Based on interview and record review, the facility failed to ensure staff followed their abuse and neglect policy. Resident #4 informed Certified Nursing Assistant (CNA) K that CNA P was mean to him/her and twisted his/her right arm tightly. CNA K failed to notify his/her charge nurse of the accusation because he/she did not believe the resident. Due to CNA K's failure to report the resident's allegation, CNA P remained working until the Administrator was notified and suspended CNA P pending the facility's investigation. Ten residents were sampled. The census was 69. Review of the facility's Abuse and Neglect policy, issued on 1/3/22 and reviewed on 11/19/24, showed: -What: To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse. Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone. Residents must not be subjected to abuse by anyone. This includes staff; -Why: The resident has the right to be free from abuse and neglect. The facility must not use verbal, mental, sexual, or physical abuse; -The facility must develop and implement written policies and procedures that: Establish policies and procedures to investigate any such allegations. Review of the facility's Abuse - Protection of Residents policy, issued on 10/4/22 and reviewed on 5/7/25, showed: -Policy: The facility will ensure that all residents are protected from physical and psychosocial harm during and after an investigation; -Procedure: The following methods to ensure the protection of residents during an investigation may include but are not limited to: -1. Responding immediately to protect the alleged victim and integrity of the investigation; -2. Examine the alleged victim for any sign of injury, including physical examination or psychosocial assessment if needed; -3. Immediate notification of the alleged victim's practitioner and the family/responsible party; -4. Removal of access by the alleged perpetrator to the alleged victim and assurances that ongoing safety and protection is provided for the alleged victim and, as appropriate, other residents; -5. Notification of the alleged violation to other agencies or law enforcement authorities; -6. Evaluation of whether the alleged victim feels safe and if he/she does not feel safe, taking immediate steps to alleviate the fear, such as a room relocation, increased supervision, etc.; -a. Providing emotional support and counseling to the resident during and after the investigation, as needed; -b. Protection from retaliation; -7. Monitor the alleged victim and other residents at risk, such as conducting unannounced management visits at different times and shifts. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 4/28/25, showed: -Adequate hearing and vision; -Speech Clarity: Clear speech, distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands, clear comprehension; -Cognitively intact; -Diagnoses of chronic obstructive pulmonary disease (a chronic lung disease) and anxiety. Review of the resident's care plan, located in the electronic healthcare record, showed: -10/19/23: Focus: activity of daily living (ADL) assistance. Goal: Resident wishes to maintain prior level of function. Interventions: Assist with mobility and ADLs as needed. Hoyer (a machine used to transfer residents unable to bear weight) lift for all transfers; -11/8/24: Focus: Resistive to care. Will make false assumptions towards staff and has manipulative perception of healthcare concerns and needs being met. Goal: Will participate in care. Interventions: Allow resident to make decisions about treatment regime to provide a sense of control. Cares in pair, two CNAs when care is being provided. Continued documentation of behaviors. During an interview on 5/29/25 at 10:00 A.M., the resident said a few weeks ago, he/she could not recall the exact date, CNA P was taking care of him/her. CNA P became mean and squeezed his/her right arm so hard it left a bruise which was not visible at the time of the interview. He/She told Licensed Practical Nurse (LPN) A, on the day it happened. LPN A was the only one he/she told and said he/she would take care of it. During an interview on 5/29/25 at 10:25 A.M., LPN A said the resident never told him/her anything about CNA P getting mad at him/her and twisting his/her right arm. He/She has not seen any bruises on the resident's right arm. Had the resident told LPN A, and CNA P was in the building, he/she would have gotten the CNA's statement and sent him/her home immediately. He/She would have reported it to the Administrator or Director of Nursing (DON) immediately and started the investigation. During an interview on 5/29/25 at 10:44 A.M., the Administrator said he visits with the resident almost daily. The resident never told him anything about CNA P being mean to him/her and squeezing his/her arm. This was the first time he heard anything about it. He shakes the resident's hand every time after talking to him/her and he/she had not seen any bruising. During an interview on 5/30/25 at 7:22 A.M., CNA K said he/she took care of the resident every night he/she worked. On 5/8/25 or 5/10/25, he/she returned to work after being on vacation. The resident told him/her that CNA P had been mean and squeezed the resident's hand or wrist tightly and left a bruise. The resident did not say exactly when it occurred. The resident showed CNA K his hand/wrist, but CNA K did not see any bruises. Since there were no bruises and he/she had never seen CNA P be mean to anyone, CNA K thought the resident was making it all up. CNA K did not report the resident's allegations to anyone. Looking back now, he/she should have reported the resident's allegations to the charge nurse whether he/she believed the resident or not. Review of CNA K's written statement, dated 5/30/25, showed: One night he/she walked into the resident's room to do personal care. The resident said CNA P was mean and squeezed his/her arm. Don't you see the bruise? He/She told the resident no. The resident had no bruise or discoloration. Review of CNA K's time punches, showed he/she returned to work on the night shift of 5/6/25. He/She also worked on 5/8/25 and 5/9/25. During an interview on 5/30/25 at 9:15 A.M., CNA P denied being mean to the resident or squeezing the resident's arm. He/She had been nothing but nice to the resident, and could not understand why the resident would say something like that. Review of CNA P's time punches, showed he/she worked on the night shift on 5/1/25 through 5/5, 5/7 through 5/9, 5/12 through 5/14, 5/16 through 5/19, 5/21 through 5/23 and 5/26 through 5/28/25. The resident was in the CNA's group to care for on 5/4/25, 5/14, 5/19 and 5/22/25. During an interview on 5/30/25 at 8:00 A.M., the interim DON and Administrator said they expected staff to follow the facility's policies. Whether CNA K believed the resident or not, he/she should have followed the policy and reported the resident's allegation to the charge nurse. MO00254277

Based on observation, interview and record review, the facility failed to follow their policy and physician's orders by failing to notify the physician when one resident's blood sugar levels exceeded the physician's ordered parameters. In addition, the facility failed to obtain STAT (now/no delay) lab orders for the resident. The facility identified 22 residents with orders for routine blood sugar checks. Of the six that were sampled one, Resident #13, had blood sugar levels that exceeded the parameters to contact the physician. The census was 73. Review of the facility's Changes in Resident's Condition or Status, issued 11/26/25, and reviewed 9/5/24, showed:-Policy: This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status;-Notification of Changes: A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is: -A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in life threatening conditions or clinical complications); -A need to alter treatment significantly (that is, a need to discontinue an existing form or treatment due to adverse consequences, or to commence a new form of treatment).Review of Resident #13's annual Minimum Data Set (MDS,) a federally mandated assessment instrument completed by facility staff dated 4/1/25, showed:-Makes Self Understood: Rarely/never understood;-Ability To Understand Others: Rarely/never understands;-Diagnoses of high blood pressure, diabetes mellitus (low/high blood sugar level), aphasia (a partial or total loss of language skills), stroke and respiratory failure;-Received insulin injections 7 of the last 7 days.Review of the resident's care plan, located in the electronic health record (EHR), showed:-Focus: 6/20/23: Diabetes Mellitus; --Goal: The resident will have no complications related to diabetes; --Interventions/Tasks: Blood sugar checks as ordered. Diet as ordered. Medication as ordered.Review of the resident's physician's order sheet (POS) and 6/1/25 through 6/30/25 medication administration record (MAR) located in the EHR, showed:-Ordered on 4/11/25, and discontinued on 6/29/25: Notify physician for blood sugar less than 60 or greater than 400;-Ordered on 4/11/25, and discontinued on 6/29/25: Monitor blood sugar four times a day at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. -Ordered on 4/11/25, and discontinued on 6/24/25: Lantus insulin (long-acting insulin) 6 units daily at 9:00 P.M.;-Ordered on 4/11/25, and discontinued on 6/5/25: Humalog (fast-acting insulin) 5 units every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.;-Ordered on 6/5/25, and discontinued on 6/29/25: Novolog fast-acting insulin) 5 units every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M.;-Ordered on 6/24/25, and discontinued on 6/29/25: Lantus insulin 16 units daily at 9:00 P.M.Review of the resident's MARs, showed:-5/1/25 through 5/31/25: All of the resident's blood sugar levels were within the acceptable parameters;-6/1/25 through 6/21/25: All of the resident's blood sugar levels were within the acceptable parameters;-6/22/25 through 6/30/25, showed the following blood sugar level readings documented:-12:00 A.M.: 6/22 read 410, 6/23 read 439, 6/25 read 402, 6/26 read 406, 6/27 read 425, 6/28 read 466, and 6/29 read 475;-6:00 A.M.: 4/28 read 526;-12:00 P.M.: 4/28 read 444.Review of the resident's progress notes located in the EHR, showed:-No documentation the resident's physician was notified (at the time the blood sugar level was obtained) regarding the blood sugar levels on 6/22, 6/23, 6/26, 6/27, 6/28 (12:00 A.M. and 12:00 P.M.); -6/24/25 at 9:46 A.M.: Call placed to physician and informed him of multiple elevated BS readings (6/22 and 6/23). Orders received to increase Lantus by 10 units every day;-6/28/25 at 7:02 A.M.: Resident sugar level 526. Physician called and awaiting return call.Review of the nurse's report sheets for the resident, showed:-6/25/25: Blood sugar 402. New order: Increase Lantus to 16 units;-6/28/25: 6:10 A.M., Called physician. Obtain STAT CBC (complete blood count), CMP (comprehensive metabolic panel) and urine (obtain sample for urinalysis);-Review of the resident's EHR showed no documentation the facility obtained the STAT CBC, CMP and urinalysis. Review of the resident's progress note, showed:-6/29/25 at 8:34 A.M. (the next note after the 6/28/25 at 7:02 A.M. entry): 12:00 A.M., upon entering resident's room, he/she was noted to be tachypneic (rapid shallow breathing) with eyes closed. Opened eyes to name but drifted back immediately. Vitals obtained: 152/68 (blood pressure (BP) - normal 120/80), 98.8 (temperature (T) - normal 98.7), 121 (pulse (P) - normal 60-100), 86% on room air (oxygen saturation rate (O2 Sat) - normal 95-100). Blood sugar level 475. Insulin administered per orders. Resident is normally resistant to any touch to his/her abdomen, and he/she is not this time. Skin warm and dry. Cough noted: 12:13 A.M.: Call placed to EMS (emergency medical services) and departed to hospital. 12:16 A.M.: Call placed to physician. 7:15 A.M.: Director of Nursing (DON) informed. Review of the resident's SBAR ( situation, background, assessment, recommendation) Communication Form dated 6/29/25 at 12:13 A.M., showed:-Situation: This started on 6/28/25. Since this started it has gotten worse;-Background: -Changes in the past week : Lantus insulin increased to 16 units daily;-Vital Signs: BP 152/68, P 121, respirations 28 (normal respiration rate 12-20), T 98.8 and O2 Sat 86%;-Decreased level of consciousness;-Non-productive cough;-Review: Sent to hospital. Review of the resident's hospital records, showed:-admission date of 6/29/25;-discharge date of 7/10/25;-Resident admitted with history of stroke with residual left sided deficits, dysphagia (difficulty swallowing) with feeding tube (a tube inserted into the stomach to provide liquid nutrition, fluids and medication). Resident aggressive to nursing home staff at baseline, was altered at the nursing home and brought to the emergency department. Blood sugar in 400-500's;-Resident diagnoses at the time of admission included: septic shock (a life-threatening condition caused by infection and sepsis (systemic infection (affecting the entire body)) due to MRSA (methicillin resistant staphylococcus aureus), encephalopathy (syndrome of overall brain disfunction), acute (sudden) hypoxic (low oxygen level) respiratory failure, and diabetes type 2 insulin dependent;-CMP results dated 6/29/25 at 12:00 A.M. and 1:24 A.M.: Glucose (sugar) level of 534;-Sputum culture results dated 6/29/25 at 6:07 A.M., and updated on 7/2/25 at 7:13 A.M.: MRSA detected. Observations on 7/14/25 at 9:00 A.M. and 1:42 P.M., and on 7/15/25 at 9:09 A.M., showed the resident lay in bed awake and making eye contact, but unable to comprehend or respond to questions. During an interview on 7/15/25 at 9:54 A.M., Licensed Practical Nurse (LPN) D said if a resident's blood sugar exceeded the physician ordered parameter, he/she would contact the resident's physician and document it in the resident's progress note along with any new orders the physician gave. During an interview on 7/15/25 at 10:10 A.M., LPN C said if a resident's blood sugar check exceeded the physician's ordered parameter, he/she would contact and update the physician. He/She would document contacting the physician in the resident's progress notes and would document any new orders on the POS and MAR. During an interview on 7/15/25 at 11:31 A.M., the Director of Nursing (DON), Regional Director of Clinical Services and the Regional [NAME] President said if a blood sugar exceeded the physician's ordered parameters, they expected the nurse to contact the physician at the time the blood sugar was obtained and document contacting the physician as well as any new orders in the resident's EHR.During an interview on 7/15/25 at 12:44 P.M., the Regional Director of Clinical Services said the labs were not obtained. A STAT lab meant it should be obtained now. If it could not be obtained STAT, then the physician should be notified and that should be documented in the EHR.During an interview on 7/15/25 at 2:30 P.M., the Regional [NAME] President said their lab tried to obtain STAT orders within four hours, however the lab said it could take up to 24 hours for lab staff to be at the facility and obtain the lab. MO00256981

