**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate supervision to prevent accidents for one sampled resident (Resident #1). Licensed Practical Nurse (LPN) A failed to visualize the resident when performing the required midnight census safety rounds and Certified Nursing Assistant (CNA) A failed to visualize the resident when doing two-hour nightly rounds. As a result, the resident self exited into the facility courtyard after dark, without staff awareness and fell from his/her wheelchair out of six sampled residents. The facility census was 62 residents. On 6/3/25, the facility Administration was notified of the past noncompliance which occurred on 5/31/25. Facility staff had subsequently been educated on hourly checks to courtyard, abuse, neglect, and two-hour rounding by CNAs. Alarms were ordered for the courtyard doors and additional lighting installed in the courtyard. The deficiency was corrected on 6/1/25. Review of the facility's Midnight Census policy dated 12/24 showed: -It was the policy of the facility to complete an accurate count of all residents in the facility at midnight each night. -This count was known as the Midnight Census. -This manual count was to be completed each night at midnight by the nurse in charge. -A midnight census was essential to the tracking of residents for accountability for clinical and bookkeeping purposes. -All disciplines should be aware of the daily midnight census. -Each resident would be visualized for accuracy of the count and the resident's presence or absence and the changes in the past 24 hours would be noted on the Midnight Census Report. 1. Review of Resident #1's admission Record face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Parkinson's disease (a progressive disorder that affects movement and coordination). -Alzheimer's disease (a progressive, irreversible brain disorder that slowly affects memory, thinking skills, and the ability to carry out basic tasks). -Difficulty walking. -Reduced mobility. -Insomnia (a sleep disorder which caused difficulty going to sleep, staying asleep and waking early). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 3/7/25, showed he/she was cognitively intact. Review of the resident's Care Plan Report dated 2/28/25 showed: -He/She had activity preferences including taking care of plants/garden; going outside and getting fresh air when the weather was good; being alone and doing things by him/herself. -He/She had decreased mobility. Interventions included staff participation for transfers. -He/She had Parkinson's disease. Interventions included monitoring for risk of falls; mobility as tolerated; monitoring for poor balance, poor coordination and insomnia. Review of the Resident's Fall Incident Report dated 6/1/25 at 4:35 A.M. showed: -The resident was able to make his/her needs known. -He/She had gone out in the courtyard and was found lying face down on the concrete walkway. -He/She was found around 4:30 A.M. according to staff, after they did not find him/her in his/her room during regular room checks by his/her CNA. -He/She initially said he/she had gone outside around 8:00 P.M., but staff said this was not accurate. -He/She stated he/she went outside to find a spot to plant his/her tomato plant, he/she stood up and fell. -He/She did not know why he/she stood up. -He/She didn't remember the time he/she went out to the courtyard. -The staff state he/she was visiting with another resident until around 9:00 P.M. and that resident collaborated the same time. -The CNA stated he/she helped the resident to bed around 9:30 P.M. -The CNA stated when he/she did rounds, the resident was in bed until the 4:00 A.M. check, which occurred between 4:00 A.M. and 4:30 A.M. -When he/she was found by CNA A, the charge nurse was alerted and the resident was checked for injuries. -Staff stated neuro checks were within normal limits; blood pressure was noted to be low. -Ambulance was called per protocol for unwitnessed fall since the resident was on an anticoagulant. -Staff reported the resident was up more during the night, but had only tried to go out on the courtyard a couple times. -Staff stated they had never noticed him/her trying to leave the facility. -New interventions would be added when the resident returned from the hospital. Review of the resident's Progress Notes dated 6/1/25 at 6:58 A.M. showed: -He/She was found outside in the courtyard lying face down on the concrete walkway. -He/She did not tell staff he/she was going outside. -He/She went outside to find a place to plant his/her tomato plant. -He/She stood up and fell, but did not remember why he/she stood up. -He/She moved all extremities and denied any pain. -His/Her daughter stated his/her symptoms of Parkinson's, memory and cognition had worsened greatly. -He/She was encouraged to leave the door to his/her room open for more frequent monitoring and to not go to the courtyard late at night without staff knowledge. Review of the resident's Progress Notes dated 6/1/25 at 5:30 P.M. showed: -The resident was alert and able to have a conversation. -He/She was asked if he/she remembered when he/she had gone out in the courtyard and he/she could not remember the exact time he/she went out. -He/She did recall being in another resident's room crocheting prior to going to his/her room. -The other resident he/she was visiting thought he/she had left his/her room around 9:00 P.M. -He/She voiced that he/she was going out in the courtyard to see where he/she could plant the tomato plants he/she had gotten while out of the facility with his/her daughter the day before. -He/She said he/she didn't yell for help and did not have his/her cell phone with him/her. -He/She did attempt to get him/herself up and was unable to do so. -He/She could not give a time frame for how long he/she was outside. During an interview on 6/2/25 at 9:30 A.M. the resident said: -He/She went out to the courtyard to see where he/she was going to plant his/her tomato plant. -He/She did not tell anyone he/she was going outside. -He/She did not call out for help because he/she didn't think anyone would hear him/her. -He/She fell because he/she stood up from his/her wheelchair. He/She probably should not have stood up. -He/She did not remember telling staff not to wake him/her during the night. During an interview at 11:43 A.M. CNA A said: -He/She found the resident in the courtyard. -The staff would do rounds every two hours, but did not typically check the courtyard. -He/She did not remember what time he/she last saw the resident up and around. -When rounding, he/she would stop near the resident's bathroom to check him/her, since he/she was continent, so he/she would not wake the resident up. -The resident had said not to bother him/her unless he/she needed something. -He/She could see the resident's feet in his/her bed from by the bathroom. -He/She came to work around 10:00 P.M. -The resident was very active at night sometimes, but usually stayed in his/her room. Sometimes he/she would be laying down or sometimes stay up knitting. -There was a light in the courtyard, but not very bright. -The resident was far enough back from the exit door in the courtyard that he/she would not have been seen if someone had glanced out. -The resident used his/her wheelchair to get around, but thought he/she could do more than he/she actually could. -He/She went in the resident's room at 4:30 A.M., because something just told him/her to check and see if the resident was there. -He/She swore he/she saw the resident's feet in bed during the previous rounds. -He/She went to the nurse and the nurse had not seen the resident. -He/She got another CNA to assist him/her looking for the resident. -He/She decided to check the courtyard because the resident liked to go out there. -He/She found the resident face down and his/her wheelchair was behind him/her. -The resident was awake. -The resident said he/she had a tomato plant and was trying to find a spot to plant it. -The staff did rounds to check the residents every two hours, which is what they are trained to do. During an interview at on 6/2/25 at 12:00 P.M. Physician A said: -He/She was advised of the situation with the resident that morning. -The resident would sometimes go around in the facility during the evenings. -He/She had been working with the resident due to his/her difficulty sleeping, trying different medications. -He/She was not sure how mobile the resident was at night. -He/She had been having very thorough conversations with the resident about his/her sleep concerns; he/she was able to make his/her needs known. -The expectation would be that the resident was checked per the facility protocol during the night. During an interview on 6/2/25 at 1:10 P.M. CNA B said: -He/She assisted CNA A with the resident. -He/She started his/her round around 4:00 A.M. and CNA A came to him/her and said the resident was not in his/her room. -He/She checked all of the rooms in his/her hall and the resident was not in any of the other rooms. -He/She asked CNA A if he/she had checked the staff bathroom and it had been checked by the nurse. -They rechecked all of the resident rooms. -The previous week he/she had stopped the resident from going out to the courtyard around midnight because he/she was looking for his/her knitting bag, which was on the back of his/her chair. -The resident was a little forgetful. -They found the resident in the courtyard, face down on the ground, with his/her wheelchair to the side of him/her and folded on the ground. -The resident said he/she was out there trying to figure out where he/she was going to put his/her tomato plant. -Rounding was done every two hours and that meant laying eyes on the residents to make sure they were breathing. -The staff had not been checking the courtyard at night. During an interview on 6/2/25 at 1:30 P.M. Licensed Practical Nurse (LPN) A said: -When he/she was doing rounds at around 8:00 P.M. the resident was awake and laying in his/her bed. -The resident liked to go visit the other residents throughout the facility. -CNA A made rounds every two hours and said he/she walked in the resident's room and saw his/her feet. -The resident did not want to be awakened during the night, and did not want the light turned on. -During 4:00 A.M. rounds CNA A went further in the resident's room and found him/her missing. -The staff began looking for the resident; they checked all of the resident rooms and the bathrooms. -The resident was found in the courtyard. -He/She had no idea the resident had been going outside at night without staff knowledge. -The staff had never had anyone go out to the courtyard at night and and never thought of checking the courtyard. -If all the residents were in their beds, there would be no need. -The resident was awake when he/she was found, and denied pain. -The resident was sent to the hospital due to being on a blood thinner. -Rounding to check residents should be done every two hours. During an interview on 6/3/25 at 11:00 A.M. Resident #3 said: -He/She knew the resident and there were times the resident would try to get him/her to go with him/her to the courtyard. -The resident had been in the courtyard the night before he/she fell. -The resident was a night person; sometimes he/she would go to bed in the early morning hours. -He/She knew the resident went out at night, but did not think the staff were aware. During an interview on 6/3/25 at 11:10 A.M. Resident #2 said: -The resident had come to see him/her the night he/she fell, and left his/her room around 10:00 P.M. or a little before. -The resident did not ask him/her to accompany him/her to the courtyard that night, but had asked him/her earlier in the day. -The resident was a night owl and sometime would come visit him/her at 8:00-9:00 P.M. -He/She did not know if the staff knew the resident had been going out in the courtyard. During an interview on 6/3/25 at 12:30 P.M. the Director of Nursing (DON) said: -There was not an assignment for staff to check the courtyard. -He/She did not think the resident could have been out there long or he/she would have developed hypothermia (low body temperatures), since he/she was not a big person. -He/She was used to it being the standard that the charge nurse physically counted the residents at midnight and that was his/her expectation. -CNA A should have gone in and visualized the resident. -The resident did not wish to be awakened during the night because he/she didn't sleep well. -The resident stayed up later than people were used to. -The resident typically stayed in his/her room and staff had to encourage him/her to come out. He/She was just settling in to the facility. -The resident was excited about his/her plant as this was an activity he/she could do with the other residents. -The resident was starting to have more issues with his/her memory. During an interview on 6/3/25 at 1:00 P.M. the Administrator said: -The facility did not have a specific policy on rounding. -CNA A said he/she rounded every two hours and he/she saw the resident's feet in his/her bed at 2:00 A.M. -CNA A peeked at the resident in his/her room at 10:00 P.M., 12:00 A.M. and 2:00 A.M. At 4:30 A.M. he/she was not in his/her bed. -The resident had asked not to be bothered at night. -They had caught the resident trying to go out late at night before but it was not unusual for him/her to be up late at night. -If the resident had gone through the dining room exit to the courtyard, the staff would have seen him/her. He/She went out the other exit to access the courtyard. -There had been some changes in the resident's cognition, but he/she was not an elopement risk. -The resident would go outside and sit in the courtyard for hours taking pictures of flowers. -He/She had been excited he/she could have his/her own tomato plant. -The facility did not lock the doors to the courtyards because another facility had gotten in trouble for doing so. -The courtyard had lighting. -The expectation was that rounding was done every two hours and maybe more if needed. -The charge nurse did not check residents' room-to-room at midnight. It was his/her expectation that this would be done. -It had not previously been a practice to check the courtyard at night, so they never did it. -CNA A should have gone into the room to check the resident. -The staff had seen the resident go outside before; it was a known thing. -It was his/her expectation that staff would follow the midnight census policy. -The resident's vital signs were within normal limits, when he/she was found. He/She did not say he/she was upset or cold. -The resident denied calling for help even though there were windows surrounding the courtyard. MO00255085 MO00255111 1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent the misappropriation of 30 tablets of 2 milligrams (mg) Hydrocodone (an opioid pain medication used to treat moderate to severe pain) belonging to one sampled resident (Resident #2) out of four sampled residents. The facility census was 66 residents. The Administrator was notified on 9/18/24 of Past Non-Compliance which occurred on 9/3/24. An all nursing staff in-service was completed on drug diversion and working under the influence of drugs/alcohol by 9/3/24. The resident's missing medications were replaced and paid for by the facility. The deficiency was corrected 9/3/24. Review of the facility's Controlled Substance Policy revised 5/23 showed: -Controlled substances were subject to special handling, storage, disposal and record-keeping requirements. -The facility would maintain compliance with these special provisions. -Such drugs were to be accessible only to authorized nursing and pharmacy personnel. -The Director of Nurses (DON) was responsible for the control of such drugs. -Drugs listed in Schedules II, III, and IV (drugs that are regulated by the Drug Enforcement Administration, categorized based on their medical use, potential for abuse and risk of dependence) were to be stored under double-lock conditions. -The key to the separately locked storage area was not the same key used to gain access to other drugs. -The medication nurse or Certified Medication Technician (CMT) where applicable on duty at the time would maintain possession of the key. The key must remain in possession of the licensed nurse or CMT where applicable that completed the count at all times during their shift. Should it be necessary to give the keys to another licensed nurse or CMT, a count would be done to verify the inventory. A count would be done again when the keys were returned to the original licensed nurse or CMT. -A physical inventory of the controlled substance medications would be made at the change of each nursing shift. Shift verification count sheets/packages should be made at the change of each shift. -The person performing the inventory would sign to verify that the inventory was done. All controlled substances were to be counted every shift. The count was to be performed by the on-coming licensed nurse or CMT and the off-going licensed nurse or CMT. The on-coming nurse or CMT would be responsible for looking at the medication to verify the amount of medication present at the time of the count. The off-going nurse or CMT would be responsible for viewing the Controlled Substance Proof of Use Record to verify the amount on the record at the time of the count. Both nurses or CMT would sign on the Narcotic Sign In & Out Sheet that the count was completed. -Any discrepancy in the inventory of a controlled substance was to be reported to the DON immediately. The DON was responsible for investigating and making a reasonable effort to reconcile all reported discrepancies. The discrepancy of a controlled substance was to be reported to the Administrator and the Regional Nurse immediately. If a discrepancy was not reconciled, the DON was to document the details on the audit record, including the possible shift or persons responsible for the discrepancy and the efforts made to reconcile it, 1. Review of Resident #2's admission Record face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Sickle cell disease with crisis (a condition in which red blood cells become abnormally shaped like crescents or [NAME], rather than the usual round shape). -Critical illness myopathy (a condition that affects patients who have been critically ill and have had prolonged immobility, characterized by muscle weakness). Review of the resident's Order Summary Report dated 9/18/24 showed: -He/She had an order for Hydromorphone HCl 2 mg tablet. Give 1 tablet by mouth every 3 hours as needed for pain. -He/She had an order for Hydromorphone HCl 2 mg tablet. Give 2 tablets by mouth every 3 hours as needed for pain. Review of the resident's Medication Administration Record (MAR) for the dates of of 9/2/24 and 9/3/24 showed: -The resident received Hydrocodone HCL 2 mg 2 tablets on 9/2/24 at 9:00 A.M. for pain, which was given by Licensed Practical Nurse (LPN) B. -The resident received Hydrocodone HCL 2 mg 1 tablet on 9/2/24 at 1:01 P.M. for pain, which was given by LPN B. -The resident received Hydrocodone HCL 2 mg 2 tablets on 9/2/24 at 5:00 P.M. for pain, which was given by LPN B. -The resident received Hydrocodone HCL 2 mg 2 tablets on 9/2/24 at 8:32 P.M. for pain, which was given by LPN A. -The resident received Hydrocodone HCL 2 mg 1 tablet on 9/3/24 at 2:15 A.M. for pain, which was given by LPN A. -The resident received Hydrocodone HCL 2 mg 2 tablets on 9/3/24 at 5:45 A.M. for pain, which was given by LPN A -The resident received Hydrocodone HCL 2 mg 2 tablets on 9/3/24 at 9:05 A.M. for pain, which was given by LPN B. Review of the resident's Care Plan dated 9/3/24 showed he/she was prescribed opioid medication. Interventions were to give the medication as ordered and monitor for side effects. Review of the facility Narcotic Diversion timeline investigation dated 9/3/24 showed: -The DON was notified by LPN B the narcotic card count was one card short. He/She believed that a card of Dilaudid (Hydromorphone HCL) 2 mg was missing. He/She stated he/she had counted the cart with the other nurse in the building and all the other medications were accounted for. -The DON received a text from LPN A stating he/she needed to talk to him/her. -The DON called LPN A, who stated he/she had left the facility as he/she had to take his/her child to school. He/She stated LPN B accused him/her of taking a card of narcotics because the count was off and he/she was offended. He/She was told he/she would need to take a urine drug screen and he/she stated he/she would come take the test. -LPN B was interviewed and statement obtained. -Registered Nurse (RN) A was interviewed and statement obtained. -All medication carts, narcotic drawers and medication rooms were cleaned and organized. Narcotic counts verified for all 3 medication carts. -Audit was completed of narcotic book against the MAR. -The DON spoke with pharmacist at the facility's pharmacy and requested to be sent a list of the narcotics sent to the facility after 6:00 P.M. on 9/2/24. He/She stated he/she was unable to run that report and would have his/her supervisor contact him/her. He/She requested the pharmacy send out a new card of Dilaudid 2 mg tabs that the facility would be paying for and the resident was not to be billed. -The Medical Director was notified of the missing narcotics. Resident #2 was his/her own person and notified of the missing narcotic and that they would be replacing it for him/her. -The Administrator called and sent multiple messages to LPN A explaining why he/she needed to come to the community to give his/her statement and complete a drug test. -LPN A returned to the facility around lunch time and was interviewed by the Administrator and DON. He/She stated he/she didn't know what happened to the card that LPN B said was missing when they counted the cards. -There were 22 cards when LPN A took the cart from LPN B at the start of his/her shift. LPN B verified there were 22 cards when he/she took the cart and he/she only removed one empty card for the resident. -LPN A stated he/she couldn't remember for sure, but that he/she was pretty sure he/she did not give his/her keys to anyone else during his/her shift. -LPN A was notified that he/she was being suspended pending investigation. -After interviews and investigation, the only person who had access to the medication that was missing was LPN A. Based on this and the behavior during the investigation, it was believed that he/she was the nurse that took the medications. Review of LPN A's written statement dated 9/3/24 showed: -When LPN B came into work that morning, he/she gave him/her report and counted with him/her. All of his/her counts were correct, but then he/she started asking about a card of 30 hydromorphone that he/she said was missing. He/she told him/her he/she didn't know anything about that, the only card he/she took out was a card for hydromorphone for another resident, but he/she did not remember for which one. -LPN B kept stating that it was missing and that the card was there when they counted the evening before. He/she told him/her he/she did not remember and he/she asked how he/she could not remember. He/She continued to tell him/her he/she did not remember, and then he/she said he/she knew he/she took it so just to say that he/she did. -He/She told him/her he/she didn't take anything and would do whatever possible to show he/she did not take it. -At that point, he/she had already given report and counted with him/her. -LPN B threw the keys down and said he/she would not take the cart. -He/She told him/her he/she had class that morning and had to leave. At that point, LPN B walked away and he/she left. Review of LPN B's written statement dated 9/3/24 at 10:56 A.M. showed: -On 9/2/24 at 6:35 P.M., he/she counted the medication cart #2. There were 22 cards left in the cart. The night nurse accepted the count and took the keys. -On 9/3/24 around 6:40 A.M. he/she counted the cards and there were only 20 cards. The night nurse said there were 21. -He/She confirmed there were only 20 cards there. -He/She attempted to call the Assistant Director of Nursing (ADON) and received voice mail. -He/She told the night nurse to wait until they talked to the ADON or DON, but he/she said he/she was not waiting, that he/she had class and left. -He/She and the RN A counted 20 cards. He/She later realized the card for hydromorphone was missing for Resident #2 and reported that to the DON. -Confirmed from the pharmacy that 2 cards were sent on 8/31/24 for 60 tablets. Review of the pharmacy packing slip dated 9/3/24 showed 60 2 mg tablets of Hydromorphone were delivered to the facility for Resident #2 to replace missing medications. During an interview on 9/18/24 at 10:55 A.M., the Administrator said: -The facility's system caught the medication problem. -A card count was done and then the pills were counted at shift changes. -LPN B counted with LPN A at 6:00 P.M. the night of 9/2/24, and the next day, he/she relieved him/her on the same cart. -LPN A had just come off orientation and this was the first shift he/she worked alone. -The counting could not have been done differently. -His/Her expectation was that when people came to work, they did not steal drugs. -Other staff did not have access to the keys. The expectation was that the narcotic boxes were kept locked and only the nurse had the key, -The nurses were trained to do the narcotic count each shift. This was never something that was not done. During an interview on 9/18/24 at 12:15 P.M., RN A said: -There was a process for the narcotic counts. -After report the off-going and on-coming nurses would count the cards and pills. -If something was off, the DON should be called. -When medications were delivered, they would come in plastic bags and the nurse and the pharmacy staff sign off on the count. -If the pharmacy were called, they would know who signed off on the medications. -He/She had not had any issues with that. -LPN B worked the previous day. When LPN A came in that night, they did the count together, and the count was accurate at that time. -LPN A worked the night shift. -LPN B came in the next morning and worked at the same hall with the same medication cart. -He/She heard the two of them talking about a medication card being missing. -LPN A said one of the cards had gone down to zero medications, so he/she removed it. -A card would have the resident's name on it. Normally when the card got down to zero medications, the staff person would sign it and remove it. -LPN B said there was not a page in the narcotic book for the card and the card was not subtracted, so he/she called the DON and told LPN A not to leave. -LPN A said he/she had a class to go to and left anyway. -He/She then did the count with LPN B, which was accurate except for the missing card. -Only the nurse for that medication cart had access to the keys for the cart. The box where the narcotics were kept had a separate key from the cart. During an interview on 9/18/24 at 12:30 P.M., LPN B said: -LPN A came to work at 6:00 P.M. that night. LPN A worked nights and he/she worked days. -They counted the medication cards and there were 21. -The next day, he/she came to work at the same cart and noticed a medication card was missing. -When he/she noticed the card was missing, LPN A did not stay to count the individual pills. -This was possibly LPN A's fourth week at work. He/She had worked at the facility almost 3 years. -He/She had never had this happen before at that facility. -They looked for the missing card and could not find it. -He/She contacted the DON immediately. -The DON asked him to count with RN A, since LPN A had left. -Only he/she and LPN A had access to the medication keys. -The staff were not supposed to let anyone else have the keys. -He/She was called in to the office and he/she wrote a statement and told the DON the same thing. During an interview on 9/18/24 at 1:10 P.M., Resident #2 said: -He/She was getting all of his/her pain medication. -He/She did not know about any missing medications. During an interview on 9/18/24 at 2:00 P.M., RN B said: -When he/she came to work, he/she would not take the cart until the medications are counted. -If there was a discrepancy, they should call the DON. -It would not have been possible for a full card of medications to be missing. -When a card was emptied, it was recorded in the narcotic book. -He/She had three keys, one for the cart and two for the narcotic boxes in the cart. -Each key only worked on a specific drawer. -Cart keys only would open specific carts and did not interchange. -Nobody else would hold his/her keys while he/she was working. -He/She would only give his/her keys to the ADON or DON. -He/She never would take lunch away from the facility premises so he/she would not have to turn the keys over to someone else. Observation on 9/18/24 at 2:00 P.M. with RN B showed a medication cart, narcotic drawers, keys and demonstration of how they worked. During an interview on 9/18/24 at 2:05 P.M., the ADON said: -The day it was reported the narcotics were missing, LPN B realized there was a discrepancy and that a card was missing and the count was off. -The nurses counted the medications every shift. -LPN B did what he/she was supposed to do, which was contact him/her and the DON. -There was no way the card could have been lost. -The medication cart was locked. -If the count was wrong, unless the resident left the facility, nothing would be destroyed. -LPN A had just completed orientation. He/She would have been the only one who had access to that cart that night. -If a staff person gave the keys to someone else, they should count the medications together. During an interview on 9/18/24 at 2:15 P.M., LPN A said: -He/She was aware of the missing narcotics. -He/She offered to work that night. -He/She counted the narcotics with LPN B and worked through the night. -He/She passed possible 2-3 as needed medications that night. -His/Her count was right, but LPN B said a card was missing and accused him/her of taking the card. -He/She called the DON and told him/her what LPN B was saying and that it was not his/her place to say that. -His/Her medication cart was visible in the hallway at all times. -He/She had to go to a class that day, so he/she left the facility. -Between 11:00 A.M. and 11:30 A.M., he/she got a call from the DON or the Administrator; he/she could not remember who. -The Administrator asked him/her why he/she didn't stay when he/she got off work and he/she had already told the DON. -They asked him/her a lot of questions. He/She said he/she had to pick up his/her child from school, so he/she had to leave. -He/She did not think anyone had access to his/her keys. He/She had them on the counter when he/she was charting. Only he/she and one other nurse were working that night. He/She did not remember who the other nurse was. -He/She had not really had training specific to the facility for doing the narcotic count. -This was not his/her first night off orientation. -He/She had not heard back from the facility and assumed he/she was fired. During an interview on 9/18/24 the DON said: -LPN A said he/she did not give anyone else the keys. -The nurses were supposed to count the medication cards; how many cards were added or removed, and then they count the individual pills on each card and compare against the individual residents' narcotic sheets. -LPN B got really agitated because of the missing medication. -He/She did everything he/she was supposed to do and called him/her when he/she found the discrepancy. -They asked LPN A to come to the facility at 10:45 A.M. and he/she didn't come until 12:45 P.M. -This would have been the first shift LPN A worked by him/herself. He//She picked up the extra shift. -There were cameras at the front of the facility. LPN A made multiple trips to his/her car during that shift. He/She worked from 6:00 P.M. to 6:00 A.M. This was not a normal pattern for a nurse. He/She took the keys with him/her. -Every narcotic box had a key with a number on it, and the medication cart had another key with a number and a matching number on the cart,; they are not interchangeable. -There was no master key for the medication carts. -The keys were the nurse's responsibility. MO00241543

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide transportation to two scheduled follow up appointments for one sampled resident (Resident #2) out of four sampled residents. The facility census was 68 residents. A policy for outside appointments was requested from the facility's Director of Nursing (DON). He/she reported the facility had no policies related to outside appointments for residents. 1. Review of Resident #2's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 9/25/23, showed: -The resident scored a 05 on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions. --This showed the resident had severe cognitive impairment. Review of the resident's face sheet, undated, showed: -The resident was admitted to the facility on [DATE] with the following diagnoses: --Cancer of the left eye. --Aftercare following surgery of eye removal. --Acquired absence of eye. --Skin transplant status. Review of the resident's care plan, dated 9/18/23, showed the resident had an activity of daily living (ADL) deficit related to neoplasm (a growth that developed in the body) of his/her left eye resulting in the removal of his/her left eye and an allogenous skin transplant (a skin graft harvested from a human, but not from the recipient patient) on 9/7/23. Review of the hospital discharge/referral paperwork (page three), dated 9/18/23, and showed: -On 9/25/23 at 11:30 A.M., the resident had a scheduled appointment with the Ear, Nose and Throat (ENT) physician. -On 10/5/23 at 9:00 A.M., the resident had a scheduled appointment with a cancer center. During an interview on 10/11/23 at 8:40 A.M., the resident said: -He/she had a biopsy which showed cancer around his/her left eye. -He/she had chemotherapy (a drug treatment that uses powerful chemicals to kill fast-growing cells in your body) and radiation but ended up losing his/her eye anyway. -He/she had no follow up appointments since arriving at the facility. During an interview on 10/11/23 at 10:59 A.M., a Nurse Practitioner (NP) said: -He/she was familiar with the resident. -He/she was not in charge of follow up appointments. -The resident should have follow up appointments as ordered by the physician. -The admission and rehabilitation unit nurse checked the hospital discharge paperwork for any follow up appointments. During an interview on 10/11/23 at 11:57 A.M., Licensed Practical Nurse (LPN) A said the nurses were in charge of making any follow up appointments. During an interview on 10/11/23 at 12:06 P.M., LPN B said: -He/she had recently started working with the resident. -The resident's graft site was cleaned daily with no issues. During an interview on 10/11/23 at 12:28 P.M., the DON said: -The resident had an appointment on 9/25/23. -The discharge paperwork said the appointment was at 11:30 A.M. -The time was incorrect on the paperwork and the correct time was at 10:00 A.M. -The notification of the wrong time was not timely enough for the transportation company to get the resident to the appointment. -The rehab nurse was trying to reschedule the appointment and was getting the run around. -The facility could not get confirmation from the doctor office of the rescheduled appointment for 9/26/23. -The appointment for 9/26/23 was never actually scheduled. -He/she had no knowledge of the appointment scheduled for 10/5/23. -There was no documentation of phone contacts prior to 10/5/23. During a three way phone call on 10/11/23 at 1:23 P.M., the Assistant DON (ADON) said: -There was confirmation from the transportation company that the resident was dropped off for the 9/26/23 appointment. -The transportation company did not pick up the resident. -The issue was playing phone tag with the cancer center social worker. -The calls to the cancer center dropped off and then went to a fax line. -He/she gave his/her personal cell phone number to the cancer center. -He/she left a voicemail with the ENT surgeon. -He/she was unaware of an appointment for 10/5/23. During an interview on 10/11/23 at 1:52 P.M., Nurse LPN C said: -The hospital discharge paperwork showed the resident had a follow up appointment scheduled for 11:30 A.M. on 9/25/23. -The physician's office left a message with the facility receptionist requesting the appointment be moved to 10:00 A.M. on 9/25/23. -It was too short of notice for the transportation company to change their schedule and could not take the resident to the 10:00 A.M. appointment on 9/25/23. -He/she made calls to the cancer center on 9/25/23, 9/27/23 and 9/28/23 to attempt to reschedule the missed appointment. -No follow calls were made to the cancer center 9/29/23 through 10/4/23. During an interview on 10/11/23 at 2:20 P.M., the DON said: -He/she expected to be notified if a resident had missed any appointments. -He/she expected to be notified of any issues with follow up appointments. -He/she would reach out his/herself to the cancer center to get appointment scheduled. During an interview on 10/11/23 at 2:25 P.M., the Administrator said no one at the facility was aware of the 10/5/23 appointment until the cancer called the facility on 10/9/23. During an interview on 10/12/23 at 9:35 A.M., the cancer center social worker said: -He/she had been contacting the facility phone number and spoke to the ADON and LPN C. -He/she also called the facility and spoke to the facility receptionist and gave messages to the ADON. -He/she talked to the ADON and LPN C regarding rescheduling appointments for the resident. -He/she received on message from the ADON on 10/10/23 around 2:00 P.M. and returned that call on 10/10/23 around 4:00 P.M. but had to leave a message regarding rescheduling at both the ENT and cancer center. -The electronic chart showed the resident's appointments on 9/26/23 and 10/5/23 as a no show. -The resident's appointments were on the hospital discharge paperwork provided to the facility. MO00225745

