**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents' code statuses were listed in the chart, care planned and up to date with the most accurate information for four residents (Resident #1, #16, #65 and #101) out of 19 sampled residents. The facility census was 92.Review of the facility’s policy, “Advanced Directives-Missouri, revised on [DATE], showed: - Individuals have the right to make decisions concerning their care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives as permitted under state statutory and case law; - It is the policy of this facility to follow the directions given by each resident with regard to accepting or refusing medical or surgical treatment to the extent permitted by law; - At the time of admission as a resident of the facility, the resident or their legal representative will be provided with information on Advance Directives; - There shall be documented in the resident’s medical record whether the resident has executed any advanced directives, and copies shall be made a permanent part of the resident’s medical record; - The resident’s attending physician shall be timely notified by the Director of Nursing (DON) or designee if the resident has any advanced directives and requested to write appropriate orders; - If a resident is being readmitted to the facility as a resident, and previously provided copies of advance directives, they shall be verified as being current to this admission; - It is the responsibility of the Administrator to review the advance directives of each resident and to instruct all employees of the facility with regard to each resident’s advanced directives and any related physician’s orders. 1. Review of Resident #1's medical record showed: - admitted on [DATE]; - The Physician's Order Sheet (POS), with an order, dated [DATE], for Full Code; - Care Plan, last revised, [DATE], with Do Not Resuscitate (DNR-revive from potential or apparent death) interventions; - A full code status sheet signed on [DATE]. 2. Review of Resident #16’s medical record showed: - admitted on [DATE]; - No code status listed next to the resident’s name in the facility's online charting system for electronic health records; - No code status listed on the POS, last order review [DATE]; - No code status listed on the care plan, initiated on [DATE] and revised on [DATE]. 3. Review of Resident #65’s medical record showed: - admitted on [DATE]; - No code status listed next to the resident’s name in the facility's online charting system for electronic health records; - No code status listed on the POS, last order review [DATE]; - Full code listed on the care plan, date initiated [DATE], last revised [DATE]. 4. Review of Resident #101's medical record showed: - admitted on [DATE]; - The POS, with an order, dated [DATE], for Full Code; - Care Plan, undated, with DNR interventions; - No signed documentation for code status. During an interview on [DATE] at 5:40 P.M., Licensed Practical Nurse (LPN) L said that code statuses are listed on the POS, on the front screen of the electronic medical record when you search by resident’s name, and in their care plans. He/She also said there is a book with residents’ names and code statuses at the nursing station, but isn’t for sure where it is. During an interview on [DATE] at 5:43 P.M., Certified Medication Technician (CMT) N said code statuses are in the electronic medical record and in a book at the Nurse’s station, but he/she doesn’t know where the book is. During an interview on [DATE] at 8:25 P.M., the Administrator and Director of Nursing (DON) collectively said they would expect residents to have a code status order and the code status to be documented consistently throughout the chart.

Based on interview and record review, the facility failed to follow appropriate discharge procedures by not completing a discharge recapitulation or documentation of the reason for discharge by the physician for one resident (Resident #96) out of three closed record reviews. The facility census was 92. Review of the facility's Transfer/Discharge, Immediate Discharge and Therapeutic Leave policy, last reviewed 06/12/25, showed:- The facility may discharge or transfer a resident if needs can not be met;- Resident no longer needs the service provided by facility;- The safety of individuals in facility is or would be endangered;- The resident failed, after reasonable and appropriate notice, to pay for stay at facility;- The facility ceases to operate;- When resident is transferred or discharged due to welfare and needs can not be met or health has improved, the attending physician must document in medical record, the reason for transfer/discharge, specific needs the facility could not meet, specific services the receiving facility will provide to meet those needs;- When resident is transferred or discharged due to safety or health of individuals in facility being endangered, a physician must document the reason for transfer and discharge;- When a resident is discharged or transferred, the Interdisciplinary Discharge Summary (recapitulation) must be completed. Review of Resident #96's medical record showed:- admission date of 06/03/25;- Diagnoses of dementia (a group of thinking ad social symptoms that interfere with daily functioning), Parkinson's disease (a disorder of the central nervous system that affects movement and often including tremors), Alzheimer's (a progressive disease that destroys memory and other important mental functions), disorientation (a state of confusion), and bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the undated, unsigned and incomplete Discharge Recapitulation showed:- Reason for discharge was inappropriate behaviors and elopement risk;- Resident discharged to another facility. Review of the resident's Progress Notes on 07/21/25 showed medication had been given. No discharge notes. Review of the discharge Minimum Data Set (MDS-a federally mandated assessment completed by the facility), dated 7/22/25, showed discharge to hospital with return anticipated. During an interview on 08/07/2025 at 6:50 P.M., the Administrator said Resident #96 had been exit seeking, had said something to another resident that had scared them, and it was decided, along with Resident #96's family member, that he/she should be moved to a different facility and that is what happened. There was no documentation of this. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) said they would expect a recapitulation of stay to be completed and a progress note to be completed at the time of discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing, of a transfer or discharge to a hospital, for four residents (Resident #1, #6, #16 and #65) and failed to complete a discharge summary that included a recapitulation of the resident's stay that consisted of but not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for one resident (Resident #98) out of 19 sampled residents. The facility census was 92.Review of the facility's Transfer/Discharge and Therapeutic Leave Policy, last reviewed on 06/12/25, showed:- Residents sent emergently to the hospital are considered transfers because the resident's return is generally expected;- Before any resident is transferred or discharged , the facility must notify the resident and the resident's representative, the reason for transfer or discharge in writing, in a manner they understand;- The written notice shall include reason for transfer, effective date of transfer and location to which resident is transferred or discharged ;- When a resident is transferred to the hospital or other location, the facility must provide to the resident or legal representative, a written copy of the bed hold policy;- When a resident is discharged or transferred, the Interdisciplinary Discharge Summary (recapitulation), must be completed. Review of the Bed Hold Policy, last reviewed 06/12/25, showed:- When resident is discharged to the hospital or goes on therapeutic leave, the facility will provide to the resident or legal representative, a copy of the bed hold policy;- If a resident was transferred with the expectation of returning to the facility and the resident cannot return, the facility must follow requirements for a discharge. 1. Review of Resident #1's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE] and returned to the facility on [DATE];- No documentation that written notification was provided to the resident and/or the resident representative at the time of transfer. During an interview on 08/07/25 at 10:33 A.M., the Director of Nursing (DON) said a transfer and bed hold had not been sent because resident went out as an emergency. 2. Review of Resident #6's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE] and had not yet returned on 08/07/25;- No documentation that written notification was provided to the resident and/or the resident's representative at the time of transfer. During an interview on 08/07/25 at 7:07 P.M., the DON said there was not a bed hold/transfer sheet completed for the resident. 3. Review of Resident #16's medical record showed:- admitted on [DATE];- Transferred to the hospital on [DATE], and returned to the facility on [DATE];- No documentation that written notification was provided to the resident and/or the resident's representative at the time of transfer. 4. Review of Resident #65's medical record showed: - admitted on [DATE];- Transferred to the hospital on [DATE] and returned to the facility on [DATE];- No documentation that written notification was provided to the resident and/or the resident's representative at the time of transfer. 5. Review of Resident #98's medical record showed:- admitted on [DATE];- discharged home on [DATE], as therapy goals had been met;- No recapitulation of stay. During an interview on 08/07/25 at 1:15 P.M., the DON said she is not sure who was responsible for the bed holds, transfers and discharges since the new owners took over. During an interview on 08/07/25 at 8:25 P.M., the Administrator and DON said they would expect a notification of transfer and bed hold to be given to the resident and/or resident's representative in writing when discharged to the hospital. The discharged residents should have a recapitulation of stay along with a progress noted completed with the reason for discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS-a federally mandated assessment completed by the facility staff) for five residents (Resident #2, #26, #39, #93 and #96) out of 19 sampled residents. The facility census was 92. Review of the facility's “MDS 3.0, Care Assessment Summary and Individualized Care Plans” policy, last reviewed 11/06/23, showed (The MDS 3.0) is an assessment tool that addresses the wholistic person, including functional status, quality of life, and individual plan of care to address and meet needs of the individual resident. 1. Review of Resident #2's medical record showed: - admission date of 05/15/25; - Diagnoses of Tracheoesophageal Fistula (an abnormal connection between the esophagus and trachea), bipolar disorder (a disorder with episodes of mood swings ranging from depressive lows to manic highs), chronic kidney disease (longstanding disease of the kidneys that leads to kidney failure due to the inability to filter wastes from the blood) and asthma. Review of the resident's Physician's Order Sheet (POS), dated 08/07/25, showed no orders for tracheostomy. Review of the resident's admission MDS assessment, dated 06/09/25, showed Section E marked YES for having a tracheostomy while a resident. Observation on 08/04/25 at 2:20 P.M. showed Resident #2 seated at a table with no tracheostomy. During an interview on 08/05/25 at 12:10 P.M., the Director of Nursing (DON) said they do not have anyone with a tracheostomy (a surgically inserted tube used to maintain an open airway). 2. Review of Resident #26's medical record showed: - admission date of 07/08/25; - Diagnoses of schizophrenia (a disorder that affects a person’s ability to think, feel and behave clearly), morbid obesity (overweight), obstructive sleep apnea (intermittent air flow blockage during sleep) and asthma. Review of the POS, dated 08/05/25, showed: - No orders for Continuous Positive Airway Pressure (CPAP) machine; - No orders for how to care for a CPAP machine or appropriate settings to use. Review of the resident’s admission MDS, dated [DATE], showed Section O marked no for oxygen. Observation on 08/05/25 at 2:49 P.M., showed the resident had a CPAP in his/her room. During an interview on 08/05/25 at 2:49 P.M., the resident said he/she was unsure if the CPAP got cleaned but the staff fill it up for him/her and it is used every night. 3. Review of Resident #39's medical record showed: - admission date of 04/26/22; - Diagnoses of urinary system disorder, low back pain and hematuria (blood in urine), dysuria (painful or uncomfortable urination), and acute kidney failure (kidneys suddenly cannot filter waste from the blood). Observation of the resident on 08/04/25 at 1:00 P.M. showed a urinary catheter (a thin, flexible tubing that drains urine from the bladder) attached to a leg bag while lying in bed. Review of the resident's POS, dated 08/06/25, showed no order for a urinary catheter. Review of the resident’s annual MDS, dated [DATE], showed: - Section H checked no for indwelling device; - Section H checked always for Urinary Continence. 4. Review of Resident #93's medical record showed: - admission date of 07/08/24; - Diagnoses of dyspnea (difficulty breathing), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block the airflow and make it difficult to breathe) and heart disease. Observation of the resident on 08/04/25 at 3:06 P.M., showed oxygen at two liters per minute via nasal cannula and dated 07/18/25. During an interview on 08/06/25 at 1:03 P.M., Resident #93 said his/her tubing (now dated 8/1/25) was just changed yesterday. Review of the resident's POS, dated 08/06/25, showed no order for oxygen. Review of the resident's annual MDS assessment, dated 07/03/25, showed Section O marked no for oxygen. 5. Review of Resident #96's medical record showed: - admission date of 06/03/25; - Diagnoses of dementia (a group of thinking and social symptoms that interfere with daily functioning), Parkinson's disease (a disorder of the central nervous system that affects movement and often including tremors), Alzheimer's (a progressive disease that destroys memory and other important mental functions), disorientation (a state of confusion), and bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's undated, unsigned and incomplete Discharge Recapitulation showed: - Reason for discharge was inappropriate behaviors and elopement risk; - Resident discharged to another facility. Review of the resident's discharge MDS, dated [DATE], showed discharge to hospital with return anticipated. Review of the resident's Progress Notes, dated 07/21/25, showed medication had been given. No discharge notes. During an interview on 08/07/2025 at 6:50 P.M., the Administrator said Resident #96 had been exit seeking, had said something to another resident that had scared them, and it was decided, along with Resident #96’s family member, that he/she should be moved to a different facility and that is what happened. There was no documentation of this. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) said they would expect the MDS to be completed accurately per the RAI manual. During an interview on 08/15/25 at 11:13 A.M., the MDS Coordinator said he/she is at the facility about three to four times a month. When there, the MDSs’ that are due will have the assessment components completed. He/She would expect the MDS to be coded accurately and the Resident Assessment Instrument (RAI-an instrument that helps nursing home staff gather definitive information on resident’s strengths and needs) manual is followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for four residents (Resident #26, #39, #93, and #101) out of 19 sampled residents. The facility census was 92. Review of the facility's Comprehensive Care Plan Policy, last reviewed 10/31/25, showed:- It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident;- The care plan process will include an assessment of the resident's strengths and needs;- The comprehensive care plan will describe, at minimum, services that are to be furnished to maintain the resident's highest practicable physical, mental and psychosocial well-being;- Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment;- Any specialized services as a result of the Pre-admission Screening and Resident Review (PASARR-a federal requirement that helps to ensure individuals are not inappropriately placed in nursing homes for long-term care) recommendations;- Resident goals for admission, desired outcomes and preference for future discharge;- Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated;- The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS- federally mandated assessment completed by the facility staff) assessment;- The comprehensive care plan will include measurable objectives and time-frames to meet the resident's needs as identified in the comprehensive assessment. 1. Review of Resident #26's medical record showed: - An admission date of 07/08/25;- Diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), morbid obesity (overweight), obstructive sleep apnea (intermittent air flow blockage during sleep) and asthma.- Physician's Order Sheet (POS), dated 08/05/25, showed no orders for Continuous Positive Airway Pressure (CPAP) machine, how to care for it, or appropriate settings;- Care Plan, dated 07/15/25, showed altered respiratory status and breathing difficulty, and did not address CPAP. Review of the resident's admission MDS, dated [DATE], showed:- Section O marked no for oxygen. During an interview on 08/05/2025 at 2:49 P.M., Resident #26 said he/she was unsure if the CPAP gets cleaned, but he/she uses it every night and they fill it up for him/her. 2. Review of Resident #39's medical record showed:- An admission date of 04/26/22;- Diagnoses of urinary system disorder, low back pain and hematuria (blood in urine), dysuria (painful or uncomfortable urination), and acute kidney failure (kidneys suddenly cannot filter waste from the blood).