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident #7 had fall mats in place and the resident's bed was kept in the lowest possible position when the resident was in bed and unattended by staff, and failed to include the fall mats and low bed as interventions on the resident's care plan. The facility also failed to ensure Resident #9's bed was kept in the lowest position when the resident was in bed and unattended by staff. Four residents were sampled. The census was 69. Review of the facility's Fall Management policy, issued on 6/4/20, and revised on 3/11/25, showed: -Policy: The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls; -Federal Regulations: The facility must ensure that the resident remains as free of accident hazards as is possible. Each resident receives adequate supervision and assistance devices to prevent accidents; -Definitions: Accident - Refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident; -Avoidable Accident - This means that an accident occurred because the facility failed to: -1. Identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; -2. Evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazards/risks as much as possible; -3. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident; -4. Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice; -Fall - Refers to unintentionally coming to rest on the ground, floor, or other lower level. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred; -Risk - Refers to any external factor, facility characteristic or characteristic of an individual resident that influences the likelihood of an accident; -Hazards - Refer to elements of the resident environment that have the potential to cause injury or illness; -1. Hazards over which the facility has control are those hazards in the resident environment where reasonable efforts by the facility could influence the risk for resulting injury or illness; -2. Free of accident hazards as is possible refers to being free of accident hazards over which the facility has control; -Procedure: -1. Residents will be assessed for fall indicators upon admission, readmission, quarterly, change in condition and with any fall utilizing the Fall Risk Assessment; -2. During the admission and readmission process, a care plan will be developed and initiated by the admitting nurse on any residents assessed to be a risk for falls; -3. Upon completion of the other interdisciplinary team's admission and readmission assessments, the interdisciplinary team will review any additional fall risk indicators and revise the resident's care plan as indicated; -4. The interdisciplinary team will review and revise the care plan, if indicated, upon completion of each comprehensive, significant change and quarterly Minimum Data Set (MDS), upon a fall event and as needed thereafter; -5. Residents and/or family members will receive education on the fall management care plan and will be provided opportunity for feedback; -6. The interventions to reduce the risk of falls should be individualized based on the resident risk factors and fall history; -Identifying Patients' Fall Potential; -1. All patients have fall indicators. Fall indicators are patient specific information that, when alone or combined with other fall indicators, create a potential for a patient to fall; -2. Accurate and thorough assessment of the patient is fundamental in determining indicators for potential falls; -a. Fall indicators may be identified by multiple disciplines, utilizing various assessments, and including but not limited to review of; physician orders, progress notes, environmental factors, caregiver conversations; -b. Patient conditions may vary throughout the day, week, month or other time period and the identification of patient fall indicators is an ongoing, interdisciplinary assessment process. 1. Review of Resident #7's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/25/25, showed: -Hearing: Minimal difficulty; -Adequate vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability To Understand Others: Understands - clear comprehension; -Moderately impaired cognition; -Mobility Devices: [NAME] and wheelchair; -Substantial/maximal assistance required for: Roll left and right, lying to sitting on side of bed, sit to stand, chair/bed to - chair transfer, and walk 10 feet; -Diagnoses of heart failure, high blood pressure, diabetes mellitus and stroke; -Did the resident have a fall any time in the last month prior to admission? Yes; -Did the resident have a fall any time in the last 2 to 6 months prior to admission? Yes; -Any falls since admission? No. Review of the resident's care plan, located in the electronic healthcare records (EHR), showed: -5/20/25: Focus: activity of daily living (ADL) assistance and therapy services needed to maintain or attain highest level of function. Goal: Resident wishes to attain prior level of function. Interventions/Tasks: Assist with mobility and ADLs as needed. Therapy services as needed; -5/20/25: Focus: Decline in mobility and strength related to stroke and requires assist with all ADLs and transfer. Goal: Resident will not sustain serious injury requiring hospitalization. Interventions/Tasks: Assist with ADLs as needed. Call light within reach. Complete fall risk assessment. Mechanical lift (a machine used to transfer a resident who can bear partial weight or a machine used to transfer a resident who cannot bear weight). Orient resident to room; -5/27/25: Focus: Resident scored moderate (cognition) on Brief Interview for Mental Status (BIMS, a cognitive assessment completed by facility staff). Goal: Resident will be able to communicate basic needs. Interventions/Tasks: Allow extra time for resident to respond to questions and instructions. Ask yes/no questions in order to determine the resident's needs. Cue, reorient and supervise as needed; -The care plan did not address the resident's fall history, current fall risk or interventions specifically keeping the bed in the lowest position and fall mats on the floor when unattended. Review of the resident's Fall Risk Assessments located in the EHR, showed: -5/21/25: A score of 18 (a score of 10 or above indicates the resident is at risk of falling); -5/27/25: A score of 17. Review of the resident's progress notes, located in the EHR, showed: -5/21/25 at 12:14 A.M.: Resident arrived via ambulance and transferred to bed; -5/21/25 at 7:09 A.M.: Called to resident's room by Certified Nursing Assistant (CNA). Resident sitting on floor with back against bed. Bed in lowest position. Assisted back to bed with assist of 2. No apparent injuries noted; -5/21/25 at 12:31 P.M.: BIMS score of 12, revealing moderate cognitive impairment; -5/22/25 at 5:58 Alert and oriented x 2 (orientation is documented as one or more of the following: person, place, time, situation) although he/she wanders mentally at times. Weakness noted to left side. Resident is able to turn and reposition in bed with assist of 1. Call light within reach and bed in lowest position; -5/23/25 at 6:27 P.M.: Resident requires assistance to turn and reposition in bed. Call light within reach and bed in lowest position with floor mats on both sides for safety. Continues on observation related to fall on 5/21/25; -5/24/25 at 8:41 A.M.: Resident able to turn and reposition in bed independently. Call light within reach and bed in lowest position with floor mats on both sides for safety; -5/25/25 at 12:36 P.M.: Resident able to make needs known. Resident able to turn and reposition in bed independently. Call light within reach and bed in lowest position with floor mats on both side for safety; -5/27/25 at 5:54 A.M.: Resident able to turn and reposition in bed independently. Call light within reach and bed is in lowest position with floor mats on both sides for safety; -5/27/25 at 6:09 P.M.: Resident is able to turn and reposition in bed independently. Call light within reach and bed in lowest position with floor mats on both sides for safety. Awake at intervals during the night yelling out Jesus and Nurse; -5/27/25 at 9:45 A.M.: Resident observed in his/her room on the floor in front of wheelchair. When asked how he/she got on the floor resident stated he/she was trying to get up; -5/29/25 at 5:16 A.M.: Resident continues on observation related to unwitnessed fall on 5/27/25. Asleep in bed duration of night. Call light within reach and bed in lowest position with floor mats on both sides for safety; -5/29/25 at 10:21 P.M.: Resident continues on observation for unwitnessed fall on 5/27/25. Asleep in bed duration of the night. Call light within reach and bed in lowest position with floor mats on both sides for safety. Observation on 5/28/25, showed: -At 8:55 A.M., the resident lay in bed unattended by staff. Both of the resident's floor mats were leaned up against the wall near the window. The height of the resident's bed was 21 inches () from the floor to the top of the bed. The resident said he/she had fallen twice since his/her admission. He/She was not injured during the falls. One of the falls was from his/her bed. The facility put the fall mats down after his/her fall from the bed. Sometimes the mats are on the floor and sometimes they aren't. He/She does not mind having the fall mats down and the bed in the lowest position when unattended; -At 1:22 P.M., the resident lay in bed sleeping and unattended by staff. The fall mats remained leaning against the wall and the height of the resident's mattress from the floor to the top of mattress was 25. Observation on 5/29/25 from 9:36 A.M. to 9:44 A.M., showed the resident lay in bed with his/her eyes closed and unattended by staff. Both of the floor mats leaned against the wall. The height of the bed was 22 from the floor to the top of the bed. At 9:44 A.M., Licensed Practical Nurse (LPN) R entered the resident's room and said the resident had fallen twice since his/her admission. He/She verified the mats were leaning against the wall and there were no staff in the room attending to the resident. He/She said the floor mats should be on the floor, one on each side of the bed when staff are not in the room taking care of the resident. The bed should be in the lowest position possible. The LPN lowered the resident's bed to the lowest position at that time and the height of the bed was 13 from the floor to the top of the mattress. The resident said he/she did not mind the bed being in the lowest position or having the floor mats on each side of the bed. During an interview on 5/29/25 at 11:45 A.M., with the interim Director of Nurses (DON) and Administrator, the DON said she expected staff to keep the resident's floor mats on the floor next to the bed and the bed in the lowest position any time there are not staff in the room and the resident is in bed. The resident's care plan should identify the use of the fall mats and the bed in the lowest position possible when the resident is not being cared for. She will update the care plan. Review of the resident's updated care plan on 5/29/25, by the interim DON, showed: -Focus: Resident has had an actual fall with poor balance, he/she is at risk for future falls. Goal: The resident will resume usual activities without further incident. Interventions/Tasks: Ensure bed is in lowest position at all times when in bed. Floor mats to bilateral side of bed. Frequently used items within reach. 2. Review of Resident #9's admission face sheet, located in the EHR, showed an admission date of 9/24/25. Review of the resident's progress note, dated 1/5/25 at 9:27 A.M., showed: Resident observed sitting on the floor mat by his/her bedside. Resident was assessed back into bed. Review of the resident's Fall Risk Assessments located in the EHR, showed: -1/5/25 at 10:01 A.M.: A score of 20; -4/5/25: A score of 16. Review of the resident's quarterly MDS, dated [DATE], showed: -Makes Self Understood: Sometimes understands - responds adequately to simple, direct communication only; -Ability To Understand Others: Sometimes understands - responds adequately to simple, direct communication only; -Severely impaired cognition; -Mobility Devices: Wheelchair; -Substantial/maximal assistance required for: Sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to - chair transfer; -Diagnoses of high blood pressure and dementia; -Any falls since admission or prior assessment? No. Review of the resident's care plan, located in the EHR, showed: -10/4/24: Focus: ADL assistance and therapy services needed to maintain or attain highest level of function. Goal: Will maintain quality of life. Interventions/Tasks: Assist with mobility and ADLs as needed and 1 person assist with transfers. Resident has dementia and may participate in care with cueing and repeated verbal commands; -1/29/25: Focus: Resident has dementia and scored a BIMS assessment that suggest severe cognitive impairment. Goal: Resident will follow 1 to 2 step instructions. Interventions/Tasks: Allow extra time for resident to respond to questions and instructions. Ask yes/no questions to determine resident's needs; -9/27/24: Focus: At risk for falls. Has had falls prior to admission and is at risk for future fall. Goal: Will not sustain serious injury requiring hospitalization. Interventions/Tasks: Anticipate and meet the resident's needs. Assist with ADLs as needed. Call light within reach. Complete fall risk assessment. Ensure mats at bedside. Ensure that bed is in low position. Observation on 5/28/25, showed: -At 9:26 A.M.,: The resident lay in bed unattended by staff. One mat lay on the floor on each side of the bed. The height of the bed was 25 from the floor to the top of the mattress; -At 1:45 P.M.: The resident lay in bed unattended by staff. One mat lay on the floor on each side of the bed. The height of the bed was 27 from the floor to the top of the mattress. Observation on 5/29/25 at 8:15 A.M., showed the resident lay in bed unattended, eating breakfast. The height of the bed from the floor to the top of the mattress was 25. CNA F entered the room. He/She said he/she was not sure if the resident had a history of falls or not, but since there were fall mats down, he/she expected the bed to be in the lowest position when staff are not in the room. The CNA lowered the bed to the lowest position and the height of the bed was 13 from the floor to the top of the bed. During an interview on 5/29/25 at 11:45 A.M., the Administrator and interim DON said they expected the resident's bed to be in the lowest position when staff are not in the room attending to the resident. MO00254505 MO00254738

Based on observation, interview and record review, the facility failed to accommodate the needs of one resident with mobility impairments when staff failed to ensure the resident had access to a call light adapted to meet his/her needs (Resident #9). The sample was 18. The census was 86. Review of Resident #9's medical record, showed diagnoses included multiple sclerosis (MS, disease of the central nervous system), quadriplegia (paralysis of all four limbs), seizures, abnormal posture, generalized muscle weakness, contractures to left and right hands, cognitive communication deficit, anxiety, and depression. Review of the resident's significant change Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 2/20/25, showed: -Severe cognitive impairment; -Clear speech; -Makes self understood: Usually understood; -Dependent for eating, oral hygiene, toileting, showers, dressing, rolling left and right, and sit to stand transfer. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident has impaired mobility secondary to MS. Total assist with all activities of daily living (ADLs); -Focus: Resident has a communication problem related to neurological symptoms, weak or absent voice; -Focus: Resident is at risk for falls due to his/her impaired mobility, seizure disorder, and use of psychotropic medications; -Interventions included call light within reach; -The care plan did not identify the resident required a specialized call light. Observations on 2/24/25 at 10:52 A.M., 12:31 P.M., and 1:06 P.M., showed the resident in bed. A push button call light was on the floor behind the head of the bed. Observations on 2/25/25 at 9:06 A.M., 12:40 P.M., and 2:11 P.M., showed the resident in bed. A push button call light was on the floor behind the head of the bed. During an interview on 2/25/25 at 2:11 P.M., the resident said he/she could not move his/her arms or legs. He/She did not have a call light. He/She had no way to call staff for help when needed. Observations on 2/26/25 at 7:20 A.M., 9:14 A.M., and 12:38 P.M., showed the resident in bed. A push button call light was on the floor behind the head of the bed. Observation on 2/27/25 at 8:00 A.M., showed the resident in bed. A push button call light was on the floor behind the head of the bed. During an interview, the resident was soft spoken and provided verbal responses, in addition to nodding and shaking his/her head. He/She said he/she did not have a call light, but would like one. He/She could turn his/her head at a downward angle and demonstrated doing so during the interview. During an interview on 2/27/25 at 1:32 P.M., the Therapy Director said the resident had some mobility issues and could not use a standard call light. She was not sure if the resident had a touchpad call light, and would check with maintenance on getting one. During an interview on 2/27/25 at 1:40 P.M., Certified Nurse Aide (CNA) O said the resident's hands were contracted and he/she could not use a push button call light. The resident talked really quietly but could make his/her needs known. Observation on 2/27/25 at 1:45 P.M., showed the Therapy Director entered the resident's room and picked up the push button call light off the floor from behind the resident's bed. It was connected to a tube she identified as a breath-activated call light. The Therapy Director placed the breath-activated call light on the resident's bedside table and said he/she was going to find a touchpad call light instead. The breath-activated call light was coated with a layer of dust. CNA O and CNA Q looked at the breath-activated call light and said they did not know the resident had that particular call light and the resident did not use it. Observation on 2/57/25 at 1:54 P.M., showed the Maintenance Director tested the breath-activated call light on the resident's bedside table, and it successfully activated the panel on the wall. During an interview, the resident said he/she was happy to be getting a call light and it would make it easier for him/her to communicate. During an interview on 2/27/25 at 2:03 P.M., Registered Nurse (RN) R said the resident moved his/her limbs and had limited mobility. The resident had some minor mobility in his/her neck. He/She could make his/her needs known to an extent. RN R was not aware the resident had a breath-activated call light. Nursing staff should ensure call lights were placed within a resident's reach. During an interview on 2/28/25 at 7:11 A.M., the Infection Preventionist (IP) said the resident used to use the breath-activated call light, but his/her family opted against it. The resident did not really use his/her call light anyway. Yesterday, he/she was given a touchpad call light. He/She could move his/her head enough to be able to use it. The resident's need for a specialized call light should be documented on his/her care plan. During an interview on 2/28/25 at 8:22 A.M., the Director of Nurses (DON) said all residents should have access to a call light they could use. The resident's family member told staff the resident did not use his/her call light, so the family member did not want the resident to have the breath-activated call light. These discussions should be documented in the resident's medical record. Yesterday, the DON spoke to the resident's family member about providing a touchpad call light. The resident had quadriplegia and his/her need for a specialty call light should be documented on his/her care plan. During an interview on 2/28/25 at 9:24 A.M., the Executive Director said he expected staff to ensure call lights were accessible to residents. He expected residents to be provided call lights in accordance with their individual needs.

