Cedar Pointe

Inspectors wroteBased on interview and record review, the facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility staff failed to ensure indoor and outdoor waste containers remained covered when not in actual use. This failure has the potential to affect all facility occupants. The facility census was 65.1. Observations on 02/10/26 at 10:15 A.M. and 1:15 P.M., showed the lids to the outside dumpster, which contained waste, opened and the area unattended by staff. Observation on 02/11/26 at 9:00 A.M., showed the lids to the outside dumpster, which contained waste, opened and the area unattended by staff. Observations on 02/12/26 at 9:15 A.M., showed the lids to the outside dumpster, which contained waste, opened and the area unattended by staff. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required telephone number to the Department of Health and Senior Services (DHSS) hotline (to report allegations of abuse and neglect), or a list of names, address, phone numbers of the State Survey Agency (SA) and the name, address and phone number for the for the Long-Term Ombudsman in an accessible location for residents and visitors to view in the memory care unit. The census was 65. 1. Review of the facility's policies showed staff did not provide a policy for the required postings. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to review and revise the plan of care with changes in the resident's needs for three residents (Resident #2, #22 and #50) out of 24 sampled residents. The facility census was 65.1. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use enhanced barrier precautions ((EBP) infection control intervention designed to reduce transmission of multi-drug-resistant organisms) and/or failed to have EBP signs posted for three residents (Resident #14, #63, and #77) out of three sampled residents. The Facility Census was 65.1. Review of the facility's policy titled, Enhanced Barrier Precautions, undated, showed EBP involves gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multidrug-resistant organisms (MDRO) as well as those at increased risk of MDRO acquisition like residents with wounds or indwelling medical devices. The gown and gloves will be outside the resident room for the staff to dawn before entering the room and staff will doff inside the room before exiting.2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #1) out of one sampled resident did not receive a chemical restraint (medications used to sedate or control behavior) as a convenience to treat behaviors. The facility census was 62. The administrator was notified on 04/04/25 of past Non-Compliance which occurred on 03/28/25. Staff immediately suspended Licensed Practical Nurse (LPN) A, assessed the resident for injuries, and notified the required parties and agencies. The administrator immediately in-serviced all staff on medication administration and abuse and neglect policies and procedures. The deficiency was corrected on 03/31/25. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide services to meet professional standards when staff failed to document the controlled substance administered for one resident (Resident #2) and failed to complete shiftly controlled drug counts on the memory care unit. The facility census was 62. 1. Review of the facility's policy, Narcotics Count Change of Shift Policy dated 01/04/23, showed staff are directed as follows: -Narcotics must be counted with the Nurse/Certified Medical Technician (CMT) at the change of shift. The Nurse/CMT must count the total number of cards/packages and note total on count sheet. Each card/package must be counted to ensure that the total number of narcotics is accurate and matches the total number of narcotics in the card/package. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for two residents (Resident #1 and #2) out of five sampled residents. The facility census was 64. 1. Review of facility's Care Planning Policy and Procedure policy, dated 01/17/24, showed facility staff are directed as follows: -The facility's standard is to perform quality of care that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices; [...]

Inspectors wroteBased on interview and record review, facility staff failed to prevent the misappropriation of three resident's (Resident #1, Resident #2, and Resident #3's) narcotic medications when Licensed Practical Nurse (LPN) A took the medication without authorization of the residents or the residents' responsible parties. The facility census was 67. 1. Review of the facility's Abuse Policy and Procedures/Investigation Protocols, dated 12/14/18, showed the facility defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belonging or money without the resident's consent. 2. Review of the facility's investigation, dated 9/20/24, showed the ADON was notified LPN A displayed suspicious behavior on his/her shift. When the ADON arrived he/she observed the behaviors and issued LPN A a drug test with Human Resources (HR). [...]