- POS, dated 08/06/25, showed no orders for a urinary catheter or catheter care;- Care Plan, last revised on 08/06/25, did not address indwelling catheter. Review of the resident's annual MDS, dated [DATE], showed:- Section H checked no for indwelling device;- Section H checked always for Urinary Continence. Observation of the resident on 08/04/25 at 1:00 P.M. showed a urinary catheter (a thin, flexible tubing that drains urine from the bladder) attached to a leg bag while lying in bed. During an interview on 8/04/25 at 1:00 P.M., Resident #39 said he/she has had a catheter for a long time, prior to being here, and had always taken care of it.During an interview on 08/06/2025 at 10:10 A.M., Resident #39 said the catheter caused pain, but the facility staff had said the catheter cannot be removed without an order. Staff had never cleaned it, but if he/she needed a new bag, they would get one. He/She uses a gravity bag at night and would put it on and take it off every morning. Resident said he/she rinses the gravity bag and when it started to look cloudy, would ask for another one.During an interview on 08/06/2025 at10:32 A.M., Licensed Practical Nurse (LPN) L said the resident won't let them touch him/her. The Director of Nursing (DON) mostly takes care of the catheter. The resident avoids the LPN so they just make sure it's draining properly by sending another staff member in to check on him/her. During an interview on 08/06/2025 at 11:01 A.M., the DON said she just noticed there were no orders for Resident #39's catheter and there should have been orders for catheter care. 3. Review of Resident #93's medical record showed: - An admission date of 07/08/24;- Diagnoses of dyspnea (difficulty breathing), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block the airflow and make it difficult to breathe) and heart disease;- POS, dated 08/06/25, showed no order for oxygen; - Care Plan did not address oxygen. Review of the resident's annual MDS, dated [DATE], showed Section O marked no for oxygen.Observation of the resident on 08/04/2025 at 3:06 P.M. showed oxygen at two liters per minute via nasal cannula and dated 07/18/25.During an interview on 08/06/2025 at 1:03 P.M., Resident #93 said his/her tubing (now dated 08/01/25) was just changed yesterday. 4. Review of Resident #101's medical record showed:- An admission date of 02/24/25;- Diagnoses of psychosis (a mental disorder characterized by a disconnection from reality), schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and COPD;- POS, dated 8/07/25, showed no orders for side rails;- Side rail assessment completed on 2/24/25 and indicated no side rails.Review of the resident's care plan, dated 03/04/25, showed side rails not addressed.Observation on 08/04/25 at 2:00 P.M., showed the resident lying in bed with half side rail up on the left side of the bed.Observation on 08/07/25 at 1:05 P.M., showed the resident with half rail on left side of bed. The space between the bed rail and mattress approximately six inches, and the bed rail wobbled when the resident grabbed it. Metal bedframe observed because the mattress was smaller than the frame. During an interview on 08/07/25 at 1:05 P.M., the resident said he/she used it to get up and out of bed.During an interview on 08/07/25 at 1:08 P.M., the Administrator said he/she would have expected there to be an assessment to assure the handrail was a proper fit, but it had not been done. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing said they would expect care plans to reflect the resident's status and be updated accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a urinary indwelling catheter (a tube inserted into the bladder to drain urine) tubing and drainage bag was maintained by failing to have orders to properly care for one resident (Resident #39) out of 19 sampled residents. The facility census was 92.The facility did not provide a policy. 1. Review of Resident #39's medical record showed:- admitted on [DATE];- Diagnoses of urinary system disorder, low back pain and hematuria (blood in urine), dysuria (painful or uncomfortable urination), and acute kidney failure (kidneys suddenly cannot filter waste from the blood). Review of the Physician's Order Sheet (POS), dated 08/06/25, showed no orders for an indwelling urinary catheter or catheter care. Review of the resident's annual Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents in certified nursing homes), dated 05/03/25, showed:- Section H0100 checked No for indwelling device;- Section H0300 checked Always for Urinary Continence. Review of the resident's Care Plan, last revised 08/06/25, showed:- Resident has functional mixed bladder incontinence, retention of urine, hematuria and disorder of the urinary system;- Resident will be continent at all times and during waking hours;- Clean peri-area (genital area) with each incontinent episode;- Encourage fluids during the day to promote prompted voiding response;- Establish voiding patterns;- Care Plan did not address indwelling urinary catheter. Observation on 08/04/25 at 1:00 P.M. showed Resident #39 with a urinary catheter (a thin, flexible tubing that drains urine from the bladder) attached to a leg bag while lying in bed. Observation on 08/06/25 at 10:10 A.M., showed Resident #39 resting in bed with urinary catheter attached to leg bag.During an interview on 08/06/25 at 10:10 A.M., Resident #39 said the catheter would hurt at times and he/she has called the ambulance before, but the hospital would just place a new catheter. Resident said he/she would be having surgery on Friday to place a suprapubic catheter (a drainage tube inserted into the urinary bladder through a small incision above the pubic bone). The facility staff had said they couldn't remove the catheter without an order. Staff did not clean it. The resident said he/she was used to doing it on his/her own, but if a new bag was needed, the staff would get one. A gravity bag was used at night and the resident would put it on and take it off every morning. The resident said staff would get the supplies needed and he/she would keep the area clean with wipes. During an interview on 08/06/25 at 10:32 A.M., Licensed Practical Nurse (LPN) L said the resident would not let him/her touch the resident and that the Director of Nursing (DON) would mostly take care of the catheter. The resident avoided LPN L so he/she just made sure it was draining properly by sending another staff in to check. During an interview on 08/06/25 11:01 A.M., the DON said the resident would get frequent urinary tract pain and would tell staff he/she wasn't urinating and would call 911. They had tried the pain clinic but they wouldn't prescribe medications, so the resident wanted to see a new doctor. The resident would wear a leg bag during the day, but if he/she would lay down, the urine would flow back into the tube, so he/she tends to get frequent urinary tract infections (UTI), even though he/she had been educated. The DON said there were no orders for the catheter or catheter care. During an interview on 08/07/25 at 8:25 P.M., the Administrator and DON said they would expect residents with a urinary catheter to have a physician's order and to be care planned appropriately.

Based on observation, interview, and record review, the facility failed to obtain orders for continuous positive airway pressure machine (CPAP - a machine that uses mild air pressure to keep breathing airways open while you sleep) settings and tubing changes for one resident (Resident #26) out of one sampled resident with a CPAP and failed to obtain a physician's order prior to oxygen use and orders for nasal cannula (a small, flexible tube that contains two open prongs that sits in the nostrils and attaches to an oxygen source) and humidifier (used to increase the moisture level) changes for one resident (Resident #93) out of one sampled resident with oxygen. The facility census was 92.The facility did not provide a policy.1. Review of Resident #26's medical record showed:- An admission date of 07/08/25;- Diagnoses of paranoid schizophrenia (a mental health condition where a person has strong false beliefs and hears or sees things that aren't real, often feeling suspicious or fearful of others), disorganized schizophrenia (a type of schizophrenia that causes confused speech, unusual behavior, and trouble organizing thoughts), schizoaffective disorder, unspecified (a mental health condition with symptoms of both schizophrenia and a mood disorder, such as depression or mania), manic episodes, severe with psychotic symptoms (periods of extremely high energy, little need for sleep, risky behavior, and possible hallucinations or delusions), congestive heart failure (when the heart can't pump blood as well as it should, causing fluid buildup in the body), borderline intellectual functioning (slightly below-average intelligence that can make learning and daily tasks more difficult).Observation on 08/05/25 at 2:49 P.M. showed the resident with CPAP in his/her room. During an interview on 08/05/25 at 2:49 P.M., the resident said he/she was unsure if the CPAP got cleaned, but the staff fill it up for him/her and it is used every night.Review of the resident's Physician's Order Sheet (POS), dated 07/08/25, showed:- No order for CPAP;- No order to clean CPAP;- No order to clean tubing;- No order for changing of CPAP parts;- No order for CPAP settings.Review of the resident's comprehensive care plan, revised 07/15/25, showed it did not address CPAP, settings, cleaning, changing parts, or tubing. 2. Review of Resident #93's medical record showed:- An admission date of 07/08/24;- Diagnoses of pneumonia, unspecified organism (an infection in the lungs, cause not identified), vitamin B deficiency, unspecified (low levels of vitamin B in the body, exact type not specified), hyperlipidemia, unspecified (high levels of fats or cholesterol in the blood, cause not specified), transient cerebral ischemic attack, unspecified (a short-term mini-stroke where blood flow to part of the brain is briefly blocked, exact cause not identified), unspecified atrial fibrillation, cardiac arrhythmia, unspecified (an irregular heartbeat starting in the upper chambers of the heart, cause not specified), heart failure, unspecified (the heart is not pumping blood as well as it should, cause or type not specified), heart disease, unspecified (a problem with the heart, exact condition not specified), cerebral infarction, unspecified (a type of stroke where part of the brain is damaged due to lack of blood flow, cause not specified), peripheral vascular disease, unspecified (poor blood circulation in the arteries of the arms, legs, or other body parts, cause not specified), chronic obstructive pulmonary disease, unspecified (COPD-a long-term lung disease that makes it hard to breathe, type not specified), dyspnea, unspecified (shortness of breath, cause not specified).Observations showed:- On 08/04/25 at 3:06 P.M., the resident wore oxygen at two liters per minute via nasal cannula with oxygen tubing dated 07/18/25;- On 08/06/25 at 1:03 P.M., the resident wore oxygen at two liters per minute via nasal cannula with oxygen tubing dated 08/01/25. Review of the resident's POS, dated 04/28/25, showed:- No order for oxygen settings;- No order to check oxygen bubbler (humidifier);- An order to change oxygen tubing every Friday and as needed for leakage, contamination, and infection.Review of the resident's comprehensive care plan, revised 07/15/25, did not address oxygen use.During an interview on 08/04/25 at 3:06 P.M., Resident #93 said staff change his/her oxygen tubing monthly.During an interview on 08/06/2025 at 1:03 P.M., Resident #93 said his/her tubing (now dated 8/1/25) was just changed yesterday. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) said they would expect residents with a CPAP to have orders and they should include the settings and how to clean it. The facility had called to get settings as they were not on the discharge paperwork, but had not received a call back. Oxygen tubing should be changed according to orders and be dated appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess residents for the risk of entrapment and review possible risks and benefits of bed rails prior to installation or use. The facility also failed to obtain informed consent from the resident and/or the resident's representative for two residents (Resident #80 and #101) out of 19 sampled and for two residents (Resident #46 and #74) outside the sample. The facility census was 92. Review of the facility's Proper Use of Bed Rails policy, last reviewed on 06/26/25, showed: - If bed rails are used, the facility will ensure correct installation, use and maintenance of the bed rails; - As part of the comprehensive assessment, components will be considered when determining the resident’s needs and whether the use of bed rails meets the needs; - Components include: medical diagnoses, size/weight, medications, surgical interventions, existence of delirium, cognition, mobility, fall risk and ability to toilet self safely; - Resident assessment must include an evaluation of the alternatives that were attempted prior to installation or use of bed rail, and how alternatives failed to meet resident’s assessed needs; - The resident assessment must also assess the resident’s risk from using bed rails; - The resident assessment should assess the resident’s risk of entrapment between the mattress and bed rail or in the bed rail itself; - The facility will assess to determine if the bed rail meets the definition of a restraint; - Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails; - The facility will assure correct installation and maintenance of bed rails prior to use, which includes bed rails, mattress and bed frame compatibility, appropriate bed dimensions, installing rails as per manufacturer’s instruction and specifications to ensure proper fit, ensure bed frame, bedrail and mattress do not leave a gap wide enough to entrap a resident’s head or body and checking bed rails regularly; - Conduct routine preventative maintenance on beds and bed rails to ensure they meet current safety standards and are not in need of repair. Review of the facility’s “Bed Maintenance and Inspection” policy, last reviewed 05/14/24, showed: - The Maintenance Director, or designee, will be responsible for keeping records of bed inspections and maintenance; - A list of bed frames, mattresses and bed rails will be maintained, including the manufacturer of each; - Bed rails shall be securely and properly installed according to manufacturer’s requirements; - Bed frame, mattress and bed rail inspections will be conducted upon each item entering facility and placed on a regular scheduled inspection and maintenance cycle according to manufacturer’s recommendations and time frame. Review of the Federal Drug Administration (FDA) documents titled, “Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts,” showed the potential risks of bed rails may include: - Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; - More serious injuries from falls when patients climb over rails; - Skin bruising, cuts, and scrapes; - Inducing agitated behavior when bed rails are used as a restraint; - Feeling isolated or unnecessarily restricted; - Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet. 1. Review of Resident #46’s electronic medical record showed: - admitted on [DATE]; - Diagnoses of abnormal posture, muscle weakness, other lack of coordination, abnormalities of gait (the pattern of how someone walks) and mobility and unspecified osteoarthritis (joint inflammation that occurs when the flexible tissue at the ends of bones wear down); - No documentation of a signed consent form explaining the risks and benefits of bed rail use; - No documentation of a completed entrapment assessment. Review of the resident’s care plan, last revised 03/03/25, showed: - Bed rail use not care planned; - Impaired mobility, impaired activities of daily living (ADLs). Observations of the resident on 08/04/25 at 12:22 P.M. and on 08/07/25 at 5:05 P.M. showed the resident in bed with a half bed rail up on the left, upper side of the bed. 2. Review of Resident #74’s electronic medical record showed: - admitted on [DATE]; - Diagnoses of encephalopathy (any brain disease that alters brain function or structure), and tremors (involuntary rhythmic and shaking of body parts, often occurring due to neurological conditions); - No documentation of a signed consent form explaining the risks and benefits of bed rail use; - No documentation of a completed entrapment assessment. Review of the resident’s care plan, revised on 02/04/25, showed: - Bed rail use not care planned; - Ambulatory and performs own activities of daily living (ADLs) with stand by assist and set up assistance as needed. Observation of the resident on 08/04/25 at 12:35 P.M. and on 08/07/25 at 5:35 P.M. showed the resident sitting in a chair in his/her room watching TV with his/her roommate. Half rail up on left side of bed. During an interview on 08/07/25 at 5:35 P.M., the resident said he/she did not use the bed rail and wasn’t sure why it was there. 3. Review of Resident #80’s electronic medical record showed: - admitted on [DATE]; - Diagnoses of failure to thrive (a syndrome of decline characterized by weight loss, decreased appetite, poor nutrition and inactivity), dementia (a group of thinking and social symptoms that interfere with daily living), cognitive communication deficit (difficulty with language comprehension, language expression reasoning attention or memory), muscle weakness; - A physician's order, dated 03/31/25, for half bed rail per resident request; - No documentation of a signed consent form explaining the risks and benefits of bed rail use; - No documentation of a completed entrapment assessment. Review of the resident’s care plan, last revised 03/03/25, showed half side rail to assist with turning and repositioning. Observation on 08/04/25 at 2:15 P.M. showed the resident lying in bed, call light draped around a raised, half rail on the right side of the bed; Observation on 08/07/2025 at 3:17 P.M. showed the resident not in the room, call light draped around a raised, half rail on the right side of the bed. 4. Review of Resident #101’s electronic medical record showed: - admitted on [DATE]; - Diagnoses of psychosis (a mental disorder characterized by a disconnection from reality), schizophrenia (a disorder that affects a person’s ability to think, feel and behave clearly) and chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe); - Side rail assessment completed on 2/24/25, indicated NO side rails; - No documentation of a signed consent form explaining the risks and benefits of bed rail use. Review of the resident’s care plan, last updated 03/04/25, showed half side rail up to assist with turning and repositioning. Observation on 08/04/25 at 2:00 P.M. showed the resident lying in bed with a half rail on the left side of the bed. Observation on 08/07/2025 at 1:05 P.M. showed the resident lying in bed with a half rail on the left side of the bed. The resident said he/she used it to get up and out of bed. The resident grabbed the rail to give an example, and the rail wobbled. The space between the half rail and mattress was approximately six inches and the metal bed frame was larger than the mattress. During an interview on 08/07/2025 at 1:08 P.M., the Administrator acknowledged the gap and said there was a big space, and she would have expected an assessment to assure the handrail was a proper fit, but it had not been done. During an interview on 08/07/2025 at 12:50 P.M., the Maintenance Director said he/she made sure the handrails were maintained but had not done an actual assessment. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) collectively said they would expect bed rails to have a physician’s order, an accurate and current assessment completed, for bed rails to be assessed and maintained by maintenance and that bed rails should be assessed to ensure that the mattress/bed and bed rail(s) are not posing a hazard.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent, when medications were administered. There were 27 opportunities with three errors made, for an error rate of 11.11%. This affected one resident (Resident #2) out of 19 sampled residents and one resident (Resident #27) outside the sample, with the potential to affect all residents. The facility census was 92.Review of the facility's policy, Administration of Insulin, revised on 05/14/24, showed:- All insulin will be administered in accordance with physician's orders;- Procedure: Review the insulin order; resident name, medication name, medication dosage, time to be administered, and route of administration, perform hand hygiene, prepare insulin dose, explain procedure and provide privacy, administer insulin at appropriate times, document on the medication administration; record the time and location of the insulin injection;- Insulin pens contain multiple doses of insulin but are used for a single resident only;- Procedure: Gather supplies, perform hand hygiene, don gloves, verify resident, examine the appearance of the insulin, attach pen needle, prime the insulin pen-dial two units by turning the dose selector clockwise, with the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle, if not repeat until at least one drop appears, set the insulin dose, inject the insulin, remove gloves and perform hand hygiene, document the dosage, site and time in the medication record along with nurse signature, document any teaching, and/or demonstrations done when planning for discharge.Review of Humalog insulin pen (insulin in a pen-type device) directions showed:- Remove cap;- Attach needle:- Prime pen by turning dose selector to select two units;- Press and hold button to make sure drop of insulin appears;- Select dose;- Give injection;- After dose counter reaches zero, count to five;- After injection, remove needle and place in sharps container. 1. Observation on 08/06/25 at 11:35 A.M. showed:- Certified Medication Technician (CMT) M obtained the finger stick blood sugar for Resident #27;- CMT M obtained the insulin Humalog insulin pen from the medicine cart and adjusted the pen to the amount of insulin ordered;- CMT M did not prime the pen with two units of insulin per the manufacturer's directions prior to administering the ordered dose to the resident. 2. Observation on 08/06/25 at 11:45 A.M. showed:- CMT M obtained the finger stick blood sugar for Resident #2;- CMT M obtained the Humalog insulin pen from the medicine cart and adjusted the pen to the amount of insulin ordered;- CMT M did not prime the pen with two units of insulin per the manufacturer's directions prior to administering the ordered dose to the resident. 3. Observation on 08/06/25 at 11:50 A.M. showed:- CMT M administered a second dose of Humalog insulin to Resident #2;- CMT M did not prime the pen with two units of insulin per the manufacturer's directions prior to administering the ordered dose to the resident. During an interview on 08/06/25 at 1:46 P.M., CMT M said he/she never knew to prime insulin pens before administering insulin and did not know that was a thing, but will from now on. He/She is insulin certified.During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) collectively said that they would expect insulin pens to be primed prior to insulin administration.

Based on observation, interview, and record review, the facility failed to provide palatable, attractive food at safe and appetizing temperatures. This deficient practice affected four residents (Resident #10, #16, #47 and #78) out of 19 sampled residents and four residents (Resident #14, #44, #72 and #74) outside the sample, and had the potential to affect all residents in the facility. The facility census was 92. Review of the facility’s Dietary Food Policy, last reviewed 07/05/23, showed: - Meals will be prepared in adequate, yet not excessive amounts for all diets as determined by the current diet census; - The employees with food preparation responsibilities are trained and are able to obtain information from daily menus and determine the proper amount of food required to serve; - Foods will be served at proper temperature to ensure food safety; - Hot foods should be above 135 degrees Fahrenheit (°F), but preferably 160-175°F; - Cold foods should be less than 41 °F; - All salads will be refrigerated until time of service; - All sandwiches will be served at appropriate temperatures. Observation on 08/06/25 of the “Resident’s Choice” lunch meal showed: -Test tray delivered at 12:15 P.M.; -Slice of fresh watermelon, 63.1 °F; -Two, unidentifiable slices of lunchmeat inside a hotdog bun, 61.8 °F; -Penne noodles with broccoli, 78 °F; -Slaw made with mayonnaise, 62.9 °F. Observation on 08/06/2025 at of the dinner meal showed: -Test tray delivered at 5:00 P.M.; -Cheese quesadilla, (one thin, dry tortilla with a very small amount of melted, dry cheese) 107 °F; -White rice with cubed tomatoes and corn scattered on top, 120° F; -A piece of chocolate cake with a dry texture topped with chocolate frosting. Observation on 08/07/2025 of the lunch meal showed: -The test tray delivered at 11:55 A.M.; -Five, one-inch in diameter meatballs with sauce, 97.3 °F; -A one-half cup serving of plain mashed potatoes,113 °F; - Approximately one-fourth cup of green beans, 91.2°F; - Approximately one cup of canned peaches, 61.3 °F. During an interview on 08/04/25 at 11:55 A.M., Resident #72 said the food is cold, every single time at every meal. During an interview on 08/04/25 at 12:00 P.M., Resident #10 said the food is not good, and is always cold. During an interview on 08/04/24 at 12:08 A.M., Resident #14 said the food is not good, it's always cold and it's the same thing every day. During an interview on 08/04/25 at 12:12 P.M., Resident #16 said the food is trash, the meat is tough, and the meals are not real meals, the portions are small. The resident said he/she doesn't eat at the facility very often, he/she buys his/her own food. During an interview on 08/04/25 at 12:15 P.M., Resident #44 said the food is terrible and bland. During an interview on 08/04/25 at 12:20 P.M., Resident #74 said the food is the worst, the chicken is always so hard, you can't even cut it up. During an interview on 08/04/25 at 2:05 P.M., Resident #78 said food is questionable and had no taste. During an interview on 08/04/25 3:30 P.M., Resident #47 said for the last three months, it had seemed they were getting smaller portions. During an interview in Resident Council on 08/05/25 at 1:13 P.M., the residents collectively said sometimes the food is good and sometimes it's not. Examples included, dietary staff not using real eggs, cold French fries, and other items and melted ice cream. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) said they would expect food to be palatable and within the appropriate temperature range.

Based on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during wound care and failed to implement enhanced barrier precautions (EBP) during perineal care (peri care-the cleaning of the genitals and anus of the body) and foley catheter (a small flexible tubing inserted into the bladder to drain urine) care for one resident (Resident #78) out of one sampled resident. The facility census was 92.Review of the facility’s policy, “Enhanced Barrier Precautions”, revised on 05/18/24, showed: - It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention and transmission of multidrug-resistant organisms; - These are precautions used with all residents, such as hand hygiene, cleaning equipment, proper injection procedures, disposing of sharps, etc. Personal Protective Equipment (PPE) is used as part of standard precautions where there is an expectation of possible exposure to infectious material; - EBP is a strategy in nursing homes to decrease transmission of CDC-targeted and epidemiologically important MDROs when contact precautions do not apply; - EBP (gown and gloves) must be used for high-contact resident care activities for residents with any of the following: infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO; - EBP should be considered for high-contact resident care activities for residents with any of the following: infection or colonization with a non-CDC targeted MDRO when contact precautions do not otherwise apply; - High contact resident care activities include, but are not limited to, dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, indwelling device care or use, or wound care. - Wounds that require EBP are chronic wounds, including, but not limited to, pressure ulcer, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. These are wounds that generally require a dressing. Any wound care requires EBP; - Indwelling medical devices include, but are not limited to, central lines, urinary catheters, feeding tubes, and tracheostomies; - Make gowns and gloves available immediately near or outside of the resident’s room. Note: face protection may also be needed if performing activities with the risk of splash or spray (i.e., wound irrigation, tracheostomy care); - Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room); - Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room; - The facility infection control preventionist is responsible for the enforcement of this policy. 1. Observation on 08/07/25 at 10:35 A.M., of Resident #78’s peri and Foley catheter care showed: - Certified Nurse Aide (CNA) O entered the resident’s room and did not put on gloves and a gown; - CNA O performed hand hygiene, placed a trash bag at the end of the bed, and lowered the resident’s blankets; - CNA O performed hand hygiene, put on gloves, cleaned the resident’s peri area, did not change gloves, did not perform hand hygiene, and cleaned the Foley catheter from the insertion point down the tubing; - CNA O did not change gloves, did not perform hand hygiene, and rolled the resident onto his/her right side; - CNA O did not change gloves, did not perform hand hygiene, obtained a clean wipe from the container and cleaned the right buttock, did not perform hand hygiene, did not change gloves, obtained a clean wipe from the container and cleaned the left buttock, did not perform hand hygiene, did not change gloves, obtained a clean wipe from the container and cleaned the rectal area, did not perform hand hygiene, and did not change gloves; - CNA O changed gloves and performed hand hygiene; - CNA O placed a clean incontinent pad under the resident and rolled the resident back onto his/her left side; - CNA O removed the used pad from underneath the resident; - CNA O changed gloves, did not perform hand hygiene, pulled the blanket up around the resident’s shoulders, removed gloves, performed hand hygiene, and exited the room. 2. Observation on 08/07/25 at 3:00 P.M. of Resident #78’s peri care and wound care showed: - Licensed Practical Nurse (LPN) L entered the resident’s room; - LPN L did not don gown for EBP; - LPN L did not clean and sanitize the bedside table, placed paper towels on the bedside table for a clean barrier, placed calmoseptine (a multi-purpose barrier cream) and boarder foam gauze (a type of dressing) on the clean barrier; - LPN L performed hand hygiene and put on gloves; - LPN L removed the soiled dressing, changed gloves, and did not perform hand hygiene; - LPN L cleaned fecal material from the resident’s buttocks, changed gloves, and did not perform hand hygiene; - LPN L continued to clean additional fecal material from the resident’s buttocks, changed gloves, and did not perform hand hygiene; - LPN L placed a clean incontinent pad under the resident and rolled the resident onto his/her left side; - LPN L removed the incontinent pad soiled with fecal material, arranged the clean incontinent pad, performed hand hygiene, and changed gloves; - LPN L applied calmoseptine to the resident’s buttock wound, changed gloves, and did not perform hand hygiene; - LPN L applied the border foam dressing on the resident’s buttock wound; - LPN L picked up trash from the floor, changed gloves, and did not perform hand hygiene, - LPN L pulled the blankets up around the resident’s shoulders and adjusted the other blankets; - LPN L removed gloves, performed hand hygiene, and exited the room. During an interview on 08/07/25 at 3:15 P.M., LPN L said he/she had never heard of EBP. Supplies should be kept outside the room by the door, and he/she should wash or sanitize his/her hands in between glove changes. During an interview on 08/07/25 at 8:25 P.M., the Director of Nursing (DON) and the Administrator said they would expect staff to sanitize and or wash their hands with glove changes and that they would expect TB assessments to be completed accurately when they are due. The DON said staff should wear EBP when dealing with open wounds, cleaning dirty things such as emptying a foley, during colostomy care, and staff should wear gloves during Foley catheter care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for two residents (Residents #80 and #101) out of 19 sampled residents and two residents (Residents #46 and #74) outside the sample. The facility census was 92.Review of the facility's Proper Use of Bed Rails policy, last reviewed on 06/26/25, showed: - If bed rails are used, the facility will ensure correct installation, use and maintenance of the bed rails; - As part of the comprehensive assessment, components will be considered when determining the resident’s needs and whether the use of bed rails meets the needs; - Components include, medical diagnoses, size/weight, medications, surgical interventions, existence of delirium, cognition, mobility, fall risk and ability to toilet self safely; - Resident assessment must include an evaluation of the alternatives that were attempted prior to installation or use of bed rail, and how alternatives failed to meet resident’s assessed needs; - The resident assessment must also assess the resident’s risk from using bed rails; - The resident assessment should assess the resident’s risk of entrapment between the mattress and bed rail or in the bed rail itself; - The facility will assess to determine if the bed rail meets the definition of a restraint; - Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails; - The facility will assure correct installation and maintenance of bed rails prior to use, which includes bed rails, mattress and bed frame compatibility, appropriate bed dimensions, installing rails as per manufacturers instruction and specifications to ensure proper fit, ensure bed frame, bedrail and mattress do not leave a gap wide enough to entrap a resident’s head or body and checking bed rails regularly; - Conduct routine preventative maintenance on beds and bed rails to ensure they meet current safety standards and are not in need of repair. Review of the facility’s “Bed Maintenance and Inspection” policy, last reviewed 05/14/24, showed: - The Maintenance Director, or designee, will be responsible for keeping records of bed inspections and maintenance; - A list of bed frames, mattresses and bed rails will be maintained, including the manufacturer of each; - Bed rails shall be securely and properly installed according to manufacturer’s requirements; - Bed frame, mattress and bed rail inspections will be conducted upon each item entering facility and placed on a regular scheduled inspection and maintenance cycle according to manufacturer’s recommendations and time frame. Review of the Federal Drug Administration (FDA) documents titled, “Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts,” showed the potential risks of bed rails may include: - Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; - More serious injuries from falls when patients climb over rails; - Skin bruising, cuts, and scrapes; - Inducing agitated behavior when bed rails are used as a restraint; - Feeling isolated or unnecessarily restricted; - Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet. 1. Review of Resident #46’s electronic medical record showed: -admitted on [DATE]; - No maintenance inspection. Observation of the resident on 08/04/25 at 12:22 P.M. and on 08/07/25 at 5:05 P.M. showed the resident lying in bed with a half rail up on the left side. 2. Review of Resident #74’s electronic medical record showed: - admitted on [DATE]; - No maintenance inspection. Observation of the resident on 08/04/25 at 12:35 P.M. and on 08/07/25 at 5:35 P.M. showed the resident sat in a chair in his/her room watching TV with his/her roommate with a half rail up on the left side of bed. 3. Review of Resident #80’s electronic medical record showed: - admitted on [DATE]; - No maintenance inspection. Observation on 08/04/25 at 2:15 P.M. showed the resident lying in bed with a raised, half rail on the right side of the bed; Observation on 08/07/2025 at 3:17 P.M. showed the resident not in room, call light draped around a raised, half rail on the right side of the bed. 4. Review of Resident #101’s electronic medical record showed: - admitted on [DATE]; - No maintenance inspection. Observation on 08/04/25 at 2:00 P.M. showed the resident lying in bed with a half rail on the left side of the bed. Observation on 08/07/25 at 1:05 P.M. showed the resident lying in bed with a half rail on the left side of the bed. The resident said he/she used it to get up and out of bed. The resident grabbed the rail and the rail wobbled. The space between the half rail and mattress was approximately six inches and the metal bed frame was larger than the mattress. During an interview on 08/07/25 at 1:08 P.M., the Administrator acknowledged the gap and said there was a big space, and she would have expected an assessment to assure the handrail was a proper fit, but it had not been done. During an interview on 08/07/25 at 12:50 P.M., the Maintenance Director said he/she made sure the handrails were maintained but had not done an actual assessment. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) collectively said they would expect bed rails to have a physician’s order, an accurate and current assessment completed, for bed rails to be assessed and maintained by maintenance and that bed rails should be assessed to ensure that the mattress/bed and bed rail(s) are not posing a hazard.