Based on observation, interview and record review, the facility failed to ensure one resident's physician (Resident #26) was notified after the resident developed an elevated temperature on the evening shift of 2/24/25. The resident was sent to the hospital the next morning on 2/25/25, and admitted with a diagnosis of sepsis (a serious condition in which the body responds to infection) pneumonia (an inflammatory condition of the lungs. Symptoms may include productive or dry cough, chest pain, fever, and difficulty breathing.). The sample size was 18. The census was 86. Review of the facility's Change in Resident's Condition or Status policy, issued on 11/26/18, and revised on 9/5/24, showed: -Policy: This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. In the case of death of a resident, the resident's physician will be notified immediately by facility staff in accordance with State law; -Federal Regulations: A facility must immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is: A significant change in the resident's physical, mental, or psychosocial status; -Documenting communication: When health care team members provide information in an objective, standardized, and logical sequence, the resident receives safe, quality care timely, appropriate interventions; -Implementation: Identify a suspected acute change in the resident's status. Review the resident's medical record, including advanced directives and health history. Obtain the resident's vital signs (temperature - T, pulse - P, respirations - R, blood pressure - BP) and oxygen saturation level (O2 Sat) using pulse oximetry. Complete a complete physical assessment, focusing on the identified change in the resident's status (for example: assess respiratory status for a resident with decreased oxygen saturation level). Communicate the change in the resident's status to the appropriate physician. Implement the treatment plan or initiate the resident's transfer to another health care facility. Document the procedure. Review of the facility's Temperature Measurement policy, reviewed on 2/24/25, showed: -Introduction: Body temperature represents the balance of heat a person produces with the heat that a person loses. A stable temperature pattern promotes proper function of cells, tissues, and organs. A change in this pattern usually signals the onset of illness; -Oral temperature in adults normally ranges from 97 degrees to 99.5 degrees Fahrenheit (F). Axillary (armpit) temperature, the least accurate reading, reads 1 degree to 2 degrees lower; -Documentation associated with temperature measurement includes: Temperature, route used, date and time of measurement, name of physician notified of an abnormal temperature, date and time of physician notification, any prescribed interventions, and response to those interventions. Review of the facility Licensed Practical Nurse (LPN) job description, revised on 11/10/16, showed: -The LPN delivers quality nursing care to patients through interpersonal contact and provide care and services to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient in accordance with all applicable laws, regulations, and corporate standards; -Reports to the Director of Nursing (DON) or other nursing supervisor; -Specific Requirements: Must have advanced knowledge in field of practice. Must possess the ability to make independent decisions when circumstances warrant such action; -Essential Functions: Must be able to knowledgeably and competently deliver quality nursing care to patients. Must be able to chart appropriately and timely. Must be able to report changes in patient condition. Must be able to concentrate and use reasoning skills and good judgment. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/24, showed: -Speech Clarity: No speech, absence of spoken words; -Makes Self Understood: Rarely/never understood; -Ability to Understand Others: Sometimes understands, responds adequately to simple, direct communication only; -Functional Limitation in Range of Motion: Impairment on both sides of upper and lower extremities; -Dependent: Helper does all of the effort. Resident does none of the effort to complete activity: Toileting hygiene, shower/bathing, upper/lower body dressing, and personal hygiene; -Dependent: Roll left and right; -Not attempted due to medical condition or safety concerns: Lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer; -Diagnoses: Multidrug Resistant Organism (MDRO), pneumonia (An inflammatory condition of the lungs. Symptoms may include productive or dry cough, chest pain, fever, and difficulty breathing.), stroke, seizure disorder, malnutrition, and respiratory failure; -Risk of Pressure Ulcers (injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure or friction): Yes; -Unhealed Pressure Ulcers: No; -Special Treatments and Programs: Oxygen therapy, suctioning (removes mucus and secretions), and tracheostomy (a surgically created hole in the windpipe) care. Review of the resident's care plan, located in the electronic medical record (EMR), showed: -1/16/25: Focus: At risk for respiratory illness. Goal: The resident will remain free from respiratory illness. Interventions: Monitor for change in condition and notify physician of findings; -1/16/25: Focus: Impaired cognitive ability/impaired thought process related to TBI (traumatic brain injury). Goal: Resident's needs will be met. Interventions: Allow resident extra time to respond to questions and instructions. Ask yes/no questions; -1/16/25: At risk for rehospitalization due to one hospitalization in the past six months. Goal: Will not have an avoidable rehospitalization related to current medical diagnoses. Interventions: Staff to provide timely communication to physician. Observation on 2/24/25 at 8:56 A.M., showed the resident lay in bed with a family member at bedside, bathing the resident. The resident had a tracheostomy tube (a medical device inserted into the trachea to facilitate breathing) with humidified oxygen infusing and a gastrostomy tube (a tube surgically inserted through the abdomen into the stomach to provide hydration, nutrition and medications) with the tube feeding off while the family member bathed the resident. The family member said he/she came in every morning to check on the resident and bathed the resident every day. Another family member came in every evening. Review of the resident's progress notes, located in the EMR, showed no documentation the resident had an elevated temperature, received Tylenol, or the physician was notified on the evening shift (3:00 P.M.-11:00 P.M.) of 2/24/25 or night shift (beginning at 11:00 P.M. on 2/24/25 and ending 7:00 A.M. on 2/25/25) . Observation on 2/25/25 at 6:57 A.M., showed the resident lay in bed with humidified oxygen infusing through his/her tracheostomy tube. At 7:00 A.M., the resident's family member entered the room. He/She said he/she was concerned about the resident because the other family member that came in during the evening phoned him/her last night around 5:00 P.M. or 5:30 P.M., and said the resident had a temperature of 102.8 F, and staff gave the resident Tylenol. He/She removed the resident's covers and said the resident felt very warm to touch and he/she thought the resident still had a fever. At 7:08 A.M., the day shift nurse entered the room and the family member told him/her the resident felt hot to touch. The nurse said the night nurse told him/her during shift change they had taken the resident's temperature around 4:00 A.M., and it was 99.0 F. Review of the resident's vital and weight section of the EMR, showed the following vitals documented on 2/25/25 at 7:58 A.M.: T-104.1, P-108, R-22, BP-130/42, and O2 Sat of 98%. Review of the resident's progress note, showed on 2/25/25 at 8:18 A.M., the nurse contacted the resident's physician in regards to an elevated temperature and labored breathing. Vitals were taken and the physician said to send the resident out to the emergency room. Family member at bedside and notified. Unit Manager and DON made aware. Review of the resident's hospital notes, dated 2/25/25 at 7:14 P.M., showed an admission diagnosis of sepsis, pneumonia. During an interview on 2/25/25 at 2:53 PM, LPN F said he/she was assigned to the resident on the evening shift of 2/24/25. He/She assessed the resident around 3:30 P.M. and everything was fine. About 7:30 P.M., the resident's family member told him/her the resident felt warm and asked him/her to take the resident's temperature. He/She obtained an axillary temperature and the resident's temperature was 101 F. LPN F gave the resident Tylenol around 7:30 P.M. He/She thought the physician should be called when a resident had a temperature of 100.3 F or greater, but he/she was not sure. He/She did not document anything about the resident's temperature or administering the Tylenol, but should have. He/She did not contact the resident's physician because he/she was waiting on the resident's labs to come in that were obtained on 2/24/25. LPN F got a little swamped during the shift. He/She did not recall the last time he/she reviewed the facility's change in condition policy. During an interview on 2/26/25 at 9:53 A.M., the DON said she would have expected LPN F to have documented the resident's temperature, and administering the Tylenol. She would have expected the LPN to have contacted the physician and documented any new orders as well. During a telephone interview on 2/27/25 at 11:00 A.M., the resident's physician said he had not been made aware of the resident's elevated temperature on the evening of 2/24/25. Had the nurse notified him the resident had either a 101.2 F or 102.8 F fever, he probably would have sent the resident to the hospital. The resident was a complex patient with a tracheostomy. For a patient like that he would not want to wait for results from labs drawn at the facility. He would have expected the nurse to have notified him.

