RIVERBEND HEALTH AND REHABILITATION CENTER

A complaint survey, prompted by #CO33412 and #CO33444 was completed on 8/24/23 to 8/28/23. No deficiencies were cited.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/07/2023 and 08/13/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 07/31/2023 and 08/06/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A complaint survey, prompted by #CO32863 and #CO32864 was conducted on 7/19/23. No deficiencies were cited.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/12/2023 and 06/18/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 06/05/2023 and 06/11/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A survey for Incident #31267 was conducted 4/3/23 to 4/5/23. No deficiencies were cited.

A revisit to the 2/9/2023 survey was completed on 3/16/2023. The facility was in compliance with the regulations surveyed.

Regarding the requirements for self-determination, the facility is reminded that the resident's self-determination should include the opportunity to select the frequency (i.e., more than twice weekly) and method for bathing (i.e., methods of bathing other than just showering).

A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiencies.. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is one story, Type III (200) (III-B) construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1957 and is license for 100 beds. This re-certification survey conducted on February 28,2023 was for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) "Chapter 19, Existing Health Care Occupancies". The deficiencies cited were discussed with the Administrator and Maintenance Director during the exit conference conducted at the end on-site survey. The Administrator reported the daily census to be 79 residents on February 28, 2023.

STANDARD is not met as evidenced by: During observation of the kitchen gas fired cooking equipment it did not meet the requirements of the 2012 Edition of NFPA 54 Fuel and Gas Code 9.6.1.2. This deficient practice could affect all residents, and staff should a fire occur due to failure to operate safely due to non-code compliant. This was evidence by the following. Gas fired cooking equipment with casters where not limited by a restraining device. The Maintenance Director acknowledge lack of a restraining on the gas fired cooking appliances

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidence by the following.-sprinkler heads in Laundry shows signs of foreign materials around the working parts of the head. The Director of Maintenance acknowledge the lack of maintenance of the automatic sprinkler system deficiency during record review of the facility. NFPA 101Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on observation and staff interview during the course of the survey conducted on February 28, 2023, it was determined the facility failed to maintain The security of oxygen cylinders according to NFPA 99-Health Care Facilities. The following evidenced this:Several "empty" Oxygen cylinders were unsecured in the Oxygen storage room. 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/13/2023 and 02/19/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A recertification survey with complaints #CO30701 and #CO30724 was completed from 2/6/23 to 2/9/23. Eight deficiencies were cited.

An Emergency Preparedness survey was conducted from 2/6/23 to 2/9/23. No deficiencies were cited.

Based on the record review, observations and interviews, the facility failed to promote and maintain resident's dignity for one (#27) of three out of 37 sample residents. Specifically, the facility failed to ensure Resident #27 was offered her breakfast. Findings include:I. Facility policy and procedureThe Promoting/Maintaining Dignity During Mealtime policy and procedure,undated was provided by the nursing home administrator (NHA) on 2/9/23 at 3:50 p.m. It documented, in pertinent part,"It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes. Resident requests will be honored during meals to the extent possible. Ensure the resident receives the proper tray. Assist resident with opening items, cutting necessary food items, etc. Allow adequate time for resident to complete meal. Do not rush. Allow resident time needed to complete as much as desired of the meal. If resident is in the dining room, assist back to room as needed. If resident is in his/her room, position as resident desires or as directed."II. Resident #27A. Resident statusResident #27, age 88, was admitted on 6/14/18. According to the February 2023 computerized physician orders (CPO) diagnoses included anxiety and dementia. According to the 1/20/23 minimum data set (MDS) assessment, the resident was unable to complete the brief interview for mental status (BIMS); however, it showed that she had short-term and long-term memory impairment with severe impairment in making decisions regarding tasks of daily life. She required one-on-one extensive assistance in activities of daily living including bed mobility and locomotion dressing, and personal hygiene. She required two to one extensive assistance for transfers and toilet use. She required set up assistance for eating. B. ObservationsOn 2/9/23 at 7:20 a.m. the resident was observed lying in bed. She was awake in the bed. -At 7:50 a.m., the tray cart arrived onto the unit. The resident remained in bed.-At 8:06 a.m. the resident continued to be in the bed awake, however she had not been offered her meal. -At 8:43 a.m. certified nurse aide (CNA) #5 threw the residents breakfast meal into the trash. The resident was not offered a breakfast meal. No staff went to the resident's room to check to see if she was awake in bed. Staff took three meal cartons out to be replaced because they were cold. Resident #27 was not included in the three meals being replaced. Resident #27 was not offered a breakfast meal. -At 9:00 a.m. the resident continued to be awake in bed. C. Staff interviewCNA #5 was interviewed on 2/9/23 at 8:46 a.m. The CNA confirmed she had thrown the meal away along with her meal ticket. She said the resident did not get up until 10:00 a.m. The CNA said she did not offer the resident a breakfast, but would provide her with a peanut butter and jelly sandwich at a later time. The CNA said she was not aware the resident was awake in bed. The social worker for the secured unit was interviewed on 2/9/23 at approximately 9:00 a.m. The social worker said he was going to go to the kitchen to replace three of the resident meals as the food was cold. He confirmed Resident #27 was still in bed. He said that he did not know why she was not up, as she usually was. He said that Resident #27 was not on the list to replace her meal. He said the resident should be offered her breakfast and allow her to make the choice if she wanted to eat it, or an alternative. The meal should not have been thrown away. The NHA was interviewed on 2/9/23 at 11:52 a.m. The NHA said staff should ask the resident if they would like to eat their meals. She said staff should offer it in bed if the resident did not want to get up. She said the administration would retrain on dignity, activities of daily living and choices.

