Every finding on record at The Blossoms at Mountain View Rehab & Nursing Cen

Based on observations, interview, record review and facility policy review, the facility failed to ensure staff consistently performed hand hygiene, failed to ensure staff consistently covered mustache and hair during food preparation, and failed to ensure gloves were worn during food preparation, during one of two meals observed. The findings include:Incident #1During an observation and concurrent interview on 03/23/2026 at 10:20 AM, Dietary Aide (DA) #1 was observed actively preparing food for the residents without a hair covering over a mustache that was approximately one half (1/2) to one (1) inch long. DA #1 did have a beard cover on that did not cover the mustache area. DA #1 had on a ball style cap covering their hair, with approximately one and a half (1 1/2) to two (2) inches protruding from the edges of the cap without a hair net. DA #1 stated their beard and mustache should have been covered and moved the beard cover over the mustache. DA #1 adjusted the ball style cap without completely covering the protruding hair. During an interview on 03/23/2026 at 10:20 AM, the Dietary Manager (DM) reported that DA #1 should have covered the mustache, beard and hair. The DM confirmed DA #1's beard and mustache were long enough to require a covering. The DM confirmed that when a cap was worn, it had to cover the hair completely. Review of a facility in-service with a topic of Hair Restraints dated 06/10/2025, revealed DA #1's name was signed which indicated DA #1 received the training.Review of a facility in-service titled Policy and Procedure on Hair Restraints, dated 03/24/2026, revealed DA #1's name was signed which indicated DA #1 received the training.Review of a Job Description dated 07/10/2010, revealed DA #1 signed the last page which indicated the employee read and understood the requirements. The Job Description also revealed, that the purpose of the position was to prepare food according to applicable standard and guidelines, using established policies and procedures. A major responsibility was to follow established policies and procedures. To ensure food was prepared in accordance with established sanitary regulations, as well as following facility policies and procedures assuring safety regulations were consistently followed by facility personnel.During an observation and concurrent interview on 03/25/2026 at 11:50 PM, a female entered the kitchen through the back door, without a hair covering. The female's hair was loose and well below the level of the jaw. The female continued through the food preparation area to the dining room side of the kitchen and exited into the dining room. The DM identified the person as the Registered Dietician (RD) and confirmed that the RD should have been wearing a hair covering prior to entering the meal preparation area. Lunch was being prepared and food items were being placed on the hot table for the noon meal. Incident #2During an observation on 03/23/2026 at 12:19 PM, Certified Nursing Assistant (CNA) #3 and Licensed Practical Nurse (LPN) #2 failed to perform hand hygiene before meal trays of four residents were delivered and set up. After CNA #3 delivered the first meal tray, she placed her hands in her scrub pockets then failed to perform hand hygiene before picking up the next residents meal tray. CNA #3 delivered the second meal tray, opened the lids of the food cups, then sat down to feed assist the resident without performing hand hygiene. LPN #2 delivered a meal tray, opened the lids, and as she walked away, put her hair behind her ear. LPN #2 did not perform hand hygiene before picking up the next meal tray and delivered it to a resident. LPN #2 sat down to feed assist the resident without performing hand hygiene. No hand hygiene was performed by LPN #2 and CNA #3 during this observation.During an interview on 03/26/2026 at 12:06 PM, CNA #3 stated hand hygiene should always be performed. She indicated that when she delivered and sat up a meal tray, the lids were removed and all items were in reach of the resident, she checked the meal ticket to make sure the right foods were on the tray and assisted the residents if needed. CNA #3 stated she had been in-serviced on hand hygiene and meal tray delivery. She revealed that hand hygiene should be performed before and after each meal tray delivery. CNA #3 stated if a person placed their hands in their scrub pockets that hand hygiene should be performed before touching the meal trays. CNA #3 stated she always placed her hands in her scrub top pocket and probably did not perform hand hygiene after placing her hands in her scrub pocket nor between meal trays. During an interview on 03/26/2026 at 12:15 PM, LPN #2 stated hand hygiene should be performed between each resident and when you opened their meal trays. She stated when she delivered meal trays to residents she placed clothing protectors on the residents, opened the items on the meal tray, cut the food up for the residents, and assisted with feed if needed. LPN #2 stated hand hygiene in-services were done frequently and when issues arose. LPN #2 stated she passed meal trays in the dining room on 03/23/2026 and did not recall performing hand hygiene. Review of a facility in-service titled Hand Hygiene dated January 2026, indicated all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, visitors; all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. CNA #3 signed the in-service; LPN #2 did not.Review of a facility policy titled Hand Washing dated 04/2021, it stated employees will wash hands as frequently as needed throughout the day using proper hand-washing procedures, after touching bare human body parts other than clean hands, during food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing task.Incident #3During an observation on 03/23/2026 at 12:53 PM, CNA #4 was observed setting up meal trays for the residents in the secure unit. CNA #4 removed four meal trays from the cart, removed the sliced bread from the bagged package with bare hands and placed it next to the trays. No hand hygiene was performed. During an interview on 03/24/2026 at 1:41 PM, CNA #4 confirmed the facility had provided training for removing food items from their packaging. Food items were to be removed from the tray and set up for the residents, the packets should be opened and the bread removed from the bag. CNA #4 reported that food items should not be touched with bare hands. The bread should be removed from the bag without touching it with your bare hands. CNA #4 confirmed that they had removed several pieces of bread from the bag with bare hands. During an interview on 03/25/2026 at 11:50 AM, the DM confirmed that staff should not touch any food with bare hands. The DM stated, staff should have been educated to not touch food items with their bare hands.During an interview on 03/26/2026 at 2:32 PM, the Administrator confirmed all hair should be covered during food preparation, unless the staff was bald. The Administrator reported that hair coverings should be worn any time staff were in the kitchen area, including during food prep time. The Administrator confirmed that the RD should not have entered the kitchen area without a hair cover. The Administrator reported that all staff were provided education during orientation and as needed, related to not touching food items with their bare hands; staff were expected to use a device or gloves when moving food items from one point to another and wearing hair coverings at any time they were in the kitchen area.Review of a facility policy titled Employee Sanitary Practices without a revised or reviewed date, revealed that all food and nutrition employees would practice safe food handling procedures. All employees would wear hair restraints, such as hair nets, hat and/or beard restraint to prevent hair from coming into contact with exposed food. Gloves were to be worn while handling raw food and utensils should be used to avoid bare hand contact with food. Review of a facility policy titled Bare Hand Contact with Food and Use of Plastic Gloves without a review date, revealed single use gloves will be worn for handling food items directly with hands, to prevent contamination from food handlers hands during meal service. Handling food items with bare hands is prohibited. Staff were expected to use a clean barrier, such as gloves or a device when handling food.

Based on observations, record review, and interview the facility failed to ensure care plans were revised with interventions to provide proper care to 2 of (Residents #51 and #57) of 2 sampled residents. These are our findings: A review of the Order Summary revealed Resident #51 had diagnoses of stroke, dementia, history of falling, and anxiety disorder. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/17/2024 revealed Resident #57 scored an 8 (8 to 12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status (BIMS). A review of the Care Plan revealed that interventions for pressure reducing devices and fall mats were not added to the care plan. On 09/09/24 at 11:09 AM, the Surveyor observed Resident #51 in bed with quarter side rails up, an air mattress, and a fall mat in place on the right side of the bed with the left side up against the wall. On 09/10/24 at 01:57 PM, the Surveyor observed Resident #51 in bed with quarter side rails up, an air mattress, and a fall mat in place on the right side of the bed with the left side up against the wall. 2. A review of the Order Summary revealed Resident #57 had diagnoses of dementia, anxiety disorder, stroke, and Alzheimer's. A review of the Quarterly MDS with an ARD of 06/21/2024 revealed Resident #57 scored a 3 (severe cognitive impairment) on the BIMS. A review of the Care Plan reveal interventions for pressure reducing devices, half side rails, or a foot cradle were not added to the care plan. On 09/09/2024 at 11:41 AM, the Surveyor observed Resident #57 on an air mattress bed, half side rails up, and a foot cradle was in place at the end of the bed. On 09/10/2024 at 9:04 AM, the Surveyor observed Resident #57 on an air mattress bed, half side rails up, and a foot cradle was in place at the end of the bed. On 09/11/2024 at 11:06 AM, during an interview Certified Nursing Assistant (CNA) #3 stated she is familiar with the residents on the 300 Hall and started out as a housekeeper about 3 years ago. CNA #3 stated that Resident #51 has had the interventions since admission in July. CNA #3 then stated that Resident #57 had the interventions of a foot cradle, side rails, and pressure reducing devices for as long as she could remember. On 09/11/2024 at 11:16 AM, during an interview the MDS Coordinator confirmed the interventions for Resident #51 and Resident #57 were not on the care plan, then stated that it is important to revise a care plan as they change all the time and to have the staff know how to take care of the residents. On 09/12/2024 at 9:00 AM, during an interview the Director of Nursing (DON) stated it is important to revise a care plan, just to keep the most accurate information on the residents up to date, so you can provide the correct care for them. A review of the facility policy Care Plans, Comprehensive Person-Centered, revised on December 2016, stated, A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.