Based on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADL) care needs were met for Resident #29. The facility failed to ensure Resident #29's hair was clean, facial hair was shaved, body was clean and free from odors, and failed to provide foot care. The sample was 18. The census was 86. Review of the facility's ADL care policy, revised 2/12/24, showed: -Policy: The resident will receive assistance as needed to complete ADLs. Any change in the ability to perform ADLs will be reported to the nurse. Review of the facility's foot care policy, dated 8/28/18, showed: -Policy: This facility will ensure that foot care provided is consistent with professional standards of practice and that foot care includes treatment to prevent complications from conditions such as diabetes, peripheral vascular disease (circulatory condition), or immobility. This facility will ensure that foot care also includes assisting the resident in making necessary appointments with qualified healthcare providers such as podiatrists and arranging transportation to and from appointments; -Implementation: Clean and rinse foot, apply lotion to moisturize dry skin; -Documentation: Documentation associated with foot care should include any abnormal findings, any nursing interventions and patient response. Review of Resident #29's quarterly minimum data set (MDS, a federally mandated assessment instrument completed by facility staff), dated 1/24/25, showed: -Diagnoses of congestive heart failure, muscle weakness, and toxic liver disease; -Cognitively Intact. Review of the resident's care plan, dated 2/25/25, showed: -Focus: ADL Assistance and therapy services needed to maintain or attain highest level of function; -Goal: Resident wishes to attain prior level of function; -Interventions: Assist with mobility and ADLs as needed. Resident requires a mechanical Hoyer lift with all transfers; -Focus: Resident is followed weekly by wound care team, and has been non-compliant with wound care; -Interventions: Provide consistency in care to promote comfort with ADLs. Maintain consistency in timing of ADLs, caregivers and routine, as much as possible. Review of the resident's most recent skin assessment, dated 2/25/25, showed: -Dry skin noted but not the location; -No mention of the resident's toe nails. Observation and interview on 2/24/25 at 9:05 A.M., showed the resident awake in bed. The resident's hair was long, stringy, and oily. The resident's facial hair was unkempt. The resident had a musky odor emitting from him/her. The resident said he/she receives two bed baths a week, but staff do not always wash his/her hair. He/She said he/she sometimes spills his/her urinal on himself/herself. During observation and interview on 2/24/25 at 11:25 A.M., Certified Nursing Assistant (CNA) D and CNA U provided perineum care (peri-care, cleansing the genitals and rectal area) by turning the resident side to side on his/her bed. While the resident was turned to his/her right side, there was a dark amber colored film located on the resident's buttocks, lower and upper back. CNA D said that the resident will spill his/her urinal, and the urine may leak onto the bed pad. The residents in that particular room like the temperature very warm, so it may make the resident sweat more as well. CNA D and CNA U said they try to wipe or scrub off the film, but it always returns. Both of the resident's feet had large chunks of white dry skin, large crevices of cracked skin, and jagged thick toenails. The resident's feet had a yellow like color. The resident's mattress was dark navy blue and white large flakes of dry skin from the resident's feet were visible on the mattress. The resident's hair was stringy and oily. Observation on 2/25/25 at 9:08 A.M., showed both of the resident's feet had large chunks of white dry skin, large crevices of cracked skin, and jagged thick toenails. The resident's right big toe had a thick toenail that appeared red and green. The resident's feet had a yellow like color. The resident's mattress was dark navy blue and white large flakes of dry skin from the resident's feet were visible on the mattress. Observation on 2/26/25 at 1:36 P.M., showed the resident had a dark amber colored film located on the resident's buttocks, lower and upper back. A urine odor emitted from the resident. The resident's hair was oily and stringy. The resident's facial hair was unkempt. During an interview on 2/26/25 at 1:43 P.M., the resident said he/she has not seen a podiatrist since he/she arrived to the facility. He/She would like his/her toenail taken care of and his/her dry skin treated. He/She has a bowel movement everyday and sometimes spills his/her urinal up his/her back. It has been since about December since he/she has had an actual shower and not just a bed bath. His/Her hair had not been washed since the previous week. It had been at least a year since he/she had received a hair cut, and he/she wanted one. He/She had asked staff about a haircut but had never heard back. During an interview on 2/27/25 at 1:02 P.M., the Infection Preventionist said she would expect nursing staff to document the dry skin and nail conditions of the resident's feet in the skin assessment. She would expect staff to ensure the resident is on the podiatrist list. She said the resident's toe nail is not able to be treated by facility staff and should be seen by a podiatrist. She would expect nursing staff to ask the resident if he/she would like his/her facial hair shaved. She would expect staff to wash the resident's hair and ensure it is cut if the resident requests a haircut. She would expect the staff to clean the resident's skin thoroughly during showers or bed baths. During an interview on 2/28/25 at 8:02 A.M., CNA O said he/she would expect residents to receive at least two showers or bed baths a week. He/She would expect staff to be washing residents' hair and skin. He/She would expect staff to be asking residents if they want their facial hair shaved. He/She would expect any skin concerns or issues to be documented in the skin assessment or shower sheet. He/She would expect dry skin to be reported to the nurse. He/She said the resident's toe is beyond bad and should be seen by a podiatrist. He/She does not know if the resident was currently seen by the podiatrist. He/She would expect skin assessments to be completed and accurate. During an interview on 2/28/25 at 8:16 A.M., the Social Services Director said he is in charge of putting residents on the list to see the podiatrist. He would expect nursing staff to let him know if there are any residents who need to see the podiatrist. He was not aware that Resident #29 needed to see the podiatrist. He would expect staff to ask the residents if they would like a hair cut and to let him know. During an interview on 2/28/25 at 8:54 A.M., the Director of Nursing (DON) said she would expect residents to receive at least two showers or bed baths a week. She would expect staff to wash residents' hair and body and shave any unwanted facial hair. She would expect nursing staff to ask residents if they would like a hair cut. She would expect any skin concerns including dry skin or discoloration to be documented on the skin assessment. The social worker is in charge of putting residents on the list to be seen by the podiatrist. Once the nurse completes an assessment of the resident's feet, the resident should be placed on the podiatrist list if there are any concerns that cannot be addressed by facility staff. She would expect skin assessments to be completed and accurate. MO00249583 MO00248931 MO00250429

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain labs as ordered for one resident (Resident #14), and to document a thorough, ongoing assessment following the resident's change in condition, and to appropriately communicate the resident's change in condition to the next shift. In addition, the facility failed to ensure staff provided feeding assistance in accordance with physician orders for one resident identified as dependent on assistance for eating (Resident #9). The sample was 18. The census was 86. Review of the facility's Change in Resident's Condition or Status policy, issued on 11/26/28, and revised on 9/5/24, showed: -Policy: This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the resident's condition or status. -Procedure: The facility will utilize the Lippincott procedure - Change in status, identifying and communicating, long-term care. Review of the facility's Change in Status, Identifying and Communicating, Long-Term Care procedure, revised 8/19/24, showed: -The facility will utilize the following Interact tools per policy: Situation, Background, Assessment and Recommendation (SBAR); -Introduction: In a long-term care setting, any change from baseline in a resident's status must be identified and addressed. A resident is more likely to return to baseline status and avoid complications when a condition is recognized early so that it can be treated. When a nurse recognizes a potentially life-threatening condition or significant change in a resident's status, the nurse must communicate with other health care team members to meet the resident's needs; -The resident should be assessed for changes from baseline status on admission, at present intervals based on the resident's condition and regulatory requirements, and whenever the resident's status changes. The resident's current status should also be checked against baseline status during medication administration and other routine activities. Notable changes include a decline in functional status, new or increasing confusion, temperature elevation, shortness of breath, and behavior changes. By identifying such risk factors as chronic diseases, previous hospitalizations, and notable conditions in the resident's medical history, the nurse can quickly anticipate some acute changes in status; -A change in condition may happen quickly in just minutes, or slowly over hours or days. The condition may manifest as a change in condition or physical change. Unless the resident's condition is life-threatening, the resident can be assessed and a treatment plan started at the long-term care facility. A focused, thorough assessment of the resident's condition can help identify a recurring fluctuation in signs and symptoms such as a change in blood pressure or increased confusion that happens at the same intervals daily; -At minimum, assessment should include: Reviewing the resident's medical record. Asking how the resident feels and what symptoms the resident has. Obtaining vital signs. Observing the resident's overall condition, including function and cognition. Exploring the resident's complaints; -Recognizing status changes, assessing the resident, and intervening early on allows the resident to receive appropriate care, decreasing the need for transfer to an acute care facility or emergency department; -Every health care team member is responsible for communicating a resident's change in status from baseline; -Clear, professional communication improves diagnosis, care planning and implementation, and continuity of care. Essential elements of such communication include: Reviewing the resident's history, medications, laboratory test results, treatments, and other significant information. Providing details of the resident's current status using objective findings. Documenting communication; -When health care team members provide information in an objective, standardized, and logical sequence, the resident receives safe, quality care timely, appropriate interventions; -Implementation: Identify a suspected acute change in the resident's status. Review the resident's medical record, including advanced directives and health history. Obtain the resident's vital signs and oxygen saturation level using pulse oximetry. Complete a complete physical assessment, focusing on the identified change in the resident's status (for example, assess respiratory status for a resident with decreased oxygen saturation level). Communicate the change in the resident's status to the appropriate practitioner. Implement the treatment plan or initiate the resident's transfer to another health care facility. Document the procedure; -Complications associated with identifying and communicating a change in a resident's status may include: Delay in treatment and disruption in care; -Documentation associated with identifying and communication a change in a resident's status included: Acute status change in status, behavior changes, vital signs, oxygen saturation level, other assessment findings in the appropriate areas in the resident's medical record, nursing interventions and response to those interventions, communication with other health care team members, and diagnostic test results. Review of the facility's Vital Signs policy, issued 11/26/18 and revised on 2/20/25, showed: -Policy: Vital signs will be checked as needed and as ordered by the physician to aid in the diagnosis and treatment of the resident's medical condition and to assess for changes in condition. Abnormal vital signs will be reported to the licensed nurse. Review of the facility's Pulse Oximetry policy, revised 2/24/25, showed: -Introduction: Performed intermittently or continuously, oximetry is a relatively simple procedure used to monitor arterial oxygen saturation noninvasively. Pulse oximetry can aid clinical decision-making; however, it isn't a substitute for a clinical assessment; -Completing the Procedure: If you detect and confirm a low oxygen saturation of peripheral oxygen (SpO2), administer supplemental oxygen, as needed and prescribed, according to your scope of practice. Regularly monitor and document the patient's SpO2 level. Document the procedure; -Documentation: Documentation associated with pulse oximetry includes: date and time, activity level and position, probe site, concentration of supplemental oxygen (if applicable), method of oxygen delivery, SpO2 level, and episodes of desaturation. 1. Review of Resident #14's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/18/24, showed: -Cognitively intact; -Diagnoses included congestive heart failure, chronic respiratory failure with hypercapnia (excessive carbon dioxide in the blood), high blood pressure and kidney failure,; -Oxygen therapy received. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Resident is at risk for rehospitalization due to diagnoses of congestive heart failure and chronic obstructive pulmonary disease (COPD, lung disease), and poor adherence to diet restriction; -Interventions included: Labs as ordered; -Focus: Resident has congestive heart failure; -Interventions included: Check breath sounds and observe for labored breathing. Labs as ordered. Observe and report as needed (PRN) any signs/symptoms of congestive heart failure; -Focus: Resident has oxygen therapy related to respiratory illness. He/She also uses a continuous positive airway pressure (CPAP, machine that keeps the airways open during sleep for persons with sleep apnea); Interventions included observe for signs/symptoms of respiratory distress and report to physician PRN. Review of the resident's hospital Discharge summary, dated [DATE], showed: -hospitalized [DATE] through 2/18/25 with discharge diagnosis of congestive heart failure; -Special instructions: Basic metabolic panel (BMP, blood test that measures sugar level, electrolytes, fluid balance, and kidney function) on Monday, 2/24/25. Review of the resident's electronic physician order summary (ePOS), showed: -An order, dated 2/18/25, for BMP on Monday, 2/24/25; -An order, dated 2/18/25, for oxygen at 3 liters (L)/minute continuously per nasal cannula; -An order, dated 2/18/25, for oxygen saturation (O2) rates every shift, may titrate to keep above 92%; -An order, dated 2/24/25 at 9:47 A.M., for STAT chest x-ray. Review of the resident's electronic medical record (EMR), reviewed 2/24/25 at 11:30 A.M., showed: -No documentation of a BMP obtained on 2/24/25; -O2 sat documented as 95% on 2/24/25 at 3:22 A.M.; -No documentation of a discussion with the physician related to the x-ray ordered on 2/24/25; -No progress notes, assessments, or documentation related to a change in condition on 2/24/25. Observation on 2/24/25 at 10:58 A.M., showed the resident in bed with hands and arms shaking. The resident's oxygen was on via nasal cannula, running at 5L. The resident exhibited short, rapid breathing. During an interview, the resident said he/she started shaking this morning and that is not normal for him/her. He/She described his/her breathing as deep. Observations on 2/24/25 at 1:11 P.M. and 4:53 P.M., showed the resident in bed with oxygen on via nasal cannula, running at 5L. The resident's breathing was rapid. The resident's eyes were open and he/she did not verbally respond during an attempted interview. Review of the resident's EMR, reviewed 2/24/25 at 5:50 P.M., showed no progress notes, assessments, or documentation related to a change in condition on 2/24/25. Observation on 2/25/25 at 6:17 A.M. showed Licensed Practical Nurse (LPN) B performed cardiopulmonary resuscitation (CPR) on the resident. The resident expired. Review of the resident's EMR, reviewed 2/25/25 at 7:08 A.M., showed: -No documentation