had completed the state required dietary managers course, was a certified food service manager or met any of the qualifying training (national certification for food service management and safety from a national certifying body or an associate's or higher degree in food service management or in hospitality) to be a Dietary Manager. Record review of the food handler certification documentation for dietary staff, presented by the Dietary Manager, revealed that they all had current food handler certificates which included the dietary manager. No certified dietary manager or food service manager documentation was presented for the Dietary Manager On 6/9/21 at 10:08 AM an interview was conducted with the Dietary Manager regarding her qualifications as a dietary manager. She stated, I'm done with the school and I haven't taken the test (for Dietary Managers). It's with (a University). I'll take the test in July. I don't have any other dietary manager certifications. On 6/9/21 at 10:40 AM an interview was conducted with the Dietary Manager. The dietary manager was also asked how long she had been the dietary manager in the facility. She stated, one year here and five years as the hospital dietary manager. On 6/10/21 at 8:40 AM an interview was conducted with the Dietary Manager. She was asked why she had not completed the required dietary manager courses. She stated, I had scheduled (testing) earlier but COVID hit. Record review of the current undated facility document titled Job Description and Performance Standards, Position Title. Food Service Supervisor . revealed the following documentation, Purpose of this position. The purpose of this position is to implement and maintain effective, efficient systems to operate the dietary department and provide food service to residents in a cost effective, efficient manner to safely meet resident's needs, compliance with federal, state and local requirements. Qualifications . Certification: certified dietary manager or certification from an accredited food service program . Record review of the facility policy titled 1.11 Food Handler - Manager Certification - SLC, Policy: Food Handler/Manager Certification . Effective: March 2021 . revealed the following documentation, Policy . The nutrition services manager will obtain a Servesafe manager certification which will serve as their food handler's permit. Procedure . If a new nutrition services manager does not have a current Servesafe manager certification he/she will also be required to obtain one within 60 days of employment .

Based on interviews and record reviews, the facility failed to ensure the consultant pharmacist's monthly drug regimen review of each resident identified medication administration irregularities for five of six residents' (Residents' #9, #14, #19, #22, and #26) reviewed for drug regimen review, in that: The facility failed to ensure the consultant pharmacist completed accurate Medication Regimen Reviews for resident's [CONDITION(S)] medication that needed Gradual Dose Reductions (GDR). These failures could affect residents receiving medication, who required monthly Medication Regimen Reviews and place them at risk for medication errors, unnecessary medications, and incorrect medication administration. The findings include: Resident #9: On 06/08/2021 at 11:15 AM a resident tour was conducted with LVN A. She stated Resident #9 was confused and on psychoactive medications. Record review of the physician order report: 05/10/2021 - 06/10/2021 reveal that Resident #9 was admitted to the facility on [DATE] and was [AGE] years old. Diagnoses listed were Mild cognitive impairment, so stated (Primary, Admission), Other specified depressive episodes, Anxiety disorder, unspecified, and [CONDITION(S)], unspecified. Further record review of the physician order report revealed at Resident #9 had an order for [MEDICATION(S)] tablet; 15 mg; amount: 15 mg; oral for a diagnosis of anxiety disorder. Twice a day a.m. 6 AM - 10 AM, p.m. 5 PM - 10 PM. Start date 07/18/2020 with an open-ended date. Record review of the nine monthly observation detail list report pharmacy consultant chart reviews for Resident #9 beginning with observation date 09/29/2020 and ending with observation date 05/19/2021 revealed that there were no recommendations regarding gradual dose reduction for [MEDICATION(S)]. During an interview on 06/10/2021 at 3:30 PM with Pharmacist, she stated that she had not made recommendations for a gradual dose reduction. She stated that the physician does not respond to her request, so she quit making them. Resident #14: Record review of Resident #14's face sheet on 06/08/2021 revealed resident has a birth date of 05/01/1938 and was admitted to the facility on [DATE] with a readmitted [DATE]. Some of the resident's diagnoses include unspecified dementia with behavioral disturbance, myoglobinuria, heart failure, constipation, localized [CONDITION(S)], [CONDITION(S)], major depressive disorder, and [CONDITION(S)]. Record