**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure pharmacy services in place that established a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, that ensured drug records were in order, and ensured an account of all controlled drugs was maintained and periodically reconciled when staff had medications that could not be returned to the pharmacy stored and not destroyed in timely manner for 73 residents, which included 159 cards of controlled substance medications, and failed to have a system of accountability for the 159 cards of unused controlled substance medications located in locked cabinets in two offices that were pending destruction. The facility census was 69.Review of the facility policy titled Destruction of Medications, undated, showed the following:-The facility will destroy and dispose of medication in a safe manner and in accordance to applicable law;-All mediation not returned to the issuing pharmacy will be destroyed;-Two licensed nurses or one licensed nurse and the facility pharmacist will destroy all medications, except controlled substances which will require Director of Nursing (DON) supervision;-Documentation of medication destruction will include date, name of medication, prescription (RX) number, amount of medication to be destroyed, method of destruction, and signatures of nurses and/or pharmacist;-Scheduled II to IV medications (under the Controlled Substances Act, have a potential for medication abuse) will be destroyed as stated above with the following exceptions:-The controlled medication count sheet will include the following information:-Signature of nurses and/or pharmacist destroying the medication;-Amount destroyed and date destroyed. Review of the facility policy titled Discontinued Medications, undated, showed the following:-When the attending physician discontinued a medication, it must be recorded in the resident's medical record and medication sheet;-The staff or charge nurse receiving the order to discontinue a medication is responsible for charting such information and must also notify the issuing pharmacy of such order;-The facility and/or the issuing pharmacy may destroy discontinued medications;-When medications have been discontinued and are not to be returned, refer to medication destruction guidelines;-The following will be the protocol for controlled medications:-When a medication has been discontinued, the nurse or certified medication technician (CMT) will discontinue the controlled medication on the physician order sheet (POS) and medication administration record (MAR);-The nurse or CMT will document the amount of controlled medication to be discontinued on the MAR;-The nurse or CMT will then log the controlled medication on the individual resident's destruction record to include the following Information:-Date medication discontinued, Rx number, and amount left on card or left in bottle;-The controlled medication will then be placed in the locked cabinet for destruction;-The controlled medication sheet will be maintained in the narcotic book under the discontinued narcotic tab and will be counted until destroyed; -When narcotics are destroyed, the nurses will document on the destruction record and narcotic records date destroyed, how medication was destroyed, and both nurses' names and titles;-Controlled medications will be destroyed at least weekly with DON supervision. 1. Review of Resident #1's medical record showed the following:-admission date of 02/22/25;-discharge date of 04/15/25;-Diagnoses included cerebral infarction (stroke), traumatic brain injury (TBI - damage to the brain caused by an external force, such as a bump, blow, jolt, or penetrating injury to the head), and chronic pain syndrome (persistent pain lasting longer than three months). Review of the resident's nursing notes dated 04/15/25, at 2:43 P.M., showed staff documented the resident was discharged home with his/her spouse via private vehicle with all of his/her possessions at 1:50 P.M. Discharge paperwork signed, and copies sent home with him/her along with all of his/her available medications. No new skin issues noted. He/she left with all his/her personal belongings. Nothing has been reported missing. Review of the resident's February 2025, March 2025, and April 2025 MARs showed the following:-An order, dated 02/26/25, for oxycodone (controlled drug used to treat moderate to severe pain) 15 milligrams (mg), administer one table every eight hours as needed for pain;-Staff documented administration of oxycodone medication almost every day with last dose administered on 04/14/25 at 8:52 P.M. Review of the resident's documents tab in the electronic medical record showed the following:-A Controlled Drug Receipt, Record, and Disposition form, dated 02/27/25, for oxycodone15 mg tablets, 30 tablets dispensed. Staff documented administration of the medication from 02/28/25 through 03/16/25;-A Controlled Drug Receipt, Record, and Disposition form, dated 03/04/25, for oxycodone 15 mg tablets, 30 tablets dispensed. Staff documented administration of the medication from 03/17/25 through 04/04/25;-No Controlled Drug Receipt, Record, and Disposition Form for oxycodone medication administered from 04/05/25 through discharge on [DATE]. Review of staff provided form titled Controlled Drug Receipt, Record, and Disposition Form, showed oxycodone 15 mg tablets, 30 tablets dispensed on 04/01/25 and signed as received at facility on 04/02/25. The form showed 16 tablets remained with the last dose documented as administered on 04/14/25, at 7:45 P.M.Review of the resident's February 2025, March 2025, and April 2025 MARs showed the following:-An order, dated 03/09/25, for clonazepam (controlled drug used to help reduce anxiety) 1 mg, administer 1 tablet every 12 hours as needed for anxiety or agitation;-Staff documented administration of clonazepam medication for 12 days in March 2025 and 10 days in April 2025 with last dose documented as administer on 04/14/25 at 8:52 P.M. Review of the resident's documents tab in the electronic medical record showed no Controlled Drug Receipt, Record, and Disposition Form for clonazepam administered from 03/09/25 through discharge on [DATE]. Review of staff provided form titled Controlled Drug Receipt, Record, and Disposition Form, showed clonazepam 1 mg tablets, 30 tablets dispensed on 03/13/25 and no signed date as received at the facility. The form showed 10 tablets remained and last dose documented as administered on 04/14/25, at 7:45 P.M. During an interview on 07/29/25, at 9:00 A.M., Licensed Practical Nurse (LPN) A said when a resident discharged to home, the remaining medications were sent home with the resident, except controlled substance narcotics. Once a resident had been discharged the narcotics were to be disposed of by two nurses as soon as possible. During an interview on 07/29/25, at 9:15 A.M., CMT B said when a resident discharged , the narcotics did not go home with the resident. The medication stayed in the cart and staff continued to count during each shift change until the nurses were ready to dispose of the medications. The Assistant Director of Nursing (ADON) and a second nurse to dispose of the narcotics. He/she did not know what the schedule was for destroying medications. During an interview on 07/29/25, at 9:45 A.M., Registered Nurse (RN) C said when a resident discharged to home any remaining narcotics were not sent with the resident. The narcotic cards that were not in use were sent to the DON for destruction. The controlled drug receipt, disposition form was sent to medical records for upload to resident charts. He/she did not know if there was a schedule time to destroy medications. During an interview on 07/29/25, at 10:00 A.M., the Social Service Director (SSD) said once a discharge date was set for a resident, he/she started the process for discharge including preparing home health visits, equipment needed at home, and scheduling physician appointments. The staff sent medications, except narcotics, home with residents. The doctor would write a new order for narcotics to get to the follow up appointment. The nursing staff entered the pharmacy data base what medications were sent home with the resident. The medications that needed destroyed were locked up in the DON and ADON office to be disposed. He/she did not know the schedule when they were destroyed. During an interview on 07/29/25, at 10:15 A.M., Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) Coordinator said that once a resident was discharged home, he/she would get the resident paper records and ensure that all documents in the chart were uploaded to electronic medical record. This included controlled medication disposition papers. Narcotics were not sent home with the resident. He/she was not able to locate the April narcotic disposition paper for the resident. During an interview and observation on 07/29/25, at 10:30 A.M., the DON said that once a resident was discharged controlled substances were not sent with the resident. The left-over narcotics were destroyed, and the controlled substance disposition record was uploaded to the resident's electronic medical record. If she was not available, the narcotics were kept on the medication cart to continue to be counted each shift. Once the narcotic was given to her it was put into a locked cabinet in her locked office, it was not counted as it was behind two locks and no one else had access. When there was time two nurses destroyed the medications. Generally, the ADON and the DON destroyed the medications together, but there had not been an ADON for about two months. Additional overflow discontinued controlled substances were in the ADON office in a locked cabinet. The locked filing cabinet in the DON office contained two drawers filled with medications, containing 52 cards and 15 additional bottles of medications with the yellow disposition form folded on each item. Observation on 07/29/25, at 10:45 A.M., with the DON in the ADON office showed a locked desk drawer containing 84 medication cards with a yellow sheet of paper folder over each card. Review of the facility provided Controlled Drug Receipt, Record, and Disposition Forms, from the medications that were in the ADON and DON locked cabinets to be destroyed, showed the following:-Resident #1 - Clonazepam 1 mg, 30 tabs dispensed on 03/13/25, last given 04/14/25, 10 tabs remained and oxycodone 15 mg, 30 tabs dispensed on 04/01/25, last given 04/14/25, 16 remained;-Resident #2 - tramadol (used to treat moderate pain) 50 mg, 30 tabs dispensed 07/16/25, last given 07/18/25, 25 remained and tramadol 50 mg, 30 tabs dispensed 07/16/25, none given;-Resident #3 - hydrocodone/acetaminophen (APAP) (used to treat moderate to severe pain) 5/325 mg, 20 tabs dispensed on 07/07/25, last given 07/14/25, 14 remained; tramadol 50 mg, 30 tabs dispensed on 06/22/25, last given 07/07/25, 24 remained; and hydrocodone/APAP 5/325 mg, 30 tabs dispensed 07/08/25, none given;-Resident #4 - oxycodone 5 mg, 30 tabs dispensed on 6/30/25, none given; oxycodone 5 mg, 20 tabs dispensed on dated 6/28/25, none given; and oxycodone 5 mg, 30 tabs dispensed on 6/20/25, last given 07/13/25, four remained;-Resident #5 - oxycodone 5 mg, 30 tabs dispensed on 07/03/25, last given 7/15/25, 11 remained;-Resident #6 - tramadol 50 mg, 30 tabs dispensed on 03/20/25, last given 4/11/25, six remained; lorazepam (a controlled drug used to treat anxiety) 0.5 mg, 30 tabs dispensed on 04/02/25, none given; and tramadol 50 mg, 30 tabs dispensed on 04/0125, none given;-Resident #7 - oxycodone 5 mg, 30 tabs dispensed on 04/03/25, last given 04/14/25, 12 tabs remained;-Resident #8 - oxycodone 10 mg, 30 tabs dispensed on 06/11/25, last given 06/16/25, 26 tabs remained;-Resident #9 - oxycodone 5 mg, 20 tabs dispensed on 04/19/25, last given 04/24/25, 3 tabs remained;-Resident #10 - tramadol 50 mg, 20 tabs dispensed on 06/23/25, last given 07/01/25, 15 tabs remained and dipehn/atrop (diphenoxylate/atropine - used to treat diarrhea) 2.5 mg, 24 tabs dispensed on 06/09/25, last given 06/22/25, 18 tabs remained;-Resident #11 - tramadol 50 mg, 30 tabs dispensed on 06/04/25, last given 06/16/25, 12 tabs remained;-Resident #12 - zolpidem (a control drug, sedative) 5 mg, 30 tabs dispensed on 04/09/25, last given 04/23/25, 16 tabs remained;-Resident #13 - temazepam (a controlled drug, sedative) 30 mg, 14 tabs dispensed on 07/07/25, none given, 14 tabs remained; hydrocodone/APAP 5/325 mg, 30 tabs dispensed on 06/30/25, last given 07/08/25, 4 tabs remained; and hydrocodone/apap 5/325 mg, 30 tabs dispensed on 7/7/25, 30 tabs, none given;-Resident #14 - tramadol 50 mg, 26 tabs dispensed on 05/29/25, last given 06/28/25, 17 tabs remained and tramadol 50 mg, 30 tabs dispensed on 06/13/25, last given 07/02/25, 18 tabs remained;-Resident #15 - oxycodone 15 mg, 30 tabs dispensed on 03/19/25, last given 04/06/25, 11 tabs remained;-Resident #16 - hydrocodone 5/325 mg, 30 tabs dispensed on 06/09/25, none given, 30 tabs remained; hydrocodone 5/325 mg, 30 tabs dispensed on 06/02/25, last given 07/08/25, 12 tabs remained; and hydrocodone 5/325 mg, 30 tabs dispensed on 06/09/25, none given, 30 tabs remained;-Resident #17 - hydrocodone 5/325 mg, 30 tabs dispensed on 06/20/25, none given, 30 tabs remained;-Resident #18 - hydrocodone 5/325 mg, 30 tabs dispensed on 06/27/25, last given 07/13/25, 4 tabs remained;-Resident #19 - hydrocodone 5/325 mg, 15 tabs dispensed on 04/14/25, none given, 15 tabs remained;-Resident #20 - lorazepam 2 mg/milliliter (ml) concentrate, 30 ml dispensed on 02/25/25, last given 04/08/25, 20 ml remained;-Resident #21 - lorazepam 2 mg/ml intensol 30 ml dispensed on 05/05/25, none given; lorazepam 2 mg/ml concentrate 30 ml, dated 05/07/25, last given 05/09/25, 29ml remained; morphine sulfate (controlled drug used to treat moderate to severe pain) solution 100/5 ml, 30 ml dispensed on 05/07/25, last given 05/09/25, 24.75 ml remained; fentanyl (controlled drug used to treat moderate to severe pain) 25 microgram (mcg)/hour (hr.) patch, 5 patches dispensed on 03/17/25, none given; fentanyl 75 mcg/hr patch, 5 patches dispensed on 05/01/25, none given; fentanyl 50 mcg/hr patch, 5 patches dispensed on 04/10/25, last given 05/07/25, 4 remained; fentanyl 75 mcg/hr patch, 5 patches dispensed on 05/01/25, none given; hydrocodone/apap 7.5/325 mg, 30 tabs dispensed on 04/10/25, last given 5/8/25, 24 remained; and hydrocodone/apap 7.5/325 mg, 30 tabs dispensed on 04/10/25, none given;-Resident #22 - lorazepam 2 mg/ml, 30 ml dispensed on 03/14/25, last given 04/09/25, 28ml remained;-Resident #23 - morphine 20 mg/ml, 17 ml remain, last given 04/21/25, no amount dispensed, no date dispensed or received. First given 04/12/25; lorazepam concentrate 2 mg/ml, 30 ml dispensed on 04/09/25, last given 04/21/25, 8 ml remained; morphine sulfate 100/5 ml, 30 ml dispensed on 04/11/25, none given; lorazepam concentrate 2 mg/ml, 30ml dispensed on 04/11/25, none given; lorazepam concentrate 2 mg/ml, 30ml dispensed on 04/09/25, none given; lorazepam 0.5 mg tab, 30 tabs dispensed on 04/02/25, none given; and tramadol 50 mg, 20 tabs dispensed on 04/01/25, none given;-Resident #24 - lorazepam concentrate 20 mg/ml, 30 ml dispensed on 04/14/25, last given 04/16/25, 25.5 ml remained and morphine sulfate solution 100/5 mg, 30 ml dispensed on 04/14/25, last given 04/16/25, 28 ml remained;-Resident #25 - lorazepam concentrate 20 mg/ml, 30 ml dispensed on 04/10/25, last given 06/13/25, 11.25 ml remained; morphine sulfate solution 100/5ml, 30 ml dispensed on 4/10/25, last given 6/13/25, 19.75 ml remained; lorazepam 0.5 mg tab, 30 tabs dispensed on 06/03/25, last given 06/04/25, 29 remained; tramadol 50 mg, 12 tabs dispensed on 06/06/25, last given 06/11/25, 5 remained; and oxycodone 5 mg, 30 tabs dispensed on 12/16/24, last given 04/04/25, 9 remained;-Resident #26 - morphine sulfate oral 20 mg/ml, 30 ml dispensed on 05/04/25, last given 05/07/25, 26ml remained and lorazepam intensol 20 mg/ml, 30 ml dispensed on 05/04/25, last given 05/07/25, 26 ml remained;-Resident #27 - lorazepam concentrate 20 mg/ml, 30ml dispensed 04/13/25, last given 04/17/25. 