Based on observation, record review, and interview the facility failed to ensure residents who required assistance with activities of daily living were regularly provided with the necessary assistance to maintain good hygiene and grooming for one (Resident #12) of one resident sampled for activities of daily living. These are the findings: A review of the Order Summary revealed Resident #12 had diagnoses of type 2 diabetes, generalized anxiety disorder, depression, and chronic kidney disease. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 06/21/2024 of revealed Resident #12 scored a 15 (cognitively intact) on a Brief Interview for Mental Status (BIMS). A review of the Care Plan revealed Resident #12 had an activity of daily living care deficit and required limited assistance of one staff with bathing. On 09/09/2024 at 11:58 AM, the Surveyor observed Resident #12 up in a wheelchair with facial hair stubble on the right side of chin. Resident #12 felt of the stubble and stated they would like to be shaved as it is embarrassing. The resident stated it had been over a week from the last time they were shaved. Resident #12 then showed the surveyor their fingernails and stated it had been three weeks since they have been trimmed or painted. The Surveyor observed Resident #12's fingernails were long, with a dark brown substance under all ten of them, and that the nail polish was mostly gone. Resident #12 stated that they would like to have their fingernails trimmed and cleaned. On 09/10/2024 at 9:20 AM, the Surveyor observed Resident #12 up in a wheelchair, the resident had not been shaved and/or fingernail care provided. On 09/10/2024 at 2:20 PM, the Surveyor observed Resident #12 up in a wheelchair, the resident had not been shaved and/or fingernail care provided. On 09/11/2024 at 11:06 AM, during an interview Certified Nursing Assistant (CNA) #3 described Resident #12's fingernails as long, dirty underneath, chipped and that the resident is a diabetic, so the nurse would do nail care. CNA #3 then described Resident #12's facial hair as stubble and that the resident needed to be shaved. CNA #3 stated that nailcare and shaving should be done on bath days and as needed. CNA #3 stated it is important to do nail care and shaving to ensure the residents feel good, and they look put together. She then stated that residents do not want to eat with nasty nails, they want to keep them maintained and trimmed. On 09/12/2024 at 9:00 AM, during an interview with the Director of Nursing (DON) she stated nail care and shaving is important to keep their nails short so they do not injure themselves and shaving so they are not all grown out. Then stated that both should be done on bath days and as needed. A review of a facility policy titled, Care of Fingernails/Toenails, Revised October 2010, stated, The purpose of this procedure are to clean the nail bed to keep nails trimmed and to prevent infections. A review of a facility policy titled, Shaving the Resident, revised on October 2010, stated, The purpose of this procedure is to promote cleanliness and to provide skin care.

Based on interview and record review, the facility failed to ensure the Physician was notified of a downward trend weight loss for interventions to be implemented for 1 (Resident #47) of 1 sampled resident who had a weight loss of 5% (percent) or greater in 30 days. The findings are: 1. Resident #47's Care Plan with an initiated date of 04/06/22 documented, .Goal Promote my nutritional intake necessary to maintain or improve current weight . Notify my MD [Medical Director], DON [Director of Nursing] & [and] DSM [Dietary Service Manager] of any changes in weight of 5% more or less . 2. The electronic health records documented Resident #47 weighed 150.0 pounds (lbs.) on 05/23/23 and weighed 142.0 lbs. on 06/27/23 a -5.33% weight loss in 30 days. 3. The Progress Notes dated 6/27/2023 at 1:37 PM noted a weight warning of 5% loss over 30 days. 4. On 07/04/23 at 3:58 PM, the Surveyor asked the DON when the Physician was to be notified of a resident's significant weight loss. The DON stated, I just notified him today. I am trying to get the weights caught up. I was behind. 5. On 07/05/23 at 11:23 AM, the Surveyor asked the DON when the Physician was notified regarding a resident's weight loss and what outcomes could occur if the physician was not notified. The DON stated, I was just working on that yesterday. I've only done this a month and was behind. I am waiting on responses from the doctor. The resident could have continued weight loss. The Surveyor asked the DON how she was notified of the weight loss. The DON stated, No one tells me. I have to look them up and run a report. [Resident #47] should have been done. [Resident #47' s] weight warnings show 5.3%. Looks like I missed [Resident #47]. I just didn't do it. I skipped [Resident #47]. [Resident #47] interventions are blank. I will do that today. The Surveyor asked the DON if the Registered Dietician (RD) saw Resident #47 and recommended changes. The DON stated, The RD informs me by email. I just took over this part too, so I am depending on someone else's filing. [Resident #47] was reviewed May11th but that was before [Resident #47] had over a 5% weight loss, so I do not see any new recommendations. 6. The facility policy titled, Resident Weights, provided by the DON on 07/05/23 at 12:18 PM documented, .3. Any weight change of 5% or more since the last weight assessment will be retaken. If the weight is verified, nursing will notify the dietitian. Dietitian will review the resident's EMR [electronic medical record] to determine the root cause for the resident's weight loss. In addition, the dietitian will work with the multidisciplinary team on a plan to address weight loss .4 .Negative trends will be evaluated by the treatment team whether the criteria for significant weight change has been met .5 .interventions should be considered by the IDT to prevent further trends downward .

Based on observation, interview, record review, the facility failed to ensure catheter output bags were concealed in a privacy bag to protect the resident's dignity for 1 (Resident #277) of 1 sampled resident who had an indwelling catheter. The findings are: 1. On 07/03/23 at 11:19 AM, Resident #277 was lying in bed with a catheter bag attached to bottom rail of bed 1/4 full of yellow liquid. The bag was sitting on the floor, facing the door visible from the doorway and to visitors. A blue privacy bag was on the floor behind the catheter bag. a. The Care Plan with an initiated date of 06/27/23 documented, .Catheter: The resident has 16 FR [french] indwelling catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door . The Care Plan did not address the use of a privacy bag. b. The Physicians Orders dated 06/26/23 documented, Foley Catheter Size: 16fr 10cc balloon . Foley Catheter Care every shift. two times a day . 2. On 07/05/23 at 10:20 AM, Resident #277 was lying in bed with a catheter bag hanging on a bed rail 1/2 full of yellow liquid, facing the door, visible from the doorway and to visitors. A privacy bag was lying partially on the floor hanging by one strap under the bed. The Surveyor asked Resident #277 if it bothered her that her catheter bag was showing. Resident #277 stated, I thought it was covered. 3. On 07/05/23 at 10:24 AM, the Surveyor asked Licensed Practical Nurse (LPN) #1 when catheters were checked. LPN #1 stated, Every shift CNAs [Certified Nursing Assistants] check them and report to the nurses. Oh my, yes it should be covered. LPN #1 apologized to Resident #277 that the catheter was not covered and stated a staff person would come back and put it in a bag. The Surveyor asked LPN #1 if there were any negative outcomes for the catheter bag not being covered. LPN #1 stated, It could embarrass them. 4. On 07/05/23 at 11:23 AM, the Surveyor asked the Director of Nursing (DON) how a catheter bag should be positioned and the negative outcomes if it was not. The DON stated, Below the bladder, with the hook hanging on the bed frame, and in a privacy bag. If it's not covered, it can cause back flow or infection. It's also a dignity issue. 5. The facility policy titled Resident Dignity, provided by the DON on 07/05/23 at 12:18 PM documented, .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality .Demeaning practices and standards of care that compromise dignity is prohibited. Staff shall promote dignity and assist residents as needed by: e. Helping the resident to keep urinary catheter bags covered .

