**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for eleven residents (Resident #18, #25, #28, #34, #44, #49, #53, #81, #111, #126, and #131) out of 28 sampled residents and one resident (Resident #139) outside the sample. The facility's census was 139. Review of the facility's policy, Transfer or Discharge, Facility-Initiated, revised October 2022, showed: - Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy; - Each resident will be permitted to remain in the facility, and not be transferred or discharged unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility; - The resident and representative are notified in writing of the following information: the specific reason for the transfer or discharge, including the basis; the effective date of the transfer or discharge; the specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is being transferred or discharged ; the Notice of Facility Bed-Hold and policies; - A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative; - When residents who are sent emergently to an acute care setting, these scenarios are considered facility-initiated transfers, NOT discharges, because the resident's return is generally expected; - Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility. Residents who are sent to the acute care setting for routine treatment/planned procedures are also allowed to return to the facility; - Under the following circumstances, the notice is given as soon as it is practicable, but before the transfer or discharge: the health and/or safety of individuals in the facility would be endangered due to the clinical or behavioral status of the resident; the resident's health improves sufficiently to allow a more immediate transfer or discharge; an immediate transfer or discharge is required by the resident's urgent medical needs; or a resident has not resided in the facility for 30 days; - Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements). 1. Review of Resident #18's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 04/21/24; - The resident transferred to the hospital on [DATE] and returned to the facility 07/09/24; - The resident transferred to the hospital on [DATE] and returned to the facility 08/13/24; - The resident transferred to the hospital on [DATE] and returned to the facility 09/24/24; - The resident transferred to the hospital on [DATE] and returned to the facility 10/16/24; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 2. Review of Resident #25's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfers. 3. Review of Resident #28's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 05/02/24; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 4. Review of Resident #34's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 04/23/24; - The resident transferred to the hospital on [DATE] and returned to the facility 06/18/24; - The resident transferred to the hospital on [DATE] and returned to the facility 10/25/24; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 5. Review of Resident #44's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 6. Review of Resident #49's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 7. Review of Resident #53's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 05/27/24; - The resident transferred to the hospital on [DATE] and returned to the facility 08/05/24; - The resident transferred to the hospital on [DATE] and returned to the facility 12/31/24; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 8. Review of Resident #81's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 12/07/24; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 9. Review of Resident #111's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 10. Review of Resident #126's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfers. 11. Review of Resident #131's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. 12. Review of Resident #139's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the transfer/discharge to a hospital at the time of transfer. During an interview on 02/13/25 at 1:42 P.M., the Social Services Designee said the floor nurses send out the transfer forms upon discharge. During an interview on 02/13/25 at 1:50 P.M., Registered Nurse (RN) C said the nurse that sends a resident out is responsible for sending the face sheet, medication list, code status, Durable Power of Attorney (DPOA-legal document that allows someone to make decisions for another person), bed hold policy, and Situation/Background/Assessment/Recommendation (SBAR-a structured way to send information between people). The patient transfer form is copied and one goes to the hospital with the resident, the other goes with the ambulance personnel. During an interview on 02/13/25 at 2:18 P.M., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) said they would expect residents and/or resident's representatives to be notified of transfers in writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident and/or the resident's representative of the facility's bed hold policy at the time of transfer to the hospital for four residents (Resident #18, #34, #44, and #53) out of 28 sampled residents. The facility's census was 139. Review of the facility's policy titled, Bed Holds and Returns, revised October 2022, showed: - Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies; - All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: well in advance of any transfer (e.g., in the admission packet); and at the time of transfer (or, if the transfer was an emergency, within 24 hours). 1. Review of Resident #18's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 07/09/24; - The resident transferred to the hospital on [DATE] and returned to the facility 08/13/24; - The resident transferred to the hospital on [DATE] and returned to the facility 09/24/24; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 2. Review of Resident #34's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 04/23/24; - The resident transferred to the hospital on [DATE] and returned to the facility 10/25/24; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 3. Review of Resident #44's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. 4. Review of Resident #53's medical record showed: - admitted on [DATE]; - The resident transferred to the hospital on [DATE] and returned to the facility 08/05/24; - The resident transferred to the hospital on [DATE] and returned to the facility 12/31/24; - No documentation that the resident or the resident's representative was informed in writing of the facility's bed hold policy at the time of transfer. During an interview on 02/13/25 at 1:42 P.M., the Social Services Designee said the floor nurses send out the bed hold policies upon resident discharge, and then the bed holds are scanned into the system. During an interview on 02/13/25 at 1:50 P.M., Registered Nurse (RN) C said the nurse that sends a resident out is responsible for sending the face sheet, medication list, code status, Durable Power of Attorney (DPOA-legal document that allows someone to make decisions for another person), bed hold policy, and Situation/Background/Assessment/Recommendation (SBAR-a structured way to send information between people). During an interview on 02/13/25 at 2:18 P.M., the Administrator, Director of Nursing and Assistant Director of Nursing collectively said they would expect residents and/or resident's representatives to be made aware of bed holds in writing.

Based on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) for two residents (Resident #41 and #131) out of 28 sampled residents and two residents (Resident #40 and #138) outside the sample. The facility's census was 139. The facility did not provide a policy regarding MDS accuracy. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) version 3.0 Manual showed: - Section J1400 should be coded yes if the resident is receiving hospice services; - Section N0300 should state the number of days during the 7-day look-back period that any type of injection was received; - Section N0350A should state the number of days during the 7-day look-back period that insulin injections were received. 1. Review of Resident #40's medical record showed: - An admission date of 05/01/24; - Diagnoses of type 2 diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin, leading to high blood sugar levels), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), morbid obesity (a severe form of obesity characterized by an excessive amount of body fat that significantly impacts health and well-being), and hypertension (a condition where the blood pressure in the arteries is consistently elevated above normal levels); - An order for Humalog Injection Solution (an insulin used to lower blood sugar) 100 units per milliliter (ml), inject eight units subcutaneously (beneath the skin) one time only, dated for 12/31/24 and completed on 12/31/24; - An order for Ozempic Subcutaneous Solution (anti-diabetic medication used for the treatment of type 2 diabetes) two milligrams (mg) per three ml, inject 0.25 mg subcutaneously every Friday, dated 01/10/25, discontinued 01/16/25; - Medication Administration Record (MAR), dated January 2025, showed the resident received an injection of Ozempic on 01/10/25 and did not receive insulin in the seven day look back period; - A quarterly MDS assessment, dated 01/14/25, with Section N0350A coded as receiving one injection of insulin in the seven day look back period. 2. Review of Resident #41's medical record showed: - An admission date of 09/12/24; - Diagnoses of obstructive sleep apnea (a sleep disorder that occurs when your upper airway becomes blocked during sleep), shortness of breath, respiratory failure (a condition making it difficult to breathe on your own), chronic kidney disease (kidneys do not filter waste and fluid like they should), heart failure (the heart does not pump blood as well as it should), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), and COPD; - An order for Ozempic Subcutaneous Solution Pen-injector two mg per three ml. Inject 0.5 mg subcutaneously one time a day every Thursday, dated 10/09/24; - MAR, dated December 2024, showed the resident received an injection of Ozempic on 12/12/24 and did not receive insulin in the seven day look back period; - A significant change MDS assessment, dated 12/13/24, showed Section N0350A coded as receiving one injection of insulin in the seven day look back period. 3. Review of Resident #131's medical record showed: - An admission date of 10/08/24; - Diagnoses of dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and altered mental status; - An order for Haloperidol Lactate Injection Solution (antipsychotic medication) five milligrams (mg) per milliliter (ml), inject 10 mg intramuscularly every eight hours as needed for agitation and aggression for 14 days. Alternate with Ativan (anxiety medication) two mg intramuscularly every eight hours as needed, dated 10/09/24 and discontinued 10/23/24; - MAR, dated October 2024, with Haldol 10 mg intramuscularly administered on 10/15/24 and 10/17/24; - An admission MDS assessment, dated 10/18/24, showed Section N0300 marked zero for injections received in the seven day look-back period. 4. Review of Resident #138's medical record showed: - An admission date of 02/26/23; - Diagnoses of COPD, dementia, and muscle weakness; - admitted to hospice on 12/20/24; - A significant change MDS assessment, dated 12/23/24, with Section J1400 Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? marked no. During an interview on 02/20/25 at 8:17 A.M., the MDS Coordinator said he/she would expect the MDS to accurately reflect the residents' condition at the time of the assessment. During an interview on 02/13/2025 at 2:18 P.M., the Administrator, DON, and ADON said they would expect the MDS assessments to accurately reflect the current condition of the resident.

Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for four residents (Resident #31, #41, #55 and #111) out of 28 sampled residents. The facility's census was 139. Review of the facility's Comprehensive Person-Centered Care Plan Policy, last revised March 2022, showed: - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a a comprehensive, person-centered care plan for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The comprehensive, person-centered care plan includes measurable objectives and time frames, describes the services that are to be furnished to attain or maintain the resident's highest practical physical, mental and psychosocial well-being; - When possible, interventions address the underlying sources of the problems, not just symptoms or triggers; - Assessment of residents are on-going and care plans are revised as information about residents and residents' conditions change; - The IDT reviews and updates the care plans when there has been a significant change, when desired outcome has not been met, when resident has been readmitted from a hospital stay and at least quarterly. 1. Review of Resident #31's medical record showed: - admission date of 07/17/24; - Diagnoses of paraplegia (inability to voluntarily move lower parts of the body), rheumatoid arthritis (a chronic inflammation affecting small joints in hands and feet), morbid obesity, muscle weakness and lack of coordination; - Bed assessment and consent, dated 01/18/24; - Side rail assessment, dated 07/18/24; - Physician's Order Sheet (POS), dated February 2025, with an order for one quarter (1/4) upper side rails, bilaterally, for mobility. Observations of Resident #31 showed: - On 02/10/25 at 1:00 P.M., Resident #31 resting in bed with quarter rails up on both sides; - On 02/11/25 at 12:21 P.M., Resident #31 resting in bed with quarter rails up on both sides; - On 02/13/25 at 9:30 A.M., Resident #31 resting in bed with quarter rails up on both sides. During an interview on 02/11/25 at 12:21 P.M., Resident #31 said he/she uses the side rails to grab onto during care and mobility. Review of Resident #31's care plan, last revised 01/08/25, did not address side rails. 2. Review of Resident #41's medical record showed: - admission date of 09/12/24; - Diagnoses of obstructive sleep apnea (a sleep disorder that occurs when the upper airway becomes blocked during sleep), shortness of breath, respiratory failure (a condition making it difficult to breathe on your own), chronic kidney disease (kidneys do not filter waste and fluid like they should), heart failure (the heart does not pump blood as well as it should), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that causes restricted airflow and breathing problems); - An order for BIPAP at bedtime, dated 10/02/24. Review of the resident's significant change MDS assessment, dated 12/13/24, showed: - Oxygen therapy in Section O (O0100C) coded as being in use in the seven-day look back period; - Non invasive mechanical ventilator (BIPAP) in Section O (O0100C) coded as being in use in the seven-day look back period. Observations of the resident showed: - On 02/10/25 at 12:46 P.M., the resident sat in a recliner with oxygen via nasal cannula (NC - a flexible tube inserted into the nose to administer supplemental oxygen) at 3.5 liters per minute (LPM), and a BIPAP at bedside; - On 02/11/25 at 9:28 A.M., the resident lay in bed with oxygen via NC at 3.5 LPM; - On 02/12/25 at 12:36 P.M., the resident lay in bed with oxygen via NC at 3.5 LPM. During an interview on 02/10/25 at 12:47 P.M., the resident said he/she always uses oxygen and has for quite some time and wears a BIPAP at bedtime. Review of the resident's care plan, last revised 02/10/25, showed it did not address use of BIPAP or oxygen. 3. Review of Resident #55's medical record showed: - admission date of 07/29/24; - Diagnoses of shortness of breath, COPD, and atrial fibrillation (abnormal heart beat); - An order for oxygen at two liters per minute via nasal cannula as needed, dated 07/29/24. Review of the resident's quarterly MDS assessment, dated 02/05/25, showed Section O (O0100C) coded as oxygen therapy being used in the seven-day look back period. Observations of the resident showed: - On 02/11/25 at 08:24 A.M., the resident sat in a recliner with oxygen via NC at 2LPM; - On 02/12/25 at 12:37 P.M., the resident sat in a recliner with oxygen via NC at 2LPM. During an interview on 02/12/25 at 12:38 P.M., the resident said he/she wears oxygen all the time. Review of the resident's care plan, last revised 02/07/25, did not address the use of oxygen. 4. Review of Resident #111's medical record showed: - admission date of 04/19/24; - Diagnoses of COPD, Type II diabetes, heart failure, urinary tract infection (UTI), over active bladder and mixed incontinence; - Nurses note, dated 02/07/25, showed that Resident #111 had a bladder mesh placement years ago (per family member) and it was later found to be damaging, causing frequent UTIs. Review of the resident's POS, dated February 2025, showed: - An order on 02/06/25, for Azo tablets (phenazopyridine-medication that soothes urinary tract infection pain), one tablet by mouth, daily for chronic UTI; - An order on 02/11/25, for macrobid (antibiotic), 100 milligrams (mg), one capsule, by mouth twice daily for 5 days for UTI. During an interview on 02/10/25 at 1:00 P.M., Resident #111 said he/she had a UTI and was taking antibiotics. He/She hoped to feel better soon. Review of the resident's care plan, last revised 02/10/25, showed it did not address chronic UTIs. During an interview on 02/13/25 at 2:18 P.M., the Administrator, Director of Nursing and Assistant Director of Nursing, collectively said they would expect care plans to be updated and to include the current condition of residents.

Based on interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs for five residents (Resident #1, #6, #18, #34, and #126) out of 28 sampled residents. The facility's census was 139. Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revised March 2022, showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The interdisciplinary team reviews and updates the care plan: when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) (a federally mandated assessment instrument completed by the facility staff) assessment. 1. Review of Resident #1's medical record showed: - admission date of 05/26/22; - Diagnoses of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), vitamin B-12 deficiency anemia (a condition where the body lacks enough healthy red blood cells due to a deficiency of vitamin B12), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), gastroesophageal reflux disease (GERD-a digestive disease in which stomach acid of bile irritates the food pipe lining), and shortness of breath; - Physician's Order Sheet (POS), last order review date of 01/14/25, showed no medication orders. - Review of Resident #1's care plan, initiated 06/15/22, next review date 02/26/25, showed: - GERD - give medications as ordered; - Antidepressant - administer antidepressant as ordered; - Anemia - give medication as ordered; - Risk for infection - administer antibiotic therapy as prescribed; - Urinary tract infection (UTI-an infection of any part of the urinary tract, the system of organs that make urine) - administer antibiotic therapy as prescribed; - Behavioral problems - administer medications as ordered, monitor/document for side effects and effectiveness; - Potentially physically and verbally aggressive - administer medications as ordered and monitor/document for side effects and effectiveness; - Cognitive impairment - administer medications as ordered and monitor/document for side effects and effectiveness. - Smoker, may smoke unsupervised; - Did not address the use of vapes. Observations of the resident showed: - On 02/12/25 at 2:15 P.M., a vape in the resident's room. - On 02/13/25 at 2:00 P.M., a vape on the resident's lap, while in his/her room. During an interview on 02/12/25 at 2:15 P.M., Resident #1 said he/she doesn't take any medications. 2. Review of Resident #6's medical record showed: - admission date of 01/04/22; - Code status of DNR (Do Not Resuscitate); - An order to admit resident to hospice with diagnosis of senile degeneration of the brain (a progressive decline in cognitive function that occurs with aging), dated 07/28/24; - Care plan, last revised on 01/21/25, showed the resident as a full code, dated 01/17/22. 3. Review of Resident #18's medical record showed: - An admission date of 10/04/22; - Resident is own responsible party; - No documentation resident was informed of upcoming care plan meetings. During an interview on 02/10/25 at 1:14 P.M., the resident said he/she is not informed about upcoming care plan meetings. The resident said he/she would like to attend the meetings. During an interview on 02/13/25 at 11:02 A.M., Registered Nurse (RN) S said he/she does not document when he/she talks to residents about their upcoming care plan meetings. RN S could not recall if he/she informed Resident #18 about upcoming care plan meetings. 4. Review of Resident #34's medical record showed: - An admission date of 10/21/22; - Diagnosis of displaced fracture (occurs when the broken bone pieces move out of alignment, creating a gap or overlap between them) of right humerus (upper arm bone), epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures), dementia (a group of diseases and illnesses that affect your thinking, memory, reasoning, personality, mood and behavior), generalized anxiety disorder (constant worry that cannot be controlled), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs); - Twelve unwitnessed falls dated 08/29/24, 09/17/24, 10/09/24, 12/22/24, 01/09/25, 01/16/25, 01/21/25, 01/28/25, 01/30/25, 01/31/25, 02/03/25, and 02/04/25. Review of the resident's significant change MDS assessment, dated 02/05/25, showed: - Severe cognitive impairment; - Two or more falls with injury (except major); - One fall with major injury. Review of the resident's care plan, last reviewed on 02/10/25, showed: - Resident is at risk for falls; - Interventions for fall risk last updated on 08/01/23. The facility failed to put interventions in place after twelve falls. 5. Review of Resident #126's medical record showed: - admission date of 10/02/24; - Diagnoses of bipolar disorder, schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), need for assistance for personal care, cognitive communication deficit (a communication difficulty due to an impairment in the cognitive processes), paraplegia (chronic condition that causes partial or complete paralysis of the lower body, including the legs and sometimes the abdomen), cannabis abuse (marijuana addition), alcohol dependence, stimulant abuse, psychoactive substance abuse (a patterned use of a drug in which the user consumes the substance in amounts or methods which are harmful to themselves or others), hallucinogen dependence (abuse of using psychoactive drugs that cause changes in mood, thought and perception); - An order for Apixaban (a blood thinner). Review of Resident #126's care plan, intitiated 10/02/24, next review date 04/14/25, showed: -Smoker, does use tobacco at times and vapes, unsupervised smoker. The care plan did not address smoking marijuana; -The care plan failed to address bleeding precautions, side effects, interactions and what to avoid while taking an anticoagulant. During an interview on 02/13/25 at 2:18 P.M., the Administrator, Director of Nursing, and Assistant Director of Nursing said they would expect care plans to be updated to reflect the current condition of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide consistent resident care for activities of daily living (ADLs) when the residents went an extended amount of time without showers for two residents (Resident #24 and #55) out of three sampled residents. The facility's census was 139. The facility did not provide a facility regarding shower frequency. 1. Review of Resident #24's medical record showed: - An admission date of 11/29/23; - Diagnoses of arthritis (swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age), spinal stenosis (spaces inside the bones of the spine get too small), chronic obstructive pulmonary disease (COPD, disease that makes breathing difficult), diabetes mellitus (chronic condition that affects the way the body processes blood sugar), heart failure (the heart does not pump blood as well as it should), morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems), and severe chronic kidney disease (kidneys slowly get damaged and can't do important jobs like removing waste and keeping blood pressure normal). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by the facility), dated 11/27/24, showed: - Cognitive status intact; - Partial or moderate assistance for dressing; - Partial or moderate assistance for toileting; - Supervision or touching assistance for personal hygiene; - Partial or moderate assistance for bathing. Review of the resident's care plan, dated 02/04/25, showed: - The resident with an ADL self-care performance deficit due to morbid obesity, arthritis, spinal stenosis and dialysis that makes him/her weaker than normal; - Needs assist of one staff for toileting, transfers, and hygiene. Observation on 02/11/25 at 2:50 P.M. showed the resident lay in bed with unkempt, one quarter inch facial hair on chin. During an interview on 02/11/25 at 2:51 P.M., the resident said he/she may get a shower once every two weeks. He/She would like to have one at least twice per week, feels dirty not having a shower, and doesn't like to be seen with facial hair. Review of the shower schedule, last updated 02/05/25, showed the resident's showers were scheduled for Thursdays and Sundays on day shift. Review of the resident's shower sheets dated, December 2024 through January 2025, showed: - In December 2024, three showers documented as given or refused out of nine opportunities, a total of six opportunities for showers missed; - In January 2025, five showers documented as given or refused out of nine opportunities, a total of six opportunities for showers missed. 2. Review of Resident #55's medical record showed: - admission date 07/29/24; - Diagnoses of Parkinson's disease (a progressive neurological disorder that affects movement, balance, and coordination), pain in thoracic spine, shortness of breath, fatigue, need for assistance with personal care, muscle weakness, COPD, and heart failure. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitive status intact; - Partial or moderate assistance for dressing; - Partial or moderate assistance for toileting; - Supervision or touching assistance for personal hygiene; - Partial or moderate assistance for bathing. Review of the resident's care plan, revised 07/29/20, showed: - The resident with limited physical mobility related to disease process and pain; - Needs assist of one staff for toileting and dressing. During an interview on 02/11/25 at 08:23 A.M., the resident said it has been two weeks since he/she has had a shower, and often only gets one a month, and is nervous he/she has an odor. Review of the shower schedule, last updated 02/05/25, showed the resident's showers were scheduled for Tuesdays and Fridays on day shift. Review of the resident's shower sheets, dated December 2024 through January 2025, showed: - In December 2024, two showers documented out of nine opportunities, a total of seven opportunities for showers missed; - In January 2025, one shower documented out of nine opportunities, a total of eight opportunities for showers missed. During an interview on 02/13/25 at 9:47 A.M., Certified Nursing Assistant (CNA) Q said there is a shower schedule. There are shower aides and showers are assigned for the hall aide. Some residents have scheduled appointments that they work around, and shower sheets are filled out and marked refused if the resident refuses. During an interview on 02/13/25 at 10:08 A.M., Registered Nurse (RN) C said residents should receive two showers per week, and they are given based on the shower schedule. During an interview on 02/13/25 at 10:10 A.M., the Assistant Director of Nursing (ADON) said residents should receive two showers per week unless they refuse, and the staff have to complete 33 showers per day in order to get them all completed. During an interview on 02/13/25 at 2:18 P.M., the Director on Nursing (DON) and the Administrator said residents should receive two showers per week.

Based on observation, interview, and record review, the facility failed to obtain an order for oxygen administration and failed to ensure a physician's order for bilevel positive airway pressure (BIPAP - a noninvasive ventilation device that helps people breathe by delivering pressurized air into the airways) included settings. This affected one resident (Resident #41) out of two sampled residents. The facility's census was 139. Review of the facility's policy titled, CPAP (continuous positive airway pressure)/BIPAP Support, revised March 2015, showed in preparation for BIPAP, review the physician's order to determine the oxygen concentration and flow, and the PEEP (positive end-expiratory pressure, settings) pressure for the machine. Review of Resident #41's medical record showed: - admission date of 09/12/24; - Diagnoses of obstructive sleep apnea (a sleep disorder that occurs when the upper airway becomes blocked during sleep), shortness of breath, respiratory failure (a condition making it difficult to breathe on your own), chronic kidney disease (kidneys do not filter waste and fluid like they should), heart failure (the heart does not pump blood as well as it should), and chronic obstructive pulmonary disease (COPD - a group of lung diseases that causes restricted airflow and breathing problems). Review of the resident's Physician's Order Sheet (POS), dated February 2025, showed: - An order for BIPAP at bedtime, dated 10/02/24; - No order for BIPAP settings; - No order for oxygen. Observations of the resident showed: - On 02/10/25 at 12:46 P.M., the resident sat in the recliner with oxygen via nasal cannula (NC - a flexible tube inserted into the nose to administer supplemental oxygen) at 3.5 liters per minute (LPM), and a BIPAP at bedside; - On 02/11/25 at 9:28 A.M., the resident lay in the bed with oxygen via NC at 3.5 LPM; - On 02/12/25 at 12:36 P.M., the resident lay in the bed with oxygen via NC at 3.5 LPM. During an interview on 02/10/25 at 12:47 P.M., the resident said he/she always uses oxygen and has for quite some time, wears a BIPAP at bedtime, and the nurses put it on at night. During an interview on 02/13/25 at 10:03 A.M., Licensed Practical Nurse (LPN) D said residents with BIPAPs have an order for the settings and residents that wear oxygen have an order for oxygen. During an interview on 02/13/25 at 10:08 A.M., Registered Nurse (RN) C said residents should have an order for oxygen if they are using it, and he/she would look at the order for BIPAP settings prior to applying the BIPAP to the resident. During an interview on 02/13/25 at 10:25 A.M., the Assistant Director of Nursing (ADON) said they use a company to set up a BIPAP machine when it's ordered. During an interview on 02/13/25 at 2:18 P.M., the Director of Nursing (DON) and the Administrator said they expect residents that wear oxygen to have a physician's order for oxygen and BIPAP orders should include settings for the BIPAP.

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) during medication administration. There were 35 opportunities with three errors made, for an error rate of 8.57%, which affected three residents (Residents #32, #102 and #133) out of seven sampled residents. The facility's census was 139. Review of the facility's policy titled, Insulin Administration, revised September 2014, showed: - The type of insulin, dosage requirements, strength, and method of administration must be verified before administration; - The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery systems prior to their use. Review of the NovoLog (a rapid acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) Flex Pen (insulin in a pen-type device) instructions, revised February 2015, showed: - Before each injection small amounts of air may collect in the cartridge during normal use, to avoid injecting air and to ensure proper dosing; - Remove cap; - Attach needle; - Prime pen by turning dose selector to select two units; - Press and hold button and make sure drop of insulin appears; - Select dose; - Give injection. Review of the Insulin Lispro (a rapid acting insulin injected just below the skin that helps lower mealtime blood sugar spikes) KwikPen (insulin in a pen-type device manufacturer instructions for use, revised July 2023, showed: - Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly; - Not priming before each injection may result in too much or too little insulin; - Turn the dose knob to select two units; - Hold the pen with the needle pointing up, tap the cartridge holder gently to collect air bubbles at the top; - With the needle pointing up, push the dose knob until it stops and zero is seen in the dose window, hold and count to five slowly; - There should be insulin at the tip of the needle, if not, repeat no more than four times. 1. Review of Resident #32's Physician's Order Sheet (POS), dated February 2025, showed an order for Novolog per sliding scale (progressive increase in the pre-meal or nighttime insulin dose based on pre-defined blood glucose ranges) for a blood sugar 200-250, give three units dated 09/15/24. Observation of the resident on 02/12/25 at 11:56 A.M. showed: - Certified Medication Technician (CMT) A administered Novolog three units subcutaneously (an injection just beneath the skin) to the resident per sliding scale for a blood sugar of 204; - CMT A failed to prime the Novolog pen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 2. Review of Resident #102's POS, dated February 2025, showed an order for Insulin Lispro, inject per sliding scale, for a blood sugar 221-260, give six units, dated 01/28/25. Observation of the resident on 02/12/25 at 11:51 A.M. showed: - CMT B administered Insulin Lispro six units subcutaneously to the resident per sliding scale for a blood sugar of 236; - CMT B failed to prime the Insulin Lispro pen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. 3. Review of Resident #133's POS, dated February 2025, showed an order for Insulin Lispro, inject three units subcutaneously with meals, dated 12/19/24. Observation of the resident on 02/12/25 at 12:02 P.M. showed: - CMT A administered Insulin Lispro three units subcutaneously to the resident; - CMT A failed to prime the Insulin Lispro pen prior to the administration of the insulin to the resident per the manufacturer's instructions for use. During an interview on 02/12/25 at 12:05 P.M., CMT A said he/she was taught to prime the pen when it was used for the first time. During an interview on 02/12/25 at 12:08 P.M., CMT B said he/she thought the insulin pen should be primed when it was first opened. During an interview on 02/12/25 at 12:15 P.M., the Assistant Director of Nursing (ADON) said she expects staff to follow insulin pen manufacturer's guidelines for insulin administration. During an interview on 02/13/25 at 2:18 P.M., the Director of Nursing (DON) and the Administrator said they expect to have a medication error rate of less than five percent.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices and implement Enhanced Barrier Protections (EBP) during foley catheter (a thin, flexible tube inserted into the bladder to drain urine) care for one resident (Resident #31) out of 28 sampled residents. The facility's census was 139. Review of the facility's Handwashing/Hand Hygiene Policy, dated 2001, showed: - All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections; - All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors; - Hand hygiene products and supplies are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies; - Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with blood, body fluids or contaminated surfaces, after touching a resident or resident's environment, before moving from work on a soiled body site to a clean body site on same resident and immediately after glove removal; - Wash hands with soap and water when hands are visibly soiled and after contact with a resident with infectious diarrhea; - The use of gloves does not replace hand hygiene/hand washing. Review of the facility's EBP policy, revised August 2022, showed: - Enhanced Barrier Precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MRDOs) to residents; - EBPs employ targeted gown and glove use during high contact resident care activity when contact precautions do not otherwise apply; - Gloves and gowns applied prior to performing high contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting to bathroom, during device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care; - EBPs are indicated for residents with wounds and/or indwelling medical devices; - EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. 1. Observation of Resident #31's foley catheter care/peri care on 02/13/25 at 9:30 A.M., showed: - Resident's door with EBP signage and supplies accessible and hung on inside of door; - Certified Nursing Aide (CNA) E, entered the resident's room, donned gloves without washing or sanitizing hands, and did not don gown; - CNA E removed blanket from resident and removed gloves; - CNA E obtained wet washcloths, gloved, and provided catheter care, cleaning catheter tubing from peri area and down several inches; - CNA E folded washcloth and cleaned the resident's front peri area down the left side, folded washcloth and cleaned down the right side of the peri area; - CNA E obtained a clean washcloth and wiped under abdominal folds, removed gloves and did not sanitize or wash hands; - CNA E donned clean gloves without washing or sanitizing hands, obtained a clean washcloth and cleaned the catheter tubing again; - CNA E removed gloves, gathered trash, did not wash or sanitize hands and left the room with the bag of trash. During an interview on 02/13/25 at 9:45 A.M., CNA E said he/she had only worked at the facility for three weeks and did not know where the gowns were located. Hands should be washed in between dirty and clean and before leaving the room. He/She would have normally washed hands before leaving the room and sanitized again in the hall. During an interview on 02/13/25 at 2:18 P.M., the Administrator, Director of Nursing and Assistant Director of Nursing said they would expect staff to wear proper PPE for EBP when indicated, and for staff to perform hand hygiene between dirty and clean and prior to leaving resident rooms.

Based on observation, interview, and record review, the facility failed to maintain infection control practices during perineal care for one resident (Resident #1) out of one sampled resident. The facility's census was 137. Review of the facility's Perineal Care Policy, dated February 2018, showed: - Purpose of procedure is to provide cleanliness and comfort to the resident, to prevent infections, skin irritation and to observe the skin condition; - Place equipment on bedside stand and arrange to be easily reached; - Wash hands thoroughly, dry and put on gloves; - Wet washcloth and apply skin cleanser; - Wash perineal area from front to back; - Turn resident to side and wash rectal area thoroughly, wiping from the base of labia towards and extending over the buttocks; - Rinse and dry thoroughly; - Discard disposable items, remove gloves and wash hands; - Reposition bed covers and make resident comfortable; - Wash and dry hands thoroughly. Review of the facility's Enhanced Barrier Precaution Policy, dated August 2022, showed: - Enhanced Barrier Precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MRDOs) to residents; - EBPs employ targeted gown and glove use during high contact resident care activity when contact precautions do not otherwise apply; - Gloves and gowns applied prior to performing high contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting to bathroom, during device care or use (central line, urinary catheter, feeding tube, tracheostomy), and wound care; - EBPs are indicated for residents with wounds and/or indwelling medical devices; - EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Review of Resident #1's medical record showed: - On 11/21/24, an order to leave Peripherally Inserted Central Catheter (PICC-a long , thin and flexible tube that is inserted into a vein in the upper arm, threaded into a large vein near the heart and used to deliver fluids, blood and medications intravenously) in place for two weeks; - On 11/21/24, an order to change PICC line dressing every seven days. Observation on 11/26/24 at 6:27 P.M. of perineal (peri) care for Resident #1 showed: - EBP signage on front of door alerted staff to wear appropriate protective gear (gown, gloves, masks, eye goggles); - EBP supplies were hung on inside of door; - Certified Nursing Aide (CNA) A went to the resident's bedside and CNA B gathered supplies and washed hands; - CNA A donned gloves without washing hands; - CNA A and CNA B performed perineal (peri) care for Resident #1, rolled the resident on his/her side and placed a brief under the resident's buttocks without cleaning the area first; - CNA A removed gloves, did not wash hands and pulled sheet up and over the resident; - CNA B removed gloves, took supplies to bathroom and washed hands before leaving the room. During an interview on 11/26/24 at 6:35 P.M., CNA A said EBP is used on residents with ostomies (a surgical opening to create an opening from an are inside the body to the outside) and tracheostomies, (an opening surgically created through the neck, into the windpipe or trachea, to allow air to fill the lungs) but just wear gloves for peri care. Even though Resident #1 had a Peripherally Inserted Central Catheter (PICC-a long , thin and flexible tube that is inserted into a vein in the upper arm, threaded into a large vein near the heart and used to deliver fluids, blood and medications intravenously), it was up high on his/her arm so gloves were fine for peri care. He/She said he/she should have washed hands prior to leaving the room. During an interview on 11/26/24 at 6:36 P.M., CNA B said it had been explained to wear EBP when a resident had a Foley catheter (a tube inserted into the bladder to drain urine from the body) or ostomy, but should have wore it since the resident had a PICC line. During an interview on 11/26/24 at 6:40 P.M., Licensed Practical Nurse (LPN) C said EBP should be worn for residents with a gastrostomy tube (G tube- tube inserted through the skin and directly into the stomach, used to provide nutrition, fluids and medications), Foley catheters, tracheostomy or PICC line. He/She said staff should wear a gown, gloves and mask when performing any care to those residents. During an interview on 11/26/23 at 6:45 P.M., Resident #1 said staff had not been wearing a gown during care. Mask and gloves were worn during PICC line care and gloves for peri care. During an interview on 11/26/24 at 7:28 P.M., the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) said they would expect peri care to be done according to the policy and EBP to be used when providing care for a resident with a PICC line or any other device. Staff should have washed hands prior to leaving the room and between dirty and clean. MO00245248

Based on interview and record review, facility staff failed to report an allegation of resident-to-resident abuse to the state licensing agency officials as required for two residents (Resident #1 and #2) out of four sampled residents. Resident #2 pushed Resident #1 which caused him/her to fall and sustain a head injury that required two staples to the left forehead and a skin tear to his/her left elbow. The facility census was 141. Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, last updated 09/22, showed: - Verbal or written notification of an incident or suspicion of abuse or neglect to the immediate supervisor, charge nurse, the Director of Nurses (DON), the Social Service Designee (SSD) or the Administrator; - Verbal or written notification of an incident or suspicion of abuse or neglect to the facility's Ombudsman; - Call Missouri Department of Health and Senior Services Hotline; - If you knowingly do not report instances of abuse, you may be subject to disciplinary and legal action. Review of Resident #1's medical record showed: - Date of admission of 10/01/22; - Diagnoses of alcohol dependence with withdrawal, Wernicke's encephalopathy (brain and memory disorder due to a severe lack of vitamin B1), and alcoholic cirrhosis (irreversible liver damage); - Severely impaired cognition; - Sustained a head injury that required two staples to the resident's left forehead and a skin tear to the left elbow from an unwitnessed fall on 08/16/24, when Resident #2 pushed Resident #1. Review of the resident's Progress Note, dated 08/16/24, showed the resident sat on the floor in the hallway outside of Resident #2's room. Resident #2 said Resident #1 was in his/her room and stole his/her french fries off the tray. Resident #2 slightly pushed Resident #1 and he/she lost his/her balance and fell to the floor outside of Resident #2's room. An ambulance was called and Resident #1 was transferred to the hospital. Review of the facility's investigation, dated 08/16/24, showed: - No injuries for Resident #1 observed at the time of the incident; - Resident #2 had injuries to the face and left elbow; - An un-witnessed fall; - No predisposing situation factors; - The resident stole food from the tray of another resident. During an interview on 08/20/24 at 11:00 A.M., the DON said she was told by the state licensing agency she did not have to report a resident to resident altercation unless the resident was harmed and that was why she/he did not report the incident. During interview on 08/20/24 at 5:00 P.M., the Administrator said she would expect an incident of a resident-to-resident altercation be reported to the state licensing agency. Complaint #MO240165

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 141. Review of the facility's policy titled, Homelike Environment, revised February 2021, showed: - Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible; - Clean, sanitary and orderly environment; - Pleasant, neutral scents. Observation on 01/10/24 at 11:17 A.M., of the 200 Hall shower room showed broken tiles with rough edges surrounding the floor drain threshold for the shower entrance. Observation on 01/11/24 at 11:55 A.M., of room [ROOM NUMBER]'s bathroom sink showed water dripping from the drain into a plastic wash basin sitting on the floor. The wash basin contained dark colored liquid and more than ten dead gnats. Gnats flew around the bathroom and landed on the sink and wall. During an interview on 01/11/24 at 11:55 A.M., the resident in room [ROOM NUMBER] said the sink had been leaking for a long time and the gnats stayed in the bathroom. Observation on 01/11/24 at 12:25 P.M., of Hall Three of the Memory Care Unit shower room showed: - A strong, foul odor; - Black substance along the perimeter of the shower on the tiles; - Black substance in the back right ceiling corner; - Black substance in the right front corner of the room along the wall and ceiling; - Black substance on the linen cart covering. Observation on 01/11/24 at 12:30 P.M., of Hall Two of the Memory Care Unit shower room showed: - Dried fecal material on the floor in front of the commode; - Wall holder for a sharps container with rough edges; - Wall holder for toilet paper missing the front section with rough edges. Observation on 01/11/24 at 12:35 P.M., of 500 Hall showed a five foot section of cove base missing under the hand sanitizer dispenser to the left of the mechanical room. During an interview on 01/11/23 at 02:10 P.M., Certified Nursing Assistant (CNA) C said if anything was broken or required attention from maintenance, he/she would fill out a maintenance requisition. During an interview on 01/11/24 at 08:43 P.M., the Administrator said she was unaware of a sink issue in room [ROOM NUMBER]. She would expect the housekeeping supervisor to do environmental rounds, and would expect staff to turn in a requisition for all issues regarding maintenance when seen. During an interview on 01/11/24 at 10:00 P.M., the Administrator said she expected the facility to be in good condition, cove base to be replaced if missing, and broken tiles to be replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer to the hospital for three residents (Residents #23, #35 and #52) out of 28 sampled residents. The facility census was 141. The facility did not provide a policy regarding a facility-initiated transfer. 1. Review of Resident #23's medical record showed: - Resident transferred to the hospital for medical evaluation on 11/28/23, and readmitted to the facility on [DATE]; - No documentation of a letter notifying the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. 2. Review of Resident #35's medical record showed: - Resident transferred to the hospital for medical evaluation on 10/16/23, and readmitted to the facility on [DATE]; - No documentation of a letter notifying the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. 3. Review of Resident #52's medical record showed: - Resident transferred to the hospital for medical evaluation on 09/08/23 and readmitted to the facility on [DATE]; - No documentation of a letter notifying the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. During an interview on 01/11/2024 at 11:15 A.M., the Administrator said the facility-initiated transfer to the hospital information was not provided to the resident and/or the resident representative in writing. During an interview on 01/17/24 at 02:24 P.M., the Social Services Designee I said if the resident was not their own responsible party, the transfer form was mailed but no log or confirmation of this being done could be provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident and/or resident representative of the bed hold policy at the time of transfer to the hospital for three residents (Resident #23, #35 and #52) out of 28 sampled residents. The facility's census was 141. Review of the facility's policy titled, Bed Hold Policy, undated, showed: - Purpose is to notify all residents and/or resident's representative of the bed hold policy for the facility; - If the resident or representative wants to hold the bed, a signed authorization must be obtained with each discharge, these forms are located in the business office; - Upon discharge, the nursing supervisor will re-inform the resident and/or responsible party of the bed hold policy. The designee will follow up the next business day to assure resident and/or responsible party understands the requirements of the bed hold policy; - If the resident or representative does not choose to hold the bed, the bed will be released, and any personal belongings must be picked up within a reasonable period of time; - Bed holds are voluntary. 1. Review of Resident #23's medical record showed: - Resident transferred to the hospital for medical evaluation on 11/28/23, and readmitted to the facility on [DATE]; - No documentation of a form with written notification of the bed hold policy was received by the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. 2. Review of Resident #35's medical record showed: - Resident transferred to the hospital for medical evaluation on 10/16/23, and readmitted to the facility on [DATE]; - No documentation of a form with written notification of the bed hold policy was received by the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. 3. Review of Resident #52's medical record showed: - Resident transferred to the hospital for medical evaluation on 09/08/23, and readmitted to the facility on [DATE]; - No documentation of a form with written notification of the bed hold policy was received by the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE]. During an interview on 01/11/2024 at 11:15 A.M., the Administrator said the bed hold policy with the daily rate charge was not provided to the resident or resident representative at the time of discharge because it was provided upon admission to the facility. She had never sent the bed hold with the resident or to the resident representative at the time of discharge. During an interview on 01/17/24 at 02:24 P.M., the Social Services Designee I said the bed hold forms showing the daily rate were given upon admission and not during a transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document an accurate Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, for two residents (Resident #23 and #60) out of 28 sampled residents. The facility's census was 141. Review of the facility's policy titled, Electronic Transmission of the MDS, revised November 2019, showed the MDS coordinator is responsible for ensuring that appropriate edits are made prior to transmitting MDS data. 1. Review of Resident #23's medical record showed: - admission date of 03/24/23; - Diagnoses of chronic kidney disease, stage 4 (gradual loss of kidney function over time), type II diabetes mellitus (chronic condition that affects the way the body processes blood sugar), anxiety disorder (disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), hyperkalemia (elevated level of potassium in the blood), and essential hypertension (abnormally high blood pressure); - An order for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) off-site on Tuesday, Thursday, and Saturday, dated 11/30/23. Review of the resident's significant change MDS, dated [DATE], showed no documentation the resident received dialysis. 2. Review of Resident #60's medical record showed: - admission date of 09/05/23; - Diagnoses of anxiety disorder, insomnia (persistent problems falling and staying asleep), and type II diabetes mellitus; - An order for a modified diabetic diet, mechanical soft texture, regular consistency, dated 09/06/23; - No order for hypnotics (class of drugs whose primary function is to induce sleep and to treat insomnia). Review of the resident's annual MDS, dated [DATE], showed: - No documentation the resident received a modified therapeutic diet; - Received a hypnotic medication daily for seven days. During an interview on 01/11/24 at 6:00 P.M., the MDS Coordinator said he/she would expect all MDS assessments to be completed accurately and timely per the Resident Assessment Instrument (RAI) Manual. During an interview on 01/11/24 at 10:00 P.M., the Administrator said she would expect all MDS assessments to be completed accurately and timely per the RAI Manual. MDS assessments should reflect the current condition of the resident.

Based on observation, interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for three residents (Resident #25, #26, and #52) out of 28 sampled residents. The facility census was 141. Review of the facility's policy titled, Comprehensive Care Plan, revised December 2016, showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs will be developed and implemented for each resident. 1. Review of Resident #25's medical record showed: - An admission date of 08/25/23; - Diagnoses of dementia (progressive or persistent loss of intellectual functioning), pain in the left hip, history of falling, visual hallucinations (seeing something that is not there), atrial fibrillation (an abnormal heart beat), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities) disorder; - No documentation of an order for a side rail. Review of the resident's care plan, revised on 01/09/24, showed: - Resident was a fall risk; - Did not address side rail use. Observation of the resident on 01/10/24 at 11:13 A.M., showed the resident lay in bed with one-quarter side rail in the upright position on the right side of the bed. 2. Review of Resident #26's medical record showed: - admission date of 11/15/23; - Diagnoses include chronic non-pressure ulcer (non-healing wound not caused by pressure) of left and right lower leg, stage two pressure ulcer (shallow open injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left buttock, and unstageable (unable to see the wound bed) pressure ulcer of the sacrum (triangular bone at the base of the spinal column); - An order for quarter side rail times two for repositioning, dated 11/16/23. Review of the resident's care plan, revised on 01/09/24, did not address side rail use. Observations of the resident on 01/09/24 at 11:02 A.M., and 01/10/24 at 4:45 P.M., showed the resident lay in bed with a half rail in the upright position on the left side of the bed. 3. Review of Resident #52's medical record showed: - An admission date of 09/13/23; - Diagnoses included diabetes mellitus, major depressive disorder, pain, high blood pressure, panic disorder (an anxiety disorder characterized by unexpected and repeated episodes of fear); - No documentation of an order for the use of side rails. Review of the resident's care plan, revised on 01/09/24, showed: - Resident was a fall risk; - Did not address side rail use. Observation of the resident on 01/10/24 at 11:24 A.M., showed the resident sat on the bed with half side rails in the upright position on both sides of the bed. During an interview on 01/11/24 at 06:35 P.M., the MDS (Minimum Data Set - a mandatory assessment completed by the facility) Coordinator said she would expect side rails to be addressed on the care plan. During an interview on 01/11/24 at 10:00 P.M., the Administrator and MDS Coordinator said they would expect the care plans to have individualized interventions for each resident.

Based on interview and record review, the facility failed to follow physician's wound care orders for four residents (Resident #26, #58, #95, and #116) out four sampled residents with wounds. The facility census was 141. The facility did not provide a policy regarding following physician orders. 1. Review of Resident #26's medical record showed: - admission date of 11/15/23; - Diagnoses of chronic non-pressure ulcer (non-healing wound not caused by pressure) of left and right lower leg, stage two pressure ulcer (shallow open injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left buttock, and unstageable (unable to see the wound bed) pressure ulcer of the sacrum (triangular bone at the base of the spinal column). Review of the resident's wound care documentation showed: - An order to cleanse the right medial (middle) foot and ankle, right lateral (on the side) lower extremity with normal saline (salt and water solution that can be used for cleansing wounds) or dermal wound cleanser (first-aid antiseptic that helps reduce the risk of infection), apply calcium alginate (a wound dressing) then ABD pad (gauze pad to absorb discharges from heavily draining wounds) and kerlix (white gauze dressing) daily and as needed, dated 09/22/23 and discontinued on 09/29/23; - Treatment Administration Record (TAR), dated September 2023, documented no treatments completed on 09/23/23 and 09/28/23 with two missed out of eight opportunities; - An order to cleanse the right and left buttocks with normal saline or dermal wound cleanser, apply calcium alginate to the wound bed and cover with silicone bordered super absorbent dressing (highly absorbent dressings for wounds with light to heavy drainage) every day shift, dated 10/06/23 and discontinued on 11/10/23; - TAR, dated October 2023 and November 2023, with no treatments completed on 10/24/23, 10/27/23, 10/29/23, 10/31/23, 11/01/23, 11/04/23, and 11/08/23, with seven missed out of 36 opportunities; - An order to cleanse the right medial foot and ankle, right lateral lower extremity, and left posterior (back side) lower extremity with normal saline or dermal wound cleanser, skin prep (treatment that forms a barrier on the skin) to the scabbed areas, apply xeroform (a gauze dressing containing petroleum jelly) to the open areas, and wrap with kerlix and secure with tape daily and as needed, dated 10/20/23 and discontinued on 11/09/23; - TAR, dated October 2023 and November 2023, with no treatments completed on 10/24/23, 10/27/23, 10/29/23, 10/31/23, 11/01/23, 11/04/23, 11/08/23, and 11/09/23 with eight missed out of 21 opportunities; - An order to cleanse the bilateral (both) lower extremities with normal saline or dermal wound cleanser, apply gentian violet (antiseptic dye used to treat fungal infections of the skin), then cover with ABD, wrap with kerlix and secure with tape every other day and as needed, dated 11/17/23 and discontinued on 12/28/23; - TAR, dated November 2023 and December 2023, with no treatments completed on 11/19/23, 11/23/23, 12/03/23, 12/23/23, 12/25/23, and 12/27/23 with six missed out of 21 opportunities; - An order to cleanse the right third toe with normal saline or dermal wound cleanser, apply calcium alginate to the wound bed, cover with gauze (thin medical fabric with a loose open weave used in wound care) and secure with tape daily and as needed, dated 11/23/23 and discontinued on 12/06/23; - TAR, dated November 2023 and December 2023, with no treatments completed on 11/23/23, 12/02/23, 12/03/23, and 12/06/23 with four missed out of 14 opportunities; - An order to cleanse left and right buttocks with normal saline or dermal wound cleanser, apply hydrofera blue (a dressing that provides wound protection and addresses bacteria and yeast) to wound bed and cover with silicone bordered super absorbent dressing daily and as needed, dated 12/23/23; - TAR, dated December 2023 and January 2024, with no treatments completed on 12/23/23, 12/25/23, 12/27/23, 01/06/24, 01/07/24, 01/08/24, and 01/09/24 with seven missed out of 19 opportunities; - An order to cleanse the left lower extremity with normal saline or dermal wound cleanser, apply mupirocin ointment (used to treat skin infections), then oil emulsion dressing (nonadherent gauze mesh with petroleum jelly in an oil blend), ABD, then wrap with kerlix and secure with tape daily and as needed, dated 01/04/24; - TAR dated January 2024, with no treatments completed on 01/06/24, 01/07/24, 01/08/24, and 01/09/24 with four missed out of seven opportunities; - An order to cleanse the right lower extremity with normal saline or dermal wound cleanser, apply gentian violet then leave open to air every other day and as needed, dated 01/05/24; - TAR, dated January 2024, with no treatments completed on 01/07/24 and 01/09/24 with two missed out of two opportunities. During an interview on 01/09/24 at 11:02 A.M., the resident said he/she felt the wound care nurse was spread too thin and felt like treatments were missed. He/She believed the wound nurse worked night shift last night and was not sure who would do wound treatments today. 2. Review of Resident #58's medical record showed: - admission date of 10/26/23; - Diagnoses of unstageable pressure ulcer, stage four pressure ulcer of left hip and paraplegia (paralysis of the lower part of the body). Review of the resident's wound care documentation showed: - An order to cleanse the coccyx (tailbone) with wound cleanser, pat dry, apply Santyl (medicine that removes dead tissue from wounds so they can start to heal), silver alginate (wound dressing with antibacterial silver for wounds that drain) and bordered foam, change daily and as needed, dated 10/27/23 and discontinued on 11/02/23; - TAR, dated October 2023 and November 2023, showed no treatments completed on 10/27/23, 10/28/23, 10/29/23, and 11/01/23 with four missed out of seven opportunities; - An order to cleanse the left hip with wound cleanser, pat dry, apply Santyl, silver alginate and bordered foam, change daily and as needed, dated 10/27/23 and discontinued on 11/07/23; - TAR, dated October 2023 and November 2023, showed no treatments completed on 10/27/23, 10/28/23, 10/29/23, 11/01/23, 11/04/23, and 11/07/23 with six missed out of 12 opportunities; - An order to apply collagenase ointment (a treatment for skin ulcers and severe burns) to the affected area topically every day shift, dated 10/27/23 and discontinued on 11/15/23; - TAR, dated October 2023 and November 2023, showed no treatments completed on 10/27/23, 10/28/23, 10/29/23, 11/01/23, 11/04/23, 11/08/23, 11/11/23, 11/12/23, and 11/15/23 with nine missed out of 20 opportunities; - An order to apply mupirocin ointment topically to the mid-abdominal suture line (stitches) every day shift, dated 10/27/23 and discontinued on 11/07/23; - TAR dated October 2023 and November 2023, showed no treatments completed on 10/27/23, 10/28/23, 10/29/23, 11/01/23, 11/04/23, and 11/07/23 with six missed out of seven opportunities; - An order to cleanse the coccyx with wound cleanser, pat dry, apply Santyl, calcium alginate and bordered foam, change daily and as needed, dated 11/08/23 and discontinued on 11/14/23; - TAR, dated November 2023, showed no treatments completed on 11/08/23, 11/11/23, and 11/12/23 with three missed out of seven opportunities; - An order to cleanse the left hip and sacrum with normal saline or dermal wound cleanser, apply wound vac (therapeutic technique using a suction pump, tubing, and a dressing to remove excess drainage and promote healing in wounds) at 125 millimeters Mercury (mm/Hg) every Tuesday and Friday and as needed, dated 11/17/23 and discontinued on 01/02/24; - TAR, dated November 2023, December 2023 and January 2024, showed no treatments completed on 11/24/23, 11/28/23, and 12/08/23 with three missed out of 14 opportunities; - An order to cleanse the left hip and sacrum with normal saline or dermal wound cleanser, apply Dakin's (a solution that stops or slows down the growth of germs in wounds) moistened gauze to the wound bed, cover with ABD then secure with tape daily and as needed, dated 01/03/24; - TAR, dated January 2024, showed no treatments completed 01/05/24, 01/06/24, 01/07/24, 01/08/24, and 01/09/24 with five missed out of nine opportunities. During an interview on 01/10/24 at 3:06 P.M., the resident said he/she was worried about his/her wound healing. 3. Review of Resident #95's medical record showed: - An admission date of 04/16/21; Diagnoses of unstageable pressure ulcer of other site, stage 4 pressure ulcer of the right buttock, stage 2 pressure ulcer of other site, unspecified open wound of abdominal wall left upper quadrant without penetration into the peritoneal cavity (a fluid-packed area that houses most of the abdominal organs, and candidal stomitis (yeast infection of the mouth). Review of the resident's wound care documentation showed: - An order for the right upper quadrant abdominal previous gastrostomy tube (a tube inserted through the skin and stomach wall that delivers nutrition directly to the stomach) site to cleanse with normal saline or Dakin's wound cleanser, apply collagen flakes (wound dressing) to the wound bed, cut a hole in the center of the hydrocolloid, apply stoma (open area) paste prior to applying to the site, then cover with urostomy (a surgical procedure that creates a stoma for the urinary system) appliance. Provide urostomy care every shift but do not remove unless leaking, every day and night shift with a start date of 10/05/23 and a discontinue date of 12/19/23; - TAR, dated October 2023, November 2023, and December 2023, showed no wound treatments done for the day shift on 10/24/23, 11/01/23, 11/04/23, 11/08/23, 11/19/23, 11/23/23, 12/02/23, 12/03/23, 12/06/23, 12/16/23. No wound treatment done for the night shift on 10/08/23, 10/09/23, 10/11/23, 10/12/23, 11/28/23, 12/11/23, 12/12/23. There were 17 missed out of 150 opportunities; - An order for the right upper quadrant abdomen previous gastrostomy tube site to cleanse with normal saline or Dakin's wound cleanser, apply collagen flakes to the wound bed, cut a hole in the center of the hydrocolloid, apply stoma paste prior to applying to the site, then cover with urostomy appliance. Provide urostomy care every shift but do not remove unless leaking, every day and night shift, with a start date of 12/19/23; - TAR for December 2023 and January 2024, showed no wound treatment done for the day shift on 12/23/23, 12/24/23, 12/25/23, 12/27/23, 12/30/23, 01/01/24, 01/06/24, and 01/07/24. No wound treatment for the night shift on 12/21/23, and 12/29/23. There were 10 missed out of 39 opportunities; - An order for the left dorsal foot to apply skin prep every day shift, with a start date of 12/29/23; - TAR for December 2023 and January 2024, showed no wound treatment done on 12/30/23, 01/01/24, 01/06/24, and 01/07/24. There were four missed out of 10 opportunities; - An order for the left heel to apply skin prep every day and night shift, with a start date of 10/05/23; - TAR for October 2023, November 2023, December 2023, and January 2024, showed no wound treatment done for day shift on 10/24/23, 11/01/23, 11/14/23, 11/18/23, 11/23/23, 12/02/23, 12/03/23, 12/06/23, 12/23/23, 12/24/23, 12/25/23, 12/27/23, 12/30/23, 01/01/24, 01/06/24, 01/07/24. No wound treatment done for night shift on 10/08/23, 10/09/23, 10/11/23, 10/12/23, 10/13/23, 11/28/23, 12/11/23, 12/12/23, 12/21/23, and 12/29/23. There were 27 missed out of 189 opportunities; - An order for the right lower quadrant of the abdomen to cleanse with normal saline or Dakin's wound cleanser, fill with Iodoform strip (a wound dressing), cover with dry gauze then silicone bordered foam dressing, every day shift, with a start date of 12/29/23; - TAR for December 2023 and January 2024, showed no wound treatment done on 12/30/23, 01/01/24, 01/06/24, and 01/07/24. There were four missed out of 10 opportunities; - An order for the mid-abdomen to cleanse with normal saline or Dakin's wound cleanser, apply hydrocolloid every time gastrostomy tube urostomy was changed every day and night shift, with a start date of 12/28/23; - TAR for December 2023 and January 2024, showed no wound treatment done for the day shift on 12/30/23, 01/01/24, 01/06/24, and 01/07/24. No wound treatment done for night shift on 12/29/23. There were four missed out of 21 opportunities. 4. Review of Resident #116's medical record showed: - An admission date of 08/07/23; - Diagnoses of unstageable pressure ulcer of unspecified buttock, unstageable pressure ulcer of other site, stage 2 pressure ulcer of unspecified site, stage 3 pressure ulcer of other site, unstageable pressure ulcer of sacral region, stage 2 pressure ulcer of other site, stage 4 pressure ulcer of other site. Review of the resident's wound care documentation showed: - An order to cleanse the sacral and upper right buttock wounds with normal saline or dermal wound cleanser, pack lightly with Dakin's soaked gauze and cover with a super absorbent dressing everyday and as needed, dated 09/09/23 and discontinued on 11/22/23; - TAR, dated November 2023, showed no treatments done on 11/01/23, 11/04/23, 11/08/23, 11/12/23, 11/19/23, and 11/22/23 with six out of 22 opportunities missed; - An order to apply skin prep to the left heel every shift, dated 08/17/23; - TAR, dated November 2023, showed no treatment done during the day shift on 11/01/23, 11/04/23, 11/08/23, 11/12/23, 11/19/23, 11/23/23, and 11/25/23. No treatment done during the night shift on 11/02/23, 11/03/23, 11/08/23, 11/12/23, 11/22/23, 11/25/23, and 11/26/23. There were 14 out of 60 opportunities missed; - TAR, dated December 2023 and January 2024, showed no treatment done during the day shift on 12/02/23, 12/06/23, 12/16/23, 12/17/23, 12/23/23, 12/25/23, 12/27/23, 12/29/23, 01/06/24, and 01/07/24. No treatment done on the night shift on 12/06/23, 12/08/23, 12/13/23, 12/14/23, 12/20/23, 12/23/23, 12/28/23, 01/03/24, 01/04/24, and 01/07/24. There were 20 out of 80 opportunities missed - An order to cleanse the sacral wound with normal saline or dermal wound cleanser, apply collagen powder to wound bed, pack lightly with Dakin's soaked gauze and cover with a super absorbent dressing everyday and as need, dated 11/23/23; - TAR, dated November 2023, December 2023, and January 2024, with no treatments completed on 11/23/23, 11/25/23, 12/06/23, 12/17/23, 12/23/23, 12/25/23, 12/27/23, 12/29/23, 01/06/24, and 01/07/24. There were 10 out of 48 opportunities missed; - An order to cleanse the right upper buttock wound with normal saline or dermal wound cleanser, pack lightly with Dakin's soaked gauze and cover with a super absorbent dressing every day and as needed, dated 11/23/23; - TAR, dated November 2023, December 2023, and January 2024, with no treatments done on 11/23/23, 11/25/23, 12/06/23, 12/17/23, 12/23/23, 12/25/23, 12/27/23, 12/29/23, 01/06/24, and 01/07/24. There were 10 out of 48 opportunities missed. During an interview on 01/10/24 at 4:09 P.M., Licensed Practical Nurse (LPN)D said the floor nurses did wound treatments on the weekends. Floor nurses typically did the creams throughout the week. Nurses did not do weekly skin assessments. Resident #26's wounds were getting better. They were trying a new dressing on them. During an interview on 01/10/24 at 4:20 P.M., Registered Nurse (RN) A said the nurses did not do weekly skin assessments. The Certified Nursing Assistants (CNAs) were good to let the nurse know if there were any skin issues. He/she would do wound treatments on the weekend when he/she worked. During an interview on 01/11/23 at 10:00 P.M., the Administrator and the Director of Nursing said they would expect physician orders to be followed for wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADLs) when residents did not receive a minimum of two showers per week and preferences were not acknowledged for eight residents (Resident #1, #6, #19, #23, #51, #52, #68 and #123) out of 28 sampled residents. The facility census was 141. Review of the facility's policy titled, Shower, revised 02/03/22, showed: - All residents will be offered and given a shower on their scheduled shower days unless the resident refuses or a staffing emergency; - If a full shower is unable to be given, a bed bath will be offered and a full shower given as soon as possible; - If an alert resident declines a bed bath and only wants a shower, the shower will be completed within 48 hours. 1. Review of Resident #1's medical record showed: - admission date of 05/26/2022; - Diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), kyphosis (excessive outward curvature of the spine, causing hunching of the back), hypotension (low blood pressure), generalized anxiety disorder (disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities, causing significant impairment in daily life). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment to be completed by the facility), dated 12/08/23 showed: - No cognitive impairment; - Set up assistance of staff for upper and lower body dressing; - Moderate assistance for personal hygiene and toileting; - Maximal assistance for shower/bath. Review of the resident's shower sheets from October 1, 2023, through January 10, 2024, showed six missed showers out of 29 opportunities. During an interview on 01/09/24 at 11:30 A.M., the resident said that he/she required someone to set up the shower for him/her and he/she could do most of the shower him/herself but that no one ever wanted to help. An observation on 01/10/24 at 10:21 A.M., showed the resident sat in his/her room with unkempt hair. 2. Review of Resident #6's medical record showed: - admission date of 10/31/17; - Diagnoses of emiplegia (complete paralysis on one side of the body) and hemiparesis (partial paralysis on one side of the body) following stroke, seizures (uncontrolled electrical activity between brain cells), and muscle weakness. Review of the resident's annual MDS, dated [DATE], showed: - No cognitive impairment; - Maximal assist of staff for upper body dressing and dependent on staff for lower body dressing; - Dependent on staff for personal hygiene and bathing. Review of the resident's care plan, reviewed on 11/02/22, showed the resident required extensive/total assist with ADLs. Review of the resident's shower sheets for October 1, 2023, through January 10, 2024, showed seven missed showers out of 29 opportunities. During an interview on 01/08/24 at 8:20 P.M., the resident said he/she had not had a shower in six weeks until today. Observation of the resident on 01/10/24 at 9:40 A.M., showed the resident with uncombed hair. 3. Review of Resident #19's medical record showed: - admission date of 07/25/23; - Diagnoses of diabetes mellitus (chronic condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing related problems), and stroke. Review of the resident's quarterly MDS dated [DATE] showed: - Setup/clean up assistance for oral hygiene; - Substantial/maximal assistance for toileting hygiene, shower/bath, and personal hygiene. Review of the resident's shower sheets for October 1, 2023, through January 10, 2024, showed 12 missed showers out of 29 opportunities. During an interview on 01/09/24 at 3:21 P.M., the resident said he/she brushed his/her own teeth and hair. He/She never got a shower more than once per week, but would like to have a shower at least twice per week. Going without a shower caused his/her skin to itch. 4. Review of Resident #23's medical record showed: - admission date of 03/24/23; - Diagnoses of chronic kidney disease, stage 4 (gradual loss of kidney function over time); type II diabetes mellitus; anxiety disorder (disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities); hyperbole (elevated level of potassium in the blood); and essential hypertension (abnormally high blood pressure). Review of the Resident's significant change MDS, dated [DATE] showed: - No cognitive impairment; - Set up assistance of staff for upper and lower body dressing; - Moderate assistance for personal hygiene; - Moderate assistance to shower/bathe; - Supervision for toileting hygiene. Review of the resident's shower sheets for October 1, 2023, through January 10, 2024, showed 25 missed showers out of 29 opportunities. During an interview on 01/10/24 at 2:06 P.M., the resident said that he/she had only one shower in the last 3 weeks. An observation on 01/09/24 at 3:30 P.M., showed the resident's hair slightly unkempt. 5. Review of Resident #51's medical record showed: - admission date of 05/06/2022; - Diagnoses of Alzheimer's Disease, hypothyroidism (a condition is which the thyroid gland does not produce enough thyroid hormone and may disrupt things such as heart rate, body temperature and all aspects of metabolism), anemia (a condition in which the blood does not have enough healthy red blood cells which may cause symptoms such as fatigue, shortness of breath or dizziness) and dementia. Review of the resident's quarterly MDS, dated [DATE], showed: - Supervision for oral care; - Moderate assistance with toileting; - Maximal assistance with showers; - Supervision with upper body dressing. Review of the resident's shower sheets for October 1, 2023, through January 10, 2024, showed 17 missed showers out of 29 opportunities. Observations on 01/09/24 at 1:15 P.M., and 01/10/24 at 9:25 A.M., of the resident showed the resident's beard long, curling up on the ends and untrimmed, and hair uncombed and sticking up and over to the side. 6. Review of Resident #52's medical record showed: - admission date of 09/13/23; - Diagnoses of diabetes mellitus, major depressive disorder, pain, high blood pressure, and panic disorder (an anxiety disorder characterized by unexpected and repeated episodes of fear). Review of the resident's quarterly MDS dated [DATE] showed: - Setup/clean up assistance for oral hygiene; - Partial/moderate assistance for toileting hygiene; - Substantial/maximal assistance for shower/bath; - Partial/moderate assistance for personal hygiene. Review of the resident's shower sheets for October 1, 2023, through January 10, 2024, showed seven missed showers out of 29 opportunities. Observation on 01/10/24 at 11:26 A.M., showed the resident sat in the bed with greasy hair. During an interview on 01/10/24 at 11:26 A.M., the resident said he/she often went a week between showers. Tomorrow it would be one week since he/she received a shower. 7. Review of Resident #68's medical record showed: - admission date of 10/01/21; - Diagnoses of muscle weakness, anxiety disorder, and heart failure. Review of the resident's quarterly MDS, dated [DATE], showed: - Moderate cognitive impairment; - Supervision or touching assistance of staff for upper body dressing and substantial/maximal assistance of staff for lower body dressing; - Set up assistance of staff for personal hygiene; - Substantial/maximal assist of staff for bathing. Review of the resident's care plan, revised 01/09/24, showed: - Resident preferred a bed bath to showering and per personal decision, stayed in bed most of the time; - Resident was able to wash his/her own face and shave him/herself with set up/clean up assist. Review of the resident's shower sheets for October 1, 2023, through January 10, 2024, showed 18 missed showers out of 29 opportunities. During an interview on 01/08/24 at 08:34 P.M., the resident said he/she was overdue for a shower and may get them once a month. 8. Review of Resident #123's medical record showed: - admission date of 04/21/23; - Diagnoses of Alzheimer's Disease, dementia, hypothyroidism and anxiety. Review of the resident's quarterly MDS, dated [DATE], showed: - Moderate assistance with oral care and upper body dressing; - Maximal assistance with toileting and showering. Review of the resident's shower sheets for October 1, 2023, through January 10, 2024, showed 14 missed showers out of 29 opportunities. Observations on 01/09/25 at 12:00 P.M., 01/10/24 at 9:40 A.M., and 01/11/24 at 8:00 A.M., of the resident showed the resident walked around the common area and the hall with stringy and greasy hair. During an interview on 01/11/24 at 10:00 P.M., the Administrator said she would expect residents to receive showers as scheduled, and have hair and beards trimmed and/or shaved as needed.

Based on interview and record review, the facility failed to ensure staff reconciled narcotics (a process that allows one staff to reconcile the exact narcotic inventory on hand with another staff) at each shift change for three out of three observed medication carts. This had the potential to affect all residents. The facility census was 141. Review of the facility's policy titled, Controlled Substances, dated April 2019, showed: - The facility will follow all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled substances; - Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift; - Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together; - Policies and procedures for monitoring controlled medications to prevent loss, diversion or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist. Review of the 100/200/300 Hall nurse's medication cart narcotic book showed no documentation for shift change narcotic reconciliation. Review of the 400/500/600 Hall nurse's medication cart narcotic book showed no documentation for shift change narcotic reconciliation. Review of the Court Hall medication cart narcotic book showed no documentation for shift change narcotic reconciliation. During an interview on 01/11/24 at 09:58 A.M., Registered Nurse (RN) A said there was no documentation to show a narcotic count shift change in nurse's narcotic books. During an interview on 01/11/24 at 10:15 A.M., RN B said there had always been a shift change reconciliation log at other facilities he/she had worked at, but not at this facility. During an interview on 01/11/24 at 10:27 A.M., the Pharmacy Consultant said he/she expected the facility to monitor the narcotic reconciliation's. During an interview on 01/11/24 at 10:45 A.M., the Assistant Director of Nursing said she expected nurses and Certified Medication Technicians (CMT) to perform controlled substances shift counts. During an interview on 01/11/24 at 10:55 A.M., the Administrator said she expected nurses and CMTs to perform controlled substance reconciliation's at shift change, and believed they used to have a form to reflect this.

Based on observation, interview, and record review, the facility failed to ensure vials of Insulin Glargine (medication to control high blood sugar with diabetes) and Tubersol (a solution used during a tuberculosis test) were dated when opened. This had the potential to affect all residents. The facility's census was 141. Review of the facility's policy titled, Storage of Medications, revised November 2020, showed: - The facility stores all drugs and biologicals in a safe, secure, and orderly manner; - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; - Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Review of the manufacturer's recommendations for Tubersol, revised September 2015, showed the medication to be discarded 30 days after opened. Review of the manufacturer's recommendations for Insulin Glargine, revised December 2020, showed the medication to be discarded after 28 days, even if there is insulin left in the pen or vial. Observation on 01/11/24 at 09:54 A.M., of the nurse's medication room refrigerator showed: - Two opened vials of Tubersol, not labeled with an opened date; - One opened vial of Insulin Glargine, not labeled with an opened date. During an interview on 01/11/24 at 09:58 A.M., Registered Nurse (RN) A said he/she was unsure how long the opened vials were good for, but would check the opened date on the vial, and the vials should be dated when opened and medications should be destroyed when they were discontinued. During an interview on 01/11/24 at 10:15 A.M., RN B said multidose vials were to be dated when opened and discarded after so many days after being opened. Tubersol solution was good for 30 days. During an interview on 01/11/24 at 10:00 P.M., the Assistant Director of Nursing and Administrator said they would expect vials to be dated when opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to appropriately assess the use of bed rails for 12 residents (Resident #6, #23, #25, #26, #27, #47, #52, #60, #68, #88, #90, and #91) of 28 sampled residents. The facility census was 141. Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013, showed seven different potential zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment. Review of the FDA document entitled, Guide to Bed Safety Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, showed the potential risks of bed rails may include: - Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress; - More serious injuries from falls when patients climb over rails; - Skin bruising, cuts, and scrapes; - Inducing agitated behavior when bed rails are used as a restraint; - Feeling isolated or unnecessarily restricted; - Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet. 1. Review of Resident #6's medical record showed: - admitted on [DATE]; - Diagnoses of hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial paralysis on one side of the body) following stroke, seizures (uncontrolled electrical activity between brain cells), and muscle weakness; - Side rail assessments, dated [DATE] and [DATE], documented a half rail will be used to assist in positioning and/or transfer for the resident; - An order for quarter side rail times two for repositioning, dated [DATE]; - No documentation of an informed consent signed explaining the risks and benefits; - No documentation of an entrapment assessment completed. Review of the resident's annual Minimum Data Set (MDS) (a federal mandated assessment completed by facility staff), dated [DATE], showed: - No cognitive impairment; - Dependent for bed mobility; - Did not use bedrails. Review of the resident's care plan, revised on [DATE], showed: - Resident was a fall risk with a history of actual falls; - Quarter rail times two for repositioning; - Resident was extensive/total dependence with activities of daily living (ADLs). Observations of the resident on [DATE] at 8:20 A.M., and [DATE] at 4:41 P.M., showed the resident lay in bed with half rails in the upright position on both sides of the bed. 2. Review of Resident #23's medical record showed: - admitted on [DATE]; - Diagnoses of arthritis (painful inflammation and stiffness of the joints), chronic kidney disease (gradual loss of kidney function over time), heart failure (a chronic condition where the heart doesn't pump blood as well as it should), osteoporosis (a condition in which the bones become brittle and fragile from loss of tissue), and chronic respiratory failure (a condition in which the blood doesn't have enough oxygen). - An order for the use of quarter side rails on both sides of the bed for bed mobility and transfers, dated [DATE]; - Quarterly side rail assessment, dated [DATE], documented half rail will be used to assist in positioning and/or transfer; - No documentation of an informed consent signed explaining the risks and benefits; - No documentation of an entrapment assessment completed. Review of the resident's significant change MDS, dated [DATE], showed: - No cognitive impairment; - Independent to roll left to right; - Independent for lying to sitting on side of bed. - Did not use side rails. Review of the resident's care plan, revised [DATE], showed: - Resident was a fall risk with a history of actual falls; - Resident had an activities of daily living (ADL) self-care performance deficit related to morbid obesity, osteoporosis, arthritis.; - Did not address side rails use. Observations of the resident on [DATE] at 09:23 P.M., [DATE] at 3:30 P.M., [DATE] at 9:23 A.M., and 4:20 P.M., and [DATE] at 2:30 P.M., showed the resident lay in bed with quarter side rails in the upright position on both sides of the bed. 3. Review of Resident 25's medical record showed: - admitted on [DATE]; - Diagnoses of dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and other mental function), pain in left hip, history of falling, visual hallucinations (seeing something that is not there), atrial fibrillation (an abnormal heart beat), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder; no order for side rail; - No documentation of an order for side rails; - Side rail assessment, dated [DATE], documented no side rail indicated; - No documentation of an informed consent signed explaining the risks and benefits; - No documentation of an entrapment assessment completed; Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Independent for bed mobility; - Partial/moderate assistance for bed to chair transfer; - Did not use side rails. Review of the resident's care plan, revised on [DATE], showed: - Resident was a fall risk; - Did not address side rail use. Observation of the resident on [DATE] at 11:13 A.M., showed the resident lay in bed with a quarter rail in the upright position on the right side of the bed. During an interview on [DATE] at 11:13 A.M., the resident said he/she did not use the side rail, but did fall out of the bed when he/she got a new mattress and maybe that's why it was there. 4. Review of Resident #26's medical record showed: - admitted on [DATE]; - Diagnoses of chronic non-pressure ulcer (non-healing wound not caused by pressure) of left and right lower leg, stage two pressure ulcer (shallow open injury to skin and underlying tissue resulting from prolonged pressure on the skin) of left buttock, and unstageable (unable to see the wound bed) pressure ulcer of the sacrum (triangular bone at the base of the spinal column); - Side rail assessments, dated [DATE] and [DATE], documented a half rail will be used to assist in positioning and/or transfer of the resident; - An order for quarter side rail times two for repositioning, dated [DATE]; - No documentation of an informed consent signed explaining the risks and benefits; - No documentation of an entrapment assessment completed. Review of the resident's care plan, revised on [DATE], showed did not address ADLs or side rail use. Observations on [DATE] at 11:02 A.M., and [DATE] at 4:45 P.M., showed the resident lay in bed with a half rail in the upright position on his/her left side. 5. Review of Resident #27's medical record showed: - admitted on [DATE]; - Diagnoses of stroke, Parkinson's disease (disorder of the central nervous system that affects movement,), repeated falls, and muscle weakness; - Side rail assessments, dated [DATE] and [DATE], documented half rail will be used to assist in positioning and/or transfer; - An order for quarter side rail times two per resident request to assist with repositioning and transfers, dated [DATE]; - No documentation of an informed consent signed explaining the risks and benefits; - No documentation of an entrapment assessment completed. Review of the resident's quarterly MDS assessment, dated [DATE], showed: - No cognitive impairment; - Set up assistance to roll left and right; - Partial/moderate assist from lying to sitting on side of bed; - Did not use bedrails. Review of the resident's care plan, revised [DATE], showed: - Resident was a fall risk related to deconditioning and gait/balance problems; - Encourage resident to ask for assistance when needed; - Did not address side rails use. Observations on [DATE] at 10:40 A.M., and [DATE] at 4:48 P.M., showed the resident lay in bed with a half rail in the upright position on the left side of the bed and a quarter rail in the upright position on the right side of the bed. 6. Review of Resident #47's medical record showed: - admitted on [DATE]; - Diagnoses of stroke, hemiplegia and hemiparesis of left side, anxiety disorder, diabetes mellitus (chronic condition that affects the way the body processes blood sugar), unspecified fall, and chronic pain; - An order for quarter side rails times two for repositioning/transfers, dated [DATE]; - No documentation of an informed consent signed explaining the risks and benefits; - No documentation of an entrapment assessment completed. Review of the resident's annual MDS, dated [DATE], showed: - Moderately impaired cognition; - Substantial/maximal assistance for bed mobility; - Dependent for bed to chair transfer; - Did not use side rails. Review of the resident's care plan, revised on [DATE], showed: - Resident was a fall risk; - One-quarter side rail times two for repositioning; - Resident was extensive/total dependence with ADLs. Observation on [DATE] at 9:36 A.M., showed the resident lay in the bed with half side rails in the upright position on each side of the bed. During an interview on [DATE] at 02:22 P.M., Resident #47 said he/she used the side rails to try to turn over in bed. 7. Review of Resident #52's medical record showed: - admitted on [DATE]; - Diagnoses of diabetes mellitus, major depressive disorder, pain, high blood pressure, and panic disorder (an anxiety disorder characterized by unexpected and repeated episodes of fear); - A side rail assessment, dated [DATE], half rail will be used to assist in positioning and/or transfer; - No documentation of an order for side rails; - No documentation of an informed consent signed explaining the risks and benefits; - No documentation of an entrapment assessment completed. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Independent for bed mobility; - Supervisory/touch assistance for bed to chair transfer; - Did not use side rails. Review of the resident's care plan, revised on [DATE], showed: - Resident was a fall risk; - Did not address side rail use. Observation on [DATE] at 11:24 A.M., showed the resident sat on the side of the bed with half bed rails in the upright position on each side of the bed. During an interview on [DATE] at 11:24 P.M., Resident #52 said he/she used the rails to turn from side to side. He/She did not recall anyone assessing the rails or him/her for the use of them, or signing a consent. 8. Review of Resident #60's medical record showed: - admitted on [DATE]; - Diagnoses of chronic pain, fatigue, and low back pain; - Side rail assessment, dated [DATE], documented half rail will be used to assist in positioning and/or transfer of the resident; - An order for quarter side rail times two per resident request for positioning, dated [DATE]; - No documentation of an informed consent signed explaining the risks and benefits; - No documentation of an entrapment assessment completed. Review of the resident's annual MDS assessment, dated [DATE], showed: - No cognitive impairment; - Dependent on staff to roll left and right; - Dependent on staff from lying to sitting on side of bed; - Did not use bedrails. Review of the resident's care plan, revised [DATE], showed: - Resident required assist of one to two staff for bed mobility and transfers; - Did not address side rail use. Observations on [DATE] at 9:05 A.M., and [DATE] at 4:46 P.M., showed the resident lay in bed with half rails in the upright position on both sides of the bed. 9. Review of Resident #68's medical record showed: - admitted on [DATE]; - Diagnoses of muscle weakness, heart failure, and Parkinson's disease; - Side rail assessment, dated [DATE], documented a half rail will be used to assist in positioning and/or transfer of the resident; - An order for quarter rail times two for repositioning per patient request, dated [DATE]; - No documentation of an informed consent signed explaining the risks and benefits; - No documentation of an entrapment assessment completed. Review of the resident's quarterly MDS assessment, dated [DATE], showed: - Moderate cognitive impairment; - Independent to roll left and right; - Independent for lying to sitting on side of bed; - Did not use bedrails. Review of the resident's care plan, revised [DATE], showed: - Resident utilized positioning grab bars on the side of the bed for mobility with turning and repositioning; - Required maximum assist for rolling/turning in bed; - Resident utilized quarter rail on one side of the bed and a grab bar on the other side of bed for mobility. Observations on [DATE] at 8:34 A.M., and [DATE] at 4:47 P.M., showed the resident lay in bed with a half rail in the upright position on the left side of the bed and a quarter rail in the upright position on the right side of the bed. 10. Review of Resident #88's medical record showed: - admitted on [DATE]; - Diagnoses of cerebral infarction (an area of necrotic tissue in the brain caused by disrupted blood supply and restricted oxygen supply), arthritis, and post traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event); - Quarterly side rail assessment dated [DATE], documented a half rail will be used to assist in positioning and/or transfer; - An order for the use of quarter side rails on both sides of the bed for bed mobility and transfers per the resident's request, dated [DATE]; - No documentation of an informed consent signed explaining the risks and benefits; - No documentation of an entrapment assessment completed. Review of the resident's significant change MDS, dated [DATE], showed: - No cognitive impairment; - Supervision required to roll left to right; - Supervision for lying to sitting on side of bed. - Did not use side rails. Review of resident's care plan, revised [DATE], showed: - Resident required limited assist with activities of daily living; - Requires assist with lower body dressing, transfers, and ambulation due to indwelling catheter; - Resident was at risk for falls related to gait/balance problems and an indwelling catheter; - Did not address side rail use. Observations on [DATE] at 8:53 A.M., [DATE] at 3:00 P.M., [DATE] at 10:02 A.M., and [DATE] at 10:30 A.M., showed the resident lay in bed with quarter side rails in the upright position on both sides of the bed. 11. Review of Resident #90's medical record showed: - admitted on [DATE]; - Diagnoses of dementia, chronic pain, kidney disease (disease of the kidneys that lead to kidney failure), Alzheimer's Disease (a progressive disease that destroys the memory and other important mental functions) and anxiety; - Side rail assessment, dated [DATE], documented no side rails. - No documentation of an order for side rails; - No documentation of an informed consent signed explaining the risks and benefits; - No documentation of an entrapment assessment completed. Review of the resident's quarterly MDS assessment, dated [DATE], showed: - Severely impaired; - Dependent for bed mobility; - No restraints used. Review of the resident's care plan, last revised [DATE], did not address side rail. Observations on [DATE] at 8:20 P.M., and [DATE] at 4:00 P.M., showed the resident lay in bed with half rails in the upright position on both sides of the bed. During an interview on [DATE] 6:33 P.M., the Assistant Director Of Nursing (ADON) said Resident #90 should not have side rails, did not have a side rail assessment from maintenance, and did not have a signed or informed consent because he/she should not have the side rails in use. The Side Rail Assessment, dated [DATE], showed the resident was not to use side rails. 12. Review of Resident #91's medical record showed: - admitted on [DATE]; - Diagnoses of pain in right knee, chronic fatigue, diabetes mellitus, major depressive disorder, anxiety disorder, and lack of coordination; - A side rail assessment, dated [DATE], documented half rails will be used to assist in positioning and/or transfer of the resident ; - An order for quarter rails times two for repositioning and/or transfer, dated [DATE]; - No documentation of an informed consent signed explaining the risks and benefits; - No documentation of an entrapment assessment completed. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Set up assistance for bed mobility; - Supervisory/touch assistance for bed to chair transfer; - Did not use of side rails. Review of the resident's care plan, revised on [DATE], showed: - Resident was a fall risk; - Did not address side rail use. Observation on [DATE] at 3:52 P.M., showed the resident lay in bed with half side rails in the upright position on both sides of the bed. During an interview on [DATE] at 2:26 P.M., Resident #91 said he/she used the right side rail to get in and out of the bed. During an interview on [DATE] at 06:00 P.M., Registered Nurse (RN) A said if a resident needed side rails, nursing did a side rail assessment and notified the Director of Nursing (DON) and ADON, who then oversaw adding it to the care plan, and had therapy assess for the need. Nursing then obtained an order and a signed consent from the Power of Attorney (POA) or guardian. Signed consent forms were kept in the medical record. During an interview on [DATE] at 6:35 P.M., the Care Plan/MDS Coordinator said if a resident was supposed to have a bed rail, he/she would expect the bed rails to be on the care plan. During an interview on [DATE] at 10:00 P.M., the Administrator said she would expect consent to be obtained, especially in the case of a resident who could not give consent themselves. Bed rails should be addressed in the care plan, and monitoring and maintenance of bedrails should occur. The education nurse did the bed rail assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to conduct regular inspections of all bed frames, mattresses and side rails as part of a regular maintenance program for 12 residents (Residents #6, #23, #25, #26, #27, #47, #52, #60, #68, #88, #90, and #91) out of 28 sampled residents. The facility's census was 141. Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Review of the FDA document entitled, Practice Hospital Bed Safety, dated February 2013, showed different potential zones of entrapment. The guidance characterizes the head, neck, and chest as key body parts that are at risk for entrapment. 1. Review of Resident #6's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessment for side rails. Observations on [DATE] at 8:20 A.M., and [DATE] at 4:41 P.M., showed the resident lay in bed with half rails in the upright position on both sides of the bed. 2. Review of Resident #23's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessment for side rails. Observations of the resident on [DATE] at 09:23 P.M., [DATE] at 3:30 P.M., [DATE] at 9:23 A.M., and 4:20 P.M., and [DATE] at 2:30 P.M., showed the resident lay in bed with quarter side rails in the upright position on both sides of the bed. 3. Review of Resident #25's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessment for side rails. Observation of the resident on [DATE] at 11:13 A.M., showed the resident lay in bed with a quarter rail in the upright position on the right side of the bed. 4. Review of Resident #26's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessment for side rails. Observations on [DATE] at 11:02 A.M., and [DATE] at 4:45 P.M., showed the resident lay in bed with a half rail in the upright position on his/her left side. 5. Review of Resident #27's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessment for side rails. Observations on [DATE] at 10:40 A.M., and [DATE] at 4:48 P.M., showed the resident lay in bed with a half rail in the upright position on the left side of the bed and a quarter rail in the upright position on the right side of the bed. 6. Review of Resident #47's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessment for side rails. Observation on [DATE] at 9:36 A.M., showed the resident lay in the bed with half side rails in the upright position on each side of the bed. 7. Review of Resident #52's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessment for side rails. Observation on [DATE] at 11:24 A.M., showed the resident sat on the side of the bed with half bed rails in the upright position on each side of the bed. 8. Review of Resident #60's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessment for side rails. Observations on [DATE] at 9:05 A.M., and [DATE] at 4:46 P.M., showed the resident lay in bed with half rails in the upright position on both sides of the bed. 9. Review of Resident #68's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessment for side rails. Observations on [DATE] at 8:34 A.M., and [DATE] at 4:47 P.M., showed the resident lay in bed with a half rail in the upright position on the left side of the bed and a quarter rail in the upright position on the right side of the bed. 10. Review of Resident #88's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessment for side rails. Observations on [DATE] at 8:53 A.M., [DATE] at 3:00 P.M., [DATE] at 10:02 A.M., and [DATE] at 10:30 A.M., showed the resident lay in bed with quarter side rails in the upright position on both sides of the bed. 11. Review of Resident #90's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessment for side rails. Observations on [DATE] at 8:20 P.M., and [DATE] at 4:00 P.M., showed the resident lay in bed with half rails in the upright position on both sides of the bed. During an interview on [DATE] 6:33 P.M., the Assistant Director Of Nursing (ADON) said Resident #90 did not have a side rail assessment from maintenance. 12. Review of Resident #91's medical record showed: - admitted on [DATE]; - No documentation of maintenance assessment for side rails. Observation on [DATE] at 3:52 P.M., showed - The resident lay in bed with half side rails in the upright position on both sides of the bed; - The right bed rail loose and moved three inches in all directions. During an interview on [DATE] at 05:35 P.M., the Maintenance Director said he/she had not done entrapment assessments for the side rails. During an interview on [DATE] at 10:00 P.M., the Administrator said she would expect there to be entrapment assessments with side rail use and maintenance logs completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident #1) was free of misappropriation of his/her property when a staff member utilized the resident's bank account for personal use. The facility census was 137. The administration was notified on 12/20/2022 of the Past Non-Compliance which occurred between 11/21/2022 and 12/8/2022. On 12/9/2022, upon notification, the facility staff started an investigation. On 12/9/2022 the facility completed disciplinary action and began emailing department heads on in-servicing and updating their staff on facility's policy and procedures on misappropriation. On 12/9/2022 the facility notified the [NAME] Terre Police Department and Department of Health and Senior Services. The non-compliance was corrected 12/9/2022. Record review of the facility's policy on Investigating Incidents of Theft and/or Misappropriation of Resident Property, dated April 2017, showed: - Residents have a right to be free from theft and/or misappropriation of personal property; - Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent; - Our facility will exercise reasonable care to protect the resident from property loss or theft, including - Implementing policies that strictly prohibit and pursue to the full extent of the law, staff or employee theft or misappropriation of resident property. 1. Record review of Resident #1's face sheet showed: - Resident was originally admitted on [DATE]; - The resident has diagnoses of Anxiety Disorder (a disorder causing worry, fear and anxiety that is strong enough to interfere with one's daily living) and Major Depressive Disorder (a disorder characterized by low mood, low self-esteem and loss of interest). Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the staff), dated 10/5/2022, showed the resident has some cognitive impairment. Record review of the facility's investigation dated 12/9/2022 showed: - On 12/9/2022, the facility Business Office Manager (BOM) was notified by the local bank [NAME] President (VP), that staff member Assistant Activities Director (AAD) had been cashing checks made to him/herself and signed by Resident #1 on the resident's account since 11/21/2022 and the total amount was approximately $4400; - The bank was suspicious and verified the Resident signature on the checks was not the same as the signed bank card; - The BOM immediately notified the Administrator (ADM) and began an investigation; - The resident said he/she did not give permission for anyone to take his/her money but then was confused as to what account he/she might have; - The AAD was questioned and admitted to taking Resident #1's checks while she had been a housekeeper. The AAD said she had been forging the checks using Resident #1's name, writing it out to her and cashing them. The AAD said she had also used a few shopping at Sav A Lot; - The facility called the police who arrested and removed the AAD from the building. Record review of Resident #1's bank records showed: - 11/21/2022check made to the AAD in the amount of $200; - 11/22/2022 check made to the AAD in the amount of $200; - 11/23/2022 check made to the AAD in the amount of $300; - 11/24/2022 check made to the AAD in the amount of $250; - 11/28/2022 check made to the AAD in the amount of $200; - 11/28/2022 check made to the Sav A Lot in the amount of $41.66; - 11/29/2022 check made to the AAD in the amount of $250; - 11/29/2022 check made to the Sav A Lot in the amount of $74.89; - 12/01/2022 check made to the AAD in the amount of $400; - 12/02/2022 check made to the AAD in the amount of $425; - 12/03/2022 check made to the AAD in the amount of $500; - 12/03/2022 check made to the AAD in the amount of $450; - 12/04/2022 check made to the Sav A Lot in the amount of $54.31; - 12/08/2022 check made to the AAD in the amount of $550; - 12/09/2022 check made to the AAD in the amount of $600 - the bank did not cash this check; Record review of the AAD's employee training information showed: - On 10/24/2022 the AAD was trained on Abuse, Neglect and Exploitation; - On 6/15/2022 the AAD was provided policy on misappropriation. Record review of the [NAME] Terre City Police Department's report dated 12/9/2022 showed: - The facility notified the Police Department of the forged checks by the ADD on 12/9/2022; - An officer was sent to the facility to question the AAD regarding the checks and other Automated Clearing House (ACH - an electronic way for banks to transfer money to other entities); - The ADD confessed to the officer the he/she had written checks for cash to fund a gambling habit and used ACH to pay monthly bills; - The officer arrested for stealing, forgery and financial exploitation of an elderly person with a disability and removed the ADD from the building. During an interview on 12/20/2022 at 9:15 A.M., the ADM said the AAD was originally hired as a housekeeper on 6/15/2022. The AAD performed the job well and was liked by all the staff and residents. The AAD was promoted to Assistance Activities Director. The ADM said during an interview with the AAD, he/she admitted to removing checks from Resident #1's room while performing housekeeping duties. The AAD admitted to forging Resident #1's signature and taking the money from the account. The facility notified the [NAME] Terre Police Department (BTPD) and the AAD was immediately terminated. During an interview on 12/20/2022 at 10:20 A.M., the BOM said the bank contacted him/her and informed the facility of the suspicious activity on Resident #1's account. The ADM was notified immediately and they started an investigation. The bank sent verification of the forged checks. The AAD admitted to them he/she had forged the checks. During an interview on 12/20/2022 at 10:45 A.M., BTPD said they had not decided anything on this case at this time. MO210989 Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident #1) was free of misappropriation of his/her property when a staff member utilized the resident's bank account for personal use. The facility census was 137. The administration was notified on 12/20/2022 of the Past Non-Compliance which occurred between 11/21/2022 and 12/8/2022. On 12/9/2022, upon notification, the facility staff started an investigation. On 12/9/2022 the facility completed disciplinary action and began emailing department heads on in-servicing and updating their staff on facility's policy and procedures on misappropriation. On 12/9/2022 the facility notified the [NAME] Terre Police Department and Department of Health and Senior Services. The non-compliance was corrected 12/9/2022. Record review of the facility's policy on Investigating Incidents of Theft and/or Misappropriation of Resident Property, dated April 2017, showed: - Residents have a right to be free from theft and/or misappropriation of personal property; - Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent; - Our facility will exercise reasonable care to protect the resident from property loss or theft, including - Implementing policies that strictly prohibit and pursue to the full extent of the law, staff or employee theft or misappropriation of resident property. 1. Record review of Resident #1's face sheet showed: - Resident was originally admitted on [DATE]; - The resident has diagnoses of Anxiety Disorder (a disorder causing worry, fear and anxiety that is strong enough to interfere with one's daily living) and Major Depressive Disorder (a disorder characterized by low mood, low self-esteem and loss of interest). Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the staff), dated 10/5/2022, showed the resident has some cognitive impairment. Record review of the facility's investigation dated 12/9/2022 showed: - On 12/9/2022, the facility Business Office Manager (BOM) was notified by the local bank [NAME] President (VP), that staff member Assistant Activities Director (AAD) had been cashing checks made to him/herself and signed by Resident #1 on the resident's account since 11/21/2022 and the total amount was approximately $4400; - The bank was suspicious and verified the Resident signature on the checks was not the same as the signed bank card; - The BOM immediately notified the Administrator (ADM) and began an investigation; - The resident said he/she did not give permission for anyone to take his/her money but then was confused as to what account he/she might have; - The AAD was questioned and admitted to taking Resident #1's checks while she had been a housekeeper. The AAD said she had been forging the checks using Resident #1's name, writing it out to her and cashing them. The AAD said she had also used a few shopping at Sav A Lot; - The facility called the police who arrested and removed the AAD from the building. Record review of Resident #1's bank records showed: - 11/21/2022check made to the AAD in the amount of $200; - 11/22/2022 check made to the AAD in the amount of $200; - 11/23/2022 check made to the AAD in the amount of $300; - 11/24/2022 check made to the AAD in the amount of $250; - 11/28/2022 check made to the AAD in the amount of $200; - 11/28/2022 check made to the Sav A Lot in the amount of $41.66; - 11/29/2022 check made to the AAD in the amount of $250; - 11/29/2022 check made to the Sav A Lot in the amount of $74.89; - 12/01/2022 check made to the AAD in the amount of $400; - 12/02/2022 check made to the AAD in the amount of $425; - 12/03/2022 check made to the AAD in the amount of $500; - 12/03/2022 check made to the AAD in the amount of $450; - 12/04/2022 check made to the Sav A Lot in the amount of $54.31; - 12/08/2022 check made to the AAD in the amount of $550; - 12/09/2022 check made to the AAD in the amount of $600 - the bank did not cash this check; Record review of the AAD's employee training information showed: - On 10/24/2022 the AAD was trained on Abuse, Neglect and Exploitation; - On 6/15/2022 the AAD was provided policy on misappropriation. Record review of the [NAME] Terre City Police Department's report dated 12/9/2022 showed: - The facility notified the Police Department of the forged checks by the ADD on 12/9/2022; - An officer was sent to the facility to question the AAD regarding the checks and other Automated Clearing House (ACH - an electronic way for banks to transfer money to other entities); - The ADD confessed to the officer the he/she had written checks for cash to fund a gambling habit and used ACH to pay monthly bills; - The officer arrested for stealing, forgery and financial exploitation of an elderly person with a disability and removed the ADD from the building. During an interview on 12/20/2022 at 9:15 A.M., the ADM said the AAD was originally hired as a housekeeper on 6/15/2022. The AAD performed the job well and was liked by all the staff and residents. The AAD was promoted to Assistance Activities Director. The ADM said during an interview with the AAD, he/she admitted to removing checks from Resident #1's room while performing housekeeping duties. The AAD admitted to forging Resident #1's signature and taking the money from the account. The facility notified the [NAME] Terre Police Department (BTPD) and the AAD was immediately terminated. During an interview on 12/20/2022 at 10:20 A.M., the BOM said the bank contacted him/her and informed the facility of the suspicious activity on Resident #1's account. The ADM was notified immediately and they started an investigation. The bank sent verification of the forged checks. The AAD admitted to them he/she had forged the checks. During an interview on 12/20/2022 at 10:45 A.M., BTPD said they had not decided anything on this case at this time. MO210989

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents at the facility. The facility's census was 131. 1. Observation of the facility on 5/6/22 at 8:47 A.M., showed: - A ceiling tile with a brown sticky substance approximately 12 inches (in.) x 12 in. above the soda machine by the main dining room and across from the staff lounge; - A ceiling tile broken in the hallway by the staff lounge and the main dining room; - A round brown stain approximately 5 in. on the ceiling tile by the bathrooms in the hallway next to the main dining room; - A brown stain on the ceiling tile approximately 6 in. x 4 in. by the soiled utility room on the 600 hallway; - A circular brown stain on the ceiling tile approximately 6 in. in diameter above the door leading to the outside smoking courtyard. 2. Observation of resident rooms 41-50 on 5/6/22 at 9:00 A.M., showed: - A brown stain on the ceiling tile approximately 1 foot (ft.) x 1 ft. in room [ROOM NUMBER]; - Three small brown circles on a 2 ft. x 4 ft. ceiling tile in front of the area of the hall; - An 8 in. x 4 ft. ceiling time with one small brown circle near the large sitting area; - A vent at the end of the hall with a brown substance on it. 3. Observation in room [ROOM NUMBER] on 5/6/22 at 9:09 A.M., showed a bedside table with approximately 12 in. of veneer trim pulled away from the outer edge. 4. Observation of the north hall on 5/6/22 at 9:10 A.M., showed: - A 2 ft. x 4 ft. tile with exposed duct work; - A cold air return vent with a large amount of a brown substance on it; - room [ROOM NUMBER] with a 1 ft. x 2 ft. open area with exposed 3 in. pipe with insulation and a missing strip of tape, and a 4 in. x 2 ft. wall area that met the ceiling with missing dry wall; - room [ROOM NUMBER]'s air conditioner/heat unit with four broken vent strips; - room [ROOM NUMBER]'s ceiling with four areas of discoloration with a trash can under the 4 ft. light fixture; - Middle of the large dining room, near room [ROOM NUMBER], a 2 ft. x 2 ft. cold air return with a brown substance on it. 5. The south end of the large dining room showed: - A 2 ft. x 4 ft. ceiling tile with a large discolored circle; - A 2 ft. x 2 ft. ceiling tile with a large light brown circle; - A 2 ft. x 2 ft. cold air return near room [ROOM NUMBER] with a brown substance on it; - An exit door with a 1-1/2 ft. of visible day light; - A housekeeping storage door 2 ft. x 1/2 ft. with black markings. 6. Observation of the area above the nurses' station on 5/6/22 at 9:30 A.M., showed: - A 1 ft. x 4 ft. ceiling tile small hole and two visible cracks about midway of the tile; - A 2 ft. x 4 ft. ceiling tile with 2 in. x 4 in. area missing. 7. Observation of the west television sitting room on 5/6/22 at 9:35 A.M., showed: - A 2 ft. x 4 ft. light cover near the courtyard exit with a visible buildup of debris. 8. Observation on 5/6/22 at 9:38 A.M., of the maintenance request book showed: - No recent requests made; - Two requests made in October 2021 and November 2021. 9. Observation on 5/6/22 at 8:40 A.M., of the 400 Hall, showed: - The call light plastic cover pulled approximately 6 in. from the call light mount which exposed the call light wires outside and above room [ROOM NUMBER]. 10. Observation on 5/6/22 at 8:36 A.M., showed: - Approximately 1 ft. x 8 in. brown discoloration on the ceiling tile on 100 hall above the mechanical room. 11. Observation on 5/6/22 at 8:37 A.M., showed: - Approximately 1-1/2 ft. x 1 ft. gray and brown area ceiling tile with sagging along the wall above the scales on 100 hall. 12. Observation on 5/6/22 at 8:39 A.M., showed: - Two ceiling tiles with approximately 1 in. gap by the exit door on 100 hall. 13. Observation on 5/6/22 at 8:40 A.M., showed: - Approximately 2 in. gap between ceiling tile and metal frame in front of room [ROOM NUMBER]. 14. Observation on 5/6/22 at 8:42 A.M., showed: - A corner of a ceiling tile in room [ROOM NUMBER] by the window with approximately a 1 in. x 1 in. brown circle with a white area in the middle. 15. Observation on 5/6/22 at 8:44 A.M., showed: - One ceiling tile in room [ROOM NUMBER] with approximately a 1 in. x 6 in. brown area by the wall above the bed. 16. Observation on 5/6/22 at 8:45 A.M., showed: - One ceiling tile in room [ROOM NUMBER] with a dark brown semi-circle area approximately 1 in. x 1 in. above the light above the bed. 17. Observation of the therapy room on 5/6/22 at 8:47 A.M., showed: - Two ceiling tiles missing between the windows partially above the exercise bike; - Exposed a yellow cord and a black/brown colored area on the sheetrock toward the ceiling. 18. Observation on 5/6/22 at 8:48 A.M., showed: - One ceiling tile with a 2 in. x 3 in. corner missing of the tile by the hall entry toward the exit door on 300 hall. 19. Observation on 5/6/22 at 8:49 A.M., showed: -One red electric outlet between rooms [ROOM NUMBERS] not flush with the wall and moved when touched. During an interview on 5/5/22 at 12:23 P.M., Licensed Practical Nurse (LPN) A said generally he/she contacts the maintenance director regarding any broken equipment, furniture, fixtures, walls and ceiling tiles. The facility does have a maintenance work order form for staff to complete for any broken equipment, furniture, fixtures, walls and ceiling tiles in the residents' rooms. During an interview on 5/5/22 at 12:36 P.M., housekeeping staff E said he/she generally informs the housekeeping supervisor of any broken equipment or any issues regarding resident rooms or common use areas. The housekeeping staff said the housekeeping supervisor will inform the maintenance director and he/she will take care of repairing and/or fixing any broken equipment or issues in the residents' rooms. During an interview on 5/5/22 at 12:29 P.M., Certified Nurse Aide (CNA) D said he/she generally informs the maintenance director of any broken equipment or any issues regarding residents' rooms. During an interview on 5/6/22 at 9:40 A.M., LPN F said if staff see any concerns, they sometimes just page the maintenance staff. During an interview on 5/6/22 at 1:55 P.M., the Maintenance Director said he/she is responsible for addressing environment or physical issues in the facility. If there are any issues in the facility, a maintenance requisition is supposed to be filled out at the nurses' station and placed in the box by his/her office. He/she did not keep the requisition once the issue was resolved. Sometimes he/she hears of issues in the facility just by word of mouth in passing the nurses' station. Walking rounds are made daily. The handrails aren't on the checklist for weekly or monthly rounds. Call light covers get messed up at times due to mop handles hitting them during housekeeping. There have been a lot of roof leaks and the roof was replaced, as well as multiple ceiling tiles. Generally issues are taken care of really quickly and there is another maintenance staff to help. During an interview on 5/6/22 at 1:55 P.M., the Administrator said maintenance requisitions are duplicated by carbon copy and she keep a copy to ensure that the work gets done. The Administrator said the roof was replaced and the contractors are here now working on the roof again and have been here multiple times. Facility did not provide a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, for six residents (Resident #18, #27, #46, #108, #112, & #120) out of 26 sampled residents. The facility census was 131. 1. Record review of Resident #18's medical record showed: - Date of admission of 7/16/21; - Quarterly MDS, dated [DATE], with a diagnosis of pneumonia; - Quarterly MDS, dated [DATE], with a diagnosis of pneumonia; - Quarterly MDS, dated [DATE], with a diagnosis of pneumonia. During an interview on 5/5/22 at 12:53 P.M., the MDS Coordinator said the resident, to his/her knowledge, did not have pneumonia other than on admission, and this diagnosis should have been removed from the subsequent MDS assessments. The infection diagnosis should be taken off if not still relevant to the MDS being performed. The system automatically fills in the diagnosis if the resident has ever had that diagnosis and it has to be unchecked if the diagnosis is not still relevant. It is the MDS Coordinator's responsibility to make sure the MDS is accurate. During an interview on 5/5/22 at 2:45 P.M., the Director of Nursing (DON) said the resident had pneumonia on admission to the facility, but to her knowledge, has not had pneumonia since then. 2. Record review of Resident 27's medical record showed: - On 3/17/21, found on the floor with the right hip internally rotated and very painful. The resident sent to the hospital for evaluation and treatment. The hospital confirmed a right hip fracture; - Quarterly MDS, dated [DATE], showed no fall with a major injury; - Quarterly MDS, dated [DATE], showed no fall with a major injury; - Quarterly MDS, dated [DATE], showed no fall with a major injury; - Annual MDS, dated [DATE], showed a fall with a major injury with no record of a fall with major injury in the resident's medical record during the look back period. 3. Record review of Resident #46's medical record showed: - Quarterly MDS, dated [DATE], with a diagnosis of pneumonia; - Quarterly MDS, dated [DATE] with a diagnosis of pneumonia; - Annual MDS, dated [DATE], with a diagnosis pneumonia. 4. Record review of Resident 108's medical record showed: - A diagnosis of Type ll Diabetes Mellitus (a chronic condition that affects the way the body produces blood sugar); - An order for insulin 100 units/milliliter to be given per a sliding scale; - Medication Administration Record (MAR), from November 2021 to May 2022, showed insulin given daily as directed; - Quarterly MDS, dated [DATE], showed received insulin seven out of seven days; - Quarterly MDS, dated [DATE], showed no insulin received. 5. Record review for Resident #112's medical record showed: - Quarterly MDS, dated [DATE], showed the resident with a catheter (a tube placed in the body to drain and collect urine from the bladder); - No order for a catheter; - No care plan for a catheter; - Observation of the resident on 5/3/22 at 11:30 A.M., showed no catheter; - Observation of the resident on 5/5/22 at 11:00 A.M., showed no catheter; - Observation of the resident on 5/6/22 at 9:00 A.M., showed no catheter. During an interview on 5/5/22 at 12:45 P.M., the DON said the resident had been sent back from the hospital on 2/6/22, with a urinary catheter, but it had been removed as the resident did not have a diagnosis or order for it. 6. Record review of Resident #120's medical record showed: - An admission date of 10/19/21; - Diagnoses of transient cerebral ischemic attack (TIA) (a neurologic deficit that produces stroke symptoms that resolve within 24 hours), urinary tract infection, depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), combined systolic and diastolic heart failure, atrial fibrillation (heart dysrhythmia), osteoarthritis (a type of arthritis marked by cartilage deterioration of joints and vertebrae), anxiety (persistent worry and fear about everyday situations), insomnia (difficulty sleeping), cardiac pacemaker, violent behavior, ulcerative colitis (chronic inflammatory bowel disease), age-related physical debility, Alzheimer's disease (progressive mental deterioration), altered mental status repeated falls, muscle weakness, hypertension (high blood pressure); - Physician Order Sheet (POS), dated May 2022, showed an order to monitor the personal safety alarm to assure it remains on and in place during the med pass, dated 12/2/21. Record review of the resident's care plan, dated 11/9/21, showed: - The resident to use physical restraints (bed alarm/chair alarm) related to confusion, repeated falls and POA's (Power of Attorney) insistence. Record review of the Restraint - Physical Evaluation form dated 11/9/21, showed: - Resident to have a bed/chair alarm. Record review of the resident's significant change MDS, dated [DATE], showed: - No physical restraint of a bed or chair alarm. Observation of the resident showed: - On 5/3/22 at 11:53 A.M., the resident sat in the chair with the bed/chair alarm turned off; - On 5/3/22 at 2:24 P.M., the resident sat in the chair with the bed/chair alarm turned off; - On 5/4/22 at 8:12 A.M., the resident lay in bed with the bed/chair alarm turned off; - On 5/4/22 at 1:44 P.M., the resident lay in bed with the bed/chair alarm turned off; - On 5/5/22 at 9:02 A.M., the resident lay in bed with the bed/chair alarm turned off; - On 5/5/22 at 12:18 P.M., the staff checked the chair alarm under the resident in the chair but did not check the on/off switch of the alarm. Observation showed the bed/chair alarm turned off; - On 5/6/22 at 8:44 A.M., the resident sat in the chair with the bed/chair alarm turned off. During an interview on 5/06/22 at 8:56 AM., CNA (Certified Nursing Assistant) C said the resident's family wanted the alarm to ensure if he/she moved, staff would know. The resident does not ambulate well anymore. The alarm should be on at all times as the resident is in the bed or chair. During an interview on 5/6/22 at 9:21 A.M., LPN (Licensed Practical Nurse) B said the resident's bed/chair alarm should be checked with the med pass to make sure it is on. During an interview on 5/6/22 at 1:44 P.M., the MDS Coordinator said a bed/chair alarm should be indicated on the MDS as it would require a physician's order and be considered a restraint. The MDS Coordinator is responsible for signing off and the accuracy of the MDS's completed by the MDS team and any restraint should be indicated on the MDS. The facility follows the Resident Assessment Instrument (RAI) procedure manual and did not provide a policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an individualized comprehensive care plan with specific interventions for two residents (Resident #1 and #120) out of 26 sampled residents. The facility's census was 131. Review of the facility's Comprehensive Person Centered Care Plan policy, revised December 2016, showed: - The care plan should include measurable objectives and timetables to the resident's physical, psychosocial and functional needs and implemented for each resident; - It will incorporate identified problem areas and risk factors associated with them; - It will build on the resident's strengths; - It will aid in preventing or reducing decline in the resident's functional status; - Care plan interventions will be chosen after careful data gathering; - The comprehensive care plan will be developed within seven days of completion of the required Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff; - The interdisciplinary team must review and update the care plan with a resident's significant changes, when the desired outcome not met, on readmission from a hospital stay, and at least quarterly. 1. Record review of Resident #1 medical record showed: - admission date of 10/1/21; - Diagnoses included depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety (persistent worry and fear about everyday situations), Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors), metabolic encephalopathy (an alteration of brain function resulting from other internal organ failure), acute kidney failure, atrioventricular block (a partial or complete interruption of impulse transmission from the atria to the ventricles of the heart), diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), pressure ulcer stage 2 (damage to the skin and/or underlying tissue as a result of pressure), muscle weakness, syncope (passing out) and collapse, delirium (state of disorientation or confusion) due to known physiological condition, and gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints); - Continuous oxygen order discontinued on 10/4/21. Record review of the resident's Physician Order Sheet (POS) dated May 2022, showed: - An order for the resident's pulse oxygen (measurement of oxygen saturation in the blood) to be checked every shift and to keep it above 90 percent (%), dated 2/5/22; - Oxygen via nasal cannula (device used to deliver supplemental oxygen via a tube extending from an oxygen container to the nostrils of the person) to keep the resident's pulse oxygen above 90% as needed, dated 2/6/22. Record review of the resident's quarterly MDS, dated [DATE], showed: - Received oxygen. Record review of the resident's nurse's note dated 10/14/21, showed: - Resident fell out of his/her bed with the left knee noted to be swollen; - An x-ray ordered, obtained and negative for any abnormalities. Record review of the resident's Fall Risk Evaluation, dated 1/2/22, showed: - Resident a fall risk and no falls within the last three months. Record review of the resident's comprehensive care plan, dated 10/6/21, showed: - Oxygen not addressed with specific interventions and/or goals; - Falls not addressed with specific interventions and/or goals. During an interview on 5/6/22 at 1:44 P.M., the MDS Coordinator said a fall and the oxygen use should be care planned with interventions. Oxygen should be care planned if it is continuous or as needed. Care plans are updated as the MDS is updated, and when the MDS Coordinator is made aware of changes. 2. Record review of Resident #120's medical showed: - An admission date of 10/19/21; - Diagnoses of TIA (transient cerebral ischemic attack) (a neurologic deficit that produces stroke symptoms that resolve within 24 hours), urinary tract infection, depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), combined systolic and diastolic heart failure, atrial fibrillation (heart dysrhythmia), osteoarthritis (a type of arthritis marked by cartilage deterioration of joints and vertebrae), anxiety (persistent worry and fear about everyday situations), insomnia (difficulty sleeping), cardiac pacemaker, violent behavior, ulcerative colitis (chronic inflammatory bowel disease), age-related physical debility, Alzheimer's disease (progressive mental deterioration), altered mental status repeated falls, muscle weakness, hypertension (high blood pressure). Record review of the resident's quarterly MDS, dated [DATE], showed: - No use of a side rail. Record review of the resident's restraint assessment dated , 11/9/21, showed: - No use of a side rail. Observations of the resident showed: - On 5/4/22 at 8:12 A.M., the resident lay in bed with both side rails up; - On 5/4/22 at 1:44 P.M., the resident lay in bed with both side rails up; - On 5/5/22 at 9:02 A.M., the resident sat up in bed with both side rails up. During an interview on 5/06/22 at 8:56 A.M., Certified Nursing Assistant (CNA) C said the resident does use the side rails to help turn at times, but other times, he/she just hangs on to them which makes care difficult. During an interview on 5/6/22 at 1:44 P.M., MDS Coordinator said side rails should be care planned with interventions. Care plans are updated as the MDS is updated and when the MDS Coordinator is made aware of changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update and revise care plans with specific interventions tailored to meet the needs for two residents (Resident #18 and #123) out of 26 sampled residents. The facility census was 131. Record review of the facility's Comprehensive Person-Centered Care Plans policy, dated December 2016, showed: - Care plans revised as information about the resident and the resident's condition change. 1. Record review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/15/22, showed: - Received insulin; - Received an anticoagulant (blood thinning medication). Record review of the resident's care plan, revised on 5/3/22, showed: - Diagnoses of diabetes mellitus (DM) (a chronic metabolic disorder affecting blood sugar) and cerebrovascular accident (CVA) (stroke); - No interventions for diabetes or the use of insulin; - No interventions for CVA or use of an anticoagulant. Record review of the resident's Physician's Order Sheet (POS) , dated 5/3/22, showed: - An order for insulin glargine 100 units per milliliter (units/ml) 40 units daily for DM; - An order for novolog 100 units/ml per sliding scale, three times a day as needed for DM; - An order for xarelto (an anticoagulant medication) 20 milligram (mg) daily for CVA. During an interview on 6/6/22 at 1:44 P.M., the MDS Coordinator said it should be on the care plan if a resident has diabetes and takes insulin, as well as if a resident is on an anticoagulant. He/she said care plans should be updated annually, quarterly and if there is a change in status. 2. Record review of Resident #123's quarterly MDS, dated [DATE], showed: - At risk for pressure ulcers (any lesion caused by unrelieved pressure that results in damage to the underlying tissue); - An unhealed pressure ulcer; - A stage 2 (partial thickness loss of dermis) pressure ulcer. Record review of the resident's care plan, revised on 3/29/22, showed: - No interventions in place for pressure ulcer care or prevention. Record review of the resident's skin/wound notes, showed: - On 3/29/22 at 4:26 P.M., a stage 2 pressure ulcer noted to the resident's left lateral heel; - On 5/5/22 at 9:42 A.M., continued stage 2 pressure ulcer to the resident's left lateral heel. Observations of wound care on 5/5/22 at 9:42 A.M., showed: - A pressure ulcer to the resident's left lateral heal. During an interview on 6/6/22 at 1:44 P.M., the MDS Coordinator said if a resident has a pressure ulcer, it should be on the care plan.

Based on observation, interview and record review, the facility failed to appropriately assess the use of bed rails/side rails (a structural support attached to the frame of a bed intended to prevent one from falling or assist with mobility) for two residents (Resident #1 and #120) out of the 26 sampled residents. The facility census was 131. Record review of the facility's Side Rail policy, dated 4/22/21, showed: - With the utilization of side rails, they will be in the least restrictive form possible; - A side rail assessment will be completed to include the risks of the side rail use and will be discussed with the resident and/or family. 1. Record review of Resident #1 medical record, showed: - An admission date of 10/1/21; - Diagnoses of depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety (persistent worry and fear about everyday situations), Parkinson's disease (a disease of the central nervous system that affects movement, often including tremors), metabolic encephalopathy (an alteration of brain function resulting from other internal organ failure), acute kidney failure, atrioventricular block (a partial or complete interruption of impulse transmission from the atria to the ventricles of the heart), diabetes mellitus (DM) (a condition that affects the way the body processes blood sugar), pressure ulcer stage 2 (damage to the skin and/or underlying tissue as a result of pressure), muscle weakness, syncope (passing out) and collapse, delirium (state of disorientation or confusion) due to known physiological condition, and gout (a form of arthritis characterized by severe pain, redness, and tenderness in joints); - No documentation of attempts made with alternative methods other than side rails; - No interventions in place for the use and monitoring of the side rails; - No side rail or entrapment assessment. Observations of the resident showed: - On 5/3/22 at 12:04 P.M., the resident lay in bed with four quarter side rails up; - On 5/4/22 at 8:10 A.M., the resident lay in bed with four quarter side rails up; - On 5/4/22 at 1:52 P.M., the resident lay in bed with four quarter side rails up; - On 5/5/22 at 9:15 A.M., staff assisted the resident with care and he/she lay in bed with the four quarter side rails up; - On 5/5/22 at 2:53 P.M., the resident lay in bed with four quarter side rails up with approximately a 6 inch (in.) gap between the top left quarter side rail and the air mattress. 2. Record review of Resident #120's medical record showed: - An admission date of 10/19/21; - Diagnoses of TIA (transient cerebral ischemic attack) (a neurologic deficit that produces stroke symptoms that resolve within 24 hours), urinary tract infection, depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), combined systolic and diastolic heart failure, atrial fibrillation (heart dysrhythmia), osteoarthritis (a type of arthritis marked by cartilage deterioration of joints and vertebrae), anxiety (persistent worry and fear about everyday situations), insomnia (difficulty sleeping), cardiac pacemaker, violent behavior, ulcerative colitis (chronic inflammatory bowel disease), age-related physical debility, Alzheimer's disease (progressive mental deterioration), altered mental status repeated falls, muscle weakness, hypertension (high blood pressure); - No documentation of attempts made with alternative methods other than side rails; - No interventions in place for the use and monitoring of the side rails; - No side rail or entrapment assessment. Observations of the resident showed: - On 5/4/22 at 8:12 A.M., the resident lay in bed with both side rails up; - On 5/4/22 at 1:44 P.M., the resident lay in bed with both side rails up; - On 5/5/22 at 9:02 A.M., the resident sat in up bed with both side rails up. During an interview on 5/5/22 at 3:20 P.M., the Director of Nursing (DON) said side rail assessments should be completed with the use of side rails. During an interview on 5/6/22 at 1:44 P.M., the Minimum Data Set (MDS) (a federally mandated assessment instrument completed by facility staff) Coordinator said side rail assessments are completed on admission and updated quarterly. An assessment should be done anytime a side rail is used.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the handrails on the 200 and 500 halls were properly attached to the wall. The facility census was 131. 1. Observations on 5/5/22 from 11:12 A.M., through 11:26 A.M., showed: - Hand rail loose from the wall next to room [ROOM NUMBER] and 213; - Hand rail loose from the wall next to room [ROOM NUMBER] and 513. During an interview on 5/5/22 at 12:23 P.M., Licensed Practical Nurse (LPN) A said generally he/she contacts the maintenance director regarding any broken and/or loose hand rails. The facility has a maintenance work order form for staff to complete for any broken and/or loose hand rails. During an interview on 5/6/22 at 1:55 P.M., the Maintenance Director said he/she completes walking rounds daily to check for environmental or physical plant issues in the facility, but does not check hand rails. He/she completes a checklist for environmental and physical plant issues weekly or monthly, but does not check the stability of the hand rails. Record review of the facility's weekly and monthly maintenance checklist, dated April 2022, showed: - No documentation of the maintenance director and/or maintenance department staff checked the stability of the hand rails in the facility. During an interview on 5/10/22 at 9:15 A.M., the Director of Nurses (DON) said she expected the hand rails to be checked and included on the maintenance director's weekly or monthly checklist to ensure the stability of the hand rails throughout the facility. During an interview on 5/17/22 at 11:45 A.M., the Administrator said the facility does not have a policy and procedure regarding checking the hand rails. Facility did not provide a policy.