Based on interview and record review, the facility failed to provide the required annual competency training on dementia care (care of a resident with an impaired ability to remember, think or make decisions) for three of the three sampled Certified Nurse Aides (CNAs). This deficient practice had the potential to affect all residents. The facility census was 92.The facility did not provide a policy regarding the required annual nurse aide training requirements.1. Review of CNA H's in-service record showed:- A hire date of 12/18/18;- A total of 16 hours of annual in-services dated 01/17/25;- No documented annual dementia care training. 2. Review of CNA I's in-service record showed:- A hire date of 06/19/23;- A total of 16 hours of annual in-services dated 01/10/25;- No documented annual dementia care training. 3. Review of CNA J's in-service record showed:- A hire date of 06/03/16;- A total of 16 hours of annual in-services dated 02/02/25;- No documented annual dementia care training. During an interview on 08/07/25 at 5:15 P.M., the Director of Nursing (DON) said he/she does the nursing in-services, and there is a big packet that is to be completed every January. He/She said they use the facility's online training program. He/She said staff are supposed to log in and do monthly trainings. The DON said he/she was unsure if the trainings were for all employees or just nursing staff, he/she was also unsure how the facility was tracking who did the trainings and how many were completed. The DON said he/she was unaware of the mandatory trainings that were required. During an interview on 08/07/25 at 8:25 P.M., the Administrator and DON collectively said they would expect dementia care training to be part of their orientation and annual in-services.

Based on interview and record review, the facility failed to maintain a surety bond (a purchased bond for security of residents' personal funds) sufficient to ensure the protection of resident funds. The facility census was 92.Review of the facility's Resident Trust policy, last reviewed 06/12/25, showed:-The facility shall allow residents to access personal possessions and funds during regular business hours, Monday through Friday;-The facility shall keep an accurate and maintained accounting system for the residents that choose to have their personal funds managed;-The facility shall provide assurance of financial security by means of a surety bond. The bond shall be in an amount equal to at least one and one-half times the average total of the reconciled monthly balances. A copy of current bond shall be kept in a file in the facility by the Resident Trust Clerk.Review of the residents' personal funds account for the period July 2024 through July 2025 showed an average monthly balance of $40,973.07. An average monthly balance of $40,973.07 rounded to the nearest thousand equaled $41,000.00, at one- and one-half times will equal the required bond amount of at least $61,500.00.Review of the facility's current surety bond, effective 05/06/25, showed the facility held a bond in the amount of $50,000.00, which was insufficient by $11,500.00. During an interview on 08/07/25 at 8:25 P.M., the Administrator said the surety bond amount should be one-and one-half times the amount of the resident trust balance to meet the regulatory requirement. She said corporate was in the process of increasing the bond to $100,000.00.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 92.Review of the facility’s policy titled, “Environmental Rounds”, revised on 06/29/23, showed: - Environmental rounds are to be done daily by the Department Heads; - The Department Head should be inspecting the room for potentially hazardous items and any areas that may not be in compliance with state and federal guidelines; - Environmental rounds include the resident rooms, drawers and bathrooms. Staff will look for items during these rounds which pose a possible risk to residents and/or staff. Review of the facility's Safe and Homelike Environment Policy, last reviewed 06/05/24, showed: - In accordance with resident rights, the facility will provide a safe, comfortable and homelike environment; - The facility will create and maintain, to the extent possible, a home-like environment that deemphasizes the institutional character of the setting; - Housekeeping and maintenance services will be provided as necessary to maintain a sanitary and comfortable environment; - Minimize odors by disposing of soiled linens promptly and reporting lingering odors and bathrooms in need of cleaning to the Housekeeping Department; - Even light levels should be utilized in common areas and hallways to avoid patches of low light; - Report any furniture in disrepair to maintenance promptly; - Report any unresolved environmental concerns to the Administrator. Observation on 08/04/25 at 1:45 P.M., of room [ROOM NUMBER] showed a sign on the mirror which read out of order. The sink was half-filled with dark brown water, the area around the sink was stained with a brown substance, the cabinet underneath had chipped paint and rusted areas, and the extra bed in the room was unmade- exposing a mattress with black grime and stains. Observations on 08/05/25 at 10:15 A.M., 08/06/25 at 9:02 A.M., and 08/07/25 at 5:18 P.M. showed the entire length of the 100-hall floor sticky to walk on. Observation on 08/05/25 at 10:15 A.M., of the shower room located on the 100-hall, across from room [ROOM NUMBER], showed: - Lighting in the room dim; - All floor corners had a buildup of brown debris and grime; - Shower floor made of approximately 2 inch by 2 inch tiles with grout in between the tiles covered in a black, grimy substance; - Shower walls made of approximately 4 inch by 4 inch tiles with grout and caulk covered in a black, grimy substance; - Wall shelf in the shower with grout and caulk covered in a black, grimy substance; - Orange-stained caulk in the back right and left sides of the back wall; - The shower room floor with brown streaks; - Toilet with the seat in the upright position, splattered with a brown substance underneath the lid and in the bowl; - No toilet paper on the holder or in the vicinity; - Toilet assist bars covered in a grayish grime; - A large, white PVC (polyvinyl chloride-a thermoplastic material) pipe shower chair with a toilet seat with the right front wheel bent and leaning inward and all four legs taped together with white tape; - A metal/plastic shower bench chair with the left legs taped together. Observation on 08/05/25 at 10:22 A.M. of the 100-hall shower room with tub, across from room [ROOM NUMBER] showed: - A bathtub with dirt and debris, a pair of gloves, a bench shower chair, adjustable grab bar, and the water spigot broken off and lying in the tub; - Flooring grout/caulk covered in a black, grimy substance; - A toilet with dried brown substance on the toilet seat; - No toilet paper on the holder or in the vicinity; - Toilet hat lying on the floor, behind the toilet; - Privacy curtain in the toilet area worn, missing hooks at the top, drooping down on both upper right and left sides, with the bottom of the curtain tied up in a knot; - Shower floor tiles approximately 2 inch by 2 inch squares with a black, grimy substance covering the grout/caulk; - Three cracked shower floor tiles by the drain, two tiles missing by the drain and one tile missing from the right rear area of the shower; - A brown-stained area on the right side of the drain; approximately nine tiles across and six tiles wide; - Shower head lying on the shower floor with no holder for the shower head. Observation on 08/07/25 at 9:45 A.M. of the shower room on 100-hall, across from room [ROOM NUMBER], showed: - Shower room and shower floor with a black, grimy substance covering grout/caulk throughout; - Soiled clothes, a sheet, and towel lying on the shower room floor; - A wet washcloth lying in the corner on the wall shelf; - Black debris in the floor corners of the toilet area, water behind the toilet, and a red/brown tinged gauze dressing lying on the floor beside the toilet; - A toilet brush sitting on the floor in a clear solution; - Three wire hangers lying on a shower chair. Observation on 08/07/25 at 9:52 A.M. of the shower room with tub on 100-hall, across from room [ROOM NUMBER] showed: - Shower room and floor caulk/grout covered in a black, grimy substance throughout; - A washcloth with a dried red/brown substance lying on the shower room floor; - A soiled towel laying in the corner of the shower room floor; - A towel with a brown substance lying on the shower chair; - A worn privacy curtain worn with missing hooks and tied up at the bottom; - A toilet hat lying on the floor behind the toilet. Observation on 08/07/25 at 10:00 A.M. of the male restroom labeled 100-15 showed: - A toilet with a black, grimy substance inside the toilet bowl, around the toilet area and the surrounding floor; - The floor covered in a sticky substance with brown, grimy footprints throughout; - A sink with brown grime and stains. Observation on 08/07/25 at 5:45 P.M. of Room124 showed a section of wall with two pieces of broken tile, approximately three by five inches, by the entryway. During an interview on 08/04/25 at 12:15 P.M., Resident #72 said that he/she was afraid to use the shower room because the floor was all busted up. During an interview on 08/04/25 at 12:20 P.M., Resident #18 said the shower rooms were dirty, soap dispensers were not filled and trash cans were full and overflowing. During an interview on 08/07/25 at 9:45 A.M., Housekeeper B said shower rooms are cleaned every day in the 100 hall area, and up front they are cleaned every other day. Housekeeper B said he/she takes out the trash, sprays a disinfecting spray, wipes down surfaces and cleans the floors and used air freshener. Housekeeper B said he/she has a scrubber and scraper to clean the black grime from the floor and grout. During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) collectively said they would expect resident rooms to represent a home like environment, to be clean and odor free, and to be repaired as needed. They said they would expect shower rooms to be clean, toilets to be free of stains, showers and floors to be free of black, grimy substances and cracked tiles to be repaired or replaced. They would expect shower chairs to be in good working order and not taped together. They expect hallway grout to be clean and the tiles to be level.

Based on interview and record review, the facility failed to ensure a Certified Background Check (CBC), the Employee Disqualification List (EDL) and Nurse Aide (NA) Registry were checked prior to the employment start date for six employees out of the ten sampled employees. This deficient practice had the potential to affect all residents. The facility census was 92.Record review of the facility's policy titled, Screening-Applicant, Employee, Volunteer and Vendor (Missouri), revised on 06/12/25, showed: - Pre-employment screening; Human Resources Department (HR) will conduct pre-employment screens on applicants to determine whether the applicant has committed a disqualifying crime, is an excluded provider of any federal or state healthcare programs, is eligible to work in the United States, and if applicable is duly licensed or certified to perform the duties of the position for which they applied;- Applicants shall complete a request for criminal records check and request for consent to employee disqualification check form. Human Resources staff will conduct the following screens on potential employees prior to hire;- The results of each background check must be maintained in the applicant's file;- Using the request for criminal records check, a criminal background check should be done through the Missouri Highway Patrol's Missouri Automated Criminal History Site. If a check is made through the Family Care Safety Registry showing the applicant is registered and a no finding letter is received and printed, that will satisfy the Missouri Criminal background check requirement, and no check needs to be done with the Missouri Highway Patrol;- No applicant may begin work until the criminal background check is completed unless otherwise approved by the Reliant Care Management Company, LLC (RCMC) executive director of Human Resources;- The Certified Nurse Aide (CNA) registry must be checked on all applicants regardless of position for which they are applying. Any applicants listed with background problems, or a federal indicator may not be hired for any position; - RCMC and the facilities it manages will periodically conduct a background check of existing employees to determine whether the employee is an excluded provider of any federal or state healthcare programs and if applicable is duly licensed or certified to perform the duties of the position.1. Review of Employee B's personnel file showed:- Hire date of 10/16/24;- The facility failed to check the CBC, EDL and Nurse Registry until 10/21/24.2. Review of Employee C's personnel file showed:- Hire date of 01/31/25;- The facility failed to check the CBC, EDL and Nurse Registry. 3. Review of Employee D's personnel file showed:- Hire date of 09/02/24;- The facility failed to check the NA registry.4. Review of Employee E's personnel file showed:- Hire date of 12/03/24;- The facility failed to check the CBC, EDL and Nurse Registry until 03/06/25.5. Record review of Employee F's personnel file showed:- Hire date of 10/10/24;- The facility failed to check the CBC until 08/06/25.6. Review of Employee G's personnel file showed:- Hire date of 12/03/24;- The facility failed to check the CBC, EDL and NA registry until 03/26/25.During an interview on 08/07/25 at 5:15 P.M., the Administrator said that Employee C, Employee E and Employee F did not have an updated CBC, EDL, NA registry check since their hire dates. She said that when an applicant fills out an application, they send off for the background checks that day, and that last week you could get in the queue and print off the information, and this week they are 4 days behind on processing and the checks aren't able to be printed off. She also said NA registry checks are done only on Certified Nurse Aides (CNAs) and Certified Medication Technicians (CMTs) and run through Training Management and Updated (TMU). She said corporate did a complete audit of background checks in April 2025.During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing (DON) collectively said they would expect all employees to have a CBC/EDL and NA registry check completed before hire.

Based on observation, interview and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of food-borne illness. This had the potential to affect all residents. The facility census was 92.Review of the facility's Dietary Equipment Operations and Sanitation Policy, last reviewed 02/02/24, showed:-The Dietary Manager shall record all cleaning and sanitation tasks for the Dietary Department;-The dietary employee should complete the tasks assigned for the day shift;- All surfaces and equipment shall be washed in sanitizing solution;-Tray carts, dish carts, and utility carts should be washed after each meal, using sanitizing solution and a clean cloth;-Clean grill surface with grill stone and diluted degreaser or grill cleaner after each use;-Rinse thoroughly with water;-Wash with mild soap and water, then rinse with water;-Wash back and side guards with soap and water;-Clean counters with mild detergent and water;-Dust, mop, or sweep floors;-Mop floors with cleaning agent and warm water, according to directions on the label.The facility did not provide a policy for food storage.Observation on 08/04/25 at 11:50 A.M. showed:-Coffee counter with debris, opened sweetener packets and an opened water bottle;-Work shelf and counter with a fragment of foil, two empty soda bottles sitting next to trays of clean coffee mugs;-A three-tiered cart with debris and a personal, reusable drinking cup with a straw/lid.Observation on 08/04/25 at 11:55 A.M. of the refrigerator showed:- A box with 12, 32 ounce (oz) cartons of apple juice with no dates;- A box with 14, 32 oz cartons of apple juice with no dates;-One gallon plastic resealable bag of opened cheese slices, not labeled or dated;-A box of four, unopened, four-pound sliced cheese packages with no expiration dates;-A box of two, unopened, four-pound sliced cheese packages with no expiration dates;-Three, unopened five-pound bags of shredded cheese, package date of 5/02/25, with no expiration date; -One opened five-pound bag of shredded cheese in a plastic resealable bag with no date;-Three, unopened, five-pound packages of shredded cabbage and carrots, with a best if used by date of 07/24/25;-Four, unopened, five-pound packages of shredded cabbage and carrots, with a best if used by date of 07/23/25.Observation on 08/04/25 at 12:15 P.M. showed:-The Prep counter with debris, ink pen lids, and paper clips;-A tray with four paper wrapped straws, a penny, a strand of hair, and three thermometers with no caps.Observation on 08/04/25 at 12:18 P.M. showed:-The cereal/utensil counter with debris, several sweetener packets, paper clips, and wadded pieces of paper;-The floor with debris, sweetener packets, and salt/pepper packets;-Cooking stove with black grease and grime, food particles and back splash with thick brown/black splatter;- A metal tray cart sitting next to the stove with a butter wrapper and a soiled knife on it.During an Interview on 08/04/25 at 12:20 P.M., the Dietary Manager (DM) said he/she started as the DM the first part of July and took classes online. He/She goes by first in and first out with the use of stored food. The food is marked with date item arrived and when it expires. Refrigerated items should be used by the end of the week received. Observation of the freezer on 08/04/25 at 12:46 P.M. showed:-An opened bag of hash rounds with no label and no expiration date;-Two unopened ten-pound bags of frozen diced potatoes with an expiration date of 07/05/25;- Four unopened large bags of frozen diced peppers and onions, unknown weight, with expiration dates of 09/30/24.Observation on 08/05/25 at 10:25 A.M. showed:- Cereal counter with cereal debris, a scoop lying on the counter, paper clips, and two dietary cards;- Work counter, above the container storage area, with a tray containing paper clips and uncapped thermometers;- On the counter below, a packet of thickener, two serving spoons, a personal drinking cup with lid and straw, six dietary cards, and a used plastic sandwich bag.Observation on 08/05/25 at 10:40 A.M. showed the refrigerator with four, unopened, five-pound packages of shredded cabbage and carrots, with best if used by date of 07/23/25.During an interview on 08/07/25 at 8:25 P.M., the Administrator and Director of Nursing said they would expect the kitchen to be clean, floors, counters, and stove to be clean and free of grime, the refrigerator and freezer to be free from expired items, and food labeled with dates.

Based on interview and record review, the facility staff failed to administer medications per physician's orders for two residents (Residents #1 and #3) out of five sampled residents. The facility census was 82. Review of the facility's policy titled, Medication Administration Policy, dated 06/26/24, showed: - Administer medication as ordered in accordance with manufacturer specifications; - Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. Review of the facility's policy titled, Intravenous Therapy, dated 05/18/24, showed: - Intravenous (IV) documentation is recorded in the nurses' notes and/or Medication Administration Record. 1. Review of Resident #3's medical record showed: - An admission date of 08/19/24; - Diagnoses of osteomyelitis (a serious infection of the bone causing inflammation and potentially damaging bone tissue), essential hypertension, hypertensive heart disease with heart failure (a condition where high blood pressure causes the heart to weaken and fail), polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain), old myocardial infarction (a previous heart attack), atrial fibrillation (an irregular and often rapid heart rhythm that affects the heart's upper chambers), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), and edema (swelling caused by an abnormal accumulation of fluid in the body's tissues). Review of the resident's POS, dated 05/13/25, showed: - An order for cefepime (an antibiotic) intravenous solution two grams (gm) per 100 milliliters (ml) to be administered intravenously every twelve hours for cutaneous abscess, dated 04/28/25, and scheduled to end on 06/03/25; - An order for vancomycin (an antibiotic) intravenous solution 750 mg to be administered intravenously every 24 hours for cutaneous abscess, dated 04/28/25, and scheduled to end on 06/04/25; - An order for apixaban (an anticoagulant or blood thinner) oral tablet five mg, give one tablet by mouth two times a day related to atrial fibrillation, dated 04/28/25; - An order for clonidine (treats high blood pressure) oral tablet 0.2 mg, give one tablet by mouth three times a day related to hypertension, dated 04/27/25 and scheduled to end on 05/07/25; - An order for diltiazem (treats high blood pressure) extended-release beads oral capsule 180 mg, give one capsule by mouth one time a day related to hypertension, dated 08/19/24; - An order for hydralazine (treats high blood pressure) oral tablet 100 mg, give one tablet by mouth three times a day related to hypertension, dated 08/18/24; - An order for losartan potassium (treats high blood pressure) oral tablet 100 mg, give one tablet by mouth one time a day related to hypertension, dated 04/28/25; - An order for gabapentin (works in the brain to relieve pain for certain conditions in the nervous system) oral capsule 300 mg, give two capsules by mouth three times a day related to polyneuropathy, dated 08/18/24; - An order for ipratropium-Albuterol Inhalation Solution 0.5-2.5 mg per three ml, give one vial by mouth three times a day related to chronic obstructive pulmonary disease, dated 04/28/25; - Furosemide (water pill) oral tablet 20 mg, give one tablet by mouth one time a day related to edema, dated 04/28/25; - Metoprolol Succinate (treats high blood pressure) oral tablet extended release 50 mg, give three tablets by mouth every morning and at bedtime related to hypertension for 14 days, dated 04/28/25 and scheduled to end on 05/12/25. Review of the resident's medication administration record (MAR), dated April 2025, showed: - Diltiazem 180mg capsule by mouth daily not administered on 04/29/25 for a total of one missed dose. Review of the resident's MAR, dated May 2025, showed: - Vancomycin 750 mg every 24 hours infusion not administered on 05/01/25, 05/03/25, 05/04/25, or 05/05/25 for a total of four missed doses; - Cefepime two gm every 12 hours infusion not administered on 05/01/25 morning dose, 05/02/25 evening dose, 05/03/25 morning and evening doses, 05/04/25 morning and evening doses, and 05/05/25 morning dose for a total of seven missed doses; - Diltiazem 180 mg capsule by mouth daily not administered from 05/01/25 through 05/03/25 for a total of three missed doses; - Furosemide 20 mg tablet daily not administered on 05/01/25 and 05/03/25 and charted as medication not available for a total of three missed doses; - Losartan 100 mg tablet daily not administered from 05/01/25 through 05/03/25 and charted as medication not available for a total of three missed doses; - Apixaban five mg tablet two times a day not administered on 05/01/25 and 05/02/25 for a total of four missed doses; - Metoprolol three 50 mg tablets at morning and bedtime were not administered from 05/01/25 through 05/03/25 and 05/04/25 evening dose and charted as medication not available for a total of seven missed doses; - Clonidine 0.2 mg tablet three times a day not administered from 05/01/25 through 05/03/25 and charted as medication not available for a total of nine missed doses; - Gabapentin two 300 mg capsules three times a day not administered from 05/01/25 through 05/03/25 and charted as medication not available for a total of nine missed doses; - Hydralazine 100 mg tablet three times a day not administered from 05/01/25 through 05/03/25 and 05/04/25 evening dose and charted as medication not available for a total of ten missed doses; - Ipratropium - Albuterol solution one vial three times a day not administered from 05/01/25 through 05/02/25 and 05/03/25 evening and charted as medication not available for a total of seven missed doses. Review of resident's blood pressure readings showed: - On 04/21/25 at 3:00 P.M., a blood pressure of 140/92 charted; - On 04/29/25 at 9:55 A.M., a blood pressure of 144/88 charted; - On 04/30/25 at 3:15 P.M., a blood pressure of 136/80 charted; - On 05/01/25 at 5:35 A.M., a blood pressure of 128/78 charted; - On 05/01/25 time unknown, a blood pressure of 186/110 charted; - On 05/01/25 at 5:00 P.M., a blood pressure recheck of 177/101 charted; - On 05/02/25 at 5:32 A.M., a blood pressure of 128/74 charted; - On 05/03/25 at 4:30 P.M., a blood pressure of 210/121 charted; - On 05/04/25 at 8:38 A.M., a blood pressure of 180/101 charted; - On 05/05/25 at 8:56 P.M., a blood pressure of 138/73 charted. Review of the resident's progress notes showed: - On 04/21/25 at 3:00 P.M., Resident sent to emergency room to be evaluated for abscess to right thigh per physician's order; - On 04/28/25 at 2:30 P.M., resident readmitted to facility; - No nurses note regarding elevated blood pressure on 05/01/25; - On 05/03/25 at 4:33 P.M., resident experiencing some lightheadedness and hypertension. Resident was instructed several times throughout the day that he/she needed to go to the hospital, but resident refused; - On 05/04/25 at 10:35 A.M., resident found in floor in room, vitals revealed a blood pressure of 180/101. Resident was asked if he wanted to go to the hospital for weakness and lightheadedness, and he/she refused; - On 05/04/25 at 5:00 P.M., resident said is feeling better with a blood pressure of 161/97; - On 05/05/25 at 7:49 P.M., resident lethargic and requesting to go to the hospital; - On 05/05/25 at 8:37 P.M., resident being transferred to hospital; Review of the resident's hospital medical record, dated 05/05/25, showed: - Resident admitted to the hospital with a diagnosis of cerebellar infarct (a stroke that affects the cerebellum in your brain), acute kidney injury (a sudden decline in the ability of your kidneys to filter waste and excess fluid from the blood), and osteomyelitis; - Resident was discharged to a hospice facility on 05/13/25. 2. Review of Resident #1's medical record showed: - An admission date of 01/09/24; - Diagnoses of vascular dementia (a form of dementia caused by conditions that reduce or block blood flow to the brain leading to cognitive decline and functional impairment), cervical disc degeneration (a condition where the cushioning discs in the neck wear down over time), pathological fracture (a fracture that occurs in bone that has been weakened by a disease, such as cancer or osteoporosis, rather than by a significant injury) of the hip, chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood), essential hypertension (high blood pressure where the underlying cause is not known), and pain. Review of the resident's Physician's Order Sheet (POS), dated 05/12/25, showed: - An order for donepezil oral tablet 10 milligrams (mg), give one tablet by mouth at bedtime for dementia, dated 04/27/25; - An order for gabapentin oral capsule 100 mg, give one capsule by mouth three times a day, related to cervical disc degeneration, dated 04/27/25. Review of the resident's medication administration record (MAR), dated May 2025, showed: - Donepezil ten mg tablet by mouth at bedtime not administered from 05/02/25 through 05/04/25 for a total of three missed doses; - Gabapentin 100mg capsule by mouth three times a day was not administered on 05/02/25 evening dose, 05/03/25 evening dose, and 05/04/25 evening dose for a total of three missed doses. During an interview on 05/13/25 at 12:39 P.M., Certified Medication Technician (CMT) A said they have been having issues getting medications after changing over to a new pharmacy the first of May. During an interview on 05/13/25 at 3:05 P.M., the Assistant Director of Nursing (ADON) said all IV antibiotics are charted in the MAR and all documentation is done in the new electronic medical record starting on 05/01/25. She said Resident #3 received all his/her antibiotics because she did not have any to return when he/she was transferred to the hospital. During a telephone interview on 05/14/25 at 4:58 P.M., the Administrator said she would expect all medication to be given as ordered by the physician. During a telephone interview on 05/30/25 at 10:32 A.M., CMT A said residents' medications are ordered when they have five days of medication left. He/She said they were faxing over the medication refills at the beginning of the month, but now they are able to order through the electronic medical record (EMR). He/She said she would call the pharmacy if a resident's medication ran out and they would deliver by that evening. He/She said they did destroy left over medication at the end of April, but it was only a few. The majority of the residents' medications ran out on 04/30/25. During a telephone interview on 05/30/25 at 10:38 A.M., the ADON said the previous pharmacy ended on 04/30/25 and the new pharmacy started on 05/01/25. The new pharmacy told them they could not send medications because the insurance told them the previous company had billed through the middle of May. The residents' medication orders were sent to the new pharmacy prior to 05/01/25. The old emergency kit (E-kit) was limited on supplies and Resident #3's medications were not stocked in the E-kit. The new E-kit was delivered approximately a week after starting with the new pharmacy. The facility does not have a secondary pharmacy. During a telephone interview on 05/30/25 at 11:24 A.M., a pharmacy tech for the previous pharmacy said 23-day supply of medications for Resident #3 were delivered on 04/08/25 and a three-day supply of medications were delivered on 04/28/25. During a telephone interview on 05/30/25 at 12:00 P.M., the ADON said no medications were destroyed the end of April because there were not any left to destroy. The previous pharmacy only supplied through 04/30/25. The previous pharmacy had a pack system, and the facility would return the packs to the pharmacy when a resident was hospitalized . The pharmacy would then deliver the new packs when the resident was readmitted to the facility. She said this was done because resident medications usually changed during hospitalization. She said the IV antibiotics administration schedule for Resident #3 was set up by her. She said she is the one who would administer them during the day and failed to document when the antibiotics were administered. Complaint #MO00253879

Based on observation and interview, the facility failed to protect residents' right to privacy by not ensuring other residents did not enter the shower room during showers and not providing a shower curtain in the 100 hall shower room. This affected two residents (Resident #37 and #56) out of 18 sampled residents and one resident (Resident #10) outside the sample. The facility's census was 82. The facility did not provide a policy regarding protection of privacy during bathing. Observation on 08/20/24 at 2:00 P.M. and on 08/21/24 at 3:32 P.M. of the 100 hall shower room showed: - The shower located in the front of the room and to the right of the door with no curtain; - The toilet located past the shower on the right side of the room; - Nothing to indicate to those outside the shower room that it is occupied. During an interview on 08/19/24 at 12:35 P.M., Resident #10 said the shower curtain was missing from the shower room and had been for the past month. He/She did not like taking showers in there due to the lack of privacy. Other residents could walk in to use the bathroom while he/she was in the shower and there was no shower curtain for privacy. During an interview on 08/19/24 at 12:20 P.M., Resident #37 said he/she was only taking one shower a week because of concern for a lack of privacy during a shower. Other residents could walk in and use the toilet while he/she was in the shower and there is no shower curtain to provide privacy. During an interview on 08/20/24 at 2:00 P.M., Resident #56 said he/she did not think it was right that there was not a shower curtain and other people would sometimes come in the bathroom and use the toilet while he/she was in the shower. Previously the shower curtain got tore up and they went a full month before it was replaced. It was embarrassing and he/she did not like to take a shower in there for fear of others walking in on him/her. During an interview on 08/22/24 at 10:20 A.M., Housekeeping Staff C said he/she had been employed there for a month and there had not been a shower curtain up the whole time he/she had been employed. During an interview on 08/22/24/24 at 2:50 P.M., the Administrator said she removed the shower curtain due to a couple of residents that require physical assistance pulling on the shower curtain as a means of support and then pulling the curtain down and almost falling. The Administrator said there is nothing to indicate to others that the shower room is occupied. They can designate the other shower room that has a curtain as the shower for the residents who shower independently, and they can use the shower room without a curtain for the residents that require assistance.

Based on observation, interview, and record review, the facility failed to use proper infection control techniques during medication administration for two residents (Resident #11 and #66) out of 18 sampled residents and four residents (Resident #44, #47, #58, and #75) outside the sample. The facility's census was 82. Review of the facility's policy, Handwashing/Hand Hygiene, revised August 2019, showed: - This facility considers hand hygiene the primary means to prevent the spread of infections; - All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; - Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct contact with residents, before and after preparing or handling medications, after contact with a resident's intact skin, and after removing gloves. 1. Observation on 08/21/24 at 9:00 A.M. of medication administration for Resident #58 showed: - No hand sanitizer on medication cart; - Certified Medication Technician (CMT) A did not wash or sanitize his/her hands prior to administering the resident's medications; - CMT A did not wash or sanitize his/her hands after exiting the resident's room. 2. Observation on 08/21/24 at 9:05 A.M. of medication administration for Resident #47 showed CMT A did not wash or sanitize his/her hands before or after administration of medications. 3. Observation on 08/21/24 at 9:10 A.M. of medication administration for Resident #66 showed: - CMT A did not wash or sanitize his/her hands prior to medication administration; - CMT A handed the resident a cup of water to take medications. The resident took the medications and drank all of the water; - With bare hands, CMT A took the cup back from the resident and touched the rim before throwing the cup away; - CMT A did not wash or sanitize hands after disposing of the resident's cup and medication administration. 4. Observation on 08/21/24 at 9:15 A.M. of medication administration for Resident #75 showed: - CMT A did not wash or sanitize his/her hands prior to medication administration; - CMT A handed the resident a cup of water to take medications. The resident took the medications and drank all of the water; - With bare hands, CMT A took the cup back from the resident and touched the rim before throwing the cup away; - CMT A did not wash or sanitize his/her hands after disposing of the resident's cup and medication administration. 5. Observation on 08/21/24 at 9:20 A.M. of medication administration for Resident #44 showed: - CMT A did not wash or sanitize his/her hands prior to or after medication administration. 6. Observation on 08/21/24 at 9:30 A.M. of medication administration for Resident #11 showed: - CMT A did not wash or sanitize his/her hands prior to medication administration; - CMT A donned gloves, opened the medication drawer, obtained the resident's eye drops, closed and locked the medication cart and did not remove gloves; - With the same soiled gloves, CMT A entered the resident's room and administered medication; - CMT A did not wash or sanitize his/her hands after removing gloves. During an interview on 08/21/24 at 10:00 A.M., CMT A said that he/she normally washes and/or sanitizes his/her hands all the time. CMT A said he/she typically administers eye drops the same way as he/she did today. During an interview on 08/22/24 at 2:50 P.M., the Administrator and Director of Nursing (DON) said they would expect staff to wash their hands in between dirty and clean and between residents when passing medications.

Based on observation, interview, and record review, the facility failed to store and distribute food under sanitary conditions, increasing the risk of cross-contamination and food-borne illness. These practices had the potential to affect all residents who are served food from the kitchen. The facility's census was 82. Review of the facility's policy, Refrigerators and Freezers, revised November 2022, showed: - Refrigerators and/or freezers are maintained in good working condition. Refrigerators keep foods at or below 41° Fahrenheit (F) and freezers keep frozen foods frozen solid; - Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures; - Monthly tracking sheets include time, refrigerator temperature, temperature of potentially hazardous food and temperature control for safety (PHF/TCS) food, initials, and action taken. The last column will be completed only if temperatures are not acceptable; - Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening; - The supervisor takes immediate action if temperatures are out of range. Actions necessary to correct the temperatures are recorded on the tracking sheet, including the repair personnel and/or department contacted; - Information regarding acceptable storage periods for perishable foods are kept in the supervisor's office. A condensed version is posted by each refrigerator and freezer for reference; - All food is appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. Use by dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and use by dates are indicated once food is opened; - Foods kept in the refrigerator/freezer are stored according to the Food Receiving and Storage policy; - Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes on packaging; - Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Maintenance schedules per manufacturer guidelines are scheduled and followed; - Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary. Review of the facility's policy, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, revised November 2022, showed: - Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness; - All employees who handle, prepare, or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents; - Employees must wash their hands after personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.); - After using tobacco, eating, or drinking; - Whenever entering or reentering the kitchen; - Before coming in contact with any food surfaces; - After handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; - After handling soiled equipment or utensils; - During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; - After engaging in other activities that contaminate the hands; - Contact between food and bare (ungloved) hands is prohibited; - Gloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands are washed and gloves are replaced: - After direct contact with residents; - After assisting with medical treatments; - Between handling raw meats and ready-to-eat foods; - Between handling soiled and clean dishes; - The use of disposable gloves does not substitute for proper handwashing; - Gloves are worn when directly touching ready-to-eat foods; - Gloves are used when serving residents who are on transmission-based precautions; - Gloves are not required when distributing foods to residents at the dining tables or when assisting residents to eat, unless touching ready-to-eat food; - Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness; - Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens; - Hair nets are not required when distributing foods to residents at the dining tables or when assisting residents to dine; - Jewelry will be kept to a minimum. Hand jewelry (e.g., rings) and wrist jewelry are kept covered with gloves during food handling; - Fingernails shall be kept clean and trimmed. Intact, disposable gloves in good condition are worn and changed appropriately to reduce the spread of infection; - Clean uniforms must be worn daily; - Personnel may not smoke or use other tobacco products, eat or drink in the food preparation area. 1. Observation on 08/19/24 at 3:00 P.M. of the walk-in refrigerator showed: - Numerous items on the shelves not labeled or dated; - Dirt and debris on the floor. 2. Observation on 08/19/24 at 3:00 P.M. of the walk-in freezer outside the kitchen showed: - Numerous unopened cases of food items sitting directly on the walk-in freezer floor; - Dirt and debris throughout the floor of the freezer. 3. Observation on 08/19/24 at 3:00 P.M. of the double door freezer inside the kitchen showed numerous food items in plastic storage bags, undated and unlabeled. During an interview on 08/19/24 at 3:30 P.M., the Dietary Manager (DM) said the cook is responsible for taking the food temperatures at each meal. It is the responsibility of the dietary manager to check the temperatures for the refrigerator, freezers, and dishwasher. They do not have logs for the last week. The Dietary Manager provided logs for July for the refrigerator, freezers, dishwasher, and chemical testing of dishwasher. He/she was unable to provide logs for the month of August. A review of the food temperature logs for the months of July and August showed only nine days were completed for the month of July and only three days were completed for the month of August. 4. Observation on 08/19/24 at 3:00 P.M. and 08/20/24 at 12:00 P.M. of the dry food storage room showed: - A dented can of tuna, a dented can of jellied cranberries, and a dented can of cream of mushroom soup on the shelf among the other canned good items; - An opened, unsealed bag of graham cracker crumbs with no date or label; - An opened bag of elbow pasta with no date or label; - An opened bag of spaghetti pasta wrapped in plastic wrap, and undated; - Two bags of pepper gravy with best by dates of 05/ 23/24 and 06/10/24; - Seven bags of brown gravy with best by dates of 06/19/24, 05/22/24, 06/19/24, 06/19/24, 06/19/24, 06/19/24, and 05/08/24; - Two cans of mandarin oranges with a best by date of 12/28/23; - A large plastic tote containing flour with no use by date, the lid ajar and covered in dirt and debris, and visible debris in the flour; - Dry good items stored in opened plastic bins. Each bin contained dirt, debris, and dead insects. 5. Observation on 08/19/24 at 3:00 P.M. and on 08/20/24 at 12:00 P.M. showed: - The stove top covered in a black charred substance; - The oven covered in thick black substance; - The lower storage counter covered in dirt and debris; - A large box on the bottom shelf next to the double door freezer with large sheets of parchment paper covered in dirt, debris and dead insects; - Three plastic containers of dry cereal with no use by date; - The toaster oven covered in food particles and debris. Observation on 08/19/24 at 2:51 P.M. of food prep showed: - Dietary Aide B prepared sandwiches while not wearing gloves and laid the bread directly on the counter. The Dietary Manager told the aide to put the bread on a sheet of parchment paper. The aide then obtained and used the parchment paper located on the bottom shelf which was covered with dirt, debris, and dead insects. During an interview on 08/22/24 at 10:08 A.M., Dietary Aide B said you are supposed to wear gloves when preparing sandwiches and the food should be put on parchment paper or a dish when it is being prepared. During an interview on 08/22/24 at 10:39 A.M., the Dietary Manager said if he/she has dented cans, he/she will put the date the can was received, and put it on the left shelf at the front of the dry goods storage room. He/she will take a picture of it and send it to the food supplier for the can to be replaced. The DM said he/she found a couple on the shelf and just removed them. When asked what the items were, the DM said he/she could not remember. When asked to view the photo of the item, he/she said he/she did not take one. He/She checks the food supply once a month to see if anything is past the best by or expired date. The DM would expect the kitchen, appliances, counters, floors and containers to be free from dirt, debris and dead insects and would expect the log books to be completed and up to date, items to be properly packaged with a date and label on them, and for staff to wear gloves when touching food and to keep food off the counters or tables. During an interview on 08/22/24 at 3:00 P.M., the Administrator and Assistant Director of Nursing (ADON) said they would expect staff to wear gloves when touching food and to keep food off the counters and tables. They would expect the floors to be free from dirt, debris, and dead insects, and for expired or food past the best by date and dented cans to be removed from the shelves. They would expect food items to be wrapped, packages dated and labeled and would expect the food pantry to be free from dirt, debris, and dead insects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document a complete and accurate Minimum Data Set (MDS, a federal mandated assessment to be completed by the facility) for six residents (Resident #13, #35, #41, #48, #60, and #62) out of 18 sampled residents. The facility's census was 75. Record review of the facility's Resident Assessments policy, revised March 2022, showed: - A comprehensive assessment of every resident's needs is made at intervals designated by Omnibus Budget Reconciliation Act (OBRA- federally mandated and must be performed for all residents of Medicare and/or Medicaid certified homes); - The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments; - OBRA required assessments - conducted for all residents in the facility: admission (Comprehensive), Quarterly, Annual (Comprehensive), Significant Change in Status (Comprehensive), Significant Correction to Prior Comprehensive (Comprehensive), Significant Correction to Prior Quarterly, and Discharge (return anticipated and return not anticipated); - The Resident Assessment Instrument (RAI) Manual (Chapter 2) provides detailed information on timing and submission of assessments; - All members of the care team, including licensed and unlicensed staff members, are asked to participate in the resident assessment process; - All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. 1. Record review of Resident #13's medical record showed: - An admission date of 9/11/20; - Diagnoses of anxiety (persistent worry and fear about everyday situations), hypertension (HTN) (high blood pressure), depression, headache (Migraines), high cholesterol, coronary artery disease (CAD) (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen and nutrients), and cerebrovascular accident (CVA) (stroke, damage to the brain from interrupted blood supply); - An order for Clopidogrel (also known as Plavix) (an antiplatelet blood-thinning medication) 75 milligram (mg) by mouth at bedtime, dated 3/1/23. Record review of the resident's comprehensive annual MDS, dated [DATE], showed: - Anticoagulant use marked on section N of the assessment. 2. Record review of Resident #35's medical record showed: - An admission date of 12/18/14; - Diagnoses of chronic paranoid schizophrenia (behavior where a person feels distrustful and suspicious of other people), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), impulse control disorder (urges and behaviors that are excessive and/or harmful to oneself), and depressive disorder (persistent feeling of sadness and loss of interest); - A Level II PASSR (Pre-admission Screening/Resident Review), dated 12/12/14, showing the resident has serious mental illness as defined by PASSR. Record review of the resident's comprehensive annual MDS, dated [DATE], showed: - Question A1500 Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? was marked no. 3. Record review of Resident #41's medical record showed: - An admission date of 10/3/19; - Diagnoses of congestive heart failure (CHF) (an inability of the heart to pump sufficient blood flow to meet the body's needs), bronchitis (an inflammation of the lining of your bronchial tubes, which carry air to and from your lungs), atrial fibrillation (A-fib) (heart dysrhythmia), hyperlipidemia (high blood level of cholesterol), sciatica (nerve pain from an injury or irritation to the sciatic nerve, which originates in the buttock/gluteal area), HTN, CAD, obesity, chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), deep vein thrombosis (DVT) (A blood clot in a deep vein of the leg, pelvis, and sometimes arm), and acute embolism (obstruction of an artery, typically by a clot of blood or an air bubble); - An order for Eliquis (anticoagulant medication used to treat and prevent blood clots and to prevent stroke) five mg by mouth twice daily for A-fib, dated 8/2/21; - An order for oxygen at 2 liters (2L) per minute via nasal cannula PRN (as needed) for shortness of breath. Observations of resident #41 showed: - On 3/22/23 at 8:45 A.M., resident in bed with eyes closed, supine position with head of bed elevated, oxygen in use via nasal cannula at 2L; - On 3/23/23 at 10:40 A.M., resident up in wheel chair at bedside, oxygen in use via nasal cannula at 1L. Record review of the resident's quarterly MDS, dated [DATE], showed: - Anticoagulant use not marked on Section N; - Oxygen use not marked on Section O. 4. Record review of Resident #48's medical record showed: - An admission date of 11/03/20; - Diagnoses of HTN, dysuria (difficulty urinating), gastroesophageal reflux disease (acid reflux), depression (persistent feeling of sadness and loss of interest), deafness, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and Vitamin D deficiency. Record review of the resident's quarterly MDS, dated [DATE], showed: - Section I, Active Diagnosis of Post Traumatic Stress Disorder (PTSD) marked yes; - No documentation of PTSD in the medical record. 5. Record review of Resident #60's medical record showed: - An admission date of 4/29/21; - Diagnoses of psychosis (mental disorder characterized by a disconnection from reality), delusions (belief or altered reality that is persistently held despite evidence or agreement to the contrary), anxiety, depression, communication deficit (difficulty with thinking and how someone uses language), and dementia; - An order for acetaminophen (medication used for pain or fever) 325 mg, take two tablets by mouth every four hours PRN for pain or elevated temperature, dated 4/29/21; - Nurses note, dated 12/28/22, showed resident nonverbal; - Patient Visit Note, dated 1/20/23, showed the chief complaint is: nonverbal; - Patient Visit Note, dated 12/14/22, showed the chief complaint is: Hi; - Patient Visit Note, dated 9/21/22, showed the chief complaint is: nonverbal today. Observation of Resident #60 on 3/21/23 at 12:17 P.M. showed resident does not speak when spoken to. Record review of the resident's comprehensive annual MDS, dated [DATE], showed: - Section B marked that resident understands and is able to be understood (B0700 and B0800); - Section C Brief Interview for Mental Status (BIMS) not completed because the resident is rarely/never understood (C0100); - Section D mood interview not completed because the resident is rarely/never understood (D0100); - Section E marked yes for hallucinations and delusions (E0100), with no documentation in the resident's chart for these behaviors in the seven-day look back period; - Section J pain assessment interview conducted with the resident (J0200). J0100A checked yes for scheduled pain medication, with no order for scheduled pain medication. J0100C checked yes for non-medication intervention for pain, with no non-medication interventions documented in the five-day look back period. 6. Record review of Resident #62's medical record showed: - An admission date of 10/3/21; - A comprehensive annual MDS assessment, dated 10/3/22; - A discharge date of 12/15/22; - No discharge MDS completed. During an interview on 3/24/23 at 2:30 P.M., the Director of Nursing (who also functions as MDS Coordinator) and the Administrator said they would expect the MDS to accurately reflect the condition of the resident. The DON/MDS Coordinator added that when completing the MDS, he starts by looking at the chart and conducts staff interviews and talks with the residents. He also looks at the History and Physical as he goes through each section of the MDS. If it can't be found in the chart, then he will go ask staff. Others fill in their sections, like social services and activities director, but he reviews and signs off on the MDS. PTSD should not be marked on the MDS if the resident does not have PTSD. He would mark Plavix and Eliquis as anticoagulants. He would expect a resident who utilizes oxygen to have it marked on the MDS. He has a copy of the RAI Manual on his desk.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for a specialty care area for two residents (Resident #41 and #63) out of 18 sampled residents. The facility's census was 75. The facility did not provide a policy. 1. Record review of Resident #41's medical record showed: - An admission date of 10/3/19; - Diagnoses of congestive heart failure (CHF) exacerbation (an inability of the heart to pump sufficient blood flow to meet the body's needs), bronchitis (an inflammation of the lining of your bronchial tubes, which carry air to and from your lungs), atrial fibrillation (A-fib) (heart dysrhythmia), hyperlipidemia (high blood level of cholesterol), sciatica (nerve pain from an injury or irritation to the sciatic nerve, which originates in the buttock/gluteal area), hypertension (HTN) (high blood pressure), coronary artery disease (CAD) (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen, and nutrients), chronic obstructive pulmonary disease (COPD) (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and acute embolism (obstruction of an artery, typically by a clot of blood or an air bubble); - An order for Eliquis (anticoagulant medication used to treat and prevent blood clots and to prevent stroke) five milligrams (mg) by mouth twice daily for A-fib, dated 8/2/21; - An order for oxygen at two liters per minute per nasal cannula PRN (as needed) for shortness of breath. Record review of the resident's care plan, dated 2/3/23, showed: - Alteration in respiratory status related to COPD; - Oxygen use not addressed in the care plan; - Use of Eliquis not addressed in the care plan. Observations of Resident #41 showed: - On 3/22/23 at 8:45 A.M., resident in bed with eyes closed, supine position with head of bed elevated, oxygen in use via nasal cannula at two liters per minute; - On 3/23/23 at 10:40 A.M., resident up in wheel chair at bedside, oxygen in use via nasal cannula at one liter per minute. 2. Record review of Resident #63's medical record showed: - An admission date of 12/3/21; - Diagnoses of COPD, Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), asthma (condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), chronic hypoxia (low levels of oxygen in your body tissues), respiratory failure (a serious condition that makes it difficult to breathe on your own), and pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred); - An order for oxygen at two liters per nasal cannula PRN for shortness of breath, dated 2/21/23. Record review of the resident's care plan, dated 2/3/23, showed: - Risk for alteration in respiratory status related to COPD, Asthma, and Chronic Hypoxia; - Oxygen use not addressed in the care plan. During an interview on 3/24/23 at 2:30 P.M., the Director of Nursing (DON, who also functions as the MDS (Minimum Data Set - a federally mandated assessment completed by the facility) Coordinator, said he would expect anticoagulant and oxygen use to be addressed in a resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, facility staff failed to use proper safety techniques to transfer/transport two residents (Resident #21 and #227) out of 18 sampled residents and two residents (Resident #31 and #578) outside of the sample. The facility's census was 75. 1. Record review of Resident #21's quarterly Minimum Data Set (MDS, a federally mandated assessment tool completed by the facility), dated 03/02/23, showed: - Requires extensive assistance with two staff for transfers; - Supervision for locomotion (ability to move from one place to another) on and off the unit; - No functional limitation of range of motion (ROM) to the upper or lower extremities; - Requires extensive assistance of one staff with toileting; - Requires a wheelchair for mobility. Observation of Resident #21 showed: - On 3/22/23 at 12:10 P.M., the Director of Nursing (DON) pushed Resident #21 from the dining room to his/her room with his/her feet dragging on the ground with no foot pedals on the wheelchair; - On 3/23/23 at 11:45 A.M., the DON pushed Resident #21 from the dining room to his/her room with his/her feet dragging on the ground with no foot pedals on the wheelchair. 2. Record review of Resident #31's quarterly MDS, dated [DATE], showed: - Requires extensive assistance of two staff for transfers; - Supervision for locomotion on and off the unit; - Requires extensive assistance of one staff for toileting; - No limitation of ROM to upper/lower extremities; - Requires a wheelchair for mobility. Observation on 3/22/23 at 12:03 P.M. showed the DON pushed Resident #31 down the hall from the dining room. The resident's feet were under the wheelchair and he/she moved his/her left foot in a walking type movement, with his/her right foot toes down with top of foot tucked under, dragging on the ground while the DON pushed the resident down the hall with no foot pedals on the wheelchair. 3. Record review of Resident #227's admission MDS, dated [DATE], showed: - Requires extensive assistance of two staff for transfers; - Dependent on one staff for locomotion on and off the unit; - Requires extensive assistance of two staff for toileting; - No limitation of ROM of upper/lower extremities; - Requires a wheelchair for mobility. Observation on 3/21/23 at 11:38 A.M. showed Nursing Assistant (NA) B pushed the resident from the dining room to his/her room with his/her bare feet dragging the ground with no foot pedals on the wheelchair. 4. Record review of Resident #578's quarterly MDS, dated [DATE], showed: - Requires extensive assistance of two staff for transfers; - Requires extensive assistance of one staff for locomotion on and off the unit; - Requires extensive assistance of two staff for toileting; - No limitation of ROM of upper/lower extremities; - Requires a wheelchair for mobility. Observation on 3/21/23 at 2:16 P.M. showed NA B pushed Resident #578 from the shower room to his/her room with his/her feet dragging on the ground with no foot pedals on his/her wheelchair. During an interview on 03/24/23 at 1:28 P.M., Certified Nursing Assistant (CNA) E said when pushing a resident in a wheelchair, they should have foot pedals. Staff are not supposed to push residents with feet on the ground; no pedals, no push. CNA E said not all residents have foot pedals and if they are needed, they get them from therapy. During an interview on 3/24/23 at 1:47 P.M., Licensed Practical Nurse (LPN) D said some residents are supposed to use their feet and propel themselves; they do not have foot pedals. Staff do push some of these residents without foot pedals, but staff are not supposed to push them without the foot pedals. During an interview on 03/24/23 at 2:30 P.M., the DON and Assistant Director of Nursing (ADON) said residents should have foot pedals and feet should never be dragging the ground when being assisted by staff. The facility failed to provide a policy on proper use of a wheelchair while transporting a resident or the use of foot pedals.

Based on observation, interview, and record review, the facility failed to date the oxygen tubing (a flexible tubing that connects to the oxygen concentrator and delivers supplemental oxygen through the nostrils) and humidifier bottle and failed to have a physician's order for changing and dating oxygen tubing. This practice affected three residents (Resident #30, #41, and #63) out of 18 sampled residents. The facility's census was 75. 1. Record review of Resident #30's Physician's Order Sheet (POS), dated March 2023, showed: - Diagnoses of chronic obstructive pulmonary disease (COPD, lung disease that blocks airflow), obesity, chronic respiratory failure (condition where lungs are unable to get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and congestive heart failure (CHF, condition in which heart does not pump blood as well as it should); -An order for oxygen (O2) at 3 liters/minute (L/min) via nasal cannula (NC) for shortness of breath as tolerated; -No order to change and date the oxygen tubing. During an interview on 3/21/23 at 1:45 P.M., Resident #30 said he/she cannot remember the last time that the O2 tubing was changed. The tubing has not been changed in quite some time and does not get changed regularly. Observations of the resident showed: - On 03/21/23 at 1:41 P.M., resident with O2 via NC at 2 L/min. Tubing with a yellowish brown discoloration. No date on tubing; - On 3/22/23 at 2:23 P.M., resident in wheelchair with O2 via NC at 3 L/min via NC. Tubing with yellowish brown discoloration. No date on tubing; - On 03/23/23 at 9:16 A.M., resident lay in bed with eyes closed with O2 via NC at 3 L/min. Tubing with yellowish brown discoloration. No date on tubing; - On 3/24/23 at 11:45 A.M., resident's O2 lay across the bedside table while the resident in the dining room. Tubing with yellowish brown discoloration. No date on tubing. 2. Record review of Resident #41's POS, dated March 2023, showed: - Diagnoses of CHF, bronchitis (an inflammation of the lining of your bronchial tubes, which carry air to and from your lungs), atrial fibrillation (A-fib) (heart dysrhythmia), hyperlipidemia (high blood level of cholesterol), hypertension (HTN) (high blood pressure), coronary artery disease (CAD) (a condition causing damage to the major blood vessels that supply the heart with blood, oxygen, and nutrients), obesity, COPD, deep vein thrombosis (DVT) (a blood clot in a deep vein of the leg, pelvis, and sometimes arm), acute embolism (obstruction of an artery, typically by a clot of blood or an air bubble); and aortic stenosis (a narrowing of the aortic valve opening); - An order for oxygen (O2) at 2 liters/minute (L/min) via nasal cannula (NC) for shortness of breath; - No order to change or date the oxygen tubing. Observations of Resident #41 showed: - On 3/21/23 at 3:08 P.M., nasal cannula draped over oxygen concentrator. Not in use by resident at this time. No date on tubing; - On 3/22/23 at 08:45 A.M., resident in bed with eyes closed, supine position, with head of bed elevated, O2 noted via nasal cannula at 2L. No date on tubing; - On 3/22/23 at 2:22 P.M., oxygen tubing with nasal cannula lying on floor with no storage bag noted for tubing and nasal cannula. No date on tubing; - On 3/23/23 at 10:40 A.M., resident up in wheelchair at bedside with oxygen in use via nasal cannula at 1 liter/min. Certified Nurse Assistant (CNA) C helped resident remove nasal cannula before taking the resident to the dining room. CNA C left the tubing draped over the bed with the concentrator powered off. No date on tubing; - On 3/23/23 at 12:25 P.M., resident up in wheelchair, oxygen tubing with nasal cannula draped across bed, not in use. No date on tubing; - On 3/23/23 at 3:27 P.M., oxygen concentrator on at 2 L/min with oxygen tubing and nasal cannula on the floor, partially under the wheel of the resident's wheelchair. No date on tubing; - On 3/23/23 at 3:38 P.M., oxygen tubing and nasal cannula lying in the floor. No date on tubing. During an interview on 3/23/23 at 12:25 P.M., Resident #41 said he/she doesn't remember when O2 tubing was changed; he/she had not seen it done in a while. 3. Record review of Resident #63's POS, dated March 2023, showed: - Diagnoses of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), COPD, asthma (condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe), chronic hypoxia (low levels of oxygen in your body tissues), respiratory failure, and pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred); - An order for oxygen at two liters/minute per nasal cannula for shortness of breath; - No order to change and date the oxygen tubing. Observations of the resident showed: - On 3/21/23 at 1:06 P.M., resident's oxygen concentrator running at two liters while resident out of the room. No date on tubing; - On 3/22/23 at 9:23 A.M., resident's oxygen concentrator running at two liters with resident holding the oxygen tubing in his/her hand. No date on tubing; - On 3/24/23 at 8:50 A.M., resident's oxygen concentrator running at two liters with tubing lying on the dresser while the resident lay in bed. No date on tubing. During an interview on 03/24/23 at 10:58 A.M., the Director of Nursing (DON) said oxygen tubing should be changed every 14 days. He believes that it gets changed almost weekly because the residents are up and around and it gets broken and cracked. There is no documentation that it has been changed because it is usually the DON or Assistant Director of Nursing (ADON) that do it because it has to be gotten out of supply. The DON would expect for the residents to have bags to store in when it is not in use and for the tubing to be changed if it was on the floor. During an interview on 03/24/23 at 11:12 A.M., Registered Nurse (RN) A said oxygen tubing should be changed monthly by nursing and it is done on the first of the month. There is no documentation to show that the tubing was actually changed and the tubing is not dated when it is changed to show that it was done. RN A said there should probably be documentation to show that the tubing was changed. Residents should have a bag to store the tubing in when it is not in use instead of it being draped across things. Residents should get new tubing if the tubing is ever on the floor. During an interview on 3/24/23 at 1:28 P.M., Certified Nurse Assistant (CNA) E said if residents are not using their oxygen, they should set the tubing on the concentrator, and if it falls on the floor, staff should get a new one. The nurse has to grab a new one from the supply closet, so they have to report to the nurse. During an interview on 3/24/23 at 1:47 P.M., Licensed Practical Nurse (LPN) F said oxygen tubing should be placed in a bag when not in use, but they disappear. Staff should replace the tubing if it lands on the floor, oxygen tubing should be changed weekly, but not sure who does it, maybe night shift, but it is not charted. Tubing should be dated. During an interview on 3/24/23 at 2:30 P.M., the DON and ADON said the tubing is changed on the first of the month and should be labeled with the date it was changed. The tubing should have a bag for storage when not in use. The tubing should be changed if it fell in the floor and should not be reapplied to the patient. Staff should come and get new tubing from either the DON or ADON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform proper hand hygiene by not washing hands or changing soiled gloves during incontinent care, to use surface barriers to prevent cross contamination of items during resident care, and to ensure a mechanical lift was cleaned and disinfected between resident use for four residents (Resident #30, #41, #67, and #227) out of 18 sampled residents. The facility's census was 75. Record review of the facility's policy titled Perineal Care, revised 2/2018, showed: - Equipment: Wash basin, towels, washcloth, soap and personal protective equipment; - Place equipment on bed side stand; - Wash and dry hands thoroughly; - Fill basin one-half full of warm water. Place at bedside; - Fold the bed spread toward the foot of the bed; - Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet; - Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body; - Put on gloves; - Ask the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary; - Wet wash cloth and apply soap or skin cleanser agent; - Wash perineal area, wiping from front to back; - Continue to wash the perineum (area between genitals) moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean wash cloth; - Gently dry perineum; - Ask the resident to turn on side with top leg slightly bent, if able; - Rinse wash cloth and apply soap or skin cleansing agent; - Wash rectal area thoroughly, wiping from the base of perineum and extending over the buttocks; - Rinse and dry thoroughly; - Discard disposable items into designated containers; - Remove gloves and discard into designated container; - Wash and dry hands thoroughly; - Reposition bed covers and make resident comfortable; - Place call light within easy reach; - Clean wash basin and return to designated storage area; - Clean the bedside stand; - Wash and dry your hands thoroughly. Record review of the facility's policy titled Handwashing/Hand Hygiene, revised 8/2019, showed: - Wash hands with soap and water for the following situations: When hands are visibly soiled and after contact with a resident with infectious diarrhea; - Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: Before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with resident's skin, after contact with bodily fluids, after contact with objects in immediate vicinity of the resident and after removing gloves. Review of the U.S. Food and Drug Administration (FDA), Patient Lifts accessed at https://www.fda.gov/files/medical%20devices/published/Patient-Lifts-Safety-Guide.pdf on 3/28/23, showed, Follow manufacturer instructions to clean and disinfect lift. Always clean lift before and after each patient use. 1. Record review of Resident #30's quarterly Minimum Data Set (MDS, a federally mandated assessment tool required to be completed by facility staff), dated 2/2/23, showed: - Extensive assistance of two or more persons for bed mobility; - Total dependence with two or more persons for transferring, dressing, and toilet use; - Total dependence with one person for personal hygiene; - Frequently incontinent of urine and bowel. Observation on 3/23/23 at 10:01 A.M. showed: - Certified Nursing Assistant (CNA) C and Nursing Assistant (NA) B entered the resident's room with a basket containing wipes, loose gloves, socks, trash bags, and a bottle of peri-wash and placed on the beside table without a barrier; - CNA C and NA B both washed hands and applied gloves; - Resident was incontinent of bowel and urine; - CNA C laid the wipe package on the resident's bed, cleaned the resident, and did not wash hands or change gloves; - NA B sprayed peri wash on the resident, laid the bottle on the bed, cleaned the resident, and did not wash hands or change gloves; - CNA C and NA B dressed the resident, touching the clean incontinence brief, pants, socks, and bedding with the gloves; - CNA C and NA B removed gloves, washed hands, and obtained a mechanical lift from the hallway. CNA C placed the soiled peri wash bottle and package of wipes back in basket, then transferred the resident to his/her wheelchair with the mechanical lift without washing his/her hands. 2. Record review of Resident #41's quarterly MDS, dated [DATE], showed: - Extensive assistance of two or more persons for bed mobility and dressing; - Total dependence with two or more persons for transferring and toilet use; - Extensive assistance of one person for personal hygiene; - Frequently incontinent of urine; - Occasionally incontinent of bowel. Observation on 3/23/23 at 10:19 A.M. of the resident showed: - CNA C and NA B washed hands and applied gloves; - CNA C placed the same soiled peri-wash bottle and wipes used on Resident #30 onto Resident #41's bed without a barrier; - Resident incontinent of urine; - CNA C and NA B took turns spraying and wiping the resident, contaminating the bottle and wipe package with soiled gloves, and did not wash hands or change gloves; - CNA C and NA B dressed the resident, touching clean pants, socks, and shoes with the same gloves; - NA B positioned mechanical lift and wheelchair with soiled gloves; - NA B obtained brush from near the sink with soiled gloves, approached the resident's hair with brush, turned to trash can, removed soiled gloves and did not wash hands or put on clean gloves, brushed the resident's hair, applied oxygen tubing, and then washed hands; - CNA C picked up the peri-wash bottle and wipes from the resident's bed, placed them into the basket, contaminating the basket and its contents, washed hands and placed the mechanical lift in the hallway; - Mechanical lift not cleansed and disinfected between residents. During an interview on 3/24/23 at 10:00 A.M., NA B said: - He/she washes his/her hands between residents; - He/she uses hand sanitizer when entering resident's rooms; - He/she changes gloves between residents; - He/she attended in-services for hand sanitizing, COVID, especially personal protective equipment use, and the use of mechanical lifts. During an interview on 3/24/23 at 10:25 A.M., CNA C said: - He/She washes hands before resident care, when removing gloves, and after resident care; - He/She changes gloves when they are soiled and between residents; - He/She has attended some in-services and recalls perineal care. 3. Record review of Resident #67's quarterly MDS, dated [DATE], showed: - Extensive assistance, one person physical assist for bed mobility and transfers; - Extensive assistance, one person physical assist for dressing; - Extensive assistance, one person physical assist for toilet use and personal hygiene; - Frequently incontinent of urine; - Occasionally incontinent of bowel. Observation on 3/23/23 at 11:03 A.M. of Resident #67 showed: - CNA E and NA B entered the room to provide incontinent care. - CNA E and NA B did not perform hand hygiene and applied gloves; - CNA E and NA B checked resident's brief, dry brief noted. CNA E and NA B did not perform hand hygiene or change gloves; - CNA E and NA B transferred the resident to his/her wheelchair while wearing the same gloves; - NA B made up the resident's bed, touching the bedding with the same gloves; - CNA and NA B removed gloves and washed hands. Observation of Resident #67 on 3/23/23 at 1:15 P.M. showed: - CNA E and NA B entered the room to provide incontinence care. - CNA E and NA B did not perform hand hygiene and applied gloves; - CNA E and NA B pulled resident's pants down to knees, brief noted wet with urine and stool; - CNA E left the room without removing gloves, returned with clean brief and bath towel; gloves noted still in place; - NA B unfastened brief, tucked between legs; - CNA E wet bath towel in sink, no soap applied at this time, then used bath towel to clean peri area; - CNA E turned resident to left side and cleaned buttock area with same bath towel folded to new area, no hand hygiene completed and did not change gloves; - CNA E turned resident to right side, passed same bath towel NA B who cleaned buttock area, no hand hygiene completed and did not change gloves; - NA B turned resident to his/her back, supine position wearing the same soiled gloves, asked resident if brief could be left off due to chafing, resident said yes; - NA B touched the resident's bedding and pulled the covers up wearing the same soiled gloves, resident's pants left pulled down to thigh area; - CNA E removed gloves, took trash containing soiled brief out of room with bare hands, touching door handle, no hand hygiene completed, and returned to room with bag for soiled bath towel; - NA B placed soiled bath towel into the bag, removed gloves, did not perform hand hygiene, adjusted the resident's bedding, then washed hands; - CNA E washed his/her hands in employee bathroom at nurses station after leaving the resident's room. 4. Record review of Resident #227's admission MDS, dated [DATE], showed: - Extensive assistance, two + persons physical assistance for transfers and bed mobility; - Total dependence, one person physical assist for dressing; - Total dependence, one person physical assist for personal hygiene; - Frequently incontinent of urine; - Occasionally incontinent of bowel. Observation on 3/23/23 at 10:56 A.M. of Resident #227 showed: - CNA E and NA B entered the resident's room. - CNA E and NA B did not perform hand hygiene and applied gloves; - CNA E and NA B transferred resident to wheelchair, resident's shorts wet on back brief area, did not check or change clothing at this time; - CNA E removed gloves, washed hands; - NA B brushed resident's hair, did not remove gloves or perform hand hygiene - CNA E and CNA B assisted resident to put on back brace, foot pedals noted on wheelchair. - CNA E pushed resident in wheelchair to dining room; - NA B pulled bed cover up into place over area noted wet with urine; removed trash liner, removed gloves, washed hands. Observation on 3/23/23 at 1:20 P.M. of Resident #227 showed: - CNA E picked up peri-wash bottle, towel, wash cloth, and clothing, entered resident's room with NA B to transfer and assist resident to shower; CNA E washed hands and applied gloves; - CNA E and NA B propelled resident to shower room; - CNA E and and NA B removed the resident's back brace, the resident's shorts wet in front crease area; - CNA E unfastened the resident's brief; - Licensed Practical Nurse (LPN) F entered the shower room. LPN E did not perform hand hygiene, applied gloves, and pulled down the resident's shorts as CNA E and NA B transferred the resident to the shower chair; - CNA E and NA B removed the resident's pants and brief, brief very wet, CNA E and NA B did not remove gloves or perform hand hygiene. LPN F removed gloves, did not perform hand hygiene, and left shower room; - CNA E turned on the shower, wet the resident's hair and poured shampoo, intended for hair wash only, directly on top of the resident's head and washed his/her hair; - With the same shampoo, CNA E applied it to the wash cloth and cleansed the resident's torso, legs and arms. CNA E did not cleanse the resident's front periarea, back or either armpit; - NA B dried the resident's hair and body; - CNA E and NA B placed a gown on the resident and transferred him/her to wheelchair; - CNA E and NA B removed gloves, placed foot pedals on wheelchair, placed slippers and a blanket on resident, did not perform hand hygiene; - CNA E and NA B propelled the resident to his/her room; - NA B pulled the resident's soiled covers down on his/her bed, removed old pad and placed new pad on bed over soiled bed linens with no gloves on and did not perform hand hygiene; - CNA E and NA B transferred the resident to his/her bed without removing the resident's shoes; - NA B applied glove, no hand hygiene performed, and applied zinc cream to buttocks/gluteal crease; - NA B removed glove, did not perform hand hygiene, and positioned the resident in bed; - CNA E pulled resident's bedding up with resident's house shoes on his/her feet; - CNA E washed hands; - NA B said he/she needed to wash his/her hands; did not wash hands at this time due to resident's roommate coming out of the bathroom in wheelchair, NA B assisted roommate to sink to wash his/her hands, touching wheelchair handles. NA B did not wash his/her hands at this time; - NA B pulled the bedside table to Resident #227's bed, picked up the resident's cup and touched straw, without washing his/her hands; - NA B washed hands. During an interview on 3/24/23 at 1:28 P.M., CNA E said hands should be washed before going into a room, and before care, change gloves between cleaning, wash hands when done between front and back and sanitize between. He/she said staff receive in-services once a year on hand hygiene. During an interview on 3/24/23 at 1:47 P.M., LPN D said staff should wash their hands after pericare, after mouth care, before going to another new surface; staff should wash their hands prior to giving a resident a drink and after providing a shower. He/she said staff should clean front to back, after cleansing a bowel movement, staff should change their gloves and use different sections of the washcloth. During an interview on 3/24/23 at 2:30 P.M., the Assistant Director of Nursing said: - The mechanical lift should be cleaned between residents; - She expects the aides to take the incontinent care baskets from room to room and to sit it on a clean barrier. One of the aide's hands should remain clean and use the spray. If the bottle becomes contaminated, it should be cleaned; staff have been in-serviced on this, and will be given another in-service. During an interview on 3/24/23 at 2:30 P.M., the Director of Nursing said: - He would expect the aides to wash their hands before and after any interaction with residents, obvious soiling, coming in from outside, between residents, anytime they would become soiled, and would expect glove changes when they become soiled; - He would expect mechanical lift to be cleaned with obvious soiling and by the night shift.