review of Resident #14's physician orders revealed resident had an order for the following psychoactive medications: [MEDICATION(S)] 20mg D - start date 03/22/2020, [MEDICATION(S)] 15mg 1 tab - start date 10/07/2020. Record review of Resident #14's monthly drug regimen review from 9/29/2020 to 5/19/2021 revealed that a recommendation for a gradual dose reduction on psychoactive medications had not been completed. During an interview on 06/10/2021 at 3:30 PM with the Pharmacist, she stated that she had not made recommendations for a gradual dose reduction. She stated that the physician does not respond to her request, so she quit making them. Resident #19: Record review of face sheet for Resident # 19 documented an [AGE] year-old female who admitted [DATE] with re-admitted [DATE] with some of the following diagnoses: Unspecified dementia without behavioral disturbance (Admission), Altered mental status, unspecified, [CONDITION(S)], unspecified, Dysuria, Abnormal weight loss (History of), [CONDITION(S)], unspecified, Urinary tract infection, site not specified, Delusional disorders, [CONDITION(S)], unspecified, Type 2 diabetes mellitus without complications, Other [CONDITION(S)], Essential (primary) hypertension, Anxiety disorder, unspecified, and [CONDITION(S)], unspecified. Further record review of the physician order report dated 05/10/2021 - 06/10/2021 revealed Resident #19 had the following orders: ~ [MEDICATION(S)] tablet, 10 mg oral one time a day at 06:00 AM - 10:00 AM, start date 05/08/2018, for delusional disorders. ~ [MEDICATION(S)] tablet, 15 mg oral at bedtime, start date 05/08/2018 - open ended, for [CONDITION(S)]. ~ [MEDICATION(S)] capsule 30 mg oral at bedtime, start date 05/08/2018 open-ended, for [CONDITION(S)]. ~ [MEDICATION(S)] tablet, 1 mg oral at bedtime, start date 05/08/2018 - open ended for [CONDITION(S)]. ~ [MEDICATION(S)] tablet, 15 mg oral, start date 05/09/2018 - open ended for delusional disorders. Record review of the nine monthly observation detail list report pharmacy consultant chart reviews for Resident #19 revealed record review beginning with observation dates of 09/29/2020 through 05/19/2021 revealed that there were no recommendations given related to her psychoactive medications of [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] or [MEDICATION(S)]. Resident #22: Record review of the physician order report: 05/10/2021 - 06/10/2021 for Resident #22 revealed that she was admitted to the facility on [DATE] and was [AGE] years old. Diagnoses listed for the resident were [CONDITION(S)], unspecified, Major depressive disorder, recurrent, unspecified, Unspecified mood [affective] disorder, and Unspecified dementia with behavioral disturbance. Record review of the nine monthly observation detail list report pharmacy consultant chart reviews for Resident #22 revealed record review beginning with observation dates of 09/29/2020 through 05/19/2021 revealed that there were no recommendations given related to her psychoactive medications of Further record review of the physician order report revealed that Resident #22 had an order for [MEDICATION(S)] (fluoxetine capsule); 10 mg; amount: 10 mg; oral diagnosis: major depressive disorder, recurrent, unspecified. once a day; 6 AM - 10 AM. Start date 09/03/2019 and was open ended. Record review of the nine monthly observation detail list report pharmacy consultant chart reviews for Resident #22 revealed record review beginning with observation dates of 09/29/2020 through 05/19/2021 revealed that there were no recommendations given related to her psychoactive medication [MEDICATION(S)]. Resident #26: Record review of face sheet for Resident #26 documented a 74 -year-old female who was admitted on [DATE] with re-admitted [DATE] with the following diagnoses: Dementia in other diseases classified elsewhere with behavioral disturbance (Primary, Admission), Psychotic disorder with hallucinations due to known physiological condition, Major depressive disorder, single episode, severe without psychotic features, [CONDITION(S)] disorder, current episode manic severe with psychotic features, Pseudobulbar affect, Altered mental status, unspecified, Unspecified mood [affective] disorder, Disorientation, unspecified, Unspecified convulsions, [CONDITION(S)], unspecified, Anxiety disorder, unspecified, and Major depressive disorder, recurrent, unspecified. Further record review of the physician order report dated 05/10/2021 - 06/10/2021 revealed Resident #26 had the following orders: ~Trazadone tablet, 50 mg oral at bedtime start date 04/16/2020 - open ended, for [CONDITION(S)]. ~[MEDICATION(S)] capsule, extended release 24 hr.; 150 mg at 06:00 AM - 10:00 AM; start date 04/16/2020 open - ended, for major depressive disorder ~[MEDICATION(S)] capsule, extended release 24 hr.; 75 mg at 06:00 AM - 10:00 AM, open - ended, start date 04/16/2020, for major depressive disorder. Record review of the nine monthly observation detail list report pharmacy consultant chart reviews for Resident #26 revealed that record review beginning with observation dates of 09/29/2020 through 05/19/2021 revealed there were no recommendations given related to Resident # 26's psychoactive medications of trazadone, and [MEDICATION(S)]. 