Based on record review and interviews, the facility failed to ensure the residents' right to make choices about aspects of their lives in the facility that were significant to them for two (#28 and #37) of four out of 37 sample residents. Specifically, the facility failed to provide consistent showers for Residents #28 and #37 according to their preferences and routine shower schedules. Findings include:I. Facility policy and proceduresThe Routine Resident Care policy, revised September 2011, was provided by the nursing home administrator (NHA) on 2/8/23 at 1:51 p.m. The policy revealed residents were to receive the necessary assistance to maintain good grooming and personal/oral hygiene. The facility would ensure that a resident's capacity for self-performance of these activities did not diminish unless circumstances of the resident's clinical condition demonstrate the decline was unavoidable. Care was to be taken to ensure resident safety at all times. The facility would ensure showers, tub baths, and/or shampoos were scheduled at least twice weekly and more often as needed. II. Resident #28A. Resident statusResident #28, age under 65, was admitted on 10/20/17 and readmitted on 12/30/18. According to the February 2023 computerized physician orders (CPO), diagnoses included spina bifida (condition affects the spine at birth), anxiety, paraplegia (leg paralysis), depression, muscle wasting and atrophy (wasting). The 10/24/22 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident was totally dependent on staff for bathing with a one-person physical assist for bathing. B. Resident interviewResident #28 was interviewed on 2/6/23 at 12:15 p.m. She said she only received one bath a week sometimes. She said she would like at least two baths each week. She said her bath days were Wednesdays and Saturdays. She said she could not get out of bed and she received bed baths. She said bed baths were her choice of bathing. She said not receiving two baths per week made her frustrated. She said a lack of bathing compromised her immune system and at times caused her to develop outbreaks of yeast. C. Record reviewThe care plan, revised 6/30/2020, for activities of daily living (ADLs) self-performance deficit related to spin a bifida with decreased mobility, neurogenic bladder, depression, and anemia. The resident had a risk for musculoskeletal deficits related to spina bifida and non-weight bearing. The pertinent interventions revealed the resident preferred late afternoon baths and required extensive to total assistance with one to two staff for bathing. The November 2022 Activities of Daily Living documentation survey report for bathing revealed, the resident did not receive a bath for the entire month (30 days). The December 2022 Activities of Daily Living documentation survey report for bathing revealed, the resident missed one bath for the week of the 12/8/22 to 12/14/22 and one bath for the week of the 12/22/22 to 12/31/22. The January 2023 Activities of Daily Living documentation survey report for bathing revealed, the resident missed one bath for the week of the 1/8/23 to 1/14/23 and two baths for the week of the 1/22/23 to 1/31/23. III. Resident #37A. Resident statusResident #37, age 93, was admitted on 9/14/19. According to the February 2023 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances, macular degeneration, difficulty in walking, anxiety, depression, muscle wasting and atrophy. The 12/20/22 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of three out of 15 with no behaviors. The resident required staff supervision for bed mobility, transfers, eating, toileting and personal hygiene. The resident required limited staff assistance for dressing. The resident required physical staff help with transfers with a one-person physical assist for bathing. B. Record reviewThe care plan, revised 6/30/2020, for activities of daily living (ADLs) self-performance deficit related to impaired balance, macular degeneration, incontinence risk, depression, dementia with behaviors, dorsalgia, hearing loss, anxiety, history of facial spasms, hypothyroidism, wears partial dentures, hearing aids, glasses and forgets to wear depends at times. The pertinent intervention revealed the resident required supervision and set up staff assistance with showering, twice a week and as necessary. The November 2022 Activities of Daily Living documentation survey report for bathing revealed, the resident did not receive a bath for the entire month (30 days). The December 2022 Activities of Daily Living documentation survey report for bathing revealed, the resident missed one bath for the week of the 12/15/22 to the 12/21/22 and one bath for the week of the 12/22/22 to the 12/31/22. The January 2023 Activities of Daily Living documentation survey report for bathing revealed, the resident missed one bath for the week of the 1/1/23 to 1/7/23 and one bath for the week of the 1/15/23 to 1/21/23. IV. Staff interviewsThe NHA, assistant in training (AIT), director of nursing (DON) and the social services director (SSD) were interviewed on 2/9/23 at 10:06 a.m. They all agreed with the provided documentation for Resident #37. The NHA said Resident #37 was a one staff person physical assist for bathing and at times the resident refused a bath. The NHA said the resident received baths on Wednesdays and Fridays. The NHA said the facility transitioned from the resident computerized documentation system called point click care (PCC) from one ownership company to a second company. The NHA said there were numerous problems with the transition during the month of November 2022. The NHA said many of the custom resident tasks, such as bathing documentation, did not transfer correctly or not at all. The NHA said residents received a bath twice a week or as ordered. The NHA said certified nurse aides (CNAs) should chart if a resident received or refused a bath by at least the end of their shift. The NHA said CNAs could mark that a resident refused a bath in PCC. The DON said if a resident refused a bath, the CNA should ask the resident several more times. The DON said the CNA would tell the nurse of the resident's refusal. The DON said the nurse should ask the resident several times if they wanted a bath, before a refusal was documented in PCC.The NHA, AIT, DON and the SSD were interviewed again on 2/9/23 at 11:13 a.m. They all agreed on the above documentation for Resident #28. The NHA said the resident was a one staff person physical assist for bathing. The NHA said the resident received baths on Wednesdays and Saturdays. CNA #2 was interviewed on 2/9/23 at 1:09 p.m. She said she provided showers/baths for residents. She said she documented it in PCC as soon as she could after the shower was given. She said she could document a refusal in PCC. She said if a resident refused, she would tell the nurse. She said herself or the nurse would go ask the resident multiple times during the shift, if they wanted a shower. She said if they did not want a shower, she would pass the refusal on to the next shift and they would go ask the resident again. CNA #5 was interviewed on 2/9/23 at 1:47 p.m. She said she provided showers/baths to residents. She said she documented in PCC that a shower was given as soon as the shower was completed. She said she was able to mark refusals in PCC. She said if a resident refused, she would ask the resident several more times and then go tell the nurse. She said the nurse would also talk to the resident about getting a shower. She said if the attempts failed, then a refusal was marked in PCC.

Based on observations and interviews the facility failed to ensure residents had the right to a safe, clean and comfortable homelike environment for 14 of 24 out of 57 resident rooms. Specifically, the facility did not facilitate the necessary housekeeping and maintenance services to maintain the resident rooms to include rooms #E01, #E08, #E10, #E12, #E16, #W101, #W104, #W105, #W106, #W113, #28, #30, #31 and #32 in a sanitary, safe and comfortable manner. Findings include:I. Facility policyThe Safe and Homelike Environment policy, revised 2/1/23, was provided by the nursing home administrator (NHA) on 2/9/23 at 11:32 a.m. The policy revealed the facility would provide a safe, clean, comfortable and homelike environment that allowed the resident to use his or her personal belongings to the extent possible. The facility would also ensure that the resident could receive care and services safely. The facility further ensured that the physical layout of the facility maximized resident independence and did not pose a safety risk. The term environment referred to any area in the facility that was frequented by residents that included (but not limited to) the resident's room, bathroom, hallways, dining area, lobby, outdoor patios, therapy areas and activity areas. The facility staff would report any unresolved environmental concerns to the NHA.II. Performance improvement project (PIP)On 2/9/23 at 12:58 p.m. the NHA provided a PIP plan for the environment of resident rooms that were identified during a mock recertification survey. The baseline measure revealed that resident rooms were to be assessed utilizing the ambassador (a staff person that acts as a representative) visit form, for environmental concerns that would be prioritized based on need. The root causes were the age of the facility, maintenance turnover, new capital expense process, and conflicting priority with the kitchen that needed attention. The obstacles to the PIP were supplies procurement, staffing and ownership transition. The project outcome revealed resident rooms would be comfortable for living and free of environmental hazards. The action items section revealed ambassadors were to audit rooms for prioritization (#8, #10, #30, #101, and #108). The audit start date was 1/23/23 and the completion date was 1/25/23. This audit was completed. The second action item revealed the facility was to complete (make repairs) two rooms each month. This might increase with additional environmental staff and/or resources. The start date was 2/1/23 and a completion date was 12/31/23. The resources that were required included paint, cove base, handles, stain, spackle, flooring, blinds, tools, brushes, furniture, and side tables. III. Resident room observationsOn 2/6/23 at 10:38 a.m., observations of room #E01 revealed the resident room had a wet and sticky floor at the entrance to the room. The room smelled of urine. There was chipped paint on the room heater cover. On 2/7/23 at 10:34 a.m., observations of room #W106 revealed room cove base had scattered pieces of matter, the corners of the room were unclean with scattered pieces of matter, chipped paint on the entrance door frame, unfinished sheetrock patches in the bathroom, two blue plastic screw anchors in a bathroom wall, chipped paint on the bathroom walls, chipped paint on the bathroom door frames, and a scraped bathroom door. At 10:40 a.m., observations of room #E16 revealed sheetrock damage on a room wall, chipped paint on the bathroom door frame, two window metal blind holders attached to a bathroom wall, six blue screw anchors in one room wall, and chipped paint on the closet drawers. At 10:41 a.m., observatories of room #W105 revealed the corners of the room were unclean with scatter pieces of matter, multiple nails on the room walls, missing room cove base, loose room cove base, chipped paint on the bathroom door frames, missing towel bar in the bathroom, black scrape marks on a bathroom wall, loose entrance door laminate, chipped paint on the room wall corners, six unfinished sheetrock patches on a room wall, five blue plastic screw anchors on a room wall, and chipped paint on the entrance door frame. At 10:47 a.m., observations of room #W104 revealed chipped paint on the bathroom door frame, caulk around the toilet base discolored with matter, the room corners were unclean with scattered matter, loose cove base in the room, and scraped wood on the bathroom door. At 10:48 a.m., observations of room #E12 revealed chipped paint on the bathroom door frame and strong urine odor in the bathroom. At 10:54 a.m., observations of room #W113 revealed loose metal heater cover in the bathroom, scraped bathroom door, chipped paint on the bathroom door frame, and loose metal entrance transition strip. At 11:04 a.m., observations of room #W101 revealed bent metal heater cover in the room, sheetrock damage on one room wall, unsecure linoleum floor by entrance to the room, chipped paint around bathroom sink, loose bathroom grab bar, and missing emergency pull cord in the bathroom. On 2/8/22 at 10:42 a.m., observations of room #30 on the secure unit, revealed chipped paint on the entrance door frame, chipped paint on the entrance door, chipped paint on a room wall corner, chipped paint on the bathroom door frame, chipped paint on a bathroom wall, missing toilet paper holder tube, loose bathroom door laminate, dark stain around toilet base, loose caulk around toilet base, chipped paint on the closet drawers, two metal sharp edges on a toilet riser (sharp to touch), and loose metal drawer lock on a dresser. At 10:47 a.m., observations of room #31 on the secure unit, revealed chipped paint on the entrance door frame, a loose dresser drawer, chipped paint on the bathroom door frame, chipped paint on the room walls, missing toilet paper holder tube, dark stain around toilet base, chipped paint on the closet drawers, two glass vases sitting on closet shelf, and a loose entrance door handle. At 10:51 a.m., observations of room #28 on the secure unit revealed, chipped paint on the entrance door frame, chipped paint on room walls, chipped paint on closet drawers, chipped paint on room wall corners, chipped paint on the bathroom door frame, missing entrance transition strip and chipped paint on the window frame. At 10:54 a.m., observations of room #32 on the secure unit revealed, chipped paint on the entrance door, chipped paint on the entrance door frame, chipped paint on the metal heater cover, chipped paint on the closet drawers, chipped paint on the bathroom door frame, one-bathroom light non-functional, one missing towel bar, unfinished bathroom sheetrock patch, and uncleanable red tape on bathroom grab bar. At 11:00 a.m., observations of room #E10 revealed a large hole in the bathroom door, loose caulk around toilet base, chipped paint on the bathroom door frame, two missing towel bars, loose bathroom door laminate, unfinished sheetrock patch on the bathroom wall, torn room floor laminate, chipped paint on the room corner edges, multiple brown stains on room ceiling, chipped paint on the bathroom ceiling, black marks on a bathroom room wall and loose laminate on the entrance door. At 12:04 p.m., observations of room #E08 revealed chipped paint on the entrance door frame, chipped paint on the entrance door, torn room linoleum floor with two small sections missing, brown marks on the room ceiling, chipped paint the room ceiling, one unpainted room wall sheetrock patch, and chipped paint room the wall corners. IV. Staff interviewsOn 2/9/23 at 11:40 a.m., an environment tour of the facility was conducted with the assistant in training (AIT) and the director of maintenance (DM). The DM said there were 57 resident rooms in the facility. The DM said staff filled out maintenance logs that he reviewed several times each day. The DM said the staff also could call or text him as needed. The DM also said he was in multiple resident rooms during the course of each day. The AIT said the facility did a mock recertification survey and had identified the resident rooms that needed repairs. The AIT said Ambassador Rounds were conducted on 1/23/23 to also identify the rooms that needed repairs. The AIT said the performance improvement plan had a goal of completely repairing at least two rooms per month that took about six hours per room to complete. The AIT and DM observed and documented the above listed observations. On 2/9/23 at 2:13 p.m. the NHA said since the PIP was started, two resident rooms had been deep cleaned and the supplies had been ordered that were necessary for the repairs in resident rooms. The NHA said the PIP goals were to make all of the needed repairs in a minimum of two resident rooms each month. -However, there were safety concerns identified in the resident rooms (see observations above).

Based on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent for two residents (#20 and #76). Specifically, the facility had a medication error rate of 9.68 percent, which was three errors out of 31 opportunities for error. Findings includeI. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.sevier, St. Louis Missouri, pp. 606-607, retrieved on 2/13/23, "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environmentProfessional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication."According to the Breztri drug package insert, retrieved on 2/13/23 from: https://den8dhaj6zs0e.cloudfront.net/50fd68b9-106b-4550-b5d0-12b045f8b184/9d44f9af-438a-448b-bb5c-dae506e17e49/9d44f9af-438a-448b-bb5c-dae506e17e49_viewable_rendition__v.pdf "dosage and adminsitration after inhalation, rinse mouth with water with out swallowing."II. Facility policyThe Medication Administration policy, undated, received from the nursing home administrator (NHA) on 2/8/23 at 1:43 p.m. read in pertinent part, "Medications are administered by a licensed nurse in compliance with professional standards of practice. Compare medication source with medication administration record (MAR) to verify resident name, medication name, form, dose, route, and time. Refer to a drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects."III. ObservationsOn 2/8/23 at 8:41 a.m. licenced practical nurse (LPN) #1 was observed preparing and administering medications for Resident #76. LPN #1 dispensed two 250 milligrams (mg) tablets of vitamin C and one 50 mg tablet of zinc.-Review of Resident #76 computerized physician orders (CPO) revealed there was no dose indicated for the vitamin C or the zinc. LPN #1 had administered the vitamin C and zinc to Resident #76. On 2/8/23 at 10:32 a.m registered nurse (RN) #1 was observed preparing and administering medications for Resident #20. RN #1 handed Resident #20 a Breztri inhaler (for chronic obstructive pulmonary disease) after shaking inhaler and advised Resident #20 to take only two puffs. Resident #20 administered two puffs of the inhaler and handed inhaler back to RN #1. -Review of Resident #20 CPO revealed an order for Breztri aerosphere aerosol 160-9-4.8 micrograms per inhalation. Administer two puffs inhaled orally two times a day.-RN #1 failed to offer the resident water to rinse mouth after the inhaler was administered. The order failed to indicate the need for the resident's mouth to be rinsed after administration. IV. Staff interviewsLPN #1 was interviewed on 8/8/23 at 9:00 a.m. on 2/8/23. LPN #1 acknowledged the order for Resident #76 failed to have a dose ordered for zinc and vitamin C. LPN #1 said she gave 500 mg of vitamin C and 50 mg of zinc because it was ordered for wound care by the wound physician and that was the standard dose the wound physician ordered for everyone who had wounds. LPN #1 said she would get the order clarified. RN#1 was interviewed on 8/8/23 at 2:14 p.m. RN #1 stated she was not aware of the need for the Breztri inhaler requiring a resident to rinse mouth post administration. RN #1 said some inhalers require mouth rinse after inhalation to prevent thrush (oral yeast infection). The director of nursing (DON) was interviewed on 8/8/23 at 2:32 p.m. The DON said all orders must be reviewed for the following prior to administration; name, drug, dose, time and route. She was not aware of the missing dose on the vitamin C and zinc for Resident #76. She was not aware of the need for Resident #41 Breztri inhaler requirement to rinse mouth after the user. She explained there was a risk for thrush for some inhalers that did require a rise after administration. The DON said an education would be completed with nursing staff.

Based on observations, interviews and record review the facility failed to ensure one (#41) of one resident reviewed for dental care out of 37 sample residents received dental services timely. Specifically the facility failed to ensure Resident #41 had a referral sent to a dentist within three days of dentures missing. Finding include:I. Facility policyThe Dental Service policy, undated, received from the nursing home administrator (NHA) on 2/9/23 at 4:46 p.m. It read in pertinent part, "Facility to assist residents in obtaining routine and emergency dental care."II. Resident #41 A. Resident statusResident #41, age 83, was admitted on 5/26/22. According to the January 2023 computerized physician orders (CPO) the diagnosis included dysphagia (difficulty swallowing), cor pulmonale (heart failure), peripheral vascular disease (circulation disorder), acute and chronic respiratory failure (difficulty breathing). According to the minimum data assessment (MDS) dated 11/23/22 revealed the resident had a moderately impaired cognition with a brief interview of mental for mental status (BIMS) score of ten out of 15. She required extensive two person assistance with bed mobility, dressing, toileting and personal hygiene. She required set up assistance for eating with supervision and cueing. B. Observations and interviewsOn 2/6/23 at 12:48 a.m. resident was observed wearing no dentures and eating pudding. Resident #41 said her dentures went missing last week and she was struggling to eat her meals "which is why I'm eating pudding." She advised staff they were missing and was told they would look for them. She had not heard anything from the staff at this time. Resident #41 said she was worried about her teeth as they were expensive and she did not have the money to replace them. On 2/7/23 at 9:04 a.m. resident was observed in bed with her breakfast tray. She had no dentures in her mouth. Certified nurse aide (CNA) #1 was interviewed on 2/9/23 at 1:40 p.m. CNA #1 said Resident #41 had not had her dentures since last week and noted she had a decrease in appetite. She said Resident #41 had been complaining of gum pain recently and had reported it to the nurse. CNA #1 confirmed resident failed to have dentures at time of interview. The social service director (SSD) was interviewed on 2/9/23 at 3:20 p.m. The SSD said residents were offered ancillary services like dental once a month unless it was an emergent situation then the facility would send them out to a provider in the community. The SSD was unable to provide dental notes for Resident #41's last dental visit. She stated she was not aware of missing dentures until 2/7/23 and she had not made contact with an outside provider which was Resident #41's preference. The SSD was interviewed again on 2/9/23 at 3:55 p.m. she said she was able to obtain a dental visit for Resident #41 after the initial interview (see above) on 2/21/23. She was not able to say what the facility would be doing to aid Resident #41 until her dental appointment. C. Record reviewResident #41 medical record reviewed on 2/7/23 at 3:30 p.m. it failed to reveal:-Any documentation on when the resident last saw a dentist.-There were no progress notes in the social service section indicating knowledge of dentures missing.-There were no nursing progress notes indicating that the resident was having issues with eating related to mouth or denture concerns. On 2/9/23 at 10:28 a.m. the NHA provided a grievance form dated 2/6/23 where the resident had indicated that she was missing her dentures. The action taken according to the grievance form was the social worker had attempted to search the Resident #41's room. Resident #41 became agitated and stated she lost them at the last place. The social worker called the eye center the resident had visited on 2/3/23 but no dentures had been turned into the eye center. Social worker stated this was the last place other then the nursing facility resident #41 had been to. III. Additional informationThe NHA on 2/13/23 at 1:18 p.m. provided a social service note effective date 2/9/23 at 7:21 p.m. documenting the following in part, "social worker was notified on 2/7/23 that Resident #41 were missing dentures. She attempted to search Resident #41 room but the resident became agitated saying 'they are not here, I lost them at the other place.' Resident was unable to say where the other place was. Resident had recently had an appointment with an eye center. Center was called with no results in dentures located. Resident #41 dental offices of choice were contacted and an appointment was scheduled for 2/21/23."-However, the follow up was not done until identified during the survey, when the resident had been missing her dentures during the observations (see above) and had reported to the care staff.

Based on observations, record review and interview, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to have menu extension for the finger food diet, and had repetitive food items for the lacto-ovo-vegetarian (excludes meat except eggs and dairy) diet. Findings include:I. Finger foodsObservations during the survey revealed concerns that menu items served to residents with a therapeutic diet of finger foods, were not served finger foods. 2/15/23 noon mealThe two residents who had a diet type of finger food diet were served:-meatloaf with ketchup glaze-augratin potatoes-peas2/16/23 breakfast-oatmeal-cinnamon roll-scrambled eggs2/16/23 noon meal-chicken thighs with gravy-sweet potato souffle -brussel sprouts-apple cobblerReview of the February 2023 menu failed to show the facility had finger food extensions. The dietary manager (DM) and the regional manager were interviewed on 2/16/23 at 3:00 p.m. The DM confirmed the facility did not have menu extensions for finger food diets. The DM said the facility had only two residents who had that prescribed. The DM said that it was difficult to figure out what to serve as there was no direction. The regional manager confirmed the menus which were generated from the corporate office did not include the finger food diet. The DM agreed oatmeal, sweet potato souffle, au gratin potatoes and vegetables in juice did not constitute finger food items. II. Repetitive menuObservations during the survey revealed concerns that menu items were repetitive for the lacto-ovo-vegetarian diet. 2/6/23 noon meal-The menu called for veggie chicken patty2/6/23 dinner meal -The menu called for veggie chicken soft taco2/15/23 noon meal-The menu called for veggie beef patty with gravy2/15/23 evening meal-The menu called for a veggie beef patty2/16/23 -The menu called for veggie chicken pattyThe dietary manager (DM) and the regional manager were interviewed on 2/16/23 at 3:00 p.m. The DM confirmed the menu extensions for the lacto-ovo-vegetarian diet were repetitive. He said the beef veggie patty or the chicken veggie patty were the main items used for the vegetarian diet. The regional manager said she had noticed on 2/15/23 that the beef veggie patty was served for both the noon and dinner meal.

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to:-Ensure dispensed medications were administered in a sanitary manner;-Ensure multiple use equipment was sanitized between residents; and,-Ensure environmental service staff followed appropriate hand hygiene practices, ensure high touch areas were cleaned daily. Findings include:I. Professional referencesThe Disinfection of Medical Equipment, updated 5/24/19, retrieved on 2/13/22, from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html, documented in part. "Equipment; scissors, hemostats, clamps, blood pressure cuffs, stethoscopes should be disinfected with an EPA(Environmental Protection Agency)-registered disinfectant unless the item is visibly contaminated with blood; in that case a tuberculocidal agent (or a disinfectant with specific label claims for HBV and HIV) or a 1:100 dilution of a hypochlorite solution (500-600 ppm free chlorine) should be used. This procedure accomplishes two goals: it removes soil on a regular basis and maintains an environment that is consistent with good patient care."According to the Center for disease control (CDC) control and prevention, Hand Hygiene Basics retrieved on 2/13/23 from: http://www.cdc.gov/handhygiene/basics.html (2019), it read in pertinent part, "healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood,body fluids, or contaminated surfaces (even if gloves worn); and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in a healthcare settings)."According to the environmental cleaning procedures, reviewed 4/21/2020, retrieved on 2/13/22 from: https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html, documented in part, "At Least once daily or every 24 hours high touch surfaces are to be cleaned."II. Facility policyThe Medication Administration policy, undated, received from the nursing home administrator (NHA) on 2/8/23 at 1:43 p.m. revealed in pertinent part, "Medications are administered by a licensed nurse in a manner to prevent contamination or infection. Remove medication from source, taking care not to touch medication with bare hands."The Cleaning and Disinfection of Resident-Care Equipment policy, undated, received from the NHA on 2/9/23 at 4:47 p.m. revealed in pertinent part, "resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. Multiple-resident use equipment shall be cleaned and disinfected after each use."The Routine Cleaning and Disinfecting policy, undated, received from the NHA on 2/9/23 at 4:59 p.m. reveled in pertinent part, "it the policy of the facility to ensure the provisions of routine cleaning and disinfection in order to provide safe, sanitary environment to prevent the development and transmission of infection. Routine surfaces and disinfection will be conducted with detailed focus on visibly soiled surfaces and high touch areas to include: toilet flush handles, tray table, call buttons, tv remote, telephone, toilet seats, sinks, faucets, light switches, door knobs and handrails. Standard precautions will adhere when cleaning any blood or bodily fluid spills; hand hygiene and use of gloves, gown, mask eye protection or face shield."III. Medication not administered in a sanitary mannerA. ObsevationOn 2/8/23 at 9:55 a.m. registered nurse (RN) #1 was observed dispensing medication on the front hall medication cart. She dispensed two medications from blister packaging directly into her bare hand then transferred pills from her bare hand into a medication cup. RN #1 then went to a resident's room and administered medications. On 2/9/23 at 8:51 a.m. RN #2 was observed dispensing medication on the west hall medication cart. RN #2 was observed dispensing medication from a blister pack directly into her bare hand then into a medication cup. RN #2 dispensed medication from a house stock bottle directly into her bare hand. She dispensed too many medications into her bare hand and returned the un needed tablets back into the house stock bottle after they had touched her bare hand. RN #2 then added the tablet needed for administration into the medication cup with her bare hand. RN #2 then went to administer the medication to a resident. B. Staff interviewsRN #1 was interviewed on 2/8/23 at 2:19 p.m. RN # 1 said medication should not be touched by nurses bare hands when being dispensed. Touching medication with bare hands could cause contamination or spread of infection. Licensed practical nurse (LPN) #1 was interviewed on 2/8/23 at 2:29 p.m. LPN #1 said nurses were not to touch medication with their bare hands as it could spread infection or the medication could be harmful to the staffThe director of nursing (DON) was interviewed on 2/8/23 at 2:36 p.m. The DON said medications were not to be touched by bare hands at any time as it leads to the spread of infection. III. Multiple use equipmentA. ObservationsOn 2/8/23 at 8:39 a.m. RN #1 was observed taking a blood pressure and then holding the blood pressure cuff in her hand returning to the medication cart. She placed the unsanitized blood pressure cuff on top of the cart. -At 8:45 a.m. the blood pressure cuff was sitting on top of the medication cart, and it had not been sanitized as of yet.-At 8:51 a.m. RN #1 left the cart with the blood pressure cuff on the top of the cart, and she went to tend to a resident. Blood pressure cuff remained on the medication cart unsanitized.-At 10:06 a.m. RN #1 was observed exiting a resident room post medication administration with a blood pressure cuff used to take the resident's vital signs with. RN #1 returned to the medication cart and placed an unsanitized blood pressure cuff on the medication cart. RN # 1 sanitized her hands with alcohol based rub and began to prepare the next resident's medication. RN #1 took medications and the unsanitized blood pressure cuff to the next resident's room. RN #1 used the unsanitized blood pressure to measure the resident's blood pressure then administered medication to residents. RN #1 returned to the medication cart with the unsanitized blood pressure cuff and placed it on top of the medication cart and applied hand sanitizer to her hands.-RN #1 failed to sanitize the blood pressure cuff between residents. On 2/9/23 at 11:15 a.m. certified nurse aide (CNA) #1 and #3 were observed transferring a resident with use of the hoyer (mechanical) lift. CNA #1 was observed retrieving the hoyer lift from the storage room. CNA #1 did not sanitize the hoyer lift upon retrieval. She entered resident room with hoyer lift where CNA #2 waited with a resident who was already in a sling. After the hoyer lift was used, CNA #1 asked CNA #4 to return the hoyer lift to the storage area. -The hoyer lift was not sanitized after use for the resident transfer. B. Staff interviewsRN #1 was interviewed on 2/8/23 at 2:19 p.m. RN #1 said blood pressure cuffs were to be sanitized between residents. She acknowledged she failed to clean the blood pressure cuff between residents. RN #1 equipment should be sanitized to prevent the spread of infection. CNA #1 was interviewed on 2/9/23 at 1:40 p.m. CNA #1 said blood pressure cuffs and all vitals equipment were to be sanitized between residents. Hoyer lifts were to be wiped down with sanitizing wipes after each use. Sanitizing equipment prevented the spread of infection. CNA #3 was interviewed on 2/9/23 at 1:45p.m. CNA #3 said hoyer lift and vitals sign equipment were to be sanitized between residents to help prevent the spread of infection. CNA #4 was interviewed on 2/9/23 at 2:00 p.m. CNA #4 said hoyer lift and vitals equipment was to be sanitized after every use to prevent the spread of infection. The DON was interviewed on 2/9/23 at 4:39 p.m. The DON said multiple use equipment like blood pressure cuffs and hoyer lifts were to be cleaned between residents to prevent spread of infection. IV. Housekeeping A. ObservationsOn 2/9/23 at 11:45 am. housekeeper (HSK) #1 was observed cleaning a resident's room on the west hall. HSK #1 sanitized their hands with alcohol based hand rub then applied gloves, knocked on the resident's door and announced herself. HSK #1 collected thrasher from room and bathroom returning to cart in housekeeping cart just outside residents room. HSK#1 collected two rags that were pre soaked in a cleaning solution of Peroxide multi surface cleaner and disinfectant. One rag was placed on top of the bedside table for bed B. A second rag was used to wipe down the night stand from top to bottom, then HSK #1 took the rag placed on the bedside table and wiped down the bedside table including legs. A new rag was used to wipe down armoire in the room from top to bottom. HSK #1 returned to the cart and placed all used rags in the dirty section of the cart. She retrieved the Peroxide multi surface cleaner disinfectant in a spray bottle, entered the resident bathroom and sprayed the sink including facet and the toilet from top to bottom including inside the toilet bowl. She then indicated she had to wait three minutes for the surface disinfectant time. She returned chemical disinfectant to the cart and collected three more rags that were pre soaked in the peroxide multi surface cleaner disinfectant, ringing them out to remove excess liquid and the toilet brush. One towel was used to wipe down all the handrails in the bathroom. After three minutes, a second rag was used to wipe down the facet and the sink using a different side of the rag when touching the facet, the outside of the sink bowl and finally the inside of the sink bowl. She then collected a toilet brush and scrubbed the inside of the toilet bowl. She took the third rag and wiped the toilet from top to bottom including toilet lid and seat to the floor. HSK #1 returned toilet brush and dirty rags to cart. Wearing the same gloves, HSK #1 then collected the broom and swept the bathroom and then the main room sweeping all debris to the entrance of the room. She collected dry debris with a dustpan. She collected the mop stick and three pre soaked mopping pads. The mop pads were rung out to remove excess multi surface cleaner disinfectant above the same clean container they were removed from. One mop pad was used for the bathroom floor, removed and placed in a dirty section of the cart. A second mop pad was used for side B of the resident room and the third mop pad was used to clean side A of the resident room. Dirty mop pads placed into the dirty section of the cart. HSK #1 then removed the gloves from her hands and applied sanitizer to her hands. -HSK#1 failed to disinfect/clean the following high touch areas: door knobs to bathroom and room; call light;and bed control box.-HSK #1 failed to change gloves during the cleaning process. Wearing the same set of gloves from the beginning to end of room cleaning. Contaminating clean disinfectant solutions with touching products with dirty glovesOn 2/9/23 at 12:13 p.m. HSK #2 was observed cleaning a resident's room in the west hall. HSK#2 applied hand sanitizer and applied gloves. He knocked and announced himself, entered the room and collected trash from the room and bathroom. HSK #2 collected three pre soaked rags from the peroxide multi surface cleaner and disinfectant bucket and wring them out to remove excess fluid back into the clean bucket. HSK #2 wiped down all the handles to the main room door and bathroom using one rag with a clean section for each handle. He used a second rag to wipe down the bed A's night stand from top to bottom. A third rag was used to wipe down bed B's night stand and TV using a new section of the rag for each new item. HSK #2 returned the dirty rags to the cart, collected the peroxide multi surface cleaner and disinfectant in a spray bottle and the toilet bowl brush housed in a container. He entered the restroom and set the toilet bowl brush on the floor in a container. HSK #2 sprayed the sink inside and out including the faucet, the toilet outside and inside the bowl. Immediately after spraying the toilet, HSK #2 began scrubbing the inside toilet bowl with the toilet brush. He returned the toilet brush to the cleaning cart. Using the same gloves, he removed two pre soaked rags from the peroxide solution, wringing out the excess fluid back into the clean solution. HSK #2 returned to the bathroom and cleaned the sink with one rag from inside the sink bowl to the outside of the sink, then cleaned the faucet using a clean section of the rag as he progressed. He then took the second rag and cleaned the outside of the toilet from top to bottom including the toilet lid and seat using a clean section of the rag for each new area. HSK #2 returned to the cleaning cart with dirty rags placed into the soiled bag. Wearing the same gloves, he collected the broom and dustpan, sweeping the bathroom first and collecting debris then sweeping the main room bringing all debris to the entrance of the room, collected debris in the dustpan. HSK #2 then returned the broom and dustpan to the cart, emptying the dustpan into the trash section on the cart. Using the same gloves he removed three mopping pads from the peroxide multi surface cleanser and disinfectant bucket. He wrung out the excess cleaner back into the bucket he removed the mop pads from. He took the mopping stick and entered the resident room. HSK #2 dropped a mop pad on bed A's side of room, Bed B's side of the room and the third was dropped in the bathroom. HSK #2 started mopping in the bathroom first. He removed the mop pad he used in the bathroom and then mopped bed B's side of the room with the new mop pad, then removed the mop pad. He completed mopping the residents room on bed A's side. He returned the mop handle and all dirty mop pads to the cart. He placed a wet floor sign at the entrance of the room. HSK #2 removed his gloves and applied hand sanitizer to hands. -HSK #2 failed to disinfect the following high touch areas in the residents room: call light; bed control; and bedside table.-HSK #2 failed to change gloves after cleaning the toilet and prior to removing clean rags or mopping pads from clean solution containers/buckets leading to contamination of clean solutions. -HSK #2 failed to allow the disinfectant to sit on the surface for three minutes after spraying the toilet. B. Staff interviewsHSK #1 was interviewed on 2/9/23 at 12:04 p.m. HSK #1 acknowledged she did not change gloves when cleaning the residents room and wore the same pair of gloves even after cleaning the toilet. She was unable to identify high touch areas when asked or how often these high touch areas were to be cleaned. HSK #1 acknowledged that she failed to clean the call light, bed control and door knobs to the room and bathroom. HSK #2 was interviewed on 2/9/23 at 12:32 p.m. HSK #2 said high touch areas in the resident rooms were handrails, door knobs, dressing knobs and bedside tables. He said he was unable to clean this resident's bedside table as there was a banana on the table, staff was not allowed to clean the table if there was food present. When asked if he cleaned the call light or the bed function control he acknowledged he did not clean those areas but should have as they were a high touch surface requiring more frequent disinfection or cleaning. HSK #2 said there was no surface disinfectant time when using the Peroxide multi surface cleaner and disinfectant solution which was why he started scrubbing the toilet bowl immediately after spraying it. HSK #2 said he did not change his gloves while cleaning the room since he cleaned from the cleanest to dirtiest areas. The housekeeping supervisor (HSKS) was interviewed on 2/9/23 at 12:37 p.m. The HSKS said high touch areas like: door knobs; bedside tables; call lights; and bed controllers were all considered high touch areas and should be cleaned daily. The HSKS said there was a three minute surface disinfectant time on the peroxide multi surface cleaner. Housekeepers were to change their gloves at the following intervals between bed A and bed B sides of the room, and after cleaning the bathroom with hand sanitization occurring between changing gloves. The HSKS said staff education would be reviewed in order to correct the failures (see observations above).

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for four (#26, #27, #41 and #42) of five residents reviewed for immunizations out of 37 sample residents. Specifically, the facility failed to provide the pneumococcal 23-valent polysaccharide vaccine (PPSV23) to Resident #26, #27, #41 and #42. Findings includeI. Professional referenceAccording to to the Centers for Disease COntrol (CDC) Adult immunization schedule by age, retrieved on 2/15/23 from: https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo, revealed in pertinent part "anyone over the age of 65 who have received the PCV13 should receive a dose of PCV20 at least one year after the PCV13 or complete the recommended PPSV23 series."II. Facility policyThe Pneumococcal vaccine (series) policy, undated, was received from the nursing home administrator (NHA) on 2/9/23 at 4:39 p.m. It read in pertinent part, "it is our policy to offer our residents, staff and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines. Each resident will be assessed on admission for pneumococcal immunization. Residents will be offered pneumococcal immunization unless medically contraindicated or the resident already has immunization. Types of pneumococcal vaccines offered will depend upon the recipients age and susceptibility to pneumonia, in accordance with current CDC guidelines."III. Record reviewA. Resident #26Resident #26, age 76, admitted on 6/17/19. According to the February 2023 computerized physician orders (CPO) diagnosis include bronchopneumonia, chronic obstructive pulmonary disease, and respiratory failure. The 1/13/23 minimum data set (MDS) assessment documented the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS assessment indicated the resident was up to date on pneumococcal vaccine. Immunization record revealed Resident #26 had received Prevnar13 on 12/27/17.-Immunization record failed to show a second dose within a year or completion of Prevnar 23 series.-No consent or refusal for vaccinations concerning pneumococcal vaccine found in electronic medical record for Resident #26B. Resident #27Resident #27, age 88, admitted on 5/15/17. According to the February 2023 CPO diagnosis include dementia, anxiety disorder, and hypertension. The 10/4/22 MDS assessment documented the resident was severely cognitively impaired with a BIMS score of one out of 15. The MDS assessment indicated the pneumococcal vaccine was up to date. Immunization record revealed Resident #27 received Prevnar 13 on 1/4/18.-The resident's record failed to reveal a second dose or Prevnar 23 series being administered.-No consent or refusal for vaccinations concerning pneumococcal vaccine found in electronic medical record for Resident #27C. Resident #41Resident #41, age 83, admitted on 5/26/22. According to the January 2023 computerized CPO the diagnosis included dysphagia (difficulty swallowing), cor pulmonale (heart failure), peripheral vascular disease (circulation disorder), acute and chronic respiratory failure (difficulty breathing). The 11/23/22 MDS assessment revealed the resident had a moderately impaired cognition with a BIMS score of ten out of 15. The MDS assessment indicated the pneumococcal vaccine was up to date. Immunization record revealed Resident #41 had received the Prevnar 13 on 12/26/19.-The resident's record failed to reveal a second dose or Prevnar 23 series being administered.-No consent or refusal for vaccinations concerning pneumococcal vaccine found in electronic medical record for Resident #41D. Resident #42Resident #42, age 89, admitted on 3/9/22. According to the February 2023 CPO diagnosis include chronic kidney disease, congestive heart failure, and bipolar. The 12/22/22 MDS assessment documented the resident moderately impaired cognition with a BIMS score of 11 out of 15. The MDS assessment indicated the pneumococcal vaccine was up to date. Immunization record revealed the resident had received Prevnar 13 on 6/4/15.-The resident's record failed to reveal a second dose or Prevnar 23 series being administered.-No consent or refusal for vaccinations concerning pneumococcal vaccine found in electronic medical record for Resident #42IV. Staff interviewsThe director of nursing (DON), the infection preventionist (IP) for the facility, was interviewed on 2/9/23 at 4:39 p.m. The DON said the nursing staff are to review the resident immunizations on the resident's admission and offer vaccines if indicated. The facility was able to offer different types of vaccinations like flu, COVID and pneumococcal if needed. The immunizations had to be ordered by a physician and supply ordered from the pharmacy. The DON reviewed Resident #26, #27, #41 and #42's immunization records and acknowledged that all four residents were missing second doses after receiving Prevnar 13. She was unable to determine if the above residents had been offered pneumococcal vaccinations on admission.