of BMP obtained on 2/24/25; -O2 sat documented as 94% on 2/25/25 at 12:45 A.M.; -No assessments or documentation related to a change in condition on 2/24/25. During an interview on 2/25/25 at 9:19 A.M., Certified Nurse Aide (CNA) C said on the morning of 2/24/25, the resident's face was red, his/her lips were blue, and he/she was in and out of his/her normal state of mind. CNA C notified LPN A of the resident's change in condition. LPN A checked the resident's oxygen and it only got up to 78%. During an interview on 2/25/25 at 9:33 A.M., LPN A said he/she was the nurse assigned to the resident on day and evening shift on 2/24/25. After breakfast, the resident was not his/her usual self, wasn't joking as usual, and his/her oxygen was at 60%. He/She did not want to go to the hospital. The resident's physician ordered an increase to the resident's oxygen to get his/her O2 sats to 88%, and a STAT chest x-ray. LPN A read the x-ray results to the physician and a new order was received to adjust the resident's medication. LPN A documented his/her assessments and discussions with the physician in the resident's EMR, but it all disappeared. When his/her shift was over on 2/24/25, LPN A was giving report to the night nurse, LPN B, when LPN B was pulled away to another resident's room. LPN A did not verbally discuss the resident's change in condition with LPN B. LPN A documented the change in condition on the report sheet and gave the report sheet to LPN B. Review of the report sheet, dated 2/24/25, showed a handwritten note next to the resident's name, Monitor breathing. O2 sats were low all day off and on. During an interview on 2/25/25 at 10:25 A.M., LPN B said he/she came in for his/her shift on 2/24/25 at 10:30 P.M. He/She did not get report from LPN A, who worked day and evening shift. LPN B was not aware the resident had a change in condition or that a STAT x-ray had been obtained that day. The resident has a standing order to check his/her oxygen at each shift and LPN B checked the resident's oxygen shortly after he/she came on shift, and the O2 sats were at 95%. LPN B did not check the resident's oxygen again during his/her shift. He/She removed the resident's CPAP at 5:00 A.M. and put the resident's oxygen on at 3L. He/She was not aware the resident received oxygen at 5L the day before or that he/she had shortness of breath. There was nothing on the report sheet about the resident's change in condition. If LPN B had been made aware the resident had a change in condition, he/she would have checked the resident's oxygen more frequently and would have adjusted the oxygen to ensure the resident's oxygen level was above 88%. During an interview on 2/26/25 at 8:25 A.M., LPN B confirmed he/she did did not get verbal report from LPN A on the night of 2/24/25. He/She reviewed the report sheet when he/she came in for his/her shift and nothing was written next to the resident's name. There was no documentation on the report sheet about the resident's breathing or O2 sats. During an interview on 2/25/25 at 8:53 A.M., Physician E said staff notified him/her of the resident's shortness of breath. The physician ordered staff to increase the resident's oxygen to 5L and adjust the oxygen so his/her O2 sats were around 92%. He/She ordered a STAT x-ray, which showed increased infiltrates due to the resident's congestive heart failure. He/She expected staff to communicate the changes in between shifts. He/She understands that documentation from staff could improve, and the documentation could improve the communication with staff in between shifts. During an interview on 2/25/25 at 12:19 P.M., the LPN Unit Coordinator said the resident's BMP was scheduled to be completed on 2/24/25. The lab company came out to the facility on that day, but missed his/her labs, as well as the labs for seven other residents. The resident's BMP was scheduled for the next draw day, but he/she expired. The facility has had ongoing issues with their lab company and they are trying a new lab company. During an interview on 2/26/25 at 9:25 A.M., the Director of Nurses (DON) said the resident returned from the hospital on 2/18/25 with orders for a BMP to be completed on 2/24/25. The lab company came out to the facility on 2/24/25, but did not draw any of the residents' labs on the schedule for that today. The facility has been having issues with the lab company for a long time. The facility's corporate office makes the determination which lab company to use. On 2/24/25, LPN A notified her of Resident #14's change in condition. The DON went over next steps with LPN A in great detail, instructing him/her to notify the physician, to document the assessments for a change in condition, and to encourage the resident go out to the hospital. The DON instructed LPN A to document everything that happened, from the time he/she assessed the resident, in the EMR. LPN A did not document anything in the medical record like he/she was supposed to. An SBAR should have been completed at the time of the change in condition. LPN A should have known what to do and there was no explanation why the documentation did not get done. He/She should have documented the resident's vital signs and assessments related to his/her change in condition. LPN A said he/she gave report to LPN B and wrote the oxygen issues down on the report sheet. LPN B should have read the report sheet, as well as the x-ray results, which were at the nurse's station with the report sheet. LPN B should have followed up by encouraging the resident to go out to the hospital and by rechecking his/her oxygen levels, especially when they were up and down so much on 2/24/25. During an interview on 2/28/25 at 9:34 A.M., the Executive Director said he expected nursing staff to communicate changes in condition to the oncoming shift. Nursing staff should document their observations, assessments, and communication with the physician in the resident's medical record. Assessments should be completed in accordance with the facility's policies and procedures. 2. Review of Resident #9's medical record, showed diagnoses included dysphagia (swallowing disorder) following cerebral infarction (stroke), multiple sclerosis (MS, disease of the central nervous system), quadriplegia (paralysis of all four limbs), seizures, abnormal posture, generalized muscle weakness, anxiety and depression. Review of the resident's speech therapy Discharge summary, dated [DATE], showed: -[NAME] Assessment of Swallowing Abilities (a screening tool for identifying eating and swallowing disorders in patients with stroke): Patient with overall score of 130, indicates severe dysphagia and severe aspiration; -Diet recommendation: Minced and moist; -Compensatory strategies/positions: To facilitate safety and efficiency, it is recommended the patient use the following strategies during oral intake: General swallow techniques/precautions along with upright posture for greater than 30 minutes after meals. Review of the resident's ePOS, showed an order, dated 2/7/25, for aspiration precautions. Sit at 90 degree angle (chin to neck angle, not head of bed), alternate liquids and solids, small single sips, small bites, no straws, 100% supervision. Review of the resident's significant change MDS, dated [DATE], showed: -Severe cognitive impairment; -Clear speech; -Makes self understood: Usually understood; -Dependent for eating. Review of the resident's care plan, in use at the time of survey, showed: -Focus: Activities of daily living (ADL) assistance and therapy services needed to maintain or attain highest level of function. Resident has MS, he/she is dependent with all daily living needs and transfers; -Goals included: Resident will perform eating with dependent assist; -Interventions included: Assist with mobility and ADLs as needed. He/She requires extensive/total assistance to complete ADLs. Pillow on left side of head; -Focus: Resident has impaired mobility secondary to MS. Total assist with all ADLs; -Goals included: Resident is dependent with feeding; -Focus: Resident has a swallowing problem related to swallowing progression of MS; -Goals: The resident will not have injury related to aspiration through the review date. The resident will have no choking episodes when eating through the review date; -Interventions included: Keep head of bed elevated 45 degrees during meal and thirty minutes afterwards. Refer to Speech Therapist (ST) for swallowing evaluation. Observation on 2/24/25 at 1:06 P.M., showed the resident sat in bed. The head of the bed elevated approximately 35 degrees and the resident slumped down with his/her head leaning toward his/her left shoulder, with no pillow on the left side of his/her head. CNA D stood next to the resident's bed providing feeding assistance. CNA D scooped a large spoonful of dessert into the resident's mouth. The resident grimaced and pushed the food out of his/her mouth. Observation on 2/25/25 at 12:40 P.M., showed the resident in bed with the head of bed elevated approximately 35 degrees. The resident slumped down in bed with his/her head leaning toward his/her left shoulder, with no pillow on the left side of his/her head. CNA C stood next to the resident's bed, providing feeding assistance. CNA C held a cup of water to the resident's mouth and he/she used a straw to drink the water. Observation on 2/26/25 at 12:17 P.M., showed the resident in bed with the head of bed elevated approximately 35 degrees. The resident slumped down in bed with his/her head leaning toward his/her left shoulder, with no pillow on the left side of his/her head. CNA N stood next to the resident's bed providing feeding assistance. During an interview on 2/27/25 at 8:00 A.M., the resident said he/she cannot reposition him/herself. He/She can turn his/her head downward, but cannot straighten his/her neck or body. Observation on 2/27/25 at 8:52 A.M., showed the resident in bed with the head of bed elevated approximately 35 degrees. The resident slumped down in bed with his/her head leaning toward his/her left shoulder, with no pillow on the left side of his/her head. CNA D stood next to the resident's bed providing feeding assistance. CNA D held a cup of water to the resident's mouth and he/she used a straw to drink the water. During an interview, CNA D said the resident sometimes has a wedge pillow, but his/her family member doesn't like it and removes it. The resident requires total care and feeding assistance. He/She is a choking risk and has swallowing issues. His/Her current positioning is ok and he/she coughs when he/she has swallowing issues. He/She can have straws. During an interview on 2/27/25 at 1:34 P.M., ST Z said the resident should sit up at a 90 degree angle while eating due to aspiration precautions. He/She has poor swallowing capabilities. He/She must remain seated at a 90 degree angle for at least 30 minutes after eating. He/She cannot have straws due to aspiration precautions. Straws contribute to poor bolus control and he/she would have better swallowing control with smaller sips. After ST Z assesses a resident, he/she notifies the nurse of his/her recommendation and enters the documentation in the resident's EMR. During an interview on 2/27/25 at 1:40 P.M., CNA O said the resident requires feeding assistance from staff. He/She cannot move his/her arms or legs. Staff should ensure he/she is sitting straight up while eating. There are no other special instructions to follow while providing feeding assistance. He/She can have straws. He/She does not have issues with swallowing or choking and is not an aspiration risk. Nurses tell CNAs if there are any special precautions to take when providing feeding assistance. During an interview on 2/27/25 at 2:03 P.M., Registered Nurse (RN) R said the resident requires feeding assistance from staff. Staff should sit at bedside when providing feeding assistance. While eating, the resident must be seated completely upright, at 90 degrees, due to aspiration risk. He/She cannot have straws due to aspiration risk. Straws can cause liquids to go down too quickly. He/She should remain upright for an hour after eating to help with swallowing and digestion. He/She has limited mobility, cannot move him/herself, and leans toward the left side. Aides should ensure the resident is in the correct position when providing feeding assistance. Aides know what the correct position is by getting report from nurse. During an interview on 2/28/25 at 7:11 A.M., the Infection Preventionist said the resident used to be an aspiration risk but is not anymore. The portion about no straws on his/her physician order should be removed. He/She has to sit straight at 90 degrees while eating and staff should ensure he/she is positioned that way while providing feeding assistance. During an interview on 2/28/25 at 8:22 A.M., the DON said the resident went out to the hospital on 1/31/25 and came back with discharge paperwork showing he/she was not an aspiration risk. His/Her physician orders should have been updated when he/she came back from the hospital to show he/she was not an aspiration risk. The resident requires feeding assistance from staff and staff should ensure the resident is seated upright at a 90 degree angle while eating. He/She should remain seated upright for about 15 to 30 minutes after eating to assist with digestion. Staff should utilize pillows to assist in positioning the resident. She expected staff to provide feeding assistance in accordance with physician order. During an interview on 2/28/25 at 9:34 A.M., the Executive Director said he expected staff to ensure residents are seated upright at a 90 degree angle when providing feeding assistance. He expected staff to provide feeding assistance in accordance with physician orders. MO00248395

Based on observation, interview and record review, the facility failed ensure staff obtained a treatment order, and provided daily monitoring for one resident (Resident #26) with a history of dermatitis (skin inflammation, typically characterized by itchiness, redness and rash) on his/her coccyx (tailbone)/sacrum (area located above the coccyx) that was observed to have an open area on the morning of 2/24/25. It was not identified by staff and the physician was not notified until the morning of 2/25/25. In addition, the facility failed to ensure licensed nurses who signed bath sheets showing an open area and/or a circle around the coccyx/sacrum of an anatomical figure on the bath sheet documented an assessment of the findings on the bath sheets. The sample size was 18. The census was 86. Review of the facility's Skin Integrity & Pressure Ulcer (injury to the skin and /or underlying tissue usually over a bony prominence, as a result of pressure or friction)/Injury Prevention and Management policy, revised on 8/25/21, showed: -Policy: Provide associates and licensed nurses with procedures to manage skin integrity, prevent pressure ulcer/injury, complete wound assessment/documentation, and provide treatment and care of skin and wounds utilizing professional standards; -Procedure: A skin assessment/inspection should be performed weekly by a licensed nurse. Skin observations also occur throughout points of care provided by Certified Nursing Assistants (CNAs) during activities of daily living care (bathing, dressing, incontinent care, etc). Any changes or open areas are reported to the Nurse. The Nurse will complete further inspection/assessment and provide treatment if needed; -When skin breakdown occurs, it requires attention and a change in the plan of care may be indicated to treat the resident. Review of the facility's Treatment Orders policy, reviewed 5/24/24 and revised on 7/9/24, showed: -Policy: Treatment orders are written per Physician orders. If a resident has multiple wound sites, a complete and separate treatment order must be written for each site; -Based on the comprehensive assessment of a resident, the facility must ensure that: A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing; -Procedure: After observation/evaluation of the affected skin area, the physician is notified; -The physician writes a treatment order that includes at least the following: Site of wound, name of cleanser, name of ointment, type of dressing, and number of times to perform the treatment/duration of treatment. Review of Resident #26's wound company note, dated 11/21/24 (the last time the resident was seen by the wound care company), showed: -Chief Complaint: Patient has a rash; -Buttock: Irritated dermatitis; -Treatment: Zinc oxide based barrier cream as directed; -Reason: Decreased skin irritation; -Incontinence Brief Dermatitis Improved; -Will sign off, please re-consult as needed. Continue present skin care and breakdown prevention. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/24, showed: -Speech Clarity: No speech, absence of spoken words; -Makes Self Understood: Rarely/never understood; -Ability to Understand Others: Sometimes understands, responds adequately to simple, direct communication only; -Functional Limitation in Range of Motion: Impairment on both sides of upper and lower extremities; -Dependent, Helper does all of the effort. Resident does none of the effort to complete activity: Toileting hygiene, shower/bathing, upper/lower body dressing, and personal hygiene; -Dependent: Roll left and right; -Not attempted due to medical condition or safety concerns: Lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer; -Diagnoses: Multidrug Resistant Organism (MDRO,), pneumonia (an inflammatory condition of the lungs. Symptoms may include productive or dry cough, chest pain, fever, and difficulty breathing.), stroke, seizure disorder, malnutrition, and respiratory failure; -Risk of Pressure Ulcers: Yes; -Unhealed Pressure Ulcers: No; -Special Treatments and Programs: Oxygen therapy, suctioning (removes mucus and secretions), and tracheostomy (a surgically created hole in the windpipe) care. Review of the resident's treatment administration record (TAR), dated 1/1/25 through 1/31/25, showed no treatment to the resident's buttock/coccyx or sacrum. Review of the resident's care plan, showed: -1/16/25: Family is resistive to care and implementation from professional maintenance care and assisting with maintaining baseline well-being. Family removes treatments in place to skin integrity concerns, performs tracheostomy care; -Goal: The resident will cooperate with care; -Interventions: Educate resident/family/caregivers of the possible outcomes of not complying with treatment or care; -1/16/25: Focus: Impaired cognitive ability/impaired thought process related to TBI (traumatic brain injury); -Goal: Resident's needs will be met; -Interventions: Allow resident extra time to respond to questions and instructions. Ask yes/no questions; -1/16/25: Focus: Rash, contact dermatitis to buttock and is followed by wound care company; -Goals: Will have no complications from rash. The resident will have no signs or symptoms of infection. The rash will heal by next review date; -Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Observe skin rashes for increased spread of infection. Seek medical attention if skin becomes bloody or infected. Review of the resident's weekly skin integrity data collection notes (completed by the licensed nurse) dated 2/24/25 and 2/21/25, showed -Skin Condition: Open areas/wounds - blank; -Rash - blank; -Describe skin color - normal; -Describe temperature - warm; -Describe moisture - normal; -Describe turgor (refers to how quickly skin returns to normal position after being pinched) - good; -No documentation about a rash or contact dermatitis to the buttocks. Review of the resident's Shower Sheet/Skin Condition Report (anatomical figure on the form completed by the Certified Nurses Aide (CNA) and given to a licensed nurse for review after a shower/bath), forms showed: -2/1/25, evening shift, completed by CNA J: Open area checked, and the sacrum/coccyx area circled. A nurse co-signed the form; -2/5/25, day shift, completed by CNA J: Open area checked, and the sacrum/coccyx area circled, and a licensed nurse had co-signed the form; -2/8/25: No CNA documentation or signature. A licensed nurse checked other and documented incontinence brief dermatitis. The licensed nurse circled the area on the resident's sacrum/coccyx, and documented the shower had been given by the family on day shift; -2/15/25: A licensed nurse checked other and documented incontinence brief dermatitis. The licensed nurse circled the area on the resident's sacrum/coccyx, and documented the shower had been given by the family on day shift; -2/19/25, evening shift, CNA I documented the resident's family did the shower every morning on day shift. The CNA circled the area on the sacrum/coccyx. LPN Unit Coordinator (UC) co-signed the shower sheet; -2/22/25, evening shift. A CNA circled the area on the sacrum/coccyx, and an LPN wrote incontinence brief dermatitis and co-signed the shower sheet. Observation on 2/24/25 at 8:56 A.M., showed the resident lay in bed on a low air loss mattress. A family member was at the bedside bathing the resident. The resident had a tracheostomy tube (a medical device inserted into the trachea to facilitate breathing) with humidified oxygen infusing and a gastrostomy tube (a tube surgically inserted through the abdomen into the stomach to provide hydration, nutrition and medications) with the tube feeding off while the family member bathed the resident. The family member said he/she came in every morning to check on the resident and bathed the resident every day. Another family member came in every evening. The family member said the resident had a red area on his/her coccyx that had been there for months. After he/she bathed the resident he/she applied Desitin (incontinence brief rash medication) that he/she brought in to the area. He/She had seen the CNAs applying Desitin as well as A&D ointment (used to keep moisture off the skin), but not the licensed nurses. He/She removed a few packets of the A&D ointment from the resident's night stand drawer to show the surveyor. He/She turned the resident onto his/her left side, which revealed an inflamed red area on the coccyx/sacrum area that had a white cream applied over it. In the center of the red area was an open area with a small amount of blood drainage. Review of the resident's physician's order sheet (POS), showed no order for Desitin, A&D ointment, or zinc oxide to the resident's buttocks/sacrum/coccyx. Review of the resident's TAR, dated 2/1/25 through 2/28/25, showed no order for Desitin for the dermatitis, and no order for the open area. Observation on 2/25/25 at 7:35 A.M., showed the resident lay in bed. LPN UC and CNA J entered the room to complete a skin assessment. CNA J said he/she had been at the facility for approximately 9 months and the area on the resident's sacrum/coccyx had looked that way on and off the entire time. LPN UC described the sacrum/coccyx area as being red with red drainage and open. He/She worked yesterday on the day shift and no one told him/her about the area being open. He/She was not sure if there was a current treatment or not. Review of the resident's skin wound note in the progress notes, showed: -The LPN UC documented on 2/25/25 at 8:05 A.M., Writer in room to assist with skin assessment. Upon assessment noted that resident has open area to coccyx/sacral wound. Writer completed assessment, informed treatment nurse and called physician to obtain orders. Went back to room to measure area to coccyx/sacral 2.1 centimeters (cm) (length) by 0.5 cm (width) by 0.8 cm (depth). Obtained order to cleanse with normal saline (sodium/water solution), pat dry, apply skin prep (a thin sticky film) to periwound (the area surrounding the open area) apply calcium alginate (an absorbent dressing) and cover with border gauze. Family, Director of Nursing (DON) and treatment nurse informed of new order; -LPN UC documented on 2/25/25 at 9:00 A.M., Follow-up on assessment. Small amounts of blood noted with exudate (drainage) to disposable pad. Noted resident had previous incontinence brief dermatitis. Resident will be followed by the wound care company team for wound treatments. Review of the resident's weekly skin integrity data collection note, dated 2/25/25 at 8:16 A.M., showed: -Skin Condition: Open areas/wounds - blank; -Rash - blank; -Describe skin color - normal; -Describe temperature - very warm; -Describe moisture - moist; -Describe turgor - fair; -Describe findings - No new finding, old wound to coccyx. Physician notified. During an interview on 2/25/25 at 8:20 A.M., the facility Wound Nurse said the resident used to be seen by the wound care company at one time, but it'd been awhile. They had diagnosed the area on the resident's bottom as contact dermatitis. The facility wanted the resident to continue to be seen by the wound care company because the resident's bottom would break open and bleed. The resident was supposed to have an order for zinc oxide ointment (a mineral used to treat incontinence brief rash) on the area every shift, and the CNAs should apply between the nurse's applications. She reviewed the February TAR and confirmed there was no treatment order for the zinc oxide and/or Desitin to be applied every shift. Since the open area was noted on 2/24/25, staff would have provided care (incontinent care and turning and repositioning) to the resident throughout the day and should have noticed the open area and reported it to the charge nurse. If a treatment was not on the TAR, the computer system would not prompt the nurse to apply the treatment. During an interview on 2/25/25 at 8:25 A.M., the Assistant Director of Nursing said the resident's family did not want the resident to use the zinc oxide. They wanted Desitin to be used. No one contacted the physician to get an order for the Desitin as far as she was aware. During an interview on 2/25/25 at 10:33 A.M., CNA I said he/she had worked at the facility for about one year and the resident's bottom has been red and excoriated since he/she had worked there. The family had asked the CNAs to put Desitin cream on the resident's coccyx. If the coccyx was left wet too long it would breakdown and bleed. If it was kept dry and the Desitin was used, it wouldn't bleed. He/She told the nurses about the resident's coccyx in the past. During an interview on 2/25/25 at 11:19 A.M., the facility Wound Nurse said the area on the resident's coccyx was a stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous). During an interview on 2/25/25 at 1:02 P.M., the DON said there should have been on-going assessments of the resident's coccyx by the licensed nurses. There should have been a treatment, either the zinc oxide or Desitin on the TAR for staff to follow. Licensed nurses, not CNAs, should apply the treatment when there was skin broken down. She would have expected the licensed nurse who signed the resident's bath sheets to have assessed the resident's coccyx and documented any changes in the progress notes. If the area on the coccyx changed, she expected the physician to be notified. She confirmed the open area on the resident's coccyx was a stage 2 pressure ulcer. During an interview on 2/28/25 at 9:34 A.M., the Administrator said he expected staff to follow facility policies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being by addressing the residents' behaviors related to his/her anxiety for one resident (Resident #68). The sample was 18. The census was 86. Review of the facility's Behavioral Health Services Policy, reviewed 9/6/24, showed: -Policy: The facility will provide behavior heal care and services that create an environment that promotes emotional and psychosocial will-being, meets each resident's needs, and includes individualized approaches to care; -Procedure: Complete the nursing assessment and social services assessment upon admission/readmission. Quarterly, and as needed with change in condition; -Through this assessment the facility should identify residents who: -Develop decreased social interaction and/or increase withdrawn, angry or depressive behaviors, and may have verbalizations indicating these; -Evaluate whether the resident's distress was attributable to their clinical condition and demonstrate that the change in behavior was unavoidable; -Ensure an accurate diagnosis of mental disorder or psychosocial adjustment difficulty, or Post Traumatic Stress Disorder (PTSD) was made by a qualified professional; - Identify if the resident would benefit based on above assessments in conjunction with: mental health history and current medication regimen , and additional mental health consultation (psychiatry, psychology, and clinical social work). If determined need is present, the facility should consult with attending physician to make a referral to mental health professional for assessment and potential for ongoing follow up; -Initiate behavioral monitoring, behavior management care plan, as indicated by assessment findings, use of psychoactive medications, resident and or responsible party conversations, and observations. The Social Worker is primarily responsible for initiation of the behavioral management care plan. -The facility must provide necessary behavioral health care and services within include: -Ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy (self-directing), privacy, socialization, independence, choice and safety; -Ensuring direct care staff interact and communicate in a manner that promotes meant and psychosocial well-being; -Providing an environment and atmosphere that is conductive to mental and psychosocial well- being; -Providing meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community; Meaningful activities are those that address the resident's customary routine, interests, preferences, and enhance the resident's well-being; -Ensuring that pharmacological interventions are only used when non-pharmacological interventions are ineffective or when clinically indicated; -Communicate the behavioral management care plan to the resident and/or to the responsible party and to relevant member of the interdisciplinary team; -Provide resident/responsible party and staff education as needed; -Review and revise the behavioral management care plan as indicated. Review of Resident #68's face sheet, undated, showed diagnoses included: Anxiety, cognitive communication deficit, and spinal stenosis (narrowing) of the lumbar region (lower back), chronic obstructive pulmonary disease (COPD, restricts airways in the lungs making it difficult to breath). Review of the resident's Spiritual Assessment, dated 10/30/23, showed: -Information source: Resident; -Beliefs: God; -Choice of spiritual participation: Visitor support/ Counselor; -What brings you spiritual peace: Speaking with God; -How can the facility meet your spiritual needs: Nothing at this time; -How are you responding to stress of this illness and/ treatment: The best I can. Review of the resident's Social Service Assessment, dated 10/31/24, showed: -The resident has a current psychiatric related diagnosis; -The resident has a diagnosis of anxiety; -The resident is currently taking Duloxetine 30 mg (medication used to treat depression and anxiety); -Describe the resident's current status, including psychiatric related diagnosis and especially address the problem areas or interventions that Social Services is currently reviewing: None. -No additional Social Service Assessment available for review. Review of the resident's physician order sheets, showed an order, dated 12/27/24, to check for comfort, safety, pain, and incontinence every hour. Review of the resident's Nurse Practitioner (NP) psychiatry progress notes, dated 12/30/24, showed: -Narrative: The resident reported that he/she is doing good. The resident denied feeling sad or anxious. The resident does not feel any issues with her mood or behaviors. The resident commented that he/she only uses the call light when he/she needs to be changed. The resident adamantly refuses any medication changes. Per the nursing report, the resident is compliant with the medication regimen. The resident is noted to use his/her call light very often with minor requests; -Assessment: The resident is currently stable and does not pose a risk to self or others. The resident's past history for emotional difficulties, and personal and social stressors that contribute to the current presentation. The resident is willing to participate in treatment; -Plan: Discussed with staff the ongoing treatment plan. Staff educated regarding the medication regimen and instructed to notify the provider if any adverse reactions emerge. Staff are instructed to report any suicidal or homicidal ideations, or any significant changes in mental status or level of functioning. Assure the resident with safety, nutrition, and hydration. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff dated, 1/26/25, showed: -Cognitively intact; -No behaviors or rejection of care. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is resistant to care. The resident will make false assumptions towards staff and has a manipulative perception of healthcare concerns and needs being met. The resident presents with obsessive compulsive disorder (OCD), increased anxiety, and claustrophobic like behaviors; -Interventions: Give a clear explanation of all care activities prior to and as they occur for each contact. If the resident resists activities of daily living (ADLs), reassure the resident, leave and return 5-10 minutes later and try again. Provide the resident with opportunities for choice during care provision; -Focus: The resident at times expresses unrealistic ideas or presumptions related to things that may be heard outside of resident's room. The resident make threats towards staff about harming self, and has threatened staff to throw himself/herself on the floor. The resident constantly presses the call light every 10 minutes and calls the from desk at least 10 times per day; -Interventions: Administer medications as ordered. Anticipate and meet the resident's needs. Provide care with two aides. When answering the call light step away and obtain another staff member if needed for extended conversation and provide care to the resident's request. Explain all procedures to the resident before starting and allow the resident to adjust to changes. If reasonable, discuss the resident's behavior. Explain or reinforce why behavior is inappropriate and or unacceptable. Intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Praise any indication of the resident's progress or improvement in behavior; -Focus: The resident declines to participate in independent tasks offered to improve daily living; -Interventions: The resident prefers to stay in bed and only wear soft socks foot wear. The resident likes towels in the room at random places and changes the location of where towels are placed. Towels under both sides of pillow, on the bedside table, and the side of the bed. Location changes of the towels vary from day to day and the resident will request at least four to six towels placed in random spots. Review of the resident's diagnoses listed in the electronic medical record (EMR), dated 2/26/25, showed the resident did not have a diagnosis of claustrophobia or OCD listed. Review of the resident's progress notes, showed: -On 2/7/25 at 10:45 P.M., this nurse was summoned to the resident's room by the resident's roommate, this nurse was made aware by the resident's roommate that the resident called the Department of Health and Senior Services (DHSS) with concerns. This nurse spoke with the resident of concerns he/she could help with, and the resident voiced that he/she had no concerns or questions; -No follow up note related to the resident's behavior was documented; -On 2/17/25 at 11:14 A.M., the resident is making demands while staff are in the room to get the resident up for a shower. The resident is upset and said that the staff was taking all his/her things. This nurse was in room with the aide and observed the aide cleaning the resident's room and removing old linens and towels, this was explained to the resident and the resident remained upset; -On 2/17/25, at 11:24 A.M. , the resident was being placed back in bed from having a shower, the resident began to curse, said the staff doesn't do anything for him/her and threatened to call the DHSS because the aide did not leave the call light in reach. The aide informed the resident that he/she was coming right back and that he/she was just obtaining some linens; -No follow up note related to the resident's behaviors was documented. -On 2/19/25 at 1:42 P.M., the resident is frequently on his/her call light despite making frequent rounds and checks; -On 2/19/25 at 11:05 P.M., the resident's physician documented, the resident is quite demanding and wants some sort of inappropriate treatment. At times the resident asks for antibiotics and cough syrup. Rounds were made with the Infection Preventionist (IP) and the IP did not have any concerns but said the resident is very needy and wants medications that are not appropriate; -Plan: Did not address the resident's behaviors or anxiety. -On 2/22/25, at 12:13 P.M., the aide was giving care to the resident's roommate and the resident demanded that the aide stop giving care to the resident's roommate and retrieve the resident's lunch or the resident was going to report the aide; -No follow up note related to the resident's behavior was documented. Observation and interview on 2/24/25 at 9:40 A.M., 2/25/25 at 12:55 P.M., and 2/28/25 at 8:35 A.M., showed the resident lay in bed listening to Christian music. The resident said he/she doesn't want to take showers anymore because when he/she is taken to the shower room by staff, another staff member goes into his/her room and removes linens and clothing without his/her permission. This makes him/her very upset and increases his/her anxiety. The resident said this has happened at least five times within the last six months. The resident said that the unknown about his/her day increases his/her anxiety. He/She is rarely informed on a daily basis who the nurse or who the aides are for the day. He/She requires nebulizer treatments (a medication to assist with breathing) as needed and must wait prolonged periods of time for the treatment. That creates anxiety and increased shortness of breath (SOB). He/She will turn on his/her call light to be cleaned because no one comes in for hours. Sometimes when he/she turns the call light on, staff turn it off without even asking what he/she needs. If he/she doesn't get a response to the call light, the resident will call the front desk. The resident said he/she is incontinent of bowel and bladder and does not like to lay in a soiled brief for extended periods because he/he is prone to urinary tract infection (UTI) and bed sores (wounds that occur laying in one position for extended periods). The resident is grateful that his/her snacks and drinks are provided but feels as though his/her care concerns are landing on deaf ears and the staff get tired of answering his/her light or the front desk phone. He/She lacks a sense of trust with the staff and facility administration because they make it feel like everything that he/she has issues with are not important, lack any type of evidence, or he/she makes things up. The resident does not know how to file a grievance and has never spoken to the Ombudsman. The resident said he/she does not want his/her medication changed related to his/ her anxiety but is open to speak with a counselor. The resident said his/her Christian values are important to him/her. He/She prays a lot to calm his/her nerves. He/She has never been offered any type of chaplain services since he/she has been at the facility. There are certain staff members that he/she works better with, but it seems like those staff members are not assigned to him/her consistently. Review of the facility's grievance log for November and December 2024 and dated January 2025, showed no grievances filed by the resident. Observation on 2/26/25 at 9:29 A.M., showed Certified Nursing Assistant (CNA) N entered the resident's room without knocking, walked past the resident's bed and assisted the resident's roommate. At 9:37 A.M., CNA N exited the room and did not acknowledge the resident while leaving the room. The resident used his/her grabber to maneuver things in the room. Observation and interview on 2/27/25 at 11:05 A.M., showed CNA D propelled the resident on the shower stretcher into the spa room. The resident said he/she hoped no one took his/her stuff in his/her room while he/she is in the shower. CNA D completed the resident's shower and propelled the resident back to his/her room using the shower stretcher. Once the resident returned to his/her room, he/she immediately looked around the room and noticed that some of his/her clothing on his/her bedside table was missing along with two towels and a bed blanket. The resident was upset and asked CNA D two times, Where is my clothing? CNA D said he/she didn't see any clothing on the resident's nightstand. The resident said it must have been another staff member that did it. CNA S entered the room and informed the resident that he/she took the resident's towels and bath blanket off the nightstand because it was soiled. CNA S said he/she did not see the resident's clothing. The resident described to CNA S what the clothing looked like. CNA S again said he/she did not take the resident's clothing, only took the soiled linen that was resting on the resident's nightstand. CNA S said to the resident, I will try my best to find your clothing. The resident asked CNA S to look in the soiled linen room for his/her clothing because his/her clothing did not have his/her name on it. CNA S said again, I will try my best to locate the resident's clothing. The resident said he/she was feeling very anxious. During an interview on 2/27/25 at 2:10 P.M. CNA S said he/she had taken the resident's clothing and bed linens off his/her nightstand without the resident's permission. The linens on top of the clothing were soiled. CNA S said the resident would not allow staff to remove things out of his/her room. The resident became upset when staff tried to do so. CNA S said the resident was a hoarder. He/She would discreetly remove clothing that need to be laundered when the resident was not in his/her room. When working with the resident, two aides were to be in the room to provide care. He/She wasn't sure why but just thought the more the merrier. The resident turned his/her call light on a lot for minor things and was more demanding when DHSS was in the building. CNA S said staff were not to argue with the resident. He/She felt as though staff tried their best to meet the resident's needs with a positive spirit and attitude and not create any emotional distress for the resident. During an interview on 2/27/25 at 12:45 P.M. and 2:25 P.M., Licensed Practical Nurse (LPN) T said he/she thought the resident didn't like the staff and believes the resident's family doesn't like the staff. The resident is on his/her call light frequently and calls the front desk frequently. The resident is always upset about something, and LPN T will try to redirect the resident with being extremely nice to him/her. Staff should not remove items from the resident's room without his/her permission. The resident requires a lot of time sometimes when you answer his/her call light. LPN T said he/she just goes along with the resident's requests and just deals with it because that is the resident's personality. Staff should not argue with the resident when the resident demands things because that increases the resident's anxiety. LPN T was not aware of any type of special behavioral management that is required for the resident. Everyone in the building that works with the resident is aware of the resident's anxiety and behaviors. All behaviors are documented in the progress notes. During an interview on 2/26/25 at 9:35 A.M., the Psychiatry NP AA said he/she has been recommending a counseling service to come in and meet with residents in the facility for at least six months. He/She has been asking the Social Service Director (SSD) to get the counseling services arranged. NP AA said his/her time with the resident is limited but a counselor could spend an extended amount of time with the resident. The resident has anxiety issues related to his/her care and current living situation and would benefit from counseling services. The resident also may have cognitive issues related to time and may not realize how often he/she places the light on. The resident refuses any new medication changes. NP AA encourages staff to be proactive and make sure the resident has everything he/she needs before leaving the resident's room. NP AA said the resident does not refuse his/her visits. During an interview on 2/26/25 at 11:15 A.M., Receptionist Y said that the resident calls the front desk at least three to 30 times a day. The resident is always anxious sounding and upset when he/she calls and says no one is answering his/her light. The resident requires a lot of reassurance. The resident will frequently call and say that he/she needs to be changed. The resident will also request a shower, nebulizer treatments and other medications. The resident mainly requests names of staff who will be taking care of him/her for the day and what staff members are going to be giving him/her medications. Receptionist Y will call the nurses' desk when the resident calls and let them know what the resident's request are. Receptionist Y said the frequent calls to the front desk from the resident have been occurring for at least a year. During an interview on 2/25/25 at 11:30 A.M. and on 2/27/25 at 12:35 P.M. the SSD said he was aware the resident called the front desk a lot with care issues. The resident doesn't get visitors very often and does not come out of his/her room. The resident's family member has recently stopped coming into visit the resident. The SSD was not sure why. The resident is always requesting someone go out and buy him/her snacks, bottled water and soda. The resident had issues with a staff member in the past but was not aware of any issues lately. The resident requires more attention and special focus because he/she calls DHSS so much with complaints. The SSD will go in and make rounds and speak with the resident daily and tries to solve any issues the resident may have, but doesn't file a grievance every time. Staff and/or the SSD will purchase the resident snacks. The facility goes above and beyond making the resident happy with frequent room visits, purchasing [NAME] (a type of peanut butter snack) and drinks with their own money. The SSD was not aware of any spiritual needs for the resident. The Activity department is responsible to complete the Spiritual Assessment. The SSD said he would reach out and see if the resident would like a preacher to visit and pray with him/her. The SSD was aware that the Psychiatry NP has been requesting a counseling service for the resident for at least 6 months. He has informed the Administrator of the counseling service request, but the Administrator said it is tied up with corporate red tape. The SSD also said the Ombudsman has been in to visit the resident. No documentation or e-mails were provided by the SSD related to the Ombudsman visiting the resident when requested. During an interview on 2/25/25 at 2:45 P.M., the Activity Director (AD) said she has been providing daily one on one activities with the resident because the resident does not like to leave her room. The AD and the resident tend to talk about the different holidays coming up. The resident will frequently go off topic and just ask the AD to straighten the resident's bedside table. The AD confirmed a spiritual assessment had not been completed since 10/30/23. The assessments were to be completed yearly. The Activity Department had recently obtained a new assistant within the last two weeks and will begin to read the Bible with the resident. During an interview on 2/28/25 at 9:34 A.M., with the Administrator and the Director of Nursing (DON), the DON said the resident can be pleasant, sweet, kind, demanding, cooperative and aggressive; it varies day to day. The DON said she is in the resident's room 1,000 times a day. They were aware the resident calls the front desk with multiple issues and frequently calls DHSS with his/her issues, and all the department heads are involved with the resident's care and needs. The resident will not start his/her day without knowing who the resident's aide is. The facility is being proactive by meeting with the resident everyday and providing snacks when he/she requests. He/She refuses any psychiatric care and does not want to change any medications. The Administrator said the resident develops anxiety when his/her call light is not answered and then he/ she calls the front desk. The Administrator has personally gone down to the resident's room after the resident calls the front desk with his/her requests. A grievance is not completed each time because the residents' concerns are usually dealt with at the time. If a grievance was made each time the resident had an issue, it would be a huge book. The Administrator has adjusted the air conditioner temperature and has fixed a privacy curtain issue. The Administrator and the DON feel as though they go above and beyond by visiting the resident daily and providing snacks out of their own pockets. The resident's behaviors and follow up visits are documented in the resident's EMR. The Administrator was aware of the Psychiatry NP's request for counseling services for the resident. He has been working on the credentialing and vetting process for obtaining the counseling services since last fall. It takes a while because it is a process with steps to follow. All outside companies have to be vetted due to concerns of Medicare and Medicaid fraud and to ensure the recommended provider does not have a relationship with the outside counseling service. The DON said she would expect all assessments to be completed to address the resident's needs and that includes a spiritual assessment. They would expect the staff to answer the resident's call light timely and address the resident's needs in a professional manner. The staff are always professional when speaking with the resident and will continue to do so. The DON feels as though they have tried to work with the resident regarding the resident's concerns but think that is just his/her personality. During a telephone interview with State Employee X and the resident on 3/3/25 at 11:31 A.M., the resident asked CNA D if the resident was assigned to CNA D. The resident informed CNA D that he/she had a bowel movement (BM) and needed to be cleaned up. CNA D did not answer the resident but was heard speaking in the background to someone else. The resident told State Employee X, this is what CNA D does to me, he/she assists the roommate and ignores me. The resident was heard informing CNA D that his/her light was on for a long time and that he/she has been sitting in BM and needed CNA D's help. With a raised voice, CNA D could be heard telling the resident, Your light wasn't on. The resident replied, to CNA D, Yes, it was. CNA D replied with a raised voice, No it was not and said that he/she was waiting on towels. The resident told CNA D that he/she called the front desk at least 10 times and the front desk would hang up on him/her. With a raised voice, CNA D said, I don't care. You can call the front desk as many times you want. I don't care. The resident told State Employee X he/she wanted to be treated like everyone else.