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) for one sampled resident (Resident #49) out of 18 sampled residents. The facility census was 70 residents. A policy for PASARR was requested from the facility and not provided. 1. Review of Resident #49's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Senile degeneration of the brain (the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age). -Generalized anxiety disorder (a condition of excessive worry about everyday issues and situations). -Cognitive communication deficit (difficulty with thinking and how someone uses language). -Stroke. -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Memory deficit following cerebral infarction (stroke). On 9/12/23 a copy of the residents PASARR was requested and not provided. During an interview on 9/12/23 at 9:54 A.M., the Administrator said: -The resident was a private pay resident. -The resident had transferred in from another facility. -The resident did not have a PASARR on file at the facility. During an interview on 9/12/23 at 2:03 P.M., Social Services Director (SSD) said: -He/she did not realize that this resident did not have a PASARR Level One performed at the prior facility. -He/she thought that since the resident was a private pay resident that a PASARR was not needed. -He/she was responsible to ensure all residents had a PASARR performed. -He/she had submitted a PASARR Level One that day for the resident. During an interview on 9/14/23 at 1:04 P.M., the Director of Nursing (DON) said: -It was his/her expectation that all residents would have a PASARR performed and on file at the facility. -The SSD was the person responsible to ensure that all residents had a PASARR performed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders for a Low Air Loss Mattress (LAL- an air mattress covered with tiny holes which are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture), to follow physician orders to apply topical medication to the resident's skin as needed for moisture and redness and to apply protective barrier cream after resident incontinent episodes with moisture associated skin breakdown per professional standards of practice for one sampled resident (Resident #32) out of 18 sampled residents. The facility census was 70 residents. A policy and procedure for physician orders, and use of barrier cream was requested and was not provided prior to exit from the facility. 1. Review of Resident #32's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Clostridium Difficile (C-diff- a disruption of normal healthy bacteria in the colon, causing diarrhea, abdominal pain and fever). Review of the resident's electronic medical record Weekly Skin Assessment showed the resident had blanchable redness on perineal area on 8/21/23. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 8/27/23 showed: -He/she was cognitively intact. -He/she needed total assist of two caregivers with toileting and hygiene. -He/she was always incontinent of bowels. -He/she was at risk for developing skin pressure sores. -He/she had moisture associated skin breakdown. -He/she had a pressure reducing device for chair and bed. -He/she had application of ointments to skin. Review of the resident's electronic medical record Weekly Skin Assessment showed the resident had redness with sores on perineal area on 8/28/23 and no new treatment ordered. Review of the resident's undated electronic medical record Physician Order Summary Report showed: -Low air loss mattress set to comfort every shift with start date of 8/21/23. -Macatin Cream (a topical cream applied to skin for fungal and yeast related skin irritations) 2% apply to perineal area topically every eight hours as needed for moisture and redness to groin. Start date 8/21/23. Review of the resident's Treatment Administration Record (TAR) dated 8/2023 showed dates 8/21/23 through 8/31/23 as needed medication Macatin Cream 2% had not been administered to the resident's perineal area for moisture and redness. Review of the resident's undated electronic medical record Physician Order Summary Report showed: -Low air loss mattress set to comfort every shift with start date of 8/21/23. -Macatin Cream (a topical cream applied to skin for fungal and yeast related skin irritations) 2% apply to perineal area topically every eight hours as needed for moisture and redness to groin. Start date 8/21/23. Review of the resident's TAR dated 9/23 showed: -Dates 9/1/23 through 9/14/23 as needed medication Macatin Cream 2% had not been administered to the resident's perineal area for moisture and redness. -Dates 9/11/23 through 9/14/23 nursing staff initialized that the LAL mattress was in place. Review of the resident's care plan dated 9/2/23 showed: -He/she required isolation precautions for C-diff. -He/she had self-care deficits with goal to maintain dignity. Interventions included the resident required two staff to turn and reposition in bed, the resident required two staff for toileting and hygiene. -He/she has actual impairment of skin with goal to not have any complications with skin impairments. Interventions included pressure redistributing mattress on bed (LAL). Review of the resident's electronic medical record Weekly Skin Assessment showed: -The resident had blanchable redness on perineal area on 9/5/23 and cream was used. -The resident had blanchable redness on perineal area on 9/12/23. Observations 9/11/23 at 10:06 A.M. showed the resident in bed on his/her back without a LAL on. Observation on 9/11/23 at 9:45 A.M. of Certified Nursing Assistant (CNA) A providing perineal care showed: -The resident had skin irritation that was red and inflamed on buttocks, perineal and genitals. -He/she did not apply barrier cream to his/her buttocks, perineal or genital area after incontinence care that was readily available at the resident's bedside. Observations of the resident showed: -He/she in bed on back without a LAL on 9/12/23 at 2:20 P.M. -He/she in bed on back without a LAL on 9/13/23 at 5:00 A.M. -He/she in bed on back without a LAL on 9/14/23 at 10:00 A.M. 2. During an interview on 9/12/23 at 10:20 A.M., CNA A said: -He/she would use barrier cream on resident's who are incontinent of bowel and/or bladder. -He/she should have applied barrier cream to the resident after incontinent care. During an interview on 9/14/23 at 9:03 A.M., CNA B said: -Barrier cream should be used anytime a resident has a red perineal area or if they are incontinent. -He/she would use barrier cream on the resident and he/she does need a LAL mattress. -He/she would know if a LAL mattress should be in place through the electronic task charting. During an interview on 9/14/23 at 9:15 A.M., Licensed Practical Nurse (LPN) C said: -He/she would apply barrier cream to all incontinent residents. -He/she would expect the resident to have barrier cream applied after incontinent care. -He/she would not sign off on TAR if a resident did not have a LAL mattress. -He/she would notify Assistant Director of Nursing (ADON), Hospice (end of life care) and the medical doctor if a LAL mattress was ordered and not on the bed. -He/she was not aware of as needed use cream was available for the resident's perineal moisture and redness. During an interview on 9/14/23 at 9:22 A.M., ADON B said: -All incontinent resident should have a barrier cream applied after perineal care. -He/she would expect caregivers to use a barrier cream on Resident #32 after incontinent episodes. -He/she would expect nursing staff to let him/her know if a LAL mattress is not in place as ordered. -He/she would not expect nursing to sign off on TAR that LAL mattress is on bed when it is not. -He/she would expect to follow physician orders on TAR for ointments/creams that are ordered. During an interview on 9/14/23 at 1:04 P.M., the Director of Nursing (DON) said: -He/she would expect nursing staff to follow physician orders. -He/she would expect nursing staff to use barrier cream on incontinent residents as a preventative measure. -He/she was not aware the resident did not have a LAL mattress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure services to prevent and heel pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for two sampled residents (Resident #37 and #67) with pressure ulcers out of 18 sampled residents. The facility census was 70 residents. Review of www.medline.com/strategies/skin-health/evidence-based-best-practices-heels-npiap-guidelines-help-prevent-pressure-injuries/ dated July 2020 showed: -For residents at risk of heel pressure injuries (pressure ulcers) and/or with Stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence) or Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) pressure injuries, elevate the heels using a specifically designed heel suspension device or a pillow or foam cushion. -Be sure to offload (minimize or removing weight placed on the foot to help prevent and heal ulcers) the heel completely to distribute the weight of the leg along the calf. -With individuals who already have a Stage III (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) or greater heel pressure injury, the same applies. However, it is not recommended to use pillows or foam cushions, only specifically designed heel suspension devices. 1. Resident #37's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/21/23 showed: -He/she was admitted to the facility on [DATE] -He/she had two unstageable (not stageable due to coverage of the wound bed with slough - tan/yellow dead tissue or eschar - dry, black hard dead tissue) pressure ulcers that were present on his/her facility admission. Review of the resident's care plan initiated on 8/3/23 showed: -He/she had an actual skin impairment to his/her right heel. -Interventions included to float (position in such a way as to remove all contact between the heel and the bed) his/her heels while he/she was in bed as tolerated. Observation on 9/11/23 at 1:26 P.M. showed: -The resident lying in bed on his/her back. -His/her heels were resting directly on his/her mattress. Review of the resident's physician's orders showed the following order dated 9/12/23: -Cleanse right heel with wound cleanser (solution used to remove contaminants, foreign debris, and fluid from wounds), pat dry then place Xeroform (a protective product designed for open wounds that traps moisture against the skin and provides a moist environment for wound healing) to wound bed. -Cover with bordered gauze dressing (a foam dressing that effectively absorbs and retains drainage and maintains a moist wound environment for wound healing), wrap with Kerlix (woven gauze) daily and as needed for wound. -Ensure right heel is elevated when in bed. Observations on 9/12/23 at 11:11 A.M., 9/13/23 at 3:16 A.M., and 9/13/23 at 6:32 A.M., showed: -The resident lying in bed on his/her back. - His/her heels were resting directly on his/her mattress. Observation on 9/14/23 at 8:57 A.M. of the resident's right heel treatment showed: -He/she had an unstageable pressure ulcer on his/her right heel approximately one and one half inches long and two inches wide that was covered with dark eschar (dry, black, hard dead tissue). -There was a small open area with pink tissue at the right edge of the wound. -Licensed Practical Nurse (LPN) D applied Xerform to the entire wound, including all of the area with eschar, and then placed a bordered gauze dressing over the residents wound. -LPN D did not wrap the resident's right heel with Kerlix. During an interview on 9/14/23 at 9:07 A.M., LPN D said: -Most of the resident's right heel wound was necrotic and black. -There was a small area on the right edge that was open and red. -He/she put the Xerform on the entire wound, including the black necrotic area. -He/she did not wrap the resident's right heel with Kerlix. -Nursing staff were to have gone into the resident's room every so often during their shift and checked that the resident's heels were floated. -He/she knew the resident's heels were to have been floated by looking at the physician's orders for his/her treatment. -He/she could not say how the Certified Nursing Assistants (CNAs) were to know which residents heels were to be floated. During an interview on 9/14/23 at 9: 50 A.M., the wound nurse said: -He/she saw the resident's right heel pressure ulcer on 9/13/23; at that time it measured 4.6 centimeters (cm) X 5.8 cm with an unknown depth, had 90% eschar and had an open area that was red and moist on the right edge. -Xerform was to be used for open skin, not for eschar covered areas. -LPN D should have cut a small piece of Xerform in a shape to cover only the resident's open area and should not have placed a large piece of Xerform that covered the entire wound with the eschar. -The resident's current physician's order for his/her right heel should have been clarified to specify that the Xerform gauze was to be applied only to the open area on the resident's right heel rather than over the entire wound that included the area of eschar. -He/she would clarify the order with the prescriber to state that Xerform was to be placed on the small open area on the right edge of the wound, would ask the prescriber if the order could include application of skin prep around the outside edge of the entire wound and on the area of eschar and if an ABD pad (a large absorbant dressing) could be placed over the resident's heel after placement of bordered gauze dressing before wrapping the wound with Kerlix. -The resident's heels should have been floated when he/she was in bed; licensed nurses were to have ensured each shift that the resident's heels were floated. 2. Review of Resident #67's admission MDS dated [DATE] showed: -He/she was admitted to the facility on [DATE]. -He/she had no pressure ulcers. Review of the resident's physician's order's dated 9/5/23 showed: -Cleanse right buttock with normal saline or wound cleanser, pat dry, apply collagen, cover with dry dressing one time a day every Tuesday, Thursday and Saturday and as needed for wound care. -Clean left heel with normal saline or wound a, pat dry, apply collagen, cover with dry dressing one time a day every Tuesday, Thursday and Saturday and as needed for wound care. -Nurse to ensure heels are floating at all times when in bed, every shift for wound care. Observation on 9/11/23 at 2:07 P.M. showed: -The resident lying in bed on his/her back. -His/her heels were resting directly on his/her mattress. Observation on 9/12/23 at 11:08 A.M. showed: -The resident lying in bed on his/her back. -His/her heels were resting directly on his/her mattress. -He/she had a pressure ulcer on his/her left heel, that was about ¾ inches long and one and ¾ inches wide that was open with red tissue in the wound bed. -Registered Nurse (RN) A completed the residents treatment and failed to float the resident's heels prior to leaving the resident's room. Observation on 9/13/23 at 3:13 A.M., 4:52 A.M., and 6:29 A.M. showed: -The resident lying in bed on his/her back. -His/her heels were resting directly on his/her mattress. During an interview on 9/14/23 at 9: 50 A.M., the wound nurse said: -He/she saw the resident's right heel pressure ulcer on 9/12/23; at that time it measured 2.2 cm long and 4.0 cm wide with granulation (pink) tissue. -The resident's heels should have been floated when he/she was in bed; licensed nurses were to have ensured each shift that the resident's heels were floated. 3. During an interview on 9/14/23 at 1:05 P.M., the Director of Nursing (DON) said: -Resident's #37 and #67 should have their heels floated at all times when in bed and should have protective boots (soft boots that provide protection from pressure to heels). -Skin prep should have been applied around the entire wound and if ordered over the eschar on Resident #37's heel and the resident's heel should have been wrapped with Kerlix if ordered. -Xerform should be applied to open areas only.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure reconciliation of a Schedule II (a drug having medical usefulness, but also a high potential for abuse) narcotic drug (an opioid - a medication which acts on the central nervous system (CNS) to relieve pain) for one sampled resident (Resident #27) out of 20 sampled residents. The resident's Medication Administration Record (MAR) showed blank spaces which were discrepancies from the resident's Controlled Drug Receipt/Record/Disposition Form. The facility census was 70 residents. On 9/14/23, the Administrator was notified of the past noncompliance which took place over a period of time to include 8/29/23 through 9/8/23. Narcotic documentation discrepancies were discovered during audits by the Corporate Nurse Manager. Education to address the problem was provided to facility staff, including the Director of Nursing (DON) and Acting Director of Nursing (ADON) A and ADON B on 9/1/23 and 9/2/23. An internal audit was conducted on 9/8/23 and problems with narcotic documentation were identified with Resident #27. Re-education was provided as needed to those nurses responsible for the resident's narcotic medication administration after the initial education dates. The deficiency was corrected on 9/8/23. Review of the facility's Controlled Substance Policy, revised May, 2023 showed: -Drugs listed in Schedules II, III (medication with a moderate to low potential for dependence), and IV (medications with a low potential for abuse/low risk of dependence) are to be stored in double locked conditions. The key to the separately locked storage is not the same as the key used to gain access to other drugs, and the medication nurse or Certified Medication Technician (CMT), where applicable, on duty will maintain possession of the key. -A physical inventory of Schedules II, III, and IV medications will be made at the change of each nursing shift and performed by the on-coming licensed nurse or CMT, where applicable, and the off-going licenses nurse or CMT. The on-coming nurse or CMT, where applicable, will be responsible for looking at the medication to verify the amount of medication at the time of the count. The off-going nurse or CMT will be responsible for viewing the controlled substance Proof of Use Record to verify the amount on the record at the time of the count. Both nurses (or CMTs where applicable) will sign on the Narcotic Sign In and Out Sheet that the count was completed. -The licensed nurse or CMT, where applicable, will sign the medication out on the Controlled Substance Proof of Use form immediately and will document the medication on the Medication Administrator Record immediately after administering the drug. The Controlled Substance Proof of Use record is to be kept in the Controlled Medication Book and the completed records are to be placed in the resident's permanent record. Copies of the Narcotic Sign In and Out Records are to be given to the Director of Nurses (DON) when completed. -Any discrepancy in the inventory of controlled substances is to be reported to the DON immediately. The DON is responsible for investigating and making a reasonable effort to reconcile all reported discrepancies. The discrepancy of a controlled substance is to be reported to the Administrator and the Regional Nurse immediately. 1. Review of Resident #27's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that include: -Low back pain. -Type II Diabetes Mellitus with Diabetic Neuropathy (weakness, numbness and pain from nerve damage, usually in the hands and feet). -Post traumatic osteoarthritis, right ankle and foot. Review of the resident's Pain Medication Care Plan, dated 8/28/23, showed: -The resident was on pain medication related to chronic back pain, neuropathy, and disease processes. -Staff were to provide medications as ordered, review for pain medication efficacy, and monitor for adverse side effects from pain medication. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/4/23 showed the resident: -Was cognitively intact. -Received scheduled and Pro Re Nata (PRN - as needed) medications for pain and had non-medication interventions for pain as well. -Had pain intensity at approximately six on a pain scale of zero to 10, with 10 being the worst imaginable pain. -Took opioids seven out of the past seven days. Review of the resident's Physician Orders dated August 2023 showed Oxycodone HCI capsule three 5 milligrams (mg) (15 mg) every six hours as needed for moderate to severe pain starting 8/28/23. Review of the resident's Controlled Drug Receipt/Record/Disposition Form dated 8/28/23 through 9/6/23 showed: -Oxycodone 15 mg tablet by mouth every four hours as needed for pain starting 8/28/23. -On 8/29/23 at 2:15 A.M. one tablet was removed and 26 were left. -On 8/30/23 at 2:00 P.M. one tablet was removed and 21 were left. Note: The Controlled Drug Receipt/Record/Dispensation Form showed one 15 mg tablet every four hours as needed while the Physician Orders showed three 5 mg capsules every six hours as needed. Review of the resident's MAR dated August, 2023 showed: -Oxycodone HCI capsule 15 mg every six hours as needed for moderate to severe pain starting 8/28/23. -There was no documentation the medication was administered to the resident on the following dates and times: --8/29/23 at 2:15 A.M. --8/30/23 at 2:00 P.M. Review of the facility's monthly in-service training dated 9/1/23 and 9/2/23 showed: -One of the training's included documentation of PRN medications in the MAR and Treatment Administration Record (TAR). -Education showed that all PRN narcotic medications, including those pulled from the automated medication dispensing machine, needed to be documented in the MAR/TAR to show they had been administered. Review of the resident's Controlled Drug Receipt/Record/Disposition Form dated 8/28/23 through 9/6/23 showed: -Oxycodone 15 mg tablet by mouth every four hours as needed for pain starting 8/28/23. -On 9/2/23 at 10:00 P.M. one tablet was removed and eleven were left. -On 9/3/23 at 4:00 A.M. one tablet was removed and 10 were left. -On 9/4/23 at 4:00 A.M. one tablet was removed and seven were left. -On 9/6/23 at 4:45 A.M. one tablet was removed and none were left. Note: The Controlled Drug Receipt/Record/Dispensation Form showed one 15 mg tablet every four hours as needed while the Physician Orders showed three 5 mg capsules every six hours as needed. Review of the facility's automated medication dispensing system report for September 2023 showed Oxycodone 15 mg was pulled on 9/6/23 at 6:30 A.M. for the day shift. Review of the resident's MAR dated September 2023 showed: -Oxycodone HCI capsule 5 mg. Give three capsules by mouth (15 mg) every six hours as needed for moderate to severe pain starting 8/28/23 and discontinuing on 9/6/23. -There was no documentation the medication was administered to the resident on the following dates and times: --9/2/23 at 10:00 P.M. --9/3/23 at 4:00 A.M. --9/4/23 at 4:00 A.M. --9/6/23 at 4:45 A.M. -Oxycodone 15 mg was administered on 9/6/23 at 11:41 A.M. Review of the resident's Physician Orders dated September 2023 showed: -Oxycodone HCI capsule 15 mg every six hours as needed for moderate to severe pain starting 8/28/23. -Oxycodone HCI capsule 5 mg. Give one tablet by mouth every six hours as needed for moderate pain starting 9/6/23 and ending 9/7/23. -Oxycodone HCI capsule 5 mg. Give two tablets by mouth every six hours as needed for severe pain starting 9/6/23 and ending 9/7/23. -Oxycodone HCI capsule 5 mg. Give three capsules by mouth every six hours as needed for moderate to severe pain (15 mg) starting 9/7/23. Review of the resident's Controlled Drug Receipt/Record/Disposition Form beginning 9/6/23 showed: -Oxycodone 5 mg tablet. Take one to two tablets by mouth every six hours PRN for moderate to severe pain. This was crossed out and hand written was changed to 15 mg every six hours PRN for moderate to severe pain. -On 9/7/23 at 5:15 A.M. two 5 mg tablets were removed and 26 were left. -On 9/7/23 at 11:15 A.M. two 5 mg tables were removed and 24 were left. -On 9/9/23 at 7:30 P.M. three 5 mg tablets were removed and zero were left. Review of the resident's MAR dated September 2023 showed: -Oxycodone HCI capsule 5 mg. Give two tablets every six hours as needed for severe pain starting 9/6/23 and ending 9/7/23. -Oxycodone HCI capsule 5 mg. Give three capsules every six hours as needed for moderate to severe pain (15 mg) starting 9/7/23. -There was no documentation the medication was administered to the resident on the following dates and times: --9/7/23 at 5:15 A.M. --9/7/23 at 11:15 A.M. --9/9/23 at 7:30 P.M. Review of the facility's PRN Narcotic Audit sheets dated 9/8/23 showed: -Oxycodone 15 mg was not documented as administered on the following dates and times: --8/30/23 at 2:00 P.M. --9/2/23 at 10:00 P.M. --9/3/23 at 4:00 A.M. --9/4/23 (a time was not noted). --9/6/23 at 4:45 A.M. --9/7/23 in the A.M. -The audit sheets showed nursing staff responsible for narcotic documentation discrepancies between 8/30/23 through 9/7/23 were re-educated on 9/8/23 related to documenting narcotic medication administration. 2. During an interview on 9/11/23 at 9:39 A.M., the resident said: -He/she took medication for pain. -He/she felt staff did not want to give pain medications, especially at night. -Staff have told him/her the facility was out of his/her narcotic pain medication and he/she would have to wait until the following day for pain medication. During an interview on 9/13/23 6:30 A.M., Licensed Practical Nurse (LPN) C said: -Staff should document on the narcotic count sheet (Controlled Drug Receipt/Record/Disposition Form) and the MAR when a narcotic medication is administered. If a scheduled narcotic is not given the nurse should document that on the MAR and document the reason. -The narcotic count sheet and the MAR should match. -When the narcotic medication card (a card in which medications are dispensed from a blister pack) is completed the medication card and narcotic count sheet will be placed in the mailbox of Assistant Director of Nursing (ADON) B who gives them to the DON. -He/she thought they may be the ones that audit to make sure the narcotic count sheets and MARs match, but wasn't sure. During an interview on 9/14/23 at 8:36 A.M., LPN D said: -The charge nurse should be documenting narcotic medication administration on the narcotic count sheet as well as on the electronic MAR. -The administration time documented on the narcotic count sheet should match the time documented in the MAR. During an interview on 9/14/23 at 1:08 P.M. with the DON and Corporate Nurse, the DON said: -Nurses were responsible for documenting in the narcotic count book and on the electronic MAR any time a narcotic was administered. -Agency nurses and CMTs have access to the electronic MAR for documentation purposes. -The facility had not been auditing the residents' narcotic administration documentation. -An issue was discovered related to narcotics at a sister facility and narcotic audits were started at all corporate facilities. -The issue of narcotic documentation discrepancies was discovered for the resident during the facility's narcotic audit which was completed within the past two weeks. -The facility did an in-service on 9/1/23 as well as subsequent narcotic education as needed to address the issue.

Based on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (5%) when staff failed to prime then insulin pen needle prior to administering insulin to two sampled residents (Residents #26 and #38) out of two sampled residents for insulin administration for an error rate of 9.68%. The facility census was 70 residents. A policy for insulin administration was requested and not received at the time of exit. Review of the product information guide for Lantus Insulin (a long acting insulin) updated 6/22 showed: -Do a safety test before each injection to make sure the pen and needle are working properly and the proper dose is administered. -Prime the needle with 2 units of insulin, if insulin comes out of the top of the needle, the pen and needle are working properly. Review of the product information guide for Novolog Insulin (a fast acting insulin) updated 2/2023 showed: -Before each injection, small amounts of air may collect in the cartridge during normal use. -To avoid injection air and to ensure proper dosing, turn the dose selector to 2 units and press. If a drop of insulin appears at the needle tip, the pen and needle are working properly. 1. Review of Resident #38's September 2023 Medication Administration Record (MAR) showed: -He/she had a diagnosis of Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -He/she had a physician's order for Novolog 5 units with meals three times daily. Observation on 9/13/23 at 7:03 A.M. with Licensed Practical Nurse (LPN) C showed: -He/she obtained the resident's blood glucose level. -He/she removed the resident's Novolog Insulin pen from the medication cart, applied the needle to the insulin pen, and dialed up 5 units of insulin without priming the pen prior to administration. 2. Review of Resident #26's September 2023 MAR showed: -He/she had a diagnosis of diabetes. -He/she had a physician's order for 15 units Novolog with meals three times daily and 22 units Lantus in the morning. Observation on 9/13/23 at 7:12 A.M. with LPN C showed: -He/she obtained the resident's blood glucose level. -He/she removed the resident's Novolog Insulin pen from the medication cart, applied the needle to the insulin pen, and dialed up 15 units of insulin without priming the pen with 2 units of insulin prior to administration. -He/she removed the resident's Lantus Insulin pen from the medication cart, applied the needle to the insulin pen, and dialed up 22 units of insulin without priming the pen with 2 units of insulin prior to administration. 3. During an interview on 9/13/23 at 7:34 A.M., LPN C said he/she would not have done anything differently related to the medication administrations observed. During an interview on 9/14/23 at 8:49 A.M., LPN C said he/she should have primed the insulin pens with 2 units of insulin prior to administering the medications to the residents. During an interview on 9/14/23 at 1:05 P.M., the Director of Nursing (DON) said: -He/She expected staff to follow manufacture guidelines related to insulin pen medication administration. -Staff should prime the insulin pen with 2 units of insulin prior to dialing up the dosage to administer to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have parameters listed in the medication orders for any medication containing Acetaminophen (an over-the-counter pain medication) or three sampled residents (Resident #12, Resident #17, and Resident #25) out of 18 sampled residents. The facility census was 70 residents. Review of the facility's undated Medication Administration-Oral checklist did not include parameters for medications. Review of the undated product information insert guide for Acetaminophen showed directions not to administer more than 3 grams (gm - 1 gm is equal to 1000 milligrams (mg)) in a 24 hour period. 1. Review of Resident #25's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 7/10/23 showed the resident used opioids (are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief) 7 out of 7 days in the the look-back period. Review of the resident's Order Summary Report dated 9/12/23 showed the following orders: -Acetaminophen 325 mg give two tablets by mouth three times a day for pain. -The order did not include the parameters of not to exceed 3 gm Acetaminophen in 24 hours from all sources. 2. Review of Resident #17's Quarterly MDS dated [DATE] showed the resident used opioids 7 out of 7 days in the the look-back period. Review of the resident's Order Summary Report dated 9/12/23 showed the following orders: -Hydrocodone-Acetaminophen (a narcotic pain reliever) 10-325 mg (Hydrocodone 10 mg with Acetaminophen 325 mg in one tablet). Give one tablet by mouth every four hours as needed for pain. -Acetaminophen Extended Release 650 mg give one tablet by mouth every 4 hours as needed for pain. -Neither order contained the parameters of not to exceed 3 gm Acetaminophen in 24 hours from all sources. 3. Review of Resident #12's Quarterly MDS dated [DATE] showed the resident used opioids 7 out of 7 days in the the look-back period. Review of the resident's Order Summary Report dated 9/12/23 showed the following orders: -Hydrocodone-Acetaminophen 10-325 mg. Give one tablet by mouth every four hours as needed for pain. -Acetaminophen Extended Release 650 mg give one tablet by mouth every 6 hours as needed for pain. -Neither order contained the parameters of not to exceed 3 gm Acetaminophen in 24 hours from all sources. 4. During an interview on 9/13/23 at 3:12 A.M., Licensed Practical Nurse (LPN) A said: -All medications that have Acetaminophen in them need to have the parameter of not to exceed 3 gm of Acetaminophen in 24 hours from all sources in the medication order. -When a medication did not have the parameters of not to exceed 3 grams in 24 hours he/she would add this parameters. -The nurse who entered the orders should have caught this. -More than 3 gm of Acetaminophen in 24 hours could be toxic. During an interview on 9/13/23 at 6:47 A.M., LPN B said: -All Acetaminophen containing medications needed to have the not to exceed three grams of Acetaminophen in 24 hours from all sources as a parameter. -When it was discovered that an Acetaminophen order did not have the parameter the physician would be would be notified and the parameters clarified with the doctor. -It was important to have this because more than 3 gm of Acetaminophen could be toxic to the liver. During an interview on 9/13/23 at 3:12 A.M., Certified Medication Technician (CMT) A said: -All medications that have Acetaminophen in them would have the parameter of not to exceed three grams of Acetaminophen in 24 hours from all sources in the medication order. -When a medication did not have the parameters of not to exceed 3 grams in 24 hours from all sources he/she would have notified the charge nurse. During an interview on 9/13/23 at 6:53 A.M., LPN C said: -All medications that have Acetaminophen in them need to have the parameter of not to exceed three grams of Acetaminophen in 24 hours from all sources in the medication order. -When a medication did not have the parameters of not to exceed 3 grams in 24 hours he/she would contact the doctor and have the order clarified. During an interview on 9/13/23 at 7:00 A.M., Assistant Director on Nursing (ADON) B said: -All medications that have Acetaminophen in them need to have the parameter of not to exceed 3 gm of Acetaminophen in 24 hours from all sources in the medication order. -The doctor would have been contacted to get the parameters once it was discovered the order did not have the parameters. During an interview on 9/14/23 at 1:04 P.M., the Director of Nursing (DON) said: -It was his/her expectation that all orders that contained Acetaminophen would have the parameter of not to exceed three grams of Acetaminophen in 24 hours from all sources. -It was his/her expectation that all nurses would have ensured that this parameter was added to all orders that contained Acetaminophen. -It was his/her expectation that when the parameter was missing on an order the nurse that discovered the error would have contacted the doctor and received the order to add the parameter. -It was ultimately his/her responsibility to ensure that all medications that contained Acetaminophen had the parameter on all the orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility policy and procedure for Catheter Care revised on 1/2017 showed: -Purpose of this procedure is to prevent catheter-associated urinary tract infection. -Use standard precautions when handling or manipulating the drainage system. -Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. -Wash hands. -Clean the catheter with downward (away from the body) strokes. A policy and procedure was requested from the facility for Perineal Care and was not provided prior to exit. Review of the facilities skills check list for Perineal Care not dated showed perineal care should start on front side then to back side of resident using different part of washcloth for each stroke from front to back. 6. Review of Resident #32's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Clostridium Difficile (C-diff- a disruption of normal healthy bacteria in the colon, causing diarrhea, abdominal pain and fever). -Urinary Tract Infection (UTI) due to urinary catheter. Review of the residents admission MDS dated [DATE] showed: -He/she was cognitively intact. -He/she needed total assist of two caregivers for bed mobility, transfers and toileting. -He/she had a urinary catheter. -He/she was always incontinent of bowels. -He/she had UTI in last thirty days. -He/she was on an antibiotic. Review of the resident's care plan dated 9/2/23 showed: -He/she required isolation precautions for C-diff. -He/she had a urinary catheter with goal to maintain dignity. Interventions included catheter care every shift and as needed and monitor for signs and symptoms of UTI. -He/she has history of UTI's with interventions to give antibiotics as ordered, check at least every two hours for the need of catheter care and monitor for signs and symptoms of UTI. -He/she had self-care deficits with goal to maintain dignity. Interventions included the resident required two staff to turn and reposition in bed, the resident required two staff for toileting. Observation on 9/11/23 at 9:45 A.M. of Certified Nursing Assistant (CNA) A providing perineal care and urinary catheter care showed: -He/she washed his/her hands, put isolation gown on and then gloved. -He/she laid the resident on his/her back while the resident was in bed and rolled the soiled brief down between his/her legs. The resident's brief had visible diarrhea stool. -He/she opened drawers of bedside table without removing soiled gloves to retrieve disposable wipes. -He/she turned the resident onto his/her left side and repeatedly wiped the resident's buttocks in a back and forth direction with two separate wipes during perineal care after cleaning diarrhea stool from the area. The resident's perineal area was noted to have redness and irritation. -He/she removed gloves washed hands with soap and water and put on new gloves. -He/she placed the resident on his/her back and repeatedly used a circular motion around the genital area then toward the urinary opening and down urinary catheter tubing, moving away from the resident's body with same disposable wipe. -He/she then removed disposable gown, gloves and washed hands. During an interview on 9/12/23 at 10:20 A.M. CNA A said: -He/she would have been more prepared and laid out needed supplies before starting perineal care. -He/she would have used a new wipe with each swipe of the perineal area going from front to back. -He/she would have started from cleanest to dirtiest. -He/she would have used a separate wipe to clean catheter tubing. -He/she had Catheter Care and Perineal training upon hire in April 2023. During an interview on 9/14/23 at 9:15 A.M. LPN C said: -He/she would use disposable wipes one way, one swipe, one time during perineal care. -He/she would use disposable one disposable wipe to wipe away from the urinary opening, one swipe and discard. -He/she would use new disposable wipe to wipe catheter tubing one way, one swipe outward away from the urinary opening. -He/she would expect the CNA's to use proper infection control during perineal and catheter care. During an interview on 9/14/23 at 9:22 A.M. Assistant Director of Nursing (ADON) B said: -He/she would expect infection control practices be used during perineal and catheter care. -He/she would be responsible to make sure staff maintain infection control practices. -He/she would be responsible for educating nursing staff on infection control practices with perineal and catheter care. During an interview on 9/14/23 at 1:04 P.M. DON said: -He/she would expect staff to follow infection control practices with perineal care and catheter care. -He/she would expect staff change gloves and wash hands before touching a clean surface from a dirty surface to prevent cross contamination. -He/she would expect staff to use one disposable wipe one way, one swipe, one time during perineal care and use a separate wipe when cleaning the catheter tubing away from the urinary opening. Based on observation, interview, and record review, the facility failed to ensure infection control to prevent cross contamination when staff failed to sanitize the access point of insulin pens prior to attaching the needle for two supplemental residents (Residents #26 and #38); to ensure infection control, including hand hygiene during wound dressing change for one sampled resident (Resident #46); to provide urinary catheter (a small tube inserted into the bladder to drain urine) care in a manner to prevent urinary tract infection and to ensure infection control practices were implemented to prevent cross contamination during perineal care on one sampled resident (Resident #32); to ensure hand hygiene during catheter care, colostomy (a surgically created opening for the large intestine, through the abdomen) care and wound care, failed to keep catheter tubing (clear tube that drains urine from the catheter to the catheter drainage bag) off the floor; to use a barrier for supplies during wound care for one sampled resident (Resident #67) and to ensure hand hygiene during perineal (peri - genital and anal area) care for one sampled resident (Resident #37) out of 18 sampled residents and two supplemental residents. The facility census was 70 residents. A policy for insulin administration was requested and not received at the time of exit. Review of the product information guide for Lantus Insulin (a long acting insulin) updated 6/2022 showed: -Wipe the rubber stopper with alcohol prior to attaching the administration needle. Review of the product information guide for Novolog Insulin (a fast acting insulin) updated 2/2023 showed to wipe the rubber stopper with alcohol prior to attaching the administration needle. 1. Review of Resident #38's September 2023 Medication Administration Record (MAR) showed: -He/she had a diagnosis of Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -He/she had a physician's order for Novolog 5 units with meals three times daily. Observation on 9/13/23 at 7:03 A.M. with Licensed Practical Nurse (LPN) C showed: -He/she obtained the resident's blood glucose level. -He/she removed the resident's Novolog Insulin pen from the medication cart, applied the needle to the insulin pen without sanitizing the rubber stopper with alcohol, and dialed up 5 units of insulin. 2. Review of Resident #26's September 2023 MAR showed: -He/she had a diagnosis of diabetes. -He/she had a physician's order for 15 units Novolog with meals three times daily and 22 units Lantus in the morning. Observation on 9/13/23 at 7:12 A.M. with LPN C showed: -He/she obtained the resident's blood glucose level. -He/she removed the resident's Novolog Insulin pen from the medication cart, applied the needle to the insulin pen without sanitizing the rubber stopper with alcohol, and dialed up 15 units of insulin. -He/she removed the resident's Lantus Insulin pen from the medication cart, applied the needle to the insulin pen without sanitizing the rubber stopper with alcohol, and dialed up 22 units of insulin. 3. During an interview on 9/13/23 at 7:34 A.M., LPN C said he/she would not have done anything differently related to infection control during medication pass. During an interview on 9/14/23 at 8:49 A.M., LPN C said he/she should have sanitized the insulin pens with alcohol prior to attaching the needles. During an interview on 9/14/23 at 1:05 P.M., the Director of Nursing (DON) said: -He/she expected staff to follow manufacture guidelines related to insulin pen medication administration. -Staff should sanitize the top of the insulin pen with alcohol prior to attaching the needles. 4. Review of the undated facility Changing Dressing/Treatment Checklist showed: -Staff should removed gloves, wash hands, and don clean gloves after removing an old dressing and before cleaning a wound. -After completing wound care, staff should wash their hands before exiting the resident's room. Review of Resident #46's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/30/23 showed he/she: -Was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 1 out of 15. -Had one unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Observation on 9/12/23 at 8:54 A.M. showed LPN B: -Entered the resident's room and placed the resident's wound care supplies on top of the desk without sanitizing the surface and without a barrier. -After washing his/her hands, he/she sanitized the resident's bedside table with a bleach wipe, then transferred the resident's wound care supplies from the top of the desk to the bedside table without a barrier. -Without washing or sanitizing his/her hands, he/she donned clean gloves, said he/she had sanitized the scissors outside the resident's room with bleach wipes, placed a towel barrier on the floor under the resident's foot, then after removing the resident's sock, cut the dressing dated 9/11/23 to remove the dressing. -After removing the old dressing, with the same gloved hands, he/she cleansed the resident's wound with wound cleanser and gauze, then pat dry. -LPN B then removed his/her gloves, sanitized his/her hands, donned clean gloves, applied the dressing to the resident's wound, put the resident's sock on the resident's foot, removed his/her gloves, put the dirty scissors and bottle of wound cleanser on the resident's desk without a barrier, gathered the trash from the wound care, picked up the supplies, and without washing or sanitizing his/her hands, touched the door handle, exited the resident's room, placed the scissors, bottle of hand sanitizer, and bottle of wound cleanser on top of the treatment cart without a barrier, then walked to the soiled utility room, touched the door handle, opened the door, and threw away the wound care trash. -LPN B then walked back to the bathroom near the resident's room to wash his/her hands, sanitized the scissors, then put the bottle of wound cleanser which he/she had taken into the resident's room in a drawer in the treatment cart without sanitizing the bottle. During an interview on 9/12/23 at 9:08 A.M., LPN B said he/she could not think of anything he/she would have done differently during wound care. During an interview on 9/14/23 at 8:32 A.M., LPN B said: -He/she should have put a barrier down on the desk and the bedside table prior to putting wound care supplies on them. -He/she should have changed his/her gloves and washed his/her hands after removing the old dressing and before doing the wound care treatment. -He/she should have washed or sanitized his/her hands prior to leaving the resident room. -He/she should have cleaned off the wound care bottle before storing it in the treatment cart. During an interview on 9/14/23 at 1:05 P.M., the DON said: -Staff should wash their hands when entering and when exiting a room. -Staff should wash their hands and change their gloves after removing an old dressing before cleaning the wound. -Staff should have hand a barrier to place the supplies on. -Staff should have sanitized anything taken in the room before storing in the treatment cart. 7. Review of Resident #37's significant change MDS dated [DATE] showed: -He/she was admitted to the facility on [DATE]. -He/she was occasionally incontinent of urine. -He/she had two unstageable pressure ulcers that were present on his/her facility admission. Observation on 9/13/23 at 4:17 A.M. showed: -Following completion of the residents peri care CNA C did not remove his/her gloves and sanitize/wash his/her hands and proceeded to fasten the resident's brief and place covers over the resident. -CNA C then removed his/her gloves and left the resident's room without first washing/sanitizing his/her hands. 8. Review of Resident #67's admission MDS dated [DATE] showed: -He/she was admitted to the facility on [DATE]. -He/she had no pressure ulcers. -He/she had a urinary catheter and an ostomy (a surgical procedure that allows bodily waste to pass through a surgically created stoma on the abdomen into a prosthetic known as a pouch or bag). Review of the resident's physician's order's dated 9/5/23 showed: -Cleanse right buttock with normal saline or wound cleanser, pat dry, apply collagen, cover with dry dressing one time a day every Tuesday, Thursday and Saturday and as needed for wound care. -Clean left heel with normal saline or wound a, pat dry, apply collagen, cover with dry dressing one time a day every Tuesday, Thursday and Saturday and as needed for wound care. -Catheter 18 French (fr -a type of urinary catheter that is kept in place with a balloon), 30 cubic centimeter (cc) balloon. -Colostomy care each shift. Observations on 9/11/23 at 9:21 A.M.,12:42 P.M. and 2:08 P.M. and on 9/12/23 at 11:08 A.M. showed the resident's catheter tubing was on the floor. Observation on 9/12/23 at 11:08 A.M. showed: -He/she had a pressure ulcer on his/her left heel, that was about ¾ inches long and one and ¾ inches wide that was open with red tissue in the wound bed. -Registered Nurse (RN) A placed supplies for the resident's wound care, including scissors, wound care spray and dressings, directly on the resident's night stand without use of a barrier. -RN A then placed a clean bath towel on the resident's overbed table and moved the resident's wound care supplies from his/her night stand to the his/her overbed table. During an interview on 9/12/23 at 11:32 A.M. RN A said: -He/she should have not put the resident's wound care supplies on his/her night stand without first placing a barrier for infection control. -He/she put a clean towel on the resident's overbed table and then moved the resident's wound care supplies from the resident's night stand to his/her overbed table. -He/she did not use the scissors during the resident's wound care and he/she wiped the scissors with a disinfectant wipe before placing them back in the treatment cart. Observation on 9/13/23 at 4:52 A.M. showed: -CNA D entered the resident's room and placed gloves on his/her hands without first washing/sanitizing his/her hands. -He/she wiped around the catheter insertion with a peri wipe (a pre moistened disposable wipe). -He/she did not get another peri wipe and wipe down the resident's catheter away from his/her body to cleanse the outside of the resident's catheter. -He/she did not remove his/her gloves and wash his/her hands before going out of the room to get supplies. -He/she reentered the resident's room, turned on the water at the resident's sink and brought a styrofoam cup with water to CNA C. -CNA C poured the water into the resident's colostomy pouch, poured the water back out, closed the resident's colostomy pouch and then without first removing his/her gloves and washing/sanitizing his/her hands, he/she arranged the resident's covers over him/her. -CNAs C and D then both removed their gloves and left the resident's room without first washing/sanitizing their hands. During an interview on 9/13/23 at 5:51 A.M. CNA D said: -He/she had entered the resident's room and did not wash/sanitize his/her hands before putting on gloves. -He/she removed the resident's covers and then he/she did not first remove his/her gloves, sanitize his/her hands and put on clean gloves before doing the residents catheter care. -He/she did not wipe down the residents catheter away from his/her body. -He/She removed his/her gloves and left the resident's room without washing/sanitizing his/her hands, got a styrofoam cup, filled it with water at the resident's sink, then gave the styrofoam cup to CNA D. -He/she then put on gloves without first washing/sanitizing his/her hands and assisted in placing the resident's covers on him/her. -He/she then left the resident's room without first washing/sanitizing his/her hands. During an interview on 9/13/23 at 5:59 A.M. CNA C said: -He/she had entered the resident's room and did not wash/sanitize his/her hands before putting on gloves. -He/she emptied feces from the resident's colostomy bag, rinsed the resident's colostomy bag with water, fastened the resident's colostomy he/she had used in cleansing the resident's bag and then touched the resident's covers with the gloved hand with feces on the index finger. -He/she then removed his/her gloves and left the resident's room without first washing/sanitizing his/her hands. During an interview on 9/14/23 at 1:05 P.M. the DON said: -During catheter care the CNAs should have wiped down the entire length of the residents' catheter. -During wound care, the licensed nurse should have used a barrier for supplies before placing the supplies on a surface in the resident's room. -During colostomy care the CNA should have practiced good hand hygiene and should not have touched the resident's covers with the same gloves used for colostomy care. During an interview on 9/4/23 at 2:31 P.M. the DON said he/she expected nursing staff to keep catheter tubing off the floor.

Based on interview and record review, the facility failed to prevent the existence of a negative balance for one discharged resident (Resident #173). The facility census was 73 residents. 1. Record review of the facility's Current Account Balance dated 1/13/22 showed Resident #173 had a negative balance of $18.00. During an interview on 1/20/22 at 11:55 A.M., the Regional Financial Analyst said: - The resident did not have a trust account at that time when he/she resided at the facility. - The previous Business Office Manager (BOM) used funds from the resident trust, to pay for hair care for Resident #173. - The facility should have contacted that resident's family or could have paid for that resident's hair care out of facility funds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to submit a Third Party Liability (TPL) form (a form which is sent to Missouri (MO) Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account), which is required to be sent within 30 days after death, to MO Health Net after the death of one sampled resident (Resident #123), 125 days prior to the date of the resident fund review on [DATE]; and to submit the balance of the resident's funds to the estate of one sampled resident (Resident #127), who was a private pay resident. The facility census was 73 residents. 1. Record review of the clinical facility census dated [DATE] showed Resident #123 expired on [DATE]. Record review of the resident's resident trust statement, showed he/she had a balance of $1,288.36 in his/her account on date of his/her death. During an interview on [DATE] at 11:38 A.M., the Regional Financial Analyst (RFA) said: - A TPL form was not sent as of the date of the resident fund review ([DATE]). - The previous Business Office Manager (BOM) should have sent a TPL form to MO Health Net. 2. Record review of Resident #127's social service's note dated [DATE] showed the facility was notified by the family that the resident expired on [DATE]. Record review of the resident's trust statement showed he/she had a balance of $200.03 as of the date of his/her death. During an interview on [DATE] at 11:47 A.M. RFA said they have sent statements to the family, they just have not sent the remaining balance of funds to the family. During a phone interview on [DATE] at 1:06 P.M., the resident's relative said: - He/she notified the facility of his/her family member's death the first week of [DATE]. - He/she kept waiting for the remainder of funds to be returned but it never came. - The delay in returning that balance to him/her had something to do with the former BOM. During a phone interview on [DATE] at 1:32 P.M., the resident's relative said during the time after the resident's death, he/she left several messages for the finance department but had a hard time getting in touch with an actual live person.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from misappropriation of property when one bottle of Lorazepam (Ativan - an anti-anxiety medication) was missing and another bottle of Ativan had eight milliliters (ml) of medication that was unaccounted for during shift change narcotic count for one sampled resident (Resident #50), and there was also a discrepancy in the documentation of the amount of Lorazepam dispensed to the resident and the facility also had medication that appeared to have been replaced with a watery substance for two sampled residents (Resident #37 and #50) out of 17 sampled residents. The facility census was 72 residents. Record review of the facility's policy, Controlled Substance Policy, dated February 2021, showed: -Controlled substances in Schedules II, III and IV (Controlled substances include opiods, stimulants, depressants, hallucinogens, and anabolic steroids) were subject to special handling, storage, disposal and record-keeping requirements. -Such drugs were to be accessible only to authorized nursing and pharmacy personnel. -The Director of Nursing (DON) was responsible for the control of such drugs. -Drugs listed in Schedules II, III, and IV were to be stored under double-lock conditions. -The key to the separately locked storage area was not the same key that was used to gain access to other drugs. -The medication nurse on duty at the time would maintain possession of the key. -The key must remain in the possession of the licensed nurse that completed the count at all times during their shift. -A physical inventory of those medications would be made at the change of each nursing shift. -Shift Verification Count Sheets would be completed at the change of each shift. -The persons performing the inventory would sign to verify that the inventory was done. -All controlled substances were to have been counted every shift. -The count was to have been performed by the on-coming licensed nurse and the off-going licensed nurse. -The on-coming nurse would be responsible for looking at the medication to verify the amount of medication present at the time of the count. -The off-going nurse would have been responsible for viewing the Controlled Substance Proof of Use Record to verify the amount on the record at the time of the count. -Both nurses would sign on the Narcotic Sign in and out Sheet that the count was completed. -Any discrepancies in the inventory of a controlled substance was to have been reported to the Director of Nurses immediately. -The Director of Nurses was responsible for investigating and making a reasonable effort to reconcile all reported discrepancies. -The discrepancy of a controlled substance was to have been reported to the Administrator and the Regional Nurse immediately. -If a discrepancy was not reconciled, the Director of Nurses was to have documented the details on the audit record, including the possible shift or persons responsible for the discrepancy and the efforts made to reconcile it. Record review of the facility's 2021 policy, Abuse, Prevention, and Prohibition Policy, showed: -Each resident has the right to be free from abuse, corporal punishment, involuntary seclusion and misappropriation of property. -The facility Administrator would ensure a thorough investigation of alleged violations of individual rights and document appropriate action. 1. Record review of Resident #50's undated face sheet showed he/she was admitted to the facility on [DATE] with diagnoses of restlessness and agitation. Record review of the resident's Care Plan, dated 12/5/21, (revision date 3/22/22) showed: -Had mood problems with periods of restlessness, agitation, anxiety and depression due to Dementia and End of Life (EOL) process. -Had mood problems and had periods of restlessness, agitation, anxiety and depression due to Dementia and EOL. -Had restlessness, agitation, verbal or physical aggression towards staff, self isolation, mood swings, changes in behavior or appetite. -Staff was to administer medications as ordered. -Had behavior problems, he/she would become anxious and restless believing spouse was dead when in fact the spouse was still alive. -Staff were to give anti-anxiety medications ordered by the physician. Record review of the resident's Physicians' Order Sheet (POS), dated 2/10/22, showed: -Lorazepam Intensol Concentrate (a scheduled IV drug used to treat anxiety - a drug or other substance that was tightly controlled by the government because it may be abused or cause addiction) 2 milligram (mg)/milliliter (ml) to be given by mouth every four hours as needed for agitation or anxiety. Record review of the facility Controlled Substance Log for the resident, dated 2/10/22, showed: -A new bottle of Lorazepam 30 ml was received by the facility on 2/10/22 for Resident #50. -The medication was given 18 times x .25 ml which would equal 4.5 ml used between 2/10/22 and 3/18/22. -(30.0 ml - 4.5 ml = 25.5 ml) was the amount that should have remained in the bottle. -On 3/18/22 the nurse documented there was 25.25 ml in the bottle. --The bottle should have had 25.50 ml remaining, 0.25 ml of Lorazepam was unaccounted for as of 3/18/22. -No medication was given after 3/18/22. Record review of resident's February Treatment Administration Record (TAR) showed: -The resident was given 13 as needed doses of the Lorazepam medication. -The facility Controlled Substance Log from February for the resident showed an extra dose was given on 2/17/22 that was not recorded on the resident's TAR. Record review of resident's March TAR showed: -The resident was given three as needed doses of the Lorazepam medication. -The facility Controlled Substance Log from March for the resident showed an extra dose was given on 3/18/22 that was not recorded on the TAR. Record review of the facility March 2022 Narcotic Shift Count for all residents on the medication cart showed: -The off-going nurse Nurse Licensed Practical Nurse (LPN) B and on-coming nurse Agency Registered Nurse (RN) A had counted the medications and the count was correct at 6:00 P.M. on 3/21/22. This sheet verified the facility staff counted narcotics for all residents and it was signed by two nurses at shift change that the count was correct. -The off-going nurse Agency RN A and on-coming nurse agency Nurse LPN C had counted the medications and the count was not correct at 6:00 A.M. on 3/22/22. There was no count of number of Controlled substance logs. -Agency LPN C did not sign the sheet verifying the count was correct because the medication box with the resident's name was empty. The resident's entire bottle of Lorazepam and the box was missing. Record review of the written statement for the facility investigation, dated 3/22/22, by agency LPN C showed: -Upon shift arrival (3/22/22 day shift) the medication count was done with the off going shift. -The count for Resident #50 was off. -One bottle of Ativan (Lorazepam) was missing for this resident. Record review of the Resident Abuse Investigation Report written by the DON, dated 3/28/22, showed: -On March 22, 2022 at 6:00 A.M. there was a narcotic discrepancy in the refrigerated/medication room on the Long Term Care (LTC) unit. -Agency LPN C counted for acceptance of the medications when he/she discovered the resident's bottle of Lorazepam which should of had 25.25 ml in it was missing the entire bottle. -An immediate investigation was launched. -Agency RN A's written statements stated he/she had control of the bottle the entire time, but when the two nurses did the morning count the off-going nurse Agency RN A was not able to account for the missing bottle of Lorazepam. -After multiple searches and reviews there was no discovery of the medication. -An investigation was completed which included review of the sign in sheets, interviews, audits of the refrigerator, medication carts, and the resident's room to no avail. -Agency RN A was made a do not return, meaning his/her agency was notified that he/she could not work at the facility. -The local police were notified. -A police officer came on 3/22/22 to investigate the narcotic discrepancy. Record review of the Police Department's report, dated 3/22/22, showed: -The officer arrived at the facility at 2:46 P.M. after having been notified by the facility of a narcotic that had gone missing from the facility. -The officer spoke with the DON who said resident's Lorazepam was missing. -The DON had done his/her own investigation and had provided a statement from Agency RN A. -The DON said it could have simply been misplaced or a honest mistake. -Agency RN A works for a third party and would likely not return to the facility in the near future. -The DON provided him/her with a written statement from the suspect. -The officer contacted the suspect via telephone. -Agency RN A had arrived at the facility on 3/21/22 at about 6:10 P.M. where he/she was assigned to unit two to work with Agency RN B. -Agency RN A said he/she had worked with Agency RN B to administer prescriptions to patients in their unit, and escorted one another when accessing the lock box of medications. -Agency RN A watched as Agency RN B opened the box and began to read out loud to him/her the amount of prescriptions that should have been in the box. -Agency RN A physically verified each medication. -When Agency RN B read out the victim's prescription of Lorazepam the contents of the bottle did not match their log. -Agency RN B turned the page and located a more recent log the bottle matched the log. -The suspect stated he/she believed the entire incident was a miscommunication and the facility was not actually out of any medication. During an interview on 4/4/22 at 12:30 P.M., the DON said: -He/she was in the facility at change of shift on 3/22/22 when he/she was notified of the discrepancy of the narcotics count at about 6:00 A.M. by the day Nurse, Agency LPN C. -He/she and the Nurses searched for the resident's missing Lorzepam and were not able to find it. -He/she obtained statements from the nurses. -He/she completed an investigation. -He/she expected all documentation to have been correct. -Agency RN A had counted the narcotics at the start of the shift and the count was correct. -Agency RN A counted at the end of the shift and the resident's bottle of Lorzepam was missing. -Agency RN A had the keys to the locked refrigerator containing the Lorazepam in his/her position all night. -The Certified Medication Technicians (CMT's) and the Nurses had key fobs (an electronic lock that uses an electronic device that controls a lock without using a key) to open the medication rooms, but only the charge nurse had a key to open the refrigerator where the narcotics that needed to be refrigerated were stored. During an interview on 4/4/22 at 2:15 P.M., Agency RN B said: -He/she had worked the day shift on 3/21/22 from 6:00 A.M. until 7:00 P.M. -At the change of shift he/she was followed by another RN. -He/she and the Agency RN A had counted the narcotics. -The count was correct. -He/she gave the Night Nurse the keys. During an interview on 4/14/22 at 4:00 P.M., Agency RN A said: -On 3/21/22 he/she worked on the Long Term Care unit from 6:00 P.M. to 6:00 A.M. on 3/22/22. -This was the first time he/she had worked in the facility, he/she was employed by a staffing agency. -He/she was the Charge Nurse. -Agency RN B opened the medication room and the refrigerator where the narcotics were stored. -In the refrigerator there was a metal box with three bottles of Lorazepam; one bottle had 25 ml in it, one bottle had 29 ml in it (for a different resident but he/she could not remember which resident), and one bottle had 30 ml in it (but could not remember for which resident). -The bottle with 30 ml was not opened. -He/she verified the names and the amounts were accurate. -The count was correct. -The medication room was very small and he/she stood on the other side of the medication refrigerator and his/her view of the nurse putting the medications into the refrigerator was obstructed by the refrigerator door. -Agency RN B handed him/her the keys to the medication room and refrigerator holding the narcotics. -He/she had went into the refrigerator to get a resident's insulin during the shift, but did not open the locked narcotic box. -In the morning he/she attempted to count the narcotics with the on-coming nurse Agency LPN C. -The bottle containing the 30 ml was there, the bottle with 29 ml was there, and the box containing the 25 ml bottle was there, but the bottle containing the medication was not there. (Each bottle had the resident's prescription which included their name on the box). -Agency LPN C notified the DON of the discrepancy. -He/she and Agency LPN C looked for the medication in the medication room, medication carts, and in the resident's room without finding the bottle of Lorazepam with the 25 ml in it. -The DON had asked him/her if he/she had the bottle. -He/she pulled out his/her pockets of his/her uniform to show that he/she did not have the missing medication. -He/she offered to have the DON go through his/her work bag and offered to take a drug test. -He/she was asked to write a statement which he/she did. -At the start of the shift he/she was given a key ring with a key and a key fob (keyless entry device) for the medication room and the refrigerator with the narcotics in it. -He/she did not give the key ring to anyone. -One of the CMT's did borrow his/her fob to get into the medication room. -He/she watched the CMT go into the medication room to get his/her fob which he/she had left in the medication room and come back out immediately and got his/her fob back from the CMT. -He/she did not take the medication. Observation of the facility locked Controlled Substances refrigerator on 4/4/22 at 2:00 P.M. (change of shift) showed: -To enter the medication room a staff member, either the nurse or the CMT, would have to use their key fob to enter the locked medication room. -The medication refrigerator was not locked. -There was a metal box within the refrigerator that was attached to the refrigerator wall that was locked and required a key that only the Charge Nurse had on his/her key ring. -There were no marks on the Narcotic box or the medication room that indicated a forced entry. During a telephone interview on 4/5/22 at 9:00 A.M., the Pharmacy Representative said: -They had not noticed any irregularities with the narcotic medications at the facility. -The facility was supposed to notify their Consulting Pharmacist if there was an irregularity. -The facility had not notified the Pharmacist about the missing bottle of Lorazepam. 2. Record review of Resident #50's April 2022 POS showed: -He/she had an an order for Lorazepam Intensol Concentrate 2 mg/ml give 0.25 ml by mouth every four hours as needed for agitation or anxiety, dated 2/10/22. Record review of resident #37's POS, dated April 2022, showed: -Lorazepam concentrate 2 mg/ml give 0.25 ml by mouth every three hours as needed for anxiety or agitation dated 2/3/22. Record review of LPN B's written statement dated 4/9/22 showed: -On 4/8/22 at 6:30 A.M. he/she counted with the Agency RN C. -Neither nurse noticed any discrepancies. -When he/she returned that night at 10:00 P.M. to work he/she was informed that Resident #50's Ativan (Lorazepam) had been unsealed from the bottom and 8 ml were missing. -He/she and Agency Nurse RN D went to count the narcotics. -When he/she pulled Resident #50's Lorazepam out of the box he/she noticed how watery the medication was. -Lorazepam should have been viscous (thick and sticky). -He/she checked Resident #37's Lorazepam, it was the same (not viscous). -Lorazepam sticks to the side of the dropper and the dropper would have to be squeezed several times to empty it. -The liquid in Resident #37's bottle did not stick to the dropper, it ran out of the dropper like water. -He/she touched a tiny drop to his/her finger, the liquid was not oily at all. Record review of the facility's narcotic misappropriation investigation showed: -On 4/9/22 at 6:10 A.M., LPN B notified the DON two bottles of Lorazepam had the appearance of water (one bottle each for Resident #37 and Resident #50). -The police were notified. -The police took both bottles to send to their lab to be tested. During an interview on 4/12/22 at 10:00 A.M., the Administrator and DON said: -On 4/9/22 it was discovered by LPN B that the consistency of two of the bottles of Lorazepam was water like. -The DON had started investigating this issue. -The two bottles of Lorazepam were sent to the Police lab for testing. -On 4/10/22 it was noticed that there was a circular scratch around the lock on the box containing the narcotics in the medication refrigerator. Observation on 4/12/22 at 10:30 A.M., showed: -A circular scratch around the lock on the narcotic box which was not present prior to incident. During an interview on 4/12/22 at 3:00 P.M., Agency RN D said: -On 4/8/22 during the narcotic count he/she discovered that Resident #50's Lorazepam only had 22 ml in it instead of the 30 ml that should have been according to the count. -None had been recorded as having been given. -He/she had counted with the off going Agency RN C. -When Agency RN C came on shift he/she told him/her that he/she had not actually taken the bottle all the way out of the box to count it because he/she thought it was full. -When you come on and go off shift you count the narcotics with a second nurse and then sign the log book to verify the count was correct. -When the count was off he/she told the Administrator and DON. -The Administrator and DON came back to the medication room and verified the log book to the number on the bottle. -Agency CMT A asked him/her about the missing medications. -Anyone with a fob had access to the medication room. -The CMT's fob would let them into the medication room so they could get stock medications. -The staff would borrow each other's fob. -The Charge Nurse had the only key to the Narcotic box inside of the refrigerator. -The Nurse did not let anyone borrow his/her key or fob. -On 4/6/22 when he/she had worked the Narcotic count was correct. -On 4/8/22 at 2:00 P.M. it was discovered someone had manipulated the bottles of Lorazepam and extracted some doses. -The on-coming Nurse LPN B thought water may have replaced some of the medication. -This also happened to Resident # 37 where the medication looked like water. -He/she did not remember seeing any scratches on the locked Narcotic box. -The agency CMT left at 2:30 P.M. and did not work his/her shift. During an interview on 4/12/22 at 3:30 P.M., Agency RN C said: -He/she had worked on 4/8/22 from 6 A.M. until 2 P.M. on the Long Term care side as the Charge Nurse. -He/she and the Agency RN D counted the Narcotics in the refrigerator. -The Lorazepam for Resident #50 was in it's box and looked full with the seal on it. -At 2:00 P.M. when he/she was counting with RN D he/she thought the seal on the bottle of Lorazepam looked disturbed. -There was 22 ml in the bottle. -According to the Narcotic Count sheet there should have been 30 ml. -He/she wrote the discrepancy on the Narcotic Count sheet. -He/she then told the DON. -The DON was ultimately responsible for ensuring the medications were accounted for. -The DON told the nurse there had been an issue with someone stealing drugs. -He/she did not know if anyone else had a key to the locked Narcotic box. -He/she did not see anyone going into the medication room. -He/she absolutely did not take any medications. -He/she did not know who could have taken the medications for Resident #50. Record review of the facility's investigation, dated 4/8/22, for narcotic misappropriation showed: -The facility did not definitively know who misappropriated the Lorazepam, but the system they used caught the errors. -Were working with the authorities to help identify the perpetrator. -There was a misappropriation of narcotics for both Resident #50 and Resident #37. -On 4/8/22 at 2:05 P.M. the on-coming nurse RN D reported to the DON there was a discrepancy for the amount of Lorazepam for Resident #50 in the locked refrigerator in the medication room on Long Term care. Record review of Agency RN D's written statement, dated 4/8/22, by Agency RN D showed: -On 4/8/22 at 2:00 P.M. he/she had taken report from Agency RN C. -He/she was working as Charge Nurse. -While counting the narcotics in the locked refrigerator in the medication room with Agency RN C he/she noticed the seal around one of the bottles (for Resident #50) of Lorazepam appeared loose. -He/she pulled the bottle out of the box and discovered the seal had been opened near the neck of the bottle, but left intact at the top, making it appear sealed at a quick glance in the box. -Upon inspection the measure of the medication in the bottle (for Resident # 50) contained 22 ml of liquid. -The narcotic count book read 30 ml at last count and none had been recorded as given from the bottle (for Resident #50). -He/she had counted the refrigerated medications three times in the same week and had not noticed the loose plastic (seal) before that day. -Agency RN C said he/she had not removed the bottle from the box when counting narcotics that morning so he/she had not noticed the loose plastic. -Both nurses signed the narcotic sheet declaring the finding and the change. -Agency RN C left the facility. -He/she took the count book and went to the Administrator's office where the DON was. -He/she reported the findings to them. -They went with him/her to the medication room and verified his/her findings. -The DON asked who had access to the medication room and he/she said all the nurses and medications technicians did. -Only the Charge Nurse had access to the locked narcotic box inside of the refrigerator. -There was only one CMT who had worked that day, Agency CMT A. -Agency CMT A was sitting at the nurses' station. -The DON asked if he/she knew anything about the missing medications in the locked narcotic box and the CMT said she didn't have anything to do with that. -The DON told Agency CMT A that they would have to give everyone a drug test. -He/she immediately called the DON. Record review of Agency RN C's written statement, dated 4/11/22, showed: -He/she worked on 4/8/22 on the Long Term care side from 6:00 A.M. to 2 P.M. -He/she and the Night Nurse counted in the refrigerated lock box which was correct. -He/she counted with the on-coming nurse when they discovered the bottom of the seal on the cap of the bottle did not appear intact. -There were 22 ml in the bottle- not the 30 ml that should have been in the bottle. -He/she did not do narcotics nor steal them. During an interview on 4/12/22 at 10:00 A.M., the Administrator said: -There was a volume dispute on 4/8/22. -It was discovered by Agency RN D at 2 P.M. there was only 22 ml in a bottle of Lorazepam that should have had 30 ml in it for Resident #50. -The bottle appeared to be sealed but some areas on the bottom of the seal appeared to have been disturbed. -Agency RN D notified the DON and he/she started an investigation. -The bottle was delivered on March 29th. -Agency RN C who had worked the previous shift was asked if he/she had taken the medication and he/she said no. During an interview on 4/18/22 at 1:10 p.m., Agency CMT A said: -He/she had quit the facility. -He/she did not know anything about the missing medications. -He/she did not take any medications. 3. During an interview on 4/18/22 at 3:30 P.M., the DON said: -He/she had interviewed all of the staff who may have been involved. -After each incident he/she had started an investigation right away. -The staff had let him/her know right away when a discrepancy was discovered so their procedures were working. -Pharmacy was notified when an email was sent for replacement medications. -Agency RN C and Agency RN D were taken off of the schedule until the investigation was completed. -He/she still does not know who took the medication. -The facility was still waiting for the Police Lab report concerning the medication that appeared to have been watered down, which might be several weeks before anything is known. Complaint: MO 00199628 and MO 00198821

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide medications and treatments as prescribed by the physician for two sampled residents (Resident# 2 and #59) out of 19 sampled residents. The facility census was 73 residents. Record review of the facility's policy, Medication Administration, dated May 2019 showed: -The staff was to obtain and record any vital signs as necessary prior to medication administration. -The staff was to give the resident the medication. -The staff was to remain with the resident to ensure that the medication was swallowed. -The staff was to circle initials on the Medications Administration Record (MAR) if a medication was not given as ordered and record the reason in the as needed (PRN)/Omission Medication section of the MAR. 1. Record review of Resident #2's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Pneumonia (an infection in the lungs which may fill up with fluid). -Chronic Obstructive Pulmonary Disease (COPD a group of diseases that causes airflow blockage and breathing related problems). -Bronchiectasis with acute lower respiratory infection (a condition in which the lungs become damaged making it hard to clear mucus). -Hypothyroidism (a condition in which the thyroid gland does not produce enough hormone). -Hypertensive Heart Disease (a heart condition caused by high blood pressure). Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 1/11/22 showed: -He/she had a Brief Interview for Mental Status (BIMS) of 15, indicating he/she was cognitively intact. -He/she had a debility, cardiorespiratory condition. -He/she had Dysrhythmias (abnormal heart rhythm). -He/she had high blood pressure. -He/she had a Thyroid condition. -He/she had COPD. Record review of the resident's undated care plan showed: -The staff was to give medications as ordered by the physician. -The resident had Hypothyroidism. -The staff was to administer thyroid replacement as ordered. -The resident had high blood pressure. -The staff was to give antihypertensive medications as ordered. Record review of the resident's Physicians Order Sheet (POS), MAR, and Treatment Administration Sheet (TAR) dated January 2022 showed the following orders: -Flush central line (a tiny tube placed in a vein for long term drug therapy) with 10 milliliters (ml) after mediation infused every 12 hours. --No documentation by the facility staff the flush was completed four out of 26 opportunities. -Albuterol Sulfate Nebulization Solution (a medication used to treat breathing problems) 2.5 milligrams (mg)/3 ml 0.083%, 2.5 mg inhale orally via nebulizer (a machine that changes medication into a mist so it could be inhaled into the lungs) four times a day related to bronchietasis with acute lower respiratory infection. --No documentation by the facility staff the medication was completed 12 out of 41 opportunities. -Nebusal Nebulization Solution (a medication to help you cough up sputum) 3% four milliliter inhale orally via nebulizer four times a day related to bronchietasis with acute lower respiratory infection. --No documentation by the facility staff the medication was completed 12 out of 53 opportunities. -Levoxyl (used to treat an underactive thyroid) tablet 50 microgram (mcg) one tablet by mouth in the morning for low thyroid levels. --No documentation by the facility staff the medication was completed two out of 14 opportunities. -Dronedarone hydrochloride (HCl) (medication use to treat heart rhythm problems) 400 mg one tablet by mouth two times a day for arrhythmia (irregular heat beats). --No documentation by the facility staff the medication was completed three out of 27 opportunities. -Metroprolol Tartrate (medication used to treat high blood pressure) 25 mg one tablet by mouth two times a day for high blood pressure. --No documentation by the facility staff the medication was completed three out of 27 opportunities. -Combivent Respimat Aerosol Solution (medication used for COPD) 20-100 mcg, two puffs inhaled orally four times a day for COPD. --No documentation by the facility staff the medication was completed six out of 54 opportunities. -Tramadol HCL (medication used for pain) 50 mg one tablet by mouth at bedtime for pain for 30 days. --No documentation by the facility staff the medication was completed two out of 11 opportunities. -Meropenem Solution (medication used to treat infections) one gram, use two grams intravenously (a small tube that goes through the skin into a vein to deliver medications) every 12 hours for infection until 1/14/22, each bag must be infused over 1.5 hours and both should equal three hours total infusion time. --No documentation by the facility staff the medication was completed one out of three opportunities. -Administer one pill at a time in puree (applesauce or pudding) followed by thin liquid due to Dysphasia. Observation on 1/13/22 at 9:00 A.M. showed the resident's care giver put Albuterol in the nebulizer and gave the resident a breathing treatment. During an interview on 1/13/22 at 9:00 A.M. the resident's care giver said: -He/she put Albuterol into the resident's nebulizer. -He/she had got the medicine from the Certified Medication Technician (CMT). During an interview and observation on 1/14/22 at 7:45 A.M. the resident and care giver said: -The care giver had to get the resident's medications from the staff to give to him/her. -He/she did not believe the resident was always getting his/her medications. -In the morning the resident had 25 pills that he/she had to take one at a time as it was very hard for the resident to swallow. -The staff did not want to take the time to give the medication so they give it to the care giver and some applesauce to take with the medications. -It would take the resident 20 to 30 minutes to take the medications. -Two of the staff will not give the resident his/her medications because it takes too long. -The resident's family was going to meet with the Administration about different issues regarding the resident's care. -The staff always says they were new because they were mostly agency. -The morning medications that should have been given at 7:30 A.M. but had not been given until 10:30 A.M. to 1:00 P.M. that included the resident's Albuterol, Nebusal, Levoxyl, Dronedarone, Metroprolol, and Combivent. -The other night the resident had not had his/her medications and it was getting late. -The resident said his/her heart was racing and needed his/her medications. -The Assistant Director of Nursing (ADON) told them that he/she was taking care of 32 residents and would get to him/her as soon as he/she could. -The caregiver threatened to call 911 and have the resident transported to the hospital. -It took the ADON another hour to get the resident his/her medication. -The resident's daughter would be coming in to talk to the Administrator to get the resident moved out as they were not giving the resident his/her medications or cares that he/she needed. -The staff knew the care giver was not employed by the facility. -The facility was very short staffed. -The care giver poured a nebulizer treatment (Albuterol) into the resident's nebulizer and administered it to him/her which he/she had received from the CMT. -The care giver had been asking since 6:40 A.M. to get the resident's medications. Observation on 1/14/22 at 8:30 A.M. showed the resident had not had his/her morning medications. During an interview on 1/14/22 at 11:30 A.M. the resident and family member said: -They had talked to the Administrator yesterday about the issues the resident was having getting medications and cares done. -They employ a private nurse from outside the facility to help with the resident. -The resident still had not had his/her morning medications. -The resident said the night before last night he/she only got 1/2 of his/her antibiotic IV medication. -The staff gave the first bag but not the second bag and it was almost midnight. -The medication was to have been administered at 9 P.M. -(Documentation on the TAR was blank for the 9 P.M. administration on 1/13/22 ). -The family member talked to the Director of Nursing (DON) daily about the issues but it had not helped. Observation on 1/18/22 at 9:00 A.M. showed the resident's care giver was giving him/her a nebulizer treatment. -The care giver poured a nebulizer treatment (Albuterol) into the resident's nebulizer and administered it to him/her which he/she had received from the CMT. During an interview on 1/19/22 at 10:00 A.M. the resident and care giver said: -The resident's care giver gives him/her the medications as the staff was very late in giving them as they do not have enough staff. -The care giver will go out and beg the medications off of the facility CMT. -The staff will hand him/her a container of applesauce and the pills. -The care giver gave the resident his/her medications when he/she was at home and will do that again when the resident leaves to go into an apartment. -The staff did not come into the room to ensure the resident took the medications. -The care giver also administered the residents breathing treatments. -The facility CMT has said the resident had refused many of his/her medications. -The resident said the only time he/she had refused a medication was when the staff tried to get him/her to take it when it was almost midnight. -The resident and the caregiver had told the staff that the resident had a physician appointment to get the resident's central line removed and would need to have his/her medications before they left for the appointment. -The morning of the appointment they both asked many times to get the resident's medications before they left for the appointment. -The resident was very anxious because he/she did not get his/her morning medications before they left. -The care giver gave the resident a breathing treatment with medication he/she had received from the facility staff. -The appointment was at 8:45 A.M. which took a little over two hours to get his/her central line removed. -The resident did not get his/her morning medication for two hours after they returned from the appointment. -They had informed the staff they were back and needed the medications. During an interview on 1/19/22 at 11:00 A.M. CMT C said: -He/she had worked with the resident before. -The resident had refused his/her medications at times. -It was OK that the care giver gave the resident his/her medications, it was very helpful. -The nurses were aware the medications were given by the care giver. -Medications were usually late. 2. Record review of Resident #59's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Heart failure (a chronic condition where the heart does not pump blood as effectively as it should). Record review of the resident's admission MDS dated [DATE] showed: -He/she had heart failure. -He/she had high blood pressure. Record review of the resident's undated care plan showed: -The resident had altered cardiovascular status related to high blood pressure and Heart failure. -The staff was to monitor vital signs and weights as ordered. -The staff was to notify the physician of any abnormal readings. -The staff was to administer medications as ordered. Record review of the resident's POS, MAR, and TAR dated January 2022 showed the following orders: -Gabapentin (an anticonvulsant used to prevent seizures and treat certain types of pain) Capsule to be given one 100 mg capsule orally at bedtime for neuropathy pain in the left lower extremity. --No documentation by the facility staff the medication was completed two out of six opportunities. -Rosuvastatin Calcium (medication to lower cholesterol) one 5 mg tablet by mouth one time a day for lipid control. --No documentation by the facility staff the medication was completed two out of 16 opportunities. -Daily weight one time a day for heart failure. Notify the provider of a gain of 2 pounds in one day or 5 pounds in one week. --No documentation by the facility staff the daily weight was completed two out of five opportunities. -Vital signs every shift for three days post admission every evening shift. --No documentation by the facility staff the vital signs were completed two out of three opportunities. During an interview on 1/14/22 at 10:00 the ADON said: -No documentation on the MAR or TAR meant the medication or treatment was not done. 3. During an interview on 1/14/22 at 12:00 P.M. Nurse Practitioner (NP) A said if a resident had refused medications or treatments he/she would have expected staff to notify the physician by the next day. During an interview on 1/18/22 at 11:37 A.M. Registered Nurse (RN) D said: -It was not ok for family or anyone not employed by the facility to give medications or treatments. -If a medication or treatment was not documented it was not done. -If a resident refused medications more than once the physician should have been notified. During an interview on 1/19/22 at 12:41 P.M. the DON said: -They had a daily meeting to review admission orders, special procedures and new admissions. -Medications should have been documented on the MAR. -Treatments should have been documented on the TAR. -If the staff did not document it then it was not done. -The Charge Nurse should have ensured all medications and treatments were done before the end of the shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a discharge summary which included a recapitulation of the residents stay, and a reconciliation of the resident's post-discharge medication for one sampled closed record resident (Resident #72) out of three closed record residents. The facility census was 73 residents. Record review of the Discharge Summary and Plan policy reviewed 2/2021 states: -The Discharge Plan, Instructions, & Summary provides a recapitulation or summary of the resident's stay. -Discharge planning will begin upon admission to the Skilled Nursing Facility (SNF) and include family/caregiver plan for discharge. -Social Service Director or Social Service Designee will initiate and update the discharge plan in the Care Plan section of the resident's record. -Discharge Plan, Instructions, & Summary will include: --Completed by the interdisciplinary team. Copy of the assessment will be given to resident, family/caregiver on discharge from the SNF. --Social Service Director or Designee will complete sections A, B, D, H and will ensure the completed copy of the assessment is given to resident, family/caregiver. ---Nursing will complete sections C & E. ---Dietary will complete section F. ---Activities will complete section G. 1. Record review of Resident #72's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Displaced Fracture of Base of Neck Left Femur (the leg bone above the knee), Subsequent Encounter For Closed Fracture with Routine Healing. -Aftercare Following Joint Replacement Surgery. -Presence of Left Artificial Hip Joint. -Unilateral Post-Traumatic Osteoarthritis (a degenerative disease of the bones and joints), Left Hip. -Pain in Left Hip. -Repeated Falls. Record review of the resident's Progress Notes dated 11/12/21 showed: -He/she was discharged on 11/11/21. -Received a call from the receiving facility and stated the resident would be discharged about 6:30 P.M. via their transportation. -Referral was sent to another facility at the request of the resident and would be discharged that evening. Record review of the resident's electronic medical record showed: -No physician's order for the resident's discharge or transfer to another rehabilitation facility. -No documentation by the facility staff of a discharge summary. -No documentation by the facility staff of a recapitulation of stay. -No documentation by the facility staff of the resident's medication reconciliation. During an interview on 1/14/22 at 10:28 A.M., Administrator said: -No recapitulation of stay or final status of resident's stay could be produced. -This would have included what happened to the resident's medication. -If it was not listed under the assessment tab as Discharge Summary, then it was not done. -The nurse should have charted a noted with all this information also. During an interview on 1/14/22 11:46 A.M., Registered Nurse (RN) B said: -When a resident was discharged an order was given and charted. -The order needed to state where the resident was discharged to. -A discharge summary was performed and this would have included a recapitulation of the residents stay. -Discharge vital signs would be taken and charted. -A printed copy of all the paperwork would be sent with the resident. -The emergency contact would be contacted and informed of all this, -The place where the resident was going would be called and given a verbal report. -Medications would be gathered and sent with the resident with documentation of who received the medication. -Controlled medications would be counted and destroyed by two nurses, or signed for by the person that transported the resident and the nurse that was discharged the resident. -Nursing note would be documented about the discharge and who signed for the medications to include any controlled medications sent with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #2's face sheet showed he/she was admitted on [DATE] with the following diagnoses to include Multiple Sclerosis (MS - a disease where the immune system eats away at the protective covering of the nerves). Record review of the resident's admission MDS dated [DATE] showed: -He/she had a Brief Interview for Mental Status (BIMS) of 15, indicating he/she was cognitively intact. -He/she needed extensive assistance with cares. Record review of the resident's undated care plan showed: -The resident had activities of daily living deficit related to weakness, debility, severe shortness of air, Multiple Sclerosis, and his/her disease processes. -The resident required the participation of one staff member for bathing. -The resident required the participation of one staff member for eating. -The resident required the participation of one staff member for personal hygiene and oral cares. During an interview and observation on 1/14/22 at 7:45 A.M. the resident and care giver said: -They were very angry at the lack of care given to the resident. -They had told the staff the resident had a physician's appointment offsite yesterday. -The appointment was at 8:30 A.M. and they have been asking for help to get the resident cleaned up and dressed since 6:40 A.M. -The resident said he/she was very anxious as he/she couldn't get help from the staff to get ready to go to the physician's appointment. -The resident's assistant was rushed trying to dress the resident and comb his/her hair so they could leave. -The staff had told them they would get to them as soon as they could. -The resident said he/she was very anxious as he/she was afraid they would be late for the appointment. -The resident was very anxious and his/her face was red. -The resident and assistant left for the physician's appointment without any assistance getting dressed from the staff. During an interview on 1/18/22 at 11:42 A.M. the resident said: -There was not enough staff in the facility. -He/she had not had a shower since he/she came to the facility. -He/she had been in the facility for two weeks. -He/she said he/she could not wait to leave so he/she could get his/her hair washed as it was itchy. -He/she had to wait until his/her personal assistant could help him/her get washed up. -He/she liked to be dressed before meals which did not happen often at the facility. -The resident was leaving to go to an apartment. -This was not a good experience but he/she survived. Observation on 1/18/22 at 11:45 A.M. showed: -The resident's hair was matted and dirty. -The resident was scratching his/her scalp. -The resident was still in his/her night clothes with pieces of toast on his/her clothes. During an interview on 1/19/22 at 9:58 A.M. CNA D said: -It was hectic to get the residents up in the morning. -The CNAs should document showers in the ADL charting. -The charge nurse would tell the CNAs what cares need to have been done. -There was a list for which resident was to get showers on which day. -The residents should have had two showers a week. -The residents should have been changed if there was food on their clothing after meals. During an interview on 1/19/22 at 10:30 A.M. Certified Medication Technician (CMT) D said: -The residents should have had two showers a week as per the schedule. -The residents have sometimes not had all of their cares done as there was not enough staff. -The facility has been short staffed for the last two months. -There was no orientation or a list of what cares needed to be done (cheat sheet) for the agency staff. -There was a lot of agency staff working in the facility. -If there was no documentation cares such as baths were done then they were not done. During an interview on 1/19/22 at 12:41 P.M. the DON said: -The residents should have been offered two showers a week or whatever the resident preferred. -The staff should not have allowed the resident's assistant to provide the resident's cares. -The resident's assistant should have only been allowed to push the nurse call light if the resident needed something. Based on observation, interview and record review, the facility failed to provide assistance with toe nail clipping for one sampled resident (Resident #7) and did not provide assistance for activities of daily living for one sampled resident (Resident # 2) out of 19 sampled residents. The facility census was 73 residents. The facility did not have a policy related to nail care. Record review of the facility's undated job description, Certified Nursing Assistant (CNA) showed: -The staff was to assist residents with bath function as directed. -The staff was to assist residents with dressing as necessary. -The staff was to keep the residents dry change gown, clothing, linen when it becomes wet or soiled. -The staff was to assist in transporting the residents to/from appointments. -The staff was to perform after meal care, clean the resident's hands, face, clothing, brush teeth as needed. 1. Record review of Resident #7's care plan originated upon his/her date of admission on [DATE] showed the resident required assistance with activities of daily living (ADLs such as grooming, bathing, hygiene, etc.). Record review of the resident's medical record showed no podiatry notes. Upon request for podiatry notes the Medical Records Associate acquired two progress notes from the podiatrist on 1/18/22. There were no additional podiatry visits. Record review of the resident's Orders Administration Note dated 7/18/21 showed he/she had a skin infection in his/her left, great toe. Record review of the resident's care plan updated on 10/7/21 showed: -He/she wore an open toe shoe to his/her right foot while he/she has a toe infection. -He/she had a right, great toe infection due to an ingrown toenail. -He/she received antibiotic therapy related to his/her right, great toe infection. Record review of the resident's health status note dated 12/2/21 showed: -He/she complained of pain in his/her left, great toe. -His/her toe was red at the nail bed and swollen. -His/her physician was notified. Record review of the resident's skin/wound note dated 12/3/21 showed: -The resident's left, great toe was red and swollen. -A podiatry appointment was scheduled. -The Nurse Practitioner (NP) was present and assessed the resident's left, great toe and ordered Keflex (an antibiotic) for seven days. Record review of the resident's health status note dated 12/6/21 at 11:34 A.M. showed: -His/her left, great toe was red and blue and was swollen. -His/her left, great toe had a 2 centimeter (cm) x 0.5 cm white, infected pocket noted at the nail bed. -His/her physician was notified. Record review of the resident's health status note dated 12/6/21 at 3:31 P.M. showed he/she was transferred to the hospital to evaluate and treat his/her left, great toe nail bed. Record review of the resident's health status note dated 12/6/21 at 4:50 P.M. showed he/she returned from the hospital with an order for cephalexin (an antibiotic) 500 milligrams (mg) three times a day for five days and orders for a toe soak for 10 minutes twice a day for three days and apply an antibiotic ointment. Record review of the resident's physician's progress note dated 12/7/21 showed: -He/she was following-up on the resident's left toe abscess. -The resident said an incision and drainage was done in the emergency department and he/she was sent back to the facility with orders for antibiotics and to soak his/her toe. Record review of the resident's podiatry progress note dated 12/8/21 showed: -The resident presented for an initial evaluation of an infection of the left, great toe. -The toe was red and had drainage. -The left, great toenail was removed. -There was no documentation that the resident's nails were trimmed. -The recommendation was for the resident to have a follow up visit in two weeks. Record review of the resident's podiatry progress note dated 12/22/21 showed: -The resident presented for a nail removal postoperative examination of the resident's left, great toe with no complaint. -The nail border was healing and showed no signs of infection. -Dead tissue on the resident's left, great toe was removed. -There was no documentation that the resident's nails were trimmed. -The recommendation was that the resident could return as needed or if any problems arose. Record review of the resident's health status note dated 1/5/22 at 11:30 A.M. showed: -The resident's right, big toe was sore. -On the inner side of the resident's nail had a 1 centimeter (cm) long wound. Record review of the resident's January 2022 order summary report showed physician's orders dated: -11/23/21 Resident may see a Podiatrist to be treated as needed. -1/6/22 for Amoxicillin-Potassium Clavulanate (a combination penicillin-type antibiotic used to treat a wide variety of bacterial infections) tablet 875/125 mg, give 1 tablet by mouth two times a day for toe infection for 14 Days. -1/12/22 Mupirocin Ointment (an antibiotic that prevents bacteria from growing on one's skin) 2 %, apply to right, great toe topically two times a day for toe infection for 14 Days. Observation and interview on 1/10/22 at 11:30 A.M. showed: -The resident's toe nails were long (about 0.5 cm past nail bed) and jagged. -The resident said the nurse needed to cut his/her toe nails. Observation on 1/11/22 10:02 A.M. showed the resident's toe nails were long and jagged. Record review of the resident's 1/11/22 quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) showed the following staff assessment of the resident: -admitted to the facility on [DATE]. -Required extensive assistance of one person with bed mobility, transferring from one surface to another and dressing. -Required limited assistance of one person with personal hygiene. -Some of his/her diagnoses included diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), stroke, hemiplegia (paralysis of one side of the body) or paraplegia (loss of movement of both legs and generally the lower trunk) and Parkinson's disease (a neurological disease). -Had open lesion(s) on his/her foot. -Had an infection of the foot. Observation on 1/12/22 at 9:56 A.M. showed the resident's toe nails were long and jagged. Observation and interview on 1/13/22 at 7:34 A.M. showed: -Registered Nurse (RN). A said: --The resident had something on his/her other toe and went to the podiatrist for it. --The podiatrist clips the resident's nails because he/she is diabetic. --He/she doesn't know how often the podiatrist comes to the facility. --The resident had been seen by a podiatrist. -The resident's toe nails were long and jagged. During an interview on 1/18/22 at 12:56 P.M., the Medical Records Associate said: -He/she called the podiatrist to obtain the resident's records. -The podiatrist only sent back a copy of a prescription and a sheet on care for the removed toe nail. During an interview on 1/18/22 at 1:36 P.M., the Medical Records Associate said he/she called the podiatrist again and the podiatrist sent the resident's progress notes for two appointments. During an interview on 1/19/22 at 12:41 P.M., the Director of Nursing (DON) said: -The nurses were responsible for clipping nails for residents who have diabetes. -Residents who were diabetic should have a podiatry visit every six weeks. -The facility nursing staff were responsible for making appointments with the podiatrist. -The resident went to an outside podiatrist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure wound assessments were completed, to document treatments were completed, and to provide wound care for two sampled residents (Resident #59 and Resident #279) out of 19 sampled residents. They facility census was 73 residents. The facility policy was requested but was not provided. 1. Record review of Resident #59's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Sepsis (a life threatening complication of an infection) due to Methicillin Resistant Staphylococcus Aureus (MRSA - a group of bacteria that are difficult to treat as they are resistant to antibiotics). -Local infection of the skin and subcutaneous tissue (an infection that affects one part of the body). -Non-pressure chronic ulcer of the left foot (areas on the skin that have tissue damage that has caused skin loss leaving a raw wound that takes a long time to heal). -Cellulitis of the left lower limb (a bacterial skin infection that causes redness, swelling and pain in the infected area). -Peripheral Vascular Disease (PVD - a blood circulation disorder that causes the blood vessels outside of your heart to narrow, block, or spasm). -Skin graft infection (pain, warmth, swelling or redness to a patch of skin that was surgically transferred to another site). -Left humerus (arm bone) fracture. Record review of the resident's undated Care Plan showed: -The resident had PVD. -The staff was to monitor the resident's extremities for signs and symptoms of injury, infection or ulcers. -The resident was admitted with wounds and had the potential for further actual impairment to skin integrity related to PVD, decreased mobility, acute infection, and his/her disease process. -The nurse was to administer medication as ordered. -The nurse was to administer treatments as ordered and monitor for effectiveness. Record review of the resident's Progress Notes dated 12/29/21 showed the resident was admitted with a left foot wound. Record review of the resident's nursing admission data collection sheet dated 12/29/21 showed: -The resident had a scab surrounded by one larger flaky skin piece. (no documentation showing location). -The resident had a dressing on his/her left foot which he/she declined to have the dressing changed. Record review of the resident's nurses' progress notes dated 12/30/21 showed the resident required skilled nursing services related to a left foot wound with MRSA infection. Record review of the resident's Physician's Order Sheet (POS) dated 1/10/22 showed: -The resident had an order for wound care to his/her left foot. -Cleanse with saline daily, use adaptic (foam dressing), ABD pad (pad used in wound care to cushion) and soft roll up to knee. -Scheduled one time daily for left foot wound. Observation on 1/10/22 at 1:30 P.M. of the resident showed: -The resident was in bed with his/her left foot wrapped up. -There was no date on the dressing. Record review of the resident's Treatment Administration Record (TAR) dated January 2022 showed: -Cleanse with saline daily, use adaptic, ABD pad, and soft roll up to knee. -Scheduled one time daily for left foot wound. -Treatment to the resident's left foot was blank on 1/12/22, 1/13/22, 1/14/22, and 1/15/22. During an interview on 1/12/22 at 3:00 P.M. Registered Nurse (RN) C said: -The facility was short staffed. -There were times when he/she would take off a dressing that he/she had applied a week before and had not been changed since the last time he/she had worked. -The dressing should have been changed daily. -If the TAR was left blank the treatment was not done. Record review of the resident's Minimum Data set (MDS - a federally mandated assessment tool completed by the facility for care planning) Discharge sheet dated 1/19/22 showed: -The resident's Brief Interview for Mental Status (BIMS) score was 7, cognitively moderately impaired. -The resident had PVD. 2. Record review of Resident #279's Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Bilateral post traumatic osteoarthritis of knee (degeneration of the joint cartilage and the underlying bone). -Cellulitis of left and right lower limbs (bacterial skin infection that causes redness, swelling, and pain the the infected area of the skin). -Local infection of the skin. -Surgical aftercare following surgery on the skin. -Peripheral vascular disease (PVD - a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm). -Venous thrombosis and embolism (when a blood clot forms in a deep vein). Record review of the resident's admission MDS dated [DATE] showed: -The resident's BIMS score was 15 indicating he/she was cognitively intact. -The resident was admitted with orthopedic conditions. -The resident was able to understand others and to make self understood. Record review of the resident's electronic medical record showed no documentation of an admission skin assessment or wound documentation upon admission to the facility. Record review of the resident's POS dated January 2022 showed: -An order to treat his/her bilaterally anterior knees with normal saline, pat dry, apply xeroform (a type of non adherent petroleum) gauze (a double layer) to open skin, cover with an ABD pad, secure with kerlix (gauze used to dress wounds) and tape daily and as needed one time a day for open wounds dated 1/8/22. -An order for the Wound care physician to consult, evaluate, and treat as indicated dated 1/7/22. -An order to ensure all bony prominences are off-loaded (weight of the body part not touching the sheets or bedding) by pillow or wedges. -Ensure Prevalon boots (pressure relieving device used mainly on heels) were on bilateral lower extremities at all times unless ambulating every shift dated 1/8/22. -An order for Cephalaxin (medication used as an antibiotic) one 500 mg tablet to take by mouth four times a day for skin and soft tissue infection for 36 administrations dated 1/7/22. Record review of the resident's undated care plan showed: -The resident had an infection of both knees. -The staff was to administer antibiotic as ordered by the physician. -The staff was to monitor the extremities for signs and symptoms of injury infection or ulcers. -The resident had the potential for further actual impairment to skin integrity related to PVD, wound to bilateral knees, and his/her disease process. -The staff was to administer medications as ordered. -The staff was to administer treatments as ordered and monitor for effectiveness. -The staff was to ensure all bony prominences were off-loaded by pillows or wedges. Ensure Prevalon boots were on at all times unless ambulating. -The staff was to evaluate wound for size, depth, margins, peri-wound skin, sinuses, undermining, exudates, edema, granulation, infection, necrosis, eschar, gangrene. -The staff was to document progress in wound healing on an ongoing basis. -The staff was to notify the physician as indicated. -The staff was to perform a daily skin inspection and report abnormalities to the nurse. -The resident was resistive to care and had refused some medications. -The physician was aware of medication refusals. -The physician and family was aware of medication refusal. -The staff was to provide education as needed to encourage to comply with ordered plan of care and medication regimen. Record review of the resident's Medication Administration Record (MAR) dated January 2022 showed: -An order for Cephaleaxin 500 mg to be given four times a day for skin and soft tissue infection for 36 administrations. -The resident had refused the medication on 1/9/22 all four doses, 1/10/22 all four doses, 1/11/22 all four doses, and 1/12/22 all four doses. --All refusals were documented by Certified Medication Technician (CMT) C. Observation on 1/10/22 at 2:00 P.M. showed: -The resident was lying on his/her back in bed. -The resident's legs were up on pillows with bloody drainage on pillows and sheets. Record review of the resident's Nurses' Progress Notes dated 1/10/22 showed: -The resident was confused. -The resident had both long and short term memory problems. -Family was in agreement with the plan of care dated 1/10/22 at 2:49 P.M. Observation on 1/11/22 at 11:33 A.M. showed: -There was blood on pillows that were under the resident's legs and sheets. -No Prevalon boots were in place. During an interview on 1/11/22 at 11:35 A.M. the resident's family said the resident had been in the same position for several hours. Record review of the resident's Physician's Progress Notes dated 1/12/22 at 8:15 A.M. showed: -The resident was unreliable and had impaired cognition. -The resident had bilateral knee wounds covered with dressings which were clean dry and intact. -The resident had a new skin tear on the back of the left calf with sanguineous (bloody red) discharge on leg and pillow. -Intravenous (IV- given through a vein) antibiotics will continue until 1/16/22. Observation on 1/12/22 at 10:18 A.M. showed: -The resident was lying on his/her back in bed. -The sheets were soiled with blood. -The pillow under the residents knees was soiled with blood. -The family did not believe the staff had changed his/her dressings on his/her legs. During an interview on 1/12/22 at 1:34 P.M. the resident's family said: -The resident was still lying in bed the same position. -The staff had not tried to get him/her up out of bed. -The staff had not been in to turn him/her. -The same linens still had blood on them. -The family did not think that the resident had the dressings on his/her legs changed. During an interview on 1/13/22 at 11:00 A.M. the resident's family said: -They were very angry about the lack of care and they wanted to move the resident to a different facility as he/she was not getting his/her medications or treatments. -Blood stains were still on the resident's bed linens. -They had been at the resident's bedside daily from 10:00 A.M. to 7:00 P.M. -The staff still had not got the resident up out of bed. -The resident was not getting his/her antibiotic for his/her knees. -The resident was supposed to receive the medication four times a day. -This was reported to the Assistant Director of Nursing (ADON) who said he/she would report it to the Nurse Practitioner (NP) who was in the building. -The family said the nurse did not come into the room. -The resident would not have refused the medications especially when they were in the room. Observation on 1/13/22 at 11:20 A.M. showed: -The resident did not have Prevalon boots on. -The resident's knees where on a pillow. --The residents heels were on the bed. Record review of the resident's Administration note dated 1/13/22 showed NP A was notified of finding that the resident had refused medications since admission. During an interview on 1/14/22 at 11:00 A.M. the resident said he/she had not refused any medications or treatments. Observation on 1/14/22 at 11:15 A.M. showed there were no Prevalon boots in the room. Record review of the resident's electronic medical record showed no weekly skin assessment or wound assessment/documentation from 1/7/222 - 1/17/22. During an interview on 1/18/22 at 11:37 A.M., RN D said: -Treatments and medications should be given as ordered. -If a resident refused to take their medication such as an antibiotic, the physician should be notified right away. -Wounds should be documented on weekly by a nurse and documented in the chart. -The Director of Nursing (DON) would be responsible for ensuring it was done. -The staff should look at the care plans for the resident. During an interview on 1/18/22 at 11:45 A.M., CMT C said: -The resident refused all of his/her medications the first week he/she was here. -He/she did not need to tell the charge nurse that the resident was refusing his/her medications. -He/she only had to document that the resident refused the medications. During an interview on 1/18/22 at 12:00 P.M., Certified Nursing Assistant (CNA) C said: -He/she did not know the resident was to have Prevalon boots on. -He/she did not know if the nurse was supposed to get the boots for the resident or if they came from therapy. -The resident never refused any cares. 3. During an interview on 1/14/22 at 11:52 the Wound Physician said: -He/she sees the residents in this facility weekly. -The facility had a problem as there was no Wound Nurse at the current time. -The Wound Nurse would take his/her notes off of the computer to have them scanned into the resident's charts. -He/she did not think that was currently being done. -He/she would have expected that a nurse was assessing the resident's wounds weekly which should have included what the wound looked like and measurements. -It should have been documented in the chart if it was done. -The staff was expected to follow the physician's orders and document that they were done in the chart. -If a treatment was not charted it was not done. During an interview on 1/14/22 at 12:00 P.M., NP A said: -He/she sees all of the residents in the facility. -There had not been consistent wound care in the facility for the last couple of months. -The staff should do a weekly wound update on wounds. -If a resident refused a medication or treatment he/she should have been notified by the next day. -The nurses were expected to follow the physicians orders. -If the orders could not be followed then the physician or he/she should have been notified. -If charting was not charted it was not done. -The DON would be in charge of ensuring orders were done as written by the physician. During an interview 1/18/22 at 1:54 P.M., the ADON said: -They do not currently have a Wound Nurse. -The DON was ultimately responsible for ensuring wound care was done. During an interview on 1/19/22 at 12:41 P.M. the DON said: -The Charge Nurse should verify all medications and treatments were done by the end of the shift, the computer program will turn red indicating not signed off on. --If it was left blank it was not done. -Treatments should have been documented on the TAR. -The DON was ultimately responsible to ensure treatments were done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident with a Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) had orders for the Foley catheter to include the reason for the catheter and for catheter care, and to provide catheter care for one sampled resident (Resident #36) out of 19 sampled residents. The facility census was 73 residents. Record review of the facility's Urinary Catheter Care policy dated 1/2017 showed: -The purpose of the procedure was to prevent catheter associated urinary tract infections. -Documentation should include the date and time catheter care was given. -The policy did not include what should be included on the order for a Foley catheter. 1. Record review of Resident #36's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Obstructive and reflux uropathy (a condition in which the urine flow is obstructed and the backward flow of urine causing kidney damage). -Presence of urogenital implants (a treatment to help control urine leakage caused by a weak urinary sphincter muscle). Record review of the resident's Care Plan dated 11/29/21 showed: -He/she had a Foley catheter due to obstructive uropathy. -Staff were directed to provide catheter care each shift and as needed. -His/her catheter was a size 16 French with no documentation of the amount of fluid for the balloon. -The care plan was dated the day prior to the resident's admission to the facility. Record review of the resident's Physician's Order Sheet (POS)dated 12/2021 showed: -Catheter care each shift and as needed dated 11/30/21 and discontinued on 12/11/21. --NOTE: the orders did not include the size of the catheter or balloon and did not include a reason or diagnosis for the catheter. -Flush Foley with 60 milliliters (ml) of normal saline at bedtime every evening dated 12/1/21 and discontinued on 12/11/21. -Catheter 16/10 (indicating the size of the catheter was a 16 French and the amount of fluid needed to fill the balloon was 10 ml) dated 12/15/21. The order did not include the reason or diagnosis for the catheter. -Change catheter drainage bag as needed for leakage dated 12/15/21. -Change Foley catheter as needed for blockage or dislodgement dated 12/15/21. --NOTE: The order did not include the size of the catheter or balloon and did not include a reason or diagnosis for the catheter. -Irrigate the catheter with 30 ml normal saline as needed for sluggishness dated 12/15/21. --NOTE: The resident was discharged from the facility to the hospital on [DATE] and returned to the facility on [DATE]. Orders for catheter care each shift and as needed were not resumed once the resident returned to the facility. Record review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 12/2021 showed: -Catheter care each shift and as needed dated 11/30/21 and discontinued on 12/11/21 and was documented as completed per orders. --NOTE: the orders did not include the size of the catheter or balloon and did not include a reason or diagnosis for the catheter. -Flush Foley with 60 ml of normal saline at bedtime every evening dated 12/1/21 and discontinued on 12/11/21 and was documented as completed per orders. -Change catheter drainage bag as needed for leakage dated 12/15/21. Staff documented this was completed on 12/18/21. -Change Foley catheter as needed for blockage or dislodgement dated 12/15/21. Staff documented this was completed on 12/18/21. --NOTE: the orders did not include a reason or diagnosis for the catheter. The catheter size and balloon fill amount was not included on the MAR/TAR. -Irrigate the catheter with 30 ml normal saline as needed for sluggishness dated 12/15/21. --NOTE: The resident was discharged from the facility to the hospital on [DATE] and returned to the facility on [DATE]. Orders for catheter care each shift and as needed were not resumed once the resident returned to the facility. There was no documentation by the facility staff that catheter care was provided for the resident from 12/13/21 - 12/31/21. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 12/2/21 showed the resident: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. -Had a Foley catheter. -Did not refuse cares. Record review of the resident's Health Status Notes dated 12/18/21 showed: -The resident complained about the inability to urinate and pain due to the Foley catheter. -The Foley was removed and replaced with a 18 French/10 ml catheter (same size) with no difficulty. --NOTE: the resident's Foley catheter order was for a 16 French/10 ml balloon catheter. Record review of the resident's POS dated 1/2022 showed: -Catheter 16/10 (indicating the size of the catheter was a 16 French and the amount of fluid needed to fill the balloon was 10 ml) dated 12/15/21. The order did not include the reason or diagnosis for the catheter. -Change catheter drainage bag as needed for leakage dated 12/15/21. -Change Foley catheter as needed for blockage or dislodgement dated 12/15/21. --NOTE: The order did not include a reason or diagnosis for the catheter. -Irrigate the catheter with 30 ml normal saline as needed for sluggishness dated 12/15/21. --NOTE: The resident was discharged from the facility to the hospital on [DATE] and returned to the facility on [DATE]. Orders for catheter care each shift and as needed were not resumed once the resident returned to the facility. Record review of the resident's MAR and TAR dated 1/2022 showed: -Change catheter drainage bag as needed for leakage dated 12/15/21. -Change Foley catheter as needed for blockage or dislodgement dated 12/15/21. --NOTE: the orders did not include a reason or diagnosis for the catheter and the catheter size and amount to fill the balloon was not carried over from the POS to the MAR/TAR. -Irrigate the catheter with 30 ml normal saline as needed for sluggishness dated 12/15/21. --NOTE: The resident was discharged from the facility to the hospital on [DATE] and returned to the facility on [DATE]. Orders for catheter care each shift and as needed were not resumed once the resident returned to the facility. There was no documentation by the facility staff that catheter care was provided to the resident from 1/1/22 - 1/19/22. During an interview on 1/12/22 at 9:09 A.M., the resident said staff do not perform catheter care routinely. He/she thought it had been a few days since catheter care was done by facility staff. During an interview on 1/14/22 at 9:20 A.M., agency Certified Nursing Assistant (CNA) E said he/she did not know who provided the catheter care for the residents. He/she was not told he/she had to do catheter care for any of the residents. During an interview on 1/19/22 at 9:28 A.M., agency CNA C said: -He/she would know if a resident had a catheter because he/she would see it. -Any staff can complete a resident's catheter care. -Staff should document the completion of catheter care in the resident's electronic medical record. During an interview on 1/19/22 at 9:58 A.M., CNA D said: -Any staff can complete a resident's catheter care. -Staff should document the completion of catheter care in a resident's electronic medical record. During an interview on 1/19/22 at 10:43 A.M., Registered Nurse (RN) A said: -The CNA can do catheter care for a resident and document the care was completed in the resident's electronic medical records. -The facility had a batch order that had basic cares included if it was entered correctly when a resident was admitted to the facility. -For a Foley catheter the batch order would include catheter care per shift. -Orders for a Foley catheter should include the catheter size and the reason or diagnosis for the catheter. -The Director of Nursing (DON) and/or the Assistant Director of Nursing (ADON) were responsible to verify orders were carried over from the POS to the MAR/TAR. During an interview on 1/19/22 at 12:05 P.M., the resident said: -It had been at least a couple days since anyone cleaned his/her catheter site or completed catheter care for him/her. -Staff had changed his/her catheter over the weekend and did not do it correctly, they did not inflate the balloon. -He/She told the nurse he/she could feel urine leaking from the catheter and that he/she was soaking wet from urine. -The nurse told him/her there was urine in the bag so it must be working and did not check him/her to see if he/she was wet. -He/She was laying in urine for about 18 hours, until his/her family member visited the next day and discovered his/her entire bed covered in urine. -His/Her family member found a nurse and the nurse cleaned him/her up and inserted a new catheter. -He/She was not happy he/she was forced to lay in a urine soaked bed that long. During an interview on 1/19/22 at 12:10 P.M., agency CNA F said he/she did not know who provided catheter care for the residents, but he/she just gave the resident a bath so that should count. During an interview on 1/19/22 at 12:12 P.M. agency CNA G said he/she was not sure who provided catheter care for the residents, He/she was not told he/she had catheter care for any of the residents, including Resident #36. During an interview on 1/19/22 at 12:40 P.M., the DON said: -Any nursing staff, including CNAs can complete a resident's catheter care. -He/she would expect staff to document the completion of catheter care in the resident's electronic medical record. -He/she would expect Foley catheter orders to include when/how often to complete catheter care, the size of the catheter, and the diagnosis or reason for the catheter. -He/she watched staff do catheter care on Resident #36 yesterday and did not know why it was not documented. -If staff had changed the resident's catheter, he/she would have expected it would have been documented on the resident's MAR/TAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident with a Percutaneous Endoscopic Gastrostomy tube (PEG tube - a tube that is placed into a patient's stomach as a means of feeding them when they were unable to eat) had orders for care, cleaning, and monitoring of the PEG tube site for one sampled resident (Resident #36), and failed to provide PEG tube care for two sampled residents (Resident #36 and #11) out of 19 sampled residents. The facility census was 73 residents. A policy for PEG tube care and PEG tube orders was requested and not received. 1. Record review of Resident #36's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of having a gastrostomy tube (PEG). Record review of the resident's Care Plan dated 11/29/21 showed: -He/she had a gastrostomy tube and received water flushes only. -Staff were directed to check for tube placement per orders. -Staff were directed to provide local care to the PEG site per orders and to monitor for signs and symptoms of infection. -The care plan was dated the day prior to the resident's admission to the facility. Record review of the resident's Physician's Order Sheet(POS)dated 12/2021 showed: -Enteral Feed Order: Every night shift apply split gauze sponge to tube site daily and as needed dated 12/1/21 and discontinued on 12/11/21. -Enteral Feed Order: Every night shift cleanse tube site with soap and water dated 12/1/21 and discontinued on 12/11/21. -Enteral Feed Order: Every night shift tube site may be left open to air if clean and no drainage dated 12/1/21 and discontinued 12/11/21. -Check feeding tube placement before administering any medications/feeding by confirming tube measures 26.5 centimeters (cm) in length every shift dated 12/1/21 and discontinued on 12/11/21. -Enteral Feed Order: Every shift check tube placement prior to water flush dated 12/1/21 and discontinued on 12/11/21. -Enteral Feed Order: Every shift elevate head of bed 30 to 45 degrees while flushing with water dated 12/1/21 and discontinued on 12/11/21. -Enteral Feed Order: Every shift flush tube with 50 milliliters (ml) of water dated 12/1/21 and discontinued on 12/11/21. -Enteral Feed Order: as needed cleanse tube site with soap and water for soiling dated 12/1/21 and discontinued on 12/11/21. -Enteral Feed Order: every hour as needed apply split gauze sponge to tube site daily and as needed if soiled dated 12/1/21 and discontinued on 12/11/21. --NOTE: The resident was discharged from the facility to the hospital on [DATE] and returned to the facility on [DATE]. Orders for PEG tube and care each shift and as needed all Enteral Feed Orders were not resumed once the resident returned to the facility. Record review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 12/2021 showed: -Enteral Feed Order: Every night shift apply split gauze sponge to tube site daily and as needed dated 12/1/21 and discontinued on 12/11/21. --No documentation by facility staff this was completed three out of 10 opportunities. -Enteral Feed Order: Every night shift cleanse tube site with soap and water dated 12/1/21 and discontinued on 12/11/21. --No documentation by facility staff this was completed three out of 10 opportunities. -Enteral Feed Order: Every night shift tube site may be left open to air if clean and no drainage dated 12/1/21 and discontinued 12/11/21. --No documentation by facility staff this was completed three out of 10 opportunities. -Check feeding tube placement before administering any medications/feeding by confirming tube measures 26.5 cm in length every shift dated 12/1/21 and discontinued on 12/11/21. --No documentation by facility staff the tube placement was checked five out of 28 opportunities. -Enteral Feed Order: Every shift check tube placement prior to water flush dated 12/1/21 and discontinued on 12/11/21. --No documentation by facility staff the tube placement was checked prior to water flushes five out of 30 opportunities. -Enteral Feed Order: Every shift elevate head of bed 30 to 45 degrees while flushing with water dated 12/1/21 and discontinued on 12/11/21. --No documentation by facility staff the resident's head of bed was elevated four out of 30 opportunities. -Enteral Feed Order: Every shift flush tube with 50 ml's of water dated 12/1/21 and discontinued on 12/11/21. --No documentation by facility staff the tube was flushed four out of 30 opportunities. -Enteral Feed Order: as needed cleanse tube site with soap and water for soiling dated 12/1/21 and discontinued on 12/11/21. -Enteral Feed Order: every hour as needed apply split gauze sponge to tube site daily and as needed if soiled dated 12/1/21 and discontinued on 12/11/21. --NOTE: The resident was discharged from the facility to the hospital on [DATE] and returned to the facility on [DATE]. Orders for PEG tube and care each shift and as needed all Enteral Feed Orders were not resumed once the resident returned to the facility. There was no documentation by the facility staff that PEG tube care was provided for the resident from 12/13/21 - 12/31/21. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 12/2/21 showed the resident: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. -Had a PEG tube. -Did not refuse cares. Record review of the resident's POS dated 1/2022 showed the resident did not have any orders related to the care and monitoring of his/her PEG tube. --NOTE: The resident was discharged from the facility to the hospital on [DATE] and returned to the facility on [DATE]. Orders for PEG care and monitoring each shift and as needed were not resumed once the resident returned to the facility. Record review of the resident's MAR and TAR dated 1/2022 showed the resident did not have any orders related to the care and monitoring of his/her PEG tube. --NOTE: The resident was discharged from the facility to the hospital on [DATE] and returned to the facility on [DATE]. Orders for PEG care and monitoring each shift and as needed were not resumed once the resident returned to the facility. There was no documentation by the facility staff that PEG tube care was provided for the resident from 1/1/22 - 1/19/22. During an observation of the resident and interview on 1/12/22 at 9:09 A.M., the resident said: -Staff do not perform feeding tube care routinely. -He/she thought it had been a few days since feeding tube care was done by facility staff. -Observation of the PEG tube site showed the site was not covered and the skin around the opening was reddened with crusting around the opening. During an observation of the resident and interview on 1/19/22 at 12:05 P.M., the resident said: -It had been at least a couple days since anyone cleaned his/her PEG tube site. -Observation of the PEG tube site showed the site was not covered and the skin around the opening was reddened with crusting around the opening. 2. Record review of Resident #11's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnoses of gastrostomy tube. Record review of the resident's care plan dated 10/13/21 showed: -The resident had a PEG tube. -Staff were to check tube placement and gastric residuals per facility protocol and record. -Staff were to provide local care to the tube site and monitor for signs and symptoms of infection. Record review of the resident's POS dated 1/2022 showed: -Enteral Feed Order: Every night shift apply split gauze sponge to tube site daily and as needed dated 10/13/21. -Enteral Feed Order: Every night shift cleanse tube site with soap and water dated 10/13/21. -Enteral Feed Order: Every shift check and record residual, if residual is greater than 150 ml, notify the resident's physician dated 10/13/21. -Enteral Feed Order: Every shift elevate head of bed 30 to 45 degrees while flushing with water dated 10/13/21. -Check feeding tube placement before administering any medications/feeding by confirming tube measures 41.5 cm in length every four hours dated 12/3/21. -Enteral Feed Order: Every shift flush PEG tube with 75 ml water before and after feeding dated 10/21/21. Record review of the resident's MAR/TAR dated 1/2022 showed: -Enteral Feed Order: Every night shift apply split gauze sponge to tube site daily and as needed dated 10/13/21. Staff documented this was completed daily between 1/1/22 - 1/11/22. -Enteral Feed Order: Every night shift cleanse tube site with soap and water dated 10/13/21. Staff documented this was completed each shift between 1/1/22 - 1/11/22. --NOTE: observation of the resident's PEG tube dressing on 1/10/22, 1/12/22, and 1/14/22 showed the dressing was dated 1/8/22. -Enteral Feed Order: Every shift check and record residual, if residual is greater than 150 ml, notify the resident's physician dated 10/13/21. --No documentation the resident's residual was checked three out of 33 opportunities. -Enteral Feed Order: Every shift elevate head of bed 30 to 45 degrees while flushing with water dated 10/13/21. --No documentation by facility staff two out of 33 opportunities. -Check feeding tube placement before administering any medications/feeding by confirming tube measures 41.5 cm in length every four hours dated 12/3/21. --No documentation staff assessed the length of the tube five out of 69 opportunities. -Enteral Feed Order: Every shift flush PEG tube with 75 ml water before and after feeding dated 10/21/21. --No documentation by facility staff two out of 33 opportunities. During an observation of the resident on 1/10/22 at 11:04 A.M. showed the date on the resident's PEG tube dressing was dated 1/8/22. During an observation of the resident and interview on 1/12/22 at 1:10 P.M., the resident said: -Staff does his/her PEG tube dressing change and clean the site about every three days or so. They do not do it every day. -The date on the resident's PEG tube dressing was 1/8/22. During an observation of the resident and interview on 1/14/22 at 9:11 A.M., the resident said: -The staff had not cleaned his PEG tube site or changed the dressing all week. -The date on the resident's PEG tube dressing was 1/8/22. 3. During an interview on 1/19/22 at 10:43 A.M., Registered Nurse (RN) A said: -The licensed nursing staff provide PEG tube care for a resident and document the care was completed in the resident's electronic medical records. -The facility has a batch order that has basic cares included if it is entered correctly when a resident is admitted to the facility. -For a PEG tube the batch order would include cleaning the site and assessing for signs and symptoms of infection. -If the MAR/TAR is blank, then it means it was not completed. -If staff documented a care was completed, it should be accurate. -It was not appropriate to clean a resident's PEG site then re-apply the previous dressing, staff should put on a new dressing. -The Director of Nursing (DON) and/or the Assistant Director of Nursing (ADON) were responsible to verify orders were carried over from the POS to the MAR/TAR. During an interview on 1/19/22 at 12:40 P.M., the DON said: -The licensed nursing staff provide PEG tube care for a resident and document the care was completed in the resident's electronic medical records. -He/She would expect staff to document the completion of PEG care in the resident's electronic medical record. -If the MAR/TAR was blank, then it means it was not completed. -Resident #36's PEG care was completed yesterday and should have been documented. -If staff documented a care was completed, it should be accurate. -It was not appropriate to clean a resident's PEG site then re-apply the previous dressing, staff should put on a new dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (%). Two medication errors were observed out of 27 opportunities for an error rate of 7.4%. The facility census was 73 residents. Record review of the facility Medication Administration policy dated 5/2019 showed: -Staff should review the resident's Medication Administration Record (MAR). -Read and follow any special directions on the label. -Administer the medication and document the medication administration in the resident's MAR. Record review of the product insert for Humalog insulin (a fast acting insulin) dated 4/2020 showed the medication should be administered 15 minutes before or immediately after a meal. Record review of the product insert for Novolg insulin dated 7/2021 showed the medication should be administered within five to 10 minutes before a meal. 1. Record review of Resident #49's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of diabetes. Record review of the resident's January 2022 Physician's Order Sheet (POS) showed: -Staff were to monitor the resident's blood sugar levels before meals and before bedtime. -Humalog insulin given on sliding scale (the amount administered is based on the resident's blood sugar level) as follows; blood sugar of 151-200 give 1 unit, 201-250 give 2 units, 251-300 give 3 units, 301-350 give 4 units, and 351-400 give 5 units and call MD. Record review of the resident's January 2022 MAR showed: -Monitor blood sugar before meals and before bedtime. -Humalog insulin given on sliding scale as follows; blood sugar of 151-200 give 1 unit, 201-250 give 2 units, 251-300 give 3 units, 301-350 give 4 units, and 351-400 give 5 units and call MD. -Blood sugar of 170 recorded with 1 unit Humalog insulin given 1/12/22 at 11:30 A.M. --NOTE observation of the medication pass on 1/12/22 at 11:15 A.M. - 1:10 P.M. showed the resident was not administered insulin by the facility staff at 11:30 A.M. per the documentation. Observation on 1/12/22 at 12:12 P.M. showed: - The resident was in a wheelchair in his/her room yelling, I'm a diabetic, I need food. -Resident had turned on call light. -Resident rummaged through nightstand and found single serving bag of potato chips which he/she ate. Observation on 1/12/22 at 12:33 P.M. showed: -Licensed Practical Nurse (LPN) C checked the resident's blood sugar with glucometer (small, portable machine that measures the glucose level in the blood by placing a drop of blood on a test strip which has already been inserted into the machine) which resulted at 170. -LPN C left resident's room without administering insulin and he/she walked away from the resident's room to another hall. Observation on 1/12/22 at 12:47 P.M. showed Certified Nursing Assistant (CNA) E brought a lunch tray to the resident in his/her room and placed on his/her table then left the room. Observation on 1/12/22 at 1:10 P.M. showed unknown staff removed resident's lunch tray with 65% of meal eaten. -NOTE: Constant direct observation between 12:12 P.M. until 1:10 P.M. showed staff did not administer insulin during this time frame. 2. Record review of Resident #53 Face sheet showed he/she was admitted on [DATE] with the diagnosis of Diabetes. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 12/23/21 showed: -The resident had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact). -The resident needed extensive assistance. -The resident was a Diabetic. Record review of the resident's undated care plan showed: -The resident had Diabetes. -The staff was to administer diabetic medication as ordered by Physician. Record review of the resident's January 2022 POS showed: -The resident had an order for Blood sugar to be taken before meals and at bedtime for Diabetes dated 12/17/21. -The resident had an order for Novolog Solution 100 units per milliliter (ml) to inject five units subcutaneously before meals for Diabetes dated 12/20/21. -The resident had an order for Novolog Solution 100 units per ml inject as per sliding scale before meals: 150 to 180 give two units; 181 to 220 give four units; 221 to 270 give seven units; 271 to 320 give 10 units dated 12/20/21. Record review of the resident's January 2022 Treatment Administration Record (TAR) showed: -On 1/10/22 the resident's blood sugar at the noon meal was 201. -The resident was given five units plus an additional four units per sliding scale for a total of nine units. Observation on 1/10/22 at 11:47 A.M. of Insulin administration showed LPN D gave the resident nine units of Novolog Insulin subcutaneously. During an interview 1/10/22 at 11:48 A.M. LPN D said: -He/she had taken the resident's blood sugar 20 minutes ago. -The resident's blood sugar was 201. -He/she was to administer five units of Novolog and four additional units of sliding scale Novolog insulin's. -The resident was to get their insulin within 30 minutes of a meal. -The resident's lunch was scheduled for 12:30 P.M. --NOTE: Novolog product insert showed the insulin was to be administered 5-10 minutes before a meal. Observation on 1/10/22 at 1:07 P.M. showed the resident was just served lunch. This was 1 hour 22 minutes after his/her insulin was administered by staff. During an interview on 1/13/22 at 10:30 A.M. the resident said that his/her insulin was administered 30% of the time more than 30 minutes before the meal was served. 3. During an interview on 1/12/22 at 10:30 A.M. LPN C said: -If you have an order from the physician you should follow it. -Meals at this facility were often late and you needed to give the residents insulin 30 minutes from when the meal was actually served. -He/she would wait until he/she saw the food cart was on the hall being delivered to the rooms. During an interview on 1/19/22 at 12:41 P.M. the DON said: -Accu checks should be done as ordered and before meals. -Insulin should be administered when food is available not more than 30 minutes. -The staff would have to recheck the blood sugar if it has been a long time.

Based on observation, record review and interview, the facility failed to ensure sausage was pureed (to make food into a paste or thick liquid suspension usually made from cooked food that was ground finely) to a smooth pudding or soft mashed potato consistency in accordance with the pureed sausage recipe. This practice potentially affected one sampled resident with a pureed diet. The facility census was 73 residents. 1. Record review of the undated pureed sausage recipe for 5 servings of pureed sausage showed: Ingredients: --5 sausage patties. --1/4 teaspoon of pork base. --½ cup hot water. --2 ½ pieces of toast. Directions showed: --Dissolve pork base in water to make broth. --Place prepared sausage patty, broth and toast in a washed and sanitized food processor. --Blend until smooth. --Reheat to greater than 165 degrees Fahrenheit(°F) Observation on 1/12/22 at 9:49 A.M., showed Dietary [NAME] (DC) D pureed sausage. -No recipe book was open for DC D to follow. -DC D pureed the sausage for about 1 minute. -DC D did not reheat the pureed sausage to 165 °F. Observation on 1/12/22 at 9:52 A.M., showed the pureed sausage was not smooth and had a grainy texture during a taste test of the pureed sausage. During an interview on 1/12/22 at 9:54 A.M., the Dietary Manager (DM) said pureed sausage was grainy and should have been smoother, after he/she tasted the pureed sausage. During an interview on /14/22 at 3:27 P.M., the DM said: -He/she has tried to show employees how to puree the food correctly. -He/she believed that the lack of proper pureed food, went back to a training and staffing issue -He/she believed that pureed food should be a mashed potato consistency. -The consistency should be thicker than applesauce but hold a form like mashed potatoes. -Food needs to look palatable and grainy consistency should not be there.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #67's face sheet showed he/she was admitted on [DATE] with the following diagnoses local infection of the skin. Record review of the resident's undated care plan showed: -The resident had the potential for further actual impairment to skin integrity related to recent surgery, decreased mobility, peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), incontinence, and other disease processes. -The resident was admitted with a deep tissue pressure injury to the coccyx. -The staff was to administer treatments as ordered and monitor for effectiveness. -The staff was to administer medications as ordered and monitor for effectiveness. -A wound care company was to evaluate and treat for wound management. Record review of the resident's December 2021 POS showed: -There was an order for a Wound care company to evaluate and treat, dated 12/28/21. -There was an order for the coccyx (pressure) wound to have been cleansed with normal saline, pat dry, apply silver alginate and to have been covered with foam daily and as needed to be done every day shift, dated 12/28/21. Record review of the resident's December 2021 TAR showed: -The resident had an order for the coccyx wound to have been cleansed with normal saline, pat dry, apply silver alginate and to have been covered with foam daily and as needed to be done every day shift, dated 12/29/21. -No documentation by the facility staff the treatment was completed one out of three opportunities. Record review of the resident's January 2022 POS showed: -There was an order for a wound care physician to consult, evaluate and treat as indicated relate to worsening sacral pressure wound dated 1/3/22. -There was an order for the coccyx wound to have been cleansed with normal saline, pat dry, apply silver alginate and to have been covered with foam daily and as needed to be done every day shift, dated 12/28/21. Record review of the resident's January 2022 TAR showed: -The resident had an order for the coccyx wound to have been cleansed with normal saline, pat dry, apply silver alginate and to have been covered with foam daily and as needed to be done every day shift, dated 12/28/21. -No documentation by the facility staff the treatment was completed four out of 16 opportunities. Record review of the resident's admission MDS dated [DATE] showed: -The resident's BIMS score was 7 out of 15, indicating he/she was moderately cognitively impaired. -The resident needed extensive assistance to transfer. -The resident had an unstageable pressure ulcer present on admission. Record review of Wound Care Physician's notes dated 1/7/22 showed: -The resident was seen on 1/7/22 for multiple ulcers initial assessment. -The resident was admitted with sacral pressure ulcer that has worsened notably. -The wound now has eschar, deep tissue injury and was large. -The wound was suspicious for indicator of skin failure and overall decline given the residents advanced age, COVID-19 positive, recent hip fracture, advanced dementia, and malnutrition. -The resident was started on Augmentin for the sacrum which appears to be worsening pressure injury rather than acute infection. -The resident had a low air loss mattress. -The resident needed aggressive offloading (repositioned every two hours and heels floated). -Wound #1 the sacrum (triangular bone at the base of the vertebrae), the original cause of the wound was pressure injury. -The wound was currently classified as unstageable. -The wound measures 12 cm length by 10 cm width with an area of 94.248 cm. -The fat layer was exposed. -There was a small amount of serosanguineous(bloody red) drainage noted. -67% to 100% of amount of necrotic (dead cells) tissue within the wound bed including Eschar (a piece of dead skin that was cast off from the surface of the skin). -The staff was to have cleansed the wound then applied zinc barrier cream applied twice a day. -(This order was not carried over to the POS/MAR/TAR). -Wound #2 the right Calcaneous (heel bone), the original cause of the wound was pressure injury. -The wound was currently classified as unstageable. -The wound measures 5 cm length by 9.5 cm width with an area of 37.306 cm. -There was a small amount of serous (a watery) drainage. -The staff was to have cleansed the wound with cleanser pat dry, protect with periwound with skin prep and apply skin prep to wound bed daily. -(This order was not carried over to the POS/MAR/TAR). .-Wound #3 the left Calcaneous, the original cause of the wound was pressure injury. -The wound was currently classified as unstageable. -The wound measures 3.5 cm length by 5 cm width with an area of 13.744 cm. -No drainage was noted. -The staff was to have cleansed the wound with cleanser pat dry, protect with periwound with skin prep and apply skin prep to wound bed daily. -(This order was not carried over to the POS/MAR/TAR). Observation on 1/12/22 at 3:00 P.M. of the resident showed: -The resident's sacral area was necrotic unable to stage, three inches long triangular shaped. -The resident had an open area on the heel of each foot quarter sized unstageable. -The pressure ulcers looked red, raw, and the first layer of skin was gone. -Wound care was observed to have been done correctly according to the POS ordered by the facility physician, not what the wound care physician (specialist ordered by the facility physician) had ordered. During an interview on 1/12/22 at 3:00 P.M. Registered Nurse (RN) C said: -The facility is short staffed. -There are times when he/she will take off a dressing that he/she had applied a week before and had not been changed since the last time he/she had worked. -The dressing should have been changed daily. -If it was left blank the treatment was not done. -The charge nurse was responsible for taking off new orders. -The nurses have to do their own wound care as there was no wound care nurse at that time. -The nurse was not aware the resident had open areas on his/her heels. -The nurse did not know how long the resident had open wounds on his/her heels as the nurse had not worked for a few days and it had not been passed on in report. -The wound care nurse did the weekly wound evaluations but they did not currently have one at the facility. Record review of resident's Wound Care Physician's notes dated 1/14/22 showed: -The resident was admitted with sacral pressure ulcer that has worsened notably since last week, despite low air loss mattress and offloading attempts. -Wound #1 has improved. -The wound measures 11.5 cm length by 9.2 cm width with an area of 83.095 cm. -Wound #2 was unchanged. -The wound measures 4.5 cm length by 8 cm width with an area of 28.274 cm. -There was a small amount of necrotic tissue in the wound bed. -Wound #3 has improved. -The wound measures 2.5 cm length by 4.0 cm width with an area of 7.854 cm. -Wound #4 was a skin tear. -The resident had an overall decline with multiple acute illnesses. -The resident would likely need surgical debridement of the sacral ulcer. -Continue protect pressure ulcer and foam dressing to encourage autolytic debridement (the body breaks down the dead skin cells). -(This was not on the POS/MAR/TAR). During an interview on 1/14/22 at 11:52 A.M. the wound care physician said: -He/she sees the residents weekly. -The facility did not have a wound care nurse currently which has been a problem as the nurse had taken his/her orders off and sent them to medical records to ensure they were in the system. -He/she would expect a nurse to assess the wounds weekly. -He/she would expect his/her orders to have been followed. -The resident's skin was very thin and fragile. -The resident was [AGE] years old and his/her health was declining. -After the resident comes out of the COVID unit they were looking at surgical debridement (cutting away of the dead skin) of the sacral area on his/her back. 4. During an interview on 1/14/22 at 10:30 A.M., the outside wound physician said he/she would expect the facility staff to follow the resident's wound care orders as prescribed, including applying the wound dressing that was ordered. During an interview on 1/14/22 at 12:00 P.M. the Nurse Practitioner (NP) said: -The facility has not had consistent wound care there the last few months. -There was no dedicated wound care nurse currently. -The nurses should follow the physician's orders for medications and treatments. -If there was any questions the physician should have been notified. -The residents should have been assessed upon admission and weekly by a nurse in the facility. -He/she was not aware of who took the physician's orders off but ultimately it was the Director of Nursing's (DON) responsibility. During an interview on 1/19/22 at 10:43 A.M., Registered Nurse (RN) A said: -The nurse would do wound treatments and should document the treatment was completed on the resident's MAR/TAR. -If a wound care supply was not available, he/she would let the wound nurse know. -He/She thought the wound nurse was the Assistant Director of Nursing (ADON) at this time. During an interview on 1/19/22 at 12:40 P.M., the DON said: -Nurses were responsible to ensure orders were carried over to the resident's POS, MAR, and TAR. -Since the facility used agency staff, the weekend supervisor, ADON, and wound nurse would be the ones responsible to put orders in the electronic medical record. -He/She expected staff to complete wound care as ordered by the resident's physician. -He/She expected staff to document in the resident's MAR/TAR when wound care was completed. -He/She would expect staff to notify the resident's physician if wound care supplies were not available and a treatment was not able to be completed as ordered. Based on observation, interview, and record review, the facility failed to ensure physician's orders for wound care for a resident's pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) was completed as prescribed for three sampled residents (Residents #33, #36 and #67) out of 19 sampled residents. The facility census was 73 residents. Record review of the facility's Pressure Ulcer/Pressure Injury Prevention policy revised on 3/2021 did not address documentation of wound care treatments. 1. Record review of Resident #36's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the resident's Care Plan dated 11/29/21 showed: -He/She was admitted to the facility with pressure ulcers. --Staff were to administer medications as ordered. --Staff were to administer treatments as ordered and monitor for effectiveness. -He/She had an unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to his/her coccyx (tailbone) upon admission to the facility. --An outside wound care company was involved with the resident's wound care . --Staff were to administer treatments as ordered. ---12/3/21 new treatment orders. ---12/13/21 new treatment orders. ---12/20/21 new treatment orders. -The resident's Care Plan was dated prior to the resident's admission to the facility. Record review of the resident's Physician's Order Sheet (POS) dated 12/2021 showed: -Cleanse left buttock wound with wound cleanser/normal saline, pat dry, apply Therahoney (a medical grade honey used as a specialized wound treatment to clear away necrotic (dead) tissue and create a moist wound bed while eliminating odors), cover with Abdominal pad (ABD - a thick, absorbent dressing), change daily and as needed dated 12/2/21 and discontinued 12/3/21. -Cleanse right buttock wound with wound cleanser/normal saline, pat dry, apply Therahoney, cover with ABD, change daily and as needed dated 12/2/21 and discontinued 12/3/21. -Cleanse sacral (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) wound with wound cleanser, apply Therahoney, cover with ABD, change daily and as needed dated 12/2/21 and discontinued 12/3/21. -Cleanse sacral wound with wound cleanser/normal saline, pat dry, apply Skin Prep (a topical barrier between skin and adhesives) to periwound (skin around the outside of the wound) and allow 30 seconds to dry, to wound bed apply Santyl (an ointment used for the debridement of pressure ulcers) nickel thick and cover with calcium alginate (a highly absorbent wound dressing), and silicone border gauze (an adhesive dressing) daily and as needed every day shift for wound care dated 12/4/21 and discontinued 12/11/21. -Cleanse sacral wound with wound cleanser/normal saline, pat dry, apply skin prep to periwound and allow 30 seconds to dry. Cover with Santyl nickel thick and calcium alginate and cover with silicone foam (an adhesive dressing) daily and as needed every day shift dated 12/14/21 and discontinued 12/29/21. -Cleanse sacral wound with Dakin (a strong topical antiseptic solution used to clean infected wounds, ulcers, and burns. It can dissolve necrotic tissue and can be used to irrigate, cleanse, or as a component in wet-to-dry dressings to treat or prevent skin and soft tissue infections) 1/2 strength soaked 4 x 4 (gauze), pat dry, apply Skin Prep to periwound, cover with Santyl nickel thick and cover with calcium alginate, cover with silicone foam daily and as needed dated 12/29/21. Record review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 12/2021 showed: -Cleanse sacral wound with wound cleanser/normal saline, pat dry, apply Skin Prep to periwound and allow 30 seconds to dry, to wound bed apply Santyl nickel thick and cover with calcium alginate, and silicone border gauze daily and as needed every day shift for wound care dated 12/4/21 and discontinued 12/11/21. --No documentation by the facility staff the treatment was completed one out of seven opportunities. -Cleanse sacral wound with wound cleanser/normal saline, pat dry, apply skin prep to periwound and allow 30 seconds to dry. Cover with Santyl nickel thick and calcium alginate and cover with silicone foam daily and as needed every day shift dated 12/14/21 and discontinued 12/29/21. --No documentation by the facility staff the treatment was competed five out of 16 opportunities. -Cleanse sacral wound with Dakin 1/2 strength soaked 4 x 4 (gauze), pat dry, apply Skin Prep to periwound, cover with Santyl nickel thick and cover with calcium alginate, cover with silicone foam daily and as needed dated 12/29/21. ---No documentation by the facility staff the treatment was competed one out of two opportunities. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 12/2/21 showed the resident: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. -Had an unhealed pressure ulcer. -Had one unstageable pressure ulcer upon admission. -Had three Deep Tissue Injury (DTI - Deep tissue injury may be characterized by a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Presentation may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue) upon admission. -Received pressure ulcer care including application of non-surgical dressing with or without topical medication to an area other than the feet. -Did not refuse cares. -Did not have pain. Record review of the resident's outside wound care provider physician orders dated 12/3/21 showed: -The resident had an unstageable pressure ulcer to his/her sacral region. -Wound cleansing and dressings included: Cleanse the wound with saline, protect the periwound with Skin Prep, apply Santyl to the wound bed - nickel thick; pack loosely with calcium alginate, cover wound with ABD, secure dressing, change daily and as needed for soiling and/or saturation. --NOTE: The resident's POS and MAR/TAR did not instruct staff to loosely pack the resident's wound. Record review of the resident's outside wound care provider physician orders dated 12/17/21 showed: -The resident had an unstageable pressure ulcer to his/her sacral region. -Wound cleansing and dressings included: Cleanse the wound with saline, protect the periwound with Skin Prep, apply Santyl to the wound bed - nickel thick; pack loosely with calcium alginate, cover wound with ABD, secure dressing, change daily and as needed for soiling and/or saturation. --NOTE: The resident's POS and MAR/TAR did not instruct staff to loosely pack the resident's wound. Record review of the resident's outside wound care provider physician orders dated 12/22/21 showed: -The resident had an unstageable pressure ulcer to his/her sacral region. -Wound cleansing and dressings included: Cleanse the wound with saline, protect the periwound with Skin Prep, apply Santyl to the wound bed - nickel thick; pack loosely with calcium alginate, cover wound with ABD, secure dressing, change daily and as needed for soiling and/or saturation. --NOTE: The resident's POS and MAR/TAR did not instruct staff to loosely pack the resident's wound. Record review of the resident's outside wound care provider physician orders dated 12/29/21 showed: -The resident had an unstageable pressure ulcer to his/her sacral region. -Wound cleansing and dressings included: Cleanse the wound with saline, protect the periwound with Skin Prep, apply Santyl to the wound bed - nickel thick; pack loosely with 1/4 strength Dakin's moistened gauze, cover wound with ABD, secure dressing, change daily and as needed for soiling and/or saturation. --NOTE: The resident's POS and MAR/TAR did not instruct staff to loosely pack the resident's wound. The order transcribed to the resident's POS and MAR/TAR showed to cleanse the wound with 1/2 strength Dakin, pat dry, apply skin prep to periwound, cover with Santyl, cover with calcium alginate, and cover with silicone foam. Record review of the resident's POS dated 1/2022 showed: -Cleanse sacral wound with Dakin 1/2 strength soaked 4 x 4 (gauze), pat dry, apply Skin Prep to periwound, cover with Santyl nickel thick and cover with calcium alginate, cover with silicone foam daily and as needed dated 12/29/21. Record review of the resident's MAR/TAR dated 1/2022 showed: -Cleanse sacral wound with Dakin 1/2 strength soaked 4 x 4 (gauze), pat dry, apply Skin Prep to periwound, cover with Santyl nickel thick and cover with calcium alginate, cover with silicone foam daily and as needed dated 12/29/21. --No documentation the treatment was completed by the facility staff three out of 12 opportunities. Record review of the resident's outside wound care provider physician orders dated 1/7/22 showed: -The resident had an unstageable pressure ulcer to his/her sacral region. -Wound cleansing and dressings included: Cleanse the wound with saline, protect the periwound with Skin Prep, apply Santyl to the wound bed - nickel thick; pack loosely with saline moistened rolled gauze, cover wound with ABD, secure dressing, change daily and as needed for soiling and/or saturation. --NOTE: The resident's POS and MAR/TAR did not instruct staff to loosely pack the resident's wound. The order transcribed to the resident's POS and MAR/TAR showed to cleanse the wound with 1/2 strength Dakin, pat dry, apply skin prep to periwound, cover with Santyl, cover with calcium alginate, and cover with silicone foam. Record review of the resident's Order Administration Notes dated 1/12/22 showed: -The resident's dressing was changed. Dakins was not available, so normal saline was used instead. -The wound had heavy watery, greenish drainage and the previous dressing was saturated. --No documentation staff notified the Director of Nursing (DON) or the resident's physician regarding not having the prescribed wound treatment available or of the documented increased wound drainage. --NOTE: The resident's wound care physician order on 1/7/22 was for staff to loosely pack the resident's wound with saline moistened rolled gauze and did not include the previous order of Dakins solution. Record review of the resident's outside wound care provider physician orders dated 1/14/22 showed: -The resident had an unstageable pressure ulcer to his/her sacral region. -It was recommended to pack the resident's wound with rolled gauze due to the size of the wound, but packing strips were being used. -Wound cleansing and dressings included: Cleanse the wound with saline, protect the periwound with Skin Prep, apply Santyl to the wound bed - nickel thick; pack loosely with saline moistened gauze, cover wound with ABD, secure dressing, change daily and as needed for soiling and/or saturation. --NOTE: The resident's POS and MAR/TAR did not instruct staff to loosely pack the resident's wound. The order transcribed to the resident's POS and MAR/TAR showed to cleanse the wound with 1/2 strength Dakin, pat dry, apply skin prep to periwound, cover with Santyl, cover with calcium alginate, and cover with silicone foam. Observation on 1/14/22 at 11:00 A.M. showed: -The wound physician removed the resident's dressing and packing to the resident's ulcer. -After the wound physician completed a bedside debridement (removal of dead tissue), the DON cleansed the resident's pressure ulcer with normal saline, pat dry, applied Santyl nickel thick to the wound bed then loosely packed the wound with saline soaked packing strips, covered with calcium alginate cut to fit the wound, applied skin prep to the periwound, then covered with a foam dressing. --NOTE: The wound care order on the resident's POS/MAR/TAR was to cleanse the wound with 1/2 strength Dakin, pat dry, cover with Santyl, cover with calcium alginate, and cover with silicone foam. The wound care orders from the resident's 1/7/22 wound care physician's order was to cleanse the wound with saline, apply Santyl, pack loosely with saline moistened gauze, then cover with an ABD. 2. Record review of Resident 33's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of a Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) sacral pressure ulcer. Record review of the resident's admission MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS of 15 out of 15. -Did not reject cares. -Had a Stage IV pressure ulcer that was not present upon admission or re-entry. Record review of the resident's care plan revised on 8/25/21 showed: -He/She had a pressure ulcer. -Administer treatments as ordered and monitor for effectiveness. -Monitor dressing when providing care to ensure it is intact and adhering. Report dressing loss to nurse. -Treatment as ordered. --10/15/21, 10/21/21, 10/28/21, 11/4/21, 11/11/21, 11/23/21, 12/1/21, 12/14/21, 12/20/21 continue current wound care. -The resident was admitted with a Stage IV pressure ulcer to his/her coccyx on 7/29/21. -Outside wound care provider as ordered. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS of 15 out of 15. -Did not reject cares. -Had a Stage IV pressure ulcer that was present upon admission or re-entry. Record review of the resident's POS dated 12/2021 showed: -Cleanse coccyx with normal saline, pat dry, apply hydrofera blue (an antibacterial dressing)moist with saline, cover with foam dressing every Monday, Wednesday, and Friday and as needed dated 11/1/21 and discontinued on 12/15/21. -Cleanse coccyx with normal saline, pat dry, apply silver alginate (a highly absorbent, antimicrobial wound dressing), cover with foam dressing every Monday, Wednesday, and Friday dated 12/16/21 and discontinued 12/23/21. -Cleanse coccyx with normal saline, pat dry, apply alginate foam (an absorbent dressing) and tape every Monday, Wednesday, and Friday and as needed dated 12/24/21. Record review of the resident's MAR/TAR dated 12/2021 showed: -Cleanse coccyx with normal saline, pat dry, apply hydrofera blue (an antibacterial dressing)moist with saline, cover with foam dressing every Monday, Wednesday, and Friday and as needed dated 11/1/21 and discontinued on 12/15/21. --No documentation the facility staff completed this dressing change three out of seven opportunities. -Cleanse coccyx with normal saline, pat dry, apply silver alginate (a highly absorbent, antimicrobial wound dressing), cover with foam dressing every Monday, Wednesday, and Friday dated 12/16/21 and discontinued 12/23/21. --No documentation the facility staff completed this dressing change one out of three opportunities. -Cleanse coccyx with normal saline, pat dry, apply alginate foam (an absorbent dressing) and tape every Monday, Wednesday, and Friday and as needed dated 12/24/21. --No documentation the facility staff completed this dressing change two out of four opportunities. Record review of the resident's POS dated 1/2022 showed: -Cleanse coccyx with normal saline, pat dry, apply alginate foam (an absorbent dressing) and tape every Monday, Wednesday, and Friday and as needed dated 12/24/21 and discontinued on 1/10/22. -Cleanse coccyx with normal saline, pat dry, apply silver alginate foam, secure with bordered gauze and tape every Monday, Wednesday, and Friday and as needed dated 1/12/22. Record review of the resident's MAR/TAR dated 1/2022 showed: -Cleanse coccyx with normal saline, pat dry, apply alginate foam (an absorbent dressing) and tape every Monday, Wednesday, and Friday and as needed dated 12/24/21 and discontinued on 1/10/22. --No documentation the facility staff completed this dressing change one out of four opportunities. -Cleanse coccyx with normal saline, pat dry, apply silver alginate foam, secure with bordered gauze and tape every Monday, Wednesday, and Friday and as needed dated 1/12/22. --No documentation staff completed the dressing change two out of two opportunities. Observation on 1/14/22 at 10:30 A.M. showed: -The wound physician removed the resident's dressing and said the dressing was supposed to be a silver foam dressing not a foam dressing. A foam dressing was removed from the resident's wound. -After the wound physician completed a bedside assessment of the resident's pressure ulcer, the DON cleansed the resident's wound with normal saline on gauze and covered with a foam dressing. He/She told the resident he/she would return to complete the wound dressing after the wound physician was completed making wound rounds and the resident agreed.

Based on observation, and interview, the facility failed to ensure staff were awake and assisting residents during their shift when staff were found sitting in chairs wrapped in blankets with one staff slumped over in the chair with his/her eyes closed and mouths hanging open. The facility census was 73 residents. 1. Observation of the rehabilitation and transitional units on 1/13/22 at 5:00 A.M. showed: -Three high back chairs at the end of the hall out of facility camera range. -Agency Certified Nursing Assistant (CNA) K and Agency CNA L were each sitting in a high back chair wrapped up in blankets with their eyes opened. -CNA M was sitting in the third chair, was wrapped up in a blanket, slumped over in the chair with his/her eyes closed and mouth hanging open sleeping. -One Agency Registered Nurse (RN) working on the unit. -No other staff were located as assigned and working on the unit. During an interview on 1/13/22 at 5:05 A.M., Agency RN E said: -The three CNAs were not on break and had been sitting in the same spot wrapped up in blankets sleeping most of the shift. -CNA M was currently sleeping, Agency CNA K and Agency CNA L just woke up. -He/she had been trying to wake the staff up, even physically shook them to wake them up, but they kept going back to their chairs and sleeping. -He/she had to answer call lights and provide care to residents all night because of the sleeping staff. Observation on 1/13/22 from 5:15 A,M. to 5:25 A.M. showed: -Agency CNA K and Agency CNA L were still sitting in the same chairs wrapped in blankets with their eyes open. -CNA M was still sitting in the third chair wrapped up in a blanket, slumped over in the chair with his/her eyes closed and mouth hanging open sleeping. During an interview on 1/13/22 at 5:30 A.M., Agency RN E said: -He/she has had trouble in the past with staff sleeping while on duty. -He/she had not worked with Agency CNA L before, however he/she had worked with Agency CNA K and CNA M at the facility before. -CNA M had previously reported Agency CNA K to his/her agency for sleeping while on duty, he/she thought this occurred within the last week or so. -He/she had tried to build rapport with Agency CNA K and CNA M by bringing them food, snacks, and beverages, but he/she still meets resistance with them during their shifts. -He/she has physically shook the CNAs in the past to try to wake them up, but they would just go back to sleep. -He/she had reported the staff sleeping to the previous administrative staff, but nothing was never done about it. -It was difficult to get everything done he/she needed to do on his/her shift when he/she also had to do the work of the sleeping CNAs. During an interview on 1/13/22 at 6:30 A.M., the Director of Nursing (DON) said: -Agency RN E had reported to him/her about the sleeping staff this morning. -He/she was not aware staff had been sleeping at night during their shift until then. -He/she was not familiar with Agency CNA L and thought it was his/her first shift at the facility. -Agency CNA K was on a work contract with the facility and had worked other shifts at the facility prior to that night. -He/she was going to suspend Agency CNA K and Agency CNA L and contact their agency related to them sleeping during their shift. -CNA M worked for the facility. -He/she had been unaware that CNA M had reported agency CNA K frequently slept during his/her shifts. -He/she was going to talk to the Administrator about what to do with CNA M. -It was his/her expectation staff did not sleep during their shift. -He/she was going to start coming in during the night and weekend shifts to monitor staff behaviors. During an interview on 1/13/22 at 9:00 A.M., the Administrator in Transition said: -He/she heard about the sleeping staff from the previous shift. -He/she was going to investigate the allegations of sleeping staff. -He/she was going to contact the agency for Agency CNA K and Agency CNA L regarding their contracts with the facility. -He/she was suspending CNA M while the allegations were being investigation. -It was his/her expectation staff stayed awake during their shift.

Based on interview and record review, the facility failed to post staffing information in a location that was easily accessible to residents on the Long Term Care (LTC) and Rehabilitation units of the facility and to ensure staffing data was posted for visitors that consistently included the facility name, daily census, and the actual hours worked per shift for each of the three categories of nursing employees: Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Certified Medication Technicians (CMTs) directly responsible for resident care. The facility census was 73 residents. Record review of the facility's Posting Direct Care Daily Staffing Numbers policy, revised 2/2021, showed the facility will post the staffing on a daily basis at the beginning of each shift showing: -The date and daily census. -Information will be listed for each of the following staff: RN, LPN, and CNA. -Actual hours worked and the total number of hours will be posted. -Information will be clear and legible and posted in a prominent place readily accessible to residents and visitors. 1. Record review and observation of the staff postings for 1/10/22 through 1/19/22 showed: -A clear plastic stand was at the front desk where staffing information was inserted. One side showed the Daily staffing Hours form and one side showed the Direct Care Daily Staffing, which listed the individual staff members assigned to work on each shift and unit. -The Daily Staffing Hours form totaled the number of all nursing staff responsible for resident care for each shift and unit, but did not show the total numbers of hours worked for each category of licensed nurses (RNs and LPNs) and unlicensed nursing staff (CNAs/CMTs). -Observations on 1/10/22 through 1/14/22 and 1/18/22 showed there was no staffing information prominently posted and readily available to the residents on the Rehabilitation and LTC units on those dates. -On 1/18/22 the Daily Staffing Hours was placed at the receptionist's desk where the writing was displayed vertically rather than horizontally, making the information difficult to read. -On 1/19/22 the Direct Care Daily Staffing sheet, showing staff assignments, was turned to face visitors at the front desk and did not include the facility name, census or totaled hours worked by each of the three categories of nursing staff (RNs, LPNs, and CNAs/CMTs) responsible for resident care. During an interview on 1/18/22 at 11:45 A.M. Registered Nurse (RN) A said: -No staffing information is posted on the LTC unit. -The staffing sheets are only posted at the front entrance at the receptionist's desk. During an interview on 1/18/22 11:58 A.M. RN D said: -There was no staffing information posted and available for residents on the Rehabilitation unit. -The only staffing information available on the unit was kept in a manual for staff use only and showed daily staff assignments. During an interview on 1/18/22 at 11:18 A.M. the Director of Nursing (DON) said: -Staffing information was posted daily at the front entrance at the receptionist's desk. -Staffing information is not posted on either unit for the residents. -The Direct Care Daily Staffing information is kept in a binder on each unit for staff use only and shows staffing assignments. -The Daily Staffing Hours is posted at the front desk for visitors to view and the Direct Care Daily Staffing sheet is placed in the same plastic stand, but faces the receptionist so he/she has access to the daily staff assignments. During an interview on 1/19/22 at 12:40 P.M. the DON said: -The Daily Staffing Hours is used to post staffing information for visitors. As of 1/19/22 the staffing information was posted for residents in the dining room on both units where meals and activities take place. -The other staffing sheet showed nursing staff assignments and didn't calculate staffing hours or show the facility census. -He/She trained the most recent Staffing Coordinator on posting the staffing information in mid-December, 2021, but the Staffing Coordinator was no longer at the facility. -Since there was no current Staffing Coordinator he/she had been posting the daily staffing information and was responsible for ensuring the staffing information is posted according to federal regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #21's face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable). Record review of the resident's progress notes by the consulting pharmacist showed: -On 3/13/2021 the MRR was completed and to see pharmacist's monthly report, given to the DON for action to be taken. -On 7/1/2021 See note regarding follow up previous MRR. -On 10/6/2021 See report for any noted irregularities and/or recommendations. -On 11/8/2021 MRR Completed: See report for any noted irregularities and/or recommendations. -On 12/6/2021 MRR Completed: See report for any noted irregularities and/or recommendations. -On 1/6/2022 MRR Completed: See report for any noted irregularities and/or recommendations Record review of the Consulting Pharmacy Reports showed no reports on file for the resident. Record review of the resident's MDS dated [DATE], showed his/her Brief Interview for Mental Status (BIMS) score was a five indicating he/she had a low level of cognitive functioning. Record review of the resident's care plan, dated 11/16/21, showed: -The resident had impaired cognitive function/dementia or impaired thought processes related to diagnosis: Dementia, impaired decision making and short term memory loss. --Intervention was to administer medications as ordered. -The resident had Anxiety due to Dementia and required psychoactive medication use to manage. --Consult with pharmacy, physician to consider dosage reduction when clinically appropriate. Record review of the resident's POS dated December 2021, showed: -Wellbutrin XL (an antidepressant used to treat depression) Tablet Extended Release 24 Hour 150 milligrams (mg). -Give 1 tablet by mouth two times a day for Depression/ anxiety. Record review of the resident's Medication Administration Record (MAR) dated December 2021, showed: -Wellbutrin XL Tablet Extended Release 24 Hour 150 mg. -Give 1 tablet by mouth two times a day for Depression/ anxiety with a start date 2/25/21. 3. Record review of Resident #11's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Gastrostomy (surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube). -Vitamin B12 deficiency (Vitamin B12 deficiency is from inadequate diet, subtotal gastrectomy, or other condition, disorder, or disease, except malabsorption, related to pernicous anemia or other GI disease). Record review of the resident's care plan dated 10/13/21 showed: -He/she had Vitamin B12 deficiency. -Give medications as ordered. -Review pharmacy consults recommendations and follow up as indicated. Record review of the resident's POS dated 11/2021 showed Esomeprazole (Nexium) 40 mg every morning before breakfast for gastroesophageal reflux disease (GERD - back-up of stomach acid/heartburn). Record review of the resident's MAR dated 11/2021 showed: -Esomeprazole (Nexium) 40 mg every morning before breakfast for GERD. -Staff documented the medication was administered daily from 11/1/21 - 11/30/21 for a total of 30 out of 30 opportunities. Record review of the resident's Consulting Pharmacy Note dated 11/9/21 showed Medication Regimen Review Completed: See report for any noted irregularities and/or recommendations. Record review of the resident's Note to Attending Physician/Prescriber dated 11/9/21 showed: -The MRR dated was 11/9/21. -The pharmacist made the following recommendation: --Resident is receiving Esomeprazole (Nexium) 40 mg daily for GERD. A lower dose may be effective for symptom suppression. Long-term use is associated with hypomagnesemia (low blood magnesium), Vitamin B12 deficiency, and increased incidence of clostridium difficile (C. diff - an infection which typically occurs after use of antibiotic medications that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon). -The options for the physician's response was the following: --Discontinue Esomeprazole. --Discontinue Esomeprazole. Initiate Famotidine 20 mg twice daily. --Benefits outweigh risks with continuation of proton pump inhibitor. Change to more cost effective medication omeprazole 20 mg daily before breakfast. --Other. -The option Discontinue Esomeprazole was checked and signed by the resident's physician on 12/10/21. --NOTE: The order to discontinue Esomeprazole was not transcribed to the resident's POS and/or MAR. Record review of the resident's POS dated 12/2021 showed Esomeprazole (Nexium) 40 mg every morning before breakfast for GERD. Record review of the resident's MAR dated 12/2021 showed: -Esomeprazole (Nexium) 40 mg every morning before breakfast for GERD. -Staff documented the medication was administered from 12/1/21 - 12/31/21 for a total of 29 out of 31 opportunities. --NOTE: The resident's MRR dated 11/9/21 recommended Esomeprazole 40 mg be discontinued and the resident's physician signed the MRR on 12/10/21 to discontinue Esomeprazole 40 mg. The order was not transcribed to the resident's POS and/or MAR and the medication continued to be administered by the facility staff. Record review of the resident's Consulting Pharmacy Note dated 12/6/21 showed Medication Regimen Review Completed: See report for any noted irregularities and/or recommendations. Record review of the resident's medical record showed no documentation of the resident's 12/6/21 Note to Attending Physician/Prescriber (the resident's MRR). Record review of the resident's POS dated 1/2022 showed Esomeprazole (Nexium) 40 mg every morning before breakfast for GERD. Record review of the resident's MAR dated 1/2022 showed: -Esomeprazole (Nexium) 40 mg every morning before breakfast for GERD. -Staff documented the medication was administered from 1/1/22 - 1/12/22 for a total of 12 out of 12 opportunities. --NOTE: The resident's MRR dated 11/9/21 recommended Esomeprazole 40 mg be discontinued and the resident's physician signed the MRR on 12/10/21 to discontinue Esomeprazole 40 mg. The order was not transcribed to the resident's POS and/or MAR and the medication continued to be administered by the facility staff. Record review of the resident's Consulting Pharmacy Note dated 1/6/22 showed Medication Regimen Review Completed: See report for any noted irregularities and/or recommendations. Record review of the resident's Note to Attending Physician/Prescriber dated 1/6/22 showed: -The MRR dated was 1/6/22. -The pharmacist made the following recommendation: --Resident is receiving Esomeprazole (Nexium) 40 mg daily for GERD. A lower dose may be effective for symptom suppression. Long-term use is associated with hypomagnesemia, Vitamin B12 deficiency, and increased incidence of C. diff. -The options for the physician's response was the following: --Discontinue Esomeprazole. --Discontinue Esomeprazole. Initiate Famotidine 20 mg twice daily. --Benefits outweigh risks with continuation of proton pump inhibitor. Change to more cost effective medication omeprazole 20 mg daily before breakfast. --Other. -The option Discontinue Esomeprazole. Initiate Famotidine 20 mg twice daily was checked and signed by the resident's physician on 1/13/22. --NOTE: The order to discontinue Esomeprazole from the resident's MRR dated 11/9/21 was not transcribed to the resident's POS and/or MAR prior to the MRR on 1/6/22 and the medication continued to be administered by the facility staff. 4. During an interview on 1/14/22 9:20 A.M., the Administrator in transition said: -The DON was responsible for the overall MRR process. -The MRRs go to the DON. -The DON prints the MRRs for the physicians. -Once the physicians respond, the MRR forms are given to medical records to scan into each resident's medical record. -They did not know where the MRRs after June 2021 were. During an interview on 1/14/22 at 2:19 P.M. Nurse Practitioner (NP) A said: -He/she was notified of MRR from facility physician after he/she reviewed them. -MRR's were completed monthly. -He/she was unaware of where the DON filed completed MRR reports. -The physician signed off on the MRR. -If there were recommended and agreed upon changes he/she expected to see those changes to the orders immediately or within a couple of days. -He/she would attempt a reduction for the resident's Wellbutrin but with the dementia diagnosis it was in his/her best interest to monitor for side effects. During an interview on 1/19/22 at 10:43 A.M., Registered Nurse (RN) A said: -Usually the evening shift nurse takes care of any MRRs that come in. -He/She is not really familiar with the whole process, but knows that pharmacist will make a recommendation and that goes to the physician for review. -He/She just got a pile of recommendations. -He/She does not know the process, the floor nurses does not know about recommendations until it goes to the resident's POS, MAR, and TAR. During an interview on 1/19/22 at 12:41 P.M., the DON said: -The pharmacist does chart reviews remotely. -The pharmacist emails him/her, the Administrator, the primary care physician and the Medical Director. -The doctors review all of the recommendations, agree or disagree with the recommendations and if orders are required, they input them into their medical records system. -The follow-up should occur as soon as possible after the recommendation. -If a doctor signs to have a medication discontinued or writes a new order, it should be transcribed and followed as soon as possible. -The nurses and nurse managers should process the order changes. -He/she oversees the MRR process. Based on interview and record review, the facility failed to maintain and follow-up on medication regimen reviews (MRR) for three sampled residents (Resident #7, #11, and #21) out of 19 sampled residents. The facility census was 73 residents. Record review of the facility's undated policy titled Distribution of Medication Regimen Review report showed: -The consultant pharmacist would report any recommendations of apparent irregularities resulting from the medication regimen review report form or in electronic record keeping system. -Each recommendation must be acted upon. -The report form will be used by the consultant pharmacist to communicate findings of the monthly pharmaceutical care consultation. -The policy did not specify any time frames for responses and actions or steps that must be taken when an irregularity requires urgent action. -The report would be forwarded to the Director of Nursing (DON). -The attending physician and/or medical director will document their review and response to the recommendations made by the consultant pharmacist directly on the MRR form or in the resident's medical record. If the physician disagrees with the recommendation or no change is being made, the physician must document rationale in the resident's medical record. -The DON will follow up with any nursing actions needed relative to the physician's response. -Physician response to recommendations resulting in changes in medication therapy for individual residents will be forwarded to the DON or facility nurses. The order will be transcribed to the POS or documented in electronic record keeping system and the nurse will order the medication from the pharmacy. -Copies of the recommendations should be retained by the facility for a period of one year. 1. Record review of Resident's #7's care plan dated 2/18/21 showed he/she received medications for diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), hypothyroidism (a condition in which your thyroid gland doesn't produce enough of certain crucial hormones), pain, high blood pressure, Parkinson's disease (a neurological disease), infections, depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life) and anxiety (nervousness, fear, apprehension, and worrying). Record review of the resident's MRRs showed: -On 3/13/21, the MRR was completed and to refer to the pharmacist's monthly report. The report was given to the DON for action to be taken.] -On 4/29/21, the MRR was completed and there were no recommendations. -On 5/11/21, the MRR was completed and to refer to the note regarding lactobacillus and artificial tears. -On 6/13/21, the MRR was completed and there were no recommendations. -On 7/1/21, the MRR was completed and referred to the note for follow-up on previous MRR. -On 8/15/21, the MRR was completed and there were no recommendations. -On 9/10/21, the MRR was completed and there were no recommendations. -On 10/6/21, the MRR was completed and to refer to the report for any noted irregularities and/or recommendations. -On 11/9/21, the MRR was completed and to refer to the report for any noted irregularities and/or recommendations. -On 12/6/21, the MRR was completed and to refer to the report for any noted irregularities and/or recommendations. -On 1/5/22, the MRR was completed and to refer to the report for any noted irregularities and/or recommendations. Record review of the Consulting Pharmacy Reports showed no reports on file for the resident. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by staff and used for care planning) dated 1/11/22 showed the following staff assessment of the resident: -Entered the facility on 2/17/21. -Had moderately impaired cognition. -Received the following medications over the past seven days: insulin, antidepressants, antibiotics and opioids. Record review on 1/13/22 of the resident's current Physician's Order Sheet (POS) showed the resident had physician's orders for: -Wound treatments. -Medications to treat Parkinson's, high blood pressure, depression and anxiety. -Insulin. -Narcotic pain medication. -An antibiotic. -Aspirin as prophylaxis (preventative treatment). -A muscle relaxant

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #49's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of diabetes ( disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose). Record review of the resident's care plan dated 11/18/21 showed staff were to monitor the resident's blood sugar levels per physician's orders. Record review of the resident's POS dated January 2022 showed: -Staff were to monitor the resident's blood sugar levels before meals and before bedtime. -Insulin given on sliding scale as follows; blood sugar of 151-200 give 1 unit, 201-250 give 2 units, 251-300 give 3 units, 301-350 give 4 units, and 351-400 give 5 units and call physician. Record review of the resident's MAR dated January 2022 showed: -No blood sugar recorded or insulin given 1/3/22 at bedtime. -No blood sugar recorded or insulin given 1/4/22 at evening meal. -No blood sugar recorded or insulin given 1/5/22 at bedtime. -No blood sugar recorded or insulin given 1/7/22 at afternoon meal. -No blood sugar recorded or insulin given 1/12/22 at bedtime. -No blood sugar recorded or insulin given 1/13/22 at bedtime. Observation on 1/12/22 at 12:12 P.M. showed: -Resident was in a wheelchair in his/her room yelling, I'm a diabetic; I need food. -Resident had turned on call light. -Resident rummaged through nightstand and found single serving bag of potato chips which he/she ate. Observation on 1/12/22 at 12:33 P.M. showed: -Licensed Practical Nurse (LPN) C checked the resident's blood sugar with glucometer (small, portable machine that measures the glucose level in the blood by placing a drop of blood on a test strip which has already been inserted into the machine) which resulted at 170. -LPN C left resident's room without administering insulin and he/she walked away from the resident's room to another hall. Observation on 1/12/22 at 12:47 P.M. showed Certified Nursing Assistant (CNA) E brought a lunch tray to the resident in his/her room and placed it on his/her table then left the room. Observation on 1/12/22 at 1:10 P.M. showed unknown staff removed the resident's lunch tray with 65% of meal eaten. -NOTE: Constant direct observation between 12:12 P.M. until 1:10 P.M. showed staff did not administer insulin during this time frame. 4. Record review of Resident #53's Face sheet showed he/she was admitted on [DATE] with a diagnosis of Type 2 Diabetes. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 12/23/21 showed: -The resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating he/she was cognitively intact. -The resident needed extensive assistance. -The resident had Diabetes. Record review of the resident's undated care plan showed: -The resident had Diabetes. -The staff was to administer Diabetes medication as ordered by his/her physician. Record review of the resident's POS dated January 2022 showed: -An order for blood sugar to be taken before meals and at bedtime for Diabetes dated 12/17/21. -An order for Novolog Solution 100 units/mililter (ml) to inject five units subcutaneously before meals for Diabetes dated 12/20/21. -An order for Novolog Solution 100 units/ml inject per the following sliding scale, 150 to 180 give two units, 181 to 220 give four units, 221 to 270 give seven units, 271 to 320 give 10 units. -Give the insulin subcutaneously (under the skin) before meals for diabetes dated 12/20/21. -The resident was on a regular diet dated 12/17/21. Record review of the resident's Treatment Administration Record (TAR) dated January 2022 showed: -The resident's blood sugar was taken three times a day. --NOTE: the resident's blood sugar should have been taken four times a day. -The resident's blood sugar level was higher than 225 seven times. -The resident's blood sugar level was higher than 300 an additional two times. -On 1/10/22 the resident's blood sugar at the noon meal was 201. --The resident was given five units plus an additional four units per sliding scale for a total of nine units. Observation on 1/10/22 at 11:47 A.M. of Insulin administration showed LPN D gave the resident nine units of Novolog Insulin subcutaneously. During an interview 1/10/22 at 11:48 A.M. LPN D said: -He/she had taken the resident's blood sugar 20 minutes ago. -The resident's blood sugar was 201. -He/she was to administer five units of Novolog and four additional units of sliding scale Novolog insulin. -The resident was to get their insulin within 30 minutes of a meal. -The resident's lunch was scheduled for 12:30 P.M. Observation on 1/10/22 at 1:07 P.M. showed: -The resident was just served lunch. -NOTE: lunch was served one hour and 22 minutes after the insulin was administered. During an interview on 1/12/22 at 10:30 A.M. LPN C said: -Physician's orders should be followed. -Residents should receive their Insulin 30 minutes before the meal. -Meals were often late. -He/she would wait until he/she saw the food cart was on the hall being delivered to the rooms. During an interview on 1/13/22 at 10:30 A.M. the resident said: -He/she had an issue with the facility getting him/her back onto his/her sliding scale insulin scale as it was a little different than other people have. -After talking to the physician a couple of times he/she was now on his/her home insulin schedule. -He/she kept track of his/her blood sugar levels and the amount of insulin given as he/she had done at home. -On 1/12/22 breakfast was served at 8:45 A.M. -He/she was given his/her insulin at 9:30 A.M. while he/she was in therapy. -The nurse came down to therapy to administer his/her insulin. -When meals were off schedule he/she got upset. -The late meals were a staffing problem as they were short. -It made him/her feel antsy when the food was served late. -His/her insulin was administered more than 30 minutes before the meal was served. -He/she told his/her displeasure to the Nursing Administration about the meals being served late. -He/she had high blood sugar over 225 three or four times since he/she had been in the facility. -His/her blood sugar had been as high as 300 twice and it had not been that high for a long long time. -He/she believed it was that high because the insulin was given too early and the food was delivered late. -He/she was only offered an evening snack the first couple of nights when he/she first came to the facility. 5. During an interview on 1/19/22 at 12:41 P.M. the DON said: -Accu checks should be done as ordered. -Insulin should be administered no more than 30 minutes before the resident eats. -If the meal was not available within 30 minutes of taking the resident's blood sugar, the staff would have to recheck the blood sugar. -Insulin should be given as ordered. -The resident's physician should be notified if blood sugars were not checked as ordered and if insulin was not given as ordered. Based on interview and record review, the facility failed to ensure an order signed by the resident's physician was transcribed to the resident's Physician's Order Sheet (POS) and Medication Administration Record (MAR) resulting in staff administering a medication which had been discontinued for one sampled resident (Resident #11); to monitor blood sugars (the concentration of glucose in the blood) and administer Insulin (a hormone that lowers the level of glucose (a type of sugar) in the blood) as ordered for two sampled residents (Resident #49 and #53) out of 19 sampled residents. The facility census was 73 residents. Record review of the facility's undated Distribution of Medication Regimen Review (MRR) Report showed: -Physician responses resulting in changes in the resident's medication therapy for an individual resident will be forwarded to the Director of Nursing (DON) or facility nurses. The order will be transcribed in the POS or documented in electronic record keeping system and the nurse will order the medication from the pharmacy. --The policy did not address how long between the pharmacy consultant recommendation until the resident's physician should address the recommendation or how long after the resident's physician makes changes before the order should be transcribed to the resident's POS. Record review of the facility Medication Administration policy dated 5/2019 showed: -Staff should review the resident's Medication Administration Record (MAR). -Read and follow any special directions on the label. -Administer the medication and document the medication administration in the resident's MAR. Record review of the product insert for Humalog insulin (a fast acting insulin) dated 4/2020 showed the medication should be administered 15 minutes before or immediately after a meal. Record review of the product insert for Novolg insulin dated 7/2021 showed the medication should be administered within five to 10 minutes before a meal. 1. Record review of Resident #11's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Gastrostomy (surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube). -Vitamin B12 deficiency (Vitamin B12 deficiency is from inadequate diet, subtotal gastrectomy, or other condition, disorder, or disease, except malabsorption, related to pernicous anemia or other GI disease). Record review of the resident's care plan dated 10/13/21 showed: -He/She had Vitamin B12 deficiency. -Give medications as ordered. -Review pharmacy consults recommendations and follow up as indicated. Record review of the resident's Note to Attending Physician/Prescriber dated 11/9/21 showed: -The MRR dated was 11/9/21. -The pharmacist made the following recommendation: --Resident is receiving Esomeprazole (Nexium) 40 milligrams (mg) every morning before breakfast for gastroesophageal reflux disease (GERD - back-up of stomach acid/heartburn). A lower dose may be effective for symptom suppression. Long-term use is associated with hypomagnesemia (low blood magnesium), Vitamin B12 deficiency, and increased incidence of clostridium difficile (C. diff - an infection which typically occurs after use of antibiotic medications that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon). -The option Discontinue Esomeprazole was checked and signed by the resident's physician on 12/10/21. --NOTE: The order to discontinue Esomeprazole was not transcribed to the resident's POS and/or MAR. Record review of the resident's POS dated 12/2021 showed Esomeprazole (Nexium) 40 mg every morning before breakfast for GERD. Record review of the resident's MAR dated 12/2021 showed: -Esomeprazole (Nexium) 40 mg every morning before breakfast for GERD. -Staff documented the medication was administered 19 out of 21 opportunities after the order was discontinued on the resident's MRR. --NOTE: The resident's MRR dated 11/9/21 recommended Esomeprazole 40 mg be discontinued and the resident's physician signed the MRR on 12/10/21 to discontinue Esomeprazole 40 mg. The order was not transcribed to the resident's POS and/or MAR and the medication continued to be administered by the facility staff. Record review of the resident's POS dated 1/2022 showed Esomeprazole (Nexium) 40 mg every morning before breakfast for GERD. Record review of the resident's MAR dated 1/2022 showed: -Esomeprazole (Nexium) 40 mg every morning before breakfast for GERD. -Staff documented the medication was administered from 1/1/22 - 1/12/22 for a total of 12 out of 12 opportunities after the order was discontinued on the resident's MRR. --NOTE: The resident's MRR dated 11/9/21 recommended Esomeprazole 40 mg be discontinued and the resident's physician signed the MRR on 12/10/21 to discontinue Esomeprazole 40 mg. The order was not transcribed to the resident's POS and/or MAR and the medication continued to be administered by the facility staff. 2. During an interview on 1/14/22 9:20 A.M., the Administrator in Transition said: -The DON was responsible for the overall MRR process. -The MRRs go to the DON. -The DON prints the MRRs for the physicians. -Once the physicians respond, the MRR forms are given to medical records to scan into each resident's medical record. During an interview on 1/14/22 at 2:19 PM Nurse Practitioner A said: -He/she was notified of MRR from facility physician after he/she reviewed them. -MRR's were completed monthly. -He/she was unaware of where the DON filed completed MRR reports. -The physician signed off on the MRR. -If there were recommended and agreed upon changes he/she expected to see those changes to the orders immediately or within a couple of days. During an interview on 1/19/22 at 10:43 A.M., Registered Nurse (RN) A said: -Usually the evening shift nurse takes care of any MRRs that come in. -He/She is not really familiar with the whole process, but knows that pharmacist will make a recommendation and that goes to the physician for review. -He/She does not know the process, the floor nurses do not know about recommendations until it goes to the resident's POS, MAR, and TAR. During an interview on 1/19/22 at 12:41 P.M., the DON said: -The pharmacist does chart reviews remotely. -The pharmacist emails him/her, the Administrator, the primary care physician and the medical director. -The doctors review all of the recommendations, agree or disagree with the recommendations and if orders are required, they input them into their medical records system. -The follow-up should occur as soon as possible after the recommendation. -If a doctor signs to have a medication discontinued or writes a new order, it should be transcribed and followed as soon as possible. -The nurses and nurse managers should process the order changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation and interview on [DATE] at 3:00 P.M. on the coronavirus disease 2019 (COVID-19-a respiratory disease caused by a new coronavirus) unit with Registered Nurse (RN) C showed: -The medication cart was unlocked and one loose, white pill was on the floor. -RN C said the medication cart should have been locked. -RN C said he/she did not know where the pill came from but it should not have been on the floor. 4. During an interview on [DATE] at 10:43 A.M., RN A said: -The night shift staff checks the crash carts and should remove any expired items and have them replaced. -Medication carts should be locked when unattended. -Medications should not be left out on top of the medication cart unattended. During an interview on [DATE] at 11:35 A.M., Agency Certified Medication Technician (CMT) said: -Medications should not be left out on top of the medication cart unattended. -Medication carts should be locked when unattended. During an interview on [DATE] at 12:40 P.M., the DON said: -Medications should not be left out on top of the medication cart unattended. -Medication carts should be locked when unattended. -If staff are in the middle of medication pass, the cart should be facing in toward the resident room and not out toward the hall. Based on observation, interview and record review, the facility failed to ensure an unattended medication cart was locked and a loose pill was not left on the floor. The facility census was 73 residents. Record review of the facility's Medication Storage in the Facility policy dated [DATE] showed: -Medication carts and medications supplies were to be locked and attended by authorized personnel or locked. -Medications that were not stored within secure closures shall be removed from inventory and disposed of according to drug disposal procedures. 1. Observation on [DATE] from 9:03 A.M. to 10:41 A.M. showed: -9:03 A.M. to 9:58 A.M., three medication carts at the end of the hall near the nurse's station were unlocked and unattended. One medication cart had a resident's intravenous (IV) bag of medication on top of the cart unattended. -9:58 A.M., Registered Nurse (RN) C was at the medication cart, then left the cart with the medication still on top of the cart and the carts unlocked and unattended. -9:59 A.M. to 10:41 A.M., three medication carts at the end of the hall near the nurse's station were unlocked and unattended. One medication cart had a resident's intravenous (IV) bag of medication on top of the cart unattended. RN C locked the cart that had been unlocked. Observation on [DATE] from 5:05 A.M. to 6:06 A.M. showed three medication carts at the end of the hall near the nurses' station were unlocked and unattended. One medication cart had a resident's intravenous (IV) bag of antibiotics on top of the cart unattended. Observation on [DATE] at 5:10 A.M. showed the crash cart had two bags of IV fluid with the expiration date 9/2021 in the cart. Observation on [DATE] at 8:00 A.M. and 9:55 A.M. showed two medication carts at the end of the hall near the nurse's station were unlocked and unattended. One medication cart had two medications on top of the cart unattended and the other cart had three medications on top of the cart unattended. -At 9:57 A.M., the Director of Nursing (DON) locked one cart and removed the medications from the top of the cart and placed them behind the nurse's station. Observation on [DATE] from 11:50 A.M. to 12:05 P.M. three medication carts at the end of the hall near the nurse's station were unlocked and unattended. 2. During an interview on [DATE] at 10:43 A.M., RN A said: -The night shift staff checks the crash carts and should remove any expired items and have them replaced. -Medication carts should be locked when unattended. -Medications should not be left out on top of the medication cart unattended. During an interview on [DATE] at 11:35 A.M., Agency Certified Medication Technician (CMT) said: -Medications should not be left out on top of the medication cart unattended. -Medication carts should be locked when unattended. During an interview on [DATE] at 12:40 P.M., the DON said: -Medications should not be left out on top of the medication cart unattended. -Medication carts should be locked when unattended. -If staff are in the middle of medication pass, the cart should be facing in toward the resident room and not out toward the hall.

Based on observation, interview and record review, the facility failed to maintain corn and green beans at a temperature of 135 degrees Fahrenheit (°F) at the steam table, during the lunch meal on 1/10/22; to maintain the temperature of the macaroni salad at or below a temperature of 41 °F during the lunch meal on 1/10/22; to maintain the temperature of bacon at a temperature of 135 °F on the steam table during the breakfast meal on 1/12/22. This practice potentially affected at least 72 residents who at food from the kitchen during those meals. The facility census was 73 residents. 1. Record review of the maintenance log showed the steam table has not been working since December 2021, two wells of steam table not working. Observations during the lunch meal preparation on 1/10/22 from 10:23 A.M. through 1:00 P.M., showed: - At 11:46 A.M., the temperature of the macaroni salad was 45.1 °F. - At 11:54 A.M., the temperature of the green beans on the steam table was 119.5 °F and the temperature of the corn was 123.4 °F. - At 12:10 P.M., the temperature of the macaroni salad was 45.2 °F. - At 12:22 P.M., the temperature of the green beans on the steam table was 121.5 °F and the temperature of the corn was 117.4 °F. - At 12:58 P.M., the temperature of the macaroni salad, was 49 °F. During an interview on 1/10/22 at 2:08 P.M. the Corporate Project Manager said the dietary staff is supposed place items that are to be kept cold, in the deli station or on top of ice and that is how he/she trained the dietary staff to do things, but now he/she would train them to do cold items in batches, so one big batch will not increase in temperature, as quickly. During an interview on 1/10/22 at 2:38 P.M., Dietary [NAME] (DC) A said he/she checked the macaroni salad before the dietary department started the meal service, but not during the service. During an interview on 1/11/22 at 10:56 A.M., the Dietary Manager (DM) said the main steam table has not been working since December and that contributes to the food not staying warm. Observations during the breakfast meal preparation on 1/12/22 showed: - At 8:29 A.M., the holding temperature of the bacon in a pan on the stove, was 114 °F. - At 8:37 A.M., the holding temperature of the bacon in a pan on the stove, was 108 °F. Record review of the following chapter 2017 Food and Drug Administration (FDA) Food Code showed: Chapter 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under paragraphs B and C of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 135 ºF or above, except that roasts cooked to a temperature and for a time specified in paragraph 3-401.11(B) or reheated as specified in paragraph 3-403.11(E) may be held at a temperature of 130 ºF) or above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the timely delivery of breakfast and lunch meals to eleven residents (Residents #65, #5, #53, #15, #318, #69, #56, #22, #28, #38 and #35) on 1/10/22 and on 1/12/22; and failed to ensure the meal ticket system worked properly to facilitate meal ticket orders. The facility census was 73 residents. 1. Record review of the facility's undated meal schedule showed meal pass times of 8:00 A.M. for breakfast and 12:00 P.M. for lunch. 2. Observation on 1/10/22 at 9:53 A.M. and 10:20 A.M., showed Resident #65 was in his/her recliner waiting on breakfast since 7:00 A.M. At 10:20 A.M., facility staff discussed that they did not have the Resident's breakfast. During an interview on 1/10/22 at 10:37 A.M., Resident #65, a resident identified by his/her admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 1/2/22, as a resident who understood others, was able to make themselves understood, and a resident who was cognitively intact with a Brief Interview for Mental Status (BIMS- an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) of 11, said: -He/she has waited since about 6:30 A.M. -The food was often late. -That day he/she wanted bacon, eggs, toast and coffee. -He/she had not received his/her food as yet. During an interview on 1/10/22 at 10:44 A.M. Dietary Aide (DA) A said he/she would have to check the computer to find out if there was a ticket for Resident #65. During an interview on 1/10/22 at 10:47 A.M. DA A said the dietary department did not receive a ticket for Resident #65 or many other residents for the breakfast meal. Observation on 1/10/22 at 10:52 A.M., Resident #65 still did not have his/her breakfast. During an interview on 1/10/22 at 10:53 A.M., about the process of obtaining the meal information from the residents, the Corporate Project Manager said: -The Certified Nursing Assistants (CNAs) go around and ask the residents what they want for breakfast and then enter the information through the dining application (a program or computer software package that performs a specific function directly for an end user or, in some cases, for another application. An application can be self-contained or a group of programs) used by facility staff to take orders for the meal tickets on tablets. - From the tablets, the information is sent to a printer which is supposed to print the tickets within the kitchen. -There is a possibility that Resident #65's information was not entered on the tablets. -The CNAs should check with the residents. Observation on 1/10/22 at 11:10 A.M. (3 hours and 10 minutes after the scheduled breakfast time), showed Resident #65 finally had received his/her breakfast. 3. During an interview on 1/10/22 at 10:29 A.M. Resident #5 (a resident identified by his/her quarterly MDS dated [DATE] as a resident who understood others, was able to make himself/herself understood, and had a BIMS score of 15), said: - Sometimes they were short of staff. -The kitchen is slow and he/she didn't always get everything he/she ordered. -Facility staff asked them before the meal what they want. -There were times when meals were late and at times, he/she hasn't gotten any food at all. -The last time they skipped him/her for a meal, was about a week ago. 4. During an interview on 1/10/22 at 10:42 A.M., Resident #38 (a resident identified by his/her annual MDS dated [DATE] as a resident who understood others, was able to make himself/herself understood, and had a BIMS score of 15) said: -The facility cannot keep enough help in the dining room to serve drinks and things they need. -There were not enough staff taking the residents' orders. Observation and interview on 1/12/22 at 9:40 A.M. (one hour and 40 minutes after the breakfast start time) showed: -The resident said someone came and asked what he/she wanted for breakfast that morning but he/she didn't remember what time. -He/She ordered a biscuit, sausage, orange juice and hot chocolate. -He/She had not received his/her breakfast yet. -He/She had not told anyone yet about not getting his/her breakfast as he/she was just still waiting. Observation and interview on 1/12/22 at 9:45 A.M. (one hour and 45 minutes after the breakfast start time), showed: -The resident's breakfast was delivered to the resident. -The resident said it depended on how much or what he/she ate for breakfast when it was served so late as to whether he/she would be hungry for lunch at lunchtime. -He/She said lunch was usually served around 1:00 P.M. Observation and interview on 1/14/22 showed: -At 9:52 A.M., the resident had not received breakfast yet. -At 10:21 A.M., (two hours and 21 minutes after the breakfast start time) the resident's breakfast which included scrambled eggs, sausage and toast,was served to him/her. 5. During an interview on 1/10/22 at 12:47 P.M. Resident #53 (a resident identified by his/her quarterly MDS dated [DATE] as a resident who understood others, was able to make himself/herself understood, and had a BIMS score of 15), said the meals were served late with cold food some of the time. 6. Observation on 1/12/22 at 7:21 A.M. (39 minutes before serving time of 8:00 A.M.), showed Dietary [NAME] (DC) C as the only dietary staff in the kitchen at that time. he/she cooked potatoes, bacon, and sausage. During an interview on 1/12/22 at 7:39 A.M., DC C said there were usually four dietary staff which included one DC, two servers and one dishwasher, but not on that morning. 7. Observation on 1/12/22 at 8:10 A.M., 8:40 A.M. and 8:53 A.M., showed Resident #15 in dining room, waiting on breakfast. Observation on 1/12/22 at 9:00 A.M., showed Resident #15 received his/her breakfast. During an interview on 1/12/22 at 9:04 A.M., Resident #15 (a resident identified by the quarterly MDS dated [DATE] as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 15) said: -He/she came to the dining room at 7:40 A.M., and gave the Certified Nurse's Assistant (CNA) his/her order, but evidently, the order did not take. -Getting breakfast happens late. -The breakfast service sucks. -He/she liked his/her breakfast to be on time. -He/she felt it was Ok to wait about 15 minutes but waiting more than that, was just too long. 8. During an interview on 1/12/22 at 9:33 A.M., Resident #318 (a resident identified by the quarterly MDS dated [DATE], as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 15), said breakfast has been late for the last week. 9. During an interview on 1/12/22 at 9:42 A.M., Resident #69 (a resident identified by the admission's MDS dated [DATE], as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 8), said he/she had not received his/her breakfast as yet. During an interview on 1/12/22 at 9:44 A.M., Resident #56 (a resident identified by the quarterly MDS dated [DATE], as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 10), said breakfast usually came to his/her room round 9:00 A.M. Observations on 1/12/22 at 10:04 A.M., showed Residents #69 and #56 had not received their breakfast trays as yet. Observation on 1/12/22 at 10:20 A.M. (1 hour and 20 minutes after the start of breakfast), showed Residents #69 and #56 finally received their breakfast trays, 10. During an interview on 1/12/22 at 11:35 A.M. Resident #22 (a resident identified by the quarterly MDS dated [DATE], as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 10), said dinner usually late, comes anytime between 5:30 P.M.-7:30 P.M. 11. During an interview on 1/19/22 at 3:00 P.M., Resident #28 (a resident identified by the quarterly MDS dated [DATE], as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 7), said: - Meals are always late and cold. -The most recent time a meal was late and cold was the breakfast on 1/19/22. -He/she has told a nurse, but could not remember which nurse. - The late and cold meals made him/her feel bad like he/she was not worth being taken care of. 12. During an interview on 1/19/22 at 3:06 P.M., Resident #35 (a resident identified by the quarterly MDS dated [DATE], as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 13), said: - Breakfast was late and cold on that day. - Breakfast was served at 10:30 A.M. and lunch was served at 1:00 P.M. -On one recent night, dinner was served at 9:30 P.M. He/she told a previous Administrator about this issue. 13. During an interview on 1/10/22 at 3:03 P.M., the Director of Nursing (DON) said: -The facility has have scheduled meal times. -The CNAs operate within those time in getting the residents prepared to receive the meals. -The CNAs took orders through a mobile application on a tablet. -There have been some discussions at stand up meetings about serving the food differently. -Improving the whole dining experience is one of the areas they are exploring. -They have not implemented the new system yet. - He/she has heard complaints from residents about getting food late or getting cold food. -He/she noticed that the residents' meal tickets got mixed up on 1/10/22, because there were some tickets form 100 and 200 hall that got mixed on the same cart. During an interview on 1/12/22 at 10:33 A.M., DC C said: -He/she started working in the kitchen by himself/herself at 5:30 A.M. on 1/12/22. -There should have been at least two people in the kitchen by 7:00 A.M., and there was not. -A second person came into the kitchen at 7:20 A.M., - Before that second person came, he/she was doing everything. -Working by himself/herself, in addition to the issues with printing the tickets contributed to the food getting out late to some of the residents. - Some of the CNAs told him/her that there were issues with the application that was used to print the resident meal tickets. During an interview on 1/12/22 at 10:39 A.M., the Dietary Manager (DM) said: -He/she did not have enough staff to make everything right. - It has been frustrating for him/her. - He/she had to give some of his/her dietary staff a day off. - The dietary department was already short staffed at that time because, some dietary department staff left employment during the changeover from the dietary department being operated by Dining Services Company A and Dining Services Company B. -Currently, he/she was trying to get the staffing levels back up to what they were. 10. During an interview on 1/12/22 at 3:14 P.M., the Administrator in Transition said: -He/she has only been here one week and one day, and has not had the time to delve into the dietary issues. -He/she was unaware of any issues with the dining application. -He/she expected residents to be finished with breakfast around 9:30 A.M. if breakfast started at 8 A.M. During a phone interview on 1/12/22 at 3:21 P.M., the Consultant Registered Dietitian, said: -It has come to his/her attention that room trays have been late. -There have been issues with the dining application. -Between the ticket system and the shortage of facility staff, meals were sometimes late. -He/she did not have a good answer for why meals were late in the dining room, because that was not normal. During an interview on 1/19/22 at 9:27 A.M., Agency CNA C said: - He/she has worked at the facility since July 2021. -The facility was usually short of staff two out of three days. -On Fridays there are more call-ins or the staff didn't show up. -CNAs and sometimes CMTs, deliver meal trays. -Breakfast is supposed to be around 8:30 AM, 9:00 AM, the dining room gets served first, then room trays. -Lunch is supposed to be served between 12:15 P.M.-12:30 P.M., usually. -Serving breakfast in the mornings, was difficult because some agency staff do not know how to take orders for meals. -On that day (1/19/22), the machines that were used to take meal orders, were not working. - In the mornings meals can be cold. During an interview on 1/19/22 at 12:41 P.M., the Director of Nursing (DON) said -He/she was aware there's been some late meal trays. -The nursing staff deliver the meal trays. -If the residents complain of cold foods, they should get another tray. -The dining application was a problem, because the technology did not work at times including not printing out the tickets in order -The CNAs and the nurse take the meal orders. -He/she did not know the whole process, but the facility management will look into that issue. MO 00195838

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a system to ensure hot foods that should be hot at breakfast and lunch, were served to residents at a temperature at or close to 120 degrees Fahrenheit (ºF). This practice potentially affected 72 residents who ate food prepared by the kitchen. The facility census was 73 residents. Record review of the facility's policy entitled Healthcare Culinary Group and Lifestyles, dated 1/1/21 showed: -All food items are evaluated for proper food temperature, taste and appearance prior to meal service. -Food and drinks should be palatable attractive and served at a safe and appetizing temperature, as determined by the type of food, to ensure patients'/residents' satisfaction. -All food (including pureed) will be tasted to evaluate flavor and consistency. -Any problems must be corrected prior to meal service. -If the product is unacceptable a substitution must be made. -When food is transported to a remote serving location, final cook temperatures are taken and recorded in the kitchen. -Temperatures are taken and recorded again once transported to service location and prior to serving. -The absence of what an acceptable range of temperature is for foods at the time of service. -The absence of a process for using test trays in different sections of the facility. 1. Observation on 1/10/22 at 10:19 A.M., with Agency Certified Nurse's Assistant (CNA) J showed: -Eight breakfast trays that were headed for rooms on the rehabilitation side of the facility. -The eight trays were in clear plastic snap lid containers. -The temperature of one tray and the following was found; the hash browns were 87 ºF, the eggs were 113 ºF and the sausage patties were 94.9 ºF. During an interview on 1/10/22 at 10:24 A.M., the Dietary Manager (DM) said the cooks take the initial temperature of the food once it is cooked, but there was not enough dietary staff to temperatures of a sampling of the food at the time of service to the residents. During an interview on 1/10/22 at 10:37 A.M., Resident #65, a resident identified by his/her admission's Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning) dated 1/2/22, as a resident who understood others, was able to make themselves understood, and a resident who was cognitively intact with a Brief Interview for Mental Status (BIMS- an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) of 11, said: - He/she has waited for breakfast since about 6:30 A.M. - The food id cold always. - He/she felt neglected when they presented him/her with cold food. During an interview on 1/10/22 at 10:29 A.M. Resident #5 (a resident identified by his/her quarterly MDS dated [DATE] as a resident who understood others, was able to make himself/herself understood, and had a BIMS score of 15), said: - Sometimes food is cold, - He/she has only told them once that her food was cold and they warmed it up, otherwise he/she just ate it. During an interview on 1/10/22 at 12:47 P.M. Resident #53 (a resident identified by his/her quarterly MDS dated [DATE] as a resident who understood others, was able to make himself/herself understood, and had a BIMS score of 15), said the meals were served late with cold food some of the time. During an interview on 1/10/22 at 2:34 P.M., the Corporate Project Manager said that there was not a person available from dietary department to check food temperatures, when the food was delivered to the hallways. During an interview on 1/10/22 at 3:13 P.M., the Director of Nursing (DON) said he/she has heard complaints from residents about getting cold food. During a phone interview on 1/11/22 at 9:02 A.M., the Consultant Registered Dietitian said: - He/she always made sure the expectation is the temperature of the food is met before the food leaves the kitchen. -The struggle is when the food leaves the kitchen is the amount of time of the food sits on the trays before the meals get to the rooms. -He/she has suggested that the product is warmer than it should be when the food left the kitchen. During an interview on 1/12/22 at 11:34 A.M., Resident #12 (a resident identified by the quarterly MDS dated [DATE], as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 7), said there was not enough help and the food was not hot enough. During an interview on 1/12/22 at 11:44 A.M., Resident #32 (a resident identified by the quarterly MDS dated [DATE], as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 15), said the food was delivered to the room, the food was in clear plastic containers but it did not keep hot foods warm, food delivered was cold. During an interview on 1/12/22 at 11:49 A.M., Resident #18 (a resident identified by the quarterly MDS dated [DATE], as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 15), said the food seems to be cold or the order sent was incorrect. During an interview on 1/12/22 at 11:54 A.M., Resident #54 (a resident identified by the quarterly MDS dated [DATE], as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 10), said the food seems to be cold as the resident ate his/her food at that time. During an interview on 1/12/22 at 12:39 P.M., Resident #20 (a resident identified by the annual MDS dated [DATE], as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 15), said: -There were a couple of mornings that week when the food was cold. -The eggs were cold that day. -All of the meals are cold at times. -They have talked about it during the Resident Council meeting. -The Resident Council let them know and sometimes we (the residents who are a part of the resident council) tell them in between the meetings. -Nothing has been done. -Getting cold food made him/her want to find another place that will serve the food at a reasonable temperature. During an interview on 1/12/22 at 3:15 P.M., the Administrator in Transition said: -He/she has only been here a week and one day and has not had the time to delve into the dietary issues. -He/she expected the residents to receive hot food and expects dietary staff to do a better job of monitoring temperatures of room trays. During an interview on 1/19/22 at 9:27 A.M., Agency CNA C said: -He/she has worked at the facility since July 2021. -The facility was usually short of staff two out of three days. -On Fridays, there were more call-ins or the staff didn't show up. -CNAs and sometimes CMTs, deliver meal trays. -Breakfast is supposed to be around 8:30 A.M. through 9:00 A.M. -The dining room gets served first, then the room trays get served. -Lunch is supposed to be served between 12:15 P.M. through 12:30 P.M., usually. -Serving breakfast in the mornings, was difficult because some agency staff do not know how to take orders for meals. -On that day (1/19/22), the machines that were used to take meal orders, were not working. -In the mornings meals can be cold. During an interview on 1/19/22 3:06 P.M., Resident #35 (a resident identified by the quarterly MDS dated [DATE], as a resident was able to make himself/herself understood, able to understand others and had a BIMS score of 13), said: -Breakfast was late and cold today. -He/she told the kitchen staff. -He/she did not like the breakfast foods because the foods didn't taste good.

Based on observation, interview and record review, the facility failed to do the following: place a label on foods that were not easily identifiable; maintain the floors under the preparation table and the steam table free of debris, and food particles; maintain the ceiling vents over the food preparation area, free of dust; maintain the cucumbers free of mold; to prevent cross contamination by using the same spatula for turning the burgers and removing the burgers from the griddle; maintain three cutting boards free from numerous grooves and areas that were not easily cleanable; to check the temperature of sausage patties before they were pulled from the griddle. This practice potentially affected at least 70 residents who ate food from the kitchen. The facility census was 73 residents. 1. Observations of the lunch meal preparation on 1/10/22 from 9:25 A.M. through 1:20 P.M., showed: - Shredded food in a plastic bag that was not easily identifiable in the walk-in refrigerator. - A heavy layer of dust on the fan vent covers in the walk-in refrigerator -The presence of mold on the cucumbers in the walk-in refrigerator. -A container of a white substance that was not labeled, the texture of the white substance was very similar to salt, sugar, or food thickener. - At 9:33 A.M., Dietary Aide (DA) A said the white substance in the container was sugar and the facility had trained him/her in labeling containers. -The presence of numerous plastic covers, condiment packets, napkins, food debris under the refrigerator that drinks were stored in and the table used to prepare tea and coffee. -The presence of debris in the utensil container at the dishwashing area. -At 9:46 A.M., DA B said he/she did not know how long the debris was in the utensil container. -A buildup of dust on the ceiling vents in the kitchen. -Two bottles of chocolate syrup which stated refrigerate after opening, which were not refrigerated. -Melted areas on the spatula, which rendered the handle not easily cleanable. -Three cutting boards which were not easily cleanable with numerous grooves and stains 2. Observations on 1/10/22 from 11:04 A.M. through 11:27 P.M., showed: -The first batch of burgers were cooked on the griddle. -DC A flipped the burgers on the griddle. -DC B used the same spatula that was used to flip the burgers, to remove the first batch of burgers from the griddle. -DC B cooked the second batch of the burgers. -DC B flipped the second batch of burgers on the griddle. -DC B used the same spatula that was used to flip the burgers, to remove the second batch of burgers from the griddle. During an interview on 1/10/22 at 2:09 P.M., the DM said: -Each shift, both the A.M. and the P.M. shifts are responsible for sweeping and mopping. -He/she expected staff to pull out the refrigerators so they can get behind there as well when cleaning. During an interview on 1/10/22 at 2:11 P.M., the DM said he/she had not trained the DC's in preventing cross contamination with utensils before that day. During an interview on 1/10/22 at 2:28 P.M., the Corporate Project Manager said he/she told the Maintenance Person last month about cleaning the ceiling vents and ceiling tiles in the kitchen. During an interview on 1/10/22 at 2:30 P.M., the DM said: -He/she has only worked at the facility for one month. -There was not a in house DM before he/she came. -He/she was the first DM in a while. During an interview on 1/10/22 at 2:38 P.M., DC A said: -He/she has worked at the facility for three years. -He/she was not trained in preventing cross contamination in using the utensils. During an interview on 1/10/22 at 2:45 P.M., DC B said: -He/she has worked at the facility for about one month. -He/she was trained in preventing cross contamination at a previous job. -He/he was in a hurry on 1/10/22. During an interview on 1/10/22 at 2:53 P.M., the DM said he/she had not trained his/her DC's in using the utensils to ensure they do not melt. During an interview on 1/11/22 at 9:36 A.M. the Dietary Manager (DM) said: -The carrots were not labeled and he/she understood why the shredded carrots could be mistaken for cheese. -It was his/her responsibility to check the cucumbers for mold. -Those cucumbers were delivered on 12/30/21. 3. Observations of the breakfast meal preparation on 1/12/22 from 7:21 A.M. through 8:17 A.M., showed: -DC C used a spatula with numerous melted areas and indentations to cook sausage patties. -DC C failed to check the temperature of the first batch of sausage patties when he/she took the sausage patties off of the griddle. -DC C failed to check the temperature of the second batch of sausage patties when he/she took the sausage patties off of the griddle. -A container of a white powdery substance that was not labeled. During an interview on 1/12/22 at 8:08 A.M., the DM said the white powdery substance was confectioner's sugar. During an interview on 1/12/22 at 8:15 A.M. DC C said he/she has been cooking for a long time, and did not get the temperature of the sausage patties. During an interview on 1/14/22 at 3:33 P.M., the DM said: -There needs to be a cleaning schedule in place. -The kitchen looked better than it did six months ago. -He/she has discussed with dietary staff about moving out equipment from walls. -He/she has stressed the importance of getting under the tables to sweep the debris from under those tables. Review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Code, showed: 3-401.11 Raw Animal Foods. (2) 155 degrees Fahrenheit (ºF) for 17 seconds or the temperature specified in the following chart that corresponds to the holding time for mechanically tenderized and injected meats; - In Chapter 3-602.11, FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, and label information shall include the common name of the FOOD, or absent a common name, an adequately descriptive identity statement. - In Chapter 4-601.11, Equipment FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch, and the FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. - In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced. - In Chapter 4-601.11, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. - In Chapter 4-602.13, nonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. - In Chapter 3-501.16; Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) shall be maintained: - In Chapter 4-602.13, non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. - In Chapter 4-601.11, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. - In Chapter 4-602.13, nonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues; - In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of the resident's Face Sheet showed he/she had been admitted to the facility on [DATE]. Record review of the residents vaccine tab in the EHR showed no documentation regarding the resident's status of the influenza or pneumonia vaccine. Record review of the resident's medical records showed no documentation regarding the resident receiving or declining the influenza or pneumonia vaccination. Record review of the resident's EHR showed no documentation regarding the influenza or pneumonia vaccine being offered, declined or received. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/2/2022 showed: - The resident was admitted to the facility on [DATE]. - The box that asked if the resident was up to date on his/her flu vaccination was checked no. - The box that stated that the resident was offered and refused the flu vaccination was checked. - The box that asked if the resident was up to date on his/her pneumonia vaccination was checked no. - The box that stated that the resident was offered and refused the pneumonia vaccination was checked. 4. Record review of Resident #277's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's vaccine tab in the EHR showed no documentation regarding the resident's status of influenza or pneumonia vaccine. Record review of the resident's medical records showed no documentation regarding the resident receiving or declining the pneumonia vaccination. Medical records dated 12/21/2021 showed the resident's last influenza vaccination was given on 9/14/2018. Record review of the resident's EHR showed no documentation regarding the influenza or pneumonia vaccine being offered, declined or received. Record review of the residents' admission MDS dated [DATE] showed: - The resident was admitted on [DATE]. - The box that asked if the resident was up to date on his/her flu vaccination was checked no. - The box that stated that the resident was offered and refused the flu vaccination was checked. - The box that asked if the resident was up to date on his/her pneumonia vaccination was checked no. - The box that stated that the resident was offered and refused the pneumonia vaccination was checked. 5. During an interview on 1/14/22 at 1:03 P.M., the Administrator in transition said: -The admitting nurse should document the resident's influenza vaccine status upon admission, offer the influenza vaccine, provide the risks and benefits of the influenza vaccine, obtain consent or refusal for the influenza vaccine and administer the influenza vaccine if desired by the resident. -Vaccine administration should be documented on the vaccine tab in the EHR. -The nurse managers do a 24-hour chart review that should have identified any missing vaccine information for any newly admitted residents. During an interview on 1/18/22 at 10:50 A.M., Registered Nurse (RN) A said the admitting nurse was responsible for offering and providing the influenza vaccine for any newly admitted residents. During an interview on 1/18/22 at 12:12 P.M., the Administrator in transition said: -The admitting nurse should have documented the resident's influenza vaccine status and Pneumococcal vaccination upon admission, offered the needed vaccines, provided the risks and benefits of the vaccines, obtain consent or refusal for the influenza vaccine and Pneumococcal vaccines and administered either or both the vaccines if desired by the resident. -Vaccine administration should be documented on the vaccine tab in the EHR. -He/She could not produce any forms where the vaccinations were given or declined. During an interview on 01/19/2022 12:40 P.M., the Director of Nursing (DON) said: -When the clinical liaison receives the information and they accept a resident, the admissions coordinator should upload the vaccinations. -Infection control should verify the vaccination information. -Vaccines should be under immunizations in the EHR. -If a resident didn't have an influenza or pneumonia vaccine, they would get the necessary permission to give the resident the vaccine and then order the vaccine to give it to the resident. -There should be a consent form for vaccines indicating whether they consented or refused vaccines. -The consent form should be under the miscellaneous tab in the EHR. -The influenza vaccine and Pneumococcal vaccine should be offered when a resident was admitted . -If the influenza vaccine or Pneumococcal was provided, it should be documented on the immunization tab in the EHR. -If a vaccine is not listed under immunizations, the vaccine was not given. -Any documentation regarding vaccinations would be scanned in under miscellaneous in the EHR. -The infection preventionist should audit resident vaccine status. Based on interview and record review, the facility failed to offer or administer the influenza vaccine for four sampled residents (Residents #52, #172, #68 and #277) and to offer or administer the pneumonia vaccine for two sampled residents (Residents #68 and #277) out of 19 sampled residents. Five residents were sampled for immunizations. The facility census was 73 residents. Record review of the facility's policy Influenza Vaccine Program dated 2019 showed: -Policy of the facility that annually residents are offered immunizations against influenza. -Vaccinations would be offered for influenza October 1 thru March 31 annually. -All new admissions will be screened and given the influenza unless specifically ordered otherwise by the Primary physician on admission orders. -Every admission was screened using the criteria contained within the standing protocol and given the vaccine if indicated, after receiving the education regarding the vaccine. -Licensed nursing staff performed the screening and vaccine administration. -A record of vaccination would be placed in the resident's medical record and their vaccination record. -Nursing Procedures: -Check to see if medical contraindications for influenza vaccine exist. -Consulted physician if contraindications were present. -Before the influenza vaccine is offered, each resident or residents representative received education regarding the benefits and potential side effects of the vaccine. -Each resident, unless already immunized or if medically contraindicated, will be offered an influenza vaccine. -The resident or resident's representative had the opportunity to refuse the immunization. -If a resident is afebrile and had no moderate to severe acute illness, give vaccine via the intramuscular (IM) route. -Documentation in the resident's medical record would include: -That the resident or resident's representative was provided education regarding the benefits an potential side effects of the influenza vaccine. -Consent obtained. -The resident received the influenza vaccine: -Temperature and symptoms. -Date and time of administration. -Lot number, Manufacture, Expiration date, -Site of administration. -The resident did not received influenza vaccine and the reason: -Medical contraindication. -Refusal -Declination of vaccine form signed Record review of the facility's policy Pneumococcal Vaccine Program dated 2019 showed: -It was the policy of the facility that residents will be offered immunizations against Pneumococcal disease. -Primary care physicians will be asked that all new admissions be screened and given both Pneumococcal vaccines. -Every admission was screened using the criteria contained within the standing protocol and given the vaccine if indicated, after receiving the education regarding the vaccine. -Licensed nursing staff performed the screening and vaccine administration. -A record of vaccination would be placed in the resident's medical record and vaccination record. -Nursing Procedure: -Upon admission, follow the standing protocol to determine eligibility to receive the vaccine. -If resident was eligible, provided education to the resident/the resident's representative regarding the benefits and potential side effects of the immunization. -Offer the immunization. -The resident or resident's representative had the opportunity to refuse the immunization. -If the immunizations was refused, document the education and refusal in the medical record. -If resident chose to be immunized, after education was provided, ordered the vaccine. -Give the vaccine via the intramuscular route. -Document in the resident's medical record, and on the immunization record the education provided, medication, route of administration, site of injection, and the time the vaccine was given. 1. Record review of Resident #52's admission Record showed he/she admitted to the facility on [DATE]. Record review of the resident's electronic medical record showed: -No physician orders for the flu vaccine. -No physician orders for the pneumonia vaccine. -No documentation of education provided to the resident or the resident's representative about the risks and benefits of the flu and pneumonia vaccines. -No documentation the resident or his/her representative was offered, declined, or received the flu and/or pneumonia vaccines. -No documentation of the status of the resident's previous flu and pneumonia vaccines. 2. Record review of Resident #172's census log showed he/she admitted to the facility on [DATE]. Record review of the resident's vaccine tab in the electronic health record (EHR) showed no documentation regarding the resident's status of the influenza vaccine. Record review of the resident's hospital discharge instructions dated 1/4/22 showed no documentation regarding the influenza vaccine. Record review of the resident's EHR showed no documentation regarding the influenza vaccine being offered, declined or received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 13. Record review of the facility's undated job description, Certified Nursing Assistant: showed: -The Staff was to wash hands before entering and after leaving an isolation room/area. -The Staff was to follow established procedures in the use and disposal of personal protective equipment. Observation of the Transitional Unit (unit where residents were kept when they returned from the hospital to ensure they did not have COVID-19) on 1/14/22 at 1:45 P.M., showed: -Certified Nurses Assistant (CNA) H came out of the Transitional unit through the zippered tarps without closing the tarps. -He/she walked 20 feet into the non-COVID-19 unit with full PPE on. -He/she was pushing the meal cart down the hallway. -He/she took off the isolation gown and gloves waded them up and stuck them in a hall handrail. -Without washing or sanitizing his/her hands entered a resident's room to pick up their lunch tray. During an interview on 1/14/22 at 1:50 P.M., CNA H said: -He/she had received education from the facility on COVID-19. -He/she had received education from the facility on how to put on and take off PPE. -There was usually a barrel to take off PPE before leaving the COVID-19 unit, but there was not one today. -There was nothing to clean his/her hands with when he/she left the COVID-19 unit. -There usually was hand cleaner there, but not today. During an interview on 1/19/22 at 9:27 A.M., CNA C said: -The CNAs will deliver and pick up meal trays for the residents. -On the Transitional or COVID unit you would wear full PPE(gown, gloves, mask, and eyewear). -There should be a red bucket at the exit of the COVID or Transitional unit where you take off your PPE. -There should be a hand sanitizer when you exit. -Currently there was not a bucket to put PPE when it was removed nor hand sanitizer to use there. During an interview on 1/19/22 at 9:58 A.M., CNA D said: -PPE was be removed in the resident's room before leaving the unit. -Hands were to be sanitized. During an interview on 1/19/22 at 10:30 A.M., RN A said: -The PPE should have been taken off in the resident's room. -Hands should have been washed or sanitized. During an interview on 1/19/22 at 12:41 P.M. the DON said: -He/she would expected staff to DOFF PPE (remove PPE clothing) correctly before leaving the COVID/Transitional units then wash or sanitize hands before going into a resident's room. 14. Record review of the facility Blood Sampling - Capillary (finger stick) policy, dated 2/2021, showed: -Wash hands and put on gloves. -Place the glucometer on a clean field. -After obtaining the sample, clean and disinfect the glucometer after each use. -Remove gloves and wash hands. Record review of Resident #54's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of diabetes. Record review of the resident's undated care plan showed staff were to monitor the resident's blood sugar levels per physician's orders. Record review of the resident's January 2022 POS and MAR/TAR showed staff were to monitor the resident's blood sugar levels before meals and before bedtime. Observation on 1/12/22 at 9:53 A.M., showed: -RN C put on clean gloves without washing or sanitizing his/her hands, removed the glucometer from the top of the medication cart, entered the resident's room and placed the glucometer on the resident's meal tray with the resident's breakfast meal without a barrier. -RN C obtained the resident's blood sugar sample and placed the glucometer with the blood sample on the resident's breakfast tray with the meal without a barrier. -With the same gloved hands, RN C removed the glucometer from the resident's meal tray and exited the resident's room and placed the glucometer on top of the medication cart without a barrier. -RN C removed his/her gloves and without washing or sanitizing his/her hands, touched the laptop tablet to chart the resident's blood sugar results in his/her electronic medical record. -Without washing or sanitizing his/her hands, RN C opened the medication cart and removed medication for another resident. -Without washing or sanitizing his/her hands, RN C put on clean gloves, entered the another unidentified resident's room to administer medication. -RN C exited that resident's room, removed his/her gloves, opened his/her laptop tablet, then sanitized his/her hands. 15. Record review of Resident #49's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of diabetes. Record review of the resident's care plan, dated 11/18/21, showed staff were to monitor the resident's blood sugar levels per physician's orders. Record review of the resident's January 2022 POS/MAR/TAR showed: -Staff were to monitor the resident's blood sugar levels before meals and before bedtime. Observation on 1/12/22 at 12:33 P.M., showed: -Licensed Practical Nurse (LPN) C sanitized his/her hands, put on gloves, then entered the resident's room and placed the glucometer and test strips on the resident's bedside table without a barrier. -LPN C obtained the resident's blood sample and placed the glucometer on the resident's bedside table without a barrier next to the resident's water cup. -LPN C removed his/her gloves and removed the blood contaminated test strip from the glucometer with ungloved hands and disposed of the test strip and gloves in trash. -LPN C placed the glucometer in a box with new, unused lancets (the sharp object used to puncture the skin to obtain drops of blood for blood sugar monitoring). -Without washing or sanitizing his/her hands, LPN C exited the resident's room to the medication cart and placed the box with the lancets with the glucometer on top of the medication cart. -LPN C sanitized his her hands, removed an alcohol wipe from the medication cart and wiped off the glucometer. -The Director of Nursing (DON) approached LPN C and instructed him/her to sanitize the glucometer with a sani-wipe and not an alcohol wipe. 16. During an interview on 1/19/22 at 10:43 A.M., RN A said: -Staff should wash or sanitize their hands before putting on gloves and after removing gloves. -Staff should clean the surface with a bleach or sani-wipe before placing the glucometer on a barrier on that surface. -Staff should not leave a room with their gloves on. -Staff should not touch anything after removing their gloves until they have sanitized or washed their hands. During an interview on 1/19/22 at 12:40 P.M., the DON said: -He/She expected staff to wash or sanitize their hands before putting on gloves and after removing gloves. -He/She expected staff to place a glucometer on a barrier and not on the resident's bedside table, food tray, or on the medication cart without a barrier. -Staff could put the glucometer in a cup to use as a barrier. -The glucometer should have been sanitized with a sani-wipe and not alcohol wipes. -It was not appropriate to touch anything, including the laptop tablet, or the medication cart drawers after removing gloves without washing or sanitizing hands first. 11. Record review of Resident #31's face sheet, showed he/she admitted to the facility on [DATE] with the following diagnoses: -Subarachnoid hemorrhage (bleeding in the [NAME] surrounding the brain). -Arthritis (an inflammatory condition of the joints) of the knee. -Dysphagia (inability or difficulty swallowing). Record review of the resident's immunization record in the electronic medical record showed: -The resident received step one of the Mantoux (intracutaneous administration by injecting a 0.1 ml of a liquid containing 5 tuberculin units into the top layers of skin immediately under the surface of the skin of the forearm) TB skin test on 5/28/2021. -A negative result was recorded with no date of when the results were read. -A second TB test was not recorded. Record review of the resident's care plan, updated November 2021, showed no information regarding the resident refusing the TB skin test. Record review of the resident's Physician Order Summary, undated, showed: -No order for TB skin test or chest x-ray. Record review of the resident's May 2021 Treatment Administration Record (TAR) showed: -No order for the resident to receive a TB test. Record review of the resident's June 2021 TAR showed: -No order for the resident to receive a TB test. Record review of the resident's medical record attachments showed no chest x-ray for the purpose of ruling out or diagnosing TB. 12. During an interview on 1/18/22 at 10:04 A.M. Registered Nurse (RN) A said: -Residents received TB tests immediately upon admission. -Ten days after the first test the residents received the second TB. -Both tests were read within 48 hours. -It was part of the admissions process. -Usually the admissions nurse administers the test. -If there was not one admissions nurse, it was whoever admitted the resident that was responsible for doing the TB test. -New resident usually came in the afternoon then admissions were done by the evening shift. -If a resident refused the TB they had a chest x-ray immediately, as soon as they could get it. -Residents recommended to stay in room until the x-ray happened. During an interview on 1/19/22 at 10:30 A.M., RN A said: -There were residents in the facility who were COVID positive on the COVID hall. -COVID assessments were done daily. -On the COVID hall the assessment should have been done every shift (twice a day). During an interview on 1/19/22 at 12:41 P.M. the Director of Nursing (DON) said: -They have a daily meeting to review admission orders to ensure they were complete and correct. -A COVID assessment should have been done every shift (2 nursing shifts) and documented on the COVID assessment form. -The TB test should have been administered in the first 72 hours after a resident was admitted . -The facility uses a two step test. -The test should have been read 48 to 72 hours after administration. -The second test would have been administered 7 to 21 days after the first test was read. -The nurse was responsible for administering the test and reading the results. -The results from the TB test should have been documented on the TAR. -If a resident had a reaction a chest x-ray would have been done and documented the results. During an interview via telephone on 1/21/22 at 1:00 P.M., the Administrator said: -Ensuring the TB tests were completed was the DON's responsibility. -The TB tests were to have been given within the first 48 hours after admission. -The TB test was to have been given then read between 48 to 72 hours after it was administered. -The second TB test was to have been given a week after the first test was read. -The second TB test was to have been read 48 to 72 hours after it was administered. -The results should have been documented in the resident's record. -If this was not done the process would have been started over with the first TB test. 2. Record review of the facilities Infection Prevention and Control Manual- TB control plan, dated 2019, showed: -For new admissions, a TB test will be done within 72 hours after admission if there is no documented Tuberculin Skin Test (TST - used to screen for TB) result from within three months before admission. -The two-step TST method would be performed using five units (0.1 milliliter (ml)) of purified protein derivative PPD given intracutaneously. -The first step must be performed within 72 hours of admission. -TB tests were read between 48 and 72 hours after administration by someone trained in TST reading and interpretation. -TST results were documented in the resident's medical record. -If the first TST was non-reactive, the second TST was administered one to three weeks later. -Results were to be documented in mm (millimeter) of induration rather than stating positive or negative. -Individual who refused the TST should have a chest x-ray, unless the individual provided documentation of a negative chest x-ray taken within the past five years and have no signs or symptoms of active TB disease. Record review of the facility's unnamed policy, dated 1/16/22, showed: -All residents in Skilled Nursing Facilities and Long Term Care were to have been assessed for changes in respiratory status and temperature daily. -Residents were to have been evaluated for fever or symptoms consistent with COVID-19 infection. -The staff were to refer to Center for Disease Control resource for performing respiratory infection surveillance in long term care facilities during an outbreak. -If a resident was in the transition or recovery areas then respiratory assessment were to be performed every shift and vital signs were to have been obtained every four hours. 3. Record review of Resident #53's face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Type 2 Diabetes with circulatory complications (when high blood sugar over time has damaged the blood vessels and nerves that control the heart). -Moderate protein calorie malnutrition (a nutritional status in which reduced availability of nutrients lead to changes in the body). -History of venous thrombosis and embolism (the blood clot that had formed in a deep vein such as the lower leg thigh, or pelvis. Record review of the resident's undated care plan showed: -The resident was at risk for COVID-19. -The staff was to complete COVID-19 screening assess, per facility action plan. Record review of the resident's December 2021 Treatment Administration Record (TAR) showed the resident's second dose of his/her TB skin test was administered on 12/25/21; the results were documented as read on 12/26/21 prior to the required 48 hours. Record review of the resident's COVID-19 Daily Screening sheets showed the resident was not screened on the following days: -12/18/21 through 12/28/21. -12/31/21 through 1/5/22. -1/7/22, 1/9/22 and 1/10/22. -1/12/22 through 1/14/22. 4. Record review of Resident #67's face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Fracture left hip. -Acute kidney failure (a condition in which the kidneys cannot filter waste from the blood). -Fusion of the spine (a surgery which permanently connects two or more vertebrae in the spine). -The resident was his/her own person. Record review of the resident's discharge MDS, dated [DATE], showed: -The resident was totally dependant on staff for cares. -The resident was discharged to the hospital. Record review of the resident's December 2021 TAR showed the resident's first dose of his/her TB skin test was administered on 12/28/21; the results were documented as read on 12/29/21 prior to the required 48 hours. Record review of the resident's January 2022 TAR showed no documentation showing when the resident's second dose was administered; the test was documented as read on 1/8/22. 5. Record review of Resident #279's Face Sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Bilateral pos-traumatic osteoarthritis of knee (a degeneration of a joint cartilage after an accident). -Cellulitis of left and right knees (inflammation) -Local infection of the skin (an infection in one area of the skin). -Chronic peripheral venous insufficiency (improper functioning of the vein valves in the legs that does not allow blood to flow back to the heart). -Long term use of anticoagulants (medications used to treat or prevent blood clots). Record review of the resident's undated Care Plan showed: -The resident was at risk for COVID-19. -The staff was to complete the COVID-19 screening assessment per facility action plan. -The staff was to adhere to current COVID-19 infection control precautions per CDC guidelines including use of proper personal protective equipment (PPE - equipment worn to minimize exposure to hazards in the workplace). Record review of the resident's January 2022 TAR showed the resident's first dose of his/her TB skin test was administered on 1/8/22; the results were documented as read on 1/9/22 prior to the required 48 hours. Record review of the resident's COVID-19 Daily Screening sheets showed the resident was not screened on 1/9/22, 1/10/22, and 1/14/22. 6. Record review of Resident #2's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen). -Absence of parts of urinary tract (when parts of the urinary system are missing). Record review of the resident's undated care plan showed: -The staff was to administer medications as ordered. -The staff was to obtain and monitor lab/diagnostic work as ordered. Record review of the resident's January 2022 TAR showed the resident's first dose of his/her TB skin test was administered on 1/5/22; the results were documented as read on 1/6/22 prior to the required 48 hours. 7. Record review of Resident #59's Face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Sepsis due to Methicillin Resistant Staphylococcus Aureus (a life threatening emergency that happens when an infection you have triggers a chain reaction throughout the body). -Local infection of the skin. -Chronic ulcer of left and right foot (area where underlying tissue damage or trauma has caused skin loss that leaves a raw area which takes a long time to heal. Record review of the resident's undated Care Plan showed: -The resident was at risk for COVID-19. -The staff was to complete the COVID-19 screening assessment per facility action plan. Record review of the resident's December 2022 TAR showed the resident's second dose of his/her TB skin test was administered on 1/8/22; the results were documented as read on 1/9/22 prior to the required 48 hours. Record review of the resident's COVID-19 Daily Screening sheets showed the resident was not screened on the following days: -12/31/21. -1/3/22 through 1/5/22, 1/9/22, 1/10/22, 1/12/22 and 1/13/22. 8. Record review of Resident #68's face sheet showed the resident was admitted to the facility on [DATE]. Record review of the resident's undated care plan showed: -The resident was at risk for COVID-19. -The staff was to complete COVID-19 screening assessment, per facility action plan. Record review of the resident's December 2021 TAR showed: -The resident had an order for Tuberculin PPD solution 5 units/0.1 ml to be injected 0.1 ml intradermally (in the skin) one time only for TB monitoring for one day. Document administration on MAR and in the immunization tab dated 12/29/21. -The first dose was administered on 12/30/21 at 10:01 A.M. -The resident had an order to have the PPD test read 48 hours after administration. The results were to have been documented on the MAR and in immunization tab one time only for one day dated 12/31/21. -The first test was read on 12/31/21 at 10:52 P.M., which was before the 48 hour waiting period. Record review of the resident's January 2022 TAR showed: -The resident had an order for Tuberculin PPD solution 5 units/0.1 ml to be injected 0.1 ml intradermally one time only for TB monitoring for one day. Administer seven days after step one has been read. Document administration on MAR and in the immunization tab dated 01/07/22. -The second dose was administered on 01/08/22 at 07:38 P.M. -The resident had an order to have the PPD test read 48 hours after administration. The results were to have been documented on the MAR and in immunization tab one time only for one day dated 12/31/21. -The resident had an order to have the second PPD test read 48 hours after administration. The results were to have been documented on the MAR and in immunization tab one time only for one day dated 01/09/22. -The second TB test was read on 01/09/22 at 10:38 P.M., which was before the 48 hour waiting period. Record review of the resident's COVID-19 Daily Screening sheets showed the resident was not screened one time per shift (two nursing shifts per day), on the following days: -12/30/21 - not screened. -01/03/22-01/05/22 - not screened. -01/08/22 - 01/14/22 not screened. 9. Record review of Resident #277's face sheet showed the resident was admitted to the facility on [DATE]. Record review of the resident's undated care plan showed: -The resident was at risk for COVID-19. -The staff was to complete COVID-19 screening assessment, per facility action plan. Record review of the resident's January 2022 TAR showed: -The resident had an order for Tuberculin PPD solution 5 units/0.1 milliliter (ml) to be injected 0.1 ml intradermally (in the skin) one time only for TB monitoring for one day. Document administration on MAR and in the immunization tab dated 01/06/22. -There was no documentation of the first dose being administered. -The resident had an order to have the PPD test read 48 hours after administration. The results were to have been documented on the MAR and in immunization tab one time only for one day dated 01/08/22. -The first TB test was read on 01/08/22 at 7:55 P.M., which was before the 48 hour waiting period. -The resident had an order for Tuberculin PPD solution 5 units/0.1 ml to be injected 0.1 ml intradermally one time only for TB monitoring for one day. Administer seven days after step one had been read. Document administration on TAR and in the immunization tab dated 01/15/22. -The first dose was administered on 01/16/22 at 11:42 A.M. -The resident had an order to have the PPD test read 48 hours after administration. The results were to have been documented on the MAR and in immunization tab one time only for one day dated 01/17/22. -The second TB test was read on 01/17/22 at 09:13 P.M., which was before the 48 hour waiting period. Record review of the resident's COVID-19 Daily Screening sheets showed the resident was not screened one time per shift (two nursing shifts per day), on the following days: -01/06/22 - not screened. -01/09/22-01/10/22 - not screened. -01/12/22-01/14/22 - not screened. 10. Record review of Resident #172's census log showed he/she admitted to the facility on [DATE]. Record review of the resident's January 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed: -A physician's order, dated 1/4/22, for Tuberculin purified protein derivative (PPD) Solution 5 unit/0.1 milliliter (ml), Inject 0.1 ml intradermally (inject into the skin layer underneath the upper skin layer) one time only for TB monitoring for one day was not administered on 1/4/22 or 1/5/22 and referred to a progress note. -A physician's order, dated 1/5/22, for Tuberculin PPD Solution 5 unit/0.1 ml, Inject 0.1 ml intradermally one time only for TB monitoring for one day was administered on 1/6/22 at 2:04 P.M. -A physician's order, dated 1/6/22, to read PPD 48 hours after administration one time only for one day showed it was negative on 1/6/22 at 11:24 P.M., which was approximately nine hours after administration (1/6/22 at 2:04 P.M.). -A physician's order, dated 1/7/22, to read PPD 48 hours after administration, one time only for one day showed on 1/7/22 at 12:20 P.M. it was not read and referred to a progress note. -A physician's order, dated 1/13/22, for Tuberculin PPD Solution 5 unit/0.1 ml Inject 0.1 ml intradermally one time only for TB monitoring for one day to be administered seven days after step one was read was documented as not administered on 1/14/22 at 10:07 A.M. and referred to a progress note. -A physician's order, dated 1/16/22, to read PPD 48 hours after administration, one time only for one day showed it was negative on 1/16/22 at 11:22 A.M. However, there was no documentation that the second TST was administered. Record review of the resident's order administration note, dated 1/14/22 at 10:07 A.M., showed: -A physician's order for Tuberculin PPD Solution 5 unit/0.1 ml, Inject 0.1 ml intradermally one time only for TB monitoring for one day. Administer seven days after step one was read. -The Tuberculin PPD was on order. -The nurse would continue to monitor until the supply came in. -No other notes regarding the administration or reading of the resident's TST. Record review of the resident's January 2022 COVID 19 daily resident screenings showed no COVID 19 screenings were completed on 1/5/22, 1/7/22 and 1/9/22 through 1/17/22. Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), failed to have the hot water boilers set to high enough temperature that would prevent the growth of waterborne pathogens, and failed to provide documented assessments for such an outbreak, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents and staff who reside in, use, or work in the facility. The facility further failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when staff failed to assess residents for signs and symptoms of coronavirus disease 2019 (COVID-19-a respiratory disease caused by a new coronavirus) each shift for six sampled residents (Residents #53, #279, #59, #172, #68, and #277); failed to ensure residents were tested and/or screened for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for nine sampled residents (Residents #2, #53, #172, #279, #59, #31, #68, #277, and #67); failed to ensure infection control practices to prevent cross-contamination during blood glucose monitoring for two sampled residents (Residents #54 and #49); failed to ensure staff were adhering to standard and transmission-based precautions when coming out of the Isolation Unit; and failed to maintain tuberculosis testing records for nine employees (Employees A, B, C, D, E, F, G, H, and J) out of ten sampled new employees. The facility census was 73 residents. 1. Record review of the Legionella (a [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis) Environmental Assessment (a form which enables public health officials to gain a thorough understanding of a facility's water systems and assist facility management with minimizing the risk of legionellosis (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease )) form produced by the Centers for Disease Control and Prevention, dated 6/2015, showed that conditions promoting Legionella amplification include water stagnation and warm temperatures (77-108 °F). Record review of CMS's Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD -A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever (a non-pneumonic, epidemic form of legionellosis with symptoms similar to flu such as fever, tiredness, myalgia, arthralgia, headache, cough, sore throat and nausea), revised 7/6/18, showed facilities are expected to have a water management policy and procedures in place to reduce the risk of growth/spread of Legionella and other opportunistic pathogens in the building water systems. The facilities must do the following: - Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. - Implement a water management program that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard and the Centers for Disease Control (CDC) toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. - Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Record review of the facility's Water Management Worksheet, revised on 5/23/19, showed: - None of the pages were filled out with any facility specific standards. - The absence of a facility-specific risk assessment that considers the ASHRAE industry standard. - No mention that the facility actually had monitoring kits to specifically check for the presence of the legionella bacteria in the Control Measures and Monitoring section on page 8 of the facility's Water Management Worksheet. - A facility-specific infection prevention program or plan on how to manage outbreaks of Legionella and/or other waterborne pathogens. - An outline of specific actions would be taken in response to a legionella positive water sample. - The absence of which positions of the employees in the facility would be a part of the water management team. - Assessments of each individual potential risk level. - Facility-specific interventions or action plans for when control limits are not met. - The absence of a list of employees who may have been trained in recognizing legionella symptoms. Record review of the facility's hot water temperature record, dated 1/5/22, showed the following hot water temperatures: - A hot water temperature of 108 degrees Fahrenheit (°F ) in resident room [ROOM NUMBER]. - A hot water temperature of 104 °F in resident room [ROOM NUMBER]. - A hot water temperature of 104 °F in resident room [ROOM NUMBER]. - A hot water temperature of 106.5 °F in resident room [ROOM NUMBER]. Observations on 1/12/22, during a segment of the facility's environmental/life safety tour with the Maintenance Director and the Regional Maintenance Person, showed the hot water temperatures in the following resident rooms after the hot water was allowed to run for two minutes in those rooms: - At 11:45 A.M., the hot water temperature in resident room [ROOM NUMBER], was 105.1°F. - At 11:51 A.M., the hot water temperature in resident room [ROOM NUMBER], was 103.4 °F - At 11:57 A.M., the hot water temperature in resident room [ROOM NUMBER], was 103.3 °F. - At 12:04 P.M., the hot water temperature in resident room [ROOM NUMBER], was 101.2 °F. - At 12:12 P.M., the hot water temperature in resident room [ROOM NUMBER], was 103.5 °F. - At 12:19 P.M., the hot water temperature in resident room [ROOM NUMBER], was 98.6 °F. - At 12:24 P.M., the hot water temperature in resident room [ROOM NUMBER], was 102.3 °F. - At 12:34 P.M., the hot water temperature in resident room [ROOM NUMBER], was 102.9 °F. - At 12:47 P.M., the hot water temperature in resident room [ROOM NUMBER], was 103.1 °F. - At 12:52 P.M., the hot water temperature in resident room [ROOM NUMBER], was 102.0 °F. - At 1:06 P.M., the hot water temperature in resident room [ROOM NUMBER], was 100.7 °F. - At 1:14 P.M., the hot water temperature in resident room [ROOM NUMBER], was 101.5 °F. - At 1:20 P.M., the hot water temperature in resident room [ROOM NUMBER], was 102.1 °F. - At 2:02 P.M., the hot water

Based on observation, interview and record review, the facility failed to ensure two wells of Steam Table A in the kitchen operated properly to ensure suitable holding temperatures of 135 degrees Fahrenheit (°F) or higher, of food placed in two of three wells of Stem Table A, and to ensure the numbers of the dials on Steam table B, were visible to dietary staff. This practice potentially affected 72 out of 73 residents who ate food from the kitchen. The facility census was 73 residents. 1. Record review of the Maintenance log dated 11/23/21, 12/6/21, and 12/7/21, showed two wells of the Steam Table A have not been working. Record review of Maintenance Log dated 11/25/21, showed parts were ordered to fix Steam Table A. Record review of the Maintenance Log dated 1/7/22 showed two wells of Steam Table A that were also not operating properly on 12/7/21. Observations during the lunch meal preparation on 1/10/22 from 10:23 A.M. through 1:00 P.M., showed: - At 11:54 A.M., the temperature of the green beans on Steam Table A was 119.5 °F (degrees Fahrenheit) and the temperature of the corn was 123.4 °F - At 12:22 P.M., the temperature of the green beans on the Steam Table was 121.5 °F and the temperature of the corn was 117.4 °F During an interview on 1/11/22 at 10:56 A.M., the Dietary Manager (DM) said: - Steam Table A has not been working since December 2021. - On 1/11/22, a service repair person said he/she would order two switches. - He/she did not get an estimated time of arrival (ETA) of the parts. 2. Record review of the Maintenance Log dated 12/7/21, showed the numbered dials could not be read on Steam Table B. During an interview on 1/12/22 at 8:23 A.M., the DM said: - He/she could not read the settings on the dial of the Steam Table B with one well. - Steam Table A with the two wells that did not work, at that current time (1/12/22), had not operated properly since 1/7/22. During a phone interview on 1/12/22 at 3:17 P.M., the Consultant Registered Dietitian (CRD) said: - He/she has asked the DM about the Steam Table A. - He/she has questioned Steam Table A for about six months. During an interview on 1/17/22 at 1:17 P.M. the Regional Director said: - The equipment was the facility's responsibility. - He/she has not been made aware that the Steam Table A was not working. - He/she was authorized to approve repairs that cost more than $500. - There is an internal process and there was nothing entered into on the corporation's internal process for the repair of Steam Table A. - Before 1/1/22, when he/she also took over as the Administrator, he/she visited the facility a few times a month and was not involved on a day to day basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure all the necessary equipment was available for the facility to comply with the both the audible and visual requirements of the exception to state regulation 19 Code of State Regulations (CSR) 30-85.012 (124) and for facility staff to use, to adequately answer call lights. This practice potentially affected all residents. The facility census was 73 residents. 1. Record review of the facility's exception certificate, dated 5/31/18, showed: -The operator will ensure the wireless nurse call system is fully operational twenty-four (24) hours per day, seven (7) days a week. -The operator will maintain, at a minimum and in accordance with the manufacturer's recommendations, all the features of the wireless call system. -The operator will ensure that all direct care staff carry and utilize the wireless nurse call pagers or phones at all times. Record review of a grievance report form dated 8/25/21 showed Resident #17 wrote: - Aides not coming to the light or to the yelling. Aids say they are not going to respond to the yelling. Call lights don't work half the time. - No follow up or resolution to that particular grievance was noted. Observations on of the Rehab Unit side nursing station on 1/11/22 at 2:17 P.M., showed a charging station with six spaces for six call light alert devices with no call light alert devices on the charging station. Observations on of the Long Term Care Unit side nursing station on 1/11/22 at 2:24 P.M., showed a charging station with six spaces for six call light alert devices with no call light alert devices on the charging station. During an interview on 1/13/22 at 2:47 P.M., Agency Licensed Practical Nurse (LPN) B said: - He/she has been working at the facility for about two months. - Call lights can be activated but there was no sound. - Only the light outside the room lights up. - He/she has not seen the call light alert devices that were used with the call light system since he/she started to go the facility as an assignment. During an interview on 1/13/22 at 2:49 P.M., Agency Certified Nursing Assistant (CNA) A said: - He/she has been working at the facility for about two months. - He/she not seen call light alert devices that were available for use by facility staff. - Sometimes, when he/she was in a room providing assistance to a resident, he/she was unaware that a call light in a different room on the hall, was activated. - Hearing the call lights would help him/her answer the call lights faster. During an interview on 1/13/22 at 2:52 P.M., Registered Nurse (RN) A said: - The call lights signal at the nurse's station but the signal is not very audible. - There used to be call light alert devices that facility staff could use for the call light system. - There were call light alert devices available for a while, then some went missing, then they bought a new set of call light alert devices. - The lack of the call light alert devices placed the facility staff at a disadvantage when they could not hear the call lights and when they cannot see the call lights because they may be in a resident's room. During an interview on 1/13/22 at 2:54 P.M., LPN A said the call light alert devices used to be available he/she was not sure what happened with the call light alert devices and it would help if the call light alert devices were available for use, so that staff could respond faster. During an interview on 1/13/22 at 2:59 P.M., the Maintenance Director said: - There used to be six call light alert devices at each nurse's station. - He/she was not sure what happened to the call light alert devices. - Since the call light alert devices which are components of the call light system, have been absent, they have resorted to using walkie-talkies (a compact easily transportable battery-operated radio transmitting and receiving set). - The corporate office has said that new call light alert devices may be coming soon. During an interview on 1/14/21 at 12:05 P.M. Certified Medication Technician (CMT) A said: - He/she has worked at the facility for about 12 months. - There used to be call light alert devices that they would use that would vibrate in the pockets of the aides. - The call light alert devices disappeared after a while. - There used to be call light alert devices at the charging stations. - The system used to be that the person leaving the shift, would give report and the call light alert device to the next person that coming onto the shift. - There was not anyone overseeing the transfer of call light alert devices from one shift to the next shift. During a phone interview on 1/14/21 at 3:05 P.M., the Former staffing Coordinator said: - He/she used to work at the facility from May 2021 through December 2021. - Even as far back as May 2021, all the call light alert devices were not available for staff use. - A former Administrator who left in November 2021, tried to address the issue. - Then there was an interim administrator who did not address the issue of missing call light alert devices. - At one time, (he/she could not remember the exact month), there were two call light alert devices on the Rehabilitation side, and by the time he/she left, there were none. - There was only one call light alert devices on the long term care side. - It was easier to respond to the call lights when he/she was alerted via the call light alert system. During a phone interview on 1/17/22 at 1:06 P.M., the Regional Director said: - An order for the call light alert devices, was placed. - The lack of call light alert devices for facility staff, was brought to his/her attention again, when he/she took over as Administrator on 1/1/22. - Prior to that date (1/1/22), he/she was not made aware by any previous Administrator or any other Director of Nursing (DONs) that the call light alert devices were not available for the call light system. - There was an order placed sometime (date unknown) ago. - He/she instructed the staff to search for the call light alert devices and asked facility staff to conduct and inventory to find out what they had or did not have. - There was another technology available to alert staff to let the call light signals go to mobile phones or iPods (a portable electronic device for playing and storing digital audio and video files) - Any repairs with the call light system would have to go through the Information Technology (IT) Department. - They ordered those call light alert devices as far back as January 2021. He/she had to follow up and find out if and when, they were delivered to the facility. During an interview on 1/19/22 at 9:10 A.M., the Administrator said there was not a call light policy after one was requested. During an interview on 1/19/22 at 9:58 A.M., CNA D said: - He/she has worked at the facility for about a year. - The call lights have a buzzer at the nurse's station or he/she may see the lights illuminate on the wall. - In the past, the employees had access to the call light alert devices, which were used for a only a short time. - The call light alert devices have not been used for a while. During an interview on 1/19/22 at 10:43 A.M., RN A said: -The call light system started out using call light alert devices, but those call light alert devices did not work so well so the facility placed lights on the door, - The call light alert devices will ring but those call light alert devices have disappeared. - There is a sound at the nurse's station but that sound is faint. - If there is some amount of background noise, the sound form the nurse's station is so faint, that they cannot hear it. - He/she relied on being able to see the lights outside the door. - He/she will carry one when he/she was in the dining hall, because the call light alert device will buzz for the whole facility. During an interview 1/19/22 at 12:40 P.M., the DON said: - He/she's worked at the facility for about a month. - The nursing staff need to educate the residents on how to use the resident call system upon admission. - The call light signals are supposed to go to a call light alert devices and facility staff should have had one, but he/she found out the call light alert devices were missing. - Facility staff should do rounds or look at the nursing station or look at the light on the outside of the door. - As a quick, fix walkie-talkies were purchased to assist facility staff in answering the call lights faster. -If a call light was illuminated, he/she would expect nursing staff to respond and other department staff could see what the resident needed and get someone if they couldn't take care of it. -Staff should not walk by an illuminated call light and not respond. During a followup phone interview on 1/28/22 at 2:21 P.M., the Regional Director said: -Ten call light alert devices with ten spare batteries were delivered to the facility on [DATE]. -Between that time and the present, it was reported to him/her that the majority of those call light alert devices devices were misplaced or lost.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to submit a Third Party Liability Form (TPL-a form which is sent to MO Health Net, which gives an accounting of the remaining balance of that resident's funds in the resident trust account), which is required to be sent within 30 days after death, to Missouri (MO) Health Net after the death of one sampled resident (Resident #1000). The facility census was 59 residents. 1. Record review of facility records showed Resident #1000 died on [DATE]. Record review of documents on [DATE], also showed the TPL form was not sent in to MO Health Net, 64 days after the resident's death. During an interview on [DATE] at 2:31 P.M., the Business Office Manager (BOM) said the form was not sent in because he/she was not aware that a TPL form should be sent in after a resident who received Medicaid, dies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #41's admission Face sheet showed he/she was admitted to the facility on [DATE] with diagnoses of: - Presence of Cardiac Pacemaker (a small device that's placed in the chest or abdomen to help control abnormal heart rhythms). -Atrial Fibrillation (A-Fib, is a quivering or irregular heartbeat) and -Congestive Heart Failure (occurs when your heart muscle doesn't pump blood as well as it should). Record review of the resident's medical record found in downloaded document showed the resident: -Had a hospital Medical Pacemaker check- Fast Path Summary dated 12/29/18 had six alerts noted including he/she had 16 events related fast heart rate. -Had a Wrap-Up Overview report that showed the type of pacemaker he/she had and showed the model number Assurity DR 2240 and the Serial 7786080 and -Had his/her pacemaker was implanted on 6/16/16. Record review of the resident's medical record the resident's physician orders sheet, Treatment Administration Record (TAR) and progress notes showed: -No documentation or information found related to the type or make of the his/her pacemaker, to include serial number and model number, when was placed in the resident. -Had no details, plan of care, or physician's orders on how to monitor or check his/her pacemaker, to include: --When and where his/her pacemaker checks were to be done; --Who was responsible for ensuring the monitoring of the pacemaker checks were being done, who should receive the pacemaker checks report and --No documentation found related to the resident's pacemaker check findings dated 12/29/18 that include the information had been reviewed by nursing staff and the physician, the resident results and any new intervention or physician's orders from the pacemaker monitoring. Record review of the resident's Physician Progress notes dated 1/25/19, showed the resident's physician plan of care: -He/she had repeated fall the plan was to check the resident's orthostatic blood pressure and -He/she had A-Fib with Bradycardia the plan was to check the resident's EKG and the resident's physician would compare with pacemaker interrogation from 1/11/19. Record review of the resident's individualized Care Plan dated 1/25/19 showed the resident: -Had no documentation related to the resident's pacemaker checks review for the resident results or intervention from the pacemaker monitoring on 12/29/18. -Did have a cardiac care plan that mention the resident had a pacemaker and -Intervention for him/her to be followed per the in-house Cardiology physician care; --Had an EKG and chest x-ray on 1/25/19; --Nursing staff are to monitor the resident for chest pain, and enforce the need with the resident, to call for nursing assistant when his/her chest pain starts; --Notify the physician of any abnormal findings and -Did not have a detail pacemaker care plan to include the type of pacemaker the resident had and how to check the pacemaker, how often, when the pacemaker was to be checked. Record review of the resident's Physician Progress noted dated 2/14/19 showed the resident's physician plan of care: -He/she had A-Fib with Bradycardia the plan was to check the resident's EKG and the resident's physician would compare with pacemaker interrogation from 1/11/19. -He/she added a new diagnosis of Transient Ischemic Attack (TIA, is often called a mini-stroke) and Dizziness; -The resident was to be evaluated at a specialty clinic that treated patient's that had TIA: -No orders at this time. -Encouraged to have him/her follow up in TIA clinic at hospital: -The facility charge nurse was to call and establish an appointment; -If the resident had dizziness the plan was to encourage the resident to call for assistance from facility staff; -He/she said that this may not happen related to the resident's impulsive behaviors and -He/she had A-Fib with Bradycardia the plan was to check the resident's EKG and the resident's physician will compare with pacemaker interrogation from 1/11/19. Record review of the resident individualized Cardiac Care Plan last updated on 2/14/19 showed the resident: -Had documentation under care plan intervention was an appointment with the TIA clinic and had a EEG. -No documentation related to the resident's pacemaker checks review of the resident results or intervention from the pacemaker monitoring on 12/29/18. -Did not have a detail pacemaker care plan to include the type of pacemaker the resident had and how to check the pacemaker, how often, when or where the pacemaker was to be checked. Record review on of the resident's POS dated May 2019 showed: -Diagnoses including Presence of Cardiac Pacemaker, Atrial Fibrillation and Congestive Heart Failure. -Consult cardiology (teleMedico physicians to evaluation and treat as indicated for A-fib and hypertension) ordered in 2018. -A physician's order to schedule a follow-up appointment with the TIA clinic as soon as possible and -Did not have a detailed physician order for the resident's pacemaker to include the type of pacemaker the resident had and how to check the pacemaker, who responsible for ensuring the monitoring and follow-up, how often the pacemaker was to be checked and when or where the resident's pacemaker was to be checked. Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was severely cognitively impaired and had short term and long term memory problems. -Was usually able to understand others and make his/her needs known and -Did not require assistance from staff for cares and transfers but needed reminders or cueing at times. Observation on 5/28/19 at 9:30 A.M., of the resident's room showed: -The resident had a transmitter monitor on his/her bedside table with a green light that was on. - The resident said that he/she had a pacemaker for quite a while and it was on left side of his/her chest. -He/she said staff do check his/her pacemaker and -He/she was not sure why the transmitter monitoring box was in his/her room. During an interview on 5/30/19 at 11:00 A.M., the MDS Coordinator said: -The resident's care plan for pacemaker could be either a separate plan of care or under the cardiac care plan. -The resident's pacemaker was under the cardiac care plan. -The resident was to be followed by Cardiologist in house and -The care plan did not specifically say for pacemaker monitoring but was to be a reference for all concerns related to cardiac care. During an interview on 5/30/19 at 11:30 A.M., RN A said: -Most of the resident pacemaker checks were done by an outside company that came to the facility. -Some residents were also monitored by in house Cardiology management. -Each resident care plan should be detailed for pacemaker check process, including who should be monitoring the resident's pacemaker, the type and how often to checked. -Should have a detailed physician's order for the monitoring of the residents pacemaker. -He/she was not for sure how the resident's pacemaker was monitored. -The resident was being seen by in-house Cardiologist who monitor the resident cardiac needs. -He/she was not aware of the resident' pacemaker results from 12/29/19 he/she thought the results may go to his/her Cardiologist to review and -The resident had other issue and had order for EKG and follow-up with TIA clinic. Observation on 5/31/19 at 3:00 P.M. of the resident transmitter monitor showed: -A monitor box that was on the resident's bedside table. -The machine brand was a [NAME] at home transmitter. -Had a green light on and was plugged into the wall outlet. -Had a phone number to call for technical assistance and -The machine serial number was #1001573 9 - EX 150. During a telephone interview on 5/31/19 at 3:11 P.M., the Technical Assistant Agent A from the Transmitter Company said: -The transmitter monitor is normally placed at resident's bedside table. -The transmitter wakes up every morning around 2:00 A.M. to 4:00 A.M. to run a monitoring check on the resident's pacemaker and for heart irregularity issues daily. -Everyday wakes - finds concerns. --Doctors were monitoring the devices and receives all reports and findings. -If an issue with the resident's pacemaker then company would contact the resident's doctor. -The physician would be responsible for call the facility nursing staff with any follow-up orders. --Facility or the resident would monitor to ensure the green power light stay on the transmitter and -Transmitter automatically if cannot send data will then beep or lights not on, the facility or the resident are to call 1-800- number. During an interview on 5/31/19 at 10:24 A.M., Certified Medication Technician (CMT) A said: -He/she was not aware of the resident pacemaker monitoring process and -When he/she worked at another facility, if the transmitter went off he/she had to go get the nurse to follow-up. During an interview on 5/31/19 at 10:33 A.M., Certified Nursing Assistant (CNA) D said he/she was not informed what to do if the transmitter alarm system goes off. During an interview on 5/31/19 at 10:42 A.M., RN B said: -Residents with a pacemaker; if new pacemaker they would have electronic and have a blue tooth monitoring systems that stay's at their bedside. -The facility or physician would get a call if the resident was having a cardiac issue. -The nursing staff monitor the resident's vital signs and assess the pacemaker site as needed. -The resident should have had complete instructions on the use of the pacemaker monitor process and how to use the bedside pacemaker transmitter included in his/her care plans. -He/she was not aware of the resident having any pacemaker issues. -If he/she received any lab or testing reports at the facility, they would review the results and notify the resident's physician for any abnormal findings and -Should have nurse's note with any appointment the resident went on or lab medical appointments. During an interview on 5/31/19 at 10:54 A.M., RN A said: -He/she was not aware of any pacemaker issues. -He/she was not aware of the process for the resident transmitter pacemaker monitoring machines. -He/she was not sure when the resident pacemaker checks should have been done. -In January 2019 and February 2019 the resident was having issues related to dizziness and seizure like activity. -The in house Cardiologist had looked at the resident pacemaker monitoring and other testing results; -Had diagnosed the resident with TIA and dizziness not a pacemaker issue and -The resident's physician had stopped several of the resident's medications that helped with the dizziness and TIA. During an interview on 5/31/19 at 11:36 A.M., the DON said: -He/she was thinking the resident was being seen in an outpatient clinic for his/her pacemaker checks, but was not sure. -He/she expected the resident to have a Physician's order for monitoring the resident's pacemaker and -Since the resident goes out for pacemaker checks the facility normally would not get a copy of the resident's pacemaker checks. During an interview on 5/31/19 at 1:43 P.M., the DON said: -The charge nurse should be following physician orders. -Nursing staff were responsible for documentation of the testing or lab results and who they reported to. -The resident pacemaker report goes to the cardiology department and not always to the facility and -The resident should have a detailed care plan and physician order on when and how to monitor the resident's pacemaker. Based on observation, interview and record review, the facility failed to ensure physician's orders for a pacemaker was documented on the resident's physician's order sheet, to include identifying the resident had a pacemaker, frequency of monitoring, and who was responsible for monitoring for two sampled residents (Resident #15 and #41); to ensure documentation of the resident's pacemaker assessment and monitoring was in the resident's medical record for one sampled resident (Resident #15); and to ensure the resident's care plan showed the frequency of pacemaker monitoring and assessment for two sampled residents (Resident #15 and #41) out of 21 sampled residents. The facility census was 59 residents. 1. Record review of Resident #15's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including dementia, high blood pressure,high cholesterol, heart failure, respiratory failure, chronic obstructive pulmonary disease (COPD-a progressive disease that is characterized by shortness of breath and difficulty breathing), shortness of breath, muscle weakness and had a cardiac pacemaker (an artificial device for stimulating the heart muscle and regulating its contraction-it sends electrical signals throughout the heart that determine the timing of the heartbeat and cause the heart to beat in a coordinated, rhythmic pattern). Record review of the resident's Nursing Notes dated 7/16/18, showed he/she had a chest x-ray and the results were he/she had an enlarged heart but his/her lungs were clear. There were no fractures or disease noted and the resident did not have a collapsed lung or fluid in his/her lungs. A cardiac pacemaker was present. Record review of the resident's medical record showed he/she received Hospice (end of life) services from 10/12/17 to 9/21/18 for COPD. Documentation showed the resident had not resumed Hospice services since 9/21/18. There was no documentation in the resident's medical record showing when the resident's pacemaker was last interrogated (check the battery and function of the pacemaker), before Hospice services were initiated or after they were discontinued. Record review of the resident's Cardiology Report dated 3/22/19, showed: -The resident had a history of high blood pressure, high cholesterol, heart failure, pneumonia and edema, therefore Cardiology is currently following. -The resident was seen in his/her room, sleeping but easily arousable. He/she had dementia. -Nursing staff deny any acute concerns. -The resident was no longer on Hospice and was generally well developed, well nourished, with no distress. -The Cardiologist completed a physical exam of the resident and reviewed his/her medical record and medications. -The Cardiologist noted the resident's diagnoses and abnormal heartbeat (he/she noted the resident had a pacemaker). The resident had no edema on exam. His/her weight was up four pounds this month. His/her blood pressure overall, was well controlled as was his/her pulse. The resident had no acute cardiac concerns and -The Cardiologist documented he/she was unsure of last interrogation of the resident's pacemaker, but documented the plan was to have the resident's pacemaker interrogated later today or early next week, and to order an Echocardiogram (a test of the action of the heart using ultrasound waves to produce a visual display, used for the diagnosis or monitoring of heart disease). Record review of the resident's Physician's Orders Sheet (POS) showed there was a physician's order for an Echocardiogram to be completed on 3/25/19 (the order date was 3/22/19), for a pacemaker interrogation or diagnostic testing for the resident. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/25/19, showed he/she: -Had some confusion. -Needed supervision with transferring and eating and needed extensive assistance with walking, toileting, dressing and bathing/hygiene and -Used oxygen. Record review of the resident's Nursing Notes showed: -On 3/26/2019 an Echocardiogram was ordered (from the radiology vendor) and -No documentation that the resident had his/her pacemaker interrogated. There were no nursing notes documenting that the Cardiologist received the resident's diagnostic report concerning the interrogation of the resident's pacemaker or that the results were provided to the facility. Record review of the resident's medical record showed there was no diagnostic report in the resident's medical record showing when he/she had last had his/her pacemaker interrogated, and there was no documentation showing the diagnostic report and results of the resident's pacemaker interrogation (from 3/22/19). Record review of the resident's Care Plan updated 4/9/19, showed he/she had a pacemaker. The care plan showed the resident was unable to provide a history of his/her pacemaker and when he/she followed up with his/her Cardiologist, or who his/her Cardiologist was. The resident's family was also unaware. It showed the resident had an Electrocardiogram completed in house on 9/22/17. Interventions showed nursing staff was to: -Monitor vital signs as ordered/per facility protocol and record. Notify the physician of significant abnormalities. -Monitor/document/report to the physician as needed, any signs/symptoms of altered cardiac output or pacemaker malfunction: dizziness, syncope, difficulty breathing, pulse rate lower than programmed rate, lower than baseline blood pressure. -Teach the resident/family/caregiver to avoid activities and equipment which interfere with pacemaker activity and -There was no documentation showing the frequency that the resident's pacemaker was to be interrogated, where the resident's pacemaker would be checked or who was monitoring it. Record review of the resident's Physician's Notes dated 4/24/19, showed: -The resident's Physician saw the resident in his/her room and the resident was laying down talking to himself/herself. -The resident was no longer receiving Hospice services. -The resident's primary care physician documented he/she completed a physical examination of the resident and reviewed the resident's labs, medications and medical record. -The resident's physician documented the resident's pacemaker was stable and that he/she was on daily, continuous oxygen and that was also stable and -There was no documentation showing the resident had an interrogation of his/her pacemaker and that the results had been obtained and provided to the Cardiologist or facility. Record review of the resident's POS dated 5/1/19 to 5/31/19, showed: -There were no current physician's orders for Hospice services. -There was no documentation showing the resident had a pacemaker and -There were no physician's orders to check, assess or monitor the resident's pacemaker. Record review of the resident's Cardiology report dated 5/7/19, showed: The resident had a history of high blood pressure, high cholesterol, heart failure, pneumonia and edema, therefore cardiology was currently following. -The resident was seen in his/her room, he/she was awake, without distress, speaking nonsensically. -Nursing staff deny any acute concerns. -The resident was no longer on Hospice and was generally well developed, well nourished, with no distress. -The Cardiologist completed a physical exam of the resident and reviewed his/her medical record and medications. -The Cardiologist noted the resident's diagnoses and abnormal heartbeat (noted he/she had a pacemaker). The resident had no edema on exam. His/her weight was stable. His/her blood pressure overall, was well controlled as was his/her pulse. The resident had no acute cardiac concerns. -The Cardiologist documented the resident's Echocardiogram results (3/28/19) showed the resident had 55-60% aortic sclerosis (narrowing of the aortic valve in the heart), and mild thickening of the heart muscle. The plan was to continue oxygen therapy and -The Cardiologist documented he/she was unsure of when the last interrogation of the resident's pacemaker was, and documented the resident's pacemaker interrogation was pending. Record review of the resident's Nursing Notes showed: -On 5/31/19, When asked about resident's last pacemaker interrogation this Registered Nurse (RN) looked at previous Cardiology reports and noted that the last one was done in March and that (the diagnostics vendor) was to release the report to the Cardiologist. When (the vendor) was called they stated they could only release reports to the entity that ordered them. When this RN attempted to contact (the physician), the operator stated that phone lines were down and that our Director of Nursing (DON) would receive and email of how to contact them. This information was reported to the DON and Education Director (ED). During an interview on 5/31/19 at 11:22 A.M., the Director of Nursing (DON) said: -The resident previously was on Hospice services and those services were discontinued as of 9/21/18. -He/She did not see that the resident had his/her pacemaker checked within the last year or since Hospice was discontinued. -There were no physician's orders showing how they were to monitor the resident's pacemaker. -He/she was trying to contact the facility's Cardiologist but had not been able to reach him/her to find out if the report showing the results of the resident's pacemaker interrogation had been received. -He/She would contact the Cardiologist to get an order to check the resident's pacemaker. -The resident's care plan showed that the Cardiologist would follow up with the resident's pacemaker. -They would make sure they received the results of the pacemaker interrogation and have the vendor fax the report and -They would also ensure the physician's orders showed the resident had a pacemaker and showed the frequency of monitoring of the resident's pacemaker. During an interview on 5/31/19 at 2:47 P.M., with the DON and Corporate Nurse, the DON said: -They had obtained the Echocardiogram report and physician's orders for the resident's pacemaker. -The physician should provide orders for how to follow up on any resident with a pacemaker including how frequently to follow up/how often it should be checked. -Their Cardiologist will then follow up and the Cardiologist will complete the assessment and should show that the resident's pacemaker was checked. -The resident's care plan should show any cares that would be required for follow up that the facility provides for monitoring the resident's pacemaker. -The nurse would have to know that there is a pacemaker and how often the checks would be. -They work very closely with the facility Cardiologist and they rely on him/her to complete monitoring of the resident's pacemaker. -The Cardiologist should document in his/her notes if/when the resident's pacemaker was checked and the result of the check and -The Corporate Nurse said they would not expect the cardiologist to notate anything else unless there was a problem the facility needed to follow up on. He/she said that he/she was going to follow up to ensure all of the facilities were checking the resident's with pacemakers to ensure the assessments and monitoring were completed and documented. Record review of the resident's Echocardiogram Report (received on 5/31/19) showed the resident's pacemaker palpitations (a noticeably rapid, strong, or irregular heartbeat) were checked on 3/22/19. There was no report or summary of findings of the diagram. Record review of the resident's Physician's Telephone order dated 6/1/19, showed a physician's order was obtained that showed the resident had a pacemaker and orders to interrogate it every six months. One time a day every 180 day(s) for coronary artery disease (CAD-blockage of one or more arteries that supply blood to the heart). The order showed this will need to be on a week day with cardiology.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide adequate urostomy (a surgical opening in the belly (stoma) to allow urine to pass out of the body into a collection bag) care and to ensure accepted infection control practices were maintained during care to prevent cross contamination for one sampled resident (Resident #15) out of 21 sampled residents. The facility census was 59 residents. 1. Record review of Resident #15's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including dementia, high blood pressure,high cholesterol, heart failure, respiratory failure, kidney failure, chronic obstructive pulmonary disease (COPD-a progressive disease that is characterized by shortness of breath and difficulty breathing), shortness of breath, muscle weakness and had a cardiac pacemaker (an artificial device for stimulating the heart muscle and regulating its contractions). Record review of the resident's Care Plan dated 3/9/19, showed he/she had a urostomy due to a history of bladder cancer. The resident's goal was to show no unresolved signs or symptoms of urinary infection through the next review date. Interventions showed nursing staff was to: -Empty the resident's urostomy every shift and as needed; and to change (the urostomy bag) weekly. -Follow up with the resident's Urologist. -Monitor the resident for signs and symptoms of discomfort on urination and frequency. -Monitor/record/report to physician signs and symptoms of urinary tract infection. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/25/19, showed he/she: -Had some confusion. -Needed supervision with transferring and eating and needed extensive assistance with walking, toileting, dressing and bathing/hygiene and -Had a urostomy and was incontinent of bowel. Record review of the resident's Physician's Order Sheet (POS) dated 5/1/19 to 5/31/19 showed physician's orders to change the urostomy bag weekly, every day shift on Wednesday and as needed for leaking due to history of bladder cancer. Observation on 5/29/19 at 9:39 A.M., showed the resident was fully dressed and laying on his/her back on his/her bed with his/her oxygen on at 3 liters and his/her walker was next to his bed. Registered Nurse (RN) A entered the resident's room and washed her hands. He/she stepped out then came back into the resident's room and sanitized his/her hands. The resident's supplies were in his/her bathroom in a plastic bag. The following occurred: -RN A pulled several gloves out of the box and wiped down the resident's tray table with alcohol wipes, then degloved, washed his/her hands, turning off the faucet with his/her left hand, then gathered the supplies. -Certified Nursing Assistant (CNA) C came into the resident's room and washed his/her hands, turning off the faucet with a paper towel. He/she then gloved and assisted the resident to sit up on the side of his/her bed. -CNA C placed a bin and cleansing agent on the tray table and placed the measurement cup inside of the bin. He/she then assisted the resident to slide his pants down exposing the urostomy. -CNA C emptied the contents of the urostomy into the measuring container, then, using an alcohol wipe, he/she cleaned the spout of the urostomy. -CNA C de-gloved, sanitized his/her hands, re-gloved and cleaned the resident's skin around the urostomy site with a wet wash cloth. Once he/she was finished, CNA C removed the supplies from the tray table and took them into the bathroom. -RN A gloved and using an alcohol wipe, he/she cleaned the tray table while CNA C was emptying the contents of the measuring container into the toilet. -CNA C then cleaned the measuring container, rinsed out the bin and placed them in the bathroom to dry. He/she de-gloved then washed his/her hands using a paper towel to turn off the water. -RN A de-gloved after cleaning the resident's tray table, then washed his/her hands, turning the water off with his/her left hand, then dried them, gloved and placed a clean towel on the tray table. -RN A placed all of the supplies for changing the resident's urostomy on the towel. He/She wet a wash cloth and gave it to the resident to wash his/her hands. -RN A then degloved and washed his/her hands, turning off the faucet with his/her left hand before drying them and gloving. -Using an alcohol wipe, RN A began wiping under the resident's urostomy bag to loosen the sealant so he/she could remove the urostomy bag. After removing the resident's urostomy bag, RN A used a wet wash cloth to clean the skin around the stoma. -RN A then then discarded his/her gloves and without using hand sanitizer or washing his/her hands, he/she gloved, used a measurement device to measure the size of the resident's stoma, removed sterile scissors from the storage bag, then used the scissors to cut an area of the sterile urostomy bag. -RN A then picked up skin prep (skin protectant ointment) and began to place it on the resident's skin around the stoma site. -RN A then placed the new urostomy bag over the resident's stoma and secured it. -Once the urostomy bag was secured over the resident's stoma, RN A covered the resident, de-gloved and washed his/her hands, using her hand to turn off the faucet. -RN A gloved and went to assist the resident to reposition in bed. -RN A then gathered his/her supplies, completed data entry (on his/her computer that was in the resident's room), then took the bin to the bathroom and dumped the water out, placed the scissors into a plastic bag, took the other used supplies off of the tray table, put them in a plastic bag and placed them in the bathroom. -RN A then wiped the tray table down with an alcohol wipe and put it by the resident's bed and -RN A then gathered the soiled linen and trash, took them to the bathroom, placed the linen on the floor and pulled the trash. He/She de-gloved and washed his/her hands, turning off the water with her left hand before drying them with a paper towel. RN A then left the resident's room to get the linen cart. During an interview on 5/29/19 at 10:09 A.M., RN A said: -He/she did not wash or sanitize his/her hands after removing the resident's urostomy and cleaning the resident's skin around his/her stoma. -He/she did not want to leave the resident's stoma exposed to go to the bathroom to wash his/her hands during the resident's care and was not sure if he/she should have. -He/she did not realize that he/she was using his/her hand to turn off the faucet after washing his/her hands and -He/she was supposed to wash his/her hands after de-gloving and when going from a dirty to clean task. During an interview on 5/31/19 at 2:47 P.M., with the Director of Nursing (DON) and Corporate Nurse, the DON said: -The nurse should wash and/or sanitize his/her hands between clean and dirty tasks and after they change the resident's urostomy. -After draining and removing the resident's urostomy, they need to wash their hands, after cleaning around the stoma site they should wash or sanitize their hands, after placing the new urostomy bag on the resident and before they leave the residents room. -When staff completes handwashing, they should not use their hands to turn off the water, they should use a dry paper towel to turn off the water because when they turn on the water, the faucet handle is a dirty surface and they are re-contaminating their hands by turning the faucet off with their hands. Using a dry paper towel to turn off the faucet prevents cross contamination.

Based on observation and interview, the facility failed to create a safe environment for dietary staff by not repairing a leak from a drainage pipe under the ice machine which created a large amount of standing water. This practice potentially affected all dietary staff. The facility census 59 residents. 1. Observation on 5/28/19 at 9:31 A.M., showed a large puddle of water which originated from under the ice machine into the area close to the entrance of the kitchen. 2. Observations on 5/29/19 at 5:46 A.M., and 6:22 A.M., showed a large (approximately 3 feet (ft.) in diameter) puddle of water that originated from under the ice machine and into the area close to the entrance into the kitchen from the dining room. That puddle of water became a tripping hazard for a few dietary employees and including the state surveyor. Further observation showed a large puddle of water in the back part of the kitchen close to the three compartment sink. During an interview on 5/29/19 at 6:53 A.M., DC A said he/she has cooked on the Skilled side of the community for about two and a half weeks, every time he/she came in, he/she saw standing water on the floor. During an interview on 5/29/19 at 7:02 A.M. the Dietary Manager (DM) said they are supposed to be squeegeeing (the usage of a scraping implement with a rubber-edged blade set, on a handle, typically used for cleaning) to sweep the water towards the drain in the back part of the kitchen at the end of the evening dietary shift. 3. Observation with the DM on 5/31/19 at 8:53 A.M., showed an active drip from the drainage pipe under the ice machine and the pipe was loose. During an interview on 5/31/19 at 8:54 A.M., the DM said that the drainage pipe became loose when dietary staff attempted to sweep under the ice machine in the past and he/she acknowledged that it (the leak) needed to be repaired.

Based on observation, interview and record review, the facility failed to adequately label and store medications including a Lidocaine patch for one out four sampled medication carts and to ensure monitoring for expired medications in the medication refrigerators in one out three medication rooms. The facility census was 59 residents. Record review of the undated medication manufacturer reference information showed: -The Lidocaine patches as an alternative pain solution. Lidocaine patches may be effective for patients who are in pain but are looking to avoid drugs that could be addictive and -Systemic adverse effects of Lidocaine are similar in nature to those observed with other amide local anesthetic agents, including light-headedness, nervousness, apprehension, euphoria, confusion, dizziness, drowsiness, tinnitus, blurred or double vision, vomiting, sensations of heat. 1. Observation on 5/29/19 from 9:42 A.M. to 9:47 A.M., of the 100 hall licensed medication cart showed: -Registered Nurse (RN) A had obtained supplies and went into a resident room. -On top of the licensed medication cart was a Lidocaine patch Over the Counter (OTC) left unsupervised. -The living area had four residents in wheelchairs in the area. -Certified Medication Technician (CMT) A was in and out of resident's room but was not close to the licensed medication cart and -At 9:47 A.M. RN A came out of the resident's room to get his/her laptop and saw the patch on the cart and placed it in his/her hand and took it with him/her to the resident's room. Observation with interview on 5/30/19 at 11:15 A.M. of the medication storage room on the first floor unit showed: -The Tuberculin (TB) Purified Protein derivative box was dated 4/24/2019 when it had been opened and no date on the open bottle. -CMT A said the RN's provide the TB screening and monitor the medication refrigerator. -CMT A said he/she did all the monitoring and stocking for OTC medication and -The licensed nursing staff have the key to the narcotic lock box. Observation on 5/30/19 at 11:25 A.M. of the medication narcotic lock box that was located in the medicine refrigerator with RN A showed: -One 30 milliliter (ml) bottle of Lorazepam (Ativan used to treat anxiety) that was open. --There was no resident name on the bottle or box. --There was not a dated on the bottle when it was opened. -RN A said the controlled substance sheet showed the medication was obtained on 1/23/19 had a total of 30 ml in the bottle and the resident was given .5 ml which left 29.5 ml and -RN A said he/she was not sure how long Ativan was good for after the medication had been opened. During an interview on 5/30/19 at 11:40 A.M., RN A said: -He/she found out that the TB solution was good for 30 days once it had been opened. -Ativan was good for 90 days once it was opened. -Both medications had been available to use longer than the recommended amount of time after they had been opened and -He/she said they have to have two nursing staff to be able to destroy the Ativan. During an interview on 5/31/19 at 10:24 A.M. CMT A said: -Lidocaine patches are only given by licensed nurses and -No medication should be left unattended on top of the medication cart. During an interview on 5/31/19 at 10:40 A.M., RN A said Lidocaine patches are not to be left unattended on top of the medication cart. During an interview on 5/31/19 at 1:43 P.M., the Director of Nursing (DON) said: -The Administration team does random checks of the medication rooms and the medication carts to ensure safe storage and labeling of medications. -Medications were not to be left unattended on top of the medication cart. -TB solution was only good for 30 days once it had been opened. -He/she expected the nursing staff to date the medication bottle and the box when it was opened. -House stock medication should be documented who it was given to. --The vial or bottle and the box should be dated when opened and have the resident name on the box and vial or bottle who was assigned to and -Ativan was only good for 90 days once it had been opened.

Based on observation, interview and record review, the facility failed to schedule sufficient dietary staff to ensure the necessary cleaning was done during the evening dietary shift and to ensure that food was served in a timely manner after the stated times of the breakfast and lunch meals. This practice potentially affected 59 residents who ate food from the kitchen. The facility census was 59 residents. 1. Record review of the dining services opening and closing checklist for PM dining services, showed: - Sanitize all work surfaces. - Empty and clean dish machine and turn off the power. - Sweep and mop floors. - Place all soiled linen in appropriate receptacles, and - Empty and clean sanitizer buckets. Record review of the dining services opening and closing checklist for PM dining services, showed the absence of pulling out appliances and cleaning the floors behind and under those appliances. 2. Observations during the breakfast meal preparation on 5/29/18 from 5:46 A.M. through 8:45 A.M., showed the presence of the following: - At 5:46 A.M., food debris under steam, table, deli refrigerator and cooking appliances. - At 5:47 A.M., debris was present in the upper nozzle of dishwasher. - At 5:48 A.M., one baker's scraper (used in working with pastry, bread, and other doughs; it is a flat, rectangular piece of metal or plastic, often with a handle on the top) with food debris on the blade part of the utensil stored with clean appliances. - At 5:57 A.M., there was food debris under dishwasher, back storage shelf, and 3 compartment sink. - At 5:58 A.M., there was debris and liquid, left in the dustpan from the previous night because the no dietary employee started to cook or clean as yet. - At 6:00 A.M., a baker's scrapers with food debris on it stored with clean kitchen utensils on the shelf on the back, and - At 6:22 A.M. 6 out of 6 cutting boards not in easily cleanable condition. During an interview on 5/29/19, the following was said about the lack of cleaning in the kitchen during the evening shift: - At 8:42 A.M., Dietary [NAME] (DC) A said there is only one person that works at night because that person cooks an cleans. - At 9:16 A.M., Dietary Aide (DA) A said the night shift employees should be pulling out the refrigerator and the table to get behind there because it (the food debris) could attract little critters, even though little critters were not there yet, and - At 10:43 A.M., the Dietary Manager (DM) said the dustpan should be cleaned and rinsed out at night. 3. Record review of the Dietary schedule for the evening dietary shift during the week of 5/10/19 through 5/16/19, showed: - On 5/10/19, 5/11/19, 5/12/19 and 5/14/19, during the evening shift, two servers (who also worked as dietary aides) were scheduled with only one cook and - On 5/13/19, 5/15/19 and 5/16/19, during the evening shift one server was scheduled with only one cook. Record review of the Dietary schedule for the evening dietary shift during the week of 5/17/19 through 5/23/19, showed: - On 5/17/19, during the evening shift, two servers were scheduled with only one cook and - On 5/18/19, 5/19/19, 5/20/19, 5/21/19, 5/22/19, and 5/23/19, during the evening shift, only one server was scheduled with one cook. Record review of the Dietary schedule for the evening dietary shift during the week of 5/24/19 through 5/30/19, showed: - On 5/24/19, 5/26/19, 5/29/19 and 5/30/19, two servers were scheduled with one cook and - On 5/25/19 and 5/27/19, one server was scheduled with one cook, and on 5/27/19, the cook was the DM. During an interview one 5/29/19 at 9:59 A.M., about the scheduling of dietary staff, the On-Point Director from the Food Service Provider said: - He/she agreed that there was not enough staff scheduled for the evening shift. - There was not enough facility staff allocated to serve the needs of the business. - He/she said they have tried to get facility staff hired. - Hiring additional staff has been difficult because some staff leave their positions too soon. - The food service provider has prevented him/her from allocating additional hours for the staff that they had. - The food service provider has prevented him/her from offering higher wages. - They have not been able to find enough employees at 4 people per shift or for the servers to stay until 10:00 P.M., and - Everyone needed to be more productive until other dietary staff get hired, and - Some of things such as cleaning may fall by the wayside. During an interview on 5/30/19 at 2:55 P.M., DC B said: -The dietary staff do not have enough time to the cleaning done on the evening shift. - It is difficult to pull the flat top grill from the wall. -There used to be more cooks in past months. -They have been this short of dietary staff since March 2019. - If they do not have enough servers/aides, sometimes the food gets out to the residents late, and It would be nice to have two servers, one dishwasher, and one cook while one of the dishwashers clean as well. During an interview on 5/31/19 at 8:57 A.M., the DM said there needed to be at least four dietary staff to run the kitchen during the evening shift. 4. Record review of documentation provided by the facility, showed the breakfast times were from 7:30 A.M. through 9 A.M., and lunch times were from 12:00 P.M. to 1:30 P.M. Observations on 5/29/19 at 8:40 A.M. (80 minutes after the start of breakfast), showed Resident # 12 at table with no meal at that time. Record review of Resident Council Minutes dated 1/19 through 5/19, showed the Dining room service wait time is too long. During the group interview on 5/30/19 at 10:36 A.M, regarding the food, the residents said: - They have a food council as of 4/19, and they have switched to a new company Resident #31 who had a Brief Interview of Mental Status (BIMS) score of 13, said they wait to send the food out up to 45 minutes after the residents sit down to eat. -Resident #30 with a BIMS score of 14, said he/she has left the dining room and come back and still did not receive her meal timely, and also said the food was not always hot.

Based on observation, interview, and record review, the facility failed to do or prevent the following: ensure food debris was removed from the upper nozzle of the dishwasher; to remove food debris including 4 small containers of butter like spread from under the ice machine and the coffeemaker table the 6 burner stove and deep fryer and the three compartment sink; to ensure soiled dishes were not stored with clean dishes; to remove the debris and liquid from the dustpan that was used on a previous night; ensure the cutting boards were free from unremovable stains and numerous nicks and grooves which made the cutting boards not easily cleanable; and failed to remove a scoop from a container sugar after the sugar was scooped out. This practice potentially affected at least 59 residents who ate food from the kitchen. The facility census was 59 residents. 1. Observations during the initial kitchen tour on 5/28/19 from 9:23 A.M. through 9:31 A.M., showed the presence of the following: - Food debris and a spray can behind and under the six burner stove and deep fryer. - Food debris in the upper nozzle of the dishwasher and - Food debris, 4 small containers of spreadable butter like substance and drinking cups under the ice machine and the coffee making table. Observations during the breakfast meal preparation on 5/29/18 from 5:46 A.M. through 8:45 A.M., showed the presence of the following: - At 5:46 A.M., food debris under steam, table, deli refrigerator and cooking appliances. - At 5:47 A.M., debris was present in the upper nozzle of dishwasher. - At 5:48 A.M. one baker's scraper (used in working with pastry, bread, and other doughs; it is a flat, rectangular piece of metal or plastic, often with a handle on the top) with food debris on the blade part of the utensil stored with clean appliances. - At 5:49 A.M., one utensil with a handle that was not easily cleanable due to melted areas. - At 5:57 A.M., there was food debris under dishwasher, back storage shelf, and 3 compartment sink. - At 5:58 A.M., there was debris and liquid, left in the dustpan from the previous night because the no dietary employee started to cook or clean as yet. - At 5:59 A.M. dust on the ceiling vent above utensil storage area. - At 6:00 A.M., a baker's scrapers with food debris on it stored with clean kitchen utensils on the shelf on the back. - At 6:03 A.M., a metal scoop left inside the sugar container without the handle being stored in the up position, before anyone started to use it. - At 6:22 A.M. 6 out of 6 cutting boards not in easily cleanable condition. - At 7:04 A.M., Dietary cook (DC) A used the scoop and left the scoop in the sugar bin without the handle side up, and - At 8:52 A.M., the DM noticed there was a buildup of grease in bottom of deep fat fryer. During interviews on 5/29/19, the following was said: - At 8:33 A.M., the Dietary Manager (DM) said he/she could contact a company to service the dishwasher chemical service company to service the dish washer. - At 8:53 A.M. the DM said the grease at the bottom of the inside of the deep fryer needed to be removed. - At 8:57 A.M., DC A said he/she had to wash the baker's scraper this am before using it. - At 8:59 A.M., the DM said the cutting board needed to be replaced. - At 9:00 A.M., the DM noticed all the food debris under the steam table fridge and stove and said they are not pulling out the appliances. - At 9:03 A.M., the DM said the cooks wash the cooking equipment and the aides are supposed to wash the dishes. - At 9:16 A.M., Dietary Aide (DA) A said the night shift employees should be pulling out the refrigerator and the table to get behind there because it (the food debris) could attract little critters, even though little critters were not there yet, and - At 10:43 A.M. the DM said the dustpan should be cleaned and rinsed out at night. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: In Chapter 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD preparation or dispensing, FOOD preparation and dispensing UTENSILS shall be stored: (B) In FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD with their handles above the top of the FOOD within containers or EQUIPMENT that can be closed, such as bins of sugar, flour, or cinnamon; - In Chapter 3-305.14, During preparation, unPACKAGED FOOD shall be protected from environmental sources of contamination, - In Chapter 4-202.11, regarding Food-Contact Surfaces; Multi-use FOOD-CONTACT SURFACES shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; and 4) Finished to have SMOOTH welds and joints; - In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced. - In Chapter 4-601.11, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. - In Chapter 4-602.13, nonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues; - In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure infection control practices to prevent cross contamination were implemented during a resident transfer of one sampled resident (Resident #40); to ensure proper storage of oxygen tubing and nebulizer mask after use for one sampled resident (Resident #12) out of 21 sampled residents, and the facility failed to ensure handwashing station in the clean utility room next to resident room [ROOM NUMBER], was equipped with soap. The facility census was 59 residents. Record review of the Center for Disease Control and Prevention Handwashing Guidelines or Recommendations dated 3/7/16 showed: -Indications for Handwashing and Hand Antisepsis (Prevention of infection by inhibiting or arresting the growth and multiplication of germs). -When hands are visibly dirty or contaminated or visibly soiled with blood or other body fluids, wash hands either a non-antimicrobial soap and water or antimicrobial soap and water. -Wash hands before having direct contact with patients. -Wash hands after contact with a patient's intact skin ( e.g. when taking a pulse, blood pressure, and lifting a patient. -Wash hands if moving from a contaminated - body site to a clean body site during patient care. -Wash hands after contact with inanimate objects ( including food or medical equipment). -Washing before, during and preparing food after blowing your nose, coughing, sneezing. -Wash hands after removing gloves. -Wash hands before eating and after using a restroom with soap and water. -Hand - Hygiene Techniques: --When washing hands first with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers; --Rinse hands with water and dry thoroughly with a disposal towel and use the towel to turn off the faucet and --When washing hands with an alcohol -based hand rub, apply product to palm of one hand and rub hands together covering all surfaces of hands and fingers, until hands are dry. 1. Record review of the Resident's #40's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Hemiplegia (Muscle weakness or partial paralysis on side of the body that can affects arms, legs, and facial muscle). -Abnormalities of Gait and Mobility (gait requires that many systems, including strength, ostentation and coordination, function in an integrated fashion); Mobility ( The ability to move freely and easily). -Contractures (A muscle or tendon that's shortened or tighten to the point that is can not stretch normally) and -Muscle Weakness. Record record of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool be completed by facility staff for care planning) dated 5/9/19 showed he/she: -Had a Brief Interview Mental Status (BIMS) score of 12 which means the resident had mild to moderate cognitive impairment. -Was able to express his/her wants and needs to others. -He/she was totally dependent on nursing staff. -He/she required assistance from two staff members with the following Activities of Daily Living (ADL's), bathing, bed mobility, dressing, personal hygiene/oral care, and toilet use. -He/she was able to eat his/her meals independently, but required one staff member to assist with set up and may require verbal cueing at times and -He/she required assistance from two staff members with transfers via a full body mechanical lift. Observation on 5/29/19 at 7:45 A.M. showed Certified Nursing Assistant (CNA) C and CNA D performed a full body mechanical lift transfer on the resident in his/her room: -Both CNA C and CNA D had on gloves. -Both CNA C and CNA D had attached the sling to the lift. -CNA D moved the mechanical lift closer to the resident's bed area. -CNA D moved the mechanical lift away from the resident's wheelchair while CNA C stood behind the resident's wheelchair to guide the resident. -Both CNA C and CNA D had general conservation and engaged the resident during the transfer and asked the resident where are we going today, the resident replied Greece. -CNA D had pulled the lift away from the resident's bed and CNA C and CNA D had placed the resident safely in his/her wheelchair. -CNA D had on his/her gloves from the mechanical lift transfer and proceeded to get the resident's red blanket and draped it over the resident's lap and lower leg and feet areas. -CNA D proceed to take off his/her gloves and proceeded to take the handles of the resident's wheelchair and pushed the resident to the dining room for breakfast and -CNA D did not wash his/her hands after he/she did the mechanical lift transfer. During an interview on 5/29/19 at 8:00 A.M. CNA D said: -He/she should have pulled off his/her gloves before handling the resident's wheelchair. -He/she did not use alcohol hand rub. -He/she was to wash his/her hands after the mechanical lift transfer and -He/she was trained to always wash his/her hands prior to and after resident cares with soap and water. During an interview on 5/29/19 at 8:15 A.M. Registered Nurse (RN) B said he/she expected the nursing staff to wash their hands prior to and after performing cares on the resident. During an interview on 5/29/19 at 2:40 P.M. the Director of Nursing (DON) said: -He/she expected the nursing staff to following all handwashing hygienic policies and protocols at the facility. -He/she expected the employees to wash his/her hands after arriving to the workplace. -He/she expected the employees to wash hands after using the bathroom. -He/she expected the nursing staff to wash his/her hands when going in and coming out of a resident's room. -He/she expected the nursing staff to wash his/her hands after providing or performing cares on a resident. -He/she expected the nursing staff to washing his/her hands prior to putting on or wearing gloves and -He/she expected the nursing staff to wash his/her hands after taking off gloves. 2. Record review of Resident #12's admission Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Dementia (is a general term for loss of memory and other mental abilities severe enough to interfere with daily life). -Shortness of Breath. -Cerebral infraction (or stroke, is a brain lesion in which a cluster of brain cells die when they don't get enough blood); and -Transient Ischemic attack (TIA, is often called a mini-stroke). Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Required the use of oxygen and did not have shortness of breath marked on his/her MDS; and -Had a diagnosis of chronic lung disease and Atrial Fibrillation (A Fib an irregular, rapid heart rate that may cause symptoms like heart palpitations, fatigue, and shortness of breath). Observation on 5/28/19 at 9:54 A.M., of the resident who had just returned to his/her room showed: -The resident's oxygen (O2) tubing and nebulizer mask was not stored in a bag. -The O2 tubing was draped over the O2 concentrator machine (a medical device used to deliver oxygen to those who require it). -CNA D said the resident used oxygen at night and has breathing treatment during the day; and -CNA D did not address the issue of the storage of the O2 tubing or the nebulizer tubing and it being left laying uncovered. Observation on 5/28/19 at 2:48 P.M. of the resident's room showed his/her O2 tubing remained uncovered on the O2 concentrator and his/her nebulizer mask was uncovered laying on the bedside table. Observation on 5/29/19 10:34 A.M. of the resident's nebulizer treatment showed: -RN A washed his/her hands and put on gloves. -The resident's nebulizer mask was in a plastic storage bag. -He/she listened to the resident's lungs (the resident had expiratory wheezing). -RN A checked the resident's O2 saturation (O2 sat the amount of oxygen in a person's bloodstream) which was 94% at room air and his/her pulse was 71. -RN A said those were normal findings for the resident. -RN A said the resident had signed a waiver for refusal of thicken liquids and he/she was at risk for aspiration with liquids. -RN A had setup the nebulizer medication already in the Nebulizer machine. -The resident received Ipratropium-Albuterol (used to prevent wheezing, difficulty breathing, chest tightness, and coughing in people with chronic obstructive pulmonary disease) Solution 0.5-2.5 (3) milligram (mg)/3 milliliter (ml) and was given 3 ml inhale orally every 4 hours as needed for shortness of breath or wheezing and 3 ml inhale orally after meals for aspiration precaution; and -RN A started the breathing treatment and stayed with the resident. Record review of the resident Physician Order Sheet (POS) dated May 2019 showed: -The resident had physician orders to have nursing staff check his/her O2 sats every shift. refer to prn O2 order to keep sats above 90% required oxygen every shift for apnea (stopping of breathing) and -Had a physician order for Albuterol Solution 0.5-2.5 (3) mg/3 ml to be given 3 ml inhale orally every 4 hours as needed for shortness of breath or wheezing and 3 ml inhale orally after meals for aspiration precaution. During an interview on 5/31/19 at 10:24 A.M., Certified Medication Technician (CMT) A said: -The overnight staff change the resident O2 tubing once a week. -CMT A said he/she would check in the morning if the resident had their O2 on and would ensure it was on and positioned properly. -The O2 tubing and nebulizer mask were to be stored in a plastic bag when not in use. -All staff were responsible for checking on the resident to ensure safe storage of O2 tubing when they entered the resident room. -If the O2 tubing and nasal cannula were found on the floor, he/she would go get new tubing and -The resident did not use O2 during the daytime as much, he/she mainly wears it at night. During an interview on 5/31/19 at 10:33 A.M., CNA D said the resident's O2 tubing and nebulizer mask were to be stored in a plastic bag when not in use. During an interview on 5/31/19 at 1:43 P.M., the DON said: -He/she expected the storage of O2 tubing to be in a bag if not in use; the bag should have a date of when it was last changed. -The night shift staffing were responsible for ensuring O2 tubing and nebulizer tubing were changed weekly. -The Administration team have selected rooms to walk through to in ensure the cleanliness and safe storage of medical supplies; and -If a resident shows a pattern of taking off his/her O2 nasal cannula and leaving it uncovered, he/she would expect that to be noted in the resident's medical record and care plan. 3. Observations on 5/28/19 at 11:33 A.M., and with the DON on 5/31/19 at 8:49 A.M showed the absence of soap from the hand washing sink within the clean utility room next to resident room [ROOM NUMBER]. During an interview on 5/31/19 at 8:49 A.M., the DON said he/she did not know who was responsible for placing soap in the clean utility room, but he/she would ensure soap would be available in the future.