AVIR AT MONAHANS

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible and includes ensuring that the resident could receive care and services safely and that the physical layout of the facility maximized resident independence and did not pose a safety risk for 1 of 4 hallways (hall 100) and 1(Resident #2) of 3 residents reviewed for clean homelike environment. <BR/>1. The facility failed to ensure Hallway 1 did not smell of urine. <BR/>2. The facility failed to ensure Resident #2 did not have a dirty bed linens. <BR/>These failures could place residents at risk of residing in an unsafe, unsanitary, and uncomfortable environment. <BR/>Findings include:<BR/>1. Observation on 02/24/25 at 8:14 AM, with the Administrator, revealed her coming down hallway 1 to get state agency. Walking down the hallway smelled of urine. <BR/>During an interview on 02/25/25 at 4:50 PM, with the Administrator, she stated the day the state survey agency was in hallway 1 and went to get him she could smell the odor of urine in the hallway. The Administrator stated the urine smell was strong and was inappropriate and she would not like being in a place where it smelled like urine. The Administrator stated that housekeeping was responsible for cleaning and should have cleaned the urine smell. <BR/>2. Observation on 02/24/25 at 8:21 AM, revealed, Resident #2's white bed sheets had a large brown unknown substance on it. <BR/>During an interview on 02/24/25 at 2:09 PM with Resident #2, she stated the facility staff went to change out her bed sheets. Resident #2 did not respond and turned her head away, when asked about the brown unknown substance on the bed sheets. The interview was terminated. <BR/>During an interview on 02/25/25 at 10:24 AM with the DON, she stated the CNAs were to be checking the resident beds to ensure they were clean and made. The DON stated it was not okay to have dirty or stained sheets. The DON stated it was a dignity issue. <BR/>During an interview on 02/25/25 at 10:44 AM with CNA C, she stated when residents got up for the day the bed sheets, if they were dirty were picked up and changed for new ones. CNA C stated the residents deserved clean sheets and it was unsanitary to leave them on the bed. CNA C stated it was everyone's responsibility for ensuring the bed sheets were clean and changed. <BR/>During an interview on 02/25/25 at 4:50 PM with the Administrator, she stated it was the responsibility of the CNAs to change the bed sheets for the residents. The Administrator stated it was inappropriate for the resident to have dirty and or stained sheets. The Administrator stated it was a dignity issues for the residents. <BR/>During an interview on 02/27/25 at 8:27 AM with CNA A, she stated staff were expected to change the bed sheets of the residents. CNA A stated this was to keep it clean and sanitized which was the responsibility of the CNAs. CNA A stated any dirty or stained sheets would not be appropriate and she would not like it if she had dirty or stained sheets. <BR/>Record review of the facility's Homelike Environment Policy, dated 02/2021, revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Clean, sanitary, and orderly environment, inviting colors and d&eacute;cor, clean bed and bath linens that are in good condition.

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible and includes ensuring that the resident could receive care and services safely and that the physical layout of the facility maximized resident independence and did not pose a safety risk for 1 of 4 hallways (hall 100) and 1(Resident #2) of 3 residents reviewed for clean homelike environment. <BR/>1. The facility failed to ensure Hallway 1 did not smell of urine. <BR/>2. The facility failed to ensure Resident #2 did not have a dirty bed linens. <BR/>These failures could place residents at risk of residing in an unsafe, unsanitary, and uncomfortable environment. <BR/>Findings include:<BR/>1. Observation on 02/24/25 at 8:14 AM, with the Administrator, revealed her coming down hallway 1 to get state agency. Walking down the hallway smelled of urine. <BR/>During an interview on 02/25/25 at 4:50 PM, with the Administrator, she stated the day the state survey agency was in hallway 1 and went to get him she could smell the odor of urine in the hallway. The Administrator stated the urine smell was strong and was inappropriate and she would not like being in a place where it smelled like urine. The Administrator stated that housekeeping was responsible for cleaning and should have cleaned the urine smell. <BR/>2. Observation on 02/24/25 at 8:21 AM, revealed, Resident #2's white bed sheets had a large brown unknown substance on it. <BR/>During an interview on 02/24/25 at 2:09 PM with Resident #2, she stated the facility staff went to change out her bed sheets. Resident #2 did not respond and turned her head away, when asked about the brown unknown substance on the bed sheets. The interview was terminated. <BR/>During an interview on 02/25/25 at 10:24 AM with the DON, she stated the CNAs were to be checking the resident beds to ensure they were clean and made. The DON stated it was not okay to have dirty or stained sheets. The DON stated it was a dignity issue. <BR/>During an interview on 02/25/25 at 10:44 AM with CNA C, she stated when residents got up for the day the bed sheets, if they were dirty were picked up and changed for new ones. CNA C stated the residents deserved clean sheets and it was unsanitary to leave them on the bed. CNA C stated it was everyone's responsibility for ensuring the bed sheets were clean and changed. <BR/>During an interview on 02/25/25 at 4:50 PM with the Administrator, she stated it was the responsibility of the CNAs to change the bed sheets for the residents. The Administrator stated it was inappropriate for the resident to have dirty and or stained sheets. The Administrator stated it was a dignity issues for the residents. <BR/>During an interview on 02/27/25 at 8:27 AM with CNA A, she stated staff were expected to change the bed sheets of the residents. CNA A stated this was to keep it clean and sanitized which was the responsibility of the CNAs. CNA A stated any dirty or stained sheets would not be appropriate and she would not like it if she had dirty or stained sheets. <BR/>Record review of the facility's Homelike Environment Policy, dated 02/2021, revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Clean, sanitary, and orderly environment, inviting colors and d&eacute;cor, clean bed and bath linens that are in good condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 4 residents (Resident #3) reviewed for accuracy of MDS assessment. <BR/>The facility failed to ensure Resident #3's quarterly MDS, dated 01/2025, accurately reflected the residents' behaviors. <BR/>This deficient practice could place residents at risk of not receiving adequate care.<BR/>Findings include:<BR/>Record review of Resident #3's face sheet, dated 02/25/25, revealed an admission to the facility on [DATE] and re-admission on [DATE] to the facility. <BR/>Record review of Resident #3's hospital history and physical, dated 07/05/24, revealed a [AGE] year-old male with diagnoses which included Wernicke-Korsakoff disorder (a life-threatening brain disorder caused by a severe deficiency of thiamine, or vitamin B1), Dementia, and anxiety disorder. <BR/>Record review of Resident #3's MDS, dated 01/2025, revealed a moderate cognitive impairment BIMS score of 12 to recall and or make daily decisions. Behaviors were not coded for any behaviors.<BR/>Record review of Resident #3's Care Plan, dated 03/30/23, revealed Problem: Resident has verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others). Resident will verbalize understanding of need to control verbal abusive behaviors. Maintain a calm, slow, understandable approach. Remove resident from group activities when behavior was unacceptable. <BR/>During an interview on 02/26/25 at 10:54 AM with the MDS Coordinator, she stated Resident #3 had behaviors in 01/25 and the MDS did not reflect this in the Behavioral Section (E) of the MDS. The MDS Coordinator stated the MDS was incorrect for Resident #3's 01/2025 MDS assessment. The MDS Coordinator stated the negative outcome could be the inaccurate MDS would create an inaccurate care plan and billing would not be accurate. The MDS Coordinator stated it was her responsibility for ensuing the MDS assessment was accurate and correct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive person-centered care plan for each resident , consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment which were to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 4 of 4 residents (Resident #3, Resident #4, Resident #5, Resident #6) reviewed for care plans.<BR/>1. The facility failed to implement a comprehensive person-centered care plan for Resident #3's physical altercation with Resident #4 on 07/10/24. <BR/>2. The facility failed to implement a comprehensive person-centered care plan for Resident #4's incident on 07/10/24 with Resident #3 in which Resident #3 physical hit Resident #4. <BR/>3. The facility failed to implement a comprehensive person-centered care plan for Resident #5's physical altercation with Resident #6 on 07/21/24.<BR/>4. The facility failed to implement a comprehensive person-centered care plan for Resident #6's incident on 07/21/24 with Resident #5 in which Resident #5 physical hit Resident #6. <BR/>These deficient practices could place residents at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include:<BR/>1. Record review of Resident #3's face sheet, dated 02/25/25, revealed an admission to the facility on [DATE] and re-admission on [DATE]. <BR/>Record review of Resident #3's hospital history and physical, dated 07/05/24, revealed a [AGE] year-old male with diagnoses which included Wernicke-Korsakoff disorder (a life-threatening brain disorder caused by a severe deficiency of thiamine, or vitamin B1), Dementia, and anxiety disorder. <BR/>Record review of Resident #3's MDS dated 01/2025, revealed a moderate cognitive impairment BIMS score of 12 to recall and or make daily decisions. <BR/>Record review of Resident #3's Care Plan, dated 03/30/23, revealed Problem: Resident has verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others). Resident will verbalize understanding of need to control verbal abusive behaviors. Maintain a calm, slow, understandable approach. Remove resident from group activities when behavior was unacceptable. <BR/>During an interview on 02/25/25 at 9:46 AM with the DON, she stated Resident #3 had an incident on 07/10/24 in which he hit another resident. The DON stated she did not see Resident #3 had a focus area care planned for the incident in which he had a physical behavior. The DON stated the purpose of the care plan was to direct staff as far as the resident had a problem or condition and to provide to care. The DON stated the negative outcome of not having it care planned would be staff not monitoring for and where and how to intervene. The DON stated for Resident #3 the staff would not know to intervene if he had a physical behavior placing the other residents at risk. The DON stated the MDS department, and the nurses were responsible ensuring the comprehensive care plans were accurate. <BR/>During an interview on 02/25/25 at 3:00 PM with the Administrator, she stated Resident #3 had an incident on 07/10/24, were he hit another resident. The Administrator stated she would have to check to see if it was care planned and should have been care planned. The Administrator stated if it was not documented in the care plan it did not happen. The Administrator stated the purpose of the care plan was to inform the resident or representative party of a complete picture of the care the resident was being provided. <BR/>The Administrator stated the negative outcome would be the resident or the representative party would be they would not make informed decisions that were mindful. The Administrator stated the DON, and the Social Worker were responsible for ensuring the care plans were accurate. <BR/>2. Record review of Resident #4's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Resident #4 was a [AGE] year-old male with diagnoses which included Diabetes Mellitus, chronic pain due to trauma, major depressive disorder.<BR/>Record review of Resident #4's Care Plan, reviewed on 02/25/25, revealed there was no focus area nor interventions in place for the resident-to-resident altercation on 07/10/24. <BR/>During an interview on 02/25/25 at 9:46 AM with the DON, she stated she did not see the interventions care planned for Resident #4 any focus area or interventions for the incident he had with Resident #3 on 07/10/24 in which they got into a physical altercation. <BR/>3. Record review of Resident #5's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Resident #5 was a [AGE] year-old female which diagnoses which included Cerebral Palsy and intellectual disabilities. <BR/>Record review of Resident #5's annual MDS, dated [DATE], revealed there was no BIMS score taken to measure the cognition of impairment of the resident. <BR/>Record review of Resident #5's care plan, reviewed on 02/25/25, revealed there was not a focus area or interventions documented for the altercation on 07/21/24 with Resident #6. <BR/>Record review of Resident #5's progress notes, dated 07/21/24, revealed Another resident in wheelchair refuse to give a different resident the cordless phone state, 'This was her phone. She was not giving it up.' This resident struck another resident in the face with a closed fist and began crying, both residents were separated and taken to their rooms.<BR/>During an interview on 02/26/25 at 10:54 AM with MDS Coordinator, she stated there were not interventions or focus areas in the care plan for Resident #5's altercation with Resident #6 on 07/21/24. <BR/>During an interview on 02/27/25 at 10:28 AM with the DON, she stated Resident #5 had a physical altercation with Resident #6 in which she hit her while trying to get the phone. The DON stated it was not care planned for both Resident #5 and Resident #6. <BR/>4. Record review of Resident #6's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Resident #6 was an [AGE] year-old female with a diagnosis which included anxiety disorder. <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], revealed a severely impaired cognition BIMS score of 7. Resident #6 was able to recall or make daily decisions. Resident #6 had diagnoses which included dementia, anxiety and depression. <BR/>Record review of Resident #6's care plan, reviewed on 02/25/25, revealed there was no focus area or interventions documented for the incident with the physical altercation incident on 07/21/24. <BR/>During an interview on 02/26/25 at 10:54 AM, with the MDS Coordinator, revealed the MDS department and the DON were responsible for the care plans and ensuring they were accurate. The MDS Coordinator stated the purpose of a care plan was to provide the best service for the resident and if the resident had a problem, then the care plan would address the steps to help provide the best care for the resident. The MDS Coordinator stated Resident #3 and Resident #4 did not have focus areas with interventions addressed to each resident with their specific incident. The MDS Coordinator stated the risk would be the facility staff not knowing how to care for the resident(s).<BR/>Record review of the facility's Comprehensive Assessments Policy, dated 10/2023, revealed Comprehensive MDS assessments are conducted to assist in developing person-centered care plans. The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using the Resident Assessment Instrument specified by CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 5 (Resident #3) reviewed for pharmacy services.<BR/>The facility failed to record Tramadol-50 mg Schedule IV tablet was given to Resident #3 at 7:30 AM per physician orders in the narcotic logbook. <BR/>This failure could place residents at risk for being over mediated which could result in medical complications and drug diversion. <BR/>Findings include:<BR/>Record review of Resident #3's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. <BR/>Record review of Resident #3's hospital history and physical, dated 07/05/24, revealed a [AGE] year-old male with diagnoses which included Wernicke-Korsakoff disorder (a life-threatening brain disorder caused by a severe deficiency of thiamine, or vitamin B1), Dementia and anxiety disorder. <BR/>Record review of Resident #3's MDS, dated 01/2025 revealed, a moderate cognitive impairment BIMS score of 12. Resident #12 was able to recall and or make daily decisions. <BR/>Record review of Resident #3's Orders, dated 09/18/23, revealed Tramadol - Schedule IV tablet- 50 mg oral four times a day. at 7:30AM, 1:00PM, 7:30PM, 1:00AM. <BR/>Observation and interview on 02/26/25 at 12:49 PM with the MA, she stated observed logging on the bingo card (medication card) and then looked at the narcotic logbook. The MA was seen writing down that tramadol was given in the morning and then writing med error next to it. The MA stated she forgot to log down the tramadol -50 mg which was given in the morning to Resident #3 at 7:30 AM. MA stated it was expected to log it in the narcotic logbook and not doing it would be considered a medication error. <BR/>During an interview on 02/26/25 at 1:19 PM with the Physician, he stated narcotic medications were given had to be documented on the narcotic logbook as it was being taken out to be given. The Physician stated logging the narcotic that was taken out was for counting purposes and had to be documented in the narcotic logbook. The Physician stated a negative outcome would be the count would be wrong and would not know if the resident received the medication. <BR/>During an interview on 02/26/25 at 4:37 PM with the RN , she stated the medication aides gave the narcotics to the residents. The RN stated they were to fill out the narcotic logbook as it was given. The RN stated this was to prevent another nursing staff member from coming by and giving the resident more medication causing the resident to be overly medicated. The RN stated it would also be a med error . <BR/>During an interview on 02/27/25 at 11:40 AM, with the DON, he stated Resident #3 had an order for Tramadol-50 mg. The DON stated when giving the medication since it was a narcotic, it had to be logged in the narcotic logbook at the same time it was going to be given. The DON stated not logging it in the narcotic logbook would throw off the bingo card (the medication card) and show that it was off by one medication pill. The DON stated the risk would be the resident could be over mediated or the medication could be stolen by facility staff. <BR/>Record review of the facility's Administering Medications Policy, dated 04/2019, revealed Medications are administer in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. Medications errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training .

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 washing machine and 1 of 4 resident wheelchair brakes reviewed for essential equipment. <BR/>1. The facility did not provide necessary repairs for 1 industrial washing machines.<BR/>2. The facility failed to ensure Resident #1's wheelchair brakes were not broken <BR/>These failures could place residents at risk of not having clean clothes to wear and place residents at risk of function mobility and injuries. <BR/>Findings include:<BR/>Observation and interview on 02/24/25 at 8:40 AM with Resident #1 revealed the right wheelchair brake would not disengage, and the handle was observed loose. Resident #1 was observed trying to move his wheelchair with his right arm/hand and moving slowly and veins in his arm could be seen popping out of his right arm/hand. Resident #1 did not have any legs as they were amputated. <BR/>During an interview on 02/24/25 at 2:31 PM Resident #1 stated he told RN on 02/23/25 in the evening that his wheelchair brake was broken. Resident #1 stated she told him okay and walked away. <BR/>During an interview on 02/25/25 at 10:44 AM with CNA C, she stated the maintenance department had a maintenance logbook by their office to put in work orders for broken items. CNA C stated it was expected for everyone to put work orders in the maintenance logbook for broken items. CNA C stated not doing so could be a hazard to the residents. <BR/>Observation and interview on 02/25/25 at 2:41 PM with the DON revealed, the DON looked at Resident #1's wheelchair brake. Resident #1 was observed giving the DON the screw and another metal piece in the DON's hand. The DON stated she was not notified of the broken wheelchair brake and was generally notified of issues. The DON stated it was expected of the nursing staff to report any broken equipment to the charge nurse, physician and the DON. The DON stated the equipment should be pulled and not used and looked at. The DON stated by looking at Resident #1's broken right wheelchair brake, it was not reported as it should have been done. The DON stated the risk was mobility and injury. <BR/>Observation and interview on 02/25/25 at 2:49 PM with the Maintenance Director revealed the Maintenance Director observed Resident #1's right wheelchair brake. The Maintenance Director stated he verbally gave an in-service to the facility on how to report broken items. The Maintenance Director stated there was a maintenance logbook in which they were to write down the name, date, time of the broken item (work orders). The Maintenance Director stated sometimes the staff told him of the broken items (work orders), but it was expected for the facility staff to document it in the maintenance logbook because he did have a lot of work and might forget to fix it. The Maintenance Director stated the risk for Resident #1 would be him rolling off the wheelchair and affect his mobility. <BR/>During an interview on 02/25/25 at 4:50 PM with the Administrator, she stated if something was broken then it needed to be removed until it was fixed. The Administrator stated if it was reported to them about the broken wheelchair brake then they could have removed it and got a rental wheelchair for Resident #1. The Administrator stated it was expected and the responsibility of the staff and everyone to report broken items. The Administrator stated the risk for Resident #1 could be him hurting himself .<BR/>During an interview on 02/26/25 at 4:56 PM with RN, she stated she was notified of the broken right wheelchair brake from Resident #1. The RN stated she asked Resident #1 how long the wheelchair brake had been broken and Resident #1 had told her he had already reported it. The RN stated she did not confirm it had been reported nor did she log it in the maintenance logbook. The RN stated it was expected to be place work orders in the maintenance logbook for broken items. The RN stated the facility staff was trained on how to place work orders. The RN stated the risk would be Resident #1 having a fall. <BR/>During an interview on 02/27/25 at 12:03 PM with the DON, she stated the facility staff were trained and in-serviced on placing work orders. The DON stated it was expected for staff to be placing it in the work order logbook. The DON stated she saw the broken blinds and had reported it in the morning meeting and during stand down meeting but failed to place it in the work order logbook .<BR/>Record review of the facility's Maintenance Service Policy, dated 12/2009, revealed Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to: maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. Maintain the building in good repair and free from hazards. Maintain the heat/cooling system, plumbing fixtures, wiring etc., in good working order. The Maintenance Director was responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Records shall be maintained in the maintenance director's office. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.<BR/>Record review of the facility's Work orders, Maintenance Policy, dated 04/2010, revealed, Maintenance work orders shall be completed in order to establish a priority of maintenance service. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 2 of 2 (Broken blinds), 2 warped tiles, 3 holes in the walls, 1 exit door missing sweep of 4 exit doors, and 1 of 1 maintenance log reviewed for environment.<BR/>1. The facility failed to ensure the blinds were not broken.<BR/>2. The facility failed to ensure floor tiles were not warped.<BR/>3. The facility failed to ensure there were not holes in hallway 3 and a hole in the hall leading to the back smoking patio/laundry room.<BR/>4. The facility failed to ensure the hallway 1 Exit door was not missing a sweep and created a seal on the mid-top side of the door to not expose the outside elements. <BR/>5. The facility staff failed to input broken items into the maintenance work order log. <BR/>These failures could residents at risk of living, working and visiting in an unsafe, unsanitary, and uncomfortable environment. <BR/>Findings include:<BR/>Observation on 02/24/25 at 8:04 AM revealed in hallway 1 in room [ROOM NUMBER] the blinds were broken. <BR/>Observation on 02/24/25 at 8:21 AM revealed in room [ROOM NUMBER] had broken blinds. <BR/>Observation on 02/24/25 at 8:37 AM revealed in hallway 3 there was a large scrap hole on the bottom wall just above the border near room [ROOM NUMBER] around a foot or more in length. On the opposite side of the wall towards the back smoking/patio hall was another hole just above the border around 4-5 inches in lengths and around 2-3 inches wide. On the floor was two long warped floorboards with 2 wheelchairs next to them. <BR/>During an interview on 02/2/525 at 4:30 PM with the Administrator, she stated the washer and drier had broken down. The Administrator stated the facility fixed the drier and was sending resident clothes to the laundry mat until the washer got fixed. The Administrator stated the residents had their clothes washed and cleaned. <BR/>During an interview on 02/25/25 at 4:50 PM with the Administrator, she stated if something was broken then it needed to be removed until it was fixed. The Administrator stated the staff were to report it and the department heads would remove the broken item. The Administrator stated it was expected and the responsibility of the staff and everyone was to report broken items. The Administrator stated not reporting broken items could be a risk of residents hurting themselves. <BR/>During an interview on 02/26/25 at 9:12 AM with the Maintenance Director, he stated the residents were always breaking the blinds and the facility staff placed work orders in the maintenance logbook. The Maintenance Director stated the exit door in hallway 1 was not reported and was missing the seep on the bottom of the door as there was a black blanket placed. The Maintenance Director stated the risk of having the blanket on the floor could be impeding the resident's movement to go outside. The Maintenance Director stated he could see the light coming from outside on the side of the exit door as it was not creating a seal preventing the outside weather and pest from coming into the facility. The Maintenance Director stated the broken walls in hallway 3 were not reported to him and it was not in the maintenance logbook. The Maintenance Director stated the floorboards in hallways 3 had been reported to him a couple of weeks ago but was waiting on corporate to see how they were going to fix it. The Maintenance Director stated it was a fall hazard. The Maintenance Director stated the washer had been broken for about 2-3 weeks and was fixed but the water came out to fast that it overflowed and leaked back onto the laundry room. The Maintenance Director stated the risk would be structural damage and could be creating an environment suitable for mold and pests.<BR/>Observation and interview on 02/26/25 at 2:54 PM with the DON, revealed she observed the hallway 1 exit door with the black blanket on the floor. The DON was observed looking through the opening of the exit door that was not creating a seal. The DON was observed going to hallway 3 and looking at the holes in the wall and the hole near the smoking back patio area. The DON was observed looking at the floorboards in hallway 3 that were warped. The DON was observed looking at the towel on the floor in the laundry room placed around the washers. The DON stated the blanket on the floor of the exit door in hallway 1 created a trip hazard. The DON stated the holes on the wall were reported two weeks ago and should have been fixed. The DON stated the floorboards were a trip and fall risk. The DON stated the water leaking over into the laundry room could be a trip hazard. <BR/>During an interview on 02/26/25 at 4:37 PM with RN, she stated the washer was broken for about two weeks and the facility was washing the residents' clothes at the laundry mat. The RN stated she noticed there were towels on the floor around the washers in the laundry room to prevent the water from overflowing into the laundry room. The RN stated the risk would be slippery of the ground for someone walking by creating a hazard for the residents. The RN stated it could also create mold due to the humidity in the laundry room with the drier and water and possibly invite pests. <BR/>During an interview on 02/27/25 at 9:05 AM with LVN B, she stated the facility had a binder in which facility staff could place the work orders. LVN B stated it was expected to put the room number, date, and time it was reported to maintenance. LVN B stated an in-service was provided about placing work orders. LVN B stated it was expected for the facility staff to be placing work orders for broken items in the facility. LVN B stated the negative outcome would be for safety. <BR/>During an interview on 02/27/25 at 12:03 PM with the DON, she stated the facility staff were trained and in-serviced on placing work orders. The DON stated it was expected for staff to be placing it in the work order logbook. The DON stated she saw the broken blinds and reported it in the morning meeting and during stand down meeting but failed to place it in the work order logbook. <BR/>Record review of the facility's maintenance work order log, dated 02/26/25, revealed there was no documentation of work orders for walls being broken, broken blinds, washer/dryer break downs, hallway 1 exit door sweep missing and a gap with the exit door and building mid door. <BR/>Record review of the facility's Maintenance Service Policy, dated 12/2009, revealed Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to: maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. Maintain the building in good repair and free from hazards. Maintain the heat/cooling system, plumbing fixtures, wiring etc., in good working order. The Maintenance Director was responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Records shall be maintained in the maintenance director's office. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.<BR/>Record review of the facility's Work orders, Maintenance Policy dated 04/2010, revealed Maintenance work orders shall be completed in order to establish a priority of maintenance service. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for three of eight residents (Resident #1, #2, and #3) reviewed for infection control.<BR/>1. MA A touched Resident #3's pills with her bare hands during medication administration. <BR/>2. LVN B failed to prevent cross contamination between Residents #1 and #2 by brining in uncleaned diabetic supplies from one room to another. <BR/>These failures could place resident's risk for cross contamination and the spread of infection. <BR/>Finding included:<BR/>Review of Resident #3's CCD dated 11/01/23, revealed a 90- year- old female admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation (heart does not beat with a regular beat all the time) and acute respiratory failure (person cannot get enough oxygen). <BR/>Review of Resident #3's MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of 11 indicating moderately impaired cognition. <BR/>Review of Resident #3's Care Plan dated 12/10/24 revealed Resident #3 was at risk for frequent infections. <BR/>Review of Resident #3's Continuity of Care Document, dated 1/24/25 revealed Resident #3 had orders for <BR/>Aspirin 81 mg dated 11/2/23 for Atrial Fibrillation<BR/>Carvedilol 12.5 mg dated 4/16/24 for Atrial Fibrillation<BR/>Digoxin 125 mcg dated 11/1/23 for Atrial Fibrillation <BR/>Apixaban 2.5 mg dated 11/1/23 fore Atrial Fibrillation<BR/>Furosemide 20 mg &frac12; tablet for 20 mg dated 1/24/25 stop date 2/6/25 for Heart failure <BR/>Gabapentin 400 mg dated 11/1/23 for Chronic Pain<BR/>Guaifenesin 400 mg dated 3/30/24 for Cough<BR/>Multivitamin dated 11/22/23 <BR/>Olmesartan 40 mg 1/16/25 for Hypertension <BR/>Spironolactone 50 mg to five with Furosemide 40mg dated 11/1/23 for Congestive Heart Failure <BR/>Observation of medication administration for Resident #3 on 01/24/25 at 11:25 a.m. revealed MA A did not wash her hands or use hand sanitizer after administering the previous resident's medication or before preparing Resident #3's medications. MA A added all of Resident #3's currently due medications to a medication cup: Aspirin 81 mg, Carvedilol 12.5 mg, Digoxin 125 mcg, Apixaban 2.5 mg, gabapentin 400 mg, guaifenesin 400 mg, multivitamin, Olmesartan 40mg and spironolactone 50mg. Before entering Resident #3's room, MA A verified medication orders on the electronic medical record (EMR). MA A said the spironolactone had instructions to be given with furosemide, which was being held. MA A stated she would hold the spironolactone and ask the ADON for verification. Using her bare (not gloved, not cleaned) index finger, MA A placed the spironolactone into another medication cup. MA A proceeded to give the remaining medications to Resident #3.<BR/>In an interview on 1/24/25 at 1:44 p.m., the DON stated she monitored medication administration by watching the staff because she did not have a lot of staff who had been at the facility a long time. The DON said she did annual competencies with the staff at the first part of February and any new hires had an initial check off. <BR/>IIn an interview at 1/25/25 at 2:55 a.m., the DON stated the facility's policy about handling medications in general was medications should be popped into cup and skin should not touch a pill at all because then there was a contamination factor. The DON said her expectation with over-the-counter medications were to be tapped into lids and the lid used to dump the pill into the medication cup. <BR/>Review of Resident #1's Continuity of Care Document, dated 1/24/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including Diabetes Mellitus (body does not produce enough insulin causing the body to have abnormally high blood sugar levels). Resident #1 had orders for have blood glucose checks three times a day and insulin administer by a sliding scale beginning 5/26/23. <BR/>Review of Resident #1's Quarterly MDS Assessment, dated &frac14;/25, revealed:<BR/>She had a BIMS score of 4 of 15 (indicating she was severely cognitively impaired).<BR/>She had a diagnosis of diabetes.<BR/>She received injections 6 of 7 days prior to the assessment. <BR/>Review of Resident #1's Care Plan, beginning 3/15/25, revealed the goal was her Diabetic status would remain stable as evidenced by resident blood sugar staying within the resident's normal limits through the next quarter. <BR/>Resident #1's Care Plan, beginning 3/15/25, revealed: Enhanced Barrier Precautions will reduce risk of the spread of organisms. <BR/>Observation on 1/24/24 at 10:15 a.m. during initial rounds revealed Resident #1 was in her room lying in bed. She had a catheter. <BR/>Review of Resident #2's Quarterly MDS Assessment, dated 11/18/24 revealed:<BR/>He had a 13 of 15 on his BIMS score (indicating he was cognitively intact)<BR/>He had a diagnosis of diabetes.<BR/>He had injections for 7 of 7 days prior to the assessment.<BR/>His care plan, start date 2/22/24 read he was at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia, renal failure, cognitive/ physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. Identified interventions were to Administer medications as ordered and monitor for side effects and effectiveness. <BR/>Observation on 1/24/25 at 11:17 a.m. revealed LVN B put on gloves and set up the glucometer (machine for measuring blood sugar levels) and went into Resident #1's room. LVN B was not wearing a gown even though Resident #1 was identified as an EBP resident. LVN B took the blood level reading of Resident #1. LVN B came out with gloves on, looked at surveyor and said, she should probably not be in the hall with gloves on. LVN B kept the gloves on. LVN B put the lancet she used to poke Resident #1's finger into the sharps container. With the same gloved hands, LVN B grabbed the top drawer of the medication cart, realized it was locked, put her hands in her pocket pulled out the keys, unlocked the cart, put the keys back into her pocket. LVN B kept the same dirty gloves on, found a container of strips for the glucometer and another lancet, shut the medication cart drawer, and locked it. LVN B, with the same contaminated gloves, returned to Resident #1's room. LVN B with the same dirty gloves opened the container of glucometer strips, stuck her finger into the container and pulled out a glucometer strip, then laid the container of glucometer strips on Resident #1's bed. With the same gloves, LVN B used a new lancet and stuck Resident #1's finger and took the glucometer reading. With the same gloves, LVN B took all the supplies to the medication cart, placed the container of glucometer strips onto the top of the medication cart, disposed of the used lancet, then disposed of the gloves. LVN B cleaned her hands with ABHG and cleaned the glucometer. LVN B did not clean the bottle of glucometer strips. LVN B put on new gloves, took the glucometer, and the (uncleaned) bottle of glucometer strips. LVN B went into Resident #2's room which also had an EBP posting on the door frame, placed everything on the dresser. LVN B put her finger down the container of glucometer strips, and performed the blood glucose reading. LVN B took her supplies, left the room, took off her gloves, cleaned her hands with ABHG and cleaned the glucometer. <BR/>In an interview and observation on 1/24/25 at 11:36 a.m., LVN B stated she was an agency nurse, but had worked at the facility before. LVN B said if she could do anything different, she would have changed gloves more often and used disinfecting wipes on the glucometer instead of alcohol wipes, but she used what she had. LVN B said she would have changed gloves more often to prevent cross contamination, and she was not aware of everything she touched with the one pair of gloves. State surveyor reviewed the list with her, and her response was wow. LVN B said EBP meant she was supposed to wear a gown and gloves. LVN B said this applied to anyone who had a catheter, indwelling device or wound. LVN B stated most facilities had it posted on the door and most facilities had supplies outside the door. LVN B said she did not notice supplies outside the door. LVN B and state surveyor went to Resident #1's room. There was a sign posted but no PPE outside of the room in any fashion or visually available in the room. LVN B said there was a sign, and she was aware Resident #1 had a catheter, and could see the catheter. LVN B admitted she was aware she needed to wear a gown and did not wear one because there were none outside of the room. LVN B said the point of EBP was to protect the resident from other infections. <BR/>Interview on 1/24/25 at 11:58 a.m., the DON stated she had a container of gowns behind the nurse's station because the other containers the facility had went missing. The DON said there were a couple on order. The DON said the facility did have the type of gown container that could be hung over the door. The DON said having the gowns at the nurse's station was not an effective process because the staff had to go all over the building. The DON stated she had four residents on EBP. <BR/>Interview on 1/24/25 at 2:55 p.m., the DON explained the mechanics of cross contamination. She stated cross contamination happened when anyone did not use gloves or held linens too close to the body and the contaminate goop gets on you and you go into the next room. She said the same thing would happen when a person had gloves on. The DON stated gloves would cause cross contamination if it had germs on the surface and the staff go across hall with gloves on the staff had the risk of bringing contamination across the hall. The DON stated the Medication Cart could be contaminated because if the gloves touched the resident, they were dirty, and the gloves should have been removed and the nurse's hands should have been sanitized. The DON stated the keys to the medication cart were contaminated. The DON said the glucometer strips were now contaminated all the others and the nurse impaired the integrity. The DON said she trained nurses to tap the bottle like you would a pill until a strip comes out. The DON stated the outside of tube was contaminated when it touched the resident's bed. The DON said Resident #2 currently did not qualify for EBP, She stated he had pseudomonas UTI but it had resolved.<BR/>Review of in-services reveal the facility trained staff on EBP policy on 1/17/25:<BR/>The facility's policy and procedure on Enhanced Barrier Precautions, undated, revealed:<BR/>Enhanced barrier precautions are utilized to reduce transmission of multi-drug resistant organisms to residents. <BR/>Policy Interpretation:<BR/>Enhanced barrier precautions are used as an infection prevention and control intervention to reduce to transmission of multi-drug resistant organisms to residents. <BR/>Enhanced barrier precautions employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.<BR/>Enhanced barrier precautions are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.<BR/>B indwelling devices include urinary catheters. <BR/>Review of in-services revealed the facility in-served staff on the 6/21/24 on Glove use:<BR/>Review of the facility's policy and procedure on Personal Protective Equipment - Using Gloves, revised October 2010, revealed:<BR/>Purpose: To guide the use of Gloves<BR/>Objective: To prevent the spread of infection.<BR/>Review of the facility's policy and procedure on Handwashing/Hand Hygiene, revised April 2012, revealed:<BR/>The facility considered hand hygiene the primary means to prevent the spread of infection.<BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. <BR/>In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, used an alcohol-based hand rub containing 60 - 90% ethanol or isopropanol for all the following situations: before preparing or handling medications. <BR/>Review of the facility's policy and procedure on Administering Medications, revised December 2012, revealed: Medications shall be administered in a safe and timely manner. <BR/>Staff shall follow established infection control practices (e.g. handwashing, antiseptic technique, gloves, isolation precautions etc.) for the administration of medications, as applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive person-centered care plan for each resident , consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment which were to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 4 of 4 residents (Resident #3, Resident #4, Resident #5, Resident #6) reviewed for care plans.<BR/>1. The facility failed to implement a comprehensive person-centered care plan for Resident #3's physical altercation with Resident #4 on 07/10/24. <BR/>2. The facility failed to implement a comprehensive person-centered care plan for Resident #4's incident on 07/10/24 with Resident #3 in which Resident #3 physical hit Resident #4. <BR/>3. The facility failed to implement a comprehensive person-centered care plan for Resident #5's physical altercation with Resident #6 on 07/21/24.<BR/>4. The facility failed to implement a comprehensive person-centered care plan for Resident #6's incident on 07/21/24 with Resident #5 in which Resident #5 physical hit Resident #6. <BR/>These deficient practices could place residents at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include:<BR/>1. Record review of Resident #3's face sheet, dated 02/25/25, revealed an admission to the facility on [DATE] and re-admission on [DATE]. <BR/>Record review of Resident #3's hospital history and physical, dated 07/05/24, revealed a [AGE] year-old male with diagnoses which included Wernicke-Korsakoff disorder (a life-threatening brain disorder caused by a severe deficiency of thiamine, or vitamin B1), Dementia, and anxiety disorder. <BR/>Record review of Resident #3's MDS dated 01/2025, revealed a moderate cognitive impairment BIMS score of 12 to recall and or make daily decisions. <BR/>Record review of Resident #3's Care Plan, dated 03/30/23, revealed Problem: Resident has verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others). Resident will verbalize understanding of need to control verbal abusive behaviors. Maintain a calm, slow, understandable approach. Remove resident from group activities when behavior was unacceptable. <BR/>During an interview on 02/25/25 at 9:46 AM with the DON, she stated Resident #3 had an incident on 07/10/24 in which he hit another resident. The DON stated she did not see Resident #3 had a focus area care planned for the incident in which he had a physical behavior. The DON stated the purpose of the care plan was to direct staff as far as the resident had a problem or condition and to provide to care. The DON stated the negative outcome of not having it care planned would be staff not monitoring for and where and how to intervene. The DON stated for Resident #3 the staff would not know to intervene if he had a physical behavior placing the other residents at risk. The DON stated the MDS department, and the nurses were responsible ensuring the comprehensive care plans were accurate. <BR/>During an interview on 02/25/25 at 3:00 PM with the Administrator, she stated Resident #3 had an incident on 07/10/24, were he hit another resident. The Administrator stated she would have to check to see if it was care planned and should have been care planned. The Administrator stated if it was not documented in the care plan it did not happen. The Administrator stated the purpose of the care plan was to inform the resident or representative party of a complete picture of the care the resident was being provided. <BR/>The Administrator stated the negative outcome would be the resident or the representative party would be they would not make informed decisions that were mindful. The Administrator stated the DON, and the Social Worker were responsible for ensuring the care plans were accurate. <BR/>2. Record review of Resident #4's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Resident #4 was a [AGE] year-old male with diagnoses which included Diabetes Mellitus, chronic pain due to trauma, major depressive disorder.<BR/>Record review of Resident #4's Care Plan, reviewed on 02/25/25, revealed there was no focus area nor interventions in place for the resident-to-resident altercation on 07/10/24. <BR/>During an interview on 02/25/25 at 9:46 AM with the DON, she stated she did not see the interventions care planned for Resident #4 any focus area or interventions for the incident he had with Resident #3 on 07/10/24 in which they got into a physical altercation. <BR/>3. Record review of Resident #5's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Resident #5 was a [AGE] year-old female which diagnoses which included Cerebral Palsy and intellectual disabilities. <BR/>Record review of Resident #5's annual MDS, dated [DATE], revealed there was no BIMS score taken to measure the cognition of impairment of the resident. <BR/>Record review of Resident #5's care plan, reviewed on 02/25/25, revealed there was not a focus area or interventions documented for the altercation on 07/21/24 with Resident #6. <BR/>Record review of Resident #5's progress notes, dated 07/21/24, revealed Another resident in wheelchair refuse to give a different resident the cordless phone state, 'This was her phone. She was not giving it up.' This resident struck another resident in the face with a closed fist and began crying, both residents were separated and taken to their rooms.<BR/>During an interview on 02/26/25 at 10:54 AM with MDS Coordinator, she stated there were not interventions or focus areas in the care plan for Resident #5's altercation with Resident #6 on 07/21/24. <BR/>During an interview on 02/27/25 at 10:28 AM with the DON, she stated Resident #5 had a physical altercation with Resident #6 in which she hit her while trying to get the phone. The DON stated it was not care planned for both Resident #5 and Resident #6. <BR/>4. Record review of Resident #6's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Resident #6 was an [AGE] year-old female with a diagnosis which included anxiety disorder. <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], revealed a severely impaired cognition BIMS score of 7. Resident #6 was able to recall or make daily decisions. Resident #6 had diagnoses which included dementia, anxiety and depression. <BR/>Record review of Resident #6's care plan, reviewed on 02/25/25, revealed there was no focus area or interventions documented for the incident with the physical altercation incident on 07/21/24. <BR/>During an interview on 02/26/25 at 10:54 AM, with the MDS Coordinator, revealed the MDS department and the DON were responsible for the care plans and ensuring they were accurate. The MDS Coordinator stated the purpose of a care plan was to provide the best service for the resident and if the resident had a problem, then the care plan would address the steps to help provide the best care for the resident. The MDS Coordinator stated Resident #3 and Resident #4 did not have focus areas with interventions addressed to each resident with their specific incident. The MDS Coordinator stated the risk would be the facility staff not knowing how to care for the resident(s).<BR/>Record review of the facility's Comprehensive Assessments Policy, dated 10/2023, revealed Comprehensive MDS assessments are conducted to assist in developing person-centered care plans. The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using the Resident Assessment Instrument specified by CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure adequate supervision and assistance devices was provided for 2 of 3 residents reviewed for transfers (Resident #26 and #52).The facility failed to ensure staff locked the breaks of the mechanical lift (device used to assist in lifting a resident) during transfer for Resident #26.The facility failed to ensure staff completed gait belt transfer correctly for Resident #52. This deficient practice has the potential to affect residents in the building who required extensive assistance with proper transfers. The findings included: Resident #26Review of Resident #26's Quarterly MDS assessment dated [DATE] revealed Resident #26 was a [AGE] year-old female originally admitted to the facility on [DATE] with diagnoses including arthritis, osteoporosis (bone thinning due to loss of calcium) without fracture, and contractures.Resident #26's Brief Mental Status was scored at 13 of 15 (indicating she was cognitively intact).Resident #26 had range of motion impairment on both sides of her lower extremities.Resident #26 was totally dependent on staff for transfers.Observation at [DATE] at 10:13 AM revealed CNA A and CNA H entered the room and donned(put on) gloves. The aides put the sling(material used to hold resident) under Resident #26, then hooked the sling to the electrical mechanical lift. CNA A told CNA H to make sure the sling was positioned high enough on Resident #26's head. CNA A operated the lift while CNA H steadied the resident. CNA A did not lock the lift while raising or lowering Resident #26. While lowering the Resident #26, the lift was noted to rock back and forth not allowing Resident #26 to be positioned in her wheelchair correctly. Interview on [DATE] at 1:27 p.m. the DOR stated the mechanical lift should be locked when moving a resident up and down because the weight was unsteady and it could cause the lift to roll away. The DOR said if the lift moved away while the resident was still up in air they could not be controlled during the lowering of the resident. The DOR stated especially the electrical lifts needed to be locked. The DOR stated they had not done any checkoffs regarding resident Hoyer lift transfers for the nursing staff. Resident #52Review of Resident #52's admission Record, dated [DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including unspecified dementia. Resident #52's admission care plan, dated [DATE], did not have transfer status checked. Resident #52 did not have an admission MDS as she was still in her assessment period. Observation on [DATE] at 3:11 PM revealed CNA I and CNA A putting a gait belt on Resident #52 loosely. CNA A locked both sides of the wheelchair. Both aides were observed hooking their arms under Resident #52. CNA I grabbed the gait belt that slid up Resident #52's torso. CNA A grabbed the back of Resident #52's pants. Interview on [DATE] at 3:19 PM CNA A said Resident #52 could be spicy and she (CNA A) got bit by Resident #52 on [DATE]. CNA A said she grabbed the back of Resident #52's pants because she felt like the like the belt was slipping. Interview on [DATE] at 1:27 p.m. PTA J stated a two-person gait belt transfer should be completed by putting the gait belt on the resident and one staff stand on each side of the resident. PTA J stated at the count of three both aides should lift the resident by the front and back of the gait belt. PTA J said in her opinion it was not ok to hold a resident by the back of their pants. The Director of Rehab who was present stated it was not acceptable to hook their arms under a resident. The DOR stated grabbing the back of the pants was not comfortable for the resident and there was no point if the gait belt was present. PTA J stated the last time the therapy department in-serviced the facility on transfers was 1.5 years ago. Interview on [DATE] at 1:52 the Administrator and DON were informed of the transfers. The DON stated a two-person transfer was supposed to look like the aides putting on the gait belt at the waist or right above the hips tight enough to slide two fingers under the belt. The DON stated the aides were supposed to grab the gait belt on each side and help the resident stand up on the count of three. The DON stated hooking under the arms was not ok because the arms were more prone to fractures. The DON said if the resident had weight bearing issues the resident should be a mechanical lift. The Administrator stated picking up a resident by the waist of the pants would not be comfortable. The DON said she did not have a chance to do checkoffs for transfers because she had only been in the facility three months. The DON stated the expectation for the mechanical lift was for the aide controlling the lift to lock the lift when the resident was going up or down. The DON said if the lift was not locked the staff could lose control of the resident. The DON stated if the resident was being placed in the wheelchair, the lift unlocked could cause the resident to not be aligned properly. The Administrator and DON stated they understood the issue with transfers. Review of the Facility's policy and procedure for Safe Lifting and Movement of Residents, revised 7/2017, revealed: In order to protect the safety and well being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needed in the care plans. Such assistance shall include: Resident's mobility (degree of dependency); weight bearing status; cognitive status; whether the resident is usually cooperative with staff; and the resident's goals for rehabilitation, including restorative or maintaining functional abilities. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Review of the facility's policy and procedure on Using a Mechanical Lifting Machine, dated 7/2017, revealed: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for the manufacture's training or instructions. Mechanical lifts may be used for tasks that require: Transferring a resident from bed to chair. Lift design and operation vary across manufacturers. Staff must be trained and demonstrate competency using the specific machines or devices utilized in the facility. Make sure the lift is stable and locked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>1. The facility failed to ensure stored foods were properly labeled and dated.<BR/>2. The facility failed to ensure expired foods were discarded.<BR/>This places residents at risk of receiving outdated foods.<BR/>The findings included:<BR/>Observation of the dry storage on 4/18/23 at 8:15 AM revealed the following:<BR/>- <BR/>1, 1-lb bag jet puffed mini marshmallows expired 1/17/23<BR/>- <BR/>6 white plastic bags with very small labels that read banana cake mix, no expiration date<BR/>- <BR/>4, 1-gallon containers of Golden Italian dressing with packaged date of 11/19/19, no expiration date<BR/>- <BR/>2, 1-gallon containers of Orange French dressing with packaged date of 12/20/18, no expiration date<BR/>- <BR/>1, 5-lb container of Lite Chili Powder with expiration date of 9/9/16<BR/>- <BR/>1, 1-gallon container of dill relish with packaged date of 11/30/22, no expiration date<BR/>- <BR/>2, 1-gallon containers of heavy-duty mayonnaise with packaged date of 1/17/22, no expiration date<BR/>- <BR/>6, 16-oz containers of low sodium beef flavored base with no expiration date<BR/>- <BR/>1, 5-lb box of buttermilk pancake mix with no expiration date, box had been opened but top was closed, plastic bag of mix inside box was open and unsealed<BR/>- <BR/>16, 1-lb bags of lime gelatin dessert with no expiration date<BR/>- <BR/>4, 1-lb bags of lemon gelatin dessert with no expiration date<BR/>- <BR/>4, 1-lb bags of banana flavored instant pudding/pie filling with no expiration date<BR/>- <BR/>2, 8-oz vanilla sugar free instant pudding mix packets with no expiration date<BR/>- <BR/>17, 3.2oz ranch dressing mix packets with no expiration date<BR/>- <BR/>1 opened 5-lb bag baking cocoa (approximately 2.5-lbs remaining) with no expiration date<BR/>- <BR/>1, 5-lb bag of baking cocoa with no expiration date<BR/>- <BR/>2, 5-lb resealable plastic bags with long, straight noodles removed from original packaging with no labeling on bag<BR/>- <BR/>1, 5-lb resealable plastic bag of spiral noodles removed from original packaging with no labeling on bag<BR/>- <BR/>2, 7.5-oz instant low sodium brown gravy mix with no expiration date<BR/>- <BR/>1, 32-oz box of yellow corn meal with best by date of 4/6/23<BR/>- <BR/>4, 24-oz peppered biscuit gravy mix packets with no expiration date<BR/>- <BR/>1 opened 5-lb bag (approximately 1lb remaining) lentil penne pasta with best by date of 8/11/21<BR/>- <BR/>1 opened 10-lb box of ridged curly lasagna box top not secured and noodles inside box not in sealed packaging<BR/>- <BR/>6 unopened boxes (72 individually wrapped) fudge round cookies with no expiration date<BR/>- <BR/>1 opened box (2 individually wrapped) fudge round cookies with no expiration date<BR/>- <BR/>10 unopened boxes (240 individually wrapped) [NAME] buddy snack bars with no expiration date<BR/>- <BR/>1 opened box (5 individually wrapped) [NAME] buddy snack bars with no expiration date<BR/>- <BR/>74 apple oatmeal bars in plastic tub with expiration date of 3/25/23<BR/>- <BR/>5, 24-oz cans of chocolate syrup with no expiration date<BR/>- <BR/>2, 18-oz pink lemon drink mix packets with no expiration date<BR/>- <BR/>4, 18-oz grape drink mix packets with no expiration date<BR/>Observation of refrigerator #1 on 4/18/23 at 9:45 AM revealed the following:<BR/>- <BR/>2 broken eggs in crate<BR/>Observation of freezer #1 on 4/18/23 at 9:50 AM revealed the following:<BR/>- <BR/>4, 5-lb resealable plastic bags of frozen meat dated 4/5/23 with no label<BR/>- <BR/>4 plastic sealed tubes of frozen ground meat with no date and no label<BR/>- <BR/>3 packages of frozen sliced meat with no date and no label<BR/>Observation of freezer #2 on 4/18/23 at 9:55 AM revealed the following:<BR/>- <BR/>1 resealable plastic bag of frozen dough with no date and no label<BR/>- <BR/>1 resealable plastic bag of what appeared to be ground meat wrapped in tortillas with no date and no label<BR/>Observation of refrigerator #2 on 4/18/23 at 10:00 AM revealed the following:<BR/>- <BR/>1, 138-oz container of picante sauce with expiration date of 8/12/22<BR/>- <BR/>1, 1-gallon container of heavy-duty mayonnaise with package date of 1/17/23, no expiration date<BR/>- <BR/>1, 1-gallon container of Golden Italian dressing with package date of 11/19/19, no expiration date<BR/>- <BR/>1, 1-gallon container of home style ranch dressing manufactured date 1/15/22, no expiration date<BR/>- <BR/>1, 1-gallon container of sweet and sour sauce with expiration date 1/26/22<BR/>- <BR/>1, 2-qt container of soy sauce with expiration date of 10/1/22<BR/>- <BR/>1, 32-oz container of nacho sliced jalapenos with expiration date of 4/21/22<BR/>- <BR/>1, 1-gallon container of dill pickle chips with packaged date of 12/5/22, no expiration date<BR/>- <BR/>1, 5-lb container of parmesan cheese blend with no expiration date<BR/>- <BR/>3 packages of sliced yellow cheese not in original packaging, no label, no expiration date<BR/>- <BR/>1 package of plastic wrapped sliced meat with no label<BR/>Observation of freezer #3 on 4/18/23 at 10:15 AM revealed the following:<BR/>- <BR/>1 resealable plastic bag of unidentifiable food with no label<BR/>In an interview on 04/19/23 at 2:31 PM the Administrator was advised of unlabeled food items in the kitchen, he stated he was unaware that items removed from their original packaging had to be labeled as well as dated. When advised of the food items in the kitchen without expiration or best by dates, he appeared surprised and stated that it seemed strange that a company would be allowed to distribute food products to a nursing facility that did not have expiration dates on them.<BR/>In an interview on 04/19/23 at 03:10 PM the Dietary Supervisor stated that she was aware that most of the foods in the kitchen dry storage do not have an expiration date. She stated that she brought the issue of the expiration dates up with the former dietician and never got any response on what to do. She stated the facility did have a new Registered Dietician, but she (RD) only communicated with the DON/ADON, and she did not have any contact with her (Dietary Supervisor). She stated that she was able to order food for the facility herself off the supplier's website but there were no expiration dates available on the website. She stated she would have to call the rep resentative for the supplier and ask for a list of expiration dates for all the food she had in stock. She stated she had not done formal in-services with the staff about labeling and dating food items, but she had talked to all of them individually many times and explained that all food items must have a date and label if removed from the original packaging. She explained that the dates on all items in the dry storage area were the date the items were received and the dates on bags/containers in the refrigerators and freezers were the date the food was placed in the bag/container.<BR/>Record review of facility policy titled Food Receiving and Storage revised December 2008 revealed, in part:<BR/>Foods shall be received and stored in a manner that complies with safe food handling practices.<BR/>When food is delivered to the facility it will be inspected for safe transport and quality before being accepted.<BR/>Dry foods that are stored in bins will be removed from original packing, labeled and dated (use by date).<BR/>All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).<BR/>Review of the 2017 Food Code (https://www.fda.gov/media/110822/download ) revealed<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days<BR/>3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall 73 be identified with the common name of the FOOD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for three of eight residents (Resident #1, #2, and #3) reviewed for infection control.<BR/>1. MA A touched Resident #3's pills with her bare hands during medication administration. <BR/>2. LVN B failed to prevent cross contamination between Residents #1 and #2 by brining in uncleaned diabetic supplies from one room to another. <BR/>These failures could place resident's risk for cross contamination and the spread of infection. <BR/>Finding included:<BR/>Review of Resident #3's CCD dated 11/01/23, revealed a 90- year- old female admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation (heart does not beat with a regular beat all the time) and acute respiratory failure (person cannot get enough oxygen). <BR/>Review of Resident #3's MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of 11 indicating moderately impaired cognition. <BR/>Review of Resident #3's Care Plan dated 12/10/24 revealed Resident #3 was at risk for frequent infections. <BR/>Review of Resident #3's Continuity of Care Document, dated 1/24/25 revealed Resident #3 had orders for <BR/>Aspirin 81 mg dated 11/2/23 for Atrial Fibrillation<BR/>Carvedilol 12.5 mg dated 4/16/24 for Atrial Fibrillation<BR/>Digoxin 125 mcg dated 11/1/23 for Atrial Fibrillation <BR/>Apixaban 2.5 mg dated 11/1/23 fore Atrial Fibrillation<BR/>Furosemide 20 mg &frac12; tablet for 20 mg dated 1/24/25 stop date 2/6/25 for Heart failure <BR/>Gabapentin 400 mg dated 11/1/23 for Chronic Pain<BR/>Guaifenesin 400 mg dated 3/30/24 for Cough<BR/>Multivitamin dated 11/22/23 <BR/>Olmesartan 40 mg 1/16/25 for Hypertension <BR/>Spironolactone 50 mg to five with Furosemide 40mg dated 11/1/23 for Congestive Heart Failure <BR/>Observation of medication administration for Resident #3 on 01/24/25 at 11:25 a.m. revealed MA A did not wash her hands or use hand sanitizer after administering the previous resident's medication or before preparing Resident #3's medications. MA A added all of Resident #3's currently due medications to a medication cup: Aspirin 81 mg, Carvedilol 12.5 mg, Digoxin 125 mcg, Apixaban 2.5 mg, gabapentin 400 mg, guaifenesin 400 mg, multivitamin, Olmesartan 40mg and spironolactone 50mg. Before entering Resident #3's room, MA A verified medication orders on the electronic medical record (EMR). MA A said the spironolactone had instructions to be given with furosemide, which was being held. MA A stated she would hold the spironolactone and ask the ADON for verification. Using her bare (not gloved, not cleaned) index finger, MA A placed the spironolactone into another medication cup. MA A proceeded to give the remaining medications to Resident #3.<BR/>In an interview on 1/24/25 at 1:44 p.m., the DON stated she monitored medication administration by watching the staff because she did not have a lot of staff who had been at the facility a long time. The DON said she did annual competencies with the staff at the first part of February and any new hires had an initial check off. <BR/>IIn an interview at 1/25/25 at 2:55 a.m., the DON stated the facility's policy about handling medications in general was medications should be popped into cup and skin should not touch a pill at all because then there was a contamination factor. The DON said her expectation with over-the-counter medications were to be tapped into lids and the lid used to dump the pill into the medication cup. <BR/>Review of Resident #1's Continuity of Care Document, dated 1/24/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including Diabetes Mellitus (body does not produce enough insulin causing the body to have abnormally high blood sugar levels). Resident #1 had orders for have blood glucose checks three times a day and insulin administer by a sliding scale beginning 5/26/23. <BR/>Review of Resident #1's Quarterly MDS Assessment, dated &frac14;/25, revealed:<BR/>She had a BIMS score of 4 of 15 (indicating she was severely cognitively impaired).<BR/>She had a diagnosis of diabetes.<BR/>She received injections 6 of 7 days prior to the assessment. <BR/>Review of Resident #1's Care Plan, beginning 3/15/25, revealed the goal was her Diabetic status would remain stable as evidenced by resident blood sugar staying within the resident's normal limits through the next quarter. <BR/>Resident #1's Care Plan, beginning 3/15/25, revealed: Enhanced Barrier Precautions will reduce risk of the spread of organisms. <BR/>Observation on 1/24/24 at 10:15 a.m. during initial rounds revealed Resident #1 was in her room lying in bed. She had a catheter. <BR/>Review of Resident #2's Quarterly MDS Assessment, dated 11/18/24 revealed:<BR/>He had a 13 of 15 on his BIMS score (indicating he was cognitively intact)<BR/>He had a diagnosis of diabetes.<BR/>He had injections for 7 of 7 days prior to the assessment.<BR/>His care plan, start date 2/22/24 read he was at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia, renal failure, cognitive/ physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. Identified interventions were to Administer medications as ordered and monitor for side effects and effectiveness. <BR/>Observation on 1/24/25 at 11:17 a.m. revealed LVN B put on gloves and set up the glucometer (machine for measuring blood sugar levels) and went into Resident #1's room. LVN B was not wearing a gown even though Resident #1 was identified as an EBP resident. LVN B took the blood level reading of Resident #1. LVN B came out with gloves on, looked at surveyor and said, she should probably not be in the hall with gloves on. LVN B kept the gloves on. LVN B put the lancet she used to poke Resident #1's finger into the sharps container. With the same gloved hands, LVN B grabbed the top drawer of the medication cart, realized it was locked, put her hands in her pocket pulled out the keys, unlocked the cart, put the keys back into her pocket. LVN B kept the same dirty gloves on, found a container of strips for the glucometer and another lancet, shut the medication cart drawer, and locked it. LVN B, with the same contaminated gloves, returned to Resident #1's room. LVN B with the same dirty gloves opened the container of glucometer strips, stuck her finger into the container and pulled out a glucometer strip, then laid the container of glucometer strips on Resident #1's bed. With the same gloves, LVN B used a new lancet and stuck Resident #1's finger and took the glucometer reading. With the same gloves, LVN B took all the supplies to the medication cart, placed the container of glucometer strips onto the top of the medication cart, disposed of the used lancet, then disposed of the gloves. LVN B cleaned her hands with ABHG and cleaned the glucometer. LVN B did not clean the bottle of glucometer strips. LVN B put on new gloves, took the glucometer, and the (uncleaned) bottle of glucometer strips. LVN B went into Resident #2's room which also had an EBP posting on the door frame, placed everything on the dresser. LVN B put her finger down the container of glucometer strips, and performed the blood glucose reading. LVN B took her supplies, left the room, took off her gloves, cleaned her hands with ABHG and cleaned the glucometer. <BR/>In an interview and observation on 1/24/25 at 11:36 a.m., LVN B stated she was an agency nurse, but had worked at the facility before. LVN B said if she could do anything different, she would have changed gloves more often and used disinfecting wipes on the glucometer instead of alcohol wipes, but she used what she had. LVN B said she would have changed gloves more often to prevent cross contamination, and she was not aware of everything she touched with the one pair of gloves. State surveyor reviewed the list with her, and her response was wow. LVN B said EBP meant she was supposed to wear a gown and gloves. LVN B said this applied to anyone who had a catheter, indwelling device or wound. LVN B stated most facilities had it posted on the door and most facilities had supplies outside the door. LVN B said she did not notice supplies outside the door. LVN B and state surveyor went to Resident #1's room. There was a sign posted but no PPE outside of the room in any fashion or visually available in the room. LVN B said there was a sign, and she was aware Resident #1 had a catheter, and could see the catheter. LVN B admitted she was aware she needed to wear a gown and did not wear one because there were none outside of the room. LVN B said the point of EBP was to protect the resident from other infections. <BR/>Interview on 1/24/25 at 11:58 a.m., the DON stated she had a container of gowns behind the nurse's station because the other containers the facility had went missing. The DON said there were a couple on order. The DON said the facility did have the type of gown container that could be hung over the door. The DON said having the gowns at the nurse's station was not an effective process because the staff had to go all over the building. The DON stated she had four residents on EBP. <BR/>Interview on 1/24/25 at 2:55 p.m., the DON explained the mechanics of cross contamination. She stated cross contamination happened when anyone did not use gloves or held linens too close to the body and the contaminate goop gets on you and you go into the next room. She said the same thing would happen when a person had gloves on. The DON stated gloves would cause cross contamination if it had germs on the surface and the staff go across hall with gloves on the staff had the risk of bringing contamination across the hall. The DON stated the Medication Cart could be contaminated because if the gloves touched the resident, they were dirty, and the gloves should have been removed and the nurse's hands should have been sanitized. The DON stated the keys to the medication cart were contaminated. The DON said the glucometer strips were now contaminated all the others and the nurse impaired the integrity. The DON said she trained nurses to tap the bottle like you would a pill until a strip comes out. The DON stated the outside of tube was contaminated when it touched the resident's bed. The DON said Resident #2 currently did not qualify for EBP, She stated he had pseudomonas UTI but it had resolved.<BR/>Review of in-services reveal the facility trained staff on EBP policy on 1/17/25:<BR/>The facility's policy and procedure on Enhanced Barrier Precautions, undated, revealed:<BR/>Enhanced barrier precautions are utilized to reduce transmission of multi-drug resistant organisms to residents. <BR/>Policy Interpretation:<BR/>Enhanced barrier precautions are used as an infection prevention and control intervention to reduce to transmission of multi-drug resistant organisms to residents. <BR/>Enhanced barrier precautions employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.<BR/>Enhanced barrier precautions are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.<BR/>B indwelling devices include urinary catheters. <BR/>Review of in-services revealed the facility in-served staff on the 6/21/24 on Glove use:<BR/>Review of the facility's policy and procedure on Personal Protective Equipment - Using Gloves, revised October 2010, revealed:<BR/>Purpose: To guide the use of Gloves<BR/>Objective: To prevent the spread of infection.<BR/>Review of the facility's policy and procedure on Handwashing/Hand Hygiene, revised April 2012, revealed:<BR/>The facility considered hand hygiene the primary means to prevent the spread of infection.<BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. <BR/>In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, used an alcohol-based hand rub containing 60 - 90% ethanol or isopropanol for all the following situations: before preparing or handling medications. <BR/>Review of the facility's policy and procedure on Administering Medications, revised December 2012, revealed: Medications shall be administered in a safe and timely manner. <BR/>Staff shall follow established infection control practices (e.g. handwashing, antiseptic technique, gloves, isolation precautions etc.) for the administration of medications, as applicable.

Based on observation, interview and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 washing machine and 1 of 4 resident wheelchair brakes reviewed for essential equipment. <BR/>1. The facility did not provide necessary repairs for 1 industrial washing machines.<BR/>2. The facility failed to ensure Resident #1's wheelchair brakes were not broken <BR/>These failures could place residents at risk of not having clean clothes to wear and place residents at risk of function mobility and injuries. <BR/>Findings include:<BR/>Observation and interview on 02/24/25 at 8:40 AM with Resident #1 revealed the right wheelchair brake would not disengage, and the handle was observed loose. Resident #1 was observed trying to move his wheelchair with his right arm/hand and moving slowly and veins in his arm could be seen popping out of his right arm/hand. Resident #1 did not have any legs as they were amputated. <BR/>During an interview on 02/24/25 at 2:31 PM Resident #1 stated he told RN on 02/23/25 in the evening that his wheelchair brake was broken. Resident #1 stated she told him okay and walked away. <BR/>During an interview on 02/25/25 at 10:44 AM with CNA C, she stated the maintenance department had a maintenance logbook by their office to put in work orders for broken items. CNA C stated it was expected for everyone to put work orders in the maintenance logbook for broken items. CNA C stated not doing so could be a hazard to the residents. <BR/>Observation and interview on 02/25/25 at 2:41 PM with the DON revealed, the DON looked at Resident #1's wheelchair brake. Resident #1 was observed giving the DON the screw and another metal piece in the DON's hand. The DON stated she was not notified of the broken wheelchair brake and was generally notified of issues. The DON stated it was expected of the nursing staff to report any broken equipment to the charge nurse, physician and the DON. The DON stated the equipment should be pulled and not used and looked at. The DON stated by looking at Resident #1's broken right wheelchair brake, it was not reported as it should have been done. The DON stated the risk was mobility and injury. <BR/>Observation and interview on 02/25/25 at 2:49 PM with the Maintenance Director revealed the Maintenance Director observed Resident #1's right wheelchair brake. The Maintenance Director stated he verbally gave an in-service to the facility on how to report broken items. The Maintenance Director stated there was a maintenance logbook in which they were to write down the name, date, time of the broken item (work orders). The Maintenance Director stated sometimes the staff told him of the broken items (work orders), but it was expected for the facility staff to document it in the maintenance logbook because he did have a lot of work and might forget to fix it. The Maintenance Director stated the risk for Resident #1 would be him rolling off the wheelchair and affect his mobility. <BR/>During an interview on 02/25/25 at 4:50 PM with the Administrator, she stated if something was broken then it needed to be removed until it was fixed. The Administrator stated if it was reported to them about the broken wheelchair brake then they could have removed it and got a rental wheelchair for Resident #1. The Administrator stated it was expected and the responsibility of the staff and everyone to report broken items. The Administrator stated the risk for Resident #1 could be him hurting himself .<BR/>During an interview on 02/26/25 at 4:56 PM with RN, she stated she was notified of the broken right wheelchair brake from Resident #1. The RN stated she asked Resident #1 how long the wheelchair brake had been broken and Resident #1 had told her he had already reported it. The RN stated she did not confirm it had been reported nor did she log it in the maintenance logbook. The RN stated it was expected to be place work orders in the maintenance logbook for broken items. The RN stated the facility staff was trained on how to place work orders. The RN stated the risk would be Resident #1 having a fall. <BR/>During an interview on 02/27/25 at 12:03 PM with the DON, she stated the facility staff were trained and in-serviced on placing work orders. The DON stated it was expected for staff to be placing it in the work order logbook. The DON stated she saw the broken blinds and had reported it in the morning meeting and during stand down meeting but failed to place it in the work order logbook .<BR/>Record review of the facility's Maintenance Service Policy, dated 12/2009, revealed Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to: maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. Maintain the building in good repair and free from hazards. Maintain the heat/cooling system, plumbing fixtures, wiring etc., in good working order. The Maintenance Director was responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Records shall be maintained in the maintenance director's office. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.<BR/>Record review of the facility's Work orders, Maintenance Policy, dated 04/2010, revealed, Maintenance work orders shall be completed in order to establish a priority of maintenance service. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 5 (Resident #3) reviewed for pharmacy services.<BR/>The facility failed to record Tramadol-50 mg Schedule IV tablet was given to Resident #3 at 7:30 AM per physician orders in the narcotic logbook. <BR/>This failure could place residents at risk for being over mediated which could result in medical complications and drug diversion. <BR/>Findings include:<BR/>Record review of Resident #3's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. <BR/>Record review of Resident #3's hospital history and physical, dated 07/05/24, revealed a [AGE] year-old male with diagnoses which included Wernicke-Korsakoff disorder (a life-threatening brain disorder caused by a severe deficiency of thiamine, or vitamin B1), Dementia and anxiety disorder. <BR/>Record review of Resident #3's MDS, dated 01/2025 revealed, a moderate cognitive impairment BIMS score of 12. Resident #12 was able to recall and or make daily decisions. <BR/>Record review of Resident #3's Orders, dated 09/18/23, revealed Tramadol - Schedule IV tablet- 50 mg oral four times a day. at 7:30AM, 1:00PM, 7:30PM, 1:00AM. <BR/>Observation and interview on 02/26/25 at 12:49 PM with the MA, she stated observed logging on the bingo card (medication card) and then looked at the narcotic logbook. The MA was seen writing down that tramadol was given in the morning and then writing med error next to it. The MA stated she forgot to log down the tramadol -50 mg which was given in the morning to Resident #3 at 7:30 AM. MA stated it was expected to log it in the narcotic logbook and not doing it would be considered a medication error. <BR/>During an interview on 02/26/25 at 1:19 PM with the Physician, he stated narcotic medications were given had to be documented on the narcotic logbook as it was being taken out to be given. The Physician stated logging the narcotic that was taken out was for counting purposes and had to be documented in the narcotic logbook. The Physician stated a negative outcome would be the count would be wrong and would not know if the resident received the medication. <BR/>During an interview on 02/26/25 at 4:37 PM with the RN , she stated the medication aides gave the narcotics to the residents. The RN stated they were to fill out the narcotic logbook as it was given. The RN stated this was to prevent another nursing staff member from coming by and giving the resident more medication causing the resident to be overly medicated. The RN stated it would also be a med error . <BR/>During an interview on 02/27/25 at 11:40 AM, with the DON, he stated Resident #3 had an order for Tramadol-50 mg. The DON stated when giving the medication since it was a narcotic, it had to be logged in the narcotic logbook at the same time it was going to be given. The DON stated not logging it in the narcotic logbook would throw off the bingo card (the medication card) and show that it was off by one medication pill. The DON stated the risk would be the resident could be over mediated or the medication could be stolen by facility staff. <BR/>Record review of the facility's Administering Medications Policy, dated 04/2019, revealed Medications are administer in a safe and timely manner, and as prescribed. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. Medications errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for three of eight residents (Resident #1, #2, and #3) reviewed for infection control.<BR/>1. MA A touched Resident #3's pills with her bare hands during medication administration. <BR/>2. LVN B failed to prevent cross contamination between Residents #1 and #2 by brining in uncleaned diabetic supplies from one room to another. <BR/>These failures could place resident's risk for cross contamination and the spread of infection. <BR/>Finding included:<BR/>Review of Resident #3's CCD dated 11/01/23, revealed a 90- year- old female admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation (heart does not beat with a regular beat all the time) and acute respiratory failure (person cannot get enough oxygen). <BR/>Review of Resident #3's MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of 11 indicating moderately impaired cognition. <BR/>Review of Resident #3's Care Plan dated 12/10/24 revealed Resident #3 was at risk for frequent infections. <BR/>Review of Resident #3's Continuity of Care Document, dated 1/24/25 revealed Resident #3 had orders for <BR/>Aspirin 81 mg dated 11/2/23 for Atrial Fibrillation<BR/>Carvedilol 12.5 mg dated 4/16/24 for Atrial Fibrillation<BR/>Digoxin 125 mcg dated 11/1/23 for Atrial Fibrillation <BR/>Apixaban 2.5 mg dated 11/1/23 fore Atrial Fibrillation<BR/>Furosemide 20 mg &frac12; tablet for 20 mg dated 1/24/25 stop date 2/6/25 for Heart failure <BR/>Gabapentin 400 mg dated 11/1/23 for Chronic Pain<BR/>Guaifenesin 400 mg dated 3/30/24 for Cough<BR/>Multivitamin dated 11/22/23 <BR/>Olmesartan 40 mg 1/16/25 for Hypertension <BR/>Spironolactone 50 mg to five with Furosemide 40mg dated 11/1/23 for Congestive Heart Failure <BR/>Observation of medication administration for Resident #3 on 01/24/25 at 11:25 a.m. revealed MA A did not wash her hands or use hand sanitizer after administering the previous resident's medication or before preparing Resident #3's medications. MA A added all of Resident #3's currently due medications to a medication cup: Aspirin 81 mg, Carvedilol 12.5 mg, Digoxin 125 mcg, Apixaban 2.5 mg, gabapentin 400 mg, guaifenesin 400 mg, multivitamin, Olmesartan 40mg and spironolactone 50mg. Before entering Resident #3's room, MA A verified medication orders on the electronic medical record (EMR). MA A said the spironolactone had instructions to be given with furosemide, which was being held. MA A stated she would hold the spironolactone and ask the ADON for verification. Using her bare (not gloved, not cleaned) index finger, MA A placed the spironolactone into another medication cup. MA A proceeded to give the remaining medications to Resident #3.<BR/>In an interview on 1/24/25 at 1:44 p.m., the DON stated she monitored medication administration by watching the staff because she did not have a lot of staff who had been at the facility a long time. The DON said she did annual competencies with the staff at the first part of February and any new hires had an initial check off. <BR/>IIn an interview at 1/25/25 at 2:55 a.m., the DON stated the facility's policy about handling medications in general was medications should be popped into cup and skin should not touch a pill at all because then there was a contamination factor. The DON said her expectation with over-the-counter medications were to be tapped into lids and the lid used to dump the pill into the medication cup. <BR/>Review of Resident #1's Continuity of Care Document, dated 1/24/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including Diabetes Mellitus (body does not produce enough insulin causing the body to have abnormally high blood sugar levels). Resident #1 had orders for have blood glucose checks three times a day and insulin administer by a sliding scale beginning 5/26/23. <BR/>Review of Resident #1's Quarterly MDS Assessment, dated &frac14;/25, revealed:<BR/>She had a BIMS score of 4 of 15 (indicating she was severely cognitively impaired).<BR/>She had a diagnosis of diabetes.<BR/>She received injections 6 of 7 days prior to the assessment. <BR/>Review of Resident #1's Care Plan, beginning 3/15/25, revealed the goal was her Diabetic status would remain stable as evidenced by resident blood sugar staying within the resident's normal limits through the next quarter. <BR/>Resident #1's Care Plan, beginning 3/15/25, revealed: Enhanced Barrier Precautions will reduce risk of the spread of organisms. <BR/>Observation on 1/24/24 at 10:15 a.m. during initial rounds revealed Resident #1 was in her room lying in bed. She had a catheter. <BR/>Review of Resident #2's Quarterly MDS Assessment, dated 11/18/24 revealed:<BR/>He had a 13 of 15 on his BIMS score (indicating he was cognitively intact)<BR/>He had a diagnosis of diabetes.<BR/>He had injections for 7 of 7 days prior to the assessment.<BR/>His care plan, start date 2/22/24 read he was at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia, renal failure, cognitive/ physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. Identified interventions were to Administer medications as ordered and monitor for side effects and effectiveness. <BR/>Observation on 1/24/25 at 11:17 a.m. revealed LVN B put on gloves and set up the glucometer (machine for measuring blood sugar levels) and went into Resident #1's room. LVN B was not wearing a gown even though Resident #1 was identified as an EBP resident. LVN B took the blood level reading of Resident #1. LVN B came out with gloves on, looked at surveyor and said, she should probably not be in the hall with gloves on. LVN B kept the gloves on. LVN B put the lancet she used to poke Resident #1's finger into the sharps container. With the same gloved hands, LVN B grabbed the top drawer of the medication cart, realized it was locked, put her hands in her pocket pulled out the keys, unlocked the cart, put the keys back into her pocket. LVN B kept the same dirty gloves on, found a container of strips for the glucometer and another lancet, shut the medication cart drawer, and locked it. LVN B, with the same contaminated gloves, returned to Resident #1's room. LVN B with the same dirty gloves opened the container of glucometer strips, stuck her finger into the container and pulled out a glucometer strip, then laid the container of glucometer strips on Resident #1's bed. With the same gloves, LVN B used a new lancet and stuck Resident #1's finger and took the glucometer reading. With the same gloves, LVN B took all the supplies to the medication cart, placed the container of glucometer strips onto the top of the medication cart, disposed of the used lancet, then disposed of the gloves. LVN B cleaned her hands with ABHG and cleaned the glucometer. LVN B did not clean the bottle of glucometer strips. LVN B put on new gloves, took the glucometer, and the (uncleaned) bottle of glucometer strips. LVN B went into Resident #2's room which also had an EBP posting on the door frame, placed everything on the dresser. LVN B put her finger down the container of glucometer strips, and performed the blood glucose reading. LVN B took her supplies, left the room, took off her gloves, cleaned her hands with ABHG and cleaned the glucometer. <BR/>In an interview and observation on 1/24/25 at 11:36 a.m., LVN B stated she was an agency nurse, but had worked at the facility before. LVN B said if she could do anything different, she would have changed gloves more often and used disinfecting wipes on the glucometer instead of alcohol wipes, but she used what she had. LVN B said she would have changed gloves more often to prevent cross contamination, and she was not aware of everything she touched with the one pair of gloves. State surveyor reviewed the list with her, and her response was wow. LVN B said EBP meant she was supposed to wear a gown and gloves. LVN B said this applied to anyone who had a catheter, indwelling device or wound. LVN B stated most facilities had it posted on the door and most facilities had supplies outside the door. LVN B said she did not notice supplies outside the door. LVN B and state surveyor went to Resident #1's room. There was a sign posted but no PPE outside of the room in any fashion or visually available in the room. LVN B said there was a sign, and she was aware Resident #1 had a catheter, and could see the catheter. LVN B admitted she was aware she needed to wear a gown and did not wear one because there were none outside of the room. LVN B said the point of EBP was to protect the resident from other infections. <BR/>Interview on 1/24/25 at 11:58 a.m., the DON stated she had a container of gowns behind the nurse's station because the other containers the facility had went missing. The DON said there were a couple on order. The DON said the facility did have the type of gown container that could be hung over the door. The DON said having the gowns at the nurse's station was not an effective process because the staff had to go all over the building. The DON stated she had four residents on EBP. <BR/>Interview on 1/24/25 at 2:55 p.m., the DON explained the mechanics of cross contamination. She stated cross contamination happened when anyone did not use gloves or held linens too close to the body and the contaminate goop gets on you and you go into the next room. She said the same thing would happen when a person had gloves on. The DON stated gloves would cause cross contamination if it had germs on the surface and the staff go across hall with gloves on the staff had the risk of bringing contamination across the hall. The DON stated the Medication Cart could be contaminated because if the gloves touched the resident, they were dirty, and the gloves should have been removed and the nurse's hands should have been sanitized. The DON stated the keys to the medication cart were contaminated. The DON said the glucometer strips were now contaminated all the others and the nurse impaired the integrity. The DON said she trained nurses to tap the bottle like you would a pill until a strip comes out. The DON stated the outside of tube was contaminated when it touched the resident's bed. The DON said Resident #2 currently did not qualify for EBP, She stated he had pseudomonas UTI but it had resolved.<BR/>Review of in-services reveal the facility trained staff on EBP policy on 1/17/25:<BR/>The facility's policy and procedure on Enhanced Barrier Precautions, undated, revealed:<BR/>Enhanced barrier precautions are utilized to reduce transmission of multi-drug resistant organisms to residents. <BR/>Policy Interpretation:<BR/>Enhanced barrier precautions are used as an infection prevention and control intervention to reduce to transmission of multi-drug resistant organisms to residents. <BR/>Enhanced barrier precautions employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.<BR/>Enhanced barrier precautions are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.<BR/>B indwelling devices include urinary catheters. <BR/>Review of in-services revealed the facility in-served staff on the 6/21/24 on Glove use:<BR/>Review of the facility's policy and procedure on Personal Protective Equipment - Using Gloves, revised October 2010, revealed:<BR/>Purpose: To guide the use of Gloves<BR/>Objective: To prevent the spread of infection.<BR/>Review of the facility's policy and procedure on Handwashing/Hand Hygiene, revised April 2012, revealed:<BR/>The facility considered hand hygiene the primary means to prevent the spread of infection.<BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. <BR/>In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, used an alcohol-based hand rub containing 60 - 90% ethanol or isopropanol for all the following situations: before preparing or handling medications. <BR/>Review of the facility's policy and procedure on Administering Medications, revised December 2012, revealed: Medications shall be administered in a safe and timely manner. <BR/>Staff shall follow established infection control practices (e.g. handwashing, antiseptic technique, gloves, isolation precautions etc.) for the administration of medications, as applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a written notice of room change was received, including the reason the room was changed, for 2 (Residents #7 and #15) of 3 residents reviewed for notification of room change.<BR/>-The facility failed to provide Resident #7 and/or their RP a written notice of a room change before the resident was moved.<BR/>-The facility failed to provide Resident #15 and/or their RP a written notice of a room change before the resident was moved.<BR/>This failure could place all residents at risk for being displaced without notice and/or reason and decrease quality of life being in a new environment. <BR/>Findings Included: <BR/>Resident #7:<BR/>Record review of Resident #7's face sheet dated 12/27/2023, revealed an [AGE] year-old female who was admitted on [DATE] with diagnoses including cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and corticobasal degeneration (rare condition that can cause gradually worsening problems with movement, speech, memory and swallowing).<BR/>Record review of Resident #7's Quarterly MDS dated [DATE] revealed a BIMS score of 13 indicating the resident was intact cognitively.<BR/>During an interview on 12/27/2023 at 9:30 a.m., Resident #7 said she had been moved into her current bedroom a few weeks ago. Resident #7 said she was not given a written notice of the room change. Resident #7 said she was not provided an opportunity to ask questions about the room she was moved to. Resident #7 said she does not have any issues with her current room or her current roommate. <BR/>During an interview on 12/27/2023 at 10:45 a.m., Resident #7's RP said she had not received any notifications of any room changes for Resident #7. RP said she had not been contacted and Resident #7 had been moved several times at the facility since her admission. The RP said she was made aware of Resident #7's room changes when she visits the facility and asks what room she was in. The RP said she was Resident #7's POA and had not received anything in writing regarding any of room changes that Resident #7 has had at the facility. <BR/>Record review of Resident #7's clinical record revealed there was no documentation Resident #7, or their RP had been given a written notice of room change.<BR/>Resident #15:<BR/>Record review of Resident #15's face sheet dated 12/27/2023, revealed a [AGE] year-old female who was admitted on [DATE] with diagnoses including fracture of lumbar vertebra, rheumatoid arthritis (chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles), and osteoporosis (bone disease that develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes). <BR/>Record review of Resident #15's Quarterly MDS dated [DATE] revealed a BIMS score of 08, indicating moderate cognitive impairment.<BR/>During an interview on 12/27/2023 at 9:15 a.m., Resident #15 said she had been moved into her current bedroom a few weeks ago. Resident #15 said she did not like the bedroom she was currently in because her personal items like her television does not fit in the room on top of the dresser. Resident #15 said that every time someone comes into the room the room entrance door bangs against the dresser, and she does not like it. Resident #15 said she moved into her current room because she did not get along with her former roommate who kept her up at night. Resident #15 said she was moved into the room without given a written notice or given an opportunity to ask any questions about the room she was being moved to. Resident #15 said she was not happy with the room and would like to go back to her old room in the 200-hall that fit her personal items. Resident #15 said her RP knows about the room change but was not sure if the facility provided a written notice of the room change or reason for the change before they moved her. <BR/>During a phone interview on 12/27/2023 at 10:10 a.m., Resident #15's RP said she was Resident #15's POA. The RP said she was contacted by the facility regarding Resident #15's room move. The RP said she had not received anything in writing regarding any room changes or reason for the room change.<BR/>Record review of Resident #15's clinical record revealed there was no documentation that Resident #15 or their RP had been given a written notice of room change.<BR/>During an interview on 12/27/2023 at 9:35 a.m., the Administrator said resident room changes in the facility should be documented. The Administrator said she would look for documentation regarding Resident #7 and Resident #15's room change and provide the facility policy.<BR/>During an interview on 12/27/2023 at 9:45 a.m., the ADON said Resident #15's RP called and asked the ADON to move Resident #15 in with her past roommate (Resident #7) because Resident #15 was not happy with her roommate at the time. The ADON said it was not documented. The ADON said during the call she told the RP that she would put the residents together but at the time the ADON had Covid. The ADON said a room became available and both residents were moved into the room. The ADON said she moved Resident #7 into the room after speaking with the POA. The ADON said she forgot to document the conversations she had with the RPs of both residents. The ADON said she was responsible to document the room move and there was no documentation regarding the room move. The ADON said Resident #15 started at the facility in a room in the 400-hall shared with Resident #7. The ADON said there was an outbreak of Covid and Resident #15 was transferred to the 100-hall. The ADON said Resident #15 was cleared from Covid and moved into her current room on 12/13/2023. The ADON said the process for room moves was, the facility notifies the resident and family if they have an RP of the move. The ADON said room moves were usually documented. The ADON said there was no documentation regarding Resident #7's and Resident #15's moves because it was a quick thing.<BR/>During an interview on 12/27/2023 at 11:30 a.m., the Administrator said that policy shows that room transfers should be recorded in the resident's medical record. The Administrator said an advance notice of room transfer should have been provided. The Administrator said she was unable to locate any documentation related to the room transfers for Resident #7 and Resident #15. <BR/>Review of the facility policy titled Transfer, Room to Room, dated 12/2012, reads in part, Where feasible the facility will make room to room transfers when requested by the resident or as may become necessary to meet the resident's medical and nursing care needs. Notice of Room Change: Unless medically necessary or for the safety and well-being of the resident9s), a resident will be provided with an advance notice of the room transfer. Such notice will include the reason(s) why the move is recommended. Prior to the room transfer, the resident, his or her roommate (if any), and the resident's representative (sponsor) will be provided with information concerning the decision to make the room transfer. Documentation of a room transfer is recorded in the resident's medical record.

Based on interview and record review, the facility failed to ensure it received registry verification for 1 (CNA K) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide in that:<BR/>The facility failed to ensure CNA K had a current nurse aide certification while employed at the facility while actively providing care for residents.<BR/>This failure could place residents at risk for receiving care from someone unqualified to provide care. <BR/>Findings included:<BR/>Review of a staff roster dated 12/20/2023 reflected CNA K had a hire date of 3/31/2023. <BR/>During an interview and record review on 12/22/2023 at 10:45 a.m., the BOM reviewed CNA K's employee file which revealed CNA K's certification expired 11/08/2023, and she had worked since the expiration dated. The BOM said she was unaware that the certification was expired and did not know why CNA K had not renewed her certification. The BOM said the facility did not have a system to track the expiration dates and it was the responsibility of the department head to ensure certifications were up to date. Timecard report revealed that CAN K had been working routinely as a CNA since 11/08/2023.<BR/>During an interview on 12/22/223 at 10:55 a.m., the BOM said she spoke with CNA K who had been working at the time and was informed that CNA K had not renewed her certification because she thought the facility would do it. The BOM said CNA K had been taken off the floor on 12/22/2023 to work on renewing her certification. <BR/>During an interview on 12/22/23 at 1:42 p.m., the Administrator said the prior ADON told CNA K that she would work on and take care of CNA K recertification. The Administrator said that this process did not occur. The Administrator said she did not know that CNA K had been working as a CNA with the expired certification. The Administrator said that CNA K had been taken off direct care when she learned of the expired certification. <BR/>During an interview on 12/27/2023 at 11:15 a.m., CNA K said she was hired on 03/31/2023 as a certified nursing aide. CNA K said the previous ADON back in September said she would get her CNA certification renewed for her. CNA K said there had been issues logging into Tulip (an online system for submitting long-term care licensure applications) to get the certification updated. CNA K said she was first certified back in 2020 and the facility had paid for her certification and school. CNA K said she had since 12/22/2023 she had been working as an NA by passing out water, taking food trays and answering call lights until she was able to renew her certification. CNA K said she was up to date on her trainings at the facility. CNA K said she had her competencies reviewed about three weeks ago by the new ADON. <BR/>During an interview and record review on 12/27/2023 at 1:11 p.m., the ADON said she oversaw performing competencies on staff. The ADON said CNA K's competencies and trainings at the facility were up to date. The ADON presented the competencies for review verifying competencies were current. The ADON said on 12/20/2023 she learned CNA K's certification was expired. The ADON said she was not previously aware of the expired certification and did not have a system on tracking certifications of staff. The ADON said since then CNA K has been working 8 hours as an NA instead of 12 hours as a CNA. The ADON said NA duties include passing out water to the residents, answer call lights, making beds, and passing out snacks as long as she does not have to feed any residents. The ADON said CNA K could assist with activities within the 8-hour period until her certification was updated. The ADON said that the BOM was taking care of HR duties. The ADON said the facility failed to ensure CNA K's certification was renewed because of previous ADON failing to follow-up with the process. The ADON said the risk was residents receiving services from an unqualified staff member. <BR/>Review of facility policy titled Licensure, Certification, and Registration of Personnel, dated 2007, reads in part A copy of recertifications must be presented to the Human Resources Director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. A copy of the recertification must be filed in the employee's personnel record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for three of eight residents (Resident #1, #2, and #3) reviewed for infection control.<BR/>1. MA A touched Resident #3's pills with her bare hands during medication administration. <BR/>2. LVN B failed to prevent cross contamination between Residents #1 and #2 by brining in uncleaned diabetic supplies from one room to another. <BR/>These failures could place resident's risk for cross contamination and the spread of infection. <BR/>Finding included:<BR/>Review of Resident #3's CCD dated 11/01/23, revealed a 90- year- old female admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation (heart does not beat with a regular beat all the time) and acute respiratory failure (person cannot get enough oxygen). <BR/>Review of Resident #3's MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of 11 indicating moderately impaired cognition. <BR/>Review of Resident #3's Care Plan dated 12/10/24 revealed Resident #3 was at risk for frequent infections. <BR/>Review of Resident #3's Continuity of Care Document, dated 1/24/25 revealed Resident #3 had orders for <BR/>Aspirin 81 mg dated 11/2/23 for Atrial Fibrillation<BR/>Carvedilol 12.5 mg dated 4/16/24 for Atrial Fibrillation<BR/>Digoxin 125 mcg dated 11/1/23 for Atrial Fibrillation <BR/>Apixaban 2.5 mg dated 11/1/23 fore Atrial Fibrillation<BR/>Furosemide 20 mg &frac12; tablet for 20 mg dated 1/24/25 stop date 2/6/25 for Heart failure <BR/>Gabapentin 400 mg dated 11/1/23 for Chronic Pain<BR/>Guaifenesin 400 mg dated 3/30/24 for Cough<BR/>Multivitamin dated 11/22/23 <BR/>Olmesartan 40 mg 1/16/25 for Hypertension <BR/>Spironolactone 50 mg to five with Furosemide 40mg dated 11/1/23 for Congestive Heart Failure <BR/>Observation of medication administration for Resident #3 on 01/24/25 at 11:25 a.m. revealed MA A did not wash her hands or use hand sanitizer after administering the previous resident's medication or before preparing Resident #3's medications. MA A added all of Resident #3's currently due medications to a medication cup: Aspirin 81 mg, Carvedilol 12.5 mg, Digoxin 125 mcg, Apixaban 2.5 mg, gabapentin 400 mg, guaifenesin 400 mg, multivitamin, Olmesartan 40mg and spironolactone 50mg. Before entering Resident #3's room, MA A verified medication orders on the electronic medical record (EMR). MA A said the spironolactone had instructions to be given with furosemide, which was being held. MA A stated she would hold the spironolactone and ask the ADON for verification. Using her bare (not gloved, not cleaned) index finger, MA A placed the spironolactone into another medication cup. MA A proceeded to give the remaining medications to Resident #3.<BR/>In an interview on 1/24/25 at 1:44 p.m., the DON stated she monitored medication administration by watching the staff because she did not have a lot of staff who had been at the facility a long time. The DON said she did annual competencies with the staff at the first part of February and any new hires had an initial check off. <BR/>IIn an interview at 1/25/25 at 2:55 a.m., the DON stated the facility's policy about handling medications in general was medications should be popped into cup and skin should not touch a pill at all because then there was a contamination factor. The DON said her expectation with over-the-counter medications were to be tapped into lids and the lid used to dump the pill into the medication cup. <BR/>Review of Resident #1's Continuity of Care Document, dated 1/24/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including Diabetes Mellitus (body does not produce enough insulin causing the body to have abnormally high blood sugar levels). Resident #1 had orders for have blood glucose checks three times a day and insulin administer by a sliding scale beginning 5/26/23. <BR/>Review of Resident #1's Quarterly MDS Assessment, dated &frac14;/25, revealed:<BR/>She had a BIMS score of 4 of 15 (indicating she was severely cognitively impaired).<BR/>She had a diagnosis of diabetes.<BR/>She received injections 6 of 7 days prior to the assessment. <BR/>Review of Resident #1's Care Plan, beginning 3/15/25, revealed the goal was her Diabetic status would remain stable as evidenced by resident blood sugar staying within the resident's normal limits through the next quarter. <BR/>Resident #1's Care Plan, beginning 3/15/25, revealed: Enhanced Barrier Precautions will reduce risk of the spread of organisms. <BR/>Observation on 1/24/24 at 10:15 a.m. during initial rounds revealed Resident #1 was in her room lying in bed. She had a catheter. <BR/>Review of Resident #2's Quarterly MDS Assessment, dated 11/18/24 revealed:<BR/>He had a 13 of 15 on his BIMS score (indicating he was cognitively intact)<BR/>He had a diagnosis of diabetes.<BR/>He had injections for 7 of 7 days prior to the assessment.<BR/>His care plan, start date 2/22/24 read he was at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia, renal failure, cognitive/ physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. Identified interventions were to Administer medications as ordered and monitor for side effects and effectiveness. <BR/>Observation on 1/24/25 at 11:17 a.m. revealed LVN B put on gloves and set up the glucometer (machine for measuring blood sugar levels) and went into Resident #1's room. LVN B was not wearing a gown even though Resident #1 was identified as an EBP resident. LVN B took the blood level reading of Resident #1. LVN B came out with gloves on, looked at surveyor and said, she should probably not be in the hall with gloves on. LVN B kept the gloves on. LVN B put the lancet she used to poke Resident #1's finger into the sharps container. With the same gloved hands, LVN B grabbed the top drawer of the medication cart, realized it was locked, put her hands in her pocket pulled out the keys, unlocked the cart, put the keys back into her pocket. LVN B kept the same dirty gloves on, found a container of strips for the glucometer and another lancet, shut the medication cart drawer, and locked it. LVN B, with the same contaminated gloves, returned to Resident #1's room. LVN B with the same dirty gloves opened the container of glucometer strips, stuck her finger into the container and pulled out a glucometer strip, then laid the container of glucometer strips on Resident #1's bed. With the same gloves, LVN B used a new lancet and stuck Resident #1's finger and took the glucometer reading. With the same gloves, LVN B took all the supplies to the medication cart, placed the container of glucometer strips onto the top of the medication cart, disposed of the used lancet, then disposed of the gloves. LVN B cleaned her hands with ABHG and cleaned the glucometer. LVN B did not clean the bottle of glucometer strips. LVN B put on new gloves, took the glucometer, and the (uncleaned) bottle of glucometer strips. LVN B went into Resident #2's room which also had an EBP posting on the door frame, placed everything on the dresser. LVN B put her finger down the container of glucometer strips, and performed the blood glucose reading. LVN B took her supplies, left the room, took off her gloves, cleaned her hands with ABHG and cleaned the glucometer. <BR/>In an interview and observation on 1/24/25 at 11:36 a.m., LVN B stated she was an agency nurse, but had worked at the facility before. LVN B said if she could do anything different, she would have changed gloves more often and used disinfecting wipes on the glucometer instead of alcohol wipes, but she used what she had. LVN B said she would have changed gloves more often to prevent cross contamination, and she was not aware of everything she touched with the one pair of gloves. State surveyor reviewed the list with her, and her response was wow. LVN B said EBP meant she was supposed to wear a gown and gloves. LVN B said this applied to anyone who had a catheter, indwelling device or wound. LVN B stated most facilities had it posted on the door and most facilities had supplies outside the door. LVN B said she did not notice supplies outside the door. LVN B and state surveyor went to Resident #1's room. There was a sign posted but no PPE outside of the room in any fashion or visually available in the room. LVN B said there was a sign, and she was aware Resident #1 had a catheter, and could see the catheter. LVN B admitted she was aware she needed to wear a gown and did not wear one because there were none outside of the room. LVN B said the point of EBP was to protect the resident from other infections. <BR/>Interview on 1/24/25 at 11:58 a.m., the DON stated she had a container of gowns behind the nurse's station because the other containers the facility had went missing. The DON said there were a couple on order. The DON said the facility did have the type of gown container that could be hung over the door. The DON said having the gowns at the nurse's station was not an effective process because the staff had to go all over the building. The DON stated she had four residents on EBP. <BR/>Interview on 1/24/25 at 2:55 p.m., the DON explained the mechanics of cross contamination. She stated cross contamination happened when anyone did not use gloves or held linens too close to the body and the contaminate goop gets on you and you go into the next room. She said the same thing would happen when a person had gloves on. The DON stated gloves would cause cross contamination if it had germs on the surface and the staff go across hall with gloves on the staff had the risk of bringing contamination across the hall. The DON stated the Medication Cart could be contaminated because if the gloves touched the resident, they were dirty, and the gloves should have been removed and the nurse's hands should have been sanitized. The DON stated the keys to the medication cart were contaminated. The DON said the glucometer strips were now contaminated all the others and the nurse impaired the integrity. The DON said she trained nurses to tap the bottle like you would a pill until a strip comes out. The DON stated the outside of tube was contaminated when it touched the resident's bed. The DON said Resident #2 currently did not qualify for EBP, She stated he had pseudomonas UTI but it had resolved.<BR/>Review of in-services reveal the facility trained staff on EBP policy on 1/17/25:<BR/>The facility's policy and procedure on Enhanced Barrier Precautions, undated, revealed:<BR/>Enhanced barrier precautions are utilized to reduce transmission of multi-drug resistant organisms to residents. <BR/>Policy Interpretation:<BR/>Enhanced barrier precautions are used as an infection prevention and control intervention to reduce to transmission of multi-drug resistant organisms to residents. <BR/>Enhanced barrier precautions employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.<BR/>Enhanced barrier precautions are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.<BR/>B indwelling devices include urinary catheters. <BR/>Review of in-services revealed the facility in-served staff on the 6/21/24 on Glove use:<BR/>Review of the facility's policy and procedure on Personal Protective Equipment - Using Gloves, revised October 2010, revealed:<BR/>Purpose: To guide the use of Gloves<BR/>Objective: To prevent the spread of infection.<BR/>Review of the facility's policy and procedure on Handwashing/Hand Hygiene, revised April 2012, revealed:<BR/>The facility considered hand hygiene the primary means to prevent the spread of infection.<BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. <BR/>In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, used an alcohol-based hand rub containing 60 - 90% ethanol or isopropanol for all the following situations: before preparing or handling medications. <BR/>Review of the facility's policy and procedure on Administering Medications, revised December 2012, revealed: Medications shall be administered in a safe and timely manner. <BR/>Staff shall follow established infection control practices (e.g. handwashing, antiseptic technique, gloves, isolation precautions etc.) for the administration of medications, as applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receive services with reasonable accommodation of resident's needs and preferences for 2 of 5 (Resident #1 and Resident #2) residents reviewed for call light placement. <BR/>The facility failed to ensure call light was placed within reach for Resident #1 and Resident #2. <BR/>This failure could affect residents by not having access to call for assistance resulting in needs not being met. <BR/>The findings included: <BR/>Resident #1<BR/>Record review of Resident #1's face sheet undated revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses included Alzheimer's disease and dementia. <BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 0 indicating, severely cognitive impaired. <BR/>Record review of Resident #1's care plan dated 4/18/23 revealed a focus area for risk for falls with interventions with call bell within reach, educate and encourage use, and answer promptly.<BR/>During an observation and interview on 7/17/23 at 10:19 AM, Resident #1 was in bed, facing the wall and the call light was on the floor out of reach. Resident #1 was alert and oriented to person only. Resident #1 stated she tends to wait for staff to check on her to ask for help. Resident #1 stated she did not know how to call staff for help, did not specify if she meant how to use the call light. <BR/>Resident #2<BR/>Record review of Resident #2's face sheet undated revealed a [AGE] year-old male who was admitted on [DATE]. His diagnoses included unsteadiness on feet, memory deficit, abnormalities of gait mobility, lack of coordination, and anxiety. <BR/>Record review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 5 indicating severe cognitive impairment. <BR/>Record review of Resident #2's care plan, last reviewed on 6/2/23, revealed a focus care for falls with interventions of call bell within reach, educate and encourage use, and answer promptly. <BR/>During an interview and observation on 7/17/23 at 10:23 AM, Resident #2 was in bed, the call light was on the floor. red signs on wall that said ask for help and use the call light. Resident #2 stated he had been in the facility for several weeks. Resident #2 was asked about call light placement and use but he did not answer questions. <BR/>During an interview on 7/17/23 at 1:17 PM, CNA A stated she had worked with Resident #1 in the past several times. CNA A stated Resident #1 was able to use the call light. CNA A stated she was trained that call lights were to remain within reach of all residents. CNA A stated that residents who do not having call lights within reach could potentially get hurt if they were to lean over to reach for call light the fall and hit their head. CNA A stated all staff were responsible for ensuring call lights were within reach and CNA's would have to check call light placement before exiting a room at least every 2 hours. CNA A did not have a reason for Resident #1 and Resident #2 not having call light within reach.<BR/>During an interview on 7/17/23 at 1:37 PM, CNA B stated it was her first day working at the facility. CNA B stated she had been trained to keep call lights within reach of resident. CNA B stated she would ask residents where they preferred to have it and would tend to place it closer to their dominant hand for easy access. CNA B stated she had been trained to do rounds at least every 2 hours to ensure residents were ok and they had their call lights within reach. CNA B stated if residents did not have call lights within reach then the residents would not be able to call for help when needed. CNA B did not have a reason for Resident #1 and Resident #2 not having call light within reach<BR/>During an observation and interview on 7/17/23 at 2:05 PM, Resident #1 was not in room, call light was still on the floor from last observation at 10:19 AM. The ADON stated the call lights were expected to always be in bed and within reach. The ADON stated CNA's were responsible of ensuring call lights were within reach. The ADON stated by not having call lights within reach could potentially reduce their quality of life. The ADON stated charge nurse should be checking call light placement at least during each encounter with residents. The ADON stated staff get training on call light placement upon hire and verbal reminders daily. <BR/>During an interview on 7/17/23 at 2:06 PM, CNA C stated Resident #1 was able to use call light. CNA C stated she was trained that call lights were to remain within reach of all residents. CNA A stated that not having call lights within reach could potentially experience emotional and mental distress due to them lying in bed just waiting for someone to come and assist. CNA A stated all staff were responsible for ensuring call lights were within reach of residents and CNA's would have to check call light placement before exiting a room at least every 2 hours. CNA C did not have a reason for Resident #1 and Resident #2 not having call light within reach<BR/>During an interview on 7/17/23 at 2:53 PM, the Administrator stated DON and ADON were responsible for training staff upon hire. The Administrator stated she did not know how often staff received training regarding call light placement. The Administrator stated call lights were expected to be within reach of residents and rounds should be conducted daily to ensure residents needs were met. <BR/>During an interview on 7/17/23 at 3:20 PM, the DON stated call lights were required to be within reach of residents and all staff were responsible for ensuring call light placement was appropriate. The DON stated every time a staff exited the resident room, they should be checking for call light placement and nursing staff were expected to be doing rounds at least every 2 hours or as needed. The DON stated that not having call light within reach of resident could affect residents' assistance and care be delayed. The DON stated she does not know when the last in-service was provided regarding call light placement. The DON stated all staff get daily verbal reminders regarding call light placement within reach. <BR/>During a joint interview 7/17/23 at 4:05 PM, the Administrator and Regional Nurse stated the facility did not have a call light policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive person-centered care plan for each resident , consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment which were to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 4 of 4 residents (Resident #3, Resident #4, Resident #5, Resident #6) reviewed for care plans.<BR/>1. The facility failed to implement a comprehensive person-centered care plan for Resident #3's physical altercation with Resident #4 on 07/10/24. <BR/>2. The facility failed to implement a comprehensive person-centered care plan for Resident #4's incident on 07/10/24 with Resident #3 in which Resident #3 physical hit Resident #4. <BR/>3. The facility failed to implement a comprehensive person-centered care plan for Resident #5's physical altercation with Resident #6 on 07/21/24.<BR/>4. The facility failed to implement a comprehensive person-centered care plan for Resident #6's incident on 07/21/24 with Resident #5 in which Resident #5 physical hit Resident #6. <BR/>These deficient practices could place residents at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include:<BR/>1. Record review of Resident #3's face sheet, dated 02/25/25, revealed an admission to the facility on [DATE] and re-admission on [DATE]. <BR/>Record review of Resident #3's hospital history and physical, dated 07/05/24, revealed a [AGE] year-old male with diagnoses which included Wernicke-Korsakoff disorder (a life-threatening brain disorder caused by a severe deficiency of thiamine, or vitamin B1), Dementia, and anxiety disorder. <BR/>Record review of Resident #3's MDS dated 01/2025, revealed a moderate cognitive impairment BIMS score of 12 to recall and or make daily decisions. <BR/>Record review of Resident #3's Care Plan, dated 03/30/23, revealed Problem: Resident has verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others). Resident will verbalize understanding of need to control verbal abusive behaviors. Maintain a calm, slow, understandable approach. Remove resident from group activities when behavior was unacceptable. <BR/>During an interview on 02/25/25 at 9:46 AM with the DON, she stated Resident #3 had an incident on 07/10/24 in which he hit another resident. The DON stated she did not see Resident #3 had a focus area care planned for the incident in which he had a physical behavior. The DON stated the purpose of the care plan was to direct staff as far as the resident had a problem or condition and to provide to care. The DON stated the negative outcome of not having it care planned would be staff not monitoring for and where and how to intervene. The DON stated for Resident #3 the staff would not know to intervene if he had a physical behavior placing the other residents at risk. The DON stated the MDS department, and the nurses were responsible ensuring the comprehensive care plans were accurate. <BR/>During an interview on 02/25/25 at 3:00 PM with the Administrator, she stated Resident #3 had an incident on 07/10/24, were he hit another resident. The Administrator stated she would have to check to see if it was care planned and should have been care planned. The Administrator stated if it was not documented in the care plan it did not happen. The Administrator stated the purpose of the care plan was to inform the resident or representative party of a complete picture of the care the resident was being provided. <BR/>The Administrator stated the negative outcome would be the resident or the representative party would be they would not make informed decisions that were mindful. The Administrator stated the DON, and the Social Worker were responsible for ensuring the care plans were accurate. <BR/>2. Record review of Resident #4's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Resident #4 was a [AGE] year-old male with diagnoses which included Diabetes Mellitus, chronic pain due to trauma, major depressive disorder.<BR/>Record review of Resident #4's Care Plan, reviewed on 02/25/25, revealed there was no focus area nor interventions in place for the resident-to-resident altercation on 07/10/24. <BR/>During an interview on 02/25/25 at 9:46 AM with the DON, she stated she did not see the interventions care planned for Resident #4 any focus area or interventions for the incident he had with Resident #3 on 07/10/24 in which they got into a physical altercation. <BR/>3. Record review of Resident #5's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Resident #5 was a [AGE] year-old female which diagnoses which included Cerebral Palsy and intellectual disabilities. <BR/>Record review of Resident #5's annual MDS, dated [DATE], revealed there was no BIMS score taken to measure the cognition of impairment of the resident. <BR/>Record review of Resident #5's care plan, reviewed on 02/25/25, revealed there was not a focus area or interventions documented for the altercation on 07/21/24 with Resident #6. <BR/>Record review of Resident #5's progress notes, dated 07/21/24, revealed Another resident in wheelchair refuse to give a different resident the cordless phone state, 'This was her phone. She was not giving it up.' This resident struck another resident in the face with a closed fist and began crying, both residents were separated and taken to their rooms.<BR/>During an interview on 02/26/25 at 10:54 AM with MDS Coordinator, she stated there were not interventions or focus areas in the care plan for Resident #5's altercation with Resident #6 on 07/21/24. <BR/>During an interview on 02/27/25 at 10:28 AM with the DON, she stated Resident #5 had a physical altercation with Resident #6 in which she hit her while trying to get the phone. The DON stated it was not care planned for both Resident #5 and Resident #6. <BR/>4. Record review of Resident #6's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Resident #6 was an [AGE] year-old female with a diagnosis which included anxiety disorder. <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], revealed a severely impaired cognition BIMS score of 7. Resident #6 was able to recall or make daily decisions. Resident #6 had diagnoses which included dementia, anxiety and depression. <BR/>Record review of Resident #6's care plan, reviewed on 02/25/25, revealed there was no focus area or interventions documented for the incident with the physical altercation incident on 07/21/24. <BR/>During an interview on 02/26/25 at 10:54 AM, with the MDS Coordinator, revealed the MDS department and the DON were responsible for the care plans and ensuring they were accurate. The MDS Coordinator stated the purpose of a care plan was to provide the best service for the resident and if the resident had a problem, then the care plan would address the steps to help provide the best care for the resident. The MDS Coordinator stated Resident #3 and Resident #4 did not have focus areas with interventions addressed to each resident with their specific incident. The MDS Coordinator stated the risk would be the facility staff not knowing how to care for the resident(s).<BR/>Record review of the facility's Comprehensive Assessments Policy, dated 10/2023, revealed Comprehensive MDS assessments are conducted to assist in developing person-centered care plans. The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using the Resident Assessment Instrument specified by CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for 1 of 5 (Resident #5) residents reviewed for urinary catheter. <BR/>The facility failed to ensure Resident #5's urinary foley bag was placed below the bladder. <BR/>The facility failed to have a physician order for Resident #5's foley catheter. <BR/>This failure could place residents with urinary catheter at risk of infection. <BR/>The findings included: <BR/>Record review of Resident #5's face sheet undated revealed a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE]. Her diagnoses included urinary tract infection, paranoid schizophrenia, cognitive social or emotional deficit following cerebral infraction.<BR/>Record review of Resident #5's MDS dated [DATE] revealed a BIMS score of 0, indicating she was severely cognitive impaired. Bladder and bowel section reflected Resident #5 had an indwelling catheter. <BR/>Record review of Resident #5's electronic active physician orders dated July 2023 revealed no orders found for foley catheter placement.<BR/>During an observation on 7/17/23 at 1:51 PM, Resident #5 was taken to nurses' station with the ADON, the Foley catheter was hanging on the right side of the wheelchair arm rest. Urine was noted in the Foley catheter bag and catheter tubing. Resident #5 was then taken to the common area by the window. <BR/>During an observation and interview on 7/17/23 at 1:52 PM, the ADON stated she had not noticed Resident #5's foley catheter hanging on the right side of the wheelchair arm rest. The ADON walked over to Resident #5 and placed the foley catheter under the wheelchair. The ADON stated she noticed there was urine in the foley tubing and the urine was not flowing properly because it was not below the bladder. The ADON stated the nursing department was responsible of ensuring foley catheters were placed below the bladder. The ADON stated she does not recall the last training that was provided regarding foley catheter placement. The ADON stated that by not having foley catheter below the bladder could result in urinary tract infection. The ADON did not have an answer for Resident #5's foley catheter not positioned below the bladder.<BR/>During an interview on 7/17/23 at 2:53 PM, the Administrator referred foley catheter questions to the nursing department. <BR/>During an interview on 7/17/23 at 2:56 PM the Regional Nurse stated resident's foley catheter position was required to be below the bladder. The Regional Nurse stated the foley catheter should be hanging off the bed rail and when in wheelchair, under the wheelchair to ensure proper urine flow. The Regional Nurse stated foley care placed on arm rest in wheelchair was not appropriate due to not allowing the urine flow and could result in backflow of urine resulting in urinary tract infection. The Regional Nurse was not sure how often nursing department received training on foley catheter care. the Regional Nurse stated she had noticed this morning Resident #5 did not have a physician order to address her foley catheter during a full chart audit she was conducting. The Regional Nurse stated the admitting nurse should had been the person to include foley catheter input physician order. The Regional Nurse stated Resident #5's records were not accurate and could affect the ongoing monitoring of Foley catheter provided. The Regional Nurse did not have answer for Resident #5 not having a physician order for foley catheter.<BR/>During an interview on 7/17/23 at 3:20 PM, the DON stated foley catheter was required to be placed below the bladder. The DON stated foley care placed on arm rest in wheelchair was not appropriate due to not allowing urine flow and could result in backflow of urine resulting in urinary tract infection. The DON stated the nursing department was responsible for ensuring foley catheters were properly placed. The DON was not sure how often nursing department received training on foley catheter care. <BR/>During an attempted interview on 7/17/23 at 3:37 PM, Resident #5 did not want to talk. <BR/>Record review of Catheter Care policy dated September 2014 revealed The purpose of this procedure is to prevent catheter-associated urinary tract infections. Maintaining unobstructed flow: the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to allow the resident's representative the right to exercise the resident's rights to the extent those rights are delegated to the representative for 1 (Resident #1) out of 2 residents reviewed for resident rights. <BR/>The facility failed to honor Resident #1's Power of Attorney (POA) by having Resident #1 enroll in a funeral plan without the involvement or consent of the resident representative.<BR/>This failure could result in any resident with assigned POA and other designated agents at risk of their rights being violated. <BR/>Findings included:<BR/>Review of Resident #1's face sheet dated 4/03/2023, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included paralysis of one side of the bod following a stroke, type 2 diabetes mellitus, dementia, acquired absence of right leg above knee, anxiety disorder, hypertension, heart disease, hydronephrosis (excess fluid in a kidney due to a backup of urine), acute kidney failure (condition in which the kidneys suddenly can't filter waste from the blood), functional quadriplegia (the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord). Resident #1's Family Member A was listed as health care POA.<BR/>Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 5, which indicated severe cognitive impairment.<BR/>During an interview on 04/03/2023 at 9:08 a.m., Resident #1's Family Member A said she was Resident #1's financial and medical power of attorney. DA said that the facility failed to notify her of Resident #1 being enrolled into a funeral plan without her consent. DA said the facility BM had Resident #1 sign an Authorization for Payment Form for a funeral plan without involving her. DA said Resident 1's birthday was 8/2/1947, and the facility provided the wrong birthdate of 8/12/1947 on the funeral contract.<BR/>During an interview on 4/3/2023 at 10:32 a.m., Resident #1 said that he does not take care of his money. Resident #1 said that he does not remember signing a funeral plan. Resident #1 said the facility administration and his Family Member A was aware of what was going on with his money.<BR/>During an interview on 4/3/2023 at 11:12 a.m., the BOM said the facility had to do a spend down for Resident #1 to make sure he qualified for Medicaid. The BOM said Resident#1's Family Member A does not have financial power of attorney. The BOM said that Family Member A gave the facility a power of attorney document that did not look right and the facility did not accept it because it wasn't properly done as the year was scratched out and Resident 1's signature did not look like his signature. The BOM said that Resident #1 signed for and purchased a funeral plan totaling $5,335.00. The BOM said that after she had already got Resident #1 the funeral contract, Resident #1's Family Member A said they had a plot for him already. The BOM said that she gets funeral contracts for the residents where it includes the services and not just the plot. The BOM said that she will have to review the funeral plan with Family Member A.<BR/>Review of the Authorization for Payment of Specific Deduction from Resident Trust Fund dated 2/7/2023, revealed Resident #1 signed the document. There was no POA signature on the document. The document authorized the nursing facility to make the periodic specific deduction from the trust fund of Resident #1 for a funeral contract totaling $5335.00. Review of contract page 5 of 5 revealed Resident #1's birthdate as 8/12/2023 (incorrect birthdate on the document).<BR/>Record review of a copy of the Statutory Durable Power of Attorney sent to the surveyor by the Family member on 4/3/2023 at 2:00 p.m., revealed the document signed and notarized on 1/4/2023 by Resident #1. The document revealed that Resident #1 appointed his Family Member A as his agent to act for him in any lawful way. The signed document grants all powers to include real property transactions; tangible personal property transactions; stock and bond transactions; commodity and option transactions; banking and other financial institution transactions; business operating transactions; insurance and annuity transactions; estate, trust, and other beneficiary transactions; claims and litigation; personal and family maintenance; benefits from social security, Medicare, Medicaid, or other governmental programs or civil or military service; retirement plan transactions; tax matters; digital assets and content of electronic communications.<BR/>During an interview on 4/3/2023 at 3:17 p.m., Notary Public Official (NPO) said on 1/4/2023, she met Resident #1 and Family Member A at the nursing facility. The NPO said she read Resident #1 the information on the Power of Attorney document in his room. The NPO said that Resident #1 was assisted to sign the document by Family Member A. The NPO said that she crossed out the date on the document because the date printed was the wrong one and the document was not effective in 2021 but was effective in 2023. The NPO said that that Resident #1's Family Member A helped the resident steady his hand to sign his initials on the corrected date. The NPO said Resident #1 was fully awake and coherent at the time. The NPO said that she should have written something on the document to clarify that the resident was assisted signing the document. <BR/>During an interview on 4/4/2023 at 3:30 p.m., the Administrator said that the facility corporate office staff were present at the facility at the time the POA documentation was presented by Family Member A. The Administrator said that corporate staff thought the document was not correct due to corrections made on the document. The Administrator said that Family Member A was informed the document would need to be redone. The Administrator said that he did not speak with the NPO. The Administrator said that the facility will need to honor the notarized document. <BR/>Review of Resident Rights policy revised October 2009 read in part Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include to resident's right to: Have the facility manage his or her funds (if he or she wishes); Residents are entitled to exercise their rights and privileges to the fullest extent possible; and Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 2 of 2 (Broken blinds), 2 warped tiles, 3 holes in the walls, 1 exit door missing sweep of 4 exit doors, and 1 of 1 maintenance log reviewed for environment.<BR/>1. The facility failed to ensure the blinds were not broken.<BR/>2. The facility failed to ensure floor tiles were not warped.<BR/>3. The facility failed to ensure there were not holes in hallway 3 and a hole in the hall leading to the back smoking patio/laundry room.<BR/>4. The facility failed to ensure the hallway 1 Exit door was not missing a sweep and created a seal on the mid-top side of the door to not expose the outside elements. <BR/>5. The facility staff failed to input broken items into the maintenance work order log. <BR/>These failures could residents at risk of living, working and visiting in an unsafe, unsanitary, and uncomfortable environment. <BR/>Findings include:<BR/>Observation on 02/24/25 at 8:04 AM revealed in hallway 1 in room [ROOM NUMBER] the blinds were broken. <BR/>Observation on 02/24/25 at 8:21 AM revealed in room [ROOM NUMBER] had broken blinds. <BR/>Observation on 02/24/25 at 8:37 AM revealed in hallway 3 there was a large scrap hole on the bottom wall just above the border near room [ROOM NUMBER] around a foot or more in length. On the opposite side of the wall towards the back smoking/patio hall was another hole just above the border around 4-5 inches in lengths and around 2-3 inches wide. On the floor was two long warped floorboards with 2 wheelchairs next to them. <BR/>During an interview on 02/2/525 at 4:30 PM with the Administrator, she stated the washer and drier had broken down. The Administrator stated the facility fixed the drier and was sending resident clothes to the laundry mat until the washer got fixed. The Administrator stated the residents had their clothes washed and cleaned. <BR/>During an interview on 02/25/25 at 4:50 PM with the Administrator, she stated if something was broken then it needed to be removed until it was fixed. The Administrator stated the staff were to report it and the department heads would remove the broken item. The Administrator stated it was expected and the responsibility of the staff and everyone was to report broken items. The Administrator stated not reporting broken items could be a risk of residents hurting themselves. <BR/>During an interview on 02/26/25 at 9:12 AM with the Maintenance Director, he stated the residents were always breaking the blinds and the facility staff placed work orders in the maintenance logbook. The Maintenance Director stated the exit door in hallway 1 was not reported and was missing the seep on the bottom of the door as there was a black blanket placed. The Maintenance Director stated the risk of having the blanket on the floor could be impeding the resident's movement to go outside. The Maintenance Director stated he could see the light coming from outside on the side of the exit door as it was not creating a seal preventing the outside weather and pest from coming into the facility. The Maintenance Director stated the broken walls in hallway 3 were not reported to him and it was not in the maintenance logbook. The Maintenance Director stated the floorboards in hallways 3 had been reported to him a couple of weeks ago but was waiting on corporate to see how they were going to fix it. The Maintenance Director stated it was a fall hazard. The Maintenance Director stated the washer had been broken for about 2-3 weeks and was fixed but the water came out to fast that it overflowed and leaked back onto the laundry room. The Maintenance Director stated the risk would be structural damage and could be creating an environment suitable for mold and pests.<BR/>Observation and interview on 02/26/25 at 2:54 PM with the DON, revealed she observed the hallway 1 exit door with the black blanket on the floor. The DON was observed looking through the opening of the exit door that was not creating a seal. The DON was observed going to hallway 3 and looking at the holes in the wall and the hole near the smoking back patio area. The DON was observed looking at the floorboards in hallway 3 that were warped. The DON was observed looking at the towel on the floor in the laundry room placed around the washers. The DON stated the blanket on the floor of the exit door in hallway 1 created a trip hazard. The DON stated the holes on the wall were reported two weeks ago and should have been fixed. The DON stated the floorboards were a trip and fall risk. The DON stated the water leaking over into the laundry room could be a trip hazard. <BR/>During an interview on 02/26/25 at 4:37 PM with RN, she stated the washer was broken for about two weeks and the facility was washing the residents' clothes at the laundry mat. The RN stated she noticed there were towels on the floor around the washers in the laundry room to prevent the water from overflowing into the laundry room. The RN stated the risk would be slippery of the ground for someone walking by creating a hazard for the residents. The RN stated it could also create mold due to the humidity in the laundry room with the drier and water and possibly invite pests. <BR/>During an interview on 02/27/25 at 9:05 AM with LVN B, she stated the facility had a binder in which facility staff could place the work orders. LVN B stated it was expected to put the room number, date, and time it was reported to maintenance. LVN B stated an in-service was provided about placing work orders. LVN B stated it was expected for the facility staff to be placing work orders for broken items in the facility. LVN B stated the negative outcome would be for safety. <BR/>During an interview on 02/27/25 at 12:03 PM with the DON, she stated the facility staff were trained and in-serviced on placing work orders. The DON stated it was expected for staff to be placing it in the work order logbook. The DON stated she saw the broken blinds and reported it in the morning meeting and during stand down meeting but failed to place it in the work order logbook. <BR/>Record review of the facility's maintenance work order log, dated 02/26/25, revealed there was no documentation of work orders for walls being broken, broken blinds, washer/dryer break downs, hallway 1 exit door sweep missing and a gap with the exit door and building mid door. <BR/>Record review of the facility's Maintenance Service Policy, dated 12/2009, revealed Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to: maintaining the building in compliance with current federal, state, and local laws, regulations and guidelines. Maintain the building in good repair and free from hazards. Maintain the heat/cooling system, plumbing fixtures, wiring etc., in good working order. The Maintenance Director was responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Records shall be maintained in the maintenance director's office. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.<BR/>Record review of the facility's Work orders, Maintenance Policy dated 04/2010, revealed Maintenance work orders shall be completed in order to establish a priority of maintenance service. In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the maintenance director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive person-centered care plan for each resident , consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment which were to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 4 of 4 residents (Resident #3, Resident #4, Resident #5, Resident #6) reviewed for care plans.<BR/>1. The facility failed to implement a comprehensive person-centered care plan for Resident #3's physical altercation with Resident #4 on 07/10/24. <BR/>2. The facility failed to implement a comprehensive person-centered care plan for Resident #4's incident on 07/10/24 with Resident #3 in which Resident #3 physical hit Resident #4. <BR/>3. The facility failed to implement a comprehensive person-centered care plan for Resident #5's physical altercation with Resident #6 on 07/21/24.<BR/>4. The facility failed to implement a comprehensive person-centered care plan for Resident #6's incident on 07/21/24 with Resident #5 in which Resident #5 physical hit Resident #6. <BR/>These deficient practices could place residents at risk of not receiving the necessary care or services and having personalized plans developed to address their needs. <BR/>Findings include:<BR/>1. Record review of Resident #3's face sheet, dated 02/25/25, revealed an admission to the facility on [DATE] and re-admission on [DATE]. <BR/>Record review of Resident #3's hospital history and physical, dated 07/05/24, revealed a [AGE] year-old male with diagnoses which included Wernicke-Korsakoff disorder (a life-threatening brain disorder caused by a severe deficiency of thiamine, or vitamin B1), Dementia, and anxiety disorder. <BR/>Record review of Resident #3's MDS dated 01/2025, revealed a moderate cognitive impairment BIMS score of 12 to recall and or make daily decisions. <BR/>Record review of Resident #3's Care Plan, dated 03/30/23, revealed Problem: Resident has verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others). Resident will verbalize understanding of need to control verbal abusive behaviors. Maintain a calm, slow, understandable approach. Remove resident from group activities when behavior was unacceptable. <BR/>During an interview on 02/25/25 at 9:46 AM with the DON, she stated Resident #3 had an incident on 07/10/24 in which he hit another resident. The DON stated she did not see Resident #3 had a focus area care planned for the incident in which he had a physical behavior. The DON stated the purpose of the care plan was to direct staff as far as the resident had a problem or condition and to provide to care. The DON stated the negative outcome of not having it care planned would be staff not monitoring for and where and how to intervene. The DON stated for Resident #3 the staff would not know to intervene if he had a physical behavior placing the other residents at risk. The DON stated the MDS department, and the nurses were responsible ensuring the comprehensive care plans were accurate. <BR/>During an interview on 02/25/25 at 3:00 PM with the Administrator, she stated Resident #3 had an incident on 07/10/24, were he hit another resident. The Administrator stated she would have to check to see if it was care planned and should have been care planned. The Administrator stated if it was not documented in the care plan it did not happen. The Administrator stated the purpose of the care plan was to inform the resident or representative party of a complete picture of the care the resident was being provided. <BR/>The Administrator stated the negative outcome would be the resident or the representative party would be they would not make informed decisions that were mindful. The Administrator stated the DON, and the Social Worker were responsible for ensuring the care plans were accurate. <BR/>2. Record review of Resident #4's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Resident #4 was a [AGE] year-old male with diagnoses which included Diabetes Mellitus, chronic pain due to trauma, major depressive disorder.<BR/>Record review of Resident #4's Care Plan, reviewed on 02/25/25, revealed there was no focus area nor interventions in place for the resident-to-resident altercation on 07/10/24. <BR/>During an interview on 02/25/25 at 9:46 AM with the DON, she stated she did not see the interventions care planned for Resident #4 any focus area or interventions for the incident he had with Resident #3 on 07/10/24 in which they got into a physical altercation. <BR/>3. Record review of Resident #5's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Resident #5 was a [AGE] year-old female which diagnoses which included Cerebral Palsy and intellectual disabilities. <BR/>Record review of Resident #5's annual MDS, dated [DATE], revealed there was no BIMS score taken to measure the cognition of impairment of the resident. <BR/>Record review of Resident #5's care plan, reviewed on 02/25/25, revealed there was not a focus area or interventions documented for the altercation on 07/21/24 with Resident #6. <BR/>Record review of Resident #5's progress notes, dated 07/21/24, revealed Another resident in wheelchair refuse to give a different resident the cordless phone state, 'This was her phone. She was not giving it up.' This resident struck another resident in the face with a closed fist and began crying, both residents were separated and taken to their rooms.<BR/>During an interview on 02/26/25 at 10:54 AM with MDS Coordinator, she stated there were not interventions or focus areas in the care plan for Resident #5's altercation with Resident #6 on 07/21/24. <BR/>During an interview on 02/27/25 at 10:28 AM with the DON, she stated Resident #5 had a physical altercation with Resident #6 in which she hit her while trying to get the phone. The DON stated it was not care planned for both Resident #5 and Resident #6. <BR/>4. Record review of Resident #6's face sheet, dated 02/25/25, revealed admission to the facility on [DATE] and re-admission on [DATE]. Resident #6 was an [AGE] year-old female with a diagnosis which included anxiety disorder. <BR/>Record review of Resident #6's quarterly MDS, dated [DATE], revealed a severely impaired cognition BIMS score of 7. Resident #6 was able to recall or make daily decisions. Resident #6 had diagnoses which included dementia, anxiety and depression. <BR/>Record review of Resident #6's care plan, reviewed on 02/25/25, revealed there was no focus area or interventions documented for the incident with the physical altercation incident on 07/21/24. <BR/>During an interview on 02/26/25 at 10:54 AM, with the MDS Coordinator, revealed the MDS department and the DON were responsible for the care plans and ensuring they were accurate. The MDS Coordinator stated the purpose of a care plan was to provide the best service for the resident and if the resident had a problem, then the care plan would address the steps to help provide the best care for the resident. The MDS Coordinator stated Resident #3 and Resident #4 did not have focus areas with interventions addressed to each resident with their specific incident. The MDS Coordinator stated the risk would be the facility staff not knowing how to care for the resident(s).<BR/>Record review of the facility's Comprehensive Assessments Policy, dated 10/2023, revealed Comprehensive MDS assessments are conducted to assist in developing person-centered care plans. The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using the Resident Assessment Instrument specified by CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that medication error rates of 5 percent or greater. The facility had a medication error rate of 7.14 %, based on 2 errors out of 28 opportunities, which involved 2 of 8 residents (Resident #19 and Resident #25) reviewed for medication administration.<BR/>The facility failed to ensure Resident #19 and Resident #25 received prescribed Senna-Docusate 8.6/50 mg (stimulant laxative/stool softener combination medication) verses administered Senna 8.6mg (stimulant laxative only).<BR/>This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.<BR/>Findings included:<BR/>Record review of Resident #19's face sheet indicated an [AGE] year-old female who admitted to the facility on [DATE] with the diagnoses which included Huntington's Disease (a condition that stops parts of the brain working properly over time), and constipation (having fewer than 3 bowel movements in a week).<BR/>Record review of Resident #19's consolidated physician's orders, dated 01/27/2022, indicated she was prescribed Sennosides-docusate Sodium 8.6-50milligrams via PEG twice daily for constipation with a start date of 12/27/2022.<BR/>Record review of Resident #19's Change of Status MDS, dated [DATE], indicated she rarely understood and was rarely understood. Resident #19's BIMS score indicated she had a severe cognitive deficit. <BR/>Record review of Resident #19's Care Plan, dated 01/30/23, revealed she was at high risk of aspiration, nutritional impairment, and complications due to dysphagia related to diagnosis of Huntington s disease. The intervention was to administer medications as ordered and to monitor for side effects, effectiveness. <BR/>Record review of Resident #25's face sheet indicated an [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses which included Sepsis (blood poisoning), and constipation (having fewer than 3 bowel movements in a week).<BR/>Record review of Resident #25's consolidated physician's orders, dated 04/04/2023, indicated he was prescribed Sennosides-docusate Sodium 8.6-50milligrams PO twice daily for constipation with a start date of 04/04/2023.<BR/>Record review of Resident #25's Quarterly MDS, dated [DATE], indicated he rarely understood and was rarely understood. Resident #25's BIMS score indicated he had a severe cognitive deficit. <BR/>During an observation on 04/19/2023 at 09:00 a.m., the LVN B administered Senna 8.6 milligrams per gastrostomy tube to Resident #19.<BR/>During an observation on 04/19/2023 at 4:50 p.m., the CMA C administered Senna 8.6 milligrams by mouth to Resident #25.<BR/>During an interview on 04/19/2023 at 3:27 p.m., the DON was able to demonstrate how orders in Matrix are transferred onto the MAR and this would help prevent any confusion on what was documented on the MAR versus what was documented on the Physician Order. <BR/>During an interview on 04/20/2023 at 10:07 a.m., the DON was able to show that the two involved medication carts had both Docusate Senna and Senna present. The DON stated that the involved staff (LVN B and CMA C) had the available medication as documented in the order for Residents #19 and #25. The DON stated that medication errors are addressed with the staff on an individual basis. She stated competency is conducted for the staff annually by nursing administration and also by the Pharmacist. <BR/>Record review of the facility's policy titled, Administering Medication, dated 12/2012 indicated, .3. Medications must be administered in accordance with the orders, including any required time frame. 7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. <BR/>1. The facility failed to ensure stored foods were properly labeled and dated.<BR/>2. The facility failed to ensure expired foods were discarded.<BR/>This places residents at risk of receiving outdated foods.<BR/>The findings included:<BR/>Observation of the dry storage on 4/18/23 at 8:15 AM revealed the following:<BR/>- <BR/>1, 1-lb bag jet puffed mini marshmallows expired 1/17/23<BR/>- <BR/>6 white plastic bags with very small labels that read banana cake mix, no expiration date<BR/>- <BR/>4, 1-gallon containers of Golden Italian dressing with packaged date of 11/19/19, no expiration date<BR/>- <BR/>2, 1-gallon containers of Orange French dressing with packaged date of 12/20/18, no expiration date<BR/>- <BR/>1, 5-lb container of Lite Chili Powder with expiration date of 9/9/16<BR/>- <BR/>1, 1-gallon container of dill relish with packaged date of 11/30/22, no expiration date<BR/>- <BR/>2, 1-gallon containers of heavy-duty mayonnaise with packaged date of 1/17/22, no expiration date<BR/>- <BR/>6, 16-oz containers of low sodium beef flavored base with no expiration date<BR/>- <BR/>1, 5-lb box of buttermilk pancake mix with no expiration date, box had been opened but top was closed, plastic bag of mix inside box was open and unsealed<BR/>- <BR/>16, 1-lb bags of lime gelatin dessert with no expiration date<BR/>- <BR/>4, 1-lb bags of lemon gelatin dessert with no expiration date<BR/>- <BR/>4, 1-lb bags of banana flavored instant pudding/pie filling with no expiration date<BR/>- <BR/>2, 8-oz vanilla sugar free instant pudding mix packets with no expiration date<BR/>- <BR/>17, 3.2oz ranch dressing mix packets with no expiration date<BR/>- <BR/>1 opened 5-lb bag baking cocoa (approximately 2.5-lbs remaining) with no expiration date<BR/>- <BR/>1, 5-lb bag of baking cocoa with no expiration date<BR/>- <BR/>2, 5-lb resealable plastic bags with long, straight noodles removed from original packaging with no labeling on bag<BR/>- <BR/>1, 5-lb resealable plastic bag of spiral noodles removed from original packaging with no labeling on bag<BR/>- <BR/>2, 7.5-oz instant low sodium brown gravy mix with no expiration date<BR/>- <BR/>1, 32-oz box of yellow corn meal with best by date of 4/6/23<BR/>- <BR/>4, 24-oz peppered biscuit gravy mix packets with no expiration date<BR/>- <BR/>1 opened 5-lb bag (approximately 1lb remaining) lentil penne pasta with best by date of 8/11/21<BR/>- <BR/>1 opened 10-lb box of ridged curly lasagna box top not secured and noodles inside box not in sealed packaging<BR/>- <BR/>6 unopened boxes (72 individually wrapped) fudge round cookies with no expiration date<BR/>- <BR/>1 opened box (2 individually wrapped) fudge round cookies with no expiration date<BR/>- <BR/>10 unopened boxes (240 individually wrapped) [NAME] buddy snack bars with no expiration date<BR/>- <BR/>1 opened box (5 individually wrapped) [NAME] buddy snack bars with no expiration date<BR/>- <BR/>74 apple oatmeal bars in plastic tub with expiration date of 3/25/23<BR/>- <BR/>5, 24-oz cans of chocolate syrup with no expiration date<BR/>- <BR/>2, 18-oz pink lemon drink mix packets with no expiration date<BR/>- <BR/>4, 18-oz grape drink mix packets with no expiration date<BR/>Observation of refrigerator #1 on 4/18/23 at 9:45 AM revealed the following:<BR/>- <BR/>2 broken eggs in crate<BR/>Observation of freezer #1 on 4/18/23 at 9:50 AM revealed the following:<BR/>- <BR/>4, 5-lb resealable plastic bags of frozen meat dated 4/5/23 with no label<BR/>- <BR/>4 plastic sealed tubes of frozen ground meat with no date and no label<BR/>- <BR/>3 packages of frozen sliced meat with no date and no label<BR/>Observation of freezer #2 on 4/18/23 at 9:55 AM revealed the following:<BR/>- <BR/>1 resealable plastic bag of frozen dough with no date and no label<BR/>- <BR/>1 resealable plastic bag of what appeared to be ground meat wrapped in tortillas with no date and no label<BR/>Observation of refrigerator #2 on 4/18/23 at 10:00 AM revealed the following:<BR/>- <BR/>1, 138-oz container of picante sauce with expiration date of 8/12/22<BR/>- <BR/>1, 1-gallon container of heavy-duty mayonnaise with package date of 1/17/23, no expiration date<BR/>- <BR/>1, 1-gallon container of Golden Italian dressing with package date of 11/19/19, no expiration date<BR/>- <BR/>1, 1-gallon container of home style ranch dressing manufactured date 1/15/22, no expiration date<BR/>- <BR/>1, 1-gallon container of sweet and sour sauce with expiration date 1/26/22<BR/>- <BR/>1, 2-qt container of soy sauce with expiration date of 10/1/22<BR/>- <BR/>1, 32-oz container of nacho sliced jalapenos with expiration date of 4/21/22<BR/>- <BR/>1, 1-gallon container of dill pickle chips with packaged date of 12/5/22, no expiration date<BR/>- <BR/>1, 5-lb container of parmesan cheese blend with no expiration date<BR/>- <BR/>3 packages of sliced yellow cheese not in original packaging, no label, no expiration date<BR/>- <BR/>1 package of plastic wrapped sliced meat with no label<BR/>Observation of freezer #3 on 4/18/23 at 10:15 AM revealed the following:<BR/>- <BR/>1 resealable plastic bag of unidentifiable food with no label<BR/>In an interview on 04/19/23 at 2:31 PM the Administrator was advised of unlabeled food items in the kitchen, he stated he was unaware that items removed from their original packaging had to be labeled as well as dated. When advised of the food items in the kitchen without expiration or best by dates, he appeared surprised and stated that it seemed strange that a company would be allowed to distribute food products to a nursing facility that did not have expiration dates on them.<BR/>In an interview on 04/19/23 at 03:10 PM the Dietary Supervisor stated that she was aware that most of the foods in the kitchen dry storage do not have an expiration date. She stated that she brought the issue of the expiration dates up with the former dietician and never got any response on what to do. She stated the facility did have a new Registered Dietician, but she (RD) only communicated with the DON/ADON, and she did not have any contact with her (Dietary Supervisor). She stated that she was able to order food for the facility herself off the supplier's website but there were no expiration dates available on the website. She stated she would have to call the rep resentative for the supplier and ask for a list of expiration dates for all the food she had in stock. She stated she had not done formal in-services with the staff about labeling and dating food items, but she had talked to all of them individually many times and explained that all food items must have a date and label if removed from the original packaging. She explained that the dates on all items in the dry storage area were the date the items were received and the dates on bags/containers in the refrigerators and freezers were the date the food was placed in the bag/container.<BR/>Record review of facility policy titled Food Receiving and Storage revised December 2008 revealed, in part:<BR/>Foods shall be received and stored in a manner that complies with safe food handling practices.<BR/>When food is delivered to the facility it will be inspected for safe transport and quality before being accepted.<BR/>Dry foods that are stored in bins will be removed from original packing, labeled and dated (use by date).<BR/>All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).<BR/>Review of the 2017 Food Code (https://www.fda.gov/media/110822/download ) revealed<BR/>3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5&ordm;C (41&ordm;F) or less for a maximum of 7 days<BR/>3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall 73 be identified with the common name of the FOOD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for three of eight residents (Resident #1, #2, and #3) reviewed for infection control.<BR/>1. MA A touched Resident #3's pills with her bare hands during medication administration. <BR/>2. LVN B failed to prevent cross contamination between Residents #1 and #2 by brining in uncleaned diabetic supplies from one room to another. <BR/>These failures could place resident's risk for cross contamination and the spread of infection. <BR/>Finding included:<BR/>Review of Resident #3's CCD dated 11/01/23, revealed a 90- year- old female admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation (heart does not beat with a regular beat all the time) and acute respiratory failure (person cannot get enough oxygen). <BR/>Review of Resident #3's MDS assessment dated [DATE] revealed Resident #3 had a BIMS score of 11 indicating moderately impaired cognition. <BR/>Review of Resident #3's Care Plan dated 12/10/24 revealed Resident #3 was at risk for frequent infections. <BR/>Review of Resident #3's Continuity of Care Document, dated 1/24/25 revealed Resident #3 had orders for <BR/>Aspirin 81 mg dated 11/2/23 for Atrial Fibrillation<BR/>Carvedilol 12.5 mg dated 4/16/24 for Atrial Fibrillation<BR/>Digoxin 125 mcg dated 11/1/23 for Atrial Fibrillation <BR/>Apixaban 2.5 mg dated 11/1/23 fore Atrial Fibrillation<BR/>Furosemide 20 mg &frac12; tablet for 20 mg dated 1/24/25 stop date 2/6/25 for Heart failure <BR/>Gabapentin 400 mg dated 11/1/23 for Chronic Pain<BR/>Guaifenesin 400 mg dated 3/30/24 for Cough<BR/>Multivitamin dated 11/22/23 <BR/>Olmesartan 40 mg 1/16/25 for Hypertension <BR/>Spironolactone 50 mg to five with Furosemide 40mg dated 11/1/23 for Congestive Heart Failure <BR/>Observation of medication administration for Resident #3 on 01/24/25 at 11:25 a.m. revealed MA A did not wash her hands or use hand sanitizer after administering the previous resident's medication or before preparing Resident #3's medications. MA A added all of Resident #3's currently due medications to a medication cup: Aspirin 81 mg, Carvedilol 12.5 mg, Digoxin 125 mcg, Apixaban 2.5 mg, gabapentin 400 mg, guaifenesin 400 mg, multivitamin, Olmesartan 40mg and spironolactone 50mg. Before entering Resident #3's room, MA A verified medication orders on the electronic medical record (EMR). MA A said the spironolactone had instructions to be given with furosemide, which was being held. MA A stated she would hold the spironolactone and ask the ADON for verification. Using her bare (not gloved, not cleaned) index finger, MA A placed the spironolactone into another medication cup. MA A proceeded to give the remaining medications to Resident #3.<BR/>In an interview on 1/24/25 at 1:44 p.m., the DON stated she monitored medication administration by watching the staff because she did not have a lot of staff who had been at the facility a long time. The DON said she did annual competencies with the staff at the first part of February and any new hires had an initial check off. <BR/>IIn an interview at 1/25/25 at 2:55 a.m., the DON stated the facility's policy about handling medications in general was medications should be popped into cup and skin should not touch a pill at all because then there was a contamination factor. The DON said her expectation with over-the-counter medications were to be tapped into lids and the lid used to dump the pill into the medication cup. <BR/>Review of Resident #1's Continuity of Care Document, dated 1/24/25, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #1 had diagnoses including Diabetes Mellitus (body does not produce enough insulin causing the body to have abnormally high blood sugar levels). Resident #1 had orders for have blood glucose checks three times a day and insulin administer by a sliding scale beginning 5/26/23. <BR/>Review of Resident #1's Quarterly MDS Assessment, dated &frac14;/25, revealed:<BR/>She had a BIMS score of 4 of 15 (indicating she was severely cognitively impaired).<BR/>She had a diagnosis of diabetes.<BR/>She received injections 6 of 7 days prior to the assessment. <BR/>Review of Resident #1's Care Plan, beginning 3/15/25, revealed the goal was her Diabetic status would remain stable as evidenced by resident blood sugar staying within the resident's normal limits through the next quarter. <BR/>Resident #1's Care Plan, beginning 3/15/25, revealed: Enhanced Barrier Precautions will reduce risk of the spread of organisms. <BR/>Observation on 1/24/24 at 10:15 a.m. during initial rounds revealed Resident #1 was in her room lying in bed. She had a catheter. <BR/>Review of Resident #2's Quarterly MDS Assessment, dated 11/18/24 revealed:<BR/>He had a 13 of 15 on his BIMS score (indicating he was cognitively intact)<BR/>He had a diagnosis of diabetes.<BR/>He had injections for 7 of 7 days prior to the assessment.<BR/>His care plan, start date 2/22/24 read he was at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia, renal failure, cognitive/ physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. Identified interventions were to Administer medications as ordered and monitor for side effects and effectiveness. <BR/>Observation on 1/24/25 at 11:17 a.m. revealed LVN B put on gloves and set up the glucometer (machine for measuring blood sugar levels) and went into Resident #1's room. LVN B was not wearing a gown even though Resident #1 was identified as an EBP resident. LVN B took the blood level reading of Resident #1. LVN B came out with gloves on, looked at surveyor and said, she should probably not be in the hall with gloves on. LVN B kept the gloves on. LVN B put the lancet she used to poke Resident #1's finger into the sharps container. With the same gloved hands, LVN B grabbed the top drawer of the medication cart, realized it was locked, put her hands in her pocket pulled out the keys, unlocked the cart, put the keys back into her pocket. LVN B kept the same dirty gloves on, found a container of strips for the glucometer and another lancet, shut the medication cart drawer, and locked it. LVN B, with the same contaminated gloves, returned to Resident #1's room. LVN B with the same dirty gloves opened the container of glucometer strips, stuck her finger into the container and pulled out a glucometer strip, then laid the container of glucometer strips on Resident #1's bed. With the same gloves, LVN B used a new lancet and stuck Resident #1's finger and took the glucometer reading. With the same gloves, LVN B took all the supplies to the medication cart, placed the container of glucometer strips onto the top of the medication cart, disposed of the used lancet, then disposed of the gloves. LVN B cleaned her hands with ABHG and cleaned the glucometer. LVN B did not clean the bottle of glucometer strips. LVN B put on new gloves, took the glucometer, and the (uncleaned) bottle of glucometer strips. LVN B went into Resident #2's room which also had an EBP posting on the door frame, placed everything on the dresser. LVN B put her finger down the container of glucometer strips, and performed the blood glucose reading. LVN B took her supplies, left the room, took off her gloves, cleaned her hands with ABHG and cleaned the glucometer. <BR/>In an interview and observation on 1/24/25 at 11:36 a.m., LVN B stated she was an agency nurse, but had worked at the facility before. LVN B said if she could do anything different, she would have changed gloves more often and used disinfecting wipes on the glucometer instead of alcohol wipes, but she used what she had. LVN B said she would have changed gloves more often to prevent cross contamination, and she was not aware of everything she touched with the one pair of gloves. State surveyor reviewed the list with her, and her response was wow. LVN B said EBP meant she was supposed to wear a gown and gloves. LVN B said this applied to anyone who had a catheter, indwelling device or wound. LVN B stated most facilities had it posted on the door and most facilities had supplies outside the door. LVN B said she did not notice supplies outside the door. LVN B and state surveyor went to Resident #1's room. There was a sign posted but no PPE outside of the room in any fashion or visually available in the room. LVN B said there was a sign, and she was aware Resident #1 had a catheter, and could see the catheter. LVN B admitted she was aware she needed to wear a gown and did not wear one because there were none outside of the room. LVN B said the point of EBP was to protect the resident from other infections. <BR/>Interview on 1/24/25 at 11:58 a.m., the DON stated she had a container of gowns behind the nurse's station because the other containers the facility had went missing. The DON said there were a couple on order. The DON said the facility did have the type of gown container that could be hung over the door. The DON said having the gowns at the nurse's station was not an effective process because the staff had to go all over the building. The DON stated she had four residents on EBP. <BR/>Interview on 1/24/25 at 2:55 p.m., the DON explained the mechanics of cross contamination. She stated cross contamination happened when anyone did not use gloves or held linens too close to the body and the contaminate goop gets on you and you go into the next room. She said the same thing would happen when a person had gloves on. The DON stated gloves would cause cross contamination if it had germs on the surface and the staff go across hall with gloves on the staff had the risk of bringing contamination across the hall. The DON stated the Medication Cart could be contaminated because if the gloves touched the resident, they were dirty, and the gloves should have been removed and the nurse's hands should have been sanitized. The DON stated the keys to the medication cart were contaminated. The DON said the glucometer strips were now contaminated all the others and the nurse impaired the integrity. The DON said she trained nurses to tap the bottle like you would a pill until a strip comes out. The DON stated the outside of tube was contaminated when it touched the resident's bed. The DON said Resident #2 currently did not qualify for EBP, She stated he had pseudomonas UTI but it had resolved.<BR/>Review of in-services reveal the facility trained staff on EBP policy on 1/17/25:<BR/>The facility's policy and procedure on Enhanced Barrier Precautions, undated, revealed:<BR/>Enhanced barrier precautions are utilized to reduce transmission of multi-drug resistant organisms to residents. <BR/>Policy Interpretation:<BR/>Enhanced barrier precautions are used as an infection prevention and control intervention to reduce to transmission of multi-drug resistant organisms to residents. <BR/>Enhanced barrier precautions employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.<BR/>Enhanced barrier precautions are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.<BR/>B indwelling devices include urinary catheters. <BR/>Review of in-services revealed the facility in-served staff on the 6/21/24 on Glove use:<BR/>Review of the facility's policy and procedure on Personal Protective Equipment - Using Gloves, revised October 2010, revealed:<BR/>Purpose: To guide the use of Gloves<BR/>Objective: To prevent the spread of infection.<BR/>Review of the facility's policy and procedure on Handwashing/Hand Hygiene, revised April 2012, revealed:<BR/>The facility considered hand hygiene the primary means to prevent the spread of infection.<BR/>All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. <BR/>In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, used an alcohol-based hand rub containing 60 - 90% ethanol or isopropanol for all the following situations: before preparing or handling medications. <BR/>Review of the facility's policy and procedure on Administering Medications, revised December 2012, revealed: Medications shall be administered in a safe and timely manner. <BR/>Staff shall follow established infection control practices (e.g. handwashing, antiseptic technique, gloves, isolation precautions etc.) for the administration of medications, as applicable.

Based on interview and record review, the facility failed to use the services of a RN for at least 8 consecutive hours a day, 7 days a week for 16 days in Quarter 2 2024 reviewed for Licensed Nursing coverage from January 2024, February 2024 reviewed for nursing services. <BR/>The facility did not have the required 8 consecutive hours of RN coverage during the month of January 2024 (11 days) and February 2024 (5 days). <BR/>This failure could place residents at risk for not having their nursing care and medical needs met. <BR/>Findings included: <BR/>Review of PBJ [Payroll Based Journal] Staffing Data Report, with a run date of 06/06/2024 revealed Failed to have Licensed Nursing Coverage 24 Hours/Day was triggered for the fiscal year Quarter 2 2024 (January 1 - March 31). The infraction dates were 01/01 (MO); 01/02 (TU); 01/03 (WE); 01/04 (TH); 01/05 (FR); 01/08 (MO); 01/16 (TU); 01/17 (WE); 01/18 (TH); 01/24 (WE); 01/25 (TH); 02/02 (FR); 02/08 (TH); 02/16 (FR); 02/21 (WE); 02/22 (TH).<BR/>Record review of the January 2024 schedule/time sheets indicated no 24-hour licensed nursing coverage for any of the dates.<BR/>Record review of the February 2024 schedule/time sheets indicated no 24-hour licensed nursing coverage for any of the dates. <BR/>In an interview on 6/12/24 at 4:12 pm, ADON stated that facility only had one RN employed full time and no DON during the Quarter 2. The ADON stated that on the days in question they had no RN coverage.<BR/>In an interview on 6/12/24 at 4:30 pm, Regional Compliance Nurse stated that the facility only had 2 PRN RNs and agency RNs. Regional Compliance Nurse stated that she checked clock in logs and was unable to find any proof of RN coverage for any of the days in question. The Regional Compliance Nurse stated that she has been covering for the DON since October 2023. Stated she did not work any of the days in question.<BR/>In an interview on 6/13/24 at 11:30 am, Administrator stated that the facility lost staff when the company changed to new owners. Administrator stated that they had no DON and were unsuccessful in getting RN coverage during that time. Stated she attempted to provide coverage with agency RNs and Regional Compliance Nurse but was unsuccessful. A new DON was hired and started that week.<BR/>Review of undated facility policy titled Departmental Supervision, revised August 2006 revealed, in part:<BR/>Policy Statement: The nursing services department shall be under the direct supervision of a Registered Nurse at all times.<BR/>A Registered Nurse (RN) will be employed as the Director of Nursing (DON). The DON will be on duty during the day shift Monday through Friday. During the absence of the DON, a Registered Nurse/ Nurse Supervisor will be responsible for supervision of all direct care staff.

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible and includes ensuring that the resident could receive care and services safely and that the physical layout of the facility maximized resident independence and did not pose a safety risk for 1 of 4 hallways (hall 100) and 1(Resident #2) of 3 residents reviewed for clean homelike environment. <BR/>1. The facility failed to ensure Hallway 1 did not smell of urine. <BR/>2. The facility failed to ensure Resident #2 did not have a dirty bed linens. <BR/>These failures could place residents at risk of residing in an unsafe, unsanitary, and uncomfortable environment. <BR/>Findings include:<BR/>1. Observation on 02/24/25 at 8:14 AM, with the Administrator, revealed her coming down hallway 1 to get state agency. Walking down the hallway smelled of urine. <BR/>During an interview on 02/25/25 at 4:50 PM, with the Administrator, she stated the day the state survey agency was in hallway 1 and went to get him she could smell the odor of urine in the hallway. The Administrator stated the urine smell was strong and was inappropriate and she would not like being in a place where it smelled like urine. The Administrator stated that housekeeping was responsible for cleaning and should have cleaned the urine smell. <BR/>2. Observation on 02/24/25 at 8:21 AM, revealed, Resident #2's white bed sheets had a large brown unknown substance on it. <BR/>During an interview on 02/24/25 at 2:09 PM with Resident #2, she stated the facility staff went to change out her bed sheets. Resident #2 did not respond and turned her head away, when asked about the brown unknown substance on the bed sheets. The interview was terminated. <BR/>During an interview on 02/25/25 at 10:24 AM with the DON, she stated the CNAs were to be checking the resident beds to ensure they were clean and made. The DON stated it was not okay to have dirty or stained sheets. The DON stated it was a dignity issue. <BR/>During an interview on 02/25/25 at 10:44 AM with CNA C, she stated when residents got up for the day the bed sheets, if they were dirty were picked up and changed for new ones. CNA C stated the residents deserved clean sheets and it was unsanitary to leave them on the bed. CNA C stated it was everyone's responsibility for ensuring the bed sheets were clean and changed. <BR/>During an interview on 02/25/25 at 4:50 PM with the Administrator, she stated it was the responsibility of the CNAs to change the bed sheets for the residents. The Administrator stated it was inappropriate for the resident to have dirty and or stained sheets. The Administrator stated it was a dignity issues for the residents. <BR/>During an interview on 02/27/25 at 8:27 AM with CNA A, she stated staff were expected to change the bed sheets of the residents. CNA A stated this was to keep it clean and sanitized which was the responsibility of the CNAs. CNA A stated any dirty or stained sheets would not be appropriate and she would not like it if she had dirty or stained sheets. <BR/>Record review of the facility's Homelike Environment Policy, dated 02/2021, revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Clean, sanitary, and orderly environment, inviting colors and d&eacute;cor, clean bed and bath linens that are in good condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure that 2 of 4 (Resident #3 and #142) residents reviewed for respiratory care was provided care consistent with professional standards of practice in that:<BR/>Resident # 3's water bottle, oxygen tubing and plastic bag was not changed, labeled and dated according to policy. <BR/>Resident #142's water bottle, oxygen tubing and plastic bag was not changed, labeled and dated according to policy.<BR/>This deficient practice could affect residents who received oxygen treatments and result in respiratory infection.<BR/>Record review of Record review of Resident #3's face sheet revealed admission date of 11/10/22 with diagnoses of Congestive Heart Failure, Chronic Kidney Disease, Diabetes Mellitus. She was [AGE] years of age.<BR/>Record review of Resident #3's care plan dated 05/11/2023 failed to mention use of oxygen.<BR/>Record review of Resident #3's medication profile dated 11/10/22 revealed an order for oxygen via nasal cannula continuously on 3 liters to keep oxygen saturations above 90% every shift related to Congestive Heart Failure.<BR/>Record review of Resident #3's MDS dated [DATE] failed to mention use of oxygen.<BR/>Record review of Resident #142's face sheet revealed admission date of 03/16/23 with diagnoses of Congestive heart failure, Chronic obstructive pulmonary disease, major depression, diabetes mellitus, pressure ulcer, and stage 3 kidney disease. She was [AGE] years of age.<BR/>Record review of Resident #142's medication profile dated 03/30/23 indicated in part:<BR/>Oxygen via nasal cannula continuously on 2 liters to keep oxygen saturations above 90% every shift related to Chronic Obstructive Pulmonary Disease. <BR/>Record review of Resident #142's MDS dated [DATE] indicated in part that Oxygen was required.<BR/>During an observation on 4/18/23, 4/19/23 and 4/20/23 at 08:30 AM Resident #3's oxygen tubing revealed no date on water bottle or tubing, showing last date changed. <BR/>During an observation on 4/18/23, 4/19/23 and 4/20/23 at 08:45 AM Resident #142's oxygen tubing revealed no date on water bottle or tubing, showing last date changed. <BR/>During an interview on 4/20/23 ADON states that tubing was supposed to be changed on Sunday per policy. ADON stated that she would change the water bottle, tubing and plastic bag for both Resident #3 and resident #142 immediately since she did not know when it was last changed. ADON stated that it was her responsibility to oversee nursing staff completed their nursing duties. <BR/>Record review of the facility's policy revised 11/2011 titled Respiratory Therapy-Prevention of Infection indicated, in part: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment among residents and staff. <BR/>Infection Control Considerations related to Oxygen administration:<BR/> 1.Obtain equipment (oxygen tubing, reservoir, distilled water)<BR/>2. Use distilled water for humidification<BR/>3. [NAME] bottle with date and initials upon opening and discard after 24 hours.<BR/>4. Discard the administration set-up every 7 days

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys, for one (Treatment Cart) of 3 medication carts reviewed for drug storage.<BR/>The facility failed to ensure the treatment cart was not left unlocked and unsupervised.<BR/>This failure could place clients at risk for drug diversion or accidental ingestion.<BR/>The findings included:<BR/>During an observation on 06/11/24 at 09:38 AM, the treatment cart was seen unlocked and unattended. Inside the cart were several types of medications such as antifungal creams, triple antibiotic ointments, scissors, nail clippers and several other medicated bandages. <BR/>During an interview on 06/11/24 at 10:15 AM, the DON was made aware of the observation of the unlocked treatment cart. The DON said the cart was supposed to be locked when unattended. The DON said if the cart was left opened some of the residents could get into the cart. The DON said she was not sure who left it open and proceeded to lock it. The DON said it was the nurses or med aides job to lock their cart when left unattended and that she and the ADON would did rounds and checked to see that the carts were locked if unattended. <BR/>During an interview on 06/13/24 at 02:59 PM, the Administrator said it was her expectation for the medication or treatment carts to be locked when nursing staff were not using it or away from the carts. The Administrator said if the carts were left unlocked and unattended a resident or unauthorized staff could get access to the cart. The Administrator said the failure probably occurred because the nurse who was using the cart got sidetracked and walked away and did not notice the cart was left unlocked. The Administrator said the DON, ADON and she did walking rounds and would check to see that the carts were locked when unattended.<BR/>Record review of the facility's policy titled Storage of medications and dated April 2007 indicated in part: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Compartments (including but not limited to drawers, cabinet rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. <BR/>Record review of the facility's policy titled Medication storage and dated 01/2024 indicated in part: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations to keep their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. In order to limit access to prescription medications, only licensed nurses, pharmacy staff and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access.

Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys, for one (Treatment Cart) of 3 medication carts reviewed for drug storage.<BR/>The facility failed to ensure the treatment cart was not left unlocked and unsupervised.<BR/>This failure could place clients at risk for drug diversion or accidental ingestion.<BR/>The findings included:<BR/>During an observation on 06/11/24 at 09:38 AM, the treatment cart was seen unlocked and unattended. Inside the cart were several types of medications such as antifungal creams, triple antibiotic ointments, scissors, nail clippers and several other medicated bandages. <BR/>During an interview on 06/11/24 at 10:15 AM, the DON was made aware of the observation of the unlocked treatment cart. The DON said the cart was supposed to be locked when unattended. The DON said if the cart was left opened some of the residents could get into the cart. The DON said she was not sure who left it open and proceeded to lock it. The DON said it was the nurses or med aides job to lock their cart when left unattended and that she and the ADON would did rounds and checked to see that the carts were locked if unattended. <BR/>During an interview on 06/13/24 at 02:59 PM, the Administrator said it was her expectation for the medication or treatment carts to be locked when nursing staff were not using it or away from the carts. The Administrator said if the carts were left unlocked and unattended a resident or unauthorized staff could get access to the cart. The Administrator said the failure probably occurred because the nurse who was using the cart got sidetracked and walked away and did not notice the cart was left unlocked. The Administrator said the DON, ADON and she did walking rounds and would check to see that the carts were locked when unattended.<BR/>Record review of the facility's policy titled Storage of medications and dated April 2007 indicated in part: The facility shall store all drugs and biologicals in a safe, secure and orderly manner. Compartments (including but not limited to drawers, cabinet rooms, refrigerators, carts and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. <BR/>Record review of the facility's policy titled Medication storage and dated 01/2024 indicated in part: Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations to keep their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. In order to limit access to prescription medications, only licensed nurses, pharmacy staff and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access.

Based on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for 1 (12/20/2023) of 4 days reviewed for nurse staffing information. <BR/>The facility failed to post the required staffing information for 12/20/2023. <BR/>This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.<BR/>Finding include: <BR/>During observation on 12/20/2023 at 1:00 p.m., of the public access area nursing station located outside of the DON office, revealed a daily sheet posting information which included facility name, census, total hours for RNs, LVNs, CNAs, MAs, and shift times that was dated 12/18/2023. <BR/>During observation on 12/20/2023 at 2:45 p.m., of the public access area nursing station located outside of the DON office, revealed a daily sheet posting information which included facility name, census, total hours for RNs, LVNs, CNAs, MAs, and shift times that was dated 12/18/2023.<BR/>During an interview on 12/27/2023 at 9:45 a.m., the ADON said that the night staff were responsible for posting the nurse staffing information which included information on staff scheduled and total work hours. The ADON said she does not know why the information for 12/20/2023 was not posted that day and the information posted was from 12/18/2023. The ADON said she learned of this after observing the Surveyor looking at the information. The ADON said that night shift staff post the information at the end of their shift in the morning with the day's schedule staff and total hours. The ADON said the facility currently does not have a DON who would be responsible for overseeing the process. The ADON said currently she was responsible for monitoring the posting of nurse staffing information until a full time DON is hired. <BR/>Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, dated 2006, reads in part, Our facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Within two (2) hours of the beginning of each shift, the number of Licensed Nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The information rec recorded on the form shall include: a. The name of the facility; b. The date for which the information is posted; c. The resident census at the beginning of the shift for which the information is posted; d. Twenty-four (24) hour shift schedule operated by the facility; e. The shift for which the information is posted; f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift; g. The actual time worked during that shift for each category and type of nursing staff; and h. Total number of licensed and non-licensed nursing staff working for the posted shift.