Based on observation, interview and record review, facility staff failed to discard expired medications from the medication carts, failed to ensure all medication bottles had a date of expiration, failed to ensure eye drops/ointments were dated when opened, and failed to ensure insulin pens were stored in the refrigerator and not in the medication cart. The facility identified four medication carts, two were sampled, and problems were identified in both. The census was 86. Review of the facility Medication Storage and Administration Quick Reference Guide, dated 8/2022, showed: -Insulin Vials and Pens: Store unopened insulin in the refrigerator; -Ophthalmic Solutions Storage Parameters: Eye medication bottles/tubes with accelerated expiration dates must be dated/initialed upon opening. Follow the manufacturer instructions, or facility policy. 1. Observation of the South 2 medication cart on 2/24/25 at 4:38 P.M., showed: -South 1 medication cart: -One opened stock bottle (used for multiple residents) of Rena Vite tablets (multivitamin) expired on 12/23/24. Licensed Practical Nurse (LPN) A confirmed the expiration date, removed the bottle from the medication cart and said it should be discarded; -One opened tube of bacitracin/polyophthalmic eye ointment (an antibiotic ointment), delivered by the pharmacy on 11/23/24. The ointment tube had no date documented of when it was opened. LPN A said the eye ointment should be discarded 30 days after opening. Without knowing the opening date, staff would not know when to discard the ointment; -One opened tube of bacitracin/polyophthalmic eye ointment, delivered by the pharmacy on 1/6/25. The tube had no date documented of when it was opened. LPN A said the eye ointment should be discarded 30 days after opening. Without knowing the opening date, staff would not know when to discard the ointment; -One opened stock bottle of liquid docusate sodium (laxative), approximately three fourths empty, with no expiration date on the bottle. The LPN Unit Coordinator said there was no expiration date and removed the bottle from the medication cart; -One opened stock bottle of stock folic acid (vitamin B) with an expiration date of 1/2024. The LPN Unit Manager said the folic acid was expired; -One opened bottle of Coenzyme Q10 (a vitamin-like substance made naturally in the body) with an expiration date of 2024 (day and month illegible). The expiration date was confirmed by LPN Unit Coordinator, and removed from the medication cart; -One glargine insulin (long acting insulin) pen, unopened, and delivered from the pharmacy on 2/21/25. The LPN Unit Coordinator said the insulin pen should be stored in the refrigerator until opened. 2. Observation of the South 2 medication cart on 2/24/25 at 4:38 P.M., showed: -South 2 medication cart: -One opened bottle of of prednisolone AC 1% ophthalmic eye drops (used to treat eye inflammation) delivered from the pharmacy on 1/10/25. The eye drop bottle did not have the date it was opened on it; -One unopened aspart insulin (fast acting insulin) pen, delivered by the pharmacy on 2/17/25. The LPN Unit Coordinator said the insulin pen should be stored in the refrigerator until opened; -One opened stock bottle of boric acid vaginal suppositories (used to treat yeast infections). The suppositories had no expiration date listed on the container. The LPN Unit Coordinator said there was no expiration date on the container; -The LPN Coordinator said eye drops and ointments should be discarded after 30 or 31 days after opening. Any medication that is expired or without an expiration date should be removed from the medication cart. During an interview on 2/28/25 at 9:34 A.M., the Administrator said he expected staff to adhere to policies regarding eye drops and ointments so they can be discarded at the appropriate time. He expected staff to follow the facility policies on medication storage. The Director of Nurses said she expected insulin pens to be stored in the refrigerator until ready to use. Expired medications should be not be on the medication cart.

Based on observation, interview and record review, the facility failed to ensure staff performed appropriate hand hygiene during meal service and failed to serve food in accordance with professional food safety standards, which affected three residents (Resident #22, #24, and #27). The sample was 18. The Census was 86. Review of the facility's hand hygiene policy, dated 6/13/23, showed: -Policy: The facility has adopted the Centers for Disease Control and Prevention (CDC) core infection prevention and control practices for safe healthcare delivery in all settings for indications for hand hygiene; -Procedure: Hand hygiene should be performed before and after contact with resident, after contact with objects or surfaces in the resident's environment. 1. Review of Resident #22's medical record showed: -Diagnoses included dementia, diabetes, and Parkinson's disease (brain disorder causing unintended or uncontrolled movements); -Severe cognitive impairment. 2. Review of Resident #24's medical record showed: -Diagnoses included muscle weakness and dementia; -Severe cognitive impairment. 3. Review of Resident #27's medical record showed: -Diagnoses included depression and muscle weakness; -Moderately impaired cognition. 4. Observation on 2/24/25, of lunch in the main dining room, showed: -At 12:24 P.M., Restorative Aide (RA) BB grabbed onto Resident #27's wheelchair handle as he/she sat down next to the resident at the table; -At 12:25 P.M., RA BB picked up Resident #27's spoon and started to feed the resident; -At 12:28 P.M., RA BB picked up Resident #24's straw, opened it, and placed it in the resident's drink. RA BB then picked up the resident's drink and gave Resident #24 a drink. 5. Observation on 2/26/25, of lunch in the main dining room, showed: -At 11:52 A.M., Certified Nurses Aide (CNA) M sat at a table next to Resident #22. CNA M had his/her phone in his/her hand, texting; -At 11:55 A.M., CNA M was still seated at the table texting on his/her phone. Using his/her right hand, he/she wiped his/her forehead; -At 11:59 A.M., CNA M stood up and positioned Resident #24's feet onto his/her wheelchair foot rest and then propelled Resident #24 out of the dining room; -At 12:00 P.M., CNA M returned to the dining room without sanitizing his/her hands. CNA M walked up to the kitchen doorway, resting his/her hands on the doorframe. He/She was handed a drink for Resident #22 and went to sit back at the table; -At 12:02 CNA M touched his/her chair handles as he/she sat back down. He/She repositioned Resident #27 up closer to the table by pulling the wheelchair's arm rest; -At 12:03 P.M., CNA M used his right hand to wipe his/her head; -At 12:12 P.M., CNA M picked up Resident #27's spoon with his/her right hand and swiped his/her ungloved left hand across the bowl of the spoon, dipped the spoon in the resident's food, and gave the resident a bite; -At 12:13 P.M., CNA M picked up Resident #22's cup and handed it to the resident; -At 12 :14 P.M., CNA M held onto Resident #22's wheelchair handles as he/she stood up from his/her chair and went to the kitchen to get a drink for the resident; -At 12:15 P.M., CNA M sat back down at the table, took his/her phone out of his/her pocket and started texting; -At 12:20 P.M., CNA M took the cup out of Resident #22's hand, and propelled the resident out of the dining room in his/her wheelchair; -CNA M did not sanitize hands when leaving the dining room or entering back into the dining room; -At 12: 21 P.M., CNA M sat back down at the table next to Resident #27. He/She picked up the resident's straw, opened it, and placed it into the resident's drink. He/She rubbed his/her ear with his/her hand. He/She then picked up the resident's silverware and started to cut up the resident's food; -At 12:23 P.M., CNA M scooped up food onto Resident #27's spoon, brought the spoon close to his/her mouth and blew on the food, and then fed the resident; - At 12:24 P.M., CNA M scooped up food onto Resident #27's spoon, brought the spoon close to his/her mouth and blew on the food, and then fed the resident; -At 12:26 P.M., CNA M picked a piece of fried chicken up from Resident #27's plate with his/her ungloved hand and placed it onto the resident's spoon and then fed the chicken to the resident. 6. During an interview on 2/27/25 at 1:55 P.M., CNA L said hand hygiene is to be performed before entering the dining room, after touching residents or objects, and in between assisting residents. It is not appropriate to blow on residents' food to cool it down. Food should be set to the side if it is too warm. It was not appropriate to pick food up with your hands and place it on the fork; that would be a germ issue. 7. During an interview on 2/27/25 at 1:24 P.M., the Dietary Director said all staff should wash or sanitize their hands before entering the dining room, after touching a resident, after touching themselves, or after touching surfaces. She said it is not appropriate for staff to blow on resident food when feeding them. Food should be set aside if it is too warm. It is not appropriate for staff to pick up food with their hands when feeding a resident. She said it is not appropriate for staff to clean silverware with their hands and then use the silverware to feed a resident. 8. During an interview on 2/27/25 at 1:58 P.M., the Executive Director said he would expect hand hygiene to be performed by staff when going between touching residents and objects. He would expect staff not to blow on residents' food. He would expect staff to use utensils to pick up residents' food. He would expect staff to clean silverware with a napkin or to get new silverware for residents. He would expect staff to sanitize their hands after wiping their head with their hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS), for three residents (Residents #26, #29 and #45) with wounds requiring treatments, gastrostomy tubes (g-tube, a tube that is surgically inserted into the abdomen and is used for liquid nutrition and medications), or tracheostomies (a surgically inserted tube inserted into the windpipe to assist with breathing). The sample was 16. The census was 86. Review of the facility's EBP policy, revised 3/21/24, showed: -Policy: The facility should use EBP as an additional MDRO mitigation strategy for residents that meet the following criteria, during high-contact resident care activities: -Infection or colonization with a CDC targeted MDRO when contact precautions do not otherwise apply; -Wounds and or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO; -Wounds generally include chronic wounds, such as pressure ulcers (a wound cause by prolong pressure), diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers (wounds that are caused by damaged veins); -Indwelling medical device examples include central line (access that is surgically inserted into a large vein that is used for fluids and medications) urinary catheters (a tube that drains the bladder), feeding tubes, and tracheostomies; -Procedure: The facility should develop a process to communicate with residents who require the use of EBP for all contact resident care activities. The facility may choose to post signage on the door or wall outside of the resident's room indicating the resident is on EBP; -Provide education to affected residents and visitors on the reason and use of EBP; -Examples of high contact resident care activities requiring gown and glove use include: -Dressing; -Bathing or showering; -Transferring; -Providing hygiene; -Changing linens; -Changing briefs or assisting with toileting; -Device care or use: Central line, urinary catheter, feeding tube, and tracheostomy; -Wound care: any skin opening requiring a dressing. Review of the facility's list of residents on EBP, dated 2/24/25, showed Resident # 26, Resident #29 and Resident #45 listed on EBP. 1. Review of Resident #26's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/4/24, showed: -Speech Clarity: No speech - absence of spoken words; -Makes Self Understood: Rarely/never understood; -Ability to Understand Others: Sometimes understands - responds adequately to simple, direct communication only; -Dependent - Helper does all of the effort. Resident does none of the effort to complete activity: Toileting hygiene, shower/bathing, upper/lower body dressing, and personal hygiene; -Diagnoses: MDRO, pneumonia (an inflammatory condition of the lungs. Symptoms may include productive or dry cough, chest pain, fever, and difficulty breathing.), stroke, seizure disorder, malnutrition, and respiratory failure; -Feeding Tube; -Special Treatments and Programs: Oxygen therapy, suctioning (removes mucus and secretions), and tracheostomy care. Review of the resident's care plan, showed: -1/16/25: Focus: At risk for respiratory illness. Goal: The resident will remain free from respiratory illness. Interventions: Monitor for change in condition and notify physician of findings; -1/16/25: Family is resistive to care and implementation from professional maintenance care and assisting with maintaining baseline-well being. Family removes treatments in place to skin integrity concerns, performs tracheostomy care. Goal: The resident will cooperate with care. Interventions: Educate resident/family/caregivers of the possible outcomes of not complying with treatment or care; -1/16/25: Focus: Impaired cognitive ability/impaired thought process related to TBI (traumatic brain injury). Goal: Resident's needs will be met. Interventions: Allow resident extra time to respond to questions and instructions. Ask yes/no questions; -1/16/25: Focus: Rash, contact dