Every finding on record at Union Nursing

Based on interview and record review, facility staff failed to implement their abuse policy when they failed to complete a thorough investigation for an allegation of sexual abuse for one resident (Resident #1) out of one sampled resident, and did not ensure resident safety, when staff allowed Certified Nurse Aide (CNA) A who was alleged of the sexual abuse to continue to have contact with residents during the investigation. The facility census was 58. 1. Review of the facility's Abuse, Prevention and Prohibition policy, revised 2021, showed staff are directed as follows: -While a facility investigation is underway, steps will be taken to prevent further abuse;-When an employee is the alleged perpetrator of abuse or neglect, that employee shall immediately be barred from any further contact with residents through suspension, pending the outcomes of the facility investigation, prosecution or disciplinary action against the employee;-The administrator and/or the Director of Nursing (DON) will relay this suspension;-If sexual assault has been alleged, the physician will be contacted for an order to transfer to the emergency room for evaluation;-Every employee will be interviewed who was working on the specific hall/wing that the affected resident resides on;-If the allegation occurred on a specific shift, all staff for the identified shift only will complete a questionnaire and complete a statement if indicated. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/03/25, showed staff assessed the resident as cognitively intact, and diagnoses to include urinary tract infection (UTI), fractures and other multiple trauma. Review of the facility's initial investigation report, dated 10/22/25, showed the Director of Nursing (DON) documented the resident reported to staff and his/her family that he/she had been sexually abused the night before by CNA A. The report did not contain documentation the DON placed CNA A on suspension, did not contain documentation the physician was contacted, and did not contain a completed questionnaire or written statement from staff who worked the identified shift. Review of the facility's timekeeping records, dated 10/22/25 through 10/24/25, showed CNA A worked on 10/23/25 from 6:57 A.M. to 7:06 P.M. Review of the facility's completed investigation report summary, dated 10/24/25, showed staff documented the allegation was determined to be unsubstantiated. During an interview on 10/24/25 at 10:20 A.M., the DON said the administrator was out, and he/she investigated the resident's allegation. The DON said he/she did not suspend CNA A because CNA A had already left the building and was not scheduled to return to work until the next day. The DON said he/she interviewed CNA A and other staff that worked the shift, but did not ask any of the staff to complete a questionnaire or written statement. During an interview on 10/24/25 at 12:55 P.M., CNA B said he/she provided care to the resident on the night of 10/21/25, but he/she was not asked to complete a questionnaire or written statement regarding his/her interactions with the resident on 10/21/25. During an interview on 10/24/25 at 1:05 P.M., CNA A said he/she was contacted by the DON after he/she left work on the morning of 10/22/25 with questions about his/her interactions with the resident during the night shift on 10/21/25, but he/she was not asked to complete a questionnaire or written statement. CNA A said the DON did not notify him/her the resident had made a sexual allegation against him/her or informed him/her of a suspension from work, and he/she returned to the facility on [DATE] and worked for 12 hours on day shift. During an interview on 10/24/25 at 3:02 P.M., Licensed Practical Nurse (LPN) D said he/she was the charge nurse on the night of 10/21/25, the DON contacted him/her the morning of 10/22/25 with questions about CNA A's interactions with the resident during the night shift on 10/21/25, but he/she was not asked to complete a questionnaire or written statement. During an interview on 10/28/25 at 11:54 A.M., Certified Medication Technician (CMT) C said he/she worked on 10/21/25 from 6:15 A.M. until 12:21 A.M., but he/she was not interviewed or asked to complete a questionnaire or written statement regarding the resident's allegations. During an interview on 10/28/25 at 3:33 P.M., the resident's physician said he/she was at the facility on 10/23/25, but facility staff did not notify him/her of the resident's allegation of sexual abuse until 10/24/25 and he/she would expect staff to notify him/her when the incident occurred if the policy directed staff to do so. During an interview on 10/28/25 at 12:53 P.M., the administrator said in his/her absence from the facility, the DON was in charge and should have placed CNA A on suspension until he/she completed the investigation, the physician should have been notified shortly after the allegation was made, and all staff who worked the night shift on 10/21/25 should have been interviewed or asked to provide a statement. Complaint #2651547

Based on record review and interview, facility staff failed to contact local law enforcement and failed to report an allegation of sexual abuse for one resident (Resident #1) out of one sampled resident to the Department of Health and Senior Services (DHSS) within the two-hour required timeframe. The facility's census was 58.1. Review of the facility's Abuse, Prevention and Prohibition policy, revised 2021, showed staff are directed as follows: -Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled using technology;-The person made aware of allegations of abuse or neglect OR the administrator will report the allegations of abuse and neglect to the mandated state agency and law enforcement;-The allegation will be reported no later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/03/25, showed staff assessed the resident as cognitively intact, and diagnoses to include urinary tract infection (UTI), fractures and other multiple trauma. Review of the facility's initial investigation report, dated 10/22/25, showed the Director of Nursing (DON) documented the resident reported to staff and his/her family that he/she had been sexually abused the night before by the male aide. The report did not contain documentation facility staff reported the allegation to DHSS within the two-hour timeframe after the resident and his/her family member reported the allegation of sexual abuse, and did not notify the local law enforcement. Review of the DHSS complaint/facility self-report database did not contain documentation of a facility report in regard to resident's allegation of sexual abuse to DHSS. During an interview on 10/24/25 at 10:20 A.M., the DON said the administrator was out, and he/she was responsible to report any abuse allegations to DHSS within two hours after the allegation is made. The DON said he/she did not report to DHSS or local law enforcement because after he/she spoke with the resident and family, he/she determined it was not a true allegation. During an interview on 10/28/25 at 12:53 P.M., the administrator said in his/her absence, the DON was responsible to report any allegations of abuse to DHSS within two hours after the allegation is made, and to local law enforcement. He/She said he/she was not sure why the DON did not report the allegation to DHSS. Complaint# 2651547

Based on observation, interview, and record review facility staff failed to notify residents the different alternate food options available and failed to provide alternative meals for residents which accommodated the residents' preferences for eight residents (Resident #2, #9, #10, #27, #32, #48, #52, and #54) out of 13 sampled residents. This had the potential to affect all residents. The facility census was 46. 1. Review of the facility's Alternates and Meal Substitutions policy, undated, showed alternates shall be available for all meals for residents who dislike the menu items. For breakfast an alternate shall be available for the entree, and at lunch and dinner, an alternate shall be available for the entree and vegetable. These may be offered in the form of a posted alternate, a selective menu, or an always available menu. Alternate choices must be nutritionally consistent with the item it is replacing. Review of the resident council minutes, dated June 2025 and August 2025, showed the council addressed the following dietary concerns: -07/08/25: Running out of food/alternates. Alternates and not just leftovers from yesterday;-08/12/25: Alternates more than peanut butter and jelly sandwiches. 2. Observations on 08/25/25 through 08/28/25 during survey, showed the available food alternates were not displayed in the dining room, in resident rooms, or on the facility's weekly menu. 3. Review of Resident #2's quarterly minimal data set (MDS), a federally mandated assessment tool, dated 08/21/25, showed staff assessed the resident as cognitively intact. During an interview on 08/26/25 at 12:30 P.M., the resident said he/she does not know what alternate food options are available. The resident said he/she cannot read the menu, and staff does not ask him/her about alternate food options. The resident said if/she does not like what is served for a meal, he/she just goes back to his/her room and does not eat the meal.4. Review of Resident #9's quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.During an interview on 08/21/25 at 11:48 A.M., the resident said there are no choices for meals, you eat what they serve you. The resident said there use to be options posted at the dining room, not sure why it's not any longer. The resident said it would be nice to know if we have options at meals.5. Review of Resident #10's quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.During an interview on 08/26/25 at 12:18 P.M., the resident said he/she always eats in his/her room and gets a room tray. The resident said he/she does not know what types of alternate food options are available and staff do not ask him/her. The resident said he/she just gets what is on the menu and if he/she does not like what is being served, the only option he/she has is a peanut butter and jelly sandwich. The resident said he/she would like to have some additional food alternates because he/she is a picky eater and would like for staff to ask about alternates before the menu food item is served. 6. Review of Resident #27's quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.During an interview on 08/27/25 at 8:50 A.M., the resident said the only alternate food options he/she knows about is peanut butter and jelly sandwiches or chicken noodle soup. The resident said he/she would like to have more alternate food options. The resident said last week, he/she requested a peanut butter and jelly sandwich as an alternate, but no one came back to bring it, so he/she just didn't eat for that meal. 7. Review of Resident #32's Annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact. During an interview on 8/27/25 at 3:35 P.M., the resident said resident council meetings are always about food, and it is the number one problem the residents have with the facility. He/She said staff do not ask the resident what they want for meals. He/She said the meal alternatives used to be posted next to the menu in the dining room, but it is not posted anymore. He/She said if the residents are new, they do not have a way to know about the alternatives. He/She said the only alternative for meals are soup, a peanut butter and jelly sandwich or possibly leftovers, but they are not made aware if there are any left. He/She said, in reference to meals, they are small things, but they mean a lot to them. He/She said the residents bring meal complaints up every month and they don't get an answer or made aware of a plan.8. Review of Resident #48's annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact.During an interview on 08/28/25 at 12:46 P.M., the resident said the facility used to have alternate food options hanging on the dining room wall, but they are no longer posted and is not sure why. The resident said he/she would like to have another meal option posted on the weekly menus and additional food alternates. 9. Review of Resident #52's quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact.During an interview on 08/28/25 at 12:43 P.M., the resident said the roast beef that was served for lunch was horrible and the green beans had no flavor. The resident said the only two alternate food options he/she knows about is peanut butter and jelly sandwiches or chicken noodle soup. The resident said he/she would like additional alternate food options and said staff does not ask him/her about alternate food options. Observation on 08/28/25 at 12:48 P.M., showed the residents plate with roast beef and green beansObservation showed Dietary Aid (DA) D asked the resident if lunch was ok and the resident said not really. Observation showed an DA D told the resident I am sorry to hear that and walked away from the resident. During an interview on 08/28/25 at 1:25 P.M., DA D said if a resident wants a food alternate from what is being served from the menu, the resident will let staff know and staff will list the alternate on the resident's meal card. DA D said the alternate food options available for residents are peanut butter and jelly sandwiches, soup, leftovers from the night before, or cereal for a breakfast alternate. DA D said he/she thought the resident would have let him/her know if he/she wanted an alternate food item. 10. Review of Resident #54's Annual MDS, dated [DATE], showed staff assessed the resident as cognitively intact.During an interview on 08/25/25 at 11:17 A.M., the resident said he/she eats in their room and does not get options. The resident said, If there were alternatives, how would I know what they are, it's not posted anywhere, and no one asks me. He/She said you just get what they have.11. During an interview on 08/28/25 at 1:23 P.M., the Dietary Manager (DM) said alternate food options include leftovers from the day prior, peanut butter and jelly or ham sandwich, grilled cheese or ham/cheese, or three different soups. The DM said the resident would not receive an alternate until the resident told staff they didn't want the meal being served. During an interview on 08/28/25 at 3:13 P.M., Certified Nursing Assistant (CNA) E said alternate food options include peanut butter and jelly sandwiches, soup, leftovers, or cereal. CNA E said staff do not ask residents if they want alternates and alternates are only provided if a resident asks for it. During an interview on 08/28/25 at 3:21 P.M., the Assistant Director of Nursing (ADON) said residents always have alternate food options available, including leftovers, chicken noodle soup, and peanut butter and jelly sandwiches. The ADON said sometimes they can have vegetable beef or tomato soup and sometimes grill cheese sandwiches depending on whether the kitchen has these items in stock. The ADON said he/she thought alternate food options were posted in the dining room, but he/she has not looked in a while and not sure if they are still posted. The ADON said staff does not ask residents if they want an alternate food item and the resident would need to ask for the alternate but believes that residents are aware of all the food alternate options available. During an interview on 08/28/25 at 4:20 P.M., the Director of Nursing (DON) said residents have alternate food options. The DON said they used to have the alternate food options posted on the wall but does not know if they are still posted. The DON said he/she does not know how alternate food options are planned and that would be a question for the DM. During an interview on 08/28/25 at 12:30 P.M., the Administrator said there are alternatives for residents to have at meals, they can have leftovers, a sandwiches or soup. He/She said the alternatives use to be posted in the dining room, is not sure why they are not any longer. The administrator said most residents know they have these options but agreed residents who don't come to the dining room may not know. The administrator said the dietary manager is working on a menu plan to include more alternatives/choices to send to the Dietician because it needs to be cleared by him/her first.

Based on interview and record review, facility staff failed to refund resident funds within 30 days of discharge from the facility for 12 discharged residents (Resident #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, and #73). The facility census was 46.1.Review of the facility's-maintained Accounts Receivable Report, dated 08/26/25, showed 12 discharged residents with personal funds held in the facility operating account: Resident Amount Held in Operating Account discharge date #62 $282.00 01/25/25#63 $8,280.00 05/05/25#64 $228.45 07/17/24#65 $534.00 05/16/25#66 $7,015.00 07/09/25#67 $2,090.00 07/07/25#68 $282.00 03/14/25#69 $15,576.00 03/30/25#70 $264.00 07/27/25#71 $252.15 12/24/23#72 $564.00 06/30/25#73 $108.00 06/02/25Total $35,475.60During an interview on 08/27/25 at 2:55 P.M., the corporate Business Office Manager (BOM) said he/she has been serving as the interim BOM for the facility over the past month or so. The corporate BOM said he/she would expect for the Accounts Receivable Report to be reviewed by the BOM monthly. The corporate BOM said he/she would expect for a refund to be entered with 14 days of a resident discharging and not returning, and would expect for the discharged resident to be paid out within 30 days from the date of discharge. The corporate BOM said he/she is not sure why the previous BOM did not issue refunds to the discharged residents within 30 days of discharge. During an interview on 08/27/25 at 3:20 P.M., the administrator said the facility has not had a BOM for a couple of months. The administrator said he/she does not know a lot about the Accounts Receivable Report and still learning the requirements. The administrator said he/she is not sure why the previous BOM did not issue refunds to the discharged residents within 30 days of discharge.

Based on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan to reflect the care needs for four residents (Resident #4, #33, #54, and #55) out of 13 sampled residents. The facility census was 46.1. Review of the facility policy Resident Assessment Instrument (RAI) Policy, dated 04/14/25, showed the facility will adhere to all Center for Medicare & Medicaid Services (CMS) regulations which are considered the definitive source in completion of the RAI process. This includes coding the Minimum Data Set (MDS) with accuracy, and the development of the comprehensive care plan.2. Review of Resident #4's admission MDS, a federally mandated assessment, dated 02/26/25, showed staff assessed the resident as follows:-Cognitively intact;-Resident not assessed for mood;-Resident assessed as no behaviors.Review of the resident's Physician Order Sheet (POS) dated August 2025, showed staff are directed to monitor behaviors for the following:-Anxiety;-Agitation;-Delusions;-Hallucinations;-Psychosis;-Aggression.Review of the resident's care plan, dated 07/11/25, showed the plan did not contain direction on the documentation or monitor of the resident's behaviors.3. Review of Resident #33's admission MDS, dated [DATE], showed staff assessed the resident as follows:-Severe cognitive impairment;-Has an indwelling catheter (tube inserted int the urinary tract to drain urine form the bladder);-At risk for pressure ulcers/injuries. Review of the resident's care plan, dated 07/16/25, showed the record did not contain documentation of the resident's catheter. 4. Review of Resident #54's Annual MDS, dated [DATE], showed staff assessed the resident as follows:-Cognitively intact;-Has an ostomy (a surgically created opening in the abdominal wall that creates a new pathway for waste to exit the body);-At risk for developing pressure ulcers/injuries.Review of the resident's care plan, dated 07/18/25, showed the record did not contain documentation or interventions of the resident's ostomy.During an interview on 08/28/25 at 10:00 A.M., the resident said he/she has an ostomy and does all his/her own care. 5. Review of Resident #55's admission MDS, dated [DATE], showed staff assessed the resident as follows:-Cognitively intact;- At risk for developing pressure ulcers/injuries;-Has a catheter. Review of the residents treatment administration record (TAR), date [DATE], showed a wound treatments in place for the left great toe, left second toe, and left medial foot. Review of the resident's care plan, undated, showed the record did not contain documentation of the resident's catheter or wound. 6. During an interview 08/28/25 at 3:37 P.M., the Care Plan Coordinator said he/she is responsible for comprehensive care plans. LPN F said he/she does the MDS in their electronic medical record (EMR), and that triggers a care plan automatically from that information. LPN F said the EMR also automatically puts the date of review. LPN F does not look at the care plan after this process to adjust anything. LPN F said he/she would expect resident's behaviors, ostomy and catheters to all be care planned. LPN F said he/she does not know why they are not on there.During an interview 08/28/25 at 4:41P.M., the Director of Nursing (DON) said the residents MDS information is what gets put on their care plans. The DON said catheter, ostomy's and behaviors are things that should be on care plans. The DON said he/she was not aware the residents care plans were not updated with this information.During an interview on 08/28/25 at 4:38 P.M., the Administrator said resident care plans aren't put in the system until 14 days after admission. She would expect catheters, ostomy's and resident behaviors to all be on the residents care plan. The administrator said LPN F has only been at the facility since the end of March and is working on care plans.

Based on observation, interview and record review, the facility staff failed to ensure prepared food items were served at a safe and appetizing temperature when the facility staff failed to maintain the internal temperatures of hot food items at 120 degrees Fahrenheit (F) or higher upon service to residents who ate in their rooms. The facility census was 46.1. Review of the facility's Assistance with Meals policy, revised July 2017, showed the policy directed staff to hold foods at a temperature of 136 degrees or above until served. Review showed the policy did not contain guidance on food temperatures upon delivery to residents. Review of the facility's resident council meeting minutes showed:-Attendees on 06/10/25 listed cold food as an issue;-Attendees on 07/08/25 listed veggies cold, coffee cold, and raw breakfast meats as issues;-Attendees on 08/12/25 listed cold plates and food as issues. Observation on 08/26/25 at 12:45 P.M., showed a service cart next to the steam table contained a large stack of plates which were being used for the resident's noon meal. Observation showed the Dietary Manager (DM) removed plates from a plate warmer and placed them on the service cart when the large stack of plates was depleted.Observation on 08/26/25 at 1:04 P.M., showed a test tray delivered along with four resident room trays was left at the nurse station.Observation on 08/26/25 at 1:18 P.M., showed the delivered test tray contained a barbecued pork sandwich and corn. The temperature of the pork measured 99 degrees F and the temperature of the corn measured 100 degrees F with a calibrated digital thermometer.During an interview on 08/28/25 at 1:25 P.M., the DM said food should be served at 140 or higher and 100 degrees would not be acceptable. The DM said he/she was aware of resident complaints and kitchen staff had been working on a solution. The DM said there was a plate warmer but staff did not always use it because sometimes the plates were too hot. The DM said kitchen staff delivered the meal cart to the nurse station but he/she did not know how long it took for trays to be delivered to residentsDuring an interview on 08/28/25 at 3:00 P.M., the administrator said the DM is responsible for making sure food was served hot. The administrator said hot food should be served at 130 to 135 degrees and 99 or 100 degrees was not acceptable. The administrator said staff had been working on food temperatures since staff know it's been an issue. The administrator said he/she did not realize kitchen staff were allowing warmed plates to cool before using.

Based on observation, interview, and record review, facility staff failed to utilize personal protective equipment (PPE) for two (Resident #33, and #55) out of three sampled residents on enhanced barrier precautions (EBP) while performing care. Failed to perform appropriate hand hygiene and glove changes in a manner to prevent or reduce the spread of bacteria and other infection causing organisms during perineal care for two (Resident #29 and #61) out of two sampled residents. The facility census was 46.1. Review of the Facility's Dry/Clean Dressing policy, revised on 09/2013, showed: -Clean bedside stand. Establish a clean field;-Wash and dry hands thoroughly;-Put on clean gloves. Loosen tape and remove soiled dressing;-Pull glove over dressing and discard into plastic biohazard bag;-Wash and dry hands thoroughly;-Put on clean gloves;-Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Cleanse from least contaminated area to the most contaminated area (usually from center outward).Review of the Facility's Skills Check Suprapubic Catheter Care, undated, showed:-Wash hands and apply gloves;-Secure catheter site with non-dominant hand. Cleanse catheter from insertion site down catheter away from body;-Use a new clean area of wipe/wash cloth with each swipe down catheter, up to two times per wipe/wash cloth. Review of the Facility's EBP policy, revised 12/12/2023, showed implement EBP (use of gown and gloves) during high-contact resident care activities for residents at increased risk of multidrug-resistant organisms (MDRO) (e.g., residents with wounds or indwelling medical device)) for the prevention of transmission:-Residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO;-High-contact resident care activities include providing hygiene, changing briefs of assisting with toileting, device care or use (urinary catheters), and wound care (any skin opening requiring a dressing);-EBP should be followed outside the resident's room when performing transfers and assisting during bathing in a shared/common shower room;-EBP should be used for the duration of the affected resident's stay in the facility or until the wound heals or indwelling device is removed.Review of the Centers for Disease Control (CDC) website, https://www.cdc.gov/hicpac/workgroup/EnhancedBarrierPrecautions.html article, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities, dated June 2021, showed:-Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE required and defining high risk resident care activities;-Gowns and gloves should be available outside of each resident room, and alcohol-based hand rub should be available for every resident room (ideally both inside and outside of the room).2. Review of Resident #33's admission Minimal Data Set (MDS), a federally mandated assessment tool, dated 07/23/25, showed staff assessed the resident as:-Moderate cognitive impairment;-At risk for developing pressure ulcers/injuries;-Has an open lesion.Observation on 08/27/2025 at 11:38 A.M., showed the Assistant Director of Nursing (ADON) entered the resident's room to perform wound care. Observation showed the ADON did not put on a gown before he/she provided wound care.During an interview on 08/27/2025 at 11:38 A.M., the ADON said the resident is on EBP for his/her wounds and catheter.During an interview on 08/28/2025 at 3:34 P.M., the ADON said it is his/her expectation staff use PPE with a resident who is on EBP. He/She said residents with indwelling devices, catheters and wounds should be on EBP, and staff should wear gowns and gloves when providing direct care. He/She said he/she did not wear PPE when performing the residents wound care because he/she forgot.3. Review of Resident #55's admission MDS, dated [DATE], showed staff assessed the resident as:-Cognitively intact;-At risk for developing pressure ulcers/injuries;-Has a catheter.Observation 08/28/25 at 9:40 A.M., showed Registered Nurse (RN) A prepped the supplies for catheter care in the hallway outside the facility shower room door. He/She removed gauze from the package with his/her bare hands and placed it in a clear cup. He/She applied gloves and gathered supplies and entered the facility shower room to perform catheter care on the resident. He/She continued to wear the same soiled gloves and adjusted the resident's shirt and cleansed the resident's catheter tube with the gauze. Observation showed the RN did not put on a gown before he/she provided catheter care. Observation on 08/28/25 at 9:54 A.M., showed RN A entered the facility shower room to provide wound care to the resident. Observation showed the RN removed the resident's sock with his/her bare hands, and did not perform hand hygiene before he/she put on gloves. The RN removed the resident's wound bandage and with the same soiled gloves, cleansed the wound. Observation showed the RN did not put on a gown before he/she provided wound care. During an interview on 08/28/2025 at 11:43 A.M., RN A said staff should perform hand hygiene and apply gloves before touching supplies and before performing wound and catheter care. He/She said hand hygiene and gloves changes should be done between all clean and dirty tasks. He/She said he/she wasn't in his/her normal element because he/she usually does the resident's catheter care in the resident's room, so he/she missed steps. RN A said he/she recognized, after performing wound and catheter care, that he/she had forgot to put on a gown. He/She said he/she usually does care in the resident's room where PPE is readily available, and he/she forgot to wear gown. He/She said the resident is on EBP and any residents on EBP require staff to wear a gown and gloves while performing direct patient care. He/She said this resident has a catheter and a wound so a gown and gloves should be worn.During an interview on 08/28/2025 at 3:34 P.M., the ADON said he/she expects staff to wear gloves when touching wound care supplies like gauze. He/She said he/she expects staff to remove dressing and then remove gloves and clean hands before reapplying gloves. He/She expects staff to remove gloves after cleaning the wound and perform hand hygiene before proving the wound treatments or ointments. He/She said hand hygiene and glove changes, help prevent cross contamination and the spread of germs.During an interview on 08/28/2025 at 4:13 P.M., the Director of Nursing (DON) said staff should handle supplies with clean gloves. He/She said he/she expects staff to perform hand hygiene and apply gloves before removing the suprapubic catheter bandage, before removing the residents dressing and cleaning the wound. He/She said he/she expects staff to change gloves and perform hand hygiene before moving on to applying ointments. He/She said hand hygiene and glove changes are important to prevent the spread of infections. He/She said himself/herself and the ADON are responsible for educating staff. He/She said staff have been educated on catheter care and hand hygiene, yearly and during in-services. The DON said residents with indwelling devices, catheters, and wounds that require a dressing, should be on EBP. He/She said he/she expects staff to wear a gown and gloves when performing high contact care like wound care and catheter care. He/She said it is important for gowns and gloves to be worn during care for those residents on EBP because it helps prevent the spread of infections. He/She said himself/herself and the ADON are responsible for educating staff on EBP. He/She said staff have been educated during verbal in-services. He/She said he/she was not aware nurses were not wearing PPE during wound and catheter care.During an interview on 08/28/2025 at 4:43 P.M., the Administrator said he/she expects staff to wear gloves when handling supplies. Staff should perform hand hygiene and apply gloves before removing dressings, during catheter care and wound care. He/She said staff are the expected to remove their gloves, perform hand hygiene and replace their gloves before cleaning the wound or catheter. Then clean his/her hands and replace gloves before providing the treatment. He/She said staff are educated on hand hygiene, gloves changes, wound and catheter care yearly and during in-services that are provided by the ADON and DON. The Administrator said a resident with a wound and a catheter should be on EBP. He/She expects staff to wear a gown and gloves during personal care, wound care and catheter care. He/She said the ADON and DON are responsible for educating staff on the EBP and the importance of PPE. He/She has been here for four months, and believes the education was done for EBP. He/She said he/she was not aware nurses were not using PPE for EBP residents during care. He/She said not wearing PPE can put residents are risk for cross contamination and the spreading of infections.4. Review of the Facility's Standard Precautions policy, revised 12/2007, showed:-Standard precautions shall apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases;-Hands shall be washed with soap and water after direct contact or indirect contact; -In the absence if visibly soiling of hands, alcohol-based hand rubs are preferred for hand hygiene;-Wash hands after removing gloves;-Wear gloves (clean, non-sterile) when you anticipate direct contact with blood, bodily fluids, mucous membranes, non-intact skin, and other potentially infected material;-Change gloves, as necessary, during care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean one);-Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments.5. Review of Resident #29's admission MDS, dated [DATE], showed staff assessed the resident as follows:-Cognitively intact;-Dependent on staff for toileting, and bathing;-Always incontinent of bowel and bladder. Observation on 08/28/25 at 12:45 P.M., showed Certified Nurse Aide (CNA) E transferred Resident #29 to his/her bed. CNA E did not wash or sanitize his/her hands before he/she applied gloves, removed the resident's urine-soaked brief, performed perineal care, placed a clean brief, covered the resident with a sheet and blanket, handed the resident his/her glasses, then patted the resident on the head with his/her soiled gloves. The CNA bagged up the trash, removed his/her gloves and did not wash his/her hands before he/she left the resident's.6. Review of Resident #61's Entry MDS, showed an admission date of 08/26/25.Observation on 08/28/2025 at 1:23 P.M., showed CNA B and CNA C entered the resident's room to provide perineal care. CNA C transferred the residents from his/her wheelchair to his/her bed, removed the resident's pants, opened his/her brief and then tucked the brief under the resident's bottom. With the same soiled gloves, CNA C cleansed the resident's groin with the same portion of the wipe. He/She removed his/her gloves, applied clean gloves and helped move the resident to his/her right side. CNA C cleansed the resident's back side, placed the clean brief under the resident and applied barrier cream on the resident's back side with the same soiled gloves on. CNA C removed his/her left glove and replaced it with a new glove and did not perform hand hygiene or replace the right-hand glove. CNA C moved the resident to his/her back and CNA C applied barrier cream and powder. CNA C removed his/her left glove and replaced it with a new glove and did not perform hand hygiene or replace the right-hand glove. CNA C secured the brief, positioned the resident in bed, and placed his/her cover before he/she removed his/her gloves.7. During an interview on 08/28/2025 at 4:37 P.M., CNA C said when performing perineal care, staff should use one wash cloth to clean the resident from front to back, folding the rag with each swipe of the skin. He/She said staff should change gloves when moving from a clean to dirty area and should wash hands or sanitize every time they remove their gloves to prevent the spread of infections. He/She said typically they remove both gloves and not just one, but since he/she didn't use the other hand to provide care, he/she didn't feel the need to change both gloves. He/She is not sure why did/she did not perform hand hygiene on the one hand. He/She said he/she usually changes both gloves when he/she moved from cleaning the residents front side to cleaning the residents back side and after applying barrier cream but forgot to during observation.During an interview on 08/28/2025 at 4:13 P.M., the Director of Nursing (DON) said when performing perineal care, he/she expects staff to only change gloves when they are visibly soiled, when moving from cleaning the residents front side to the residents back side. He/She said he/she expects staff to clean the resident from front to back, turning the wipe with each swipe or two to keep the area clean. He/She said the ADON and himself/herself and responsible for educating staff on the proper way to perform perineal care and hand hygiene practices. Her/She staff have been educated on perineal care and hand hygiene yearly and during in-services. During an interview on 08/28/2025 at 4:43 P.M., the Administrator said he/she expects staff to change gloves and perform hand hygiene between clean and dirty tasks. He/She said staff are educated on hand hygiene, gloves changes, and perineal care yearly and during in-services that are provided by the ADON and DON.

Based on interview and record review, the facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This failure has the potential to affect all residents. The facility census was 53. Review of the facility provided policies, showed the records did not contain a policy related to the qualifications for Director of Food and Nutrition Services. Review of the dietary manager's (DM) personnel records showed a hire date for the DM position listed as 01/04/24. Review showed the records did not contain documentation of prior dietary manager experience in a nursing facility and certification or other education required for the director of nutritional services position. During an interview on 06/19/24 at 8:05 A.M., the DM said he/she had been the DM for about a year, and he/she did not have prior experience as a dietary manager in a nursing facility and he/she did not have a degree or certification related to food service management. The DM said he/she started certification classes through the facility's consultant registered dietician (RD) in December 2023, but only had two or three classes before the RD had to stop the classes for unknown reasons. The DM said the RD only works part-time and the facility did not have any certified or clinically qualified nutritional staff employed full-time. During an interview on 06/19/24 at 9:03 A.M., the administrator said, although the DM had been the interim DM since the previous DM left last year, he/she did not officially appointed the DM as the manager until 01/04/24. The administrator said the DM began certification classes with the facility's part-time consultant RD, but the RD had to postpone the classes due to his/her own staffing issues. The administrator said he/she placed ads to find a qualified DM upon the advisement of the RD, but they had not been able to hire a qualified DM to date. The administrator said he/she knew that the DM did not have the qualifications required for the position and the facility did not have any certified or clinically qualified nutritional staff employed full-time.

Based on observation, interview, and record review, facility staff failed to store medications in a safe manner when staff failed to ensure expired medications and supplies were not stored with current resident medications, and failed to ensure all medications and treatments were labeled in two out of four medication carts. Additionally, staff failed to ensure medications were not lose in one medication cart. The facility census was 52. 1. Review of the facility's Storage of Medications, dated April of 2007, showed drugs and biologicals shall be stored in packaging, containers or other dispensing systems in which they are received. The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean safe and sanitary manner. Drug containers that have missing, incomplete, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Drugs shall be stored in an orderly manner in carts. Each resident's medications shall be assigned to a cubicle, drawer or holding area to prevent the possibility mixing medications of several residents. 2. Observation on 06/18/24 at 3:13 P.M., showed the 200 hall medication cart contained: -One bag of 24 adhesive tape remover pads with an expiration date of of 11/2022; -Three tubes of Diclofenac Sodium 1% topical gel (used to relieve pain from arthritis) with the label removed; -One red rubber urethral catheter with an expiration date of 4/25/24; -One Eucerin topical cream with an expiration date of 10/20/22; -One Urea 20 intensive hydrating cream (lotion) unable to read label script or expiration date and one tube with an expiration date of 04/2024; -Three laxative 10 milligram (MG) suppository without a label script; -14 Acetaminophen 650 mg suppositories laying in drawer not in original container; -Three Albuterol sulfate/ Ipratropium Bromide (helps control symptoms of lung diseases, such as asthma, chronic bronchitis and emphysema) .0.5mg-3mg per 3 milliliters (ml) tubes without a label; -One bottle of vitamin C 250 MG, with an expiration date of 1/2024; -One bottle of Alcohol-free liquid skin prep with an expiration date of 01/19/2024; -Two vials of Haldol (antipychotic medication) 5 mg per ml, with an expiration date of 05/24 and without a label; -Two tubes of Diclofenac Sodium 1% topical Gel stored in a bag with two different resident's names; -Two boxes of omnifix (tape ideal for dressing retention on joints) with an expiration date of03/2024; -Roll of omnifix without a box without an expiration date; During an interview on 06/19/24 at 10:27 A.M., RN I said he/she doesn't check the medication cart often enough for expired medications, the facility needs to institute a policy for that. The RN said if a medication is missing a label or is unreadable staff should call the pharmacy for a new label. The RN said there should be dividers between residents medications and residents creams are in separate bags. The RN said he/she was not aware that two different resident's creams were stored in the same bag, they should not be. The RN said he/she never puts open dates on inhalers, he/she doesn't think it changes the expiration date. The RN said medications should stay in the original box, until used, he/she does not know why they medications are out of their box in the medication cart. The RN said to his/her knowledge you don't have to put an open date on eye drops. 3. Observation on 06/18/24 at 4:23 P.M., of 100/300 medication cart contained: -One Fluticasone Propionate/Salmeterol Diskus inhalation powder (prescription medication used to treat asthma and chronic obstructive pulmonary disease) 250-50 Micrograms (MCG) open, opened and without an open date; -One Trelegy (prescription medication used to treat asthma and chronic obstructive pulmonary disease) 100 MCG/62.5 MCG/25 MCG opened and without an open date; -One Fluticasone/Salmeterol AER 250/50 opened and without an open date; -One Trelegy 100 MCG/62.5 MCG/25 MCG opened and without an open date; -One Breo Ellipta inhaler (combination medication inhaler for the treatment of chronic obstructive pulmonary disease) 100-25 opened and without an open date; -One Anoro Ellipta AER (combination medication inhaler for the treatment of chronic obstructive pulmonary disease) 62.5-25 opened and without an open date; -One Latanoprost Solution .005 % (treats high pressure inside the eye and helps treat glaucoma) opened and without an open date; -27 unidentified loose pills in the bottom of the medication care drawers. During an interview on 06/19/24 at 4:39 P.M., CMT Q said there is not a schedule to clean out expired medications in the carts. The CMT said staff are supposed to put open dates on eye drops and inhalers, he/she tells all new staff and they don't listen to him/her. The CMT said he/she has gone to management and they do not do anything about it. The CMT said staff should destroy medications that the script has been torn off, or fell off of. The CMT said prescription creams should have dividers to keep them from touching each other. The CMT said Albuterol should remain in the original box with the script until used, or staff wouldn't know whose they are. The suppositories should remain in the original box until used. The CMT said resident medication cards are packed in the drawer and pills will fall out when staff push them in the drawer.

Based on observation, interview and record review, facility staff failed to ensure one resident (Resident #3) out of 18 sampled residents who required continuous oxygen received continuous oxygen as ordered by the physician. Facility staff failed to store oxygen tubing and nebulizer masks in a manner to prevent respiratory infection for two residents (Resident #3 and #52) out of 18 sampled residents. The facility census was 52. 1. Review of the facility's Oxygen Therapy Policy, undated, showed all oxygen and nasal cannula tubing should be stored in a plastic bag, that is attached to oxygen concentrator, or E-tank (portable oxygen tank), when not in use. Review of the facility's Nebulizer Treatment policy, undated, showed staff should store nebulizer cannula and tubing in a plastic bag at bedside, with the resident's name and date the equipment was changed. 2. Review of Resident #'3 Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 05/17/24, showed staff assessed the resident as follows: -Moderate cognitive impairment; -Required moderate assist from staff for bathing, dressing, personal hygiene, bed mobility, transfers and ambulation in wheelchair; -Did not use oxygen; -Diagnosis of Dementia, asthma and respiratory failure. Review of the resident's Physician Order Sheet (POS), dated June 2024, showed physician orders: -Oxygen at two Liters Per Minute (LPM) per nasal cannula continuously, keep oxygen saturation above 92%, every shift for shortness of breath; -Budesonide Inhalation Suspension 0.5 milligrams (mg)/2 milliliters (ml), one vial inhale orally via nebulizer every 12 hours for 14 days. Review of the resident's care plan, dated 06/17/24, showed the care plan did not address the resident oxygen use and nebulizer use. Review of the resident's nurse's note, dated 5/23/24, showed Registered Nurse (RN) I documented the resident with diminished and coarse lung sounds. X-ray results state pneumonia and bronchitis. Review of the resident's face sheet, undated, showed staff documented the resident had a new diagnosis of pneumonia on 05/26/2024. Observation on 06/17/24 at 2:32 P.M., showed the resident in his/her room. The resident wore oxygen via nasal cannula from an oxyen concentrator. Observation showed an oxygen tank sat on the back of the resident's wheelchair with an unbaggged and uncovered nasal cannula wrapped around the tank. Observation 06/18/24 at 8:06 A.M., showed the resident not in his/her room. The resident's oxygen concentrator is on and the oxygen tubing and cannula laid directly on the resident's bed pad and sheets. The tubing is not bagged or covered. Observation on 06/18/24 at 8:52 A.M., showed the resident in his/her wheelchair, in his/her room. The resident wore oxygen from the tank on the back of his/her wheelchair. Certified Nurse Aide (CNA) B entered the resident's room to assist the resident to bed. The CNA assisted the resident from the wheelchair to the bed. The resident continued to wear oxygen tubing from the tank on the back of the wheelchair. The CNA picked up the oxygen tubing and nasal cannula from the resident's bed and placed the nasal cannula and oxygen tubing on the bedside table. The CNA then took the oxygen tubing from the tank off of the resident and placed it over the handle of the wheelchair. The CNA moved the wheelchair across room, placed the call light over the resident's lap and left the room. The CNA did not bag or cover the oxygen tubing or nasal cannula over the wheelchair handle or the tubing on the bedside table. The CNA did not place the nasal cannula from the concentrator on the resident before he/she left the room. Observation on 06/19/24 at 9:23 A.M., showed the resident in his/her bed with the nasal cannula from the concentrator in his/her nose, with wheelchair out of reach. The oxygen tank on the back of the wheelchair, has the oxygen tubing and nasal cannula hung over the handle, the tubing and nasal cannula are not bagged or covered. The nasal cannula hung an inch from the floor. Licensed Practical Nurse (LPN) N entered the resident's room and checked the resident's oxygen saturation. The resident has a nebulizer mask on his/her nightstand out of reach, it is not bagged or covered. No bags observed in the resident's room for oxygen tubing or nebulizer mask. The LPN left the resident's room and did not place the resident's oxygen tubing or nebulizer mask in a bag. Observation on 06/19/24 at 11:07 A.M., showed CNA K assisted the resident out of bed and into a wheelchair. The CNA placed the resident's oxygen tubing and nasal cannula on the sheet of the resident's bed. The resident asked to use the restroom. The CNA assisted the resident to the restroom without his/her oxygen. The CNA placed the resident in a new wheelchair without an oxygen tank, and propelled the resident out of his/her room. The CNA left the oxygen tubing from concentrator on the resident's bed, not bagged or covered and the oxygen tank tubing over the other wheelchair not bagged or covered. The CNA propelled the resident passed the nurse's station where LPN N sat and into the dining room with activities and left the resident without his/her oxygen. The resident repeatedly opened his/her mouth, yawned and took multiple deep breaths. During an interview on 06/19/24 at 11:26 A.M., the resident said he/she feels short of breath, but he/she is not able to run down to his/her room to get his/her oxygen. Observation on 06/19/24 at 11:32 A.M., showed the resident propelled himself/herself in his/her wheelchair to another dinning room table. The resident took deep breaths, opened his/her mouth wide and gasped for air multiple times. Observation on 06/19/24 at 11:37 A.M., showed LPN N entered the dining room and asked the resident where is his/her oxygen. The LPN said to the resident, he/she is supposed to be on continuous oxygen and the resident's hands are really cold. The LPN left the dining room, returned with an oxygen tank and placed the resident on oxygen. During an interview on 06/19/24 11:42 A.M., CNA K said he/she did not know the resident received continous oxygen. The CNA said he/she thought oxygen was only given in the resident's room. The CNA said information doesn't get passed down to the aides very well. Observation on 06/20/24 at 7:41 A.M., showed CNA K propelled the resident down the 300 hall with the oxygen tank on the back of the resident's wheelchair. Oxygen tubing and nasal cannula hung over the oxygen tank. The resident did not have oxygen in place. Observation on 06/20/24 at 10:05 A.M., showed the resident in bed, with nasal cannula from concentrator in his/her nostrils. Over 10 feet of oxygen tubing laid directly on the floor, with debris around the tubing. A nebulizer mask laid on the nightstand not bagged or covered. Observation on 06/20/24 at 10:09 A.M., showed Restorative Aide (RA) E switched the oxygen tank on the resident's old wheelchair to the resident's new wheelchair in the hallway, outside of the resident's room. The RA then took the wheelchair with the oxygen tank, back into the resident's room and the left the resident's room. The wheelchair is out of reach of the resident. The oxygen tubing is not bagged or covered. During an interview on 06/20/24 at 1:05 P.M., the RA said there should be plastic bags on the concentrators or tanks and staff are supposed to put the oxygen tubing in the plastic bag. The RA said he/she wasn't thinking, because there wasn't a plastic bag on the tank. The RA said he/she didn't think to get a plastic bag, normally he/she would go get a bag and label it, then put the tubing in it. The RA said not putting the nasal cannula in a bag creates the risk of infection. The RA said the resident has had a respiratory infection, but he/she doesn't know any details. The RA said nebulizer masks should have a plastic bag, not sure why it wasn't bagged, but he/she didn't notice it. The RA said excess oxygen tubing is not supposed to be on the floor, it needs to be picked up. The RA said he/she did notice all of the resident's excess tubing on the floor, and he/she probably should have picked it up. Observation on 06/20/24 at 11:32 A.M., showed the resident in bed with his/her call light on. The resident had oxygen on via concentrator and nasal cannula is in the resident's nostrils. CNA K entered the resident's room and took the nasal cannula out of the resident's nose and placed the nasal cannula directly on the sheet of the resident's bed. The back of the resident's pants are wet. The sheet the CNA placed the nasal cannula on had pieces of debris and had wet spots. The CNA propelled the resident out of room and left the resident's nasal cannula on the dirty sheets and the nebulizer mask on the end table not bagged or covered. During an interview on 06/20/24 at 11:49 A.M., CNA K said he/she doesn't even know what he/she is supposed to do with oxygen tubing. The CNA said he/she also doesn't know what to do with nebulizer masks either. The CNA said he/she just tries to keep it off the floor. The CNA said he/she doesn't bag or cover oxygen tubing or nebulizer masks at all, there isn't even a bag in the resident's room. During an interview on 06/20/24 at 1:00 P.M., the Director of Nursing (DON) said the resident used to have a bag in his/her room for oxygen tubing. The DON said he/she doesn't know what happened to it. 3. Review of Resident #52's Significant MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Dependent on staff for dressing, bed mobility, transfers and ambulation in wheelchair; -Required maximal assist from staff for bathing and personal hygiene; -Frequent incontinence of bowel and bladder; -Did not use oxygen. Review of the resident's POS, dated June of 2024, showed physician orders: -Oxygen at two LPM via nasal cannula every 24 hours as needed for shortness of breath; -Ipratroplum-Albuterol Inhalation Solution 0.5-2.5 MG/3 ML, 3 ML inhale orally four times a day for Pneumonia for five days. Review of the resident's nurse's notes, dated 06/19/24, showed staff documented the resident received antibiotics for pneumonia. Review of the resident's care plan, dated 06/18/24, showed staff documented the resident has oxygen therapy due to ineffective gas exchange. Observation 06/18/24 at 8:20 A.M., showed the resident in a reclined wheelchair in the dining room. Observation showed the resident's oxygen tubing and nasal cannula from the concentrator are on the resident's bed, not bagged or covered. Observation on 06/18/24 at 9:54 A.M., showed the resident's Broda chair with an oxygen tank on the back of the chair. The oxygen tubing and nasal cannula to the tank hung over the tank and not bagged or covered. Observation on 06/19/24 at 9:34 A.M., showed the resident's reclined wheelchair in the residents room with an oxygen tank on the back of the wheelchair. Observation showed the oxygen tubing and nasal cannula hung over the oxygen tank not bagged, or covered. The resident's nebulizer mask is out of the resident's reach on the bedside table and is not bagged, or covered. The nebulizer is not on and it had liquid in the container. Observation on 06/19/24 at 11:53 A.M., showed the residents the oxygen tubing and nasal cannula from concentrator hung over the bed by the headboard and the cannula touched the frame of the bed. Observation showd the tubing and nasal cannula not bagged or covered. CNA K entered the room and removed the nebulizer mask from the resident and placed the nebulizer mask and machine back on the nightstand. The CNA did not bag or cover the nebulizer mask, or oxygen tubing on the resident's bed. 4. During an interview on 06/20/24 at 1:11 P.M., LPN N said oxygen tubing should be rolled up and placed on a higher table so its not on the floor. The LPN said he/she thinks the nebulizer mask should be put up on the machine. The LPN said excess oxygen tubing should not be on floor and if it touches the floor staff should get a new one. The LPN said if oxygen tubing on the tanks is not in use, it should be off the floor and wrapped around the tank. The LPN said putting oxygen cannulas on a resident's sheet could contaminate it. There would be a risk of infection if it gets dirty and the resident breaths it in. The LPN said he/she did know if oxygen tubing should be stored in a bag when not in use. The LPN said he/she knew nebulizer masks should be bagged. The LPN said he/she does not know why the residents did not have bags for their oxygen and nebulizer tubing and masks. The LPN said he/she did see Resident #3's oxygen tubing on the floor yesterday, he/she picked it up and placed on the table. The LPN said he/she didn't think to replace the oxygen tubing, he/she was busy. During an interview on 06/20/24 at 2:46 P.M., the DON said oxygen tubing should be kept off the floor and maintained in bags for coverage. The DON said he/she wants staff to curl up the oxygen tubing and ensure it is not on the floor, if a bag is not available. The DON said the staff can put the oxygen tubing on the bedside table and go get a bag. The DON said he/she expects staff to do the same thing for nebulizer masks and oxygen tubing for oxygen tanks. The DON said if oxygen tubing is on floor, staff need to roll it up and place on the bedside table, or bed, staff don't have to get new tubing unless its the nasal cannula touching the floor. The DON said he/she does not know why there is not bags in the resident rooms for oxygen tubing and nebulizer masks. The DON said there is a problem with keeping the bags in the resident rooms. The DON said he/she would have to look up Resident #3's order for oxygen. The DON said if a resident is on continuous oxygen, staff would have to remove the nasal cannula for changing clothes or transfers, but for the majority of the time the resident should be on oxygen. The DON said he/she expects the use of oxygen to be on a resident's care plan.

Based on observation, interview and record review, the facility staff failed to allow sanitized dishes to air dry prior to stacking in storage and use to prevent the growth of food-borne pathogens and cross-contamination. Facility staff also failed to serve drinks to residents at meals in a sanitary manner and perform hand hygiene as often as necessary to prevent cross-contamination. The facility census was 52. 1. Review of the facility's Dish and Utensil Handling policy, undated, showed the policy directed staff to air dry dishes, cups and glasses prior to storage. Observations on 04/04/23 at 11:07 A.M., showed Dietary Aide (DA) C removed sanitized insulated plate holders and dome covers from the clean side of mechanical dishwashing station while wet, stacked them together and stored them on a service cart. Observation also showed six insulated plate holders and 12 domes covers stacked together wet on the cart. During an interview on 04/04/23 at 12:24 P.M., the Dietary Manager (DM) said staff should allow dishes to dry before they are stacked and put away. Observations on 04/04/23 during the lunch meal service, which began at 12:37 P.M., showed staff used the wet stacked plate holders and dome covers to serve plates of food to residents who ate in their rooms. Observation on 04/06/23 at 10:23 A.M., showed three plastic service trays stacked together wet on a storage shelf on the clean side of the mechanical dishwashing station. During an interview on 04/06/23 at 10:34 A.M., the administrator said staff should allow clean dishes to air dry before they are put away and they staff are trained on that requirement. The administrator said the cook and DM are responsible to monitor the washing and storage of dishes daily. 2. Review of the facility's Handwashing and Glove Usage policy, undated, showed the policy directed staff to wash their hands upon entering the kitchen, between tasks, before and after they handle foods, and after they touch any part of their uniform, face or hair, and before and after they work with an individual resident. Review also showed the policy directed staff to use gloves whenever direct food contact is required. Observations on 04/04/23 from 12:22 P.M. to 12:35 P.M., showed an unidentified staff member placed his/her bare hands on the dining table, picked up a cup by the rim with his/her bare hand and delivered the cup to a resident. Observation showed the staff member then picked up a resident's eye glasses and placed them on the resident's face. Observation showed the staff member went back to the drink cart, picked up a cup by the rim with his/her bare hand, delivered it to a resident and then repeated the process for another resident. Observation showed the staff member did not wear gloves when he/she handled the cups by the rims or perform hand hygiene in between tasks. Observations on 04/06/23 from 7:15 A.M. to 7:25 A.M., showed the DM served drinks to residents in the dining room. Observation showed the DM picked up the glasses of drinks with his/hands over the tops of the drinks and his/her fingers touched the rims of the glasses. Observation also showed the DM put his/her hands in his/her pockets to obtain an item, entered the kitchen, filled up a pitcher with ice water and returned to the dining room to serve drinks to residents without performing hand hygiene. Observation on 04/06/23 from 11:58 A.M. to 12:08 P.M., showed DA C poured milk into a cup, touched the top of the cup with his/her bare hand and delivered the cup to a resident. Observation showed the DA returned to the drink cart, touched items on the drink cart, lifted a cup by the rim with his/her bare hand to prepare a drink and then delivered the drink to a resident. Observation showed the DA again returned to the drink cart, picked up another cup by the rim with his/her bare hand, put his/her hand into the ice pitcher and used a plastic cup to retrieve ice, placed the ice in the cup and then gave the cup to a resident. Observation showed the DA did not wear gloves when he/she handled the cups by the rims or perform hand hygiene in between tasks. Observation on 04/06/23 at 12:00 P.M., showed an unidentified staff member picked up a cup from the drink cart by the rim with his/her bare hand, put a beverage in the cup and then delivered the drink to a resident. Observation showed the staff member returned to the drink cart, picked up a cup by the rim with his/her bare hand and delivered it to a resident. Observation showed the staff member again returned to the drink cart, touched items on the cart, scooped up ice with a plastic cup while his/her fingers touched the side of the ice pitcher, filled two cups with the ice and a beverage and then delivered the drinks to the residents. Observation showed the staff member did not wear gloves when he/she handled the cups by the rims or perform hand hygiene in between tasks. During an interview on 04/06/23 at 7:25 A.M., the DM said staff should grab glasses by the sides and not the tops when they serve drinks to residents. The DM said he/she was half awake and did not realize he/she served the residents drinks with his/her hand over the tops of the glasses. The DM also said staff should wash their hands between dirty and clean tasks and after they touch anything dirty. During an interview on 04/06/23 at 10:35 A.M., the administrator said staff should wash their hands before food preparation and any time they make their hands dirty, which would include putting their hands in their pockets or touching their bodies. The administrator said staff should hold the bottom of glass to give residents their drinks; not with their hands over the tops or rims of the glass. The administrator said the staff are trained on this requirement and the DM and nursing staff are responsible to monitor food service and hand hygiene during food served. 37131

Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident areas were in good repair and clean. The facility census was 52. 1. Review of the policies provided by the facility showed they did not contain a policy for environmental concerns. Observation on 4/4/23 at 11:35 A.M. showed room [ROOM NUMBER] with an unpainted dry wall patch approximately two feet in length behind the bed. Observation on 4/4/23 at 3:09 P.M., showed Resident #50's room with gouges on the wall behind the bed. Further observation showed gouge marks and black marks on the wall at the foot of the bed. Observation on 4/5/23 at 10:01 A.M., showed Resident #1's room with food and debris on floor, and gouges on the wall behind the bed. Further observation showed the resident's bedside table, and refrigerator with a thick layer of dust. During an interview on 4/5/23 at 10:01 A.M., Resident #1 said staff don't clean his/her room enough. The resident said hasn't cleaned his/her room in at least three days. Observation on 4/6/23 at 9:05 A.M., showed Resident #33's bed rested against the wall in his/her room. Further observation showed an unsanded dry wall patch approximately four feet in length behind the bed. Observation on 4/5/23 at 10:22 AM., showed room [ROOM NUMBER] with a dirty floor and brown marks on the shower floor and shower chair. Further observation showed black marks on the walls and the door trim. Observation on 4/7/23 at 10:47 A.M., showed the room with a dirty floor and brown marks on the shower floor and shower chair. Further observation showed black marks on the walls and the door trim. Observation on 4/6/23 at 8:28 A.M., showed room [ROOM NUMBER] with debris on the floor and bedside table, and a white substance on the seat and arm of the resident's chair. Further observation showed the walls with gouges, chipped paint and black marks. Observation on 4/7/23 at 10:47 A.M., showed the room with debris on the floor and bedside table, and a white substance on the seat and arm of the resident's chair. Further observation showed the walls with gouges, chipped paint and black marks. During an interview on 4/7/23 at 9:28 A.M., the Maintenance Director said staff should document environmental concerns on the form hanging on the wall. He/She said he/she conducts monthly room audits, and is currently working on repairing the rooms on the 200 hall. The Maintenance Director said he/she completed repairs on the 300 hall about two months. He/She said staff has not reported any issues in room [ROOM NUMBER] or 304. During an interview on 4/7/23 at 10:07 A.M., Certified Nurse Aide (CNA) N and CNA O said staff should report environmental and housekeeping concerns to the charge nurse. They said they had not noticed the any rooms with holes or gouges in the walls. During an interview on 4/07/23 at 10:26 A.M., the Housekeeping Supervisor said the resident's rooms are cleaned daily. He/She said the housekeepers have a cleaning list they fill out daily and turn in to him/her, and she checks the rooms before he/she leaves for the day. He/She said the rooms including the bathrooms should be dusted, wiped down and sanitized, swept, and mopped daily. The Housekeeping Supervisor said staff should report any needed room repairs by filling out the maintenance for on the clipboard. During an interview on 4/7/23 at 10:13 A.M., Registered Nurse (RN) H said staff should report environmental issues to the Maintenance Director or document the information on the clipboard. He/She said staff should notify housekeeping or clean up messes if they see them. During an interview on 4/7/23 at 10:47 A.M., the Housekeeping Supervisor said he/she doesn't know who is responsible to clean the chair in room [ROOM NUMBER]. He/She said she/he just cleaned the floor yesterday, and noticed the debris around the chair and the bedside table. He/She said he/she has not cleaned room [ROOM NUMBER] in a couple of days. He/She said he/she knows the floor is disgusting and the shower needs to be cleaned.

Based on observation, interview, and record review, facility staff failed to ensure the resident's environment remained free of accident hazards when they failed to properly propel seven residents (Resident #10, #20, #22, #25, #33, #40, and #58) in wheelchairs in a manner to prevent accidents. The facility census was 52. Review of the facility's Wheelchair, Use of policy, undated, showed: -The purpose is to provide mobility for the non-ambulatory residents with safety and comfort; -Encourage and instruct resident in proper guidelines for safely propelling the wheelchair; -Place foot pedals in position and ensure feet are resting on the foot pedals when staff are propelling resident distances. 1. Review of Resident #10's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/10/23, showed staff assessed the resident as: -Severe Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/4/23 at 12:41 P.M., showed an unidentified staff member propelled the resident in a wheelchair from the dining room to the restroom without the use of foot pedals. Observation on 4/4/23 at 1:00 P.M., showed an unidentified staff member propelled the resident in a wheelchair from the hallway to the dining room. Further observation showed the resident's feet touched the floor. Observation on 4/5/23 at 8:51 A.M., showed the Activity Director (AD) propelled the resident in a wheelchair down the hallway without the use of foot pedals. Further observation showed the resident's feet slid on the floor. 2. Review of Resident #20's Quarterly MDS, dated [DATE] showed staff assessed the resident as: -Moderate Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/4/23 at 11:26 A.M., showed Certified Nurse Aide (CNA) I propelled the resident in a wheelchair without foot pedals. 3. Review of Resident #22's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/5/23 at 8:44 A.M., showed CNA G propelled the resident in a wheelchair from the dining room to the nurses' station without the use of foot pedals. Observation on 4/5/23 at 8:48 A.M., showed the AD propelled the resident in a wheelchair without the use of foot pedals. 4. Review of Resident #25's admission MDS, dated [DATE] showed staff assessed the resident as: -Severe Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/4/23 at 12:33 P.M., showed CNA I propelled the resident in wheelchair without foot pedals. Observation on 4/5/23 at 8:54 A.M., showed CNA D propelled the resident from the nurses' station to his/her room without the use of foot pedals. Further observation showed the resident's right foot slid on the floor. Observation on 4/6/23 at 8:49 A.M., showed License Practical Nurse (LPN) J propelled the resident in a wheelchair without foot pedals. Further observation showed the resident wore non-skid socks and his/her feet touched the floor. 5. Review of Resident #33's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/4/23 at 1:19 P.M., showed CNA F propelled the resident quickly from the dining room to his/her room without the use of foot pedals. Further observation showed the resident's feet touched the floor and bent backwards. Observation on 4/6/23 at 8:42 A.M., showed CNA E propelled the resident from the dining room to his/her room, back into the hall, and then back to his/her room, without the use of foot pedals. Further observation showed the resident's feet slid on the floor. 6. Review of Resident #40's Annual MDS, dated [DATE] showed staff assessed the resident as: -Severe Cognitive Impairment; -Used a wheelchair for mobility. Observation on 4/5/23 at 8:55 A.M., showed CNA D propelled the resident in a wheelchair without the use of foot pedals. Further observation showed the resident's foot slid on the floor. Observation on 4/6/23 at 8:53 A.M., showed LPN J propelled the resident in a wheelchair without the use of foot pedals. Further observation showed the resident wore non-skid socks and his/her feet touched the floor. Observation on 4/6/23 at 8:57 A.M., showed LPN J propelled the resident in a wheelchair without the use of foot pedals. Further observation showed the resident's feet touched the floor. 7. Review of Resident #58's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Used a wheelchair for mobility. Observation on 4/7/23 at 8:54 A.M., showed CNA D propelled the resident in a wheelchair from the nurses' station to his/her room without the use of foot pedals. Further observation showed the resident's right foot slid on the floor. During an interview on 4/6/23 at 8:47 A.M., the Director of Nursing (DON) said staff should monitor the position of the residents' feet when being propelled in wheelchairs. He/She said staff do not always have to use foot pedals when propelling residents. The DON said foot pedals are not required if the resident is able to propel themselves. The DON said he/she believed cognitively impaired residents are able to hold their feet up when propelled in wheelchairs. He/She said if staff do not use foot pedals the resident could be injured or fall if their feet touch the floor. During an interview on 4/6/23 at 11:18 A.M., the DON said staff should use foot pedals if the residents' feet touched the floor. He/She said the standard is if a resident can hold their legs up, the staff member can propel the resident without foot pedals. During an interview on 4/7/23 at 10:09 A.M., CNA O said staff should use foot pedals when propelling a resident in a wheelchair. During an interview on 4/7/23 at 10:13 A.M., Registered Nurse (RN) H said staff are expected to use foot pedals when propelling a resident in a wheelchair. He/She said the resident could be injured if foot pedals are not used, because the resident's foot could get in the wheels. During an interview on 4/6/23 at 8:52 A.M., the Administrator said staff are expected to use foot pedals when propelling residents if the resident is unable to hold their feet up. He/She said the resident's cognition and physical abilities dictate whether or not staff use foot pedals. He/She said if a resident has a cognitive impairment it is up to the staff member to determine whether or not foot pedals should be used. He/She said if a staff member is propelling a resident and their foot touches the floor the resident could be thrown forward, or their feet could get tangled in the wheels of the wheelchair. The Administrator said staff has not been educated on wheelchair safety in the past 10 months.

37131 Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #33) had an appropriate indication for the use of anti-psychotic medications. Additionally staff failed to provide a 14-day stop date for as needed (PRN) antianxiety medication, for six residents (Residents #5, #33, #34, #37, #50 and #52). The facility census was 52. 1. Review of the facility's Psychotropic Medication Use Policy, dated September 2022, showed: -Residents will only receive psychotropic medications when necessary to treat specific conditions for which they are indicated and effective; -Antipsychotic medications shall generally be used only for the following conditions/diagnosis as documented in the record, consistent with the definition in the Diagnostic and Statistical Manual of Mental Disorder; -The timeframe for PRN psychotropic medications, which are not Antipsychotic medications will be limited to 14 days unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner; -The timeframe for PRN psychotropic medications which are Antipsychotic medications will be limited to 14 days. A new order will not be entered without the physician or prescriber first evaluating the resident. 1. Review of Resident #33's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool dated 3/14/23, showed staff assessed the resident as: -Severe cognitive impairment; -No behaviors; -Received Antipsychotic medication seven out of seven days in look back period; -Diagnoses of Stroke, Dementia, Anxiety Disorder, and Depression. Review of the resident's Physician Order Sheet (POS), dated April 2023, showed an order dated 1/27/23 for Zyprexa (Antipsychotic) 5 milligram (mg) tablet, two times a day for Dementia. Review of the resident's medical record showed it did not contain an appropriate diagnosis for the use of an Antipsychotic medication. During an interview on 4/07/23 and 11:29 A.M., Registered Nurse (RN) P said, he/she does not know if Dementia is an appropriate diagnosis for Antipsychotic medications, he/she can not diagnose or prescribe medications. During an interview on 4/07/23 at 11:34 A.M., Director of Nursing (DON) said Dementia on it's own is not an appropriate diagnosis for Antipsychotic, but if there is certain behavioral symptoms, it is. During an interview on 4/07/23 and 11:28 A.M., the administrator said dementia is not an appropriate diagnosis to receive an Antipsychotic medication. 2. Review of Resident #5's quarterly MDS, dated [DATE], showed staff assessed the resident as: - Severely cognitively impaired; - No behaviors; - Received antianxiety medication seven days of the seven day look back period (period of time used to complete the assessment); - Diagnoses of heart failure, end stage renal disease (ESRD - permanent kidney failure that requires a regular course of dialysis or a kidney transplant), respiratory failure, dementia, anxiety and depression. Review of the resident's Physician Order Sheet (POS), dated April 2023, showed an order dated 3/26/23 for Lorazepam (to treat anxiety) 0.25 milliliters (ml) administered every two hours as needed (PRN). Further review showed it did not contain documentation of a stop date. 3. Review of Resident #33's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Did not have behaviors; -Received Antianxiety medication seven days of the seven day look back period; -Diagnoses of Stroke, Dementia, Anxiety Disorder, Depression. Review of the resident's POS, dated April 2023, showed an order to administer Lorazepam Oral Concentrate 2 MG/ML (Lorazepam), Give 0.25 ml by mouth every 2 hours as needed for anxiety related to Generalized Anxiety Disorder. Further review, showed a start date of the medication as 3/26/23 and the POS did not contain a stop date for the medication. 4. Review of Resident #34's significant change MDS, dated [DATE], showed staff assessed the resident as: - Severely cognitively impaired; - No behaviors; - Received Antipsychotic and antidepressant medications seven days of the seven day look back period; - Diagnoses of ESRD, stroke, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and depression. Review of the resident's POS, dated April 2023, showed an order dated 3/26/23 for Lorazepam 0.25 ml administered every two hours PRN for anxiety. Further review showed it did not contain documentation of a stop date. 5. Review of Resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Behaviors daily; -Received Antianxiety medication seven out of seven days in look back period; -Received Antidepressant medication seven out of seven days in look back period; -Diagnoses of Anxiety Disorder, and Depression. Review of the resident's POS, dated April 2023, showed an order to administer Lorazepam Oral Concentrate 2 MG/ML, Give 0.25 ml by mouth every 2 hours as needed for anxiety related to Generalized Anxiety Disorder. Further review, showed a start date of the medication as 4/3/23 and the POS did not contain a stop date for the medication. 6. Review of Resident #50's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Severe cognitive impairment; -Verbal behaviors directed towards others four to six days in seven day look back period; -Received Antipsychotic medication seven out of seven days in look back period; -Received Antidepressant medication seven out of seven days in look back period; -Diagnoses of Anxiety Disorder, Dementia and Schizophrenia. Review of the resident's POS, dated April 2023, showed an order to administer Lorazepam Oral Concentrate 2 MG/ML, Give 0.25 ml by mouth every 2 hours as needed for anxiety related to Generalized Anxiety Disorder. Further review, showed a start date of the medication as 4/3/23 and the POS did not contain a stop date for the medication. 7. Review of Resident #52's Admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -No behaviors or psychosis; -Did not reject care; -Did not receive an anti-anxiety medication during the seven day look back period. Review of the resident's POS, dated 2/14/23, showed an order for Lorazepam 0.25 ml administered every three hours PRN. Further review showed it did not contain documentation of a stop date. Review of the resident's care plan, dated 3/13/23, showed it did not contain direction for staff in regard to the resident receiving an anti-anxiety medication. 8. During an interview on 4/07/23 and 11:29 A.M., RN P said PRN orders for antianxiety medication is for seven days and then the medications get reevaluated. The RN said the medications have a seven day stop date. The RN said the residents on hospice do not have a stop date, because the residents are on hospice. The RN said he/she did not know hospice residents had to have a 14 day stop date, he/she thought it is different for residents on hospice. During an interview on 4/07/23 at 11:34 A.M., DON said PRN antianxiety medications should be limited to 14 days. The DON said hospice does not have stop dates, because staff reviewed with practitioner and they chose not stop them. The DON said he/she had addressed not having stop dates for hospice residents with the physician and hospice. During an interview on 4/7/23 and 11:28 A.M., the administrator said psychotropic medications administered PRN, should only be administered for 14 days and have a stop date. He/She said the physician should be contacted if the medication is needed for more than 14 days to obtain an extension. He/She said the DON is responsible to ensure medication administered on PRN basis are required to have a stop date. He/She said he/she conducted an in-service a few months ago educating staff on the requirement to get a stop date on PRN medication. He/She said he/she did not know residents were prescribed psychotropic medication without a stop date. 42815

Based on interview and record review, the facility staff failed to screen three new employees out of ten employee files reviewed, prior to employment to determine if any had a Federal indicator with the Nurse Aide Registry which would prohibit employment at the facility. The facility census was 41. 1. Review of the facility's Abuse, Prevention and Prohibition Policy, dated 11/2018 showed facility staff are directed as follows: The facility will not knowingly employ individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties. A person at a supervisory level will interview potential employees. All employees will have criminal background checks, state and federal required checks, employment reference checks (previous and current), and license/certification confirmation. The facility will make reasonable efforts to uncover information about any past criminal prosecutions. The facility will report any knowledge it has of actions by a court of law against an employee, which would indicate that they are unfit for service as a nurse aide or other facility staff, to the nurse aide registry, licensing authorities or other mandated state agencies. The facility will prescreen potential residents for behaviors, needs and personal histories, which might lead to conflict, neglect, or abuse. 2. Review of Receptionist D's employee file showed a hire date of 11/09/18. Further review showed the file did not contain a pre-employment Nurse Aide registry check. 3. Review of Housekeeper E's employee file showed a hire date of 12/17/20. Further review showed the file did not contain a pre-employment Nurse Aide Registry check. 4. Review of Registered Nurse (RN) F's employee file showed a hire date of 10/20/20. Further review showed the file did not contain a pre-employment Nurse Aide Registry check. 5. During an interview on 03/24/21 at 10:21 A.M., the business office manager (BOM) said he/she is responsible for checking staff's pre-employment records but did not know what the nurses aide registry is or that it needed to be checked for every employee, not just Certified Nurse Assistants (CNA)s. 6. During an interview on 03/24/21 at 10:35 A.M., the Director of Nursing (DON) said she was not aware all employees must have the nurse aide registry check before employment. 7. During an interview on 03/24/21 at 10:35 A.M., the administrator said she was unaware all employees must have the nurse aide registry checked before employment.

Based on interview and record review, facility staff failed to notify the resident and/or resident representative in writing of a facility initiated transfer to a hospital, including the reasons for the transfer, for three sampled residents (Resident #20, #43, and #45). The facility census was 40. 1. Review of Resident #20's Discharge Return Anticipated Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 1/12/21, showed the resident was discharged to the hospital. Review of the resident's medical record showed the resident was discharged due to injuries sustained in a fall. Further review showed record did not contain documentation the resident or resident representative were notified of the transfer or the reason for the move in writing. 2. Review of Resident #43's Discharge Return Not Anticipated MDS, dated [DATE], showed the resident was discharged to the hospital. Review of the resident's medical record showed the resident was discharged due to elevated potassium levels. Further review showed the record did not contain documentation the resident or resident representative were notified of the of the transfer or the reason for the move in writing. 3. Review of Resident #45's Discharge Return Anticipated (MDS), dated [DATE], showed the resident was discharged to the hospital. Review of the resident's medical record showed the resident was discharged due severe pain in the hip and leg. Further review showed the record did not contain documentation the resident or resident representative were notified of the of the transfer or the reason for the move in writing. During an interview on 3/25/21 at 10:00 A.M., the social service designee said the facility does not send a written notice of discharge and he/she was not aware the facility needed to do so. Documents related to transfers or discharge are the social workers responsibility. During an interview on 3/25/21 at 10:15 A.M., the Director of Nursing (DON) said they were not aware the facility was required to provide a written notice of discharge to residents or their representative. During an interview on 3/25/21 at 10:20 A,M., the administrator said the facility does not provide a written notice of transfer to residents or their representatives.

Based on observation, interview and record review, and in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for 2019 Novel Coronavirus Disease (COVID-19), the facility failed to protect residents in the facility by not following acceptable infection control practices for COVID-19. The facility failed to separate three positive Coronavirus Disease 19 (Covid-19) residents (Resident #18, #24 and #30) from three residents (Resident #17, #23 and #31) who tested negative for Covid-19 or had only been exposed to Covid-19, and failed to separate 19 positive Coronavirus Disease 19 (Covid-19) residents (Resident #2, #4, #8, #13, #15, #16, #19, #20, #22, #28, #29, #33, #34, #35, #36, #37, #38, #40 and #41) from 18 residents who had tested negative for Covid-19 or had only been exposed to Covid-19. This put nine residents (#3, #5, #11, #12, #14, #21, #25, #42 and #43) at an increased risk of contracting Covid-19. The facility census was 43. The administrator was notified on 11/10/20 of an immediate jeopardy (IJ) which began on 10/27/20. The IJ was removed on 11/10/20, as confirmed by surveyor on site verification. Review of the CDC's Coronavirus Disease 2019 (COVID-19) Responding to Coronavirus (COVID-19) in Nursing Homes, Resident Cohorting, updated 4/30/20, showed: -Determine the location of the COVID-19 care unit and create a staffing plan before residents or healthcare personnel (HCP) with COVID-19 are identified in the facility. This will allow time for residents to be relocated to create space for the unit and to identify HCP to work on this unit; -Facilities that have already identified cases of COVID-19 among residents but have not developed a COVID-19 care unit, should work to create one unless the proportion of residents with COVID-19 makes this impossible (e.g., the majority of residents in the facility are already infected); -Place signage at the entrance to the COVID-19 care unit that instructs HCP they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms; -Ensure that HCP have been trained on infection prevention measures, including the use of and steps to properly put on and remove recommended PPE; -Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing -Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents; -If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit; -Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other resident unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit); -Exposed resident may be permitted to room share with other exposed residents if space is not available for them to remain in a single room; -HCP should use all recommended COVID-19 PPE for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents. The CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (Covid-19) Pandemic Infection Control Guidance, updated 7/15/20, recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 (Covid-19) infection showed: -Place a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection in a single-person room with the door closed, and the patient should have a dedicated bathroom; -As a measure to limit Health Care Personnel (HCP) exposure and conserve personal protective equipment (PPE), facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shift. -It might not be possible to distinguish patients who have Covid-19 from patients with other respiratory viruses. As such, patients with different respiratory pathogens might be cohorted (the practices of grouping together patients who are infected with the same organism to confine their care to one area and prevent contact with other patients) on the same unit. However, only patients with the same respiratory pathogen may be housed in the same room. For example, a patient with Covid-19 should ideally not be housed in the same room as a patient with an undiagnosed respiratory infection or a respiratory infection caused by a different pathogen. Review of the CDC's Preparing for COVID-19 in Nursing Homes, updated 11/20/20, showed core practices should include: -Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19; -Have a plan for how residents in the facility who develop COVID-19 will be handled. Residents in the facility who develop symptoms consistent with COVID-19 could be moved to a single room pending results of [DIAGNOSES REDACTED]-CoV-2 testing. They should not be placed in a room with a new admission and should not be moved to the COVID-19 care unit unless they are confirmed to have COVID-19 by testing. While awaiting results of testing, HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and gown when caring for these residents. Cloth face coverings are not considered PPE and should only be worn by HCP for source control, not when PPE is indicated; -Have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them). Review of the facility's Action Plan- COVID-19, dated 9/24/20, showed each community will develop a plan that includes a separate, identified area or group of rooms that will be utilized and dedicated for residents that meet the following: -Recovery Area Residents- newly admitted or readmitted to the community that have been tested and are laboratory confirmed Covid-19 positive and current residents that have been tested and are Covid-19 positive, these two areas will be in separate areas within each community; -A plan for consistent staffing for each of these skilled nursing facility (SNF) units will be developed to the best of the ability of the community; -Restrict resident to room as much as possible, except for medically necessary purposes; -Services provided should be with the room door closed. 1. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #18 tested positive on 10/21/20. The report did not contain Resident #17. Observation on 10/27/20 at 03:15 P.M., showed Resident #18 shared a room with Resident #17 on the 200 hall. Further observation showed an isolation cart outside of the room, a sign on the door to check with the nurse before entering and the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. During an interview on 11/9/20 at 03:00 P.M., the Director of Nursing (DON) verified the Covid-19 positive report shows the residents who test positive, and said if the resident's name was not on the list, they did not test positive. 2. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #24 tested positive on 10/24/20. The report did not contain Resident #23. Observation on 10/27/20 at 11:22 A.M., showed Resident #24 shared a room with Resident #23 on the 200 hall. Further observation showed an isolation cart outside of the room, a sign on the door to check with the nurse before entering and the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. During an interview on 11/9/20 at 03:00 P.M., the DON said Resident #23 tested positive on 11/2/20. He/She verified the Covid-19 positive report shows the residents who test positive, and said if the resident's name was not on the list, they did not test positive. 3. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #30 tested positive on 10/24/20. The report did not contain Resident #31. Observation on 10/27/20 at 03:15 P.M., showed Resident #30 shared a room with Resident #31 on the 200 hall. Further observation showed an isolation cart outside of the room, a sign on the door to check with the nurse before entering and the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. During an interview on 11/9/20 at 03:00 P.M., the DON said Resident #31 tested positive on 10/26/20. He/She verified the Covid-19 positive report shows the residents who test positive, and said if the resident's name was not on the list, they did not test positive. 4. Observation on 10/27/20 at 11:27 A.M., showed the 100, 200 and 300 hall did not contain fire doors or other structure barriers to create a natural barrier to physically separate a Covid-19 positive area within the facility. All halls contained both Covid-19 positive and Covid-19 negative residents. 5. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #4 tested positive on 10/21/20. Observation on 10/27/20 at 12:01 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. Further observation showed an isolation cart outside of the room, a sign on the door to check with the nurse before entering. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. 6. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #8 tested positive on 10/21/20. Observation on 10/27/20 at 12:01 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. Further observation showed an isolation cart outside of the room, a sign on the door to check with the nurse before entering. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. 7. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #33 tested positive on 10/17/20. Observation on 10/27/20 at 12:05 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. Additionally, the resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. 8. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #36 tested positive on 10/17/20. Observation on 10/27/20 at 12:05 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. The resident could be heard coughing from the hallway and the resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. Observation on 10/27/20 at 03:14 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. During an interview on 10/27/20 at 02:48 P.M., the resident said he/she tested positive for Covid-19 and his/her door is open all the time. Additionally, the resident coughed multiple times during the interview. 9. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed the report did not contain Resident #42. Observation on 10/27/20 at 12:05 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. During an interview on 11/9/20 at 03:00 P.M., the DON verified the Covid-19 positive report shows the residents who test positive, and said if the resident's name is not on the list, they did not test positive. 10. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #37 tested positive on 10/22/20. Observation on 10/27/20 at 12:05 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. 11. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #43 tested positive on 10/22/20. Observation on 10/27/20 at 12:05 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. Observation on 10/27/20 at 03:14 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. During an interview on 10/27/20 at 12:23 P.M., the resident said he/she tested positive for Covid-19 and his/her door is open all the time. 12. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #13 tested positive on 10/24/20. Observation on 10/27/20 at 03:14 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. Further observation showed an isolation cart outside of the room, a sign on the door to check with the nurse before entering. Additionally, the resident could be heard coughing from the hallway and the resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. Observation on 10/27/20 at 04:33 P.M., showed the resident in his/her room sitting in a wheelchair not wearing a mask with the door to the room open. Additionally, the resident could be heard coughing from the hallway. 13. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed the report did not contain Resident #14. Observation on 10/27/20 at 03:14 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. Additionally, the resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. During an interview on 11/9/20 at 03:00 P.M., the DON verified the Covid-19 positive report shows the residents who test positive, and said if the resident's name was not on the list, they did not test positive. 14. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #19 tested positive on 10/21/20 and Resident #20 tested positive on 10/24/20. Observation on 10/27/20 at 03:14 P.M., showed Resident #19 shared a room with Resident #20 on the 200 hall and the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. 15. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed the report did not contain Resident #21. Observation on 10/27/20 at 03:14 P.M., showed the resident in his/her room not wearing a mask with door to the room open. Additionally, the resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. During an interview on 11/9/20 at 03:00 P.M., the DON verified the Covid-19 positive report shows the residents who test positive, and said if the resident's name was not on the list, they did not test positive. 16. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #22 tested positive on 10/21/20. Observation on 10/27/20 at 03:14 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. 17. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed the report did not contain Resident #25. Observation on 10/27/20 at 03:14 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. During an interview on 11/9/20 at 03:00 P.M., the DON verified the Covid-19 positive report shows the residents who test positive, and said if the resident's name was not on the list, they did not test positive. 18. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #29 tested positive on 10/24/20. Observation on 10/27/20 at 03:14 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. 19. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed the report did not contain Resident #3. Observation on 10/27/20 at 03:14 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. During an interview on 11/9/20 at 03:00 P.M., the DON verified the Covid-19 positive report shows the residents who test positive, and said if the resident's name was not on the list, they did not test positive. 20. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed the report did not contain Resident #5. Observation on 10/27/20 at 03:14 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. During an interview on 11/9/20 at 03:00 P.M., the DON verified the Covid-19 positive report shows the residents who test positive, and said if the resident's name was not on the list, they did not test positive. 21. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed the report did not contain Resident #11. Observation on 10/27/20 at 03:14 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. During an interview on 11/9/20 at 03:00 P.M., the DON verified the Covid-19 positive report shows the residents who test positive, and said if the resident's name was not on the list, they did not test positive. 22. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed the report did not contain Resident #12. Observation on 10/27/20 at 03:14 P. M., showed the resident in his/her room not wearing a mask with the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. During an interview on 11/9/20 at 03:00 P.M., the DON verified the Covid-19 positive report shows the residents who test positive, and said if the resident's name was not on the list, they did not test positive. 23. Review of the facility's Covid-19 Positive Report, dated 10/27/20, showed Resident #40 tested positive on 10/17/20. Observation on 10/27/20 at 03:14 P.M., showed the resident in his/her room not wearing a mask with the door to the room open. The resident's room was on a hall with both Covid-19 positive and Covid-19 negative residents. 24. During an interview on 10/27/20 at 11:27 A.M., the minimum data sheet (MDS) coordinator said the Covid-19 hall was originally the 300 hall. During an interview on 10/27/20 at 12:49 P.M., LPN B said staff wear gowns, gloves, N95 masks, goggles/facemask for the residents that tested positive and the positive and negative residents are scattered throughout the building on 100, 200 and 300 halls. He/She said we have negatives roomed with positives, but we keep the curtain closed. He/She said he/she didn't know if the residents' room doors should be closed. During an interview on 10/27/20 at 01:00 P.M., the MDS coordinator said staff wear N95 masks at all times. The residents have to wear a mask if they come out of their room. The residents eat their meals in their rooms and the meals are brought to the residents by the kitchen staff. The Covid-19 hall started on the 300 hall and when it became full, residents were moved to the 200 hall and now they are everywhere. He/She said staff are treating everyone like they have Covid-19. Staff wear a gown, gloves, mask and face shield when in resident rooms. Covid-19 positive residents' doors should be shut; he/she said he/she didn't know why the doors were open. During an interview on 10/27/20 at 3:20 P.M., CNA C said staff wear N95 masks, gowns goggles and gloves when in resident rooms. He/She said staff change gloves and gowns when they go in a new room. The CNA said during orientation he/she was told the doors need to be shut because residents keep trying to come out. During an interview on 10/27/20 at 4:45 P.M., the interim administrator said the facility was following the medical director's advice to treat everyone like they are Covid-19 positive. He/She said Covid-19 positive and negative residents were scattered throughout the facility. During an interview on 11/9/20 at 03:00 P.M., the DON said he/she did not know why the positive and negative residents were in the same room. He/She said after the first set of positive residents the 200 hall was full. The DON said as more residents tested positive, staff decided to treat everyone like they were positive. He/She said this was their first time with positive residents and he/she didn't get further direction, and I just didn't know. The DON verified the Covid-19 positive report shows the residents who test positive, and said if the resident's name was not on the list, they did not test positive. NOTE: At the time of the survey, the violation was determined to be at the immediate and serious jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

Based on observation, interview and record review, the facility failed to provide an ongoing program of activities designed to meet the resident's interests for five residents (Resident #11, #19,# 22, and #48). The facility census was 44. 1. Review of Resident # 19's admission Minimum Data Sheet (MDS), a federally mandated assessment tool used to plan care, dated 11/03/19 showed staff assessed the resident as follows: - Brief Interview for Mental Status (BIMS) of 10 (moderately impaired cognition); - Required extensive, one person assistance with locomotion; - Required total, two person assistance with mobility and transfer; - Activity preference very important to listen to music; - Activity preference somewhat important to participate in religious services, favorite activities, do things with groups of people, have books, newspapers or magazines to read. Review of the resident's medical record showed staff did not document the resident participated in an activity after 11/15/19. Review of the resident's care plan, dated 08/29/19, showed staff are directed as follows: -Attempt to find ongoing activities of preference and dislikes; -Offer and encourage daily activities; -Offer 1:1 when the resident doesn't want to attend group sessions. Observation on 12/10/19 at 03:44 P.M., showed a sign in the dining room, bingo on Monday and Thursday at 2:00 P.M. During an interview on 12/11/19 at 09:37 [NAME]M., the resident said the facility does not have a lot of activities to participate in and there aren't activities offered on the weekends. He/She said there is bingo on Tuesday and Thursday and they do not offer daily activities since the activity director quit. The resident said he/she would like more activities. 2. Review of Resident # 22's admission MDS, dated [DATE], showed staff assessed the resident as follows: - BIMS 10; - Required limited, one person assistance with mobility, transfer and locomotion; - Activity preference very important to do favorite activities; -Activity preference somewhat important to listen to music, keep up with the news, go outside and participate in religious services. Review of the resident's medical record showed staff did not document the resident participated in an activity after 11/15/19. Review of the resident's care plan, dated 10/03/19, showed staff are directed as follows: -Attempt to find ongoing activities of preference and dislikes; -Offer and encourage daily activities; -Offer 1:1s when resident doesn't want to attend group sessions. Observation on 12/11/19 at 10:16 [NAME]M., showed multiple residents sitting in the hall by the nurses station. Additional observation showed staff did not have an activity planned for the morning. During an interview on 12/11/19 at 09:41 [NAME]M., the resident said there are not enough activities at the facility and there are none offered on the weekend. The resident said he/she has not participated in activities since the activity director left and would like more activities to participate in. 3. Review of Resident #11's admission MDS, dated [DATE], showed staff assessed the resident as follows: -BIMS of 12 (moderately impaired cognition); -Totally dependent on two persons with transfer; -Required limited assistance of one person with locomotion on unit and locomotion off unit; -Activity preference is very important to participate in religious activities and do favorite activities; -Activity preference is somewhat important to have books, newspapers, and magazine to read, listen to music, keep up with the news, do things with groups of people, and go outside. During an interview on 12/11/19 at 10:59 AM, the resident said he/she is offered church activities once a week and bingo. He/She said there are occasions when there aren't staff to provide activities for residents. The resident said he/she wants to participate in activities. 4. Review of Resident # 48's significant change MDS, dated [DATE], showed staff assessed the resident as follows: -BIMS of 13 (cognitively intact); -Required extensive assistance of one person with bed mobility, transfer, walk in corridor, and locomotion on/off unit; -Required supervision with walking in room; -Activity preference is important, have books, newspapers, and magazines to read; -Activity preference is very important to listen to music, go outside, and participate in religious services or practices; -Activity preference is somewhat important, keep up with news, do thing with groups, and do favorite activity; -Activity preference is not very important to be around animals. During an interview on 12/11/19 on 11:18 AM, resident said staff offer very few activities, except bingo, but only on a couple of days during the week. The resident said he/she wants to participate in the activities. 5. During an interview on 12/11/19 at 11:51 [NAME]M., the Director of Nursing (DON) said they have not had an activity director for two to three weeks. He/She said they have some activities that were already scheduled, and a couple of family members do bingo twice a week. The DON said they don't have an activity calendar for the month of December, they don't have an activity assistant and no one in the facility has taken over the resident activities. During an interview on 12/11/19 at 12:00 P.M., Certified Nurse Assistant (CNA) D said he/she has worked at the facility for a month and a half and the activity director quit about a week later and there aren't any activities for the residents. He/She said one of the resident's family member does bingo twice a week. During an interview on 12/12/19 at 9:22 [NAME]M., CNA D said the facility does not have an activity director. He/She said the residents tell him/her they are bored. The CNA said,Wouldn't you be if you didn't have anything to do all day?

Based on observation, interview and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were given late. There were 25 opportunities with 25 errors made, for an error rate of 100 %. This affected two sampled residents (Resident #37 and #43) and four non sampled residents (Resident # 2, #18, #25 and #27) The facility census was 44. 1. Review of the facility policy Adverse Consequences and Medication Errors revised 2014 showed a medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. Additionally, medication errors include medications given at the wrong time. 2. Review of Resident # 37's Physician Order Sheet (POS), dated 12/01/19 showed: -A [DIAGNOSES REDACTED]. -an order for [REDACTED].; -an order for [REDACTED]. and 8:00 P.M.; -an order for [REDACTED]., 11:30 [NAME]M. and 4:30 P.M.; -an order for [REDACTED].; -an order for [REDACTED]. and 8:00 P.M.; -an order for [REDACTED]. Observation on 12/10/19 at 9:29 [NAME]M., showed Registered Nurse (RN) A did not give the resident's medications within the allotted time frame as ordered. Additionally, the electronic Medication Administration Record [REDACTED]. medications are late after 9:00 [NAME]M. 3. Review of Resident # 27's POS, dated 12/01/19, showed: -A [DIAGNOSES REDACTED]. -an order for [REDACTED]. and 5:00 P.M.; -an order for [REDACTED].; -an order for [REDACTED].; -an order for [REDACTED]., 12:00 P.M., 4:00 P.M. and 8:00 P.M.; -an order for [REDACTED]. Review of the resident's Pharmacy Progress Note, dated 10/9/19 showed the pharmacy staff documented Sinement works best when given at a specific time to avoid low drug levels. Observation on 12/10/19 at 9:37 [NAME]M., showed RN A did not give the resident's medications within the allotted time frame as ordered. Additionally, the electronic MAR indicated [REDACTED]. medications are late after 9:00 [NAME]M. 4. Review of Resident #2's POS, dated 12/01/19 showed: -A [DIAGNOSES REDACTED]. -An order Calcium 600/ Vitamin D one tablet orally every day at 8:00 [NAME]M.; -an order for [REDACTED].; -an order for [REDACTED].; -an order for [REDACTED].; -an order for [REDACTED].; -an order for [REDACTED].; -an order for [REDACTED]. Observation on 12/10/19 at 9:47 [NAME]M., showed RN A did not give the resident's medications within the allotted time frame as ordered. Additionally, the electronic MAR indicated [REDACTED]. medications are late after 9:00 [NAME]M. 5. Review of Resident #25's POS, dated 12/1/19 showed: -A [DIAGNOSES REDACTED]. -an order for [REDACTED].; -an order for [REDACTED]. and 5:00 P.M.; -an order for [REDACTED]. Observation on 12/10/19 at 10:52 [NAME]M., showed RN A did not give the resident's medications within the allotted time frame as ordered. Additionally, the electronic MAR indicated [REDACTED]. medications are late after 9:00 [NAME]M. 6. Review of Resident #18's POS, dated 12/01/19 showed: -A [DIAGNOSES REDACTED]. -an order for [REDACTED]. Observation on 12/11/19 at 10:22 [NAME]M., showed Licensed Practical Nurse (LPN) B did not give the resident's medications within the allotted time frame as ordered. Additionally, the electronic MAR indicated [REDACTED]. medications are late after 9:00 [NAME]M. Additionally, the LPN did not wash or sanitize his/her hands between residents. 7. Review of Resident # 43's POS, dated 12/01/19 showed: -A [DIAGNOSES REDACTED]. -an order for [REDACTED].; -an order for [REDACTED]. and 5:00 P.M.; -an order for [REDACTED]. Observation on 12/11/19 at 10:35 [NAME]M., showed Licensed Practical Nurse (LPN) B did not give the resident's medications within the allotted time frame as ordered. Additionally, the electronic MAR indicated [REDACTED]. medications are late after 9:00 [NAME]M. 8. During an interview on 12/11/19 at 04:19 P.M., showed RN A said the [NAME]M. medication pass is at 8:00 [NAME]M. and staff have an hour before and an hour after the time in the computer to give the medications. He/She said medications given after 9:00 [NAME]M. are late and staff should make a note why they are late. The RN said a medication error is when staff give the wrong medication, to the wrong person, the wrong dose and the wrong time frame. The RN said he/she tells the Director of Nurses (DON) when there is a medication error, writes an incident report and notifies the family and doctor.

Based on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene during incontinent care for three residents (Resident # 16, #32 and #52), and failed to perform proper catheter care for one resident (Resident # 19). The facility census was 44. 1. Review of the facility's Handwashing policy, dated (MONTH) of 2010, showed the purpose is to reduce transmission of organisms from resident to resident, nursing staff to resident, and resident to nursing staff. Review of the facility's Gloves Policy, dated (MONTH) (YEAR), instructs staff to wear gloves when it can reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances (blood, urine, feces, wound drainage, oral secretions, sputum, vomitus, or items/surfaces soiled with these substances) and/or persons with a rash. Dirty gloves are worse than dirty hands because microorganisms adhere to the surface of a glove easier than to the skin on your hands. 2. Review of Resident #16's Minimum Data Set (MDS), a federally mandated assessment tool used to plan care, dated 9/11/19, showed staff assessed the resident as follows: -Required supervision to transfer; -Required limited assistance by one staff person to toilet and for personal hygiene. Observation on 12/10/19 at 03:16 P.M., showed Certified Nurse Assistant (CNA) C did not wash his/her hands in between glove changes during perineal care for the resident. 3. Review of Resident #52's MDS, dated [DATE], showed staff assessed the resident required extensive assistance from two or more staff persons to transfer, toilet and for personal hygiene. Observation on 12/11/19 at 10:06 [NAME]M., showed CNA F did not change his/her gloves after he/she performed perineal care or before he/she assisted the resident to dress and transfer with a Hoyer (mechanical) lift. 4. Review of Resident #32's admission MDS dated [DATE], showed staff assessed the resident as follows: -History of contractures; -Always incontinent of bowel and bladder; -Extensive physical assistance from one staff person; -BIMs of 14 (cognitively intact). Observation on 12/10/19 at 11:22 [NAME]M. showed CNA [NAME] washed his/her hands and donned gloves to provide care for the resident. Additional observation showed the CNA removed the resident's brief soiled with feces. The CNA did not change his/her gloves or wash his/her hands after he/she removed the soiled brief. Additionally, the CNA did not use a new area of the wipe each time he/she wiped the resident and used the same soiled glove to apply barrier cream, reposition and cover the resident. 5. Review of Resident # 19's admission MDS, dated [DATE] showed staff assessed the resident as follows: -Brief Interview for Mental Status (BIMS) of 10 (moderately impaired cognition); -Required extensive, one person assistance with personal hygiene; -Required total, two person assistance with mobility and transfer and toilet use; -Has a catheter. Observation on 12/11/19 at 11:03 [NAME]M., showed CNA D wiped around the resident's supra pubic catheter insertion site multiple times with the same area of the wipe. 6. During an interview on 12/12/19 at 12:08 P.M., CNA D said he/she washes his/her hands before providing care and before leaving resident's room. CNA D said he/she changes his/her gloves after providing peri care and before changing residents clothing. During an interview on 12/12/19 at 12:16 P.M., LPN B said he/she educates the aides to wash their hands when entering a resident's room, after providing care, and before leaving the room. He/She said staff should wash their hands after disposing of dirty linens. The LPN said staff are required to wash their hands before and after providing feeding assistance. During an interview on 12/12/19 at 12:41 P.M., the Director of Nursing (DON) said she instructs staff to wash their hands upon entry of residents' rooms, put on gloves, change gloves between different types of care and then wash their hands.