Inspectors wroteBased on interview and record review, facility staff failed to contact one resident's (Resident #4's) responsible party when the resident passed away at the facility. The facility census 67. 1. Review of the facilty's Discharge of a Resident due to death policy, undated, showed staff are instructed to notify the family or the responsible party. 2. Review of Resident #4's Entry Minimum Data Set (MDS), a federally mandated assesment tool, dated 9/21/24, showed staff assessed the resident as: -admitted to the facility 9/21/24; -Diagnosis of skin cancer of scalp and neck, liver cancer with bile duct involved, rectal cancer, and throat cancer; -Received hospice services. Review of the residents nurses notes, dated 9/26/24, showed staff documented the resident passed away at 8:02 A.M. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to provide staff in accordance with their Facility Assessment based on the care needs of their residents. The facility census was 70. 1. Review of the Facility Assessment, dated 04/10/24, showed facility staff documented the staffing requirements needed on a 24-hour basis to meet the needs of their residents for an average census of 70-80 are as follows: -West Unit: Registered Nurse (RN) or Licensed practical nurse: 1 for each shift; -East Unit: Registered Nurse (RN) or Licensed practical nurse: 1 for each shift. 2. Review of the facility night shift staff schedule for the west and east area of the facility, dated 04/20/24 through 04/30/24, showed the facility scheduled only one LPN and did not have an addition LPN or RN to staff the west and east location from 04/06/24-04/30/24 as directed in the facility assessment. 3. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week. The facility census was 70. 1. Review of the facility's Resident Services Policy, dated March 27, 2017, showed the facility provides sufficiant licensed nursing and ancillary services 24 hours a day, including a registered nurse for at least 8 consecutive hours daily. 2. Review of the facility's RN staff schedule, dated June 2024, showed the facility did not have an RN in the building on: -06/01/24; -06/02/34; -06/08/24; -06/09/24; -06/15/24; -06/16/24; -06/22/24; -06/23/24; -06/29/24; -06/30/24. 3. Review of the facility's RN staff schedule, dated July 2024, showed the facility did not have an RN in the building on 07/06/24 and 07/07/24. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria. Facility staff failured to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems has the potential for the failure of staff to identify and mitigate the presence of waterborne pathogens, which places all residents of the facility at risk of exposure which could lead to illness. [...]

Inspectors wroteBased on interview and record review, facility staff failed to designate one or more individuals with specialized training in Infection Prevention and Control (IPC) as the Infection Preventionist for the facility's infection prevention and control program. The facility census was 70. 1. Review of the facility policies showed staff did not provide a policy for specialized training for the Infection Preventionist. During an interview on 07/18/24 at 3:50 P.M., the administrator said the Assistant Director of Nursing (ADON) is the facility's Infection Preventionist. He said the ADON started the required classes sometime last month, but he is not sure how much longer she/he has. The administrator said he was aware the training and certification needed to be completed before given the position or title of Infection Preventionist. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to review and revise the care plan after a fall for five (Resident #13, #21, #36, #44, and #52) out of eighteen sampled residents. Facility staff failed to document and update care plans in regard to pressure ulcers for two (Resident #5 and #44) out of seven sampled residents. Staff failed to address and update behaviors for one (Resident #4) of one sampled resident. The facility census was 70. 1. Review of the facility's Miniumin Date Set (MDS) Policy, undated, showed the care plans will be updated quarterly and with changes to the resident plan of care. Changes made to the care will be communicated to the interdisciplinary team. The staff member completing the care are assessment for the specified section will also compete the comprehensive care plan on the resident. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement their Grievance Policy for two residents (Resident #7 and #25) out of 18 residents when reported missing items and failed to maintain evidence demonstrating the results of all grievances for a period of no less than three years. The facility census was 70. 1. Review of the facility's Grievance policy, dated 09/13/19, showed: -A grievance will be translated into writing, containing the name and address of the person filing it if permitted; -The administrator or his/her designee shall conduct an investigation of the complaint; -The Grievance official will complete a review of the grievance no later than 30 days after its filing. The Resident has the right to obtain a written decision regarding his/her grievance; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to thoroughly investigate and document bruises of unknown origin for one resident (Resident #15) out of one sampled residents as directed by the facility policy. The facility census was 70. 1. Review of the facility's Abuse Policy and Procedures/Investigation Protocols, dated December 14, 2018, showed an injury of unknown source defined as not witnessed by any person and the source of the injury could not be explained by the resident, and the injury raises suspicions of possible abuse or neglect because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain professional standards of practice when staff did not complete neurological assessments for for three residents (Resident #7, #21, and #36) out of 18 sampled residents after unwitnessed falls. The facility census was 70. 1. Review of the facility's policy titled, Neurological Assessments, undated, showed when resident has an incident with a head injury/trauma, or an unwitnessed fall, the nurse is the perform neurological assessment. Review showed the nurse is required to: -Document the results on the neurological assessment flow sheet in the resident's chart; -Complete checks-Every 15 minutes for one hour, every 30 minutes for the next two hours, and every shift until the 72 hours are completed; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label medications in a safe and effective manner when staff failed to date the open multi-dose medication bottles, and placed non-medication in medication storage room refrigerator. The facility census was 70. 1. Review of the facility's Storage of Medication policy, undated, showed facility staff are directed as follows: -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; -Medications require refrigeration must be store in a refrigerator located in the drug room at the nurses' station or other secured location. -Medications must be stored separately from food and must be labeled accordingly. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure six (Resident #7, #8, #10, #21, #24, and #25) out of 18 residents have appropriate access to their trust fund account to include on the weekends. The facility census was 70. 1. Review of facility policy titled, Resident Funds/Money, dated 05/18/22, showed facility staff were to maintain a written account of all the resident's funds. Residents who have a trust account have access to their funds Monday through Friday, between 9:00 A.M and 4:00 P.M., excluding holidays. Residents who would like funds for the weekend can obtain funds on Friday before end of day. Depending on resident circumstances/financial necessity, staff may notify administration. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet the residents' interest on the weekends for three (Resident #10, #21, and #25) out of 18 residents. The facility census was 70. 1. Review of the facility's policy titled, Activity Department, dated 08/17/21, showed the facility to have an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities will provide one on one to any resident that do not want to participate in group activities or are not able to attend group activities. Review of the facility's Activity Calendar, dated June, 2024, showed: -Saturday, 06/01/24; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain personal medical information in a manner to protect three residents' privacy (Residents #1, Resident #2, Resident #3). The facility census was 77. 1. Review of the facility's Resident Confidentiality/Health Insurance Portability and Accountability Act (HIPPA), undated, showed the care of the patient is always personal in nature, and therefore any protected health information about his/her condition, treatment or personal data is absolutely confidential and must not be discussed with anyone other than those who are directly responsible for his/her care and treatment. Information generated through contact between patient and health care provides at the facility is privileged and confidential. [...]

Inspectors wroteBased on interview and record review, facility staff failed to follow professional standards when they failed to destroy narcotics with two staff present according to policy for one resident (Resident #4), failed to maintain documentation of a controlled substance destruction sheet for one resident (Resident #5), and failed to remove medications as directed from the ISTAT. The facility census was 77. 1. Review of the facility's Controlled Substances policy, revised October 2014, showed staff are to document the disposal on the medication disposition record, (the medication disposition record will contain the following information: method of disposition, reason for disposition and signature of witnesses). Review showed the documentation should include the signature(s) of at least two witnesses. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when to staff failed to properly store medications. The facility census was 77. 1. Review of the facility's Administering Medications Policy, revised December 2012, showed staff are directed during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. 2. Observation on 2/28/24 at 9:57 A.M., showed Certified Medication Technician (CMT) A left the medication cart unlocked and unattended in the hall, with his/her keys in the lock. Observation showed CMT A returned to the medication cart and retrieved the keys but did not lock the cart. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide an ongoing program of activities designed to meet residents' interests, for four (Resident #1, #2, #3, and #4) and on the weekend. The facility census was 75. 1. Review of the facility's Activity Department Policy, dated 8/17/21, showed: -The facility will provide, based on the comprehensive assessment and care plan and the preference of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to monitor one resident (Resident #220) they assessed as an unsafe smoker who used a vaping device (electronic cigarette/nicotine). Staff failed to plan and implement measures to ensure the resident's safety. Staff failed to prevent the resident from using a vape device while wearing oxygen and from keeping vape devices in his/her room. The facility census was 69. The administrator was notified on 4/4/23 at 4:15 P.M., of an Immediate Jeopardy (IJ) which began on 4/4/23. The IJ was removed on 4/7/23, as confirmed by surveyor onsite verification. 1. Review of the facility's Smoking/Vaping policy, undated showed: [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to maintain thermometers in the resident room refrigerators, clean vents over resident tables in the dining room, and ensure the ice machine drained through an air gap. This failure had the potential to affect all residents. The census was 69. 1. Review of the facility's Food Storage: Refrigeration in Resident Rooms policy, undated, showed: - Internal thermometers shall be placed in the front section of each unit and shall be large enough for easy visibility; - Refrigeration temperatures shall be maintained below 40 degrees, with a preferred temperature of 36-38 degrees for maximum chilling; - Refrigerator temperatures in residents' rooms shall be monitored daily to ensure the temperature is within the specified range; - The policy did not address documenting refrigerator temperatures; [...]

Inspectors wroteBased on interview and record review, facility staff failed to follow-up with a written response to grievances. The facility census was 69. 1. Review of the facility's Resident Rights policy, dated January 5, 2017, showed: - Residents have the right to organize and participate in resident groups in the facility; - The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings; - The facility must consider the views of a resident or family group and act promptly upon the grievance and recommendations of such groups concerning issues of resident care and life in the facility. Review of the Resident Council minutes, dated January 18, 2023, showed the council had the following concerns: - Television channels do not work. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident rooms were clean and free of needed repairs and the dining experience was free from odors. The facility census was 69. 1. Review of the facility's Homelike Environment policy, dated May 2017 showed: -Residents are provided with a safe, clean comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; -The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting which include a clean, sanitary and orderly environment, and pleasant, neutral scents. Review of the policies provided by the facility showed they did not provide a policy or procedure to manage or report environmental repairs. 2. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide written information to the resident and/or resident's representative of the facility's bed hold policy at the time of transfer to the hospital for three residents (Residents #13, #26, and #64). The facility census was 69. 1. Review of the facility's Hospital Transfer and Bed Hold Policy, undated, showed a copy of the policy will be sent with other papers accompanying the resident to the hospital. The bed hold policy represents the bed hold letter. 2. Review of Resident #13's medical record showed the cognitively impaired resident was transferred to the hospital on 1/27/23 and 2/02/23. Staff did not document they notified the resident or the resident's representative of the facility's bed hold policy. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to complete the required Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for five sampled residents (Residents #53, #58, #219, #221, and #225). The facility census was 69. 1. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI OBRA-required Assessment Summary showed assessment time frames as follows: -Entry MDS completion date no later than the 7th calendar day from the resident's entry into the facility and submitted no later than 14 days from the date of entry into the facility; -admission (Comprehensive) MDS completion date no later than 14th calendar day of the resident's admission and submitted no later than 14 calendar days from the care plan completion date; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs when staff failed to address catheter care for one resident (Resident #26), failed to address dressing assistance, toileting assistance, and restorative services for one resident (Resident #35), failed to address smoking, personal hygiene preferences and oxygen for one resident (Resident #220), failed to address falls, personal hygiene preferences, pain and edema (swelling of the limbs) and antidepressant use for one resident (Resident #221), failed to address advanced directives and personal hygiene preferences for one resident (Resident #222) and failed to address the use of an antipsychotic and intravenous antibiotics for one resident (Resident #227). The facility census was 69. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide thorough orders, monitoring, and ongoing communication with the dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) facility for two out of two residents (Residents #11 and #17) who received services at the dialysis facility. The census was 69. 1. Review of the facility's Dialysis policy, dated 9/2017, showed the following: -The facility will ensure that residents who require dialysis will receive such services, consistent with professional standard of practice, the comprehensive person-centered care plan, and the residents' goal and preferences; -Professional standards of practice include: [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN) for at least eight (8) consecutive hours per day, seven days a week. The facility census was 69. 1. Review of the facility's Nursing Staff schedule, dated 3/27/23 through 4/6/23, showed staff did not document an RN was scheduled to work on 3/27/23 through 4/6/23. Review of the facility's RN staff time sheets, dated 3/1/23 through 4/6/23, showed the hours worked between the three facility RNs as follows: -The Director of Nursing (DON), not responsible for direct resident care, Monday through Friday, 8 hours per day, he/she did not work on Saturday or Sunday; -The RN Educator worked Monday through Wednesday, averaging at least 8 hours per day. He/She worked 7 hours on Saturday 3/4, 1 hour on Saturday 3/11, 5 hours on Saturday 3/18, and 2 hours on Saturday 3/25. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure medication regimens were free from unnecessary medications when staff failed to obtain an appropriate diagnosis for the use of psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) for three residents (Residents #15, #30 and #226). The facility census was 69. 1. Review of American Geriatrics Society (AGS) 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults showed: -Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (e.g., behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manner in one of two medication storage carts, and two of two medication storage rooms. The facility census was 69. 1. Review of the facility's policy Medication Storage & Labeling Policy, undated, showed staff are directed as follows: - Medication must be stored in a clean, dry environment behind a single lock; - Expiration dates must be checked prior to administration. Expired medications are removed from the area of care immediately, and disposed of according to the facility medication disposal policy, per state and federal guidelines. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to change their gloves and/or perform hand hygiene during perineal care for one resident (Resident #44), and failed to sanitize or clean a mechanical lift (mechanical device used to lift and transfer residents) after use for two residents (Resident #56 and one unknown resident). The facility census was 69. 1. Review of the facility's Infection Control and Prevention Guidelines, undated, showed the following: -Wash hands before and after procedures and before and after resident contact; -Wear sterile or clean gloves when appropriate; -Maintain sterility or cleanliness of the equipment and working field as necessary; -Clean all equipment and return to appropriate storage area; [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against pneumococcal (infection caused by bacteria) pneumonia in accordance with national standards of practice for five (Residents #32, #47, #56, #63 and #219) sampled residents. The facility also failed to ensure two residents (Resident #63 and #219) of five sampled were offered the flu vaccine. The facility census was 69. 1. Review of the facility's Vaccination of Residents policy, undated, showed: -All new residents shall be assessed for current vaccination status upon admission; -If vaccines are refused, the refusal shall be documented in the resident's medical record; -The pneumococcal vaccine will be offered to the residents of the facility; -The policy did not provide a timeline for offering the pneumococcal vaccine. [...]

Inspectors wroteBased on interview and record review, facility staff failed to maintain and follow current guidance and procedures for immunizations of residents against Covid-19 for five (Residents #32, #47, #56, #63 and #219) sampled residents. The facility census was 69. 1. Review of the facility's Vaccination of Residents policy, undated, showed: -All new residents shall be assessed for current vaccination status upon admission; -If vaccines are refused, the refusal shall be documented in the resident's medical record; 2. Review of Resident #32's medical record showed: -Most recent admission date of 1/27/23; -The record did not contain documentation the resident received, refused, or was offered the Covid-19 vaccine. 3. Review of Resident #47's medical record showed: -Most recent admission date of 11/01/21; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the telephone number for the Department of Health and Senior Services (DHSS) Adult Abuse and Neglect Hotline (used to report allegations of abuse and neglect) in a form and manner accessible to all residents and visitors. The facility census was 69. 1. Review of the facility policies showed the facility did not provide a policy for the required postings. Observation of the facility from 4/4/23 at 10:00 A.M. through 4/10/23 at 12:00 P.M., showed the facility did not post the name, address, and toll free telephone number for the Adult Abuse and Neglect Hotline in an accessible location for residents and visitors to use if needed. During an interview on 4/10/23 at 9:25 A.M., Certified Nurse Aide (CNA) D said the abuse and neglect hotline is posted by the time clock and the breakroom. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to include the resident census on the required nurse staffing information, which is posted daily in the facility. The facility census was 69. 1. Review of the facility's Staff Hour Posting Policy, dated January 2023, showed it did not contain direction to post the daily census. Review of the facility's Staff Hour Posting sheets from 3/27/23 through 4/6/23, showed they did not contain the daily census. Observation on 4/4/23 at 12:49 P.M., showed the Administrator posted the Staff Hour Posting sheet at the front entrance. Observation from 4/4/23 at 10:00 A.M. through 4/10/23 at 12:00 P.M., showed the nurse staff posting at the front entrance did not include the facility census. [...]