06/10/21 at 02:47 PM during an interview with the DON when asked to show resident's GDR's, she said she would have to get the spreadsheet where she documents the residents' changes. When asked if she sends out the pharmacist's recommendations to the physician's she said no, the physician'' do their own changes of medications. 06/10/21 at 2:30 PM during an interview with the consultant pharmacist when asked if she sent GDR recommendations on resident psychoactive medications, she said, I send some sometimes, but not on all of them. She said the physicians' do not respond to her recommendations and they do whatever they want to with the resident's medications. She said, I have failed in documenting and I know I am supposed to do so. Record of facility policy Pharmacy Services - Role of the Consultant Pharmacist dated (Revised April 2007) documented the following: Policy Statement The facility shall obtain and retain the services of a Consultant Pharmacist . 3. The Consultant Pharmacist shall provide consultation on all aspects of pharmacy services in the facility, including (but not limited to): a. Helping the facility develop, implement, evaluate, and revise pharmaceutical services procedures that meet resident needs and conform to current standards of practice; b. Evaluating processes of receiving and interpreting prescribers' orders; acquiring, receiving, storing, controlling, reconciling, compounding, dispensing, packaging, labeling, distributing, administering, monitoring responses to, and using and/or disposing of all medications, biologicals, and chemicals; c. Helping identify and evaluate medication-related issues; d. Advising about the coordination of pharmaceutical services; .f. Identifying pertinent resources and references about medications and their proper use and monitoring in the population; g. Helping the nursing staff evaluate and optimize their medication administration and documentation processes; h. Helping the facility establish and implement effective quality assurance activities to identify, resolve, and prevent medication-related problems; .j. Helping the facility educate and inform its staff and resolve medication-related needs or problems; 4. The Consultant Pharmacist will provide specific activities related to medication regimen review including: a. A documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines; b. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated; . e. Providing the facility with written or electronic reports and recommendations related to all aspects of medication and pharmaceutical services review.

Based on interview and record review, the facility failed to transmit a resident assessment within the fourteen-day required time frame for 1 of 1 resident (Resident # 1) reviewed for data encoding and transmission. Resident #1's Discharge Minimum Data Set (MDS) Assessment was not submitted to C[CONDITION] timely. (Within 14 days) This failure affected 1 resident (Resident # 1) and placed any additional discharged residents at risk for not having their MDS Assessments transmitted to C[CONDITION] in a timely manner. The Findings: Record review of Resident #1's face sheet documented a [AGE] year-old male admitted to the facility on [DATE] and discharged [DATE] to home and had the following Diagnoses: [REDACTED]. disease without esophagitis, Constipation, unspecified, Unspecified convulsions, Long term (current) use of aspirin, Other long term (current) drug therapy, Personal history of [MEDICAL CONDITION] (TIA), and cerebral infarction without residual deficits Record Review of Resident #1's chart revealed the following: a.) Point of Care ADL Report (MDS 3.0) revealed Discharge-Return Not Anticipated. b.) Discharge Summary dated [DATE] documented discharge at [DATE] at 11:00 am. with sister. c.) Medication Release/Receipt revealed Resident #1's medications were released to family on 12-10-19. d.) Resident #1's Minimum Data Set with reference date of [DATE] was electronically signed by MDS Coordinator, LVN on 0[DATE]. e.) Review of Resident #1's Physician order [REDACTED]. There was no evidence of a telephone orders for discharge. f.) Review of Resident #1's progress notes ended with an excerpt dated 12/03/19. On 02/21/29 During an interview with MDS Coordinator - LVN #1 When asked about the process for discharging a resident out of the MDS system, she said she had to complete an MDS discharge assessment in the computer. When asked to find Resident #1's MDS discharge, she looked it up in the computer and said, I guess I just forgot to do that one. I know to do that. When asked what their facility policy was, MDS Coordinator #1 said, We follow the RAI (Resident Assessment Instrument) manual instructions.

Based on interview and record review, the facility failed to coordinate PASARR with the State designated authority to ensure that individuals with a mental disorder, intellectual disability or a related condition received care and services in the most intragrated setting appropriate to their needs for 2 of two residents (Resident #10 and #26) reviewed for PASARR in that: A. The facility failed to refer Resident #26 to the appropriate State designated local mental health authority for evaluation for Level II evaluation who was newly diagnosed with [REDACTED]. B. The facility failed to refer Resident #10 to the appropriate State designated local mental health authority for evaluation for Level II evaluation who was newly diagnosed with [REDACTED]. This deficient practice placed residents at risk for not being assessed by the local authority and not receiving an evaluation for services to determine if services would prevent decline. The findings are: Resident #10 Record review of Resident #10's clinical record on 02/20/20 02:17 PM She was admitted [DATE] PASARR Level 1 completed 12/12/2017. [DIAGNOSES REDACTED]. Resident #10 received a new [DIAGNOSES REDACTED]. Unable to locate PASRR 2. Interview with MDS Coordinator on 2/20/20 at 2:45 PM stated she was unaware of the Positive PASARR dated 5/2/18 that was on the chart and was unaware of the need to contact local authorities for PASARR 2 Evaluation. Resident #26 Review of a Resident 26's physician's orders [REDACTED].); Cough (history of); constipation; abnormality of [MEDICATION NAME]; shortness of breath; displace avulsion fracture of right ilium, initial encounter for closed fracture; a unspecified [MEDICATION NAME] fracture of right femur, initial encounter for closed fracture - secondary diagnosis; tinnitus, unspecified ear; nausea and vomiting; age-related [MEDICAL CONDITION] with current pathological fracture, vertebra(s), initial encounter for fracture; displaced interochanteric fracture of unspecified femur, initial encounter for closed fracture; [MEDICAL CONDITION] disorder, depressive type; bi-polar disorder, unspecified; unspecified [MEDICAL CONDITION], unspecified site; [MEDICAL CONDITION]; and gastro- [MEDICAL CONDITION] reflux disorder. Record review of Resident #26's PASRR Level 1 Screening was dated 0[DATE]19. Section C PASARR Screen (Screener) documented the following: C0100. Mental Illness - Is there evidence of an indicator this is an individual that has a mental illness? = No. C0200. Intellectual Disability - Is there evidence of an indicator this is an individual that has an Intellectual Disability? = No. C0300. Developmental Disability - Is there evidence of an indicator this is an individual that has Developmental Disability (e.g., Autism, [MEDICAL CONDITION], [DIAGNOSES REDACTED])? = No. Review of the PASARR Level I Screening dated 0[DATE]19 for Resident #26 was negative for mental illness. 0[DATE] 12:04 PM Interview with MDS Coordinator regarding PASARR. When asked if she notified the Local Authority (LA) after the new [DIAGNOSES REDACTED].#26, she said she did not know she was supposed contact the local mental health authority to have the PASARR re-evaluated but would do so. When asked when the last time she had training on PASARR, she said it had been awhile and she did not know much about the PASARR process. Record review of Resident #26's Physician's progress of 8/27/19 with newly evident [DIAGNOSES REDACTED]. Record review of Resident #26's physician's orders [REDACTED]. Surveyor asked facility several times for PASARR policy and received none.

Based on interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent falls for one of three residents (Resident #1) reviewed for falls by failing to ensure: Resident #1 had her personal safety alarm on according to her care plan. Resident #1 fell out of her recliner 03/03/14 and sustained a fractured right hip. This deficient practice could affect the nine residents with bed or chair alarms by placing them at risk of injury from falls and cause a physical decline in health, pain or death. The findings included: Review of Resident #1's closed clinical record, Record of Admission revealed she was an [AGE] year old female admitted to the facility 03/07/13 with [DIAGNOSES REDACTED]. Review of Resident #1's Physician's Nursing Order Report signed 01/19/14 revealed additional [DIAGNOSES REDACTED]. Review of Resident #1's Physician ' s Nursing Order Report signed 01/19/14 revealed, "...PPA (pressure pad alarm) for safety and fast alert ... May use Merry Walker for Mobility ...May Have PSA (personal safety alarm) in Merry Walker for fast alert to staff...Fall risk..." Review of Resident #1's Comprehensive Plan of Care dated 02/16/14 revealed, "Problem ...Resident is in a restraint free environment as evidenced by: personal alarm. Goal. Will continue to be in a restraint free environment, without occurrence of injury over the next 90 days..." Review of Resident #1's Comprehensive Plan of Care dated 02/16/14 revealed, "Problem ...Resident has a history of falls and is at risk for increased falls as evidenced by: Resident unable to sit still-rocks while in chairs. Moves cont (constantly?) in merry walker during day-restless-requires use of low bed ...Approach ...personal alarm attached to resident at all times..." Review of Resident #1's Quarterly MDS dated [DATE] revealed her cognition fluctuated with inattention and disorganized thinking, needed extensive assistance for transfers, dressing, eating and bathing/hygiene and was incontinent of bowel and bladder. Review of Resident #1's Nurse's Notes from 02/17/14-03/03/14 revealed she needed extensive assistance with all ADL's and was incontinent of bowel and bladder. Review of Resident #1's Nurse's Notes dated 03/03/14 at 3:00 p.m. revealed, "Heard moaning; res (resident) on left side in fetal position; small abrasion to right brow. Assisted up, wanted in merry walker; got her up but she wasn't bearing weight on right side. Assessed by nurse after found on floor and not bearing weight on right side...To E.R. via ambulance..." Review of Resident #1's CAT scan dated 03/03/14 revealed, "...slightly non-displaced comminuted right intertrochanteric fracture..." In an interview on 03/12/14 at 10:38 a.m., LVN A said Resident #1 would ambulate in her merry walker or sit in a recliner. LVN A said Resident #1 was to have an alarm on at all times due to previous falls and being a fall risk. In an interview on 03/12/14 at 12:35 p.m., the Administrator said that on 03/03/14, CNA A had put Resident #1 in a recliner in the lobby. He said that he and several staff were at the nurse's station/lobby area. He said they heard a groan, and saw Resident #1 on the floor next to the recliner. The Administrator said that CNA A had not put Resident #1's personal safety alarm on her when he put Resident #1 in the recliner as he should have. In an interview on 03/12/14 at 11:12 a.m., CNA A said Resident #1 was in her merry walker and became tired. CNA A said he put Resident #1 in a recliner in the lobby. He said he forgot to put the personal safety alarm on Resident #1. Review of the facility's policy, Fall Risk Assessment, undated, revealed, "...Residents are assessed for potential of falls and actions taken to minimize the risk of falls..." Review of a list provided 03/12/14 by the facility revealed nine residents with pressure pad alarms and/or personal safety alarms.

Based on interview and record review the facility failed to maintain an infection control program to provide a safe, comfortable, and sanitary environment to help prevent the development, and transmission of disease for 1 of 11 residents (Resident #11) reviewed for infection control. The facility failed to: a. ensure Resident #11's urinary tract infection was treated with effective antibiotics in April 2012. She continued to experience symptoms of infection and was never re-cultured to evaluate the effectiveness of treatment. b. track Resident #11's shingles infection in the Infection Control Log and document any isolation precautions implemented This deficient practice could have affected the four residents diagnosed with [REDACTED]. Findings include: 1. Record review of Resident #11's Record of admitted d 06/06/12 revealed she was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #11's Physician Telephone Order dated 04/23/12 revealed an order for [REDACTED]. Record review of Resident #11's Nurse's Notes dated 04/23/12 revealed she complained of lower back pain, and had cloudy urine with sediment. Resident #11 had a urinalysis collected 04/23/12 at 9:15 a.m. Record review of Infection Control Log dated April 2012 revealed Resident #11 had a urinary tract infection (UTI) onset date 04/24__ (no year), organism- Escheri(chia) coli and Proteus, antibiotic- Bactrim, date resolved- ongoing Record review of Resident #11's Infection Report dated 04/23/12 revealed she had urinary symptoms of odor, cloudy/sediment in her foley catheter. The bacteria identified in Resident #11's urine was Proteus, and Escheri coli. There was no documentation to the sensitivity to the antibiotic. There was no documentation of Resident #11's urine being re-cultured to confirm effective treatment. Bactrim DS was the documented intervention for Resident #11's urinary tract infection. Resident #11's urinary tract infection was resolved 05/04/12. Record review of Resident #11's urinalysis report dated 04/23/12 the specific gravity to be < 1.005, trace amounts of blood, pH- 8.5, protein- +1, and leukocytes- 3. The culture and sensitivity report revealed organisms: Proteus mirabilis- >100,000CFU/ML (colony forming unit per milliliter) sensitive to [MEDICATION NAME]/Sulfa (generic Bactrim) Escherichia coli- >100,000CFU/ML resistant to [MEDICATION NAME]/Sulfa (generic Bactrim) This report was signed " noted " by the DON. Record review of Infection Control Log dated May 2012 revealed Resident #11 had a urinary tract infection onset date 04/24__ (no year), " ...carry over from April ... " was documented resolved 05/04/12. There was no documentation of Resident #11 ' s urine being re-cultured to confirm effective treatment. Record review of Resident #11 ' s Nurse ' s Notes revealed: 04/24/12 - she had cloudy urine and complained of severe back pain, " 10 " on a 0-10 pain scale, Bactrim DS started for urinary tract infection, daughter reports complaints of back pain 04/25/12 - she had slightly cloudy urine, complained of lower back pain, stayed in bed for evening meal 04/26/12 - complained of severe lower back pain, remained in room for 6:00 a.m. to 2:00 p.m. shift, appetite poor, slightly cloudy urine, complaints of lower back pain, remains in bed for evening meal, slightly cloudy urine 04/27/12 - complaints of bladder and lower back pain, remains in bed for 6:00 a.m. to 2:00 p.m., complaints of back pain, odor noted to perineal area, urine cloudy 04/28/12 - hazy urine with faint odor, remained in bed for breakfast, complained of mid- lower back pain with minimal relief with pain medication, cloudy urine 04/29/12 - hazy urine, complained of back pain, catheter noted to be leaking and changed 04/30/12 - low back pain noted, made appointment with doctor for May 3 05/03/12 - return from doctor with new order for routine pain medicine three times a day and an appetite stimulant 05/04/12 - completed Bactrim 05/05/12 - complained of bladder pain, Tylenol 3 given for pain 05/08/12 - complained of severe lower back pain, Tylenol #3 given, new order to increase routine pain medicine to four times a day 05/09/12 - new order to increase the strength of routine pain medicine, discussion of hospice 05/11/12 - started hospice care In an interview on 09/12/12 at 9:45 a.m. the DON explained the facility's procedure for tracking infections. She said the direct care nurse writes the information on the Infection Control Log based on antibiotics being given. The DON stated she followed up on the information documented in the Infection Control Log. Then, that information was used to generate an Infection Report. The DON provided no additional information regarding how the information was used to monitor, track, trend, and/or prevent the spread of infections in the facility. The DON confirmed Resident #11's shingles infection (March 2012) was not documented on the Infection Control Log. She stated it was a mistake and should have been documented. The DON stated a shingles infection would need isolation, but could not confirm Resident #11 was in isolation during her shingles outbreak in March 2012. The DON said she was unaware one of the the microorganisms (E coli), in Resident #11's urinary tract infection (April 2012), was resistant to the antibiotic (Bactrim) used to treat it. She stated she was aware the facility had a problem with the Infection Control Program and recently hired a nurse in April to be the Infection Control Nurse, LVN A. In an interview on 09/12/12 at 10:45 a.m. LVN A stated she was the nurse responsible for the Infection Control Program in the facility. She said she started the position in April 2012. She said she had not received any training specific for the position. LVN A said she was unaware the microorganism (E coli), in Resident #11's urinary tract infection (April 2012), was resistant to the antibiotic (Bactrim) used to treat it. In an interview on 09/12/12 at 1:30 p.m. the ADON acknowledged Resident #11 experienced low back pain, fatigue, a decrease in appetite, bladder pain, cloudy urine, and urine with odor. The ADON said Resident #11's symptoms could have been from an ongoing, ineffectively treated urinary tract infection. The ADON said she was unaware the microorganism (E coli), in Resident #11's urinary tract infection (April 2012), was resistant to the antibiotic (Bactrim) used to treat it. Record review of the facility's policy " Surveillance for Nosocomial Infections dated 3/94 revealed: " ...The infection control coordinator or designee should perform routine surveillance for nosocomial infection within the facility ... " " ...1. Perform the surveillance using any or all of the following gathering tools as possible indicators of nosocomial infections ...: a. Laboratory records b. Skin care sheets c. Infection control rounds or interviews d. Infection surveillance sheets e. Temperature logs f. Pharmacy records g. Transfer logs/summaries ... " " ...2. If review of laboratory reports are used as a data gathering tool, the following findings merit further scrutiny: ...c. Urine culture above 100,000 CFUs (colony forming unit) (Note: You may elect to only follow catheter-acquired specimens of more than 100,000 CFUs) ... " " ...3. ...prioritize the reports as follows ... ...e. Urine cultures showing more than 100,000 CFUs. Evaluate trends in organisms and persons with other types of infections first, or start with residents with Foley catheters ... " " ...4.Collect the following data as appropriate on the Infection Control Log ... a. identifying information; b. admitted ; c. date on onset of infection; d. infection site; e. symptoms or related diagnosis; f. temperature; g. date of pretreatment culture; h. identify organism; i. record antibiotic or appropriate treatment; j. identify if the isolation procedures or precautions implemented; k. identify if the infection was nosocomial; l. date of post treatment C and S (culture and sensitivity); m. date resolved ... " Record review of " Urinary Tract Infections in Adults " accessed on 09/19/12 at http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult/#causes <http://kidney.niddk.nih.gov/kudiseases/pubs/utiadult/> revealed: " ...UTI symptoms typically include a frequent and intense urge to urinate and a painful, burning feeling in the bladder or urethra during urination. The amount of urine may be very small. Older women and men are more likely to be tired, shaky, and weak and have muscle aches and abdominal pain. Urine may look cloudy, dark, or bloody or have a foul smell ...Other symptoms of a kidney infection include pain in the back or side ... " " ...Most UTIs are caused by bacteria, which are treated with bacteria-fighting medications called antibiotics ... The sensitivity test takes 48 hours to complete and is especially useful in helping the health care provider select the antibiotic most likely to be effective in treating an infection. Longer treatment may be needed if the first antibiotic given is not effective ... " " ...A follow-up urinalysis helps to confirm the urinary tract is infection-free ... " Record review of Infection Control Log for April 2012 revealed four residents with a urinary tract infection. 2. Record review of Resident #11's Physician Telephone Order dated 03/13/12 revealed an order for [REDACTED]. Record review of Resident #11's Nurse's Notes dated 03/13/12 to 03/23/12 revealed she had scattered blisters over her upper torso, accress her right shoulder and up the right side of her back. There was no documentation to note if the shingles lesions were covered or uncovered. There was no evidence of contact or respiratory isolation precautions implemented for her shingles infection. Record review of Infection Control Log dated March 2012 revealed no documentation of Resident #11's shingles infection or implemented isolation precautions. Interview on 09/11/12 at 11:05 a.m. LVN B stated she had worked for the facility for five years. LVN B said she was not sure what isolation precautions would be required for a shingles infection. LVN B said she could not remember any resident being placed in isolation precautions for shingles. (Note: LVN B provided direct care to Resident 11 on 03/14/12, 03/15/12, and 03/17/12 as documented in the nurse's notes.) Information posted by the Center of Disease Control, updated 01/10/2011, at website <http://www.cdc.gov/shingles/hcp/HC-settings.html> contained the following (in part): Preventing Transmission in Healthcare Settings Management of Patients with Herpes [MEDICATION NAME] Infection-control measures depend on whether the patient with herpes [MEDICATION NAME] is immunocompetent or immunocompromised and on whether the rash is localized or disseminated. In all cases, standard infection-control precautions should be followed. If the patient is immunocompetent with ? localized herpes [MEDICATION NAME], then standard precautions should be followed and lesions should be completely covered. Record review of facility policy " Contact Isolation " dated 12/91 revealed " ...contact isolation is to be provided to prevent the spread of infections that are transmissible via direct contact as per Center for Disease Control Guidelines ... " Record review of facility policy " Respiratory Isolation " dated 07/91 revealed " ...respiratory isolation is to be provided according to Center for Disease Control Guidelines ... " The CMS 672 dated 09/10/12 revealed a census of 27.