27.5 ml remained; morphine sulfate oral 20 mg/ml, 30 ml dispensed on 04/14/25, last given 04/17/25, 28 ml remained; and hydrocodone/apap 7.5/325 mg, 20 dispensed on 04/13/25, last given 04/16/25, 14 tabs remained;-Resident #28 - nayzilam spray (used to treat seizures) 5 mg, 2 dispensed on 10/01/24, none given; lorazepam intensol, dispensed on 03/03/25, no amount dispensed, last given 04/17/25, 0 remained; morphine sulfate solution 100/5 ml, 21 received on 08/06/24, last given 04/17/25, 2 remained; lorazepam 0.5 mg tab, 30 tabs dispensed on 08/07/24, none given; lorazepam 0.5 mg tab, 30 tabs dispensed on 08/06/24, none given; and lorazepam 0.5 mg tab, 5 tabs dispensed on 08/07/24, last given 08/21/24, 4 remained;-Resident #29 - morphine sulfate solution 100/5 ml, 30 ml dispensed on 05/13/25, none given; lorazepam intensol 2 mg/ml, 30 ml dispensed on 05/13/25, last given 05/21/25, 28.5 ml remained; morphine sulfate solution 100/5 ml, 30 ml dispensed on 05/13/25, last given 05/23/25, 23.5 ml remained; and lorazepam intensol 2 mg/ml, 30 ml dispensed on 05/13/25, none given;-Resident #30 - lorazepam concentrate 2 mg/ml, 30 ml dispensed on 04/24/25, none given; Ativan (used to treat anxiety) no strength, 30 ml dated 04/24/25, none given; lorazepam concentrate 2 mg/ml, 30 ml dispensed on 03/17/25, last given 04/30/25, 15.5 ml remained; and morphine concentrate 100/5 ml, 30 ml no date dispensed, last given 05/01/25, 15 ml remained;-Resident #31 - morphine solution 20 mg/ml, 30 ml dispensed on 07/09/25, last given 07/15/25, 25.5 ml remained; lorazepam intensol solution 1 bottle dispensed on 07/03/25, last given 07/15/25, 28.75 ml remained; morphine sulfate solution 100/5 ml, 30 ml dispensed 07/14/25, none given; tramadol 50 mg, 30 tabs dispensed on 06/10/25, none given; and tramadol 50 mg, 30 tabs dispensed on 06/10/25, last given 07/09/25, 16 remained;-Resident #32 - hydrocodone 5/325 mg, 30 tabs dispensed on 06/26/25, last given 07/06/25, 21 tabs remained;-Resident #33 - oxycodone 5 mg, 30 tabs dispensed on 06/25/25, last given 07/24/25, 5 remained; and oxycodone 5 mg, 20 tabs dispensed on 07/21/25, none given;-Resident #34 - morphine concentrate, no strength noted, no dated received or dispensed, 30 ml dispensed, last given 07/09/25, 25.25 ml remained; and lorazepam concentrate 2 mg/ml, 30 ml dispensed on 07/03/25, last given 07/09/25, 22 remained;-Resident #35 - buprenorphin (used to treat pain and opioid disorder (dependence on narcotics) sublingual (SL - under the tongue) 2 mg, 30 dispensed on 06/23/25, none given; buprenorphin sublingual 2 mg, 30 dispensed on 06/23/25, none given; and buprenorphin sublingual 2 mg, 30 dispensed on 06/23/25, last given 06/26/25, 16 remained;-Resident #36 - morphine sulfate solution 20 mg/ml, 1 bottle dispensed 05/07/25, last given 07/20/25, 20.5 ml remained;-Resident #37 - lorazepam 0.5mg tab, 30 tabs dispensed 02/08/25, last given 03/31/25, 15 remained;-Resident #38 - clonazepam ODT tab 0.25 mg, 30 tabs dispensed 04/16/25, last given 05/08/25, 10 remained and tramadol 50 mg, 30 tabs dispensed 04/16/25, last given 05/06/25, 18 remained;-Resident #39 - hydrocodone/apap 5/325 mg, 30 tabs dispensed on 06/07/25, 17 tabs remained and modafinil (used to treat a sleep disorder) 100 mg, 28 dispensed on 06/08/25, last given 06/12/25, 25 remained;-Resident #40 - oxycodone 5 mg, 30 tabs dispensed 04/27/25, last given 05/10/25, 8 remained;-Resident #41 - oxycodone 5 mg, 20 tabs dispensed on 05/23/25, last given on 05/30/25, 2 tabs remained;-Resident #42 - oxycodone 5 mg, 20 tabs dispensed on 04/23/25, last given 05/05/25, 11 tabs remained;-Resident #43 - tramadol 50 mg, 30 tabs dispensed on 06/03/25, last given 06/05/25, 29 tabs remained;-Resident #44 - oxycodone 10 mg, 30 tabs dispensed on 05/20/25, last given 06/06/25, 7 tabs remained and buprenorphin sublingual 2 mg, 14 tabs dispensed on 05/07/25, last given 06/05/25, 4 remained;-Resident #45 - zolpidem 5 mg, 30 tabs dispensed on 05/23/25, none given; zolpidem 5 mg, 14 tabs dispensed on 06/01/25, none given; zolpidem 5 mg, 10 tabs dispensed on 04/23/25, last given 05/28/25, 4 remained; buprenorphin sublingual 2 mg, 20 tabs dispensed on 05/23/25, last given 06/01/25, 19 remained; and buprenorphin sublingual 2 mg, 20 tabs dispensed on 05/23/25, last given 06/23/25, 12 remained;-Resident #46 - triazolam (used to treat anxiety) 0.25 mg, 14 tabs dispensed on 04/24/25, none given;-Resident #47 - oxycodone 5 mg, 12 tabs dispensed on 04/22/25, none given and oxycodone 5 mg, 30 tabs dispensed on 04/26/25, none given;-Resident #48 - phenobarb (used to treat seizure activity) 32.4 mg, 1 tab dispensed 07/07/25, last given 07/25/25, 1 tablet remained; chlordiazepam (used to treat anxiety) 5 mg, 28 caps dispensed on 07/07/25, last given 07/24/25, 3 remained; oxycodone 5 mg, 30 tabs dispensed on 06/09/25, last given 07/25/25, 12 tabs remained; oxycodone 5 mg, 30 tabs dispensed on 06/12/25, last given 07/19/25, 6 tabs remained; oxycodone 5 mg, 20 tabs dispensed on 07/21/25, none given; phenobarb 32.4 mg, 30 tabs dispensed on 07/07/25, none given; and oxycodone 5 mg, 30 tabs dispensed on 06/10/25, none given;-Resident #49 - clonazepam 1 mg, 30 tabs dispensed on 04/18/25, last given 05/12/25, 11 remained and clonazepam 0.5 mg, 30 tabs dispensed on 05/13/25, last given 06/02/25, 1 remained;-Resident #50 - tramadol 50 mg, 30 tabs dispensed on 05/12/25, none given and tramadol 50 mg, 30 tabs dispensed on 04/11/25, last given 06/02/25, 4 remained;-Resident #51 - hydrocodone/apap 5/325 mg, 30 tabs dispensed on 05/12/25, last given 5/18/25, 27 remained;-Resident #52 - tramadol 50 mg, 20 tabs dispensed on 04/18/25, last given 04/20/25, 19 tabs remained;-Resident #53 - tramadol 50 mg, 30 tabs dispensed on 02/19/25, last given 04/11/25, 11 remained;-Resident #54 - tramadol 50 mg, 20 tabs dispensed on 05/28/25, last given 06/05/25, 7 remained;-Resident #55 - tramadol 50 mg 30 tabs dispensed on 04/28/25, last given 05/07/25, 26 remained and oxycodone 5 mg, 30 tabs dispensed on 04/28/25, last given 05/06/25, 21 tabs remained;-Resident #56 - buprenorphin sublingual 2 mg, 15 tabs dispensed on 05/10/25, none given and buprenorphin sublingual 2 mg, 15 tabs dispensed on 05/10/25, none given;-Resident #57 - oxycodone 5mg, 10 dispensed on 01/21/25, last given 05/04/25, 8 remained;-Resident #58 - buprenorphin sublingual 2 mg, 30 tabs dispensed on 05/02/25, none given; buprenorphin sublingual 2 mg, 30 tabs dispensed on 05/02/25, none given; and buprenorphin sublingual 2 mg, 30 tabs dispensed on 05/02/25, last given 05/26/25, 12 remained;-Resident #59 - Oxycontin ER (controlled pain medication) 10 mg, 14 tabs dispensed on 04/21/25, last given 04/23/25, 10 remained; hydrocodone/apap 10/325 mg, 30 tabs dispensed 04/26/25, last given 05/02/25, 21 remained; and diphen/atrop tab 2.5 mg, 30 tabs dispensed on 04/15/25, none given;-Resident #60 - hydrocodone/apap 5/325mg, 30 tabs dispensed 04/14/25, last given 04/26/25, 5 remained and oxycodone 5 mg, 30 tabs dispensed 03/24/25, last given 04/25/25, 26 remained;-Resident #61 - oxycodone 5 mg, 30 tabs dispensed on 03/24/25, last given 04/25/25, 26 remained;-Resident #62 - oxycodone 5 mg, 30 tabs dispensed on 04/07/25, last given 04/24/25, 11 remained; oxycodone 5 mg, 30 tabs dispensed on 04/21/25, none given; oxycodone 5 mg, 30 tabs dispensed on 04/07/25, last given 04/24/25, 1 remained; and oxycodone 5 mg, 30 tabs dispensed on 04/21/25, none given;-Resident #63 - oxycodone 5 mg, 30 tabs dispensed on 04/18/25, last given 04/23/25, 20 remained; tramadol 50 mg, 20 tabs dispensed on 03/03/25, last given 03/11/25, 10 remained; and oxycodone 5 mg, 30 tabs dispensed on 04/18/25, last given 04/23/25, 20 remained;-Resident #64 - tramadol 50 mg, 30 tabs dispensed on 07/20/25, none given and tramadol 50 mg, 10 tabs dispensed on 07/20/25, last given 07/20/25, 9 remain;-Resident #65 - oxycodone 5 mg, 30 tabs dispensed on 06/27/25, last given 07/03/25, 14 remained;-Resident #66 - oxycodone 5 mg, 20 tabs dispensed on 07/14/25, last given 07/28/25, 1 tabs remained;-Resident #67 - oxycodone 5 mg, 30 tabs dispensed on 03/26/25, last given 04/08/25, 18 tabs remained;-Resident #68 - oxycodone 5 mg, 30 tabs dispensed on 04/15/25, last given 04/19/25, 27 remained;-Resident #69 - oxycodone 5 mg, 30 tabs dispensed on 04/02/25, last given 04/05/25, 26 remained;-Resident #70 - oxycodone 5 mg, 30 tabs dispensed on 04/25/25, last given 04/29/25, 16 remained;-Resident #71 - oxycodone 20 mg, 30 dispensed on 04/11/25, last given 4/28/25, 2 remained and oxycodone 10 mg, 30 dispensed on 04/10/25, last given 4/27/25, 5 remained;-Resident #72 - hydrocodone/apap 5/325 mg, 30 dispensed on 04/24/25, last given 05/03/25. 25 remained;-Resident #73 - oxycodone 5 mg, 30 dispensed on 05/27/25, last given 6/8/25, 25 remained. During an interview on 07/29/25, at 11:30 A.M., the Administrator said narcotics were not commonly sent home with residents on discharge. The remaining medications were kept locked up and counted in the medication cart until two nurses could remove them and destroy them. The medication should be destroyed in a timely manner, ideally within 30 days. He was aware that staff had gotten behind with destroying narcotics. He was not aware that there were 159 cards of narcotics dating back to April 2025 waiting to be destroyed. Complaint 2560530

Based on observations, record review, and interviews, the facility failed to ensure staff assessed one resident (Resident #30), of two sampled residents reviewed for self-administration of medications, to determine if they were clinically appropriate and safe to self-administer medications before allowing them to administer their own medication. Review the facility policy titled, Medications, Self-Administration, Self Storage, Leave At Bedside, undated, showed the following: -The resident has a right to self-administer medication unless the interdisciplinary team has determined that this practice is unsafe for an individual resident; -If a resident expresses a desire to self-administer medication, the interdisciplinary team must assess the resident's cognitive, physical, and visual ability to carry out this responsibility. The mental status and any psychiatric diagnoses must be taken into account. The 'Evaluation Assessment to Self-Administer Medications will be used for this purpose; -When the resident self-administers medications, the resident will be re-assessed on an ongoing basis for continued safety of this practice. The evaluation assessment will be completed annually or with significant change by nursing and reviewed by the interdisciplinary team to determine if the resident is still capable of self-administer medications; -The physician's order sheet will reflect the current status of the resident's self-administering medications. 1. Review of Resident #30's Resident Face Sheet showed the following: -admission date of 08/09/19, with the most recent readmission date of 07/03/23; -Diagnoses included acute respiratory failure with hypoxia (decreased oxygen level) and hypercapnia (increased carbon dioxide level in the bloodstream typically caused by inadequate respiration) and acute bronchitis. Review of a resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 03/07/24, showed the resident had moderate cognitive impairment. Review of the resident's current Care Plan showed the following: -Start date of 08/19/19, indicated the resident had an alteration in respiratory status due to anemia and asthma; -The care plan directed staff to administer the resident's medications as ordered. (The staff did not care plan regarding the resident's ability to self-administration of any medications.) Review of the resident's Observation History, dated 02/19/23 through 03/20/24, showed staff did not document completion of a self-administration of medication evaluation for the resident. Review of the resident's Physician's Order Report, dated 02/20/24 through 03/20/24, showed the following: -An order, dated 09/22/19, for an albuterol sulfate aerosol inhaler (used to treat difficulty breathing), two puffs by inhalation every six hours for asthma. The order included, Special Instructions: May keep at bedside; however, the resident's Physician Order Report did not reflect orders for self-administration of their albuterol inhaler. Observations and interview on 03/20/24, at 9:01 A.M., showed a Ventolin inhaler (the name brand for albuterol) at the resident's bedside. The resident said the inhaler stayed in their room all the time. The resident said the nurses were aware the inhaler was in their room since the nurses were the ones that brought the inhaler to the room for the resident's use. During an interview on 03/20/24, at 10:30 A.M., Certified Medication Technician (CMT) #6 said he/she was aware the resident had an order to keep their inhaler at bedside. He/she thought the resident had been assessed for self-administration and acknowledged the resident administered their inhaler independently. During an interview on 03/20/24, at 11:17 A.M., the Director of Nursing (DON) said prior to a resident being allowed to self-administer medication a self-administration assessment had to be completed and an order for self-administration obtained from the physician. The DON said assessments for self-administration of medications was completed quarterly and with any change in a resident's condition and could be found in the electronic medical record (EMR) under the observation history. The DON stated there were no residents in the facility that had been approved to self-administer medications.

Based on interviews, and record review, the facility failed to resolve a grievance and document full resolution of the grievance for one resident (Resident #8) of two residents reviewed for grievances. Review of an undated facility policy titled Resident Grievances showed the following: -The coordinator (or designee) shall conduct an investigation of the complaint to determine its validity. This investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint; -The coordinator will maintain files and records of the facility, relating to such grievances; -The coordinator will issue a written decision on the grievance no later than 30 days after its filing. 1. Review of Resident #8's Resident Face Sheet showed the following: -admission date of 12/09/21; -Diagnoses included chronic diastolic (congestive) heart failure (a long-term condition in which the heart can't pump blood well enough to meet the body's needs), acute kidney failure, anemia (a condition in which the body does not have enough healthy red blood cells), type 2 diabetes mellitus with hyperglycemia (high blood sugar levels), and chronic pain syndrome. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 03/05/24, showed the resident was cognitively intact. Review of the resident's current Care Plan showed the following: -As of 12/22/21, the resident had a problem telling staff what they want or understanding staff instructions due to being hard of hearing, and the resident wore bilateral hearing aids; -Intervention directed staff to answer the resident's questions and repeat them as necessary, observe the resident to see if they understand, and allow the resident time to respond and give the resident cues/reminders if needed. Review of a facility document titled Concern/Grievance Report, dated 02/05/24, showed the following: -The resident initiated a grievance due to $200.00 being misplaced; -On 02/09/24, the facility resolved the grievance and noted, $100 was found in residents personal wallet continue search of other misplaced funds. During an interview on 03/18/24, at 11:00 A.M., the resident said they had $200.00 go missing at the facility. The Director of Nursing (DON) located $100 in their room during a search. The resident said a $100.00 was still missing, and the facility did nothing else. During an interview on 03/21/24, at 10:35 A.M., the DON said she had filed a report with the state agency as a result of the resident's grievance filed on 02/05/24. The DON indicated that they were finished with the investigation after locating some of the missing money. During an interview on 03/21/24, at 2:15 P.M., the Social Worker (SW) said she worked as the facility grievance coordinator. When she received a report of a concern or a grievance form, she interviewed the person who filled out the grievance form. She took the investigation data that was gathered to the head of the department and let them come up with a solution. She then shared the resolution with the Administrator and then with the family members verbally over the phone. The resident reported they were missing $200 cash in February (2024). The DON informed her of the grievance for the missing money. The SW oversaw this grievance and worked with the DON. The SW looked in the resident's wallet the day that the $200.00 cash was reported missing, and there was no money in the resident's wallet. Some of the money was located, but she was unaware of who had located it. After locating some of the money, they stopped the investigation.

Based on observation, interview, and record review, the facility failed to ensure two (Resident #12 and Resident #72) of 2 residents reviewed for activity of daily living (ADL) care received services to maintain grooming/personal hygiene. Specifically, the facility failed to ensure staff provided nail care and shaved facial hair for Resident #2 and #72. In addition, the facility failed to assist Resident #72 with a bath/shower twice weekly in March 2024 per the facility's shower schedule. Review of a facility policy titled Activities of Daily Living (ADL), undated, showed the purpose of the policy was to assist resident in achieving maximum function. (The policy did not addressed assisting residents with shaving or nail care. Review of the facility's Certified Nursing Assistant (CNA) Job Description, dated May 2006, showed the following: -CNA provides personal hygiene needs, including bath (complete, partial, tub/shower, Sitz and skin care); -CNA provides other duties as assigned; -CNA must have the ability to provide personal care for the frail elderly and for acute, chronic, and terminally ill patients. 1. Review of Resident #12's Resident Face Sheet showed the following: -admission date of 02/03/24; -Diagnoses included weakness, personal history of transient ischemic attack (TIA - a short period of symptoms similar to those of a stroke), chronic pain, rash, and aphasia (a brain disorder where a person has trouble speaking or understanding other people speaking). Review of Resident #12's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 02/09/24, showed the following: -Resident dependent on staff for a shower/bathing and required partial/moderate assistance with personal hygiene (including shaving and washing/drying the face and hands); -Resident had upper and lower extremity impairment on one side; -Resident exhibited no behavior symptoms of rejection of care. Review of the resident's current Care Plan, dated 02/03/24, showed the following: -Resident at risk for pressure ulcers related to immobility, incontinence, and the need for extensive assistance with transfers; -Staff to keep the resident clean and as dry as possible. (Staff did not care plan regarding the resident's personal hygiene needs or preferences.). Review of the facility's shower schedule showed the resident was scheduled to receive a shower every Tuesday and Friday. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review, dated February 2024 and March 2024, showed the following: -Staff were required to document whether the resident's toenails needed to be trimmed; -There was no specific area that prompted staff to document whether the resident was shaved or their fingernails were trimmed; -Staff wrote on the 03/07/24 shower form that the resident was shaved and their nails were cleaned and trimmed; -The resident's last documented shower was on 03/14/24. Staff did not document regarding the resident's nails or shaving of the resident on that day. During an interview on 03/18/24, at 11:16 A.M., the resident nodded their head to indicate yes when asked if they would like to be shaved and if they would like their nails to be shorter. Observations on 03/19/24, at 8:03 A.M. and 10:53 A.M., showed the resident had facial hair and long that needed to be trimmed. During an interviews on 03/19/24, at 11:15 A.M., CNA #13 said the resident liked to be shaved, noting the last time he/she provided the resident a shower was on 03/04/24 (15 days prior). At that time the CNA had shaved the resident and trimmed their nails. The resident did not refuse ADL (activities of daily living - dressing, grooming, bathing, eating, and toileting) care. During an interview on 03/20/24, at 11:40 A.M., Licensed Practical Nurse (LPN) #16 said he/she did not think the resident refused showers/bathing, noting staff should make sure the resident's nails were trimmed and facial hair was shaved. 2. Review of Resident #72's Resident Face Sheet showed the following: -admission date of 12/28/23; -Diagnoses included pain, other reduced mobility, personal history of TIA, osteoarthritis (a type of arthritis that happens when the cartilage that lines the joints is worn down and bones rub against each other) of hip, scoliosis (a sideways curve of the spine), other intervertebral disc degeneration and radiculopathy (a range of symptoms produced by the pinching of a nerve root in the spinal column) of the lumbar region, and age-related osteoporosis (a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes). Review of the resident's admission MDS, with an ARD of 01/03/24, showed the following: -Resident had intact cognition; -Resident needed setup or clean-up assistance from staff with showers/bathing and personal hygiene (including shaving and washing/drying the face and hands); -Resident had upper and lower extremity impairment on one side and exhibited no behavior symptoms of rejection of care. Review of the resident's current Care Plan showed the following: -An area, dated 01/11/24, for the resident's ability to complete ADLs, including, in part, maintaining personal hygiene, had deteriorated related to a recent health decline. (Staff did not care plan interventions to ensure the resident's personal hygiene needs were met.) Observation and interview on 03/18/24, at 10:57 A.M., showed the resident had long fingernails and facial hair. The resident said their nails were too long and they did not like having a beard. The resident said they received a shower once a week. During an interview on 03/19/24, at 2:03 P.M., the resident said they did not get a shower the previous day as scheduled, noting it had been quite a few days since they had a bath or shower. Observation and interview on 03/20/24, at 11:12 A.M., showed the resident continued to have long facial hair and long fingernails. The resident said they would like to have their face shaved and nails trimmed when they got a shower/bath, but staff did not offer. Review of the facility's shower schedule showed the resident was scheduled to receive a shower on Mondays and Thursdays. The instructions showed for staff to mark who received a shower or refused, complete shower sheet, and put in shower book in alphabetical order by last name. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review, dated March 2024, showed the following: -Staff documented they assisted the resident with a bed bath on Monday, 03/04/24; Monday, 03/11/24; and Tuesday, 03/19/24; -Staff did document assisting the resident with a shower on Thursday, 03/07/24; or Thursday, 03/14/24; -Staff did not document regarding shaving the resident or trimming his/her fingernails. During an interview on 03/20/24, at 11:14 A.M., Registered Nurse (RN) #12 said the resident did not always like to take a shower, but staff could provide an adequate bed bath, trim their fingernails, and shave their facial hair. During an interview on 03/20/24, at 11:24 A.M., CNA #13 said he/she had never assisted never assisted the resident with a shower, but typically made sure to offer to shave the resident and trim their nails. During an interview on 03/20/24 at 11:34 A.M., CNA #15 said he/she gave the resident a bed bath on 03/17/24, but failed to complete a shower sheet. He/She stated he/she did not offer to trim the resident's nails and did not offer to shave the resident, but he/she should have offered the services to the resident. During an interview on 03/20/24, at 11:40 A.M., Licensed Practical Nurse (LPN) #16 said the resident refused showers at times, but most of the time, the resident would allow staff to provide a bed bath. Staff should also ensure the resident's facial hair was shaved and nails were trimmed per the resident's preferences. 3. During an interview on 03/20/24, at 11:14 A.M., RN #12 said staff should complete a shower sheet after a bath or shower. The shower or bath process should include shaving and nail care. Staff were also supposed to shave all residents and trim their nails when needed. 4. During an interview on 03/20/24, at 11:24 A.M., CNA #13 said that showers were provided twice per week, noting residents should be shaved and have their fingernails trimmed when needed. 5. During an interview on 03/20/24, at 11:34 A.M., CNA #15 said showers and bathing should include shaving a resident and trimming the resident's nails, noting staff should complete a shower sheet. If a resident refused a bath or shower, he/she would document the refusal on the shower sheet. 6. During an interview on 03/20/24, at 11:27 A.M., CNA #14 said shaving and trimming nails were part of a bath or shower. Shower sheets were completed and placed in a binder at the nurses' station. Staff should offer to trim the residents' nails and shave them when providing baths/showers. 7. During an interview on 03/20/24, at 2:45 P.M., CNA #17 said when providing a shower or bath, staff should offer to shave facial hair and trim the residents' fingernails. 8. During an interview on 03/20/24, at 11:40 A.M., Licensed Practical Nurse (LPN) #16 said shower sheets should be completed for baths and showers. Staff were to offer to trim residents' nails and shave the residents when providing showering assistance. 9. During interviews on 03/20/24, at 8:22 A.M. and 2:52 P.M., the Director of Nursing (DON) said she expected staff to provide two showers weekly and, on alternating days, staff should provide a bed bath. She expected residents' nails to be trimmed and clean and for staff to offer to shave residents' faces every day. 10. During an interview on 03/20/24, at 3:03 P.M., the Administrator said he had high standards and expected residents to be well groomed and bathed. He said he expected staff to offer to shave residents and trim their nails as needed, particularly when long or dirty.

Based on record review, and interviews, the facility failed to monitor and document the bruit (a whooshing sound that can be heard with a stethoscope) and thrill (gentle vibration caused by blood flow) of a resident's arteriovenous (AV) shunt for one resident (Resident #61) of one sampled resident reviewed for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services. Review of a facility's policy titled, Dialysis, Care of a Resident Receiving, undated, showed the following: -Purpose to utilize the following guideline to provide care for a resident that is receiving dialysis; -Care of the AV shunt/fistula/graft specified, feel for the thrill sensation daily; -Checking the thrill sensation specified nurses will check the thrill daily and document daily. This will be documented on the resident's treatment record; -At the AV site feel for a pulse. The pulse is the blood flow through the access; -If no thrill sensation is felt notify the physician. 1. Review of Resident #61's Resident Face Sheet showed the following: -admission date of 09/28/22 with a readmission date of 06/10/23; -Diagnoses included end stage renal disease (ESRD), anxiety, and type two diabetes mellitus with diabetic nephropathy (the chronic loss of kidney function occurring in those with diabetes mellitus). Review of a quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 01/02/24, showed the following: -Resident was cognitively intact; -Received dialysis services while a resident of the facility. Review of the resident's current Care Plan showed the following: -A focus area, with a start date of 09/28/22, showing the resident had an alteration in kidney function related to ESRD; -Resident received hemodialysis each Monday, Wednesday, and Friday; -Encourage the resident to go to dialysis as ordered per the facility van, administer medications as ordered, check the resident's dialysis access site daily for signs or symptoms of infection, and to notify the physician of significant changes. (Staff did not care plan related to checking the bruit or thrill of the resident's AV shunt.) Review of the resident's Active Orders and Order History showed the following: -An order, dated 09/28/22, for staff to monitor the resident's AV site for signs and symptoms of infection every shift; -An order, dated 06/10/23, for dialysis three times per week on Mondays, Wednesdays, and Fridays. (There was no order to check the resident's AV shunt for bruit and thrill until 03/19/24, during the survey.) Review of the resident's Medication Administration Record, dated 03/01/24 to 03/19/24, showed staff did not document monitoring the bruit and thrill of the resident's AV shunt prior to 03/19/24. During an interview on 03/19/24, at 1:23 P.M., Licensed Practical Nurse (LPN) #1 said the resident currently had an AV shunt for dialysis access. Staff observed the resident's AV shunt daily for any redness or other changes, but did not check the bruit and thrill. If staff were supposed to check the bruit and thrill, there would be orders prompting them to do so. LPN #1 confirmed he/she had not been checking the bruit and thrill for the resident's AV shunt. During an interview on 03/19/24, at 2:39 P.M., the resident said their AV shunt was in their left arm. Per the resident, nursing staff felt around the shunt site periodically, but did not routinely assess their AV shunt site using a stethoscope. During an interview on 03/19/24, at 3:39 P.M., LPN #2 said when a resident was received dialysis, nursing staff checked the resident's AV shunt site for any swelling or bleeding and also checked the bruit and thrill to ensure blood was flowing and the AV shunt was functioning properly. It was important to check the bruit and thrill of an AV shunt, because it could alert nursing staff if something was wrong with the shunt. After reviewing the resident's orders, LPN #2 confirmed there was no order directing staff to check the bruit and thrill, but indicated he/she did so anyway out of habit. During an interview on 03/21/24, at 9:21 A.M., the Director of Nursing (DON) said when a resident was on dialysis and had an AV shunt, she expected nursing staff to check the bruit and thrill every shift to ensure proper blood flow. The DON was unaware there was no order directing staff to check the resident's bruit and thrill prior to 03/19/24. During an interview on 03/21/24, at 9:23 A.M., the Administrator said he expected an order to be in place for nursing staff to monitor and document the bruit and thrill of a dialysis resident's AV shunt.

Based on observation, interview, and record review, the facility failed to ensure the physician reviewed and acted upon medication irregularities reported by a Consultant Pharmacist in a timely manner for one resident (Resident #16) of five residents reviewed for unnecessary medications. Review of facility guideline titled, Drug Review, undated, showed the following: -All medications given to each resident will be reviewed on a monthly basis in order to review drug interactions, ensure adherence to stop orders. ensure accuracy in administration, and evaluate medications appropriate to diagnosis; -The pharmacist reviews all federal indicators, and a monthly report form is filled out to show any problem areas. The report lists any problems noted, the date, and signature of reporter; -Medications should not show unnecessary or excessive use and should have a diagnosis to support them; -Problems identified shall be addressed according to need in consultation with physician; -Follow up on problems needs either the Director of Nursing's (DON) or pharmacist's signature to show that the problem has been addressed; -Any order changes are handled in the proper manner and changes conveyed to pharmacy. 1. Review of Resident #16's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 01/22/24, showed the following: -admission date of 01/16/24; -Diagnoses included non-Alzheimer's dementia and unspecified disorientation; -Resident was unable to complete the interview to determine cognition; -Resident rejected care and had verbal behavioral symptoms directed toward others; -In the prior seven days or since admission, the resident had taken antipsychotic, hypnotic, and opioid medications; -There was a documented indication for use of the medications. Review of the resident's Care Plan, dated 01/16/24, showed the following: -Resident received psychotropic medications and had a potential for drug-related complications associated with the use of Seroquel (quetiapine - an antipsychotic medication) and lorazepam (a sedative, antianxiety medication); -Interventions directed staff to monitor for side effects and indicated the doctor and the pharmacist would review the resident's medications monthly for possible problems and to determine if the resident could take a lower dose. Review of the resident's Physician Order Report, dated 01/01/24 through 01/31/24, showed the following: -An order, dated 01/16/24, for oral lorazepam intensol 2 milligrams (mg)/milliliter (mL), providing 0.5 mL (1 mg) by mouth every four hours as needed (PRN) for unspecified dementia at an unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; -An order, dated 01/16/24, for delayed-release divalproex (Depakote - anticonvulsant, migraine headache preventer, and bipolar therapy agent) 125 milligrams (mg) daily, oral, at bedtime for a diagnosis of other specified health status; -An order, dated 01/19/24, for lorazepam intensol 2 mg/mL, provide 1 mL (2 mg) for agitation PRN every four hours with a diagnosis identified as unspecified dementia at an unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. (Staff did not document discontinuation of the 01/16/24 order.); -A current order for Robitussin Cough+Chest Congestion DM (dextromethorphan-guaifenesin) liquid, 5-100 mg/5 mL, providing 10 mL by mouth for acute cough PRN. (The order did not indicate how often staff could administer the medication.) Review of the resident's Pharmacist's Recommendation to Prescriber forms, with a recommendation date of 01/31/24, showed the following: -The resident had two PRN orders for lorazepam intensol, one directing staff to provide one mg every four hours as needed (ordered 01/16/24) and one directing staff to provide two mg every four hours as needed (ordered on 01/19/24). The pharmacist indicated the orders must specify when to give the 1 mg dose and when to give the 2 mg dose; -The pharmacist indicated the PRN lorazepam intensol orders lacked a stop date and that the Centers for Medicare and Medicaid Services (CMS) required for PRN orders for psychotropic drugs be limited to 14 days unless the prescriber documented the diagnosed specific condition being treated, the rationale for the extended time period, and the duration for the PRN order in the medical record; -The consultant pharmacist asked the prescriber to consider particular clarifications pertaining to the lorazepam intensol orders/diagnosis; -There was no documentation the prescribing physician reviewed/acted upon the pharmacy recommendations from 01/31/24 until 03/18/24, after the survey was initiated. Review of the resident's Pharmacist's Recommendation to Prescriber forms, with a recommendation date of 01/31/24, revealed the following: -The resident had an order for PRN Robitussin Cough+Chest Congestion DM that lacked a PRN dosing interval. The pharmacist documented that the order was incomplete without the PRN dosing interval. The pharmacist recommended the prescriber consider clarification of the dosing interval to every four hours PRN for cough or chest congestion; -There was no documentation the prescribing physician reviewed/acted upon the pharmacy recommendation from 01/31/24 until 03/18/24, after the survey was initiated. Review of the resident's Pharmacist's Recommendation to Prescriber forms, with a recommendation date of 01/31/24, showed the following: -The resident was receiving divalproex acid (Depakote) for dementia with behavioral disturbance. The pharmacist recommended the prescriber consider one of the following: obtaining laboratory (lab) tests that included a complete blood count (CBC), comprehensive metabolic panel (CMP), and a valproic acid (Depakote) level on the next routine lab day; obtaining a valproic acid level only on the next routine lab day; or denoting that lab tests were not necessary at the time due to hospice/clinical goals; -There was no documentation the prescribing physician reviewed/acted upon the pharmacy recommendations from 01/31/24 until 03/18/24, after the survey was initiated. Observation on 03/18/24, at 9:45 A.M., showed the resident had their eyes closed while in bed. Observation 03/18/24, at 10:30 A.M. showed the resident was sleeping. Observation on 03/19/24, at 9:00 A.M., showed the resident had their eyes closed in a wheelchair in front of a television by a day room. During an interview on 03/18/24, at 2:00 P.M., the resident's representative said during every visit they had with the resident, the resident was sleeping, and it was difficult to awaken the resident. During an interview on 03/20/24, at 9:00 AM, the Pharmacy Consultant said all residents' medications regimens were reviewed monthly. If there was an urgent recommendation, she contacted the facility immediately and, if the recommendation was not urgent, she emailed the recommendations to the DON and prescribing physician. The resident's 01/31/24 recommendations were emailed to facility staff on 02/19/24. She stated when she completed another resident review on 02/29/24, the physician had not addressed some of the recommendations; however, she did not address that with the facility. During an interview on 03/19/24, at 3:26 P.M., the Medical Director said he had not seen the pharmacy recommendations for the resident from 01/31/2024. The Pharmacy Consultant normally emailed the recommendations, and he typically addressed those recommendations within seven to ten days. During an interview on 03/20/24, at 10:46 A.M., the DON said the Pharmacy Consultant emailed medication regimen recommendations to the DON and Medical Director. Pharmacy recommendations should be sent to the facility within a few days of the consultant pharmacist's review. The DON was not aware that the Medical Director had not addressed the Pharmacy Consultant's recommendations for the resident. During an interview on 03/20/24, at 9:29 A.M., the Administrator said he had not received any concerns from the Pharmacy Consultant or other staff that the Medical Director was not addressing pharmacy reviews/recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure an expired medication was not stored in a resident's room for one resident (Resident #8) of 21 sampled residents. Review of the facility policy titled, Medications, Storage of, undated, showed the following: -All medications for residents must be stored at or near the nurses' station in a locked cabinet, a locked medication room, or one or more locked mobile medication carts; -No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. 1. Review of Resident #8's Resident Face Sheet showed an admission date of [DATE]. Observations on [DATE], at 11:18 A.M., showed a tube of hydrocortisone cream in the resident's room. The cream had an expiration date of [DATE]. During an interview on [DATE], at 11:22 A.M., Licensed Practical Nurse (LPN) #1 said the hydrocortisone cream in the resident's room had an expiration date of [DATE]. He/she had not previously seen the cream in the resident's room. During an interview on [DATE], at 11:15 A.M., the Director of Nursing (DON) said she was not aware that the resident had expired hydrocortisone cream in their room. Certified nurse assistants (CNAs) periodically looked for medications in residents' rooms and said she expected them to remove and report any items they found.

Based on observations and interviews, the facility failed to ensure a privacy curtain was in place between two residents (Resident #16 and Resident #17) who resided in one of 48 semi-private rooms in the facility. 1. Observations on 03/18/24, at 11:59 A.M., showed Resident #16 and Resident #17 shared a semi-private room. The privacy curtain between their beds was missing. Observations on 03/19/24, at 12:04 P.M., and on 03/20/24, at 10:35 A.M., showed the privacy curtain between the two residents was missing. During an interview on 03/20/24, at 12:09 P.M., Certified Nurse Assistant (CNA) #9 said he/she had been employed at the facility for approximately one year and did not recall if there had ever been a privacy curtain between the residents' beds. He/she did not think the privacy curtain was a concern due to the poor cognition of both residents. During an interview on 03/20/24, at 12:19 P.M., Licensed Practical Nurse (LPN) #8 said he/she was not aware of the missing privacy curtain in residents' room. If it had been brought to his/her attention, he/she would have contacted housekeeping or maintenance staff to address the concern. During an interview on 03/20/24, at 12:40 P.M., the Environmental Supervisor said a floor technician took the privacy curtain down from the residents' room on 03/17/24 to wash it. A replacement curtain should have been hung when it was taken down to wash; however, the Environmental Supervisor said the facility had a limited supply of replacement curtains available and was unsure if a replacement was available on 03/17/24. During an interview on 03/21/24, at 9:30 A.M., the Director of Nursing (DON) said semi-private rooms should have privacy curtains to provide privacy for the residents. The cognitive status of the residents was irrelevant and indicated all residents should have privacy curtains. During an interview on 03/21/24, at 10:30 A.M., the Administrator said semi-private rooms should have privacy curtains to provide privacy for the residents. The Administrator was not aware of a limited supply of privacy curtains and indicated if a curtain was taken down, a replacement curtain should be hung immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #46's Resident Face Sheet showed the following: -admission date of 08/09/22; -Diagnoses included allergic rhinitis (inflammation and swelling of the mucous membrane of the nose), chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), acute and chronic respiratory failure with hypercapnia (increased carbon dioxide levels in the bloodstream), altered mental status, respiratory failure, and vascular dementia with behavioral disturbance. Review of the resident's quarterly MDS, with an ARD of 02/11/24, showed the resident had moderate cognitive impairment. Observation on 03/18/24, at 9:25 A.M., showed medications were at the resident's bedside on the resident's rolling tray table. The medications included a three-ounce (oz) bottle of antifungal powder, fluticasone propionate nasal spray 60 milligrams (mg), and an Advair Diskus inhaler. During an interview at the time of the observation, the resident said they did not know why the antifungal powder was in their room. The resident said staff helped them administer the nasal spray and that staff did not put it away that day. During an observation and interview on 03/18/24, at 9:51 A.M., LPN #7 observed the medications at the resident's bedside and said the medications were not supposed to be left at a resident's bedside. LPN #7 said another resident could wander into the resident's room and get into the medications. 5. Review of Resident #7's Resident Face Sheet showed the following: -admission date of 08/01/16; -Diagnoses included pain in the left hip, unspecified skin changes, altered mental status, pain in the leg, and chronic pain syndrome. Review of the resident's quarterly MDS, with an ARD of 03/04/24, showed the resident was cognitively intact. Observation on 03/18/24. at 10:19 A.M., showed medications were at the resident's bedside. A 1.25-ounce (oz) tube of muscle rub cream and two 3 oz tubes of a lidocaine topical pain reliever were observed on the resident's rolling tray table, and an opened, unsealed individual 5 gram, single-use pack of skin ointment and a tube of antifungal ointment were observed on the resident's nightstand. During an observation and interview on 03/18/24, at 10:30 A.M., LPN #7 observed the medications at the resident's bedside. The LPN said the muscle rub and topical pain relievers should be in the treatment cart instead of the resident's room. 6. During an interview on 03/19/2024, at 1:23 P.M., LPN #1 said he/she had seen medications in cups left unattended in residents' rooms before. Staff became overwhelmed at times with their workload and when staff left medications with a resident to take, they normally went back to ensure the resident took them. There was no way to ensure residents safely took medications that were left with them or if they threw them away, flushed them, or if another resident took the medications. During an interview on 03/19/24, at 1:55 P.M., CMT #3 said if a resident was cognitively intact, he/she sometimes left medications with them to take on their own. He/she had found cups of medications on tables in the dining room. If medications were left unattended, a different resident could potentially take them. During an interview on 03/20/24, at 11:15 A.M., the Director of Nursing (DON) said the danger of leaving medications at a resident's bedside was that staff would not know if the resident took their medications, and the resident could have an adverse event. Someone else could take the medications. The DON expected staff administering medications to stay with the resident until they took all medications unless there was an emergency. Cups of medications should not be left in residents' rooms and indicated all unattended medications should be locked in a medication cart, a medication room, or if a resident could keep medication at their bedside. She expected them to be kept locked so that no other resident could have access. During an interview on 03/21/24, at 9:23 A.M., the Administrator said he expected CMTs and nurses to follow the facility's policies and procedures for medication administration and said if something was not appropriate to have at a resident's bedside, staff should not leave it unattended. 7. Review of the facility policy titled, Event Investigation, undated, showed the following: -Purpose to investigate the cause of all marks, discolorations, skin breaks and injuries which have not been witnessed. To identify any injuries after a resident sustains an event; -Interview the resident to determine cause of any conditions identified; -Interview any witnesses to determine cause of any condition identified; -Implement preventive measures as appropriate; -Complete a Report of Event Form as soon as possible whenever there is an unusual, unexpected and/or unintended event that is not consistent with the routine operation of the facility, the routine care of the resident and/or adversely effects or has the potential to adversely affect a resident or visitor. Examples of when a form should be completed include fall or person found on the floor; -Any staff member who discovers, witnesses, or is involved in an event should immediately report the event to the nurse in charge. The charge nurse is responsible for completion of the Report of Event Form and forwarding to the DON as soon as possible. Review of Resident #48's Resident Face Sheet showed the following: -admission date of 02/14/23 with most recent readmission on [DATE]; -Diagnoses included COPD with acute exacerbation (worsening or increase in symptoms), anxiety disorder, type two diabetes mellitus with hyperglycemia (increased blood glucose levels), peripheral vascular disease, iron deficiency anemia, and chronic congestive heart failure. Review of the resident's quarterly MDS, with an ARD of 02/18/24, showed the resident had moderate cognitive impairment. The resident required supervision or touching assistance for chair/bed-to-chair transfers. Review of the resident's Care Plan showed revealed a Problem area, with a start date of 02/14/23, that indicated the resident was at risk for falls due to COPD exacerbation. During an interview on 03/21/24, at 9:03 A.M., LPN #7 said on 03/06/24 the resident reported they got tangled up in their oxygen tubing and went down on one knee, but was able to get themselves up and into the bed from the floor. The resident indicated the incident occurred overnight the night before the resident reported it to LPN #7. Despite the resident's description of what happened, he/she did not consider the incident a fall because the resident only went down on one knee. LPN #7 said to be considered a fall, both knees would have needed to go down on the floor. LPN #7 said when a resident had a fall, the facility's process was to check the resident's vital signs, conduct neurological assessments, check the resident's range of motion, notify the resident's medical doctor and resident representative, and document information about the fall in the resident's progress notes. Review of the resident's Resident Progress Notes showed staff did not document regarding a fall on 03/06/24. During an interview on 03/21/24, at 10:35 A.M., the DON said following a fall, he/she expected staff to assess the resident, ensure their safety, notify the physician , resident representative, and the DON, document in the resident's electronic medical record (EMR), and create a fall event in the EMR. An event report should be completed for each fall. The DON said she ran event reports off on a weekly basis and reviewed them daily, along with interventions. The DON was not aware of a fall involving the resident on 03/06/24. If a resident's knee went to the ground, it was considered a fall, and staff should initiate a fall assessment and follow the facility's fall process. During an interview on 03/21/24 at 3:12 P.M., the Administrator said if a resident reported their knee went down to the ground, he expected staff to investigate the incident as a fall. He said a fall investigation involved interviewing the resident and gathering additional statements to determine what happened. MO00232950 Based on observations, interviews, and record review, the facility failed to ensure nursing staff supervised residents during medication administration to ensure medications were taken as prescribed and medications were not left unattended in residents' rooms for four residents (Residents #51, #33, #46, and #7) of nine sampled residents reviewed for accidents and hazards. The facility also failed to identify and investigate a fall for one resident (Resident #48) of three sampled residents reviewed for falls. 1. Review of the facility policy titled, Medications, Storage Of, undated, showed the following: -All medications for residents must be stored at or near the nurses' station in a locked cabinet, a locked medicine room, or one or more locked mobile medication carts. Review of the facility policy titled Medication Administration, undated, showed the following: -Remain in room while the resident takes the medication. 2. Review of Resident #51's Resident Face Sheet showed an admission date of 04/21/22 with the most recent readmission date of 10/26/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), with an Assessment Reference Date (ARD) of 02/01/24, showed the resident was cognitively intact. Observation on 03/18/24, at 9:48 A.M., showed a cup that contained three white pills in the resident's room. Upon return to the room, after getting a nurse, the pill cup was empty. The resident said they had just taken the medications. During an interview on 03/18/24, at 10:12 A.M.,, the resident said nursing staff normally remained with them while they took their medications and did not normally leave them at their bedside. The resident indicated they were sleepy that morning and fell asleep before taking all of their medications. 3. Review of Resident #33's Resident Face Sheet showed the following: -admission date of 10/09/23; -Diagnoses that included essential hypertension (high blood pressure), cognitive communication deficit, and unspecified macular degeneration (a disease that affects a person's central vision). Review of the resident's quarterly MDS, with an ARD of 01/15/24, showed the resident had moderate cognitive impairment. Observation on 03/18/24, at 9:38 A.M., showed a medication cup that contained a small blue-gray tablet and four white tablets in the resident's room. The resident said the nurse brought the pills into their room that morning about 9:00 A.M. and left the medications in the room for them to take as they wanted. During an interview on 03/18/24, at 9:54 A.M., Licensed Practical Nurse (LPN) #4 said she did not leave the medications in the resident's room and indicated Certified Medication Technician (CMT) #5 had given the medications to the resident. LPN #4 said the medications should not have been left in the resident's room. During an interview on 03/18/24, at 9:56 A.M., CMT #5 said he/she had been taught that medications should not be left in residents' rooms; however, he/she left the resident's medications in their room, because he/she trusted the resident would take them. CMT #5 identified the tablets observed in the resident's room as Tylenol 325 milligrams (mg), two tablets of vitamin C 500 mg tablets, one tablet of amiodarone (a medication to treat an irregular heartbeat), and Sinemet (a medication for Parkinson's disease). CMT #5 said the danger of leaving the medication in the resident's room could be another resident or visitor taking the medications, or if the resident waited too long to take the medications, there was a risk of double-dosing some of the medications.

Based on interviews and record review, the facility failed to ensure all allegation of possible abuse were reportedly immediately to the facility manager and within two hours to the State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) when the Medical Director did not report an allegation of possible abuse received from one resident (Resident #1). The facility census was 79. Review of the facility's policy titled Abuse Prohibition and Protocol Manual, undated, showed the following: -It is the policy of the facility that each resident will be free from abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion; -The facility will ensure that all allegations of abuse or serious bodily injury are reported to the SSA within two hours; -Allegations involving a sexual event (even if the event did not result in serious bodily injury) must be considered as serious bodily injury and reported to the SSA within two hours; -The two hour timeframe must be met even during the night shift or during the weekend. 1. Review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admission date of 01/22/21; -Diagnoses included heart disease, chronic kidney disease stage 4 (kidneys are moderately or severely damaged and are not working as they should to filter out waste from the blood), pain, high blood pressure, difficulty in walking, unsteady on feet, and penile prosthesis. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 09/17/23, showed the resident was cognitively intact. During interviews on 09/27/23, at 11:55 A.M. and 12:45 P.M., the Medical Director said the following: -The resident asked the doctor if he could fix his penile pump; -Two days ago the resident reported approximately a year and a half ago an aide asked the resident if she could sit on his penile prosthesis and that it has never worked again after that; -The Medical Director said he did not believe the resident and he did not report this allegation of abuse to anyone because he did not think this was abuse; -The Medical Director said all abuse should be reported, but he was not sure of the time frame of abuse being reported to DHSS. During an interview on 09/27/23, at 3:05 P.M., the resident said the following: -The Director of Nursing (DON) came and talked with him/her today and informed the resident that he had been sexually abused with what he told the Medical Director; -The resident said he had a penile pump and about one and a half years ago an aide had asked if he/she could sit on it and the resident scooted to the edge of the bed in a sitting position and the aide sat on it; -The resident said he/she believed the aide may have broke the pump because it has never worked since that day; -The resident said he/she had never reported the incident until two days ago when he/she told the Medical Director. Review of DHSS records showed the facility did not self-report the allegation of possible abuse. During an interview on 09/29/23, at 11:00 A.M., Certified Nurse Aide (CNA) B said all allegations of abuse must be reported. The allegation of abuse should be reported to the DON and Administrator immediately and to the SSA within two hours. During an interview on 09/29/23, at 11:05 A.M., CNA C said all aegations of abuse must be reported. Allegation of abuse should be reported to the DON and Administrator immediately and to the SSA within two hours. During interviews on 09/27/23, at 12:15 P.M. and 12:35 P.M., and on 09/29/23, at 3:50 P.M., the DON said the following: -All allegations of abuse should be reported immediatley to the DON and the Administrator; -All allegations of abuse should be reported to DHSS within two hours; -The DON said she was not aware of what the Medical Director reported until he told the surveyor; -The DON said the Medical Director should have reported this allegation of sexual abuse by an employee towards a resident as soon as the resident reported the incident; -The DON said she spoke to the resident and he/she confirmed what the Medical Director reported. MO00225068

Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN-form CMS-10055) or a denial letter at initiation, reduction, or termination of Medicare Part A benefits for one resident (Resident #2) who remained in the facility after discharge from Medicare Part A services. The facility census was 77. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/09/09, and showed the following: -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them his/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Record review of the facility policy titled Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055, dated 2018, showed the following: -These abbreviated instructions explain when and how the SNFABN must be delivered. Please also refer to the Medicare Claims Processing Manual, Chapter 30 for general notice requirement and detailed information on the SNFABN; -Medicare requires Skilled Nursing Facility's (SNFs) to issue the SNFABN to original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers, but may not pay for in this instance because the care is not medically reasonable and necessary or considered custodial; -The SNFABN provides information to the beneficiary so the he/she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNFs must use the SNFABN when applicable for SNF Prospective Payment System (Medicare Part A). Record review of the facility policy titled Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, undated, showed the following: -A Medicare provider or health plan (Medicare Advantage plans and cost plans collectively referred to as plans) must deliver a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), comprehensive outpatient rehabilitation facility, and Hospice services; -The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily; -A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Medicare providers are responsible for the delivery of the NOMNC; -The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that termination discussion can be disputed. 1. Record review of Resident #2's Skilled Nursing Beneficiary Protection Notification Review showed the following: -Medicare Part A skilled services episode start date 01/24/2022; -Services ended on 03/18/2022; -Last covered day of Medicare Part A services as 03/18/2022; -The facility staff did not provide the resident or his/her legal representative the SNFABN or NOMNC. During an interview on 07/28/22, 11:30 A.M., the Social Service Director said he/she had been taught about the NOMNC when he/she started, but had not been trained on ABNs until 7/12/2022. The NOMNC should be issued 48 hours prior to last day of Medicare Part A services. The ABN should be issued when a resident's therapy, Medicare Part A is ending and the resident was transitioning to long-term care and also issue a NOMNC to these residents and/or family. The resident did not have ABN or NOMNC for this Medicare Part A service. The previous SSD should have issued both the ABN and NOMNC to the resident and or resident representative. During an interview on 07/28/2022, at 11:35 A.M. the Administrator said the resident had not been issued a NOMNC or ABN after the recent Medicare Part A therapy. The NOMNC should be issued 48 hours prior to last covered day for Medicare Part A. The ABN and NOMNC should be issued for residents whose Medicare Part A is ending and the resident was transitioning to long-term care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete baseline care plans within 48 hours for two residents (Residents #53 and #219). The facility had a census of 77. Record review of the facility's policy titled, Care Plan, Temporary, undated, showed the following: -A temporary care plan will be implemented to meet the new resident's immediate needs; -To assure that the resident's immediate care needs are met and maintained, a temporary care plan will be implemented for the resident within twenty-four hours of admission; -The interdisciplinary care plan team and/or admitting nurse will review the physician orders and implement a nursing care plan to meet the immediate care needs of the resident; -The temporary care plan will be used until the comprehensive assessment has been completed and an interdisciplinary care plan has been developed. 1. Record review of Resident #219's face sheet (a document that gives a resident's information at a quick glance) showed the following information: -admission date of 7/20/22; -Full code; -Diagnoses include non-infective gastroenteritis and colitis (food sensitivity, inflammation of the gastrointestinal tract), unspecified open wound, unspecified lower leg, irritability and anger, neoplasm of uncertain behavior of rectum (skin growth whose behavior can't be predicted), hypothyroidism (low activity of the thyroid), polyneuropathy (many nerves in different parts of the body are involved, essential hypertension (blood pressure that is higher than normal), malaise (feeling of discomfort, illness), abrasion to right upper arm, urinary tract infection (infection in any part of the urinary systems), and reduced mobility. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 7/26/22, showed the following information: -Severely impaired cognition; -Occasionally incontinent of bladder; -Always continent of bowel; -Diagnoses included anemia, hypertension, and thyroid disorder; -Resident had a fall in the last month, prior to admission to the facility; -At risk for pressure ulcer development; Record review of the resident's electronic health record (EHR) showed staff did not complete a baseline care plan. 2. Record review of Resident #53's face sheet showed the following information: -admission date of 6/29/22; -Diagnoses included acute kidney failure (kidneys stop working, subsequent encounter for fracture with routine healing), suicidal ideations (thought of wanting to take one's own life), onychogryphosis (toenail grows substantially more than the others), localized edema (excess fluid), cellulitis(infection) of left upper limb, hypoglycemia (low blood sugar), wedge compression fracture of third thoracic vertebra (bone collapses and the front part of the vertebral body forms a wedge), personal history of transient ischemic attach (sudden brief episode neurologic impairment), cerebral infraction without residual deficits (loss of brain function due to a disturbance), hyperlipidemia (body has too many fats in it), unspecified dementia without behavioral disturbances (impaired thinking), essential hypertension (high blood pressure) unspecified atrial fibrillation (irregular heart beat), chronic obstructive pulmonary disease (hard for you to breath), benign prostatic hyperplasia without lower urinary tract symptoms (enlarged prostate), and rash or other nonspecific skin eruption. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Intact cognition; -Occasionally incontinent of bowel and bladder; -Diagnoses included atrial fib (irregular heart beat), hypertension, hyperlipidemia, dementia and COPD (chronic obstructive pulmonary disease that damages the lungs); -Resident had a fall in the last month prior to admission to the facility; -Resident had a fall in the last 2 to 6 months prior to admission to the facility; -At risk for pressure ulcer development; Record review of the resident's electronic health record showed staff did not complete a baseline care plan. 3. During an interview on 7/28/22, at 8:18 A.M., with Licensed Practical Nurse (LPN) I said the following: -Did not know when the baseline care plan is supposed to be completed; -He/she makes changes to the comprehensive care plan as needed. 4. During an interview on 7/28/22, at 8:55 A.M., Certified Medical technician (CMT) N said the following: -The MDS coordinator takes care of the baseline care plans when residents first come in. 5. During an interview on 7/28/22, at 9:25 A.M., the Director of Nursing (DON) said the following: -Baseline care plans should be developed within the first 48 hours of admission; -The charge nurse that cares for the resident within the first 48 hours is responsible for developing the baseline care plan; -Resident # 219 and Resident # 53 did not have a baseline care plan developed within 48 hours of admission. 6. During an interview on 7/27/28, at 11:00 A.M., the Administrator said the following: -Baseline care plans should be completed within 48 hours of admission; -Charge nurse is supposed to complete the baseline care plan if the MDS coordinator isn't available; -There should be a baseline care plan for every resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than 5% when staff made two errors out of 31 opportunities, resulting in an error rate of 6.45%, affecting two residents (Residents #37 and #68). The facility census was 77. Record review of the Novolog FlexPen (a fast-acting insulin) manufacturer's guidance, dated 3/2021, showed the following: -Before each injection small amounts of air may collect in the cartridge during normal use; -To avoid injecting air and to ensure proper dosing, -Prime (referred to as an air shot) the flex pen before each injection; -Turn the dose selector to select two units; -Hold the flex pen with the needle pointing up. Tap the cartridge gently to make any air bubbles collect at the top of the cartridge -Keep the needle pointing upward, and press the push button all the way in. The dose selector returns all the way to 0; -Make sure a drop appears; -If a drop of insulin does not appear, change the needle and repeat the procedure, no more than six times. Record review showed the facility did not provide a policy that addressed priming insulin pens. 1. Record review of Resident #68's face sheet (a brief resident profile sheet) showed the following: -The resident was admitted on [DATE]; -His/her diagnoses included Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar). Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 7/11/2022, showed the following: -The resident was cognitively intact; -He/she received insulin injections 5 to 7 days of the look behind period (the days of the evaluation period). Record review of the resident's care plan, updated 7/13/2022, showed the following: -The resident was diabetic and had a risk for complications; -Administer medications as ordered by the physician. Record review of the resident's Physician Order Report, dated 7/1/2022 to 7/27/2022, showed the following: -An order, dated 7/25/2022, for Novolog Flexpen U-100 (100 units per milliliter) per sliding scale; -If the blood sugar reading is 140 to 199 milligrams/deciliter (mg/dL), administer two units of insulin; -If the blood sugar reading is 200 to 249 mg/dL, administer three units of insulin; -If the blood sugar reading is 250 to 299 mg/dL, administer four units of insulin; -If the blood sugar reading is 300 to 349 mg/dL, administer six units of insulin; -If the blood sugar reading is 350 to 399 mg/dL, administer eight units of insulin; -If the blood sugar reading is 400 to 449 mg/dL, administer ten units of insulin; -If the blood sugar reading is 450 to 499 mg/dL, administer 14 units of insulin; -If the blood sugar reading is 500 to 549 mg/dL, administer 16 units of insulin; -If the blood sugar reading is greater than 549 mg/dL, administer 18 units of insulin and call physician. -Check glucose and administer sliding scale three times daily at 6:30 A.M. to 10:00 A.M., 11:00 A.M. to 1:00 P.M., and 4:30 P.M. to 6:00 P.M. Observations on 7/26/2022, at 11:45 A.M., showed the following: -Licensed Practical Nurse (LPN) G checked the resident's glucose level and it was 295 mg/dL, which required four units of Novolog insulin; -The nurse injected four units of insulin into the resident's abdomen, utilizing the Novolog pen, without priming the pen prior to administration. Record review of the resident's Medication Administration History, dated 7/1/2022 to 7/27/2022, showed the following: -On 7/26/2022, between 11:00 A.M. and 1:00 P.M., LPN G documented administering 4 units of Novolog for a glucose reading of 295 mg/dL. During an interview on 7/26/2022, at 12:08 P.M., LPN G said when he/she first started he/she was given an in-service on how to properly use the insulin pen. He/she primes the pen when it is first opened, but does not prime the pen before each use. 2. Record review of the Semglee Pen (name brand for insulin glargine (a long lasting insulin)) manufacturer's website information, updated 2021, showed the following: -Before injecting insulin, always perform a safety test; -Performing the safety test ensures that you get an accurate dose by ensuring that pen and needle work properly and removing air bubbles; -Select a dose of 2 units by turning the white dose knob; -Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it; -Hold the pen with the needle pointing upwards; -Tap the cartridge so that any air bubbles rise up towards the needle; -Press the purple injection button all the way in. Check if insulin comes out of the needle tip; -Repeat if needed up to two more times. Record review of Resident #37's face sheet showed the following: -The resident was admitted on [DATE]; -His/her diagnoses included Type 2 diabetes. Record review of the resident's admission MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/she required insulin injections 6 to 7 days of the look behind period. Record review of resident's care plan, updated 6/15/2022, showed the following: -The resident was diabetic and at risk for complications; -Staff was to administer medications as ordered by the physician. Record review of resident's Physician Order Report, dated 6/6/2022-7/27/2022, showed the following: -An order, dated 6/6/2022, for insulin glargine pen, 100 unit/milliliter (ml), 30 units subcutaneously (under the first layer of the skin) daily between 6:00 A.M. and 9:00 A.M. Observations on 7/27/2022, at 7:40 A.M., showed the following: -Registered Nurse (RN) H checked the glucose level for the resident; -His/her insulin level was 146 mg/dL; -The resident required insulin glargine only; -RN H dialed the Semglee pen to 30 units; -RN H injected 30 units of insulin glargine into the resident's abdomen without priming the pen first. Record review of the resident's Medication Administration History, dated 7/1/2022 to 7/27/2022, showed the following: -RN H documented administering insulin glargine to the resident between 6:00 A.M. and 9:00 A.M. During an interview on 7/27/2022, at 9:18 A.M., RN H said he/she verifies the resident, the order, and when he/she starts to do insulin, cleans the hub (where the needle attaches), attaches a needle, dials the amount, and injects. When asked if he/she should prime the needle, he/she said yes, to make sure the needle is patent (attached securely). The nurse said he/she uses one unit to prime with. He/she said he/she does that every time, with every pen. When asked if he/she follows manufacturer's directions, the nurse said he/she primes every pen. 3. During an interview on 7/28/2022, at 8:00 A.M., LPN I said when he/she is administering insulin, he/she primes the pen with two units, then gives the dose required, and holds the pen in the skin for a few seconds after to make sure the dose completes. The facility has in-services a couple times yearly for insulin administration, and the in-services discuss proper use of the pen, including priming the pen, as well as she looks at the manufacturer's instructions. 4. During an interview on 7/28/2022, at 8:20 A.M., RN J said when he/she does insulin administration, he/she primes the needle with two units, or whatever the pen manufacture's direction calls for. He/she always follows manufacturer's directions on the pens. 5. During an interview on 7/28/2022, at 8:25 A.M., the Assistant Director of Nursing (ADON) said the facility has in-services annually and as needed for nurses regarding insulin administration. She expects staff to always follow manufacturer's instructions regarding insulin administration. 6. During an interview on 7/28/2022, at 9:00 A.M., RN K (MDS/Care Plans) said she expects staff to follow manufacturer's directions regarding insulin pens. If the directions say to prime the pens, she expects them to prime the pens. 7. During an interview on 7/28/2022, at 9:45 A.M., the Director of Nursing (DON) said she expects staff to follow manufacturer's directions regarding insulin administration. If the directions say to prime the needle, she expects them to prime the needle. 8. During an interview on 7/28/2022, at 10:05 A.M., the Administrator said he expects staff to follow manufacturer's directions on insulin pens. If the directions say to prime the pens, staff should prime the pens. They should always follow the manufacturer's directions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents were free from significant medication errors when staff administered insulin (medication used to help control blood sugar levels) without priming the insulin pens prior to administration per manufacture recommendations and standards of practice for two residents (Residents #37 and #68). The facility census was 77. Record review of the Novolog FlexPen (a fast-acting insulin) manufacturer's guidance, dated 3/2021, showed the following: -Before each injection small amounts of air may collect in the cartridge during normal use; -To avoid injecting air and to ensure proper dosing, -Prime (referred to as an air shot) the flex pen before each injection; -Turn the dose selector to select two units; -Hold the flex pen with the needle pointing up. Tap the cartridge gently to make any air bubbles collect at the top of the cartridge -Keep the needle pointing upward, and press the push button all the way in. The dose selector returns all the way to 0; -Make sure a drop appears; -If a drop of insulin does not appear, change the needle and repeat the procedure, no more than six times. Record review showed the facility did not provide a policy addressing priming insulin pens. 1. Record review of Resident #68's face sheet (a brief resident profile sheet) showed the following: -The resident was admitted on [DATE]; -His/her diagnoses included Type 2 diabetes (a chronic condition that affects the way the body processes blood sugar). Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 7/11/2022, showed the following: -The resident was cognitively intact; -He/she received insulin injections 5 to 7 days of the look behind period (the days of the evaluation period). Record review of the resident's care plan, updated 7/13/2022, showed the following: -The resident was diabetic and had a risk for complications; -Administer medications as ordered by the physician. Record review of the resident's Physician Order Report, dated 7/1/2022 to 7/27/2022, showed the following: -An order, dated 7/25/2022, for Novolog Flexpen U-100 (100 units per milliliter) per sliding scale; -If the blood sugar reading is 140 to 199 milligrams/deciliter (mg/dL), administer two units of insulin; -If the blood sugar reading is 200 to 249 mg/dL, administer three units of insulin; -If the blood sugar reading is 250 to 299 mg/dL, administer four units of insulin; -If the blood sugar reading is 300 to 349 mg/dL, administer six units of insulin; -If the blood sugar reading is 350 to 399 mg/dL, administer eight units of insulin; -If the blood sugar reading is 400 to 449 mg/dL, administer ten units of insulin; -If the blood sugar reading is 450 to 499 mg/dL, administer 14 units of insulin; -If the blood sugar reading is 500 to 549 mg/dL, administer 16 units of insulin; -If the blood sugar reading is greater than 549 mg/dL, administer 18 units of insulin and call physician. -Check glucose and administer sliding scale three times daily at 6:30 A.M. to 10:00 A.M., 11:00 A.M. to 1:00 P.M., and 4:30 P.M. to 6:00 P.M. Observations on 7/26/2022, at 11:45 A.M., showed the following: -Licensed Practical Nurse (LPN) G checked the resident's glucose level and it was 295 mg/dL, which required four units of Novolog insulin; -The nurse injected four units of insulin into the resident's abdomen, utilizing the Novolog pen, without priming the pen prior to administration. Record review of the resident's Medication Administration History, dated 7/1/2022 to 7/27/2022, showed the following: -On 7/26/2022, between 11:00 A.M. and 1:00 P.M., LPN G documented administering 4 units of Novolog for a glucose reading of 295 mg/dL. During an interview on 7/26/2022, at 12:08 P.M., LPN G said when he/she first started he/she was given an in-service on how to properly use the insulin pen. He/she primes the pen when it is first opened, but does not prime the pen before each use. 2. Record review of the Semglee Pen (name brand for insulin glargine (a long lasting insulin)) manufacturer's website information, updated 2021, showed the following: -Before injecting insulin, always perform a safety test; -Performing the safety test ensures that you get an accurate dose by ensuring that pen and needle work properly and removing air bubbles; -Select a dose of 2 units by turning the white dose knob; -Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it; -Hold the pen with the needle pointing upwards; -Tap the cartridge so that any air bubbles rise up towards the needle; -Press the purple injection button all the way in. Check if insulin comes out of the needle tip; -Repeat if needed up to two more times. Record review of Resident #37's face sheet showed the following: -The resident was admitted on [DATE]; -His/her diagnoses included Type 2 diabetes. Record review of the resident's admission MDS, dated [DATE], showed the following: -The resident was cognitively intact; -He/she required insulin injections 6 to 7 days of the look behind period. Record review of resident's care plan, updated 6/15/2022, showed the following: -The resident was diabetic and at risk for complications; -Staff was to administer medications as ordered by the physician. Record review of resident's Physician Order Report, dated 6/6/2022-7/27/2022, showed the following: -An order, dated 6/6/2022, for insulin glargine pen, 100 unit/milliliter (ml), 30 units subcutaneously (under the first layer of the skin) daily between 6:00 A.M. and 9:00 A.M. Observations on 7/27/2022, at 7:40 A.M., showed the following: -Registered Nurse (RN) H checked the glucose level for the resident; -His/her insulin level was 146 mg/dL; -The resident required insulin glargine only; -RN H dialed the Semglee pen to 30 units; -RN H injected 30 units of insulin glargine into the resident's abdomen without priming the pen first. Record review of the resident's Medication Administration History, dated 7/1/2022 to 7/27/2022, showed the following: -RN H documented administering insulin glargine to the resident between 6:00 A.M. and 9:00 A.M. During an interview on 7/27/2022, at 9:18 A.M., RN H said he/she verifies the resident, the order, and when he/she starts to do insulin, cleans the hub (where the needle attaches), attaches a needle, dials the amount, and injects. When asked if he/she should prime the needle, he/she said yes, to make sure the needle is patent (attached securely). The nurse said he/she uses one unit to prime with. He/she said he/she does that every time, with every pen. When asked if he/she follows manufacturer's directions, the nurse said he/she primes every pen. 3. During an interview on 7/28/2022, at 8:00 A.M., LPN I said when he/she is administering insulin, he/she primes the pen with two units, then gives the dose required, and holds the pen in the skin for a few seconds after to make sure the dose completes. The facility has in-services a couple times yearly for insulin administration, and the in-services discuss proper use of the pen, including priming the pen, as well as she looks at the manufacturer's instructions. 4. During an interview on 7/28/2022, at 8:20 A.M., RN J said when he/she does insulin administration, he/she primes the needle with two units, or whatever the pen manufacture's direction calls for. He/she always follows manufacturer's directions on the pens. 5. During an interview on 7/28/2022, at 8:25 A.M., the Assistant Director of Nursing (ADON) said the facility has in-services annually and as needed for nurses regarding insulin administration. She expects staff to always follow manufacturer's instructions regarding insulin administration. 6. During an interview on 7/28/2022, at 9:00 A.M., RN K (MDS/Care Plans) said she expects staff to follow manufacturer's directions regarding insulin pens. If the directions say to prime the pens, she expects them to prime the pens. 7. During an interview on 7/28/2022, at 9:45 A.M., the Director of Nursing (DON) said she expects staff to follow manufacturer's directions regarding insulin administration. If the directions say to prime the needle, she expects them to prime the needle. 8. During an interview on 7/28/2022, at 10:05 A.M., the Administrator said he expects staff to follow manufacturer's directions on insulin pens. If the directions say to prime the pens, staff should prime the pens. They should always follow the manufacturer's directions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #56's face sheet showed the following: -admission date of 8/1/2016, with a readmission on [DATE]; -Diagnoses included quadriplegia (paralysis of all four limbs), streptococcal (strep throat) infection and dysphagia, oropharyngeal (the part of the throat at the back of the mouth behind the oral cavity) phase. Record review of the resident's nursing notes showed the following: -On 6/17/2022, at 5:09 P.M., the resident's vitals were taken and showed blood pressure 83/54 (normal is considered 120/80), pulse 140 (normal 60-100), respirations 20 (normal 12-16), oxygen saturation levels 89% on room air (normal 95%-100%), and temperature 97.8 F (normal 97 F-99 F). The resident was diaphoretic (sweaty), blood glucose (blood sugar) 155 milligrams/deciliter, with increased lethargy (a pathological state of sleepiness or deep unresponsiveness and inactivity). Nurse notified the physician. The physician gave orders to send to the emergency department for evaluation. Nurse notified the resident's mother. The resident left the facility at 5:13 P.M. via ambulance. Record review of the resident's chart showed the facility staff did not provide a transfer/discharge letter to the resident or resident's representative, and did not notify the ombudsman of the resident's transfer/discharge on [DATE]. 5. During an interview on 07/27/2022, at 1:03 P.M., Social Service Director (SSD) said she was informed today she would be responsible for the written notification to resident and/or resident representative when the facility initiated emergency transfer to the hospital and a monthly report to the Ombudsman of all residents sent to the hospital for each month. The previous SSD did not teach her this. She is not sure who was responsible for sending these notices in the past. The facility did not have records that the resident or resident representative had received a written notification of the hospital transfer other than by telephone. The facility did not have written notification that the Ombudsman had received notification of the residents who had been sent to the hospital. 6. During an interview on 07/27/2022, at 1:40 P.M., the Director of Nursing (DON) and the Administrator said the facility did not have records of the written notifications to residents and resident representatives or to the Ombudsman when the residents were sent to the hospital. 2. Record review of Resident #17's face sheet (a brief resident profile sheet) showed the following: -admission date of 4/20/2022 with readmission date of 5/5/2022; -Diagnoses included diabetes, hypertension (high blood pressure), and heart disease. Record review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 5/16/2022, showed the following: -The resident was moderately cognitively impaired; Record review of the resident's nursing notes, dated 5/2/2022, showed the following: -At 9:04 A.M., staff was helping the certified nursing aide (CNA) and went in the resident's room to get vital signs. The resident's face was flushed, his/her breathing was labored, blood pressure was 79/58 (normal is considered 120/80), respirations 20 (normal is 12-16), temperature 97.7 degrees Fahrenheit (normal 97 F- 99 F), and was unable to get an oxygen saturation reading. The resident was placed on oxygen at 4 liters per minute and a reading of 92% was obtained. The resident was lethargic (weak and tired) and difficult to rouse. Staff called the physician and a verbal order was received to send the resident to the hospital. Staff notified the resident's responsible party, and they said they would meet the resident at the hospital. The resident left the facility via stretcher at 7:23 A.M. Record review of the resident's chart showed the facility staff did not provide a transfer/discharge letter to the resident or resident's representative, and did not notify the ombudsman of the resident's transfer/discharge. 3. Record review of Resident #46's face sheet showed the following: -admission date of 6/13/2022; -Diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning), and falls. Record review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact. Record review of the resident's nursing notes dated 6/21/2022, at 7:05 P.M., showed the following: -At 4:30 P.M., the resident was found on the floor, outside his/her bathroom, with blood noted on his/her head. The physician was notified and orders were received to transfer to the hospital for evaluation. Staff notified the resident's responsible party. The ambulance arrived at 5:20 P.M. Record review of the resident's chart showed the facility staff did not provide a transfer/discharge letter to the resident or resident's representative, and did not notify the ombudsman of the resident's transfer/discharge. Based on record review and interview, the facility failed to notify the resident and the resident's representative in writing of a transfer or discharge to the hospital and failed to provide the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the notification of transfer to the hospital for four residents (Resident #17, #46, #56, and #65). The facility census was 77. Record review showed the facility did not provide a policy regarding written notification to the resident and the resident's responsible party of a transfer to the hospital. Record review of the facility's Bed Hold Policy, undated, showed it included an untitled form with the following information: -Date letter written; -Responsible party/representative name and address; -RE: Emergency Transfer Notice; -This letter is to serve as your emergency notice of transfer from the facility (a space provided to enter facility name) due to your need for urgent medical care which cannot be met at the facility. The form refers back to Federal regulation 42 CFR 483.15(c)(4)(i)(D) states in relevant part that Notice must be made as soon as practicable before transfer of discharge when and immediate transfer of discharge is required by the resident's urgent medical needs. Therefore the facility is issuing this notice effective date had a spot to fill in the date; -You can receive more information on the discharge process from the State Long-Term Care Ombudsman with a space to fill this information out; -The location the resident was sent to; -The facility contact information; -And the Ombudsman Missouri Protection and Advocacy Services address and phone number. 1. Record review of Resident #65's face sheet (a brief information sheet about the resident) showed the following information: -admission date of 05/01/2019; -Diagnoses included pneumonia, chronic obstructive pulmonary disease (COPD-lung disease), history of Coronavirus (COVID) 19 (respiratory virus caused by SARS-CoV-2), diabetes, heart disease, and altered mental status; -Hospice patient. Record review of the resident's nurses' notes showed the following information: -On 05/18/2022, at 6:55 A.M., the resident's roommate called the front nurses desk at 6:15 A.M. and stated his/her roommate had fallen in the bathroom and could not get up. The resident was noted to be sitting upright in the doorway to his/her bathroom leaning against the door frame with his/her back. The resident said not to move him/her because he/she thought he/she had broken his/her back. The resident complained of pain to his/her middle of the back and rated the pain 10/10. The resident stated he/she got out of bed to go to the bathroom and waited too long and did not make it in time. The resident said he/she urinated on the floor and slid in the urine and fell to the floor hitting his/her back against the door frame. The resident's vitals were taken. The physician notified and new orders received to send the resident to the emergency room for evaluation. Staff called for emergency transport and emergency transport arrived at 6:30 A.M. After ambulance staff arrived they called the fire department for assistance due to the residents back injury. The resident was transferred to a back board by ambulance staff with the assistance of the fire department who arrived by 6:40 A.M. The resident also noted to have a skin tear on his/her right arm with minimal bleeding. The resident left the facility at 6:45 A.M. on a stretcher to go to the hospital. Attempted to call the residents' daughter (DPOA-durable power of attorney) and a message left. The daughter returned the call at 7:00 A.M., and informed the daughter of the residents fall and transport to the hospital. At 7:05 A.M., management staff notified of the residents fall and transfer to the hospital. The transfer form and paperwork sent with resident. (The staff did not note what paperwork was sent with the resident). Record review of the resident's nurses' notes showed the following information: -On 06/07/2022, at 2:21 P.M., the resident's oxygen level was 80% this A.M., with oxygen set at four liters per nasal cannula. Staff continued to monitor the resident and his/her oxygen would fluctuate between 71 to 88 percent on his/her CPAP (continuous positive airway pressure therapy used for sleep apnea-a potentially serious sleep disorder in which breathing repeatedly stops and starts). The resident had some confusion, delayed response when asked simple questions, trouble getting words out, slurred speech at times, lungs diminished, with no wheezing. The facility contacted the physician who ordered the resident be sent to the emergency room for evaluation. The resident left by ambulance at approximately 12:15 P.M Record review of the resident's medical record showed staff did not have a copy of written notices provided to the resident, resident representative, or to the Ombudsman regarding the hospital transfer for 5/18/2022 or 6/07/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #56's face sheet showed the following: -admission date of 8/1/2016, with a readmission on [DATE]; -Diagnoses included quadriplegia (paralysis of four limbs) , streptococcal (strep throat) infection and dysphagia (difficulty swallowing), oropharyngeal (part of the throat at the back of the mouth behind the oral cavity) phase. Record review of the resident's nursing notes showed the following: -On 6/17/2022, at 5:09 P.M., the resident's vitals were taken and showed blood pressure 83/54 (normal is considered 120/80), pulse 140 (normal 60-100), respirations 20 (normal 12-16), oxygen saturation levels 89% on room air (normal 95%-100%), and temperature 97.8 F (normal 97 F-99 F). The resident was diaphoretic (sweaty), blood glucose (blood sugar) 155, with increased lethargy (a pathological state of sleepiness or deep unresponsiveness and inactivity). Nurse notified the physician. The physician gave orders to send to the emergency department for evaluation. Nurse notified the resident's mother. The resident left the facility at 5:13 P.M. via ambulance. Record review of the resident's chart showed the facility staff did not provide a bed hold policy to the resident or the representative at the time of the hospitalization. 5. During an interview on 07/27/2022, at 1:03 P.M., the Social Service Director (SSD) said she started as the social worker about a month ago. She did not know what paperwork had to be sent with the resident if they went to the hospital. The SSD said the previous SSD did not train her on this. The families and residents are called when a resident is sent to the hospital and did not receive a written notice of the bed hold or hospital transfer. 6. During an interview on 07/27/2022, at 1:40 P.M., the Director of Nursing (DON) and the Administrator they said do not have documentation to show the bed hold policy had been sent with the residents when the residents transferred to the hospital or that a copy had been sent to the residents representative. 2. Record review of the Resident #17's face sheet (a brief resident profile sheet) showed the following: -admission date of 4/20/2022 with a readmission date of 5/5/2022; -Diagnoses included diabetes, hypertension (high blood pressure), and heart disease. Record review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 5/16/2022, showed the following: -Moderately cognitively impaired. Record review of the resident's nursing notes, dated 5/2/2022, showed the following: -At 9:04 A.M., nurse was helping the certified nursing aide (CNA) and went in the resident's room to get vital signs. The resident's face was flushed, his/her breathing was labored, blood pressure was 79/58 (normal is considered 120/80), respirations 20 (normal is 12-16), temperature 97.7 degrees Fahrenheit (normal 97 F- 99F), and was unable to get an oxygen saturation reading. The resident was placed on oxygen at 4 liters per minute and a reading of 92% was obtained. The resident was lethargic (weak and tired) and difficult to rouse. Staff called the physician and a verbal order was received to send the resident to the hospital. Staff notified the resident's responsible party, and they said they would meet the resident at the hospital. The resident left the facility via stretcher at 7:23 A.M. Record review of the resident's chart showed the facility staff did not provide a bed hold policy to the resident or the resident's representative at the time of the hospitalization. 3. Record review of Resident #46's face sheet showed the following: -admission date of 6/13/2022; -Diagnoses included dementia (a group of thinking and social symptoms that interferes with daily functioning) and falls. Record review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact. Record review of the resident's nursing notes dated 6/21/2022, at 7:05 P.M., showed the following: -At 4:30 P.M., the resident was found on the floor, outside his/her bathroom, with blood noted on his/her head. Staff notified the physician was notified and orders were received to transfer to the hospital for evaluation. Staff notified the resident's responsible party was notified. The ambulance arrived at 5:20 P.M. Record review of the resident's chart showed the facility staff did not provide a bed hold policy to the resident or the representative at the time of the hospitalization.Based on record review and interview, the facility failed to provide written notification to the resident and/or resident's representative of the facility's bed hold policy at the time of transfer for four residents (Resident #17, #46, #56, and #65). The facility census was 77. Record review of the facility's policy titled Bed Hold Policy Guidelines, undated, showed the following information: -The facility will notify all residents, and/or their representative of the bed hold guideline; -This notification will be given upon admission to the facility, at the time of transfer to the hospital or leave, and at the time of non-covered therapeutic leave; -The rights and limitation of the resident regarding bed-holds; -The reserve payment policy as indicated by the state plan (Medicaid residents); -The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); -The details of the transfer (per the Notice of Transfer). 1. Record review of Resident #65's face sheet (a brief information sheet about the resident) showed the following information: -admission date of 05/01/2019; -Diagnoses included pneumonia, chronic obstructive pulmonary disease (COPD-lung disease), history of Coronavirus (COVID) 19 virus, diabetes, heart disease, and altered mental status; -Hospice patient. Record review of the resident's nurses' notes showed the following information: -On 05/18/2022, at 6:55 A.M., the resident's roommate called the front nurses desk at 6:15 A.M. and stated his roommate had fallen in the bathroom and could not get up. The resident was noted to be sitting upright in the doorway to his/her bathroom leaning against the door frame with his/her back. The resident said not to move him/her because he/she thought he/she had broken his/her back. The resident complained of pain to his/her middle of the back and rated the pain 10/10. The resident stated he/she got out of bed to go to the bathroom and waited too long and did not make it in time. The resident said he/she urinated on the floor and slid in the urine and fell to the floor hitting his/her back against the door frame. The resident's vitals were taken. Staff notified the physician and new orders received to send the resident to the emergency room for evaluation. Staff called for emergency transport and emergency transport arrived at 6:30 A.M. After ambulance staff arrived they called the fire department for assistance due to the residents back injury. The resident was transferred to a back board by ambulance staff with the assistance of the fire department who arrived by 6:40 A.M. The resident also noted to have a skin tear on his/her right arm with minimal bleeding. The resident left the facility at 6:45 A.M. on a stretcher to go to the hospital. Staff attempted to call the residents' daughter (DPOA-durable power of attorney) and a message left. The daughter returned the call at 7:00 A.M., and informed the daughter of the residents fall and transport to the hospital. At 7:05 A.M., staff notified management notified of the residents fall and transfer to the hospital. The transfer form and paperwork sent with resident. (The nurse's note did not say what paperwork was sent with the resident.} Record review of the resident's nurses' notes showed the following information: -On 06/07/2022, at 2:21 P.M., the resident's oxygen level was 80% this A.M., with oxygen set at four liters per nasal cannula. Staff continued to monitor the resident and his/her oxygen would fluctuate between 71 to 88 percent on his/her CPAP (continuous positive airway pressure therapy used for sleep apnea-a potentially serious sleep disorder in which breathing repeatedly stops and starts). The resident had some confusion, delayed response when asked simple questions, trouble getting words out, slurred speech at times, lungs diminished, with no wheezing. The facility contacted the physician who ordered the resident be sent to the emergency room for evaluation. The resident left by ambulance at approximately 12:15 P.M. Record review of the resident's chart showed the facility staff did not provide a bed hold policy to the resident or the resident's representative at the time of the hospitalization.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #56's face sheet showed the following: -admission date of 8/1/2016; -His/her diagnoses included quadriplegia (paralysis of four limbs), and dysphagia(difficulty swallowing), oropharyngeal (part of the throat at the back of the mouth behind the oral cavity) phase. Record review of the resident's annual MDS, dated [DATE], showed the following: -The resident had modified independence with cognition; -He/she required extensive assistance with one person physical assist with bed mobility. Record review of the resident's care plan, dated 4/27/2022, showed the following information: -Quarter side rail for positioning and transfers; -Resident will have quarter side rails with no complication; -Nursing will assist resident as needed for all mobility and monitor for any complications using quarter side rail. Record review of the resident's paper and electronic record showed staff did have a documented side rail assessment, signed consent with benefits and risk, or gap measurements. Observations on 7/24/2022, at 10:33 A.M., showed the following: -The resident was resting in bed; -The resident's bed had U-shaped grab bars present on both sides of the bed (bilaterally), in the raised position. Observations on 7/25/2022, at 2:20 P.M., showed the following: -The resident was resting in bed; -The resident's bed had U-shaped grab bars present on both sides of the bed, in the raised position. 5. During an interview on 7/28/22, at 8:16 A.M., with CNA C said the following: -He/she doesn't know the process if a resident needs side rails. 6. During an interview on 7/28/22, at 8:18 A.M., Licensed Practical Nurse (LPN) I said the following: -Residents use side rails for repositioning and some use to assist with transfers; -When side rails are requested, nurses fill out an assessment, complete measurements of the bed and mattress, and a consent is signed by the resident or representative; -The side rails are assessed constantly. 7. During and interview on 7/28/22, at 8:26 A.M., CNA O said the following: -He/she doesn't know the process for side rails; -Residents use side rails to reposition. 8. During an interview on 7/28/22, at 8:55 A.M., Certified Medication Technician (CMT) N said the following: -He/she said residents request a handrail assessment; -Doctor or administrator completes an assessment; -Resident must consent to placing side rails on their beds; -Side rails placement is reviewed at each care plan meeting; -Residents use the side rails for positioning. 9. During an interview on 7/28/22, at 9:25 A.M., the DON said if it's found appropriate for residents to have side rails, consent is obtained from the resident or the representatives. If the consent is obtained over the phone, the form is signed when the representative is in the building the next time. Side rail assessments are completed and reviewed every three months. Residents use the side rails for repositioning. 10. During an interview on 7/28/22, at 11:00 A.M., the Administrator said the side rail process includes an assessment of needs for the side rails, measurements to determine the type needed and consent from either the resident or resident representative. Residents use the side rails for repositioning. Based on observation, interview, and record review, the facility failed to obtain written consent for side rail use, failed to complete a documented side rail assessment, failed to monitor and measure bed rails for risk of entrapment , failed to obtain physician orders for use of side rails, and failed to complete a risk versus benefits side rail assessment for four residents (Residents #38, #56, #65, and #219). The facility census was 77. Record review showed the facility did not provide a policy regarding side rail assessments. 1. Record review of Resident #219's face sheet (admission information) showed the following information: -admission date of 7/20/22; -Diagnoses include non-infective gastroenteritis and colitis (food sensitivity, inflammation of the gastrointestinal tract), unspecified open wound, unspecified lower leg, irritability and anger, neoplasm of uncertain behavior of rectum (skin growth whose behavior can't be predicted), hypothyroidism (low activity of the thyroid), polyneuropathy (many nerves in different parts of the body are involved, essential hypertension (blood pressure that is higher than normal), malaise (feeling of discomfort, illness), abrasion to right upper arm, urinary tract infection (infection in any part of the urinary systems), and reduced mobility. Record review of the resident's current July 2022 physician order sheet (POS) showed no orders for side rails. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool complete by facility staff), dated 7/26/22, showed the following information: -Severely impaired cognition; -Occasionally incontinent of bladder; -Always continent of bowel; -Diagnoses included anemia, hypertension, and thyroid disorder; -Resident had a fall in the last month, prior to admission to the facility; -At risk for pressure ulcer development. Record review of the resident's electronic medical record showed the following information: -No paper or electronic record of when the resident signed a consent for the use of side rails for positioning; -No risk versus benefits assessment for the use of the side rails; -No alternatives documented prior to the use of the side rails; -No bed gap measurements completed. Observations on 7/25/22, at 12:11 P.M., showed one half side rail and one quarter side rail in the raised position. During an interview and observation on 7/28/22, at 7:35 A.M., showed the following: -Resident lying in bed, one half side rail, and one quarter side rail in the raised position; -The resident said said the side rails could be taken off if the staff wants too; -He/she didn't care if the side rails were on the bed. During an interview on 7/28/22, at 9:25 A.M., with Director of Nursing (DON) said there was no side rail assessment found for the resident.3. Record review of Resident #38's face sheet showed the following: -admission date of 6/6/2022; -Diagnoses included cellulitis (a skin infection) and personal history of a stroke. Record review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively impaired; -Required one person assist with bed mobility. Record review of the resident's care plan showed staff did not care plan regarding the resident's grab bars. Record review of the resident's chart showed the following: -No signed consent prior to the survey start date; -No risk versus benefit or assessment for the use of side rails; -No alternatives documented prior to the use of side rails; -No bed gap measurements for the side rails. Observations on 7/24/2022, at 1:35 P.M., showed the following: -The resident was resting in bed; -The resident's bed had grab bars (U shaped bars) present on both sides of the bed (bilaterally), in the raised position. 2. Record review of Resident #65's face sheet showed the following information: -admission date of 05/01/2019; -Diagnoses included pneumonia, chronic obstructive pulmonary disease (COPD-lung disease), history of SARS COVID 19 (respiratory virus spread mainly from person to person through respiratory droplets produced when a person coughs, sneezes, or talks), obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), tremors, heart disease, acute kidney failure (a condition in which kidneys suddenly can't filter waste from the blood), and muscle weakness; -Hospice. Record review of the resident's current July 2022 POS showed no orders for side rails. Record review of the resident's significant change MDS, dated [DATE], showed the following information: -Moderately impaired cognitive status; -Limited assistance of one staff for bed mobility and transfers, -Moderate assistance of one staff for toileting, hygiene, and dressing; -Continent of bowel and bladder; -No falls since prior assessment. Record review of the resident's care plan, last revised 4/12/2022, showed staff did not care plan the resident's side rails. Record review of the resident's electronic medical record showed the following: -No paper or electronic record of a signed consent form for the use of side rails; -No risk versus benefits or assessment for the use of side rails; -No alternatives documented prior to the use of side rails; -No bed gap measurements for the side rails. Observations on 07/24/2022, at 11:30 A.M., showed the resident in bed asleep. The resident had half side rails on both sides of the bed in the raised position. Observation on 07/25/2022, at 12:20 P.M., showed the resident in bed asleep. The resident had half side rails on both sides of the bed in the raised position. During an interview on 07/28/2022, at 9:18 A.M., Certified Nurse Aide (CNA) C said the resident used his/her side rails for repositioning in bed. During an interview on 07/27/2022, at 08:32 A.M., the Director of Nursing (DON) said the facility did not have the side rail assessment, gap measurements, consent, and risk versus benefits for the resident.

Based on observation, record review, and interview, the facility staff failed to ensure serving sizes met the approved menu when serving meals to the residents. The facility census was 77. Record review of the facility's Nutrition and Dining Services Manual, dated May 2015, showed the following: -Staff should prepare meals in accordance with planned menus, standardized recipes, special diet orders and established portion control guidelines. 1. Record review of the facility's menu spread sheet showed residents should receive one half cup of spinach and one half cup of potatoes, including pureed spinach and potatoes, for lunch on 7/26/2022. Observations on 7/26/2022, at 12:09 P.M., showed the following: -The Dietary Manager (DM) placed one third cup ladles in the whole potatoes, diced potatoes, creamed spinach and pureed cream spinach; -The DM used the one third cup ladles to serve boiled potatoes, diced potatoes, creamed spinach and pureed cream spinach for all hall trays. During an interview on 7/27/2022, at 1:31 P.M., Dietary Services (DS) A said the following: -Serving ladles have color coded handles; -Staff should refer to the list of measurements with the serving amount to the color coded ladle; -When serving meals, he/she should follow the recommended servings per the recipe on the printed menu. During an interview on 7/27/2022, 1:43 P.M., the DM said the following: -Recipes in the menu and the spreadsheets contain the recommended serving size for all portions of the meals; -Ladles have color coordinated by size, and a chart is on the wall in the kitchen; -Staff should use the spreadsheet or recipe from the menu to determine the size of scoop ladle to use for serve out for meals. During an interview on 7/28/2022, at 12:58 P.M., the Administrator said the following: -The kitchen had a chart on the wall showing the ladles color coordinated to serving size; -He expected staff to follow the recommended serving size per the menus; -Kitchen staff use menu sheets with recipes, which include recommended serving sizes and the policy has the serving sizes per ladle.

Based on record review and interview, the facility failed to follow their infection control policy when staff failed to ensure staff completed employee tuberculosis (TB-a potentially serious infectious bacterial disease that mainly affects the lungs) screening tests on hire for six staff members. The facility census was 77. Record review of the facility's policy, Tuberculosis Control, undated, showed the following information: -Provide a tuberculin skin test (Mantoux - five tuberculin units of purified protein derivative (PPD)) to all employees during the pre-employment procedures, unless a previous reaction greater than 10 mm (millimeters) is documented. If the initial skin test result is 0 to 9 mm, a second test should be given at least one week later and no more than three weeks after the first test; -All employees will be screened for TB; -Once the decision has been made to employ an individual, the individual will be asked for documentation of a prior PPD skin test that determines if an individual has TB; -If the employee does not have documentation of a prior PPD, the first step PPD will be administered by the nursing department, documented on the Employee Immunization Record, and must be read prior to or no later than the start date; -All PPDs will be documented on Employee Immunization Record including new hires and annual administration. After the PPD has been administered, the results will be documented in mm. Record review of the Centers for Disease Control and Prevention website, updated 3/8/2021, showed the following: -The TB skin test is performed by injecting a small amount of fluid (called tuberculin) into the skin on the lower part of the arm; -A person given the tuberculin skin test must return within 48 to 72 hours to have a trained health care worker look for a reaction on the arm; -Results should be documented in mm; -A second skin test should be administered one to three weeks later; -The test should be read 48 to 72 hours after administration; -The results should be documented in mm. 1. Record review of Dietary Staff (DS) A's personnel file showed the following: -Hire date of 06/21/2022; -Facility staff documented the first TB test administered on 06/21/2022; -Facility staff did not document reading the first TB skin test 48 to 72 hours after the test was administered; -Facility staff did not document the second TB skin test administered or read. 2. Record review of Licensed Practical Nurse (LPN) B's personnel file showed the following: -Hire date of 06/20/2022; -Facility staff documented the first TB test administered on 06/17/2022; -Facility staff did not document reading the first TB skin test 48 to 72 hours after the first TB test was administered; -Facility staff did not document the second TB skin test administered or read. 3. Record review of Certified Nurse Aide (CNA) C's personnel file showed the following: -Hire date of 06/09/2022; -Facility staff documented the first TB skin test administered on 06/09/2022; -Facility staff documented the first TB skin test read on 06/12/2022 and noted results as 0 mm; -Facility staff did not document the second TB skin test administered or read. 4. Record review of LPN D's personnel file showed the following: -Hire date of 02/14/2022; -Facility staff documented the first TB skin test administered on 02/14/2022; -Facility staff did not to document reading the first TB skin test 48 to 72 hours after the first TB test was administered; -Facility staff did not document the second TB skin test administered or read. 5. Record review of Registered Nurse (RN) E's personnel file showed the following: -Hire date of 11/22/2021; -Facility staff documented the first TB test administered on 04/26/2022 (approximately five months after the date of hire); -Facility staff documented the first TB skin test read on 04/29/2022 and recorded as 0 mm; -Facility staff documented the second TB skin test administered on 05/26/2022; -Facility staff did not document the second TB skin test read. 6. Record review of CNA F's personnel file showed the following: -Hire date of 04/28/2022; -Facility staff documented the first TB skin test administered on 05/03/2022 (five days after the date of hire); -Facility staff did not document reading the first TB skin test 48 to 72 hours after the first step had been administered; -Facility staff did not document the second TB skin test administered or read. 7. During an interview on 07/28/2022, at 12:30 P.M., the Director of Nursing and Assistant Director of Nursing said the facility should administer the first TB skin test at hire during the orientation process. The TB skin test should be read 48 to 72 hours later and record this in mm. The staff should not work the floor until the first TB skin test has been read. The second TB skin test should be administered one to three weeks after the first TB skin test had been read. The second TB test should be read 48 to 72 hours after it had been administered and recorded in mm. The previous ADON was responsible for administering, reading, and documenting the employee TB had been administered and read. 8. During an interview on 07/28/2022, at 10:00 A.M., the Administrator said staff should have a two step TB test. The first TB test is completed at orientation. The second TB test should be administered one to three weeks after the first TB test has been read. The staff do not work the floor until after the first TB test had been read.

Based on record review, observation, and interview, the facility failed to store food in accordance with professional standards of practice and protect food from possible contamination when staff did not store dry food properly after opening and staff did not wear proper hair coverings. The facility census was 77. 1. Record review of the 2013 Missouri Food Code showed the following information: -Food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination. Record review showed the facility did not have a policy regarding dry food storage. Observations of the kitchen on 7/24/2022, beginning at 9:24 A.M., showed the following: -Containers of golden pure cane sugar and corn starch opened to the air and not covered or sealed; -Box of raisins opened to the air and not covered or sealed; -Large dry container of uncovered sugar with a large crack in the lid, which was open to air; -Large bag of unsealed panko bread crumbs and large bag of unsealed light brown sugar opened inside large dry container sitting on pallets on the floor in the dry storage area. Observation of the kitchen on 7/27/2022, at 9:30 AM, showed the following: -A box of raisins on a metal shelf near the microwave in the kitchen opened and uncovered to the air and not sealed; -Containers of baking soda and corn starch on a metal shelf near the microwave in the kitchen opened and uncovered to the air and not sealed. During an interview on 7/27/2022, at 1:31 P.M., Dietary Aide (DA) A said the following: -Dried food goods should be sealed after opening so nothing gets into the product; -Containers of raisins, brown sugar, baking soda or corn starch should be sealed because oxygen can oxidize the product; -Large dry storage bins of food should be air tight sealed; -He/she would not leave a bag of panko bread crumbs or brown sugar opened in a dry storage bin; -Bags of dry food should be rolled up and sealed with a bag clip when placing in a dry bin storage. During an interview on 7/27/2022, at 1:43 P.M., the Dietary Manager (DM) said the following -Staff are expected to place containers of dry food such as corn starch, brown sugar, raisins, and baking soda in a sealed zip lock bag after opening; -Large dried storage bins containing food items should be closed at all times with an air tight lid; -Staff are expected to rolls bag of dried foods up and seal with tape before placing them in large dry bin storage containers. During an interview on 7/28/2022, at 12:58 P.M., the Administrator said the following: -Dry foods should be dated, labeled, and sealed after opening and stored properly in appropriate temperatures and not on the floor; -Staff should close bags of dried foods before placing in dry storage bins; -Dry storage bins containing food should have an intact lid and not be open to air. 2. Record review of the 2013 Food Code, issued by the Food and Drug Administration, showed the following: -Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Record review of the facility's Nutrition and Dining Services Manual, dated May 2015, showed the following: -Hairnets or bouffant disposable caps should be worn at all times and should cover the entire head of hair. Observations of the kitchen on 7/24/2022, beginning at 9:24 A.M., showed the following: -Sign on kitchen door stating no one is allowed past the dish pit without a hair net; -DA L did not have a hair net on while in the kitchen working near the ovens. Observations of the serving area on 7/24/22, beginning at 11:57 A.M., showed the following: -DA L in the serving area putting dishes out with no hair net on; -DA L completed serve out for lunch with no hair net on. He worked over food and placed all the food on plates for the residents. During an interview on 7/27/2022, at 1:31 P.M., DA B said the following: -Staff are required to wear hair nets in the kitchen anywhere beyond the dish pit; -Staff are required to wear hair nets in the serving area; -Hair nets are supposed to cover all the hair on the head. During an interview on 7/27/2022, at 1:43 P.M., the DM said the following -Staff is expected to wear hair nets while working in the kitchen, serving area, and while serving drinks in the dining room; -Hair nets are to cover their whole head and all of their hair. During an interview on 7/28/2022, at 12:58 P.M., the Administrator said the following: -Staff is expected to wear hair nets in the kitchen and the serving area at all times; -Hair nets are to cover all hair and a beard net is required for facial hair such as beards.

2. Record review of Resident #65's face sheet showed staff admitted the resident to the facility on 2/1/19 with a stage IV pressure ulcer of the sacral (tailbone) region. Record review of the resident's care plan, last reviewed on 5/13/19, showed the following: -Risk for developing more pressure ulcers due to staying in bed frequently and staying up for extended amounts of time preventing off-loading of pressure; -admitted with a stage IV pressure ulcer to the sacrum; -Observe the resident's skin during care for discoloration and/or breaks and notify the doctor of significant changes; -Assist the resident to reposition in his/her wheelchair and in bed every two hours, use a cushion in the wheelchair, pillows to his/her back, between his/her legs, and float heels as needed; -Provide a pressure-reducing wheelchair cushion and a low air loss mattress to bed and a Roho cushion (a pressure-reducing cushion) in wheelchair. Record review of the resident's physicians order sheet and August 2019 treatment administration record (TAR) showed the following orders: -An order dated 8/16/19, to cleanse the sacral wound with Pure and Clean, Apply sure prep to the peri wound, apply a nickel-thick layer of Santyl (an enzymatic debriding ointment) to wound bed then apply calcium alginate (a highly absorbent, biodegradable alginate dressing derived from seaweed that helps maintain a moist microenvironment to promotes healing), cover with bordered gauze. Change every day and as needed for soilage; -An order dated 8/29/19, to cleanse the sacral wound with Pure and Clean, apply Sure Prep to the peri wound, apply a moistened collagen pad (a porous 100% collagen dressing for moist wound healing) to the wound base then Opti-Foam every other day and as needed for soilage. An observation on 8/26/19, at 10:15 A.M., showed LPN H and CNA D assisted the resident with incontinent care. The resident had a soiled dressing on his/her sacrum. The LPN removed the soiled dressing and said he/she needed to get supplies to perform the treatment and left the room. The LPN returned to the resident's room and placed the wound care supplies on a clean surface barrier on the resident's side table. The LPN washed his/her hands and applied gloves. The nurse said the resident's current treatment consisted of cleaning the pressure ulcer with Pure and Clean, applying Calcium Alginate to the wound bed, and covering with Opti-Foam, two times per day and as needed. The LPN cleansed the pressure ulcer with Pure and Clean then, without changing his/her gloves or sanitizing his/her hands, applied Calcium Alginate to the wound bed and covered it with an Opti-Foam dressing. During an interview on 9/3/19, at 3:35 P.M., LPN G said the following: -The nurse should review the TAR or physician's order prior to performing a treatment; -Interventions for pressure ulcers included turning and repositioning the resident every two hours, off-loading pressure, properly-fitting wheelchair, proper pillow or towel placement, observing for redness, and obtaining a Sure Prep order; -The nurse should wash his/her hands when entering and leaving a resident's room, anytime he/she changed gloves, when moving from one wound to the next, after wound care or perineal care, and before touching any clean surfaces or the resident. During an interview on 9/3/19, at 4:00 PM, the DON said the following: -During a pressure ulcer treatment, the nurse should wash his/her hands and apply gloves when entering a resident's room, going from dirty to clean, prior to cleaning the pressure ulcer, when moving from one wound to another wound, after the treatment, and before touching clean surfaces; -The ADON performed residents' weekly wound assessments; -Nurses should check the resident's TAR or physician's order prior to pressure ulcer treatments to ensure the order had not changed. Based on observation, interview and record review, the facility failed to perform an initial assessment, document the initial assessment, notify the physician, and obtain treatment orders for one resident (Resident #48) with two newly identified pressure ulcers, and failed to perform a pressure ulcer treatment per physician's orders and using appropriate infection control techniques to prevent contamination of a stage IV (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) pressure ulcer for one resident (Resident #65) in a selected sample of 18 residents. The facility's census was 78. Record review of the facility's Wound Care and Treatment policy, dated 3/2015, showed the following: -Purpose to prevent and treat all wounds; -Guidelines include there must be a specific order for the treatment; hand washing must be done as outlined in the guidelines; put gloves on; remove the soiled dressing; remove the gloves and discard; wash hands and put on clean gloves; clean the wound according to the order; remove gloves, place in trash bag, and put on clean pair of gloves; apply clean dressing as ordered; and wash hands. 1. Record review of Resident #48's care plan, revised on 11/7/17, showed the following: -Nursing staff will complete weekly skin assessments; -Observe his/her skin during care for discoloration, breaks, and notify the doctor of significant changes; -Reposition the resident in his/her wheelchair and in bed every two hours; -Place a cushion in wheel chair, and pillows for comfort as needed; -Float the resident's heels as needed; -Provide the resident with a pressure-reducing wheelchair cushion, and mattress to his/her bed; -Provide good skin care after any accident with bowels and bladder; -Encourage the resident to stay off his/her back in bed and encourage side-to-side positioning. Continue with ordered treatment until wound healed and as needed if wound reopened. Record review of the resident's face sheet (admission data) showed staff readmitted the resident to the facility on 8/5/18. His/her diagnoses included high blood pressure, diabetes, stroke, and depression. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/12/19, showed the following: -Cognitively intact for daily decision making; -Required extensive assistance for bed mobility, transfers, dressing, and personal hygiene; -Dependent on staff for toileting and bathing; -Used a wheelchair for mobility; -One Stage I pressure ulcer (an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness); -One Stage II pressure ulcer (partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue)); -Used pressure-relieving devices for chair and bed; -Used ointments and dressings. Record review of the resident's physician order, dated 7/29/19, showed instructions for staff to cleanse the pressure ulcer on the resident's left and right coccyx (tailbone) with wound cleanser, apply sure prep (a skin barrier wipe) to the peri-wound and cover with Optifoam (adhesive foam dressing), three times a week. Record review of the resident's pressure ulcer wound monitoring form dated 8/22/19, at 7:36 A.M. and 7:42 A.M., showed a nurse documented the following the information: -Stage II pressure ulcer on the resident's coccyx, acquired at the facility, and measured 0.6 centimeters (cm) x 0.6 cm x 0.1 cm. The wound improved; -Stage II pressure ulcer on the resident's left coccyx, acquired at facility, and measured 0.4 cm x 0.4 cm x 0.1 cm. The wound improved. Observation and interview on 8/27/19, at 2:20 P.M., showed the following: -Licensed Practical Nurse (LPN) A gathered supplies for wound care. Staff positioned the resident on his/her right side. The LPN removed the dressing on the resident's buttocks and showed two pressure ulcers, each approximately 1 cm x 1 cm, on the resident's middle and left coccyx area. The wound bed on each wound was pink with no drainage. The LPN identified two new on the resident's right buttock. Both pressure ulcers measured approximately 1.0 cm x 1.0 cm with a small amount of bloody drainage. The LPN cleaned each wound and covered them with Optifoam. -LPN A said he/she performed the same treatment on the newly identified pressure ulcers as he/she did for the pressure ulcers on the resident's coccyx. Record review of the resident's medical record, dated 8/27/19 to 8/28/19, showed no documentation of the nurse's initial assessment of the resident's newly identified pressure ulcers and no documentation staff notified the physician or the Assistant Director of Nursing (ADON) of the newly identified pressure ulcers on the resident's buttock. An observation and interview on 8/30/19, at 11:00 A.M., showed the following: -The ADON (facility wound nurse) and LPN B entered the resident's room to perform the treatment on the resident's pressure ulcers. -The ADON said the physician assessed the resident's pressure ulcers on 8/29/19. The resident had three pressures ulcers on his/her right buttocks and five pressure ulcers on his/her coccyx. The status of the resident's pressure ulcers changed almost daily. -Staff rolled the resident onto his/her side and showed five small pressure ulcers on his/her coccyx and three small pressure ulcers on his/her right buttocks. Record review of the resident's physician progress note, signed by the physician on 8/30/19, at 1:39 P.M., showed the following: -The resident had several wounds on his/her sacral (a triangular shaped bony structure located at the base of the lower spine)/gluteal (buttocks) area that appeared as Stage I to Stage II pressure ulcers. No redness or significant drainage. Tissue looked healthy with some bleeding after the dressing was removed. -The resident had a left gluteal lesion, a shallow shearing wound about 1.5 cm in diameter. New orders for a low air-loss mattress, and to clean the pressure ulcers daily with wound cleanser followed by placement of Optifoam dressing over the pressure ulcers. During an interview on 8/30/19, at 9:00 A.M., the ADON said if a nurse found any new wounds, he/she should assess the wound then document the assessment on the initial wound section of the wound sheet and in the nurses' notes. During an interview on 8/30/19, at 10:00 A.M., LPN A said if he/she found a new pressure ulcer, he/she would perform an initial skin assessment, document the assessment in the progress notes, and notify the physician. When he/she found the new pressure areas on the resident's buttocks, he/she did not document the initial skin assessment in the nurses' notes or on the wound sheet and he/she did not notify the ADON/wound nurse. The LPN did not call the physician to obtain treatment orders for the new wounds on the resident's buttocks. He/she thought another nurse obtained orders because the current orders were for wound on the resident's right and left coccyx. During an interview 8/30/19, at 10:10 A.M., LPN B said if he/she found a new pressure ulcer he/she would call the physician for new orders, notify the family and the ADON/wound nurse. He/she would also document the initial wound assessment in the progress notes and on the wound sheet. During an interview on 8/30/19 at 10:30 A.M., Certified Nursing Assistant (CNA) C said if he/she found a new pressure ulcer, he/she would notify the charge nurse. During an interview on 9/3/19, at 3:35 P.M., CNA D said if a CNA identified a new area on a resident's skin, the CNA should clean around the wound and report it to the nurse immediately. During an interview on 9/3/19, at 3:35 P.M., LPN G said if staff identified a new wound, the nurse should document an initial weekly wound assessment which included the location, size, wound bed appearance, surrounding tissue appearance, and drainage. The nurse should notify the physician to obtain new treatment orders, document the assessment and notification in a progress note, transcribe the new order in the TAR, contact the resident's family, and notify administration. During an interview on 9/3/19, at 3:40 P.M., CNA F said if a CNA identified a new area on a resident's skin, the CNA should clean the area and tell the nurse immediately so he/she could measure the area. During an interview on 9/3/19, at 4:00 PM, the Director of Nursing (DON) said if a nurse identified a new/worsened pressure ulcer on a resident, the nurse should cleanse, assess, and measure the area. The nurse should complete an initial skin report and slide it under the ADON's office door, then notify the DON, physician, and family.

Based on observation, record review, and interview the facility failed to ensure residents' safety and prevent the potential for accidents when staff did not remove two resident's (Resident #221 and Resident #64) oxygen tanks while they were in the designated smoking area. The facility's census was 78. Record review the facility's Smoking-Resident policy, dated 12/2016, showed the following: -Purpose: This facility shall establish and maintain safe resident smoking practices; -Guidelines include the following: -A) Prior to, or upon admission, residents shall be informed about any limitations on smoking; -B) The staff shall consult with the attending physician and the Director of Nursing services to determine any restrictions on a resident's smoking privileges; -C) Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues; D) The facility may impose smoking restrictions on residents at any time, if it is determined that the resident cannot smoke safely and requires the available levels of support and supervision. 1. Record review of Resident #221's face sheet showed staff admitted the resident to the facility on 8/23/19. His/her diagnoses included respiratory conditions due to smoke inhalation, Chronic Obstructive Pulmonary Disease (COPD) (an umbrella term used to describe progressive lung diseases), and acute respiratory failure. Record review of the resident's Smoking Risk Assessment, dated 8/24/19, showed the following: -Smoking materials included cigarettes; -Frequency of use: requested to go outside when smoke breaks was over; -No problems with smoking in unauthorized areas; -Careless with smoking materials: minimal problem, noted with cigarette butt in his lap upon assisting to bathroom; -Smoked cigarette butts from ash trays: no problem; -Inappropriately provided smoking materials to others: no problem; -Begged or stole smoking materials from others: no problem; -General awareness and orientation, including ability to understand safe smoking requirements: no problem; -General behavior and interpersonal interaction: no problem; -Capability to follow facility safe smoking guidelines: minimal problem, requesting to smoke outside of normal smoke break times; -Evaluation: Score 4.0, safe smoker-follow facility policy. Record review of the resident's Physician Order Sheet (POS) showed an order, dated 8/24/19, for Oxygen, 5 Liters (L) per minute, per nasal cannula (a lightweight tube that splits, at one end, into two prongs, that are placed in the nostrils to deliver supplemental oxygen), continuously every day and night shift. Record review of the resident's care plan showed the following: -On 8/26/19, staff added the resident had an alteration in respiratory status and received continuous oxygen due to respiratory failure and an infection. Approaches included to administer oxygen as ordered to help the resident breathe; -On 8/30/19, staff added the resident looked forward to smoke breaks as an activity. An observation on 8/26/19, at 11:27 A.M., showed five residents sat in the supervised designated smoking area. Resident #221 had his/her oxygen tank secured to the back of his/her wheelchair with it turned on at 4L. The resident's nasal cannula laid on the top of the oxygen tank. 2. Record review of Resident #64's face sheet showed staff admitted the resident to the facility on 5/1/19. His/her diagnoses included COPD exacerbation. Record review of Resident #64's Activity Assessment, dated 5/2/19, showed the following: -The resident did not smoke cigarettes; -The resident enjoyed outdoor activities; -The resident enjoyed social interaction in small and large groups. Record review of the resident's POS showed an order, dated 8/6/19, to add in Oxygen via continuous positive airway pressure (CPAP) (a common treatment for obstructive sleep apnea) at 2L per minute when sleeping. Record review of the resident's care plan, last reviewed on 8/5/19, showed the following: -Alteration in respiratory status related to COPD. Oxygen should be administered as ordered to help the resident breathe; -Resident enjoyed independent, self-initiated activities. Observations on 8/30/19 showed the following information: -At 11:10 A.M., Resident #64 sat outside, in the designated smoking area, with his/her oxygen tank secured to his/her walker. The resident's nasal cannula was on his/her face administering 3L per minute of oxygen. He/she sat next to three other residents who had lit cigarettes. -At 11:14 A.M., Dietary [NAME] E removed the resident's nasal cannula, placed it on his/her walker and moved the walker approximately 3 feet from the residents. There was no visible signage stating no oxygen in the designated smoking area. 3. During an interview on 9/3/19, at 3:35 P.M., Licensed Practical Nurse (LPN) G said the following: -He/she occasionally supervised residents while they smoked; -Residents wore smoking aprons; -No oxygen was allowed in the designated smoking area; -He/she had not received verbal training or in-services on smoking safety; -If a resident was in the smoking area with oxygen, he/she asked the resident to remove his/her oxygen and place it inside the facility. 4. During an interview on 9/3/19, at 3:35 P.M., Certified Nurses Assistant (CNA) D said no oxygen tanks are to go out of the facility, and no oxygen was allowed in the designated smoking area. 5. During an interview on 9/3/19, at 3:40 P.M., CNA F said either staff or the resident removed the oxygen tank when a resident smoked. No oxygen was allowed in the smoking area at all. 6. During an interview on 9/3/19, at 4:00 PM, the Director of Nursing (DON) said the following: -Residents smoke four times a day and are supervised by the housekeeping, dietary, and nursing staff; -Residents smoke in the designated smoking area, wear smoking aprons, and could not handle their own lighters; -No oxygen was allowed on the resident's person, wheelchair, or walker. No oxygen was allowed while residents smoked in the designated smoking area; -Staff received training on smoking safety.

Based on observation, interview, and record review, the facility failed to ensure food items were stored in accordance within professional standards for food service when the ice machine was not properly cleaned and maintained. The facility's census was 78. Record review of the facility's Nutrition and Dining Services Manual, dated May 2015, showed the following direction for monthly cleaning of the ice machine: -Unplug the ice machine and empty ice from the machine to clean the container; -Wash the inside of the ice machine thoroughly with warm detergent solution; -Rinse with baking soda water and dry; -Polish the outside with a micro-shield or glass cleaner; -Replace reserved ice back into the machine. 1. Observations of the ice machine, located in the meal serve out room attached to the main dining room, on 8/26/19, at 9:37 A.M., and on 8/29/19, at 9:58 A.M., showed the following: -The inner lip of the ice machine's lid/door was covered with a black and gray build up; -The upper interior of the ice bin showed a black spotted substance around the plastic screws holding the upper lid directly above the ice. During an interview on 8/29/19, at 10:02 A.M., [NAME] E said maintenance staff was responsible for cleaning the inside of the ice machine. Dietary staff cleaned the exterior of the ice machine. During an interview on 8/29/19, at 10:03 A.M., the Dietary Manager said maintenance staff was responsible for cleaning the ice machine weekly. She did not know if maintenance staff documented when they cleaned the ice machine. During an interview on 8/29/19, at 10:08 A.M., the Administrator said both dietary and maintenance staff are responsible for cleaning the ice machine. Staff should clean the ice machine any time it needed cleaned. The administrator did not know if staff documented cleaning of the ice machine. During an interview on 8/29/19, at 11:21 A.M., the Maintenance Supervisor said the dietary staff was responsible for cleaning the inside of the ice machine. The Maintenance Supervisor cleaned the motor to the ice machine; he cleaned the motor in May 2019. Staff did not document cleaning the ice machine. The maintenance supervisor did not know if the facility had a policy for sanitizing and cleaning the ice machine.