DELEON NURSING AND REHABILITATION

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid for 2 of 14 residents (Resident #8 and Resident #30) reviewed for resident rights. <BR/>The facility failed to ensure Residents #8 and Resident #30 were given a paper copy of the NOMNC (notice of Medicare non coverage) with information on how to appeal the decision when residents were discharged from skilled services at the facility prior to covered days being exhausted.<BR/>This failure could place residents at risk for not being aware of their right to appeal the decision to end Medicare coverage for skilled services, changes to provided services, and their financial responsibilities.<BR/>Findings included:<BR/>Resident #8<BR/>Record review of Resident 8's electronic face sheet dated 08/20/2024 revealed resident was an [AGE] year-old female who was initially admitted on [DATE] with diagnoses that include: enterocolitis due to clostridium difficile (inflammation in the bowl due to infection) sepsis (body's extreme reaction to an infection), UTI (urinary tract infection, hypertension (high blood pressure), and weakness.<BR/>Record review of Resident #8's admission MDS assessment dated [DATE] revealed Resident #8 had a BIMS score of 11 meaning moderate cognitive impairment. Further review of the MDS revealed Resident #8 sometimes needed help with written material instructions.<BR/>Record review of the SNF Beneficiary Protection Notification Review indicated Resident #8 received Medicare Part A Skilled Services on 02/29/2024 and her last covered day of Part A services was 04/08/2024. The SNF Beneficiary Protection Notification Review indicated the discharge was voluntary from Medicare Part A Services when benefit days were not exhausted. <BR/>Record review of Resident #8's NOMNC dated 04/05/2024 revealed the facility spoke with Resident #8's family member to go over NOMNC. A signature from the patient or representative was on NOMNC form. There was no evidence that form was given to patient or representative. <BR/>During a telephone interview on 08/20/2024 at 9:37 a.m., Resident #8's family stated she did not remember receiving any paperwork about Medicare coverage ending. Resident #8's family denied getting a phone call going over Medicare coverage ending. She stated she did not receive an appeal number.<BR/>Resident #30<BR/>Record review of Resident 30's electronic face sheet dated 08/20/2024 revealed resident was a [AGE] year-old male who was originally admitted on [DATE] with diagnoses that include: atherosclerosis of coronary artery bypass graft(s) without angina pectoris (occlusion of heart artery after it has had surgery to bypass in the past without chest pain), intracardiac thrombosis (blood clot in the heart), congestive heart failure (less blood is pumped through the heart and around the body due to weakened heart, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (inability to move or weakness to right dominant side following stroke), transient cerebral ischemic attack (mini stroke), and cellulitis (skin infection). <BR/>Record review of Resident #30's admission MDS dated [DATE] revealed Resident #30 had a BIMS score of 00 meaning severe cognitive impairment. Further review of MDS revealed Resident #30 had moderate difficulty hearing, unclear speech, and sometimes able to make self-understood.<BR/>Record review of the SNF Beneficiary Protection Notification Review indicated Resident #30 received Medicare Part A Skilled Services on 04/15/2024 and his last covered day of Part A services was 05/16/2024. The SNF Beneficiary Protection Notification Review indicated the discharge was voluntary from Medicare Part A Services when benefit days were not exhausted. <BR/>Record review of Resident #30's NOMNC dated 05/14/2024 revealed the facility spoke with Resident #30's family member his RR to explain NOMNC. There was no signature from patient or representative on the NOMNC form. There was no evidence the form was given to the patient or representative.<BR/>During a telephone interview on 08/20/2024 at 9:46 a.m., Resident #30's family stated she did not receive any paperwork about Medicare coverage ending. She stated she did remember a conversation about Medicare coverage ending but did not receive an appeal number. <BR/>During an interview on 08/09/2024 at 2:57 p.m., the MDS coordinator stated she would call the resident's representative if they were unable to be present to hand them the NOMNC form for signature and the resident was unable to sign themselves. She stated she explained the NOMNC including the last covered Medicare date and verified the discharge date with the representative over the phone. She stated she did not mail the paper form to the RR. She stated the RR was allowed to ask questions over the phone and she would give them the appeal number verbally if they asked for it. The MDS coordinator stated if the RR was present in person, then the form was provided to them. <BR/>During an interview on 08/20/2024 at 8:20 a.m., the ADMN stated the facility would call family if family were not available in person to sign the NOMNC. Verbal notification would be documented but she was unsure if the NOMNC form was mailed by the MDS coordinator to family. She stated residents and their representative were notified of the NOMNC and stated she felt verbal explanation was more important than given the individual a piece of paper. She stated no one had ever asked for the NOMNC form after verbal explanation. She stated she was unaware the paper form was to be mailed to individual if verbal explanation was provided over the telephone. She stated both her and the MDS coordinator monitored that NOMNCs were done, and she would give the NOMNC information to the resident or their representatives if the MDS coordinator was not working that day. She denied any negative effect to residents from not providing the NOMNC form and stated the facility would help the representatives with the appeal if the resident or their representative voiced that they wanted to appeal. <BR/>Review of facility policy titled Creative Solutions in Healthcare Advanced Beneficiary Notice NOMNC P&P with revision date of May 2024 revealed: <BR/>Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process per Chapter 4, Section 260 of the Medicare Claims Processing Manual and Chapter 13, Sections 90.2-90.9 of the Medicare Managed Care Manual. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Medicare providers are responsible for the delivery of the NOMNC. Providers nay formally delegate the delivery of the notices to a designated agent such as a courier service; however, all of the requirements of valid notice delivery apply to designated agents. <BR/>The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed. Use of assistive devices may be used to obtain a signature .<BR/>If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 3 of 14 residents (Resident #5, Resident #12, and Resident #37) reviewed for PASRR.<BR/>The facility failed to follow up with the LA for PASRR Level II determination when Resident #5, Resident #12, and Resident #37s PASRR Level 1 Screening reflected they were positive for mental illness.<BR/>This failure could place the residents with a documented mental illness, intellectual and/or developmental disability at risk for not receiving needed services.<BR/>Findings included:<BR/>Resident #5<BR/>Record review of Resident #5's electronic face sheet dated 08/20/2024 revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #5 had diagnoses of psychosis with onset date of 01/22/2021 and diagnosis of major depressive disorder added with onset date of 01/26/2021. Resident #5 had secondary diagnosis of dementia added with onset date of 01/17/2023. <BR/>Record review of Resident #5's medical record revealed no evidence a PASRR evaluation had been performed.<BR/>Record review of Resident #5's quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 15 meaning cognition was intact. Further investigation revealed active psychiatric / mood disorder of depression and psychotic disorder.<BR/>Record review of Resident #5's care plan dated 07/12/2024 revealed Resident #5 had impaired cognitive function / impaired thought processes r/t psychosis, and mood problem r/t depression, personality change and adjustment disorder.<BR/>Resident #12<BR/>Record review of Resident #12's electronic face sheet dated 08/20/2024 revealed a [AGE] year-old female initially admitted to the facility on [DATE]. Resident #12 had diagnosis of psychosis with onset date of 10/01/2022 and major depressive disorder with onset date of 05/10/2021. Resident #12 had other diagnosis of dementia with onset date of 08/20/2024.<BR/>Record review of Resident #12's medical record revealed no evidence a PASRR evaluation had been performed. <BR/>Record review of Resident #12's quarterly MDS dated [DATE] revealed Resident #12 had a BIMS score of 05 meaning severe cognitive impairment. Further review revealed active diagnosis of depression and post-traumatic stress disorder.<BR/>Record review of Resident #12's care plan dated 08/12/2024 revealed Resident #12 had depression r/t major depressive disorder and a behavior problem.<BR/>Resident #37<BR/>Record review of Resident #37's electronic face sheet dated 08/20/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. Resident #37 had diagnosis of psychosis with onset date of 11/06/2023 and major depressive disorder onset date of 06/06/2023. Resident #37 had secondary diagnosis of dementia with onset date of 06/06/2023.<BR/>Record review of Resident #37's medical record revealed no evidence a PASRR evaluation had been performed.<BR/>Record review of Resident #37's annual MDS dated [DATE] revealed Resident #37 had a BIMS of 01 meaning severe cognitive impairment. Further review revealed active diagnosis of depression.<BR/>Record review of Resident #37's care plan dated 08/18/2024 revealed Resident #37 required antidepressant medication r/t major depressive disorder and a psychosocial well-being problem r/t anxiety / depression.<BR/>During an interview on 08/20/2024 at 8:43 a.m., the MDS coordinator stated major depressive disorder did not qualify as a mental illness. She stated once the PASRR level 1 was completed with a negative response for mental illness, a new diagnosis that would qualify as mental illness should have triggered the facility to initiate a new form for PASRR evaluation to be performed. She stated when a resident had a dementia diagnosis and mental illness diagnosis then the resident would not be flagged for a PASRR evaluation. She stated she would look to see if PASRR evaluations had been performed.<BR/>During a follow up interview on 08/20/2024 at 9:01 a.m., the MDS coordinator stated nursing considered major depression as a mental illness. She stated she was unsure if major depressive disorder would qualify as mental illness on a PASRR level 1 form. She clarified dementia would need to be primary diagnosis for dementia to override a PASRR evaluation. She did not feel that a PASRR evaluation should have been done but would ask facility's corporate MDS coordinator for more guidance. <BR/>During a follow up interview on 08/20/2024 at 9:28 a.m., the MDS coordinator stated she spoke with the facility's corporate via telephone and was instructed that a 1012 form (used by nursing facilities to determine if a previously negative PASRR level 1 screening form needs to be changed to a positive PASRR level 1 for mental illness) should have been completed after a new diagnosis qualifying as mental illness but the form would a need physician's signature and she was unsure that Resident #5's physician would sign the 1012 form. She stated that she did notify the local authority and a PASRR evaluation was in the process of being scheduled. She stated she was unaware of the rules the facility should have followed when a new mental illness diagnosis had been added to have the PASRR evaluation scheduled after the first PASRR level 1 form was completed. <BR/>During an interview on 08/20/2024, the ADMN stated she expected for staff to follow the PASRR policy. She stated she expected when a significant change occurred with new diagnosis for a PASRR evaluation to be performed. She stated the MDS coordinator and Regional Corporate MDS coordinator was who monitored PASRR completion. She stated no effect on the residents occurred due to they were receiving care and psychiatric services from the facility. She stated lack of knowledge and oversight led to failure. <BR/>Review of the facility policy titled PASRR Nursing Facility Specialized Services Policy and Procedure dated 03/06/2019 revealed: 1. PL1 is completed 2. If PL1 is coded as suspicion of MI, ID, DD, then a PE is required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 5 (Resident # 6 and Resident #17) reviewed for oxygen therapy.<BR/>The facility failed to ensure that oxygen tubing and nasal cannula were placed in plastic bag for 2 of 2 residents (Resident #6 and Resident #17) when not in use.<BR/>These failures placed residents of the facility at risk for respiratory illnesses.<BR/>Findings included:<BR/>During an observation on 08/18/2024 at 2:25 PM RM [ROOM NUMBER] revealed Oxygen tubing with nasal cannula on bedside table and not in a plastic bag. Resident #6 was not in the room at the time.<BR/>Resident #6<BR/>During a review of Resident #6 's electronic face sheet revealed: [AGE] year-old female admitted on [DATE] with diagnoses of Anorexia (eating disorder), Dysphagia (difficulty swallowing), Cognitive communication deficit, and Hypertension (high blood pressure) <BR/>During a review of Resident #6 's Physician orders date 08/01/2024 revealed: Oxygen at 2 LPM (liters per minute) via nasal cannula to keep oxygen saturation above 90%. <BR/>During a review of Resident #6's Quarterly MDS dated [DATE] revealed: Section Cognitive Patterns BIMS score was 8 indicating Moderately impaired cognitive status and Section O-Special Treatments, Procedures, and Programs-Oxygen Therapy while a resident.<BR/>During a review of Resident #6's Care plan dated 06/11/2024 revealed: Focus-The resident has Oxygen Therapy. Goal: The resident will have no signs and symptoms of poor oxygen absorption through the review date. Interventions: Notify the nurse if the oxygen is off the resident-resident frequently removes O2. Oxygen at 2 liter per minute per nasal canula. <BR/>During an observation on 08/18/2024 at 2:25 PM, revealed Resident #6's oxygen tubing with nasal cannula on the bedside table was not in a plastic bag. Resident #6 was not in the room at the time.<BR/>Resident #17<BR/>During a review of Resident #17's electronic face sheet revealed: [AGE] year-old male admitted on [DATE]. Diagnoses include Chronic Obstructive Pulmonary Disease (lung disease), Hypertension (high blood pressure), Anxiety.<BR/>During a review of Resident #17's Physician Orders dated 08/01/2024 revealed: May use oxygen at 2-3 liters per minute via nasal canula. Change nasal canula as needed, check oxygen saturation every shift and as needed.<BR/>During a review of Resident #17's Quarterly MDS dated [DATE] revealed: Section C-cognitive Patterns BIMS score was 12 indicating moderately impaired cognitive status. Section O- Special Treatments, Procedures and Programs, C 1. Oxygen Therapy while a resident.<BR/>During a review of Resident #17's Care Plan dated 08/05/2024 revealed: Focus The resident has Oxygen Therapy. Goal: The resident will have no signs/symptoms of poor oxygen absorption through the review date. Interventions- for residents who should be ambulatory, proved extension tubing or portable oxygen apparatus. Oxygen 2-3 liters per minute per nasal canula. <BR/>During an observation on 08/18/2024 at 3:25 PM RM [ROOM NUMBER], revealed Resident #17's oxygen tubing with the nasal cannula was on the floor and not in a plastic bag. Resident #17 was not in the room at this time.<BR/>During an interview on 08/20/2024 at 10:25 AM with the DON. The DON stated oxygen tubing with nasal canula should not be on a table or on the floor. The DON stated oxygen tubing and nasal canula should be changed when they are visibly soiled. The DON stated when oxygen tubing is found on the floor it should be thrown away and replaced with clean oxygen tubing. The DON stated her expectations were that oxygen tubing would be placed in a plastic bag when not in use by the resident. The DON stated not replacing oxygen tubing and nasal canula after being found on the floor could possibly cause the resident to acquire an infection. The DON stated she did not know why this failure occurred. <BR/>During a review of facility's policy titled Oxygen Administration dated March 21, 2023 Oxygen therapy includes the administration of oxygen (O2) in liters/minute by cannula or face mask .<BR/>Goals<BR/>3. The resident will be free from infection.<BR/>Procedure:<BR/>10. Change the tubing (including any nasal prongs or mask) that is in use on one patient when it malfunctions or becomes visibly contaminated .<BR/>Review of facility's policy titled Hand Hygiene (no date)<BR/>You may use alcohol-based hand cleaner or soap/water for the following .<BR/>Before and after assisting a resident with meals<BR/>Upon and after coming in contact with a resident's intact skin .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 14 residents (Resident #22) reviewed for meals.<BR/>The facility failed to ensure that Resident #22 was served a pureed bowl of melon, instead of a bowl of regular melon.<BR/>This deficient practice could affect residents by placing them at risk for choking and weight loss.<BR/>The findings were: <BR/>Record review of Resident #22's electronic face sheet revealed: [AGE] year-old female admitted on [DATE]. Diagnoses include-Alzheimer's Disease (a progressive disease that destroys memory and other mental functions), and Abnormal weight loss.<BR/>Record review of Resident #22's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns Resident #22 had a BIMS score of 00 indicating had severe cognitive impairment; Section K- Swallowing/Nutritional Status Resident #22 was on mechanically altered diet.<BR/>Record review of Resident #22's Care plan dated 08/18/2024 revealed: Focus-Resident has Fortified/ Enhanced Pureed<BR/>diet and has a planned weight gain <BR/>Record review of Resident #22's Physician's Orders dated 08/01/2024 revealed: Fortified/Enhanced diet, pureed (all food has been ground, or strained to a soft, smooth consistency, like pudding) texture. <BR/>During an observation on 08/18/2024 at 5:57 PM revealed Resident #22 was served a bowl of melon that was not pureed. Resident #22 picked up a piece of the melon and put a part of the melon in her mouth and then removed the melon. Resident #22 did not show any sign of distress or coughing . <BR/>During an observation and interview on 08/18/2024 the RNC stated Resident #22 should have not had a regular bowl of melon, it should have been pureed melon and removed the bowl of melon and provided Resident #22 a pureed dessert. <BR/>During an interview on 08/19/2024 at 12:39 PM the Dietician stated she expected for residents who were on a pureed diet should have been served pureed fruit. The Dietician stated that she believed the incident was a single incident. The Dietician stated she did not know why the melons were not served pureed to Resident #22. The Dietician stated kitchen staff should have verified the resident's specific diet and had placed the correct food on the tray, before it left the kitchen, and the dining room staff should have checked that the correct diet was served prior to the resident being served. The Dietician stated serving the wrong diet could have led to harm including choking and pneumonia.<BR/>During an interview on 08/20/2024 at 4:30 PM the ADMN stated her expectation was residents who had an order for a pureed diet should have received a pureed diet. The ADMN stated the kitchen staff and nursing staff were responsible to monitor that residents received the proper diet. The ADMN stated the effect on residents not receiving the proper diet could have caused residents to choke. The ADMN stated what led to failure was staff were nervous and oversight by staff. <BR/>Record review of facility policy titled, Feeding, Assistive/Complete dated February 14, 2007, revealed: The resident will be free from aspiration . Review diet orders and tray card to confirm appropriate diet.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. <BR/>1. The facility failed to label, date and properly seal food items.<BR/>2. The facility failed to discard rancid food items.<BR/>3. The facility's kitchen staff failed to practice proper hand hygiene.<BR/>These deficient practices could place residents at risk for food borne illness and cross-contamination.<BR/>Findings include:<BR/>Observation of the kitchen on 04/24/2022 at 9:05 a.m., during an initial tour and inspection of refrigerator, revealed the following:<BR/>-Imitation bacon bits box was opened, not labeled and not properly sealed.<BR/>-Hard boiled eggs box was opened, not labeled and not properly sealed.<BR/>-Two- 5 lb. bags of Shredded lettuce were unopened, wilted, brown and watery, no expiration date noted.<BR/>-Cream of mushroom soup stored in a container labeled with an expiration date of 4/20/22.<BR/>-1 gallon size container of red sauce were not labeled or dated.<BR/>-Three- 8 oz. cups filled with brown liquid, covered with a lid, were not labeled and not dated.<BR/>-1 gallon size container of a green jello-like substance was not labeled and not dated.<BR/>Observation of the kitchen on 04/24/2022 at 9:05 a.m. during an initial tour and inspection of the pantry revealed the following:<BR/>-A 16 oz. box of Corn starch was opened and had an expiration date of 2/1/22 <BR/>-A &frac12; gallon bag of Shredded Coconut was opened and had an expiration date of 3/2/22<BR/>A 16 oz. bag o f-Brown sugar was opened and had an expiration date of 3/2/22<BR/>-A &frac12; gallon bag of Pork Gravy mix was opened and had an expiration date of 4/21/22<BR/>-A 4 lb. bag of Cheese cake mix was opened and had an expiration date of 4/4/22<BR/>-A 1 lb. bag of Mousse mix was opened and had an expiration date of 4/12/22<BR/>-5 lb. tub of peanut butter had peanut butter smeared on the outside of original container & lid. <BR/>-Sweet tea dispenser was filled with prepared tea and had no lid and was not properly covered.<BR/>-Two baked cakes, were still in the cake pans located on the counter were not properly covered.<BR/>Observation on 04/24/2022 at 11:30 a.m. revealed DM A entered the kitchen and did not wash their hands. DM A proceeded to lay on the floor to adjust steam table settings and got up off the floor. DM A grabbed the mop and mopped up the floor where tea was leaking. DM A mopped around the carts where cake was prepared for serving, and the cake was uncovered. DM A proceeded to touch the side of the cups of tea that were on the serving tray, prepped for service. DM A did not wash his hands upon entering the kitchen or between tasks.<BR/>Observation on 04/24/2022 at 11:52 a.m., revealed DM A opened the fridge and took a container of tomato juice, poured the juice into a cup and placed it on a serving tray. DM A did not wash his hands prior to handling the container of juice, DM A was not wearing gloves.<BR/>Observation on 04/24/2022 at 12:00 p.m. revealed DS B left the kitchen and did not wash their hands upon reentering the kitchen and in between serving drinks and covering the servings of cake with lids.<BR/>In an interview on 04/26/2022 at 09:50 a.m., the Admin stated the facility's policy for proper hand washing was to turn on the faucet, soap up and wash hands for 20 seconds, rinse, and dry. Use the same paper towel to turn off the faucet. The Admin said it was the facility's policy for food items in the refrigerator, freezer and pantry to be checked daily. DM A should be doing a walk-through of the kitchen every day. The Admin stated he did a walk through periodically, and corporate did them when they were in the facility. The Admin stated that corporate was at the facility on the week of 4/18/22 and they both did a walk through. The Admin said he was responsible for oversight of the DM's duties. The Admin said the last in service for hand washing was on July 12,2021.<BR/>In an interview on 04/26/2022 at 09:00 a.m., DM A said the facility's policy for proper hand washing was to open the water faucet to warm water, lather with soap and water for 30 seconds. Take a towel and dry hands, use the towel to turn off the faucet. Throw the dirty towel in trash can. DM A said it was the facility's policy for food items in the refrigerator, freezer and pantry to be checked daily. DM A said he was responsible for doing a daily walk through of the fridge and freezer. DM A stated he threw out all expired goods and the Administrator did walk throughs as well. The dietary staff swept and cleaned after every meal. Mopping was done at the end of shift unless there was a spill. After every meal, dietary staff washed the dishes, rinsed them, put them in the container, ran the container, then washed hands, pulled out the clean dishes to air dry. When State Surveyor voiced findings of multiple expired, unlabeled and undated items in pantry and refrigerator, DM A was silent and did not respond. <BR/>In an interview on 04/26/2022 at 09:30 a.m., DS A stated all food items in the fridge should be dated and were good for 7 days once opened, except for condiments.<BR/>Record review of the facility's policy titled, Dietary Services Policy & Procedure Manual under heading of Storage Refrigerators, dated 2012, read in part Food must be covered when stored, with a label identifying what is in the container. Per Admin, DM A is responsible for ensuring expired foods are thrown out.<BR/>Record review of the facility's policy titled, Dietary Services Policy & Procedure Manual under heading of Sanitation and Food Handling, dated 2012, read in part All employees wash your hands with soap and water before starting work, after coughing or sneezing, handling garbage, picking up an article from the floor, after handling soaps or detergents, after using the toilet, after smoking, and after all breaks. Touching something that is not clean and then handling food can cause food poisoning.<BR/>Record review of the facility's policy titled, Dietary Services Policy & Procedure Manual under heading of Dry Storage and Supplies, dated 2012, read in part, Open packages of food are stored in closed containers with tight covers, and dated as to when opened.

Based on observations, interviews, and record review, the facility failed to store medications in a locked compartment for 1 of 2 (Medication Cart 1) reviewed for medication storage.<BR/>The facility failed to keep each resident's drugs in their original containers/packaging. <BR/>The facility failed to keep medication cart 1 secured when not in use. <BR/>This failure could result in drug diversion.<BR/>Findings included:<BR/>During an observation on 05/06/2023 at 08:20AM, the medication cart #1 was unlocked with the medication cart keys left inserted and hanging from the outside of the narcotic lock. The cart was not in use, with staff not in line of sight of cart with residents present. In the top left drawer, there were 15 separate clear pill cups that included resident morning medications outside of their original containers and placed inside. The loose medications included:<BR/>Celexa 20 mg tablet for depressive disorder<BR/>Memantine HCI Tablet 5 mg for Alzheimer's Disease<BR/>Eliquis Tablet 2.5 mg for Atrial Fibrillation (irregular heartbeat)<BR/>Cyanocobalamin Tablet 500 Mcg for weakness<BR/>Gemtesa Tablet 75 mg for overactive bladder<BR/>Lisinopril Tablet 40 Mg for Hypertension (high blood pressure)<BR/>Acidophilus/Pectin Capsule for Diarrhea<BR/>Bentyl Capsule 10 mg for Diarrhea<BR/>Carvedilol Tablet 12.5 Mg for Hypertension (high blood pressure)<BR/>Aspirin EC Tablet 81 Mg for Cerebral Infarction (stroke)<BR/>Ferrous Sulfate Tablet 325 Mg for Anemia (low blood count)<BR/>Furosemide Tablet 20 Mg for Edema (swelling)<BR/>Gabapentin Capsule 100 Mg for Osteoarthritis (degenerative joint disease)<BR/>Plavix Tablet 75 mg for Myocardial Infarction (heart attack)<BR/>Clopidogrel Bisulfate Tablet 75 Mg for Atherosclerotic Heart Disease (plaque in veins)<BR/>Losartan Potassium Tablet 50 Mg Essential Hypertension (high BP)<BR/>Metformin HCI Tablet 500 Mg for Type 2 Diabetes <BR/>Mybetriq Tablet 50 Mg for urgency of urination. <BR/>Raloxifene HCI Tablet 60 Mg for Osteoporosis<BR/>Rosuvastatin Calcium Tablet 10 Mg for Hyperlipidemia (high cholesterol<BR/>Doxycycline Tablet 6.25 Mg for Infection<BR/>Metoprolol Tablet 25 Mg for Hypertension (high BP)<BR/>Rivastigmine Capsule 6 Mg for Alzheimer's Disease<BR/>Cilostazol Tablet 50 Mg for Atherosclerosis (buildup of fats)<BR/>Glimepiride Tablet 2 Mg for Type 2 Diabetes Mellitus <BR/>Hydralazine HCI Tablet 25 Mg for Essential Hypertension (high BP)<BR/>Hydrochlorothiazide Tablet 12.5 for Essential Hypertension (high BP)<BR/>2 Hydrocodone-Acetaminophen Tablet 7.5-325 Mg for Chronic Pain<BR/>Tylenol with Codeine #3 Tablet 300-30 Mg for pain<BR/>During an interview on 05/06/2023 at 8:25 AM, the RN-A stated she was the nurse in charge with the cart being hers. RN-A stated the medications in the pill cups were OTC drugs, heart disease medication, BP medications, Diabetes medications, ALZ medications, and Narcotics used for pain. She stated the medications in the pill cups were for the next round of morning medications for her residents. She stated the negative impact to residents were that they could have easily opened the cart and taken the medications without her knowledge, leading to possibility of drug diversion.<BR/>During an interview on 05/06/2023 at 12:34 PM, the DON stated, the charge nurse should have been monitoring the medication carts on the weekends. She stated the negative impact to residents would be, getting the medications, taking them, which would lead to something more severe such as an overdose or drug diversion. The failure she stated occurred with RN-A, she should not have and knows she cannot preset her medications and she knows as well to lock her cart when it's not in use. The DON stated, RN-A must had wanted to get her medications passed too quickly. Her expectations were for nurses to keep their medication carts locked at all times, and not previously setting up resident medications prior to administering. She stated the nurses should have pulled the medications from their original containers, in front of the resident doorway, locking the cart when stepping away. <BR/>Record review of facility policy Medication Administration Procedures dated 2003 revealed: .<BR/> .3. Open the unit dose package only when you are administering medication directly to the resident. Removing the medication from it's unit dose packaging in advance lessens the ability to positively identify the medication and increases the chance of drug administration errors and contamination.<BR/> .8. After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured. <BR/> Record review of facility Job Description Charge Nurse from the Human Resources Manual dated 2014 revealed:<BR/>The following is a non-exhaustive criteria that relates to the job of a Charge Nurse, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for a Charge Nurse and are related to the functions that are essential to the job of a Charge Nurse. <BR/>Knowledge Base: .<BR/>Properly administer resident medication.<BR/>Statement: This position reports to the DON.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. <BR/>1. The facility failed to label, date and properly seal food items.<BR/>2. The facility failed to discard rancid food items.<BR/>3. The facility's kitchen staff failed to practice proper hand hygiene.<BR/>These deficient practices could place residents at risk for food borne illness and cross-contamination.<BR/>Findings include:<BR/>Observation of the kitchen on 04/24/2022 at 9:05 a.m., during an initial tour and inspection of refrigerator, revealed the following:<BR/>-Imitation bacon bits box was opened, not labeled and not properly sealed.<BR/>-Hard boiled eggs box was opened, not labeled and not properly sealed.<BR/>-Two- 5 lb. bags of Shredded lettuce were unopened, wilted, brown and watery, no expiration date noted.<BR/>-Cream of mushroom soup stored in a container labeled with an expiration date of 4/20/22.<BR/>-1 gallon size container of red sauce were not labeled or dated.<BR/>-Three- 8 oz. cups filled with brown liquid, covered with a lid, were not labeled and not dated.<BR/>-1 gallon size container of a green jello-like substance was not labeled and not dated.<BR/>Observation of the kitchen on 04/24/2022 at 9:05 a.m. during an initial tour and inspection of the pantry revealed the following:<BR/>-A 16 oz. box of Corn starch was opened and had an expiration date of 2/1/22 <BR/>-A &frac12; gallon bag of Shredded Coconut was opened and had an expiration date of 3/2/22<BR/>A 16 oz. bag o f-Brown sugar was opened and had an expiration date of 3/2/22<BR/>-A &frac12; gallon bag of Pork Gravy mix was opened and had an expiration date of 4/21/22<BR/>-A 4 lb. bag of Cheese cake mix was opened and had an expiration date of 4/4/22<BR/>-A 1 lb. bag of Mousse mix was opened and had an expiration date of 4/12/22<BR/>-5 lb. tub of peanut butter had peanut butter smeared on the outside of original container & lid. <BR/>-Sweet tea dispenser was filled with prepared tea and had no lid and was not properly covered.<BR/>-Two baked cakes, were still in the cake pans located on the counter were not properly covered.<BR/>Observation on 04/24/2022 at 11:30 a.m. revealed DM A entered the kitchen and did not wash their hands. DM A proceeded to lay on the floor to adjust steam table settings and got up off the floor. DM A grabbed the mop and mopped up the floor where tea was leaking. DM A mopped around the carts where cake was prepared for serving, and the cake was uncovered. DM A proceeded to touch the side of the cups of tea that were on the serving tray, prepped for service. DM A did not wash his hands upon entering the kitchen or between tasks.<BR/>Observation on 04/24/2022 at 11:52 a.m., revealed DM A opened the fridge and took a container of tomato juice, poured the juice into a cup and placed it on a serving tray. DM A did not wash his hands prior to handling the container of juice, DM A was not wearing gloves.<BR/>Observation on 04/24/2022 at 12:00 p.m. revealed DS B left the kitchen and did not wash their hands upon reentering the kitchen and in between serving drinks and covering the servings of cake with lids.<BR/>In an interview on 04/26/2022 at 09:50 a.m., the Admin stated the facility's policy for proper hand washing was to turn on the faucet, soap up and wash hands for 20 seconds, rinse, and dry. Use the same paper towel to turn off the faucet. The Admin said it was the facility's policy for food items in the refrigerator, freezer and pantry to be checked daily. DM A should be doing a walk-through of the kitchen every day. The Admin stated he did a walk through periodically, and corporate did them when they were in the facility. The Admin stated that corporate was at the facility on the week of 4/18/22 and they both did a walk through. The Admin said he was responsible for oversight of the DM's duties. The Admin said the last in service for hand washing was on July 12,2021.<BR/>In an interview on 04/26/2022 at 09:00 a.m., DM A said the facility's policy for proper hand washing was to open the water faucet to warm water, lather with soap and water for 30 seconds. Take a towel and dry hands, use the towel to turn off the faucet. Throw the dirty towel in trash can. DM A said it was the facility's policy for food items in the refrigerator, freezer and pantry to be checked daily. DM A said he was responsible for doing a daily walk through of the fridge and freezer. DM A stated he threw out all expired goods and the Administrator did walk throughs as well. The dietary staff swept and cleaned after every meal. Mopping was done at the end of shift unless there was a spill. After every meal, dietary staff washed the dishes, rinsed them, put them in the container, ran the container, then washed hands, pulled out the clean dishes to air dry. When State Surveyor voiced findings of multiple expired, unlabeled and undated items in pantry and refrigerator, DM A was silent and did not respond. <BR/>In an interview on 04/26/2022 at 09:30 a.m., DS A stated all food items in the fridge should be dated and were good for 7 days once opened, except for condiments.<BR/>Record review of the facility's policy titled, Dietary Services Policy & Procedure Manual under heading of Storage Refrigerators, dated 2012, read in part Food must be covered when stored, with a label identifying what is in the container. Per Admin, DM A is responsible for ensuring expired foods are thrown out.<BR/>Record review of the facility's policy titled, Dietary Services Policy & Procedure Manual under heading of Sanitation and Food Handling, dated 2012, read in part All employees wash your hands with soap and water before starting work, after coughing or sneezing, handling garbage, picking up an article from the floor, after handling soaps or detergents, after using the toilet, after smoking, and after all breaks. Touching something that is not clean and then handling food can cause food poisoning.<BR/>Record review of the facility's policy titled, Dietary Services Policy & Procedure Manual under heading of Dry Storage and Supplies, dated 2012, read in part, Open packages of food are stored in closed containers with tight covers, and dated as to when opened.

Based on observations, interviews, and record review, the facility failed to store medications in a locked compartment for 1 of 2 (Medication Cart 1) reviewed for medication storage.<BR/>The facility failed to keep each resident's drugs in their original containers/packaging. <BR/>The facility failed to keep medication cart 1 secured when not in use. <BR/>This failure could result in drug diversion.<BR/>Findings included:<BR/>During an observation on 05/06/2023 at 08:20AM, the medication cart #1 was unlocked with the medication cart keys left inserted and hanging from the outside of the narcotic lock. The cart was not in use, with staff not in line of sight of cart with residents present. In the top left drawer, there were 15 separate clear pill cups that included resident morning medications outside of their original containers and placed inside. The loose medications included:<BR/>Celexa 20 mg tablet for depressive disorder<BR/>Memantine HCI Tablet 5 mg for Alzheimer's Disease<BR/>Eliquis Tablet 2.5 mg for Atrial Fibrillation (irregular heartbeat)<BR/>Cyanocobalamin Tablet 500 Mcg for weakness<BR/>Gemtesa Tablet 75 mg for overactive bladder<BR/>Lisinopril Tablet 40 Mg for Hypertension (high blood pressure)<BR/>Acidophilus/Pectin Capsule for Diarrhea<BR/>Bentyl Capsule 10 mg for Diarrhea<BR/>Carvedilol Tablet 12.5 Mg for Hypertension (high blood pressure)<BR/>Aspirin EC Tablet 81 Mg for Cerebral Infarction (stroke)<BR/>Ferrous Sulfate Tablet 325 Mg for Anemia (low blood count)<BR/>Furosemide Tablet 20 Mg for Edema (swelling)<BR/>Gabapentin Capsule 100 Mg for Osteoarthritis (degenerative joint disease)<BR/>Plavix Tablet 75 mg for Myocardial Infarction (heart attack)<BR/>Clopidogrel Bisulfate Tablet 75 Mg for Atherosclerotic Heart Disease (plaque in veins)<BR/>Losartan Potassium Tablet 50 Mg Essential Hypertension (high BP)<BR/>Metformin HCI Tablet 500 Mg for Type 2 Diabetes <BR/>Mybetriq Tablet 50 Mg for urgency of urination. <BR/>Raloxifene HCI Tablet 60 Mg for Osteoporosis<BR/>Rosuvastatin Calcium Tablet 10 Mg for Hyperlipidemia (high cholesterol<BR/>Doxycycline Tablet 6.25 Mg for Infection<BR/>Metoprolol Tablet 25 Mg for Hypertension (high BP)<BR/>Rivastigmine Capsule 6 Mg for Alzheimer's Disease<BR/>Cilostazol Tablet 50 Mg for Atherosclerosis (buildup of fats)<BR/>Glimepiride Tablet 2 Mg for Type 2 Diabetes Mellitus <BR/>Hydralazine HCI Tablet 25 Mg for Essential Hypertension (high BP)<BR/>Hydrochlorothiazide Tablet 12.5 for Essential Hypertension (high BP)<BR/>2 Hydrocodone-Acetaminophen Tablet 7.5-325 Mg for Chronic Pain<BR/>Tylenol with Codeine #3 Tablet 300-30 Mg for pain<BR/>During an interview on 05/06/2023 at 8:25 AM, the RN-A stated she was the nurse in charge with the cart being hers. RN-A stated the medications in the pill cups were OTC drugs, heart disease medication, BP medications, Diabetes medications, ALZ medications, and Narcotics used for pain. She stated the medications in the pill cups were for the next round of morning medications for her residents. She stated the negative impact to residents were that they could have easily opened the cart and taken the medications without her knowledge, leading to possibility of drug diversion.<BR/>During an interview on 05/06/2023 at 12:34 PM, the DON stated, the charge nurse should have been monitoring the medication carts on the weekends. She stated the negative impact to residents would be, getting the medications, taking them, which would lead to something more severe such as an overdose or drug diversion. The failure she stated occurred with RN-A, she should not have and knows she cannot preset her medications and she knows as well to lock her cart when it's not in use. The DON stated, RN-A must had wanted to get her medications passed too quickly. Her expectations were for nurses to keep their medication carts locked at all times, and not previously setting up resident medications prior to administering. She stated the nurses should have pulled the medications from their original containers, in front of the resident doorway, locking the cart when stepping away. <BR/>Record review of facility policy Medication Administration Procedures dated 2003 revealed: .<BR/> .3. Open the unit dose package only when you are administering medication directly to the resident. Removing the medication from it's unit dose packaging in advance lessens the ability to positively identify the medication and increases the chance of drug administration errors and contamination.<BR/> .8. After the medication administration process is completed, the medication cart must be completely locked, or otherwise secured. <BR/> Record review of facility Job Description Charge Nurse from the Human Resources Manual dated 2014 revealed:<BR/>The following is a non-exhaustive criteria that relates to the job of a Charge Nurse, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for a Charge Nurse and are related to the functions that are essential to the job of a Charge Nurse. <BR/>Knowledge Base: .<BR/>Properly administer resident medication.<BR/>Statement: This position reports to the DON.

Based on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. <BR/>1. The facility failed to label, date and properly seal food items.<BR/>2. The facility failed to discard rancid food items.<BR/>3. The facility's kitchen staff failed to practice proper hand hygiene.<BR/>These deficient practices could place residents at risk for food borne illness and cross-contamination.<BR/>Findings include:<BR/>Observation of the kitchen on 04/24/2022 at 9:05 a.m., during an initial tour and inspection of refrigerator, revealed the following:<BR/>-Imitation bacon bits box was opened, not labeled and not properly sealed.<BR/>-Hard boiled eggs box was opened, not labeled and not properly sealed.<BR/>-Two- 5 lb. bags of Shredded lettuce were unopened, wilted, brown and watery, no expiration date noted.<BR/>-Cream of mushroom soup stored in a container labeled with an expiration date of 4/20/22.<BR/>-1 gallon size container of red sauce were not labeled or dated.<BR/>-Three- 8 oz. cups filled with brown liquid, covered with a lid, were not labeled and not dated.<BR/>-1 gallon size container of a green jello-like substance was not labeled and not dated.<BR/>Observation of the kitchen on 04/24/2022 at 9:05 a.m. during an initial tour and inspection of the pantry revealed the following:<BR/>-A 16 oz. box of Corn starch was opened and had an expiration date of 2/1/22 <BR/>-A &frac12; gallon bag of Shredded Coconut was opened and had an expiration date of 3/2/22<BR/>A 16 oz. bag o f-Brown sugar was opened and had an expiration date of 3/2/22<BR/>-A &frac12; gallon bag of Pork Gravy mix was opened and had an expiration date of 4/21/22<BR/>-A 4 lb. bag of Cheese cake mix was opened and had an expiration date of 4/4/22<BR/>-A 1 lb. bag of Mousse mix was opened and had an expiration date of 4/12/22<BR/>-5 lb. tub of peanut butter had peanut butter smeared on the outside of original container & lid. <BR/>-Sweet tea dispenser was filled with prepared tea and had no lid and was not properly covered.<BR/>-Two baked cakes, were still in the cake pans located on the counter were not properly covered.<BR/>Observation on 04/24/2022 at 11:30 a.m. revealed DM A entered the kitchen and did not wash their hands. DM A proceeded to lay on the floor to adjust steam table settings and got up off the floor. DM A grabbed the mop and mopped up the floor where tea was leaking. DM A mopped around the carts where cake was prepared for serving, and the cake was uncovered. DM A proceeded to touch the side of the cups of tea that were on the serving tray, prepped for service. DM A did not wash his hands upon entering the kitchen or between tasks.<BR/>Observation on 04/24/2022 at 11:52 a.m., revealed DM A opened the fridge and took a container of tomato juice, poured the juice into a cup and placed it on a serving tray. DM A did not wash his hands prior to handling the container of juice, DM A was not wearing gloves.<BR/>Observation on 04/24/2022 at 12:00 p.m. revealed DS B left the kitchen and did not wash their hands upon reentering the kitchen and in between serving drinks and covering the servings of cake with lids.<BR/>In an interview on 04/26/2022 at 09:50 a.m., the Admin stated the facility's policy for proper hand washing was to turn on the faucet, soap up and wash hands for 20 seconds, rinse, and dry. Use the same paper towel to turn off the faucet. The Admin said it was the facility's policy for food items in the refrigerator, freezer and pantry to be checked daily. DM A should be doing a walk-through of the kitchen every day. The Admin stated he did a walk through periodically, and corporate did them when they were in the facility. The Admin stated that corporate was at the facility on the week of 4/18/22 and they both did a walk through. The Admin said he was responsible for oversight of the DM's duties. The Admin said the last in service for hand washing was on July 12,2021.<BR/>In an interview on 04/26/2022 at 09:00 a.m., DM A said the facility's policy for proper hand washing was to open the water faucet to warm water, lather with soap and water for 30 seconds. Take a towel and dry hands, use the towel to turn off the faucet. Throw the dirty towel in trash can. DM A said it was the facility's policy for food items in the refrigerator, freezer and pantry to be checked daily. DM A said he was responsible for doing a daily walk through of the fridge and freezer. DM A stated he threw out all expired goods and the Administrator did walk throughs as well. The dietary staff swept and cleaned after every meal. Mopping was done at the end of shift unless there was a spill. After every meal, dietary staff washed the dishes, rinsed them, put them in the container, ran the container, then washed hands, pulled out the clean dishes to air dry. When State Surveyor voiced findings of multiple expired, unlabeled and undated items in pantry and refrigerator, DM A was silent and did not respond. <BR/>In an interview on 04/26/2022 at 09:30 a.m., DS A stated all food items in the fridge should be dated and were good for 7 days once opened, except for condiments.<BR/>Record review of the facility's policy titled, Dietary Services Policy & Procedure Manual under heading of Storage Refrigerators, dated 2012, read in part Food must be covered when stored, with a label identifying what is in the container. Per Admin, DM A is responsible for ensuring expired foods are thrown out.<BR/>Record review of the facility's policy titled, Dietary Services Policy & Procedure Manual under heading of Sanitation and Food Handling, dated 2012, read in part All employees wash your hands with soap and water before starting work, after coughing or sneezing, handling garbage, picking up an article from the floor, after handling soaps or detergents, after using the toilet, after smoking, and after all breaks. Touching something that is not clean and then handling food can cause food poisoning.<BR/>Record review of the facility's policy titled, Dietary Services Policy & Procedure Manual under heading of Dry Storage and Supplies, dated 2012, read in part, Open packages of food are stored in closed containers with tight covers, and dated as to when opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents LVN A feeding 1of 1 residents (Resident #22) did not perform hand hygiene after touching resident and wiping resident mouth.<BR/> The facility failed to ensure proper hand hygiene when feeding a resident (Resident #22).<BR/>These failures placed residents of the facility at risk of infections from respiratory care and dining.<BR/>Findings included: <BR/>During a record review on 08/20/2024 of Resident #22's electronic face sheet revealed: [AGE] year-old female admitted on [DATE]. Diagnosis include-Alzheimer's Disease (a progressive disease that destroys memory and other mental functions), Abnormal weight loss.<BR/>During a record review on 08/20/2024 of Resident #22's Physician Orders dated 08/01/2024 revealed: Fortified/Enhanced diet, pureed (all food has been ground, or strained to a soft, smooth consistency, like pudding) texture. <BR/>During a record review on 08/20/2024 of Resident #22's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns BIMS score was 00 meaning Resident #22 had severe cognitive impairment.<BR/>During a record review on 08/20/2024 of Resident #22's Care plan dated 08/18/2024 revealed: Focus-The resident has an ADL (activities of daily living) self-care performance deficit. Goal: the resident will maintain or improve current level of function in Eating . Interventions: Eating: assist x 1.<BR/>During an observation on 08/18/2024 at 5:57 PM in facility dining room revealed LVN A feeding Resident #22. Observed LVN A sitting between two residents assisting both residents with their meals. LVN A assisted on resident and the assist another resident. LVN A touched one resident and wiped the resident's mouth and did not perform hand hygiene before continuing to assist residents with their meals. LVN A touched the back of Resident #22's chair and picked up a spoon and continued to assist resident with eating without performing hand hygiene before assisting Resident #6 with meal. <BR/>During an interview on 08/18/2024 at 5:57 PM with LVN A. LVN A stated she had been doing this for a long time and did not even think about it. She stated she failed to hand sanitize when she touched the resients back and face and helped her wipe her face. <BR/> Review of facility's policy titled Hand Hygiene (no date)<BR/>You may use alcohol-based hand cleaner or soap/water for the following .<BR/>Before and after assisting a resident with meals<BR/>Upon and after coming in contact with a resident's intact skin .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records that were complete and accurate for 2 of 3 residents (Resident #36 and Resident #149) reviewed for resident records. <BR/>The facility failed to document the verification of placement of a wanderguard each shift, and the function of resident's device daily for Resident #36 and Resident #149. <BR/>This failure could place residents at risk of residents having errors in care and treatment. <BR/>Findings include:<BR/>Review of Resident #36's face sheet, dated 06/28/2023, revealed an [AGE] year-old male admitted on [DATE] with the following diagnosis Dementia. <BR/>review of Resident # 36's Quarterly MDS, dated [DATE], revealed: Section C- Cognitive Behavior a BIMS score of 8 meant he had moderate cognitive impairment. <BR/>Review of Resident #36's electronic medical record revealed no evidence of documentation of verification of placement of a wanderguard documented each shift, or documentation of the function of resident's device verified at least daily. <BR/>Review of Resident #149's face sheet, dated 06/28/2023, revealed an [AGE] year-old male admitted on [DATE] with the following diagnosis Dementia and Anxiety. <BR/>Review of Resident # 149's admission MDS, dated [DATE], revealed no evidence of a BIMS score. <BR/>Review of Resident #149's electronic medical record revealed no evidence of documentation of verification of placement of a wanderguard documented each shift, or documentation of the function of resident's device verified at least daily.<BR/>Observation on 06/28/2023 at 11:10 AM revealed Resident #36 was wearing a wanderguard on the right ankle and Resident #149 was wearing a wanderguard on right wrist. <BR/>During an interview on 06/28/2023 at 5:03 PM the DON stated her expectation was that wanderguards should have been checked for placement and documented every shift in the electronic chart and wanderguard function should have been checked daily and also documented in electronic chart. The DON stated not checking placement every shift could have affected residents by resident skin not being assessed, wanderguard not placed properly or the wander guard not working . <BR/>During an interview on 06/28/23 at 5:14 PM, the ADMN stated her expectation was that there should have been documentation of placement of wanderguards every shift and functionality of wanderguards documented daily. The ADMN stated the nurses were responsible to ensure wanderguards were being verified for placement and documented each shift. The ADMN stated not checking placement each shift or functionality of wanderguard could have caused skin issues. The ADMN stated staff assuming appropriate documentation was completed led to failure of the wanderguards not being verified. <BR/>Review of the facility policy titled Elopement Prevention, dated 10/27/10, revealed Wanderguard System (locking or alarming) Placement of the resident's device to alarm the system will be verified each shift and documented on the treatment or other flow record. Function of the resident' s device will be verified at least daily and documented on the treatment of other flow record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident environment remained free of accident hazards and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #199) reviewed for accidents and supervision.<BR/>The facility failed to ensure there was adequate supervision while Resident #199 was smoking.<BR/>This failure could place residents at risk for injury due to the lack of supervision provided by the facility.<BR/>Findings include:<BR/>Record review of Resident #199's electronic face sheet revealed Resident #199 was an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #199 had diagnoses which included Dementia, Alzheimer's and Depression. <BR/>Record review of Resident #199 Comprehensive assessment, dated 06/09/2023, revealed a BIMS of 09, which indicated moderately impaired cognition. Resident #199 was a tobacco user.<BR/>Record review of Resident #199 Comprehensive Care Plan, dated 06/26/2023, revealed no evidence regarding smoking. <BR/>Record review of Resident #199 Safe Smoking Assessment, dated 06/07/2023, revealed This Resident requires direct supervision while smoking.<BR/>During an observation and interview on 06/28/23 at 02:10 PM, Resident #199 was seen outside smoking, unsupervised. Resident #199 stated his family brought him cigarettes and staff light cigarettes for him.<BR/>During an interview on 06/28/2023 at 2:35 PM, the DON stated residents should not be outside smoking alone. She also stated the facility did not allow any residents to smoke unsupervised. The DON stated her expectations about Resident #199 was to be educated and staff were to make sure cigarettes were put out entirely. She also stated the cigarettes were to be disposed down into the closed container. The DON stated staff were to ensure residents were supervised while smoking. The DON stated it was the housekeeping department's responsibility to observe Resident #199 on 06/28/2023. The DON stated Resident #199 could have burned himself.<BR/>During an interview on 06/28/202 at 5:23 PM, the Administrator stated her expectation was Resident #199 would smoke during the smoking times and would not have access to cigarettes. The Administrator stated all staff were responsible to monitor residents while smoking. She stated the resident could have burned himself while smoking unsupervised. The Administrator stated she was not sure how Resident #199 was able to get cigarettes. <BR/>Record review of the facility provided policy revealed in the Resident admission packet #26 titled, Smoking Policy, revised 11/1/17, MAKE 2, revealed the following: <BR/>(1) Smoking tobacco, matches, lighters or other ignition sources for smoking are not permitted to be kept or stored in a resident's room.<BR/>(2) A safe smoking assessment will be done regularly for each resident who smokes. Smoking by residents classified as unsafe will be prohibited except when the resident will be directly supervised by facility personnel or visitors who are aware of the resident's limitations with smoking. The resident must be within direct view of the smoking supervisor, in reasonably close proximity of the supervisor. And the supervisor must be able to quickly respond in the event of an emergency. Additionally, the supervisor. Whether staff or visitor must be aware of these responsibilities.

Based on interviews, and record reviews, the facility failed to ensure professional staff was certified in accordance with applicable State laws for 1 (NA B) of 15 personnel reviewed for licensed nursing. <BR/>The facility failed to ensure NA B had become a Certified Nurse Aide by passing her certification test. <BR/>These failures could place residents at risk of being provided care by staff who are not qualified per state law.<BR/>Findings included:<BR/>Record review of NA B's employee file revealed a hire date of 08/30/2022 and no evidence of CNA certification.<BR/>During an interview on 08/20/24 at 3:21 PM the DON stated that NA B was a NA and not a CNA. The DON stated NA B was currently enrolled in an online course. The DON stated NA B had failed the CNA certification exam twice before and had one more attempt. The DON stated her expectation was for her to complete the online course and pass her test in a timely manner. The DON did not think there was an effect on residents because NA B always worked with a CNA (who was certified). The DON stated what led to failure of NA not being certified was she could not pass because of nerves.<BR/>During an interview on 08/20/2024 at 4:30 PM the ADMN stated her expectation was for NAs to become certified as quickly as possible. The ADMN stated the DON was to monitor to ensure NAs completed test and became certified. The ADMN stated what led to failure was NA took a program from a high school and she was not sure how well it prepared NA for the test. The ADMN stated they had been waiting for the state provided online class to begin so the NA could retake class and complete the test. <BR/>Record review of facility provided job description, titled Job Description Student Nurse Aide, dated 2014 revealed; I understand that this position is not permanent but limited to 120 days in which I am required to test and obtain certification.

Based upon observation, interview and record review, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors for 2 of 3 days reviewed for nursing services and postings. <BR/>The facility failed to ensure daily staffing information was posted in a prominent place on 08/18/2024 and 08/19/2024.<BR/>This failure places residents, their families, and visitors at risk of not having access to information regarding staffing and facility census.<BR/>Findings include:<BR/>During an observation of postings in the facility on 08/18/2024 at 2:00 PM, revealed no daily nursing staffing information posted at the nurses' station or any other place in the facility.<BR/>During an observation of postings in the facility on 08/19/2024 at 8:30 AM, revealed no daily nursing staffing information posted at nurses' station or any other place in the facility.<BR/>During an interview on 08/20/2024 at 4:30 PM, the DON stated she did not know she was supposed post the daily staffing. The DON stated she did feel that this would not cause any harm to residents. The DON stated family, residents or visitors could ask what staff were working. The DON stated the failure occurred due to her not knowing she was supposed to display the daily staffing data. The DON stated they did not have a policy for nurse staff posting and they followed the federal regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents LVN A feeding 1of 1 residents (Resident #22) did not perform hand hygiene after touching resident and wiping resident mouth.<BR/> The facility failed to ensure proper hand hygiene when feeding a resident (Resident #22).<BR/>These failures placed residents of the facility at risk of infections from respiratory care and dining.<BR/>Findings included: <BR/>During a record review on 08/20/2024 of Resident #22's electronic face sheet revealed: [AGE] year-old female admitted on [DATE]. Diagnosis include-Alzheimer's Disease (a progressive disease that destroys memory and other mental functions), Abnormal weight loss.<BR/>During a record review on 08/20/2024 of Resident #22's Physician Orders dated 08/01/2024 revealed: Fortified/Enhanced diet, pureed (all food has been ground, or strained to a soft, smooth consistency, like pudding) texture. <BR/>During a record review on 08/20/2024 of Resident #22's Quarterly MDS dated [DATE] revealed: Section C-Cognitive Patterns BIMS score was 00 meaning Resident #22 had severe cognitive impairment.<BR/>During a record review on 08/20/2024 of Resident #22's Care plan dated 08/18/2024 revealed: Focus-The resident has an ADL (activities of daily living) self-care performance deficit. Goal: the resident will maintain or improve current level of function in Eating . Interventions: Eating: assist x 1.<BR/>During an observation on 08/18/2024 at 5:57 PM in facility dining room revealed LVN A feeding Resident #22. Observed LVN A sitting between two residents assisting both residents with their meals. LVN A assisted on resident and the assist another resident. LVN A touched one resident and wiped the resident's mouth and did not perform hand hygiene before continuing to assist residents with their meals. LVN A touched the back of Resident #22's chair and picked up a spoon and continued to assist resident with eating without performing hand hygiene before assisting Resident #6 with meal. <BR/>During an interview on 08/18/2024 at 5:57 PM with LVN A. LVN A stated she had been doing this for a long time and did not even think about it. She stated she failed to hand sanitize when she touched the resients back and face and helped her wipe her face. <BR/> Review of facility's policy titled Hand Hygiene (no date)<BR/>You may use alcohol-based hand cleaner or soap/water for the following .<BR/>Before and after assisting a resident with meals<BR/>Upon and after coming in contact with a resident's intact skin .