Based on record review and interview, the facility failed to ensure a mechanical lift was used to complete a transfer according to the plan of care resulting in a fall, on-coming staff and the physician were informed of the fall, and thorough assessments were completed when the resident continued to complain of pain resulting in the delay in diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . These failed practices resulted in actual harm to Resident #73, who had a fall due to staff not using a mechanical lift during a transfer. The findings are: Resident #73 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 04/05/2022 documented the resident was moderately impaired in daily decision making per a Staff Assessment for Mental Status required extensive assistance with two staff for bed mobility and transfers, and extensive assistance with one staff for dressing, toileting, and personal hygiene. a. The care plan documented, Focus I require extensive assist x [times] 2 staff with . transfers . Date Initiated: 2/22/22 . Interventions . I require assist x 2 staff and a mechanical lift with all transfers . Date initiated 2/22/22 . b. A document titled #2379 Fall documented, .[Resident #73] Incident Location: Resident's room . Nursing Description: CNAs [Certified Nursing Assistants] reported to this LPN [Licensed Practical Nurse] that as resident was put back in bed she began falling and was lowered to the floor by CNAs. She was then assisted to the bed prior to the LPN assessing the resident. She was c/o [complained of] right lower extremity pain at the time. She was pointing at her ankle and foot. Resident Description: I started falling and they lowered me to the floor . Description: Assessment done. Remind staff to be conscious of their ability to lift. Resident taken to hospital: N [No] . Injury Location: Right lower leg (front) . Predisposing Situation Factors: Incident during staff assist transfer to/from chair . Agencies/People Notified .Physician/Extender [Doctor] 03/08/2022 1513 [3:13 p.m.] Resident Representative [Husband] 03/08/2022 1513 . c. A Nurse's Note dated 03/06/2022 at 9:45 pm documented, .Previous shift stated resident had increased anxiety and pain since the tornado warning, resident screaming, inconsolable. Scheduled pain pill given and PRN [as needed] [MEDICATION(S)]. No change in resident, resident repositioned. Resident continues screaming. Called [doctor], ordered one-time extra dose of resident's prn pain medication, Tylenol with [MEDICATION(S)]. Resident lying in bed with head elevated. d. A Nursing Note dated 03/09/2022 at 6:23 pm for 03/07/22 at 08:30 am documented, Late entry: Note text: Called [Doctor] office approximately 0830 regarding resident who was calling out in pain rated 10/10. Left message explaining condition of resident and her requiring additional medication for pain and severe anxiety. [Doctor] returned my call approximately 15 minutes later and discussed status of the resident. [Doctor] could hear the resident yelling out while on the phone with me. [Doctor] ordered blood work, stat [immediate] medication which was ordered and additional PRN medication. [Husband] was notified and he came to the facility within 1-2 hours which helped relax his wife for a short period of time. Medication was dispensed and resident was closely monitored. e. An Incident note dated 03/08/2022 at 3:14 pm, documented, CNAs reported to this LPN that as resident was put back in bed she began falling and was lowered to the floor by the CNA's. She was then assisted to the bed by use of a Hoyer lift prior to this LPN assessing resident. She was c/o (complaining of) right lower extremity pain at the time. She was pointing towards her ankle and foot. Attempted to rub resident's lower extremity to reduce pain. Resident had stated it felt better at the time. f. An Activity Note 3/8/2022 at 3:48 p.m. documented, Note text: Order Received from [physician] to send Resident To ER to have Right Leg Pain Eval. g. An Injury of Unknown Origin Incident and Accident report date 03/08/2022 at 3:18 pm documented, .Resident had complaint of pain to right leg. Order obtained for x-ray of RLE [right lower extremity] where it was noted that there was a fracture of the right femur .Resident transferred to hospital for x-ray .swelling right knee front . h. The hospital Discharge Summary documented the resident was admitted on [DATE] and discharged on [DATE]. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] History of Present Illness: [Resident #73] is a [AGE] year old female patient . presented after She had a fall Sunday [3/6/2022] night at the nursing home, unable to rate her pain. She is unable to communicate fully due to prior stroke. Per her husband, during a tornado approaching on Sunday, 2 days prior to admission, she was being moved due to the inclement weather. After the storm had passed, they were trying to move her back to her bed in her room and apparently she slipped while placing her in a wheelchair injuring her right leg . Hospital Course: [Resident #73] admitted to the hospital for right shaft femur fracture . Ortho [orthopedics] was consulted for further recs [recommendations]. She has placed retrograde femoral nail on 3/11/2022 . i. The Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Resident Property and Exploitation of Residents in Long Term Care Facilities documented, .Date and Time of Discovery 3/8/2022 Time: 8:00 P.M . [Resident #73] was having continued pain in her right leg; she was sent to the ER [emergency room ] for further evaluation. Upon x-ray it was noted resident had a right femur fracture and right fibula fracture. A report was completed for an injury of unknown origin . On 3/6/22 [Resident #73] was assisted to floor by staff. Resident assessed by nurse with no change noted to baseline. From the date of 3/6/22 to 3/8/22 no change was noted to her baseline with no bruising noted. Based on the facts and information gathered we are unable to identify when or how the injury occurred . Findings and Actions Taken . Inservice completed for abuse and neglect . j. On 04/11/2022 at 02:33 PM, the husband was asked about notifications during the representative interview. He stated, They did not tell me she fell . I found out when I visited the next day [03/07/22] and she was hurting, and I questioned her. I got it out of her that they dropped her. She understands everything but just can't articulate. They didn't do anything about it for two days. They questioned the nurse about it to come in and write a statement and I haven't seen that nurse since. He was asked if he had let the nurse know. He stated, Yeah I went out and asked the nurse about them dropping her on the floor. She said she didn't know anything about it. And I went the next day because she was still hurting, and that nurse said that maybe she needs to go to the hospital. k. On 4/12/2022 at 2:20 pm [Doctor] was asked if he was aware of the fall on 3/6/22. He stated, No I was not informed until 3/8/22. He was asked about her general condition. He stated, She has had a [CONDITION(S)], [[CONDITION(S)] Accident] and she gets frustrated easily because she's hard to understand. She's really sensitive to pain. I came over to see her when she came back because I wanted to see her wound. But I will say she has big legs, and it would be hard to be able to see if something was wrong with it or not, any deformity. l. On 04/12/2022 at 2:46 pm, CNA #3 was asked about what happened with the resident on 3/6/22. He stated, [Resident #73] was hollering more than usual. I didn't notice anything unusual with her leg, no swelling or redness. I just thought she hadn't had her pain medicine yet. He was asked, Did you report to the nurse? He stated, Yeah, we asked the nurse what was going on and she just said they had a storm last night and they thought that made her more anxious. m. On 04/12/2022 at 2:55 pm, CNA #4 was asked, Did you notice anything unusual about [Resident #73] on 3/7/22 when you worked? She stated, Well she's always been a screamer and that day she was screaming more than usual. She was asked, Did you notice anything unusual with her leg? She stated, No. She was asked, Did you report her increased screaming to the nurse? She stated, Yes. She was asked, What nurse? She stated, I don't remember.

Based on observation and interview, the facility failed to ensure that the kitchen floor was clean, dietary staff washed their hands before handling clean equipment and food items, leftover food items were dated and hot foods were served at or above 135 degrees Fahrenheit (F) to potential food borne illness for residents who received meal trays from 1 of 1 kitchen The failed practices had the potential to affect (how many?) residents who received meals from the kitchen (total census: 75), as documented on a list provided by Dietary Employee. The findings are: 1. On 4/11/2022 at 11:28 AM, the following observations were made with the Dietary Supervisor.: a. There was an unsealed box of coffee filters on the counter by the steam table. a. The floor throughout the kitchen was chipped and exposing the concrete underneath and discolored with black and white stains. b. The floor in front of the walk-in refrigerator and freezer was chipped and had an accumulation of dirt and debris. c. The legs of the food preparation counter had stains on them, along with greasy lint hanging down from the edges of the deep fryer. 2. On 4/11/2022 at 11:49 AM, Dietary Employee #1 was on the tray line assisting with meal service. She picked up cartons of milk, cartons of supplements, condiments and placed them on the trays and picked up glasses that contained beverages by their rims and placed them on the trays. 3. On 4/11/2022 at 12:50 PM, the temperature of the food items when checked and read on the plates in the kitchen. Ground meat balls with gravy was checked at 128.3 degrees Fahrenheit, and the diced potatoes was checked at 126 degrees Fahrenheit. They were then ready to be delivered to the residents. 4. On 4/11/2022 at 1:38 PM, the ice machine had wet gray/black residue on the top panel. The Dietary Supervisor was asked to wipe off the top panel. She did so, and the residue easily transferred to the tissue. The Dietary Supervisor was asked to describe the contents on the tissue. She stated, There were black/gray residue on the ice machine panel. The Dietary Supervisor was asked, How often do you clean the ice machine? She stated, We look at it daily. The Maintenance Man cleans every week. The Dietary Supervisor was asked, Who uses the ice from the ice machine and how often ice machine? She stated, That's the ice the CNAs [Certified Nursing Assistants] use for the water. The Dietary Employee pushed a food cart towards the steam table. She picked up condiments, milk cartons and supplements and placed them on the lunch trays without washing her hands. She also picked up glasses by their rims. 5. On 4/11/2022 at 4:46 PM, Dietary Employee #3 lifted the trash can lid and threw away tissue paper, which contaminated his hand. He picked up an alcohol pad, and wiped off the temperature gauge with it. At 5:23 PM, Dietary Employee #3 was asked what should he have done after touching dirty objects and before handling clean objects or food items. He stated, Washed my hands, 6. On 4/12/2022 at 8:34 PM, a zip lock bag that contained leftover sausage and leftover scrambled eggs were stored on a shelf in the refrigerator and had no date. On 4/12/2022 at 1:13 PM, Dietary Employee #4 was asked what was in the bag. She stated, There were leftover sausage from breakfast. We will use them for pureed meat for breakfast tomorrow. 7. The facility hand washing policy provided by the Dietary Supervisor on 4/12/2022 documented, When to wash hands: Immediately before engaging in food preparation including working with exposed food, clean equipment or service utensils and after engaging in any other activity that contaminates the hands.

Based on observation, record review and interview, the facility failed to ensure proper infection control procedures were followed during medication pass to prevent the possible spread of infection as evidenced by not performing hand hygiene between each resident during medication pass, and not keeping mask up above nose. Failed to ensure that they maintained proper infection control measures by using the CDC (Center for Disease Control) recommended personal protective equipment (PPE), which included eye protection when collecting a COVID-19 specimen for testing and failed to ensure that proper PPE was donned prior to entering a room for 1 (R#176) of 3 (R#176, R#224, and R#17) sampled case mix that were on Transmission Based Precautions. The findings are: 1. On 04/12/22 at 07:55 AM, the Morning med pass on 400 Hall. LPN #1 had mask below nose and was walking down the hallway. She continued walking until she was asked to put her mask up above her nose. LPN #1 delivered a breakfast tray to a resident then proceeded to set up medication for a resident without hand hygiene. She brought medication in for a resident, put a liquid medication on the resident's overbed tray, assist him with drinking with a straw, but the resident refused. LPN #1 picked up the medication cup and came back to the medication cart, set the liquid medication on the cart, stated, I've never had a resident refuse liquid meds [medication] so I don't know what to do with it. She was asked, Should you be doing hand hygiene between setting up residents medicine? She stated, Yeah. a. On 04/14/22 at 011:30 AM, the Director of Nurses (DON) was asked, Should a nurse do hand hygiene before and after giving resident's their medication? She stated, Yes. b. A facility policy received from the Administrator on 04/14/2022 titled Administering Medications documents .22. Staff shall follow established facility infection control procedures (e.9., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable . Resident #176 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set with an Assessment Reference Date of 4.5.22 documented the resident scored 3 (severe cognitive impact) on a Brief Interview for Mental Status; Independent with indoor mobility(ambulation). The resident's initial care plan did not address her quarantined status. a. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . b. On 04/13/22 at 1:46 PM, resident #176 was in ambulating in her room with the door open and a Yellow Zone Transmission Based Precautions PPE required in Resident Rooms: N95 mask, gown, gloves, face shield/goggles taped to the door. At 1:47 PM RN #1 entered R#176's room wearing a surgical mask. She did not have the required isolation PPE (Personal Protective Equipment) on. RN#1 told R#176, You could fall .do you need some water . RN#1 then exited the room holding the resident's water pitcher with her bare hands. RN#1 was asked, Is she [R#176] on isolation? The nurse pointed to the sign on the resident's door. The nurse stated, She was leaning over I thought she was falling. The nurse was asked, What PPE were you supposed to don before entering her room? RN#1 stated, mask . while having difficulty remembering which type of mask. RN#1 was asked to read the sign on the door stating the PPE required. The nurse stated, N95 mask, gloves, gown and goggles or a face shield. RN#1 was asked, What is a potential complication of staff not wearing the appropriate PPE in a Resident's room that is quarantined for monitoring for COVID-19? RN#1 stated, The spread of COVID. The RN#1 then took the water pitcher to the nurse's station and was talking to other staff while only wearing a surgical mask. c. On 04/13/22 at 1:49 PM, the DON (Director of Nursing) was standing near R#176's room. She was asked, Did you see her [RN#1] enter without wearing the required PPE? The DON stated, Yes, .she [R176] will be coming off of quarantine on the 15th . d. On 4/14/22 at 9:35.AM, the IP (Infection Preventionist) nurse performed a COVID-19 rapid test on the Administrator. The IP nurse donned a N95 mask, gown and gloves to perform the procedure. After collecting the sample from the Administrator's nose and placing it in the vial she was asked, Should you have worn goggles during this procedure? She stated, Probably, I didn't think about it . The Administrator stated, We have been in the red zone for so long and we were all having to wear goggles. We just got off the Red Zone two weeks ago . On 4/14/22 at 9:58 AM, the IP nurse provided the manufacturer's instructions that documented, Collect the specimen by following CDC (Center for Disease Control) guidelines . The CDC guidelines provided by the DON on 4/12/22 titled Public Health Emergency related to Long-Term Care Facility Testing Requirements REF: QSO-20-38-NH revised date 3/10/22 page 9, documented, During Specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes a NIOSH-approved N95 or equivalent or higher- level respirator .eye protection, gloves, and gown, when collecting specimens.

Based on observation, record review, and interview, the facility failed to ensure call lights were placed in easy reach for resident's use to call for assistance for 3 (Resident #4, #16 and #63) sampled residents who used their call light to call for assistance. This failed practice had the potential to affect 28 residents who resided on 100 and 200 halls as documented on the facility Census and Condition provided by the Administrator on 04/11/2022. The findings are: 1. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/08/2022 documented the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); required extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene; and limited assistance of one person with ambulating. a. A care plan with a review start date of 1/25/2022 documented .Resident is a risk for falls related to poor safety awareness, unsteady gait, .use of pain medications .keep call light within reach . b. On 04/12/2022 at 9:00 am, Resident #4 was in bed asleep without a call light in sight. c. On 04/12/2022 at 9:06 am Certified Nursing Assistant (CNA) #2 was asked, Does she have a call light in her room? She stated, She should have. CNA #2 looked around the room and found her call light wrapped around the call light box, which was behind two gowns hanging on the wall. d. On 04/12/2022 at 9:07 am, CNA #2 was asked, Should she have her call light in reach? She stated, Yes. 2. Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS with an ARD of 01/17/2022 documented the resident scored 9 (8-12 indicates moderate impairment) on a BIMS and required extensive assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. a. A care plan with a review start date of 02/04/2022 documents .The resident is moderate risk for falls related to gait/balance problems .Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . b. On 04/11/2022 at 1:06pm, CNAs #2 and #3 assisted in putting resident in bed and left the room, leaving her call light draped over the call light box on the wall out of reach. The resident was asked, Do they forget to give you your call light often? She shrugged then stated, Your guess is as good as mine, but I don't call them unless I really need something though. I don't call them just to bug them. c. On 04/11/2022 at 1:30 pm, CNA #6 was asked, Are call lights supposed to be in reach of the residents at all times? She stated, Yes. 3. Resident #63 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly MDS with an ARD of 03/25/2022 documented the resident scored 8 (8-12 indicated moderate impairment) on a BIMS; required limited assistance by one person for bed mobility and toileting; and supervision for transfers, dressing, personal hygiene and ambulation. a. A care plan with a review start date of 01/14/2022 documents .The resident is risk for falls related to confusion, gait/balance problems, unaware of safety needs .Be sure the resident's call light is within reach and encourage resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . b. On 04/12/2022 at 2:24pm, resident was sitting in a recliner with call light draped across the bedside table halfway across the room out of resident's reach. She was asked, Do they forget to give you your call light often? She nodded yes and stated, I have to get up on my own and hold on to objects myself and do things myself. I don't like this place. 4. A facility policy titled Answering the Call Light received from the administrator on 4/14/2022 at 9:32am documented, .When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident . 5. On 04/14/2022 at 11:10 am, the Director of Nurses (DON) was asked, Should call lights be in reach of residents? She stated, Yes. She was asked, At all times? She stated, Yes.

Based on record review and interview, the facility failed to ensure the physician was promptly notified of a fall so necessary treatment could be initiated and the resident's responsible party immediately notified of a fall to allow the responsible party an opportunity to provide input on care decisions for 1 (Resident #73) of 1 resident who had a fall. The findings are: Resident #73 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 04/05/2022 documented the resident was moderately impaired in daily decision making per a Staff Assessment for Mental Status required extensive assistance with two staff for bed mobility and transfers, and extensive assistance with one staff for dressing, toileting, and personal hygiene. a. The care plan documented, Focus I require extensive assist x [times] 2 staff with . transfers . Date Initiated: 2/22/22 . Interventions . I require assist x 2 staff and a mechanical lift with all transfers . Date initiated 2/22/22 . b. A document titled #2379 Fall documented, .[Resident #73] Incident Location: Resident's room . Nursing Description: CNAs [Certified Nursing Assistants] reported to this LPN [Licensed Practical Nurse] that as resident was put back in bed she began falling and was lowered to the floor by CNAs. She was then assisted to the bed prior to the LPN assessing the resident. She was c/o [complained of] right lower extremity pain at the time. She was pointing at her ankle and foot. Resident Description: I started falling and they lowered me to the floor . Description: Assessment done. Remind staff to be conscious of their ability to lift. Resident taken to hospital: N [No] . Injury Location: Right lower leg (front) . Predisposing Situation Factors: . Incident during staff assist transfer to/from chair . Agencies/People Notified .Physician/Extender [Doctor] 03/08/2022 1513 [3:13 p.m.] Resident Representative [Husband] 03/08/2022 1513 . c. A Nurse's Note dated 03/06/2022 at 9:45 pm documented, .Previous shift stated resident had increased anxiety and pain since the tornado warning, resident screaming, inconsolable. Scheduled pain pill given and PRN [as needed] [MEDICATION(S)]. No change in resident, resident repositioned. Resident continues screaming. Called Dr. [name], ordered one-time extra dose of resident's prn pain medication, Tylenol with [MEDICATION(S)]. Resident lying in bed with head elevated. d. A Nursing Note dated 03/09/2022 at 6:23 pm for 03/07/22 at 08:30 am documented, Late entry: Note text: Called [Doctor] office approximately 0830 regarding resident who was calling out in pain rated 10/10. Left message explaining condition of resident and her requiring additional medication for pain and severe anxiety. [Doctor] returned my call approximately 15 minutes later and discussed status of the resident. [Doctor] could hear the resident yelling out while on the phone with me. [Doctor] ordered blood work, stat [immediate] medication which was ordered and additional PRN medication. [Husband] was notified and he came to the facility within 1-2 hours which helped relax his wife for a short period of time. Medication was dispensed and resident was closely monitored. e. On 04/11/2022 at 02:33 PM, the husband was asked about notifications during the representative interview. He stated, They did not tell me she fell . I found out when I visited the next day (03/07/22) and she was hurting, and I questioned her. I got it out of her that they dropped her. She understands everything but just can't articulate. They didn't do anything about it for two days. They questioned the nurse about it to come in and write a statement and I haven't seen that nurse since. He was asked if he had let the nurse know. He stated, Yeah I went out and asked the nurse about them dropping her on the floor. She said she didn't know anything about it. And I went the next day because she was still hurting, and that nurse said that maybe she needs to go to the hospital. f. On 4/12/2022 at 2:20 pm [Doctor] was asked if he was aware of the fall on 3/6/22. He stated, No I was not informed until 3/8/22. He was asked about her general condition. He stated, She has had a [CONDITION(S)], [[CONDITION(S)]] and she gets frustrated easily because she's hard to understand. She's really sensitive to pain. I came over to see her when she came back because I wanted to see her wound. But I will say she has big legs, and it would be hard to be able to see if something was wrong with it or not, any deformity. g. A facility policy Change of Condition-Clinical Protocol received from the Administrator on 4/14/2022 documented, During the initial assessment, the Physician will help identify individuals with a significant risk for having acute changes of condition during their stay . 7. For emergencies, they will call or page the Physician and request a prompt response (within approximately one-half hour or less) . The nursing staff will contact the physician based on the urgency of the situation. The Nurse and Physician will discuss and evaluate the situation

Based on observation, and interview, the facility failed to ensure infection control practices were maintained when administering IV medication for 1 (Resident #66) of 1 sampled resident who received IV medication. The findings are: Resident 66 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with an Assessment Reference Date of 03/29/22 documented the resident scored 8 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status. 1. On 04/12/22 at 07:55 AM, the Morning med pass on 400 Hall. LPN #1 had mask below nose and was walking down the hallway. She went to medication (med) room, and picked up several IV medication bags, a box of saline flushes, opened it and a package of tubing and went back to the med cart and prepared IV (Intravenous) medication. She then entered the resident's room and attached the tubing to the resident's saline lock without wearing any gloves. a) On 04/12/22 at 08:14 AM, LPN #1 was asked, Do you change the tubing every time? She stated, Well we usually change it out every 12 hours. She was asked, Do you usually label the tubing? She stated, Um, yeah, I probably didn't last night. Then she got a label for the tubing. She was asked, Do you see a date/time on that piggyback or tubing? She stated, No but that was the night nurse. b) She was asked, Should you be doing hand hygiene between setting up residents medicine? She stated, Yeah. She was asked, Did you do that after you gave his IV med and before setting up another resident's medication? She stated, Nope but I have some (hand sanitizer) right here. She was asked, Should you have worn gloves when setting up the IV? She stated, Yes. She was asked, Why is that important? She stated, For infection control. c) On 04/14/22 at 011:30 AM, the Director of Nurses (DON) was asked, Should a nurse do hand hygiene before and after giving resident's their medication? She stated, Yes. She was asked, Should IV tubing and bags be labelled? She stated, Yes. She was asked, Why is that important? She stated, For infection control.

Based on observation, record review, and interview, the facility failed to ensure that the gradual [CONDITION(S)] dose reductions (GDR) were attempted in the absence of a physician's documented evaluation of the specific risks versus benefits of continuing the medication, and a documented explanation as to why a dose reduction attempt would be contraindicated in order to ascertain the smallest effective dose and minimize the potential for adverse drug effects for 1 (Residents #72) of 3 (Residents #17, #21 and #72 ) sampled residents who received [CONDITION(S)] medications. The facility failed to ensure that residents with PRN [as needed] medication were monitored, and that the physician documented need for medication every 14 days for 1 (Resident #72) of 1 sample mix resident who had orders for PRN [CONDITION(S)] medications. This failed practice had the potential the x residents who received [CONDITION(S)] medications, according to the list provided by the Director of Nursing (DON) on 4/15/22 at 8:58 AM. Resident # 72 had diagnosis of unspecified Dementia with Behavioral Disturbance, Alzheimer's Disease. The Annual Minimum Data with an Assessment Reference Date 0f 4/01/22 documented the resident scored 1 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status, had short and long-term memory problem, had no indicators of [CONDITION(S)] or behaviors, and received an antianxiety and antipsychotic during the last 7 days. a. The Care Plan dated 9/19/18 documented, .Discuss with MD [Medical Doctor], and with the family regarding an on-going need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility police .monitor/record occurrence for target behavior . b. A Physician's order dated 8/23/19 documented, .[MEDICATION(S)] Tablet 0.5 MG [milligrams] Give 1 tablet by mouth every 6 hours as needed prior to showers . Diagnosis . anxiety . c. A Physician's Order dated 9/1/20 documented, .[MEDICATION(S)] Tablet Give 225 mg by mouth one time a day . Diagnosis . unspecified Dementia with Behavioral disturbance . d. A Physician's order dated, . 2/16/22 [MEDICATION(S)] [[MEDICATION(S)]] Tablet 15 MG Give 1 tablet by mouth three times a day . Diagnosis . anxiety . f. On 4/14/22 at 8:38 AM, the Administrator was asked to provide the GDR for [CONDITION(S)] medications. g. On 4/14/22 at 11:45 AM, the Director or Nursing was asked to provide the GDR for [CONDITION(S)] medications. h. On 04/14/22 02:12 PM, the DON and Administrator was asked, Do you have any documentation that shows why this resident was started back on [MEDICATION(S)]? They stated, No, They were asked, Do you have any documentation from the physician every 14 days for the PRN medication? They stated, No. i. On 4/14/22 at 2:43 PM, received the Assessment and Evaluation dated 2/25/22 which documented the Resident's diagnosis as Alzheimer's and Dementia with Behaviors. This Physician document did not address the use of [CONDITION(S)] medications. j. The latest behavior notes documented, On 1/2/22 at 6:13 AM., .Resident hitting and kicking staff during rounds stated that her arms hurt, arms winging (flailing) contact with staff, no one holding her just blocking hits . k. Facility Policy Antipsychotic Medication Use documented, .The attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the residents and others . l. Facility Policy Antipsychotic Medication Use documented, .The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications .

Based on observation, record review, and interview, the facility failed to ensure meals were prepared and served in accordance with the planned, written menu to meet the nutritional needs of the residents for 1 of 2 meals observed. This failed practice had the potential to affect 6 residents who received pureed diets, according to a List provided by the Dietary Employee on 4/11/2022. The findings are: 1. On Monday 4/11/2022, the facility extended its lunch menu to document that the residents on pureed diets were to receive 8 ounces of pureed lasagna. 2. On 4/11/2022 at10:59 AM, Dietary Employee #2 used #8 scoop which is equivalent to a 4 ounce serving, which was a single portion of pureed lasagna to the residents on pureed diets. The menu specified for the residents on pureed diets to receive 8 ounces of pureed lasagna. 3. On 4/11/2022 11:54 AM, Dietary Employee #2 was asked, What scoop size did you use to serve pureed lasagna? She stated, I used #8 scoop. She was asked, How much meat each resident on pureed diets received? he stated, I gave one scoop to each resident. She was asked, How many servings of pureed meat was left in the pan? She stated, It was 3 servings left in the pan. She was asked, How many residents do you have on pureed diets? She stated, We have 8 residents, but I did 9 servings of pureed 4. On 4/11/2022 at 12:26 PM, Dietary Employee #2 stated, We ran out of lasagna. We have 7 more residents to serve. At 12:50 PM, 7 residents were served diced potatoes and meatballs.

Based on observation, record review and interview, the facility failed to ensure food items were prepared by methods that conserved their nutritional value, flavor, and appearance, to maintain good nutritional intake and enhance the dining experience for 1 of 1 meal observed. The findings are: 1. On 4/11/2022 at 12:25 PM, the residents received dried and crusted lasagna. 2. Resident #34 had a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/18/2022 documented the resident scored 15 indicates cognitively intact on the Brief Interview for Mental Status (BIMS). And independent for eating with set help only. On 4/11/2022 At 12:55 PM, resident was asked if the food was good? He stated, No, I can't eat that lasagna. When asked why he stated, The noodles are over cooked and rubbery. They don't know how to cook here. 3. Resident #8 had Quarterly MDS with an ARD of 1/18/2022 documented the resident scored 14 indicates cognitively intact on the BIM. On 4/11/2022 at 1:02 PM, Resident #8 raised her lunch plate covering and stated, No, I am not eating that you taste of it. All of the food here doesn't taste good. 4. Resident #5 had Quarterly MDS with an ARD of 1/11/2022. a. On 4/11/2022 at 1:05 PM Certified Nursing Assistant (CNA) brought food tray to the resident's room. The CNA then took the tray back to the kitchen, and then returned the tray back to the resident's room. He was asked why he removed the top layer of the lasagna. He said it was due to being too hard to cut up. b. On 4/11/2022 at 1:16 PM, an unfinished plate of lasagna was sitting on Resident #5's bedside table. She was asked if she enjoyed her lasagna. She pointed at it and stated, None of their food is good. I couldn't eat that. 5. On 4/11/2022 1:07 PM, Dietary Employee #2 was asked to describe the appearance of the lasagna that was served to the residents. She stated, It was tough.

Based on interview, the facility failed to ensure the results of the most recent survey was readily accessible for residents, family members, and representatives of residents. This failed practice had the potential to affect all 75 residents at the facility per the DON (Directors of Nursing) list provided on 4/11/22. The findings are: 1. On 04/12/22 at 9:59 AM, during the Resident Council meeting the attendees stated they had not been told where to access the previous survey findings. 2. On 4/12/22, a review of the Resident Council meeting minutes for 2021/2022 were reviewed. The was no documentation of the Residents being notified about where to find the previous survey findings. 3. On 4/12/22 at 1:46 PM, the Activities Director (AD) was asked, Who is responsible for assisting with the Resident Council? She stated, I do. She was asked, Have you informed the attendees of where to find the previous survey findings? She stated, I just took this position in February [2022] and I didn't know that I was supposed to, but we keep it in the Administrators office . 4. On 04/13/22 at 2:05 PM, the Administrator was asked, Where do you keep the last survey results? The Administrator got up from her desk and pulled a large white notebook labeled Surveys from a bookshelf in her office. She opened the book and began to remove the last survey findings. The Administrator was asked, Where should you store your previous survey findings? The Administrator stated, Other than the survey book .I don't have an answer for that. The Administrator and other personnel went to the facility's entrance common area and began to look in every shelf for the previous survey findings, but they did not find them. 5. On 04/13/22 at 2:31 PM, the Administrator entered the conference room and stated, We found it [the survey notebook] down on a lower shelf it was hard to find. We moved it to where it will be easily accessible now.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's pneumonia vaccination status for 1 (Resident #3) and anticoagulant medication use for 2 (Residents #3 and #1) sampled residents whose MDS assessments were reviewed to facilitate appropriate care planning and accuracy of MDS data. The findings are: 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Admission MDS with an assessment reference date (ARD) of 12/7/19 documented the resident was offered and declined the Pneumococcal Vaccine. b. The VACCINATION CONSENT FORM documented, Pneumococcal Vaccine .If there is no pneumonia vaccination history for the patient then the vaccination is recommended. [Check mark] Yes, I want .to have the pneumococcal vaccination. This document was signed by the resident and dated 12/7/19. c. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Tablet 5 MG [milligrams]([MEDICATION(S)]) Give 5 mg by mouth two times a day . d. The December 2019 and January 2020 Medication Administration Records (MARs) had no documentation to indicate the pneumonia vaccine was administered. e. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/9/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS), received no anticoagulants, and was offered and declined the Pneumococcal Vaccine. f. The June 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This medication was initialed as being administered twice a day from 6/1/21 through 6/9/21. g. The Immunization History printed on 9/30/21 documented, [MEDICATION(S)] Dose 1 Consent Refused. 2. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This medication was initialed as administered from 8/1/21 through 8/30/21. c. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and did not receive anticoagulant medication in the past 7 days. 3. On 10/1/21 at 08:49 a.m., the MDS Coordinator was asked, Who completes section O [Special Treatments, Procedures and Programs section] of an MDS? She replied, It's me; I get my information from the Admission packet. She was asked, On [Resident #3's] Admission and Quarterly MDS, is the pneumonia vaccine coded correctly? She replied, No, it is not, according to her signed consent to receive the Pneumococcal [vaccine]. She was asked, Who completes section N [Medications section] of the MDS? The MDS Coordinator replied, I do. She was asked if the anticoagulant response was correct for Resident #1's Annual MDS Resident #3's Quarterly MDS. She replied, Yes, we do not code [MEDICATION(S)] as an anticoagulant. 4. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, October 2019, documented for MDS Item N0410E, Anticoagulant use, .Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period . Do not code antiplatelet medications such as . [MEDICATION(S)] [[MEDICATION(S)]] here . An [MEDICATION(S)] package insert documented, .Indications and Usage: [MEDICATION(S)] is a factor Xa inhibitor anticoagulant . The RAI Manual did not document that Xa inhibitor anticoagulants, such as [MEDICATION(S)], should not be coded as an anticoagulant.

Based on record review and interview, the facility failed to ensure licensed nursing staff promptly and corrected acted upon hospital discharge instructions to discontinue an anticoagulant, in accordance with accepted standards of nursing practice, to prevent potential complications for 1 (Resident #1) of 3 (Residents #1, #2, and #3) sampled residents who had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/9/21 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status and did not receive an anticoagulant medication in the past 7 days. a. The Progress Notes dated 9/7/21 at 06:17 am documented, Resident having blood noted in urine noted temp 97.2 Resident having pain with urination. b. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .[MEDICATION(S)] 2.5mg [milligrams] ([MEDICATION(S)]) . Hold date 9/7/21 .For 14 days .Reason for Hold: bleeding in urine . The restart date was documented as 9/21/21. c. The September 2021 Medication Administration Record (MAR) documented, [MEDICATION(S)] Tablet 2.5MG [milligram] Give 2.5 mg by mouth two time a day for anticoagulant . Hold from 09/07/2021 1719 [5:17 pm] to 09/21/2021 1718 [5:18 pm d. Progress Notes dated 9/9/21 at 7:55 a.m. documented, .This nurse was called into resident room to assess resident left hand, upon assessing resident hand it was noted that resident left hand was dark purple all over down into the wrist and very swollen, pulse present, when resident asked what happened resident was unable to communicate cause of injury, resident moans in pain when fingers are flexed, [Physician's] office notified of findings and awaiting orders. e. Progress Notes dated 9/9/21 at 8:55 a.m. documented, .report called to [ambulance service] at this time for transfer to [local hospital]. f. Hospital Discharge Instructions dated 9/10/21 at 09:37 a.m. documented, Discharge Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .Stop [MEDICATION(S)] . g. The September 2021 MAR documented [MEDICATION(S)] 2.5 mg tablets were restarted on 9/21/21 at 6:00 pm and was administered as follows: 9/22/21 at 6 am and 6 pm 9/23/21 at 6 pm only 9/24/21 at 6 pm only 9/25/21 to 9/27/21 at 6 am and 6 pm 9/28/21 at 6 am only 9/29/21 at 6 pm only 9/30/21 at 6 am only h. On 09/30/21 at 09:18 a.m., Registered Nurse (RN) #1 was asked, Do you remember what happened on 9/7/21 for you to place [Resident #1's] [MEDICATION(S)] on hold? He replied, Yes, she had blood in her urine. When I spoke with the doctor, he instructed me to put it on hold for 2 weeks and get a UA [urinalysis]. He also started her on [MEDICATION(S)]. Then she went out a couple of days after that for a hematoma. When she got back, the [MEDICATION(S)] was d/c'd [discontinued]. He was asked, Were you the one who readmitted her? He replied, Yes. He was asked to look on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? He looked at the orders and stated, I don't guess I did. I don't think she has been getting it. He was asked to look at the MAR and was asked, What does the MAR indicate, since the medication returned to an active order? He replied, Yes, she has been getting it. I'm so frustrated that I missed that. i. On 09/30/21 at 1:40 pm, the Administrator was asked, Do you have a policy regarding processing of orders when a resident returns from the hospital? She replied, No, we don't have a policy for that. She was asked, What is your process to verify that a resident's discharge orders have been processed correctly? She replied, Let me get the DON to answer that for you. She stepped out and got the DON. The DON was asked, Do you have a process in which discharge instructions or orders are verified after a resident returns from the hospital? She replied, Yes, they go to the Unit Manager, and she double checks them, then brings them to the morning meeting for review with the team. She was asked, Who is your Unit Manager? She replied, We don't have one right now. She quit last Thursday. She was asked, Did you have one on 9/10/21 when [Resident #1] returned from the hospital? She replied, Yes, we did, but she is not here anymore. j. A Progress Note dated 9/30/21 at 1:49 pm by RN #1 documented, .spoke with [Physician's] office about clarification of [MEDICATION(S)]. [Physician] would like [MEDICATION(S)] to be discontinued for sure, order noted and processed .

Based on record review and interview, the facility failed to ensure a pneumococcal vaccine was provided to a resident who consented to receive it, in order to reduce the risk of a pneumococcal infection for 1 (Resident #3) of 5 (Residents #3, #4, #5, #6, and #7) sampled residents whose influenza and pneumococcal vaccination status was reviewed. The findings are: Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS with an ARD of 12/7/19 documented the pneumococcal vaccine was offered and declined. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/9/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and was offered and declined the pneumococcal vaccine. a. A Vaccination Consent form dated 12/7/19 documented, Pneumococcal Vaccine .If there is no pneumonia vaccination history for the patient then the vaccination is recommended . There were spaces for the resident to check Yes or No, to indicate whether they did or did not want to receive the vaccine. Yes, I want .to have the pneumococcal vaccination was check marked. The consent was signed by the resident and dated 12/7/19. b. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] c. The December 2019 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . d. On 09/29/21 at 1:05 PM, the Immunization History in the resident's electronic medical record was reviewed. It documented, [MEDICATION(S)] Dose 1 Consent Refused . e. On 10/01/21 at 09:10 AM, the Director of Nursing was asked to provide the resident's pneumonia vaccination history. The DON stated, I could not find any documentation where the resident received or refused the pneumonia vaccine. f. The facility's policy and procedure for pneumococcal vaccines, provided by Registered Nurse (RN) #2 on 9/29/21 at 2:46 PM, documented, Policy: To minimize the risk for residents to acquire and/or transmit pneumonia . Procedure: .Offer pneumococcal vaccine to residents on admission and as ordered by physician .

Based on record review and interview, the facility failed to ensure all residents and their representatives and/or family members were notified by 5:00 PM the next calendar day following the occurrence of confirmed positive COVID-19 results of three staff members and three residents, to ensure all the individuals were promptly informed of any mitigating actions taken, such as changes in visitation or group activities. These failed practices had the potential to affect all 82 residents who resided in the facility according to the Resident Census and Condition of Resident form dated 9/29/21. The findings are: Laboratory Reports for COVID-19 tests for facility residents and employees documented the following results: For Resident #10 and Therapy employee #1: .Collected: 8/19/21 .Reported: 8/21/21 .Nasal Swab .[CONDITION(S)]-CoV-2, Detected. For Residents #8 and #9: .Collected: 9/16/21 .Reported: 9/18/21 .Nasal Swab .[CONDITION(S)]-CoV-2, Detected. For the Minimum Data Set (MDS) Coordinator: .Collected: 9/2/21 .Reported: 9/4/21 .Nasal Swab .[CONDITION(S)]-CoV-2, Detected. For Dietary employee #1: .Collected: 9/22/21 .Reported: 9/23/2 .[CONDITION(S)]-CoV-2, RNA . Detected. a. The Staff and Resident COVID Positive Log, provided by the Assistant Administrator on 09/30/21 at 09:54 am, documented, Resident #10 and Therapy employee #1 were reported positive on 8/21/21, the MDS Coordinator was reported positive on 9/4/21, Residents #8 and #9 were reported positive on 9/18/21 and Dietary employee #1 was reported positive on 9/23/21. b. The Call Broadcast Reports (Dial My Calls) for the months of August and September 2021, provided by the Assistant Administrator on 09/30/21 at 9:50 am, documented the COVID-19 notification calls went out to the residents' representatives and families as follows: Calls were completed on Monday 8/23/21 (2 days after the positive COVID-19 results for Resident #10 and Therapy employee #1); Calls were completed on Monday 9/6/21 (2 days after the positive results for the MDS Coordinator); Calls were completed on Tuesday 9/21/21 (3 days after the positive results for Residents #8 and #9). c. On 09/30/21 at 1:57 pm, the Assistant Administrator was asked, Who receives the COVID-19 results? She replied, I do and [Registered Nurse (RN) #2]. She was asked what mechanism was used to inform residents and their representatives and families of confirmed or suspected COVID-19 activity in the facility. She replied, Dial My Calls. She was asked when the residents and their representatives and families were notified. She replied, By 5 PM the next day. I thought I had two business days. I was informed today it's 5 PM the next day. She was asked, Who notifies the representatives, families, and residents if you are not here? She replied, [RN #2]. The Assistant Administrator was asked, On 8/21/21, 9/4/21, 9/18/21 and 9/23/21, staff and / or residents tested positive; can you show me the Dial My Call messages for those days? She replied, As being reported by 5PM the next day, I did not do them at that date and time.

Based on observation and interview, the facility failed to ensure expired food items were promptly removed /discarded on or before the expiration or use by dates; food items stored in the refrigerator or freezer were sealed or covered; failed to ensure dietary staff washed their hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items to minimize the potential for food borne illness for residents who received meals; an ice scoop holder and ice machines were maintained in clean and sanitary condition to decrease the potential for food borne illness for residents who received meals from 1 of 1 kitchen; These failed practices had the potential to affect 66 residents who received meals from the kitchen (Total census: 66) as documented on a list provided by the Dietary Employee Supervisor on [DATE] at p.m. The findings are: 1. On [DATE] at 2:03 p.m., The Dietary Supervisor assisted with the initial kitchen tour. On a shelf beside the Dry Storage was a 16 ounce (oz) loaf of unopened Raisin Bread with Best if Used By date of [DATE], 1 package of Wonder Country Rolls with 4 rolls in it, with Best by Used By date of [DATE] and a 20 oz loaf of unopened Nature's Own Wheat Bread with a Best if Used By date of [DATE]. A stack of plastic delivery trays had 19 unopened packages of Rolls (12 rolls) with Best if Used By date of [DATE]. The Dietary Manager stated, Those were just delivered this morning. 2. On [DATE] at 8:37 AM The following observations were made in the Walk- in freezer: a. On [DATE] at 8:37 a.m., An open box of pollock crusted fish was on a shelf in the walk-in freezer. The box was not covered or sealed b. There were 2 open boxes of Pollock fish filet on a shelf in the freezer. The boxes were not covered or sealed. c. On [DATE] at 9:02 AM, Ice scoop holder on the wall by the ice machine had wet gray sediment at the bottom of it. The scoop was stored in the scoop holder and was in direct contact with the gray sediment. The Dietary Supervisor was asked to wipe the gray sediment at the bottom of the scoop holder. She did so, and the gray sediment easily transferred to the tissue. The Dietary Supervisor was asked to describe the contents within the ice scoop holder. She stated, It was grainy. There was black residue across the ice machine panel. The Dietary Supervisor was asked, How often do you clean the scoop holder and ice machine? She stated, The Maintenance Man cleans it. The Dietary Supervisor was asked, Who uses the ice from the ice machine and how often ice machine? She stated, That's the ice the CNAs (Certified Nursing Assistants) use for the water pitchers in the residents' rooms. d. On [DATE] at 09:07 AM, The Maintenance Man was asked, How often do you clean the ice machine? He stated, They're supposed to clean it frequently and semiannually. e. On [DATE] at 9:43 AM, Dietary Employee #1 turned on the faucet and rinsed lettuce head. There was thick wet black dirt on the core of the lettuce head. Dietary Employee #1 hit the core of the lettuce head on the cutting board to separate the leaves. As he hit the core of the lettuce head on the cutting board dirt splashes on the cutting board. Dietary Employee #1 did not wash and rinse the cutting board or the lettuce leaves that were on the cutting board before he picked them up and put them in individual bowls. He then, placed tomatoes on the dirty cutting board, sliced them and placed them on the lettuce leaves in individual bowls to be served to the resident who requested for salad with their lunch meal. Dietary Employee #1 used it the same cutting board to slice tomatoes. This Surveyor immediately asked Dietary Employee #1, What should you have done after the dirt from the core of the lettuce head splashed on the cutting board, on the lettuce leaves and before using the cutting board to slice the tomatoes? He stated, I shouldn't have used it. I will clean it and do another salad. The Dietary Supervisor stated, There was a lot of dirt on the table. h. On [DATE] at 10:19 AM, Dietary Employee #2 took out a pan of cake from the walk- in refrigerator and placed it on the counter. He pushed a cart with clean dish racks that contained bowls towards the counter. He picked up a knife and cut the cake. He iced the cake with a spatula. Without washing his hands, he picked up clean glove placed it on his right hand contaminated the glove. He then, used the same right hand to pick up slices of cake and placed individual bowls to be served to the residents for lunch. 3. A Policy and Procedure titled Food Safety & Sanitation dated [DATE], provided on [DATE] at 8:39 a.m., by The Dietary Manager documented, Policy: The facility will follow safe food handling .Procedure .3. Stock must be used before the expiration date. Items not used by the expiration date will be discarded.

Complaint # (AR 773) was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure the environment was as free of accident hazards as possible and adequate supervision was provided to prevent serious injury for 1 (Resident #6) of 3 (Residents #2, 3, 6 and 9) case mix residents who self-propelled in a wheelchair. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #6, who accessed the sloped section of the corridor through an unsecured, unmonitored gate, and fell out of the wheelchair, resulting in an inoperable [MEDICAL CONDITION], and had the potential to affect 17 residents who self-propelled in wheelchairs, according to Administrator on 3/28/19. The Administrator was informed of the Immediate Jeopardy on 3/26/19 at 3:48 p.m. The findings are: Resident #6's significant change Minimum Data Set with an assessment reference date (ARD) of 2/1/19 documented the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS), required extensive assistance of 1 person for bed mobility and transfer, was independent with locomotion on and off the unit and required the use of a walker or wheelchair for mobility. a. The Care Plan dated 2/13/19 documented, .Resident transfers self and ambulates ad lib (as desired) . Resident places items in chair and places self into chair; at times hits chair arms with body . at risk for injuries either by self-inflicting and/or other residents bumping into her . Goal .Will have no significant injuries by next review date .Resident is at risk for falls/injuries r/t (related to) history of falls, unsteady gait, and needed assistance with mobility. Resident transfers self and ambulates ad-lib in facility at times. Does hold hand rails at times during ambulation. Attempts to transfer self at times. Resident wheels self, next to bed, and raises right arm on wheelchair and reaches for side rail. Resident falls asleep in wheelchair often, when asked if she desires to go to bed she says 'no' C/O (complaint of) 'dizzy spells' @ times. Places self on edge of wc (wheelchair) seat, reports she slides out of wc. Educated on need for safety precautions. Falls asleep in wc or recliner . Goal Resident will be free from falls/injuries thru next review .Assess for and record any additional fall risk factors Date Initiated: 02/13/2019 Dycem (non-slip material) . b. An Incident Report dated 3/21/19 at 6:50 p.m. documented, Incident Description . Licensed Practical Nurse (LPN) heard resident yelling in the hallway/ramp (East/West Hallway) going towards the medical records. Upon finding resident, she was lying on the floor with her wheelchair beside her. She was complaining of severe pain to her right hip/groin area .Pain 9 (on a scale of 0 to 10, with 10 being the worst) facial grimacing. Resident admitted to hospital with right [MEDICAL CONDITION]. Gate ramp is latched, alarm is placed to gate . c. On 3/25/19 at 2:43 p.m., the East/West gate ramp had an alarm that rang when the gate is opened. The ramp sloped at an angle of decline at approximately 30 degree for approximately 10 feet, then the hallway turns at approximately a 90-degree angle and continues forward. d. On 3/26/19 at 11:00 a.m., Licensed Practical Nurse (LPN) #1 was interviewed via telephone and was asked, can you tell me what happened the night (Resident #6) fell ? She stated, I was sitting at the nurses station charting and I heard her yelling. The LPN was asked, had she ever gone down toward the ramp before? She stated, No, we had a lot of visitors that day, and they were coming in the gate and not locking it back. The Surveyor asked, do you think this fall could have been prevented? She stated, Yes, the gate should have been locked. e. On 3/26/19 at 1:09 p.m., the Assistant Director of Nursing (ADON) was asked, can you tell me about the night (Resident #6) fell ? She stated, Yes, I was notified when it happened, and they were sending her out in pain. The ADON was asked, do you know how she fell ? She stated, Her wheelchair was sitting upright, and she fell out of it. The ADON was asked, did she go down the ramp? Is that how it happened? She stated, Yes. The ADON was asked, do you know what interventions were in place to prevent a resident from going through the gate down the ramp? She stated, That latch lock has always been on there. The ADON was asked, was there any monitoring of the latch lock on the gate prior to her fall, to prevent someone from going through the gate? She stated, No. f. On 3/26/19 at 1:23 p.m., the Maintenance Supervisor was asked, did you do any monitoring of the latch lock on the ramp gate prior to (Resident #6's) fall? He stated, Just as needed; it's been a little while since we needed to monitor it. The Maintenance Supervisor was asked, what happened before this incident that would make you monitor the latch lock on the gate? He stated, We had residents that were wanderers and elopement risks, so we would monitor it; we didn't feel there was a need to monitor, as we didn't have any residents getting near it. g. On 3/26/19 at 1:33 p.m., the Maintenance Supervisor provided a copy of the, Ramp Gate Daily Check Sheet, which documented the latch and alarm for the East/West Hall gate were checked on 3/21/19, 3/22/19, 3/25/19 and 3/26/19. There was no documentation to indicate the latch and alarm were checked once daily on 3/23/19 and 3/24/19 (Saturday and Sunday). h. On 3/26/19 at 1:38 p.m., the Administrator was asked, can you tell me what happened the night (Resident #6) fell ? She stated, It was after supper, and there were three Certified Nursing Assistants (CNA) and one nurse on that hall. Two of the CNAs went to lay a resident down who was a 2-person transfer. The third CNA went to lay another resident down. The CNA told (Resident #6), we are going to do you next. They heard yelling, and she had fallen. She was lying on her right side, with her wheelchair sitting upright. One of the CNAs said she was leaning forward in her wheelchair. This is rare that she has gone that distance in a long time. She would not move about alone; the staff would push her wheelchair . The Administrator was asked, did you do any monitoring on the gate latch prior to her fall? She stated, No. The Administrator was asked, how are you monitoring it now? She stated, There was always a stop sign on the gate; after that night, the Maintenance Supervisor came up and put the alarm back in place (on the gate). The Administrator was asked, when did you stop using the alarm? She stated, When our last wanderer and elopement risk resident passed away. The Administrator was asked, did (Resident #6) go through the gate onto the ramp? She stated, Yes, when she fell , she was down the ramp, past the first window. i. On 3/26/19 at 3:20 p.m., CNA #4 was asked, have you ever seen (Resident #6) propel herself around? She stated, Yes. j. On 3/26/19 at 3:21 p.m., CNA #5 was asked, have you seen (Resident #6) propel herself in her wheelchair? She stated, Yes, she can move herself; not lately, but yes. CNA #1 was asked, were you working the night (Resident #6) had her accident? She stated, Yes, she follows me around all the time; well, she did follow me around. k. On 3/26/19 at 3:25 p.m., CNA #2 was asked, were you working the night (Resident #6) had her accident? She stated, Yes, we were putting another resident to bed. The CNA was asked, have you seen (Resident #6) propel herself in her wheelchair? She stated, Yes; normally she sits in the dining room and waits for me, but earlier that day, she had rolled herself around. She had rolled herself in the activity room, and then she got out the gate. l. On 3/26/19 at 3:31 p.m., CNA #3, was asked, were you working the night (Resident # 6) had her accident? She stated, Yes, she would come back and forth up and down the hall; she did like sitting in front of the gate, watching people. The CNA was asked, had you ever seen her go through the gate? She stated, No, she just roams. m. On 3/26/19 at 4:20 p.m., the fire doors by the East/West nurse's station were closed and an alarm was placed by the Maintenance Director. A staff member (unidentified) was sitting in front of the closed doors to ensure no residents could access the gate. 3. The Immediate Jeopardy was removed, and the scope/severity reduced to G on 3/26/19 at 4:20 p.m., when the facility closed and alarmed the fire doors as above, assigned a designated staff member to monitor, and initiated the following plan of removal: a. The Resident was sent to the hospital for evaluation. She returned on 3/23/19 to remain on bedrest. b. On 3/26/19 at 4:20 p.m., the fire doors by the EW (East West) Nurse's station were closed, and an alarm was placed by maintenance director. Staff member is sitting in front of closed doors to ensure no residents have access to the gate until mag loc is installed. c. Administrator identified 51 residents who had the potential to be affected by the failed practice based on the MDS 3.0 question for self-performance of locomotion off the unit. These were assessed by DON with no negative findings. d. The facility staff will receive inservice training regarding keeping the fire doors closed, immediately responding to the alarm, not using the entrance on (name) street. This inservice began immediately on 3/26/19 by DON/designee and will be ongoing until all staff have been trained prior to clocking in for next shift. e. Maglock is scheduled to be installed on 3/27/19 to the gate to ensure the gate cannot be opened until keypad is correctly used. f. Once maglock is installed to gate, it will be monitored 5 x per week by maintenance director. g. Administrator will present all findings to QA (Quality Assurance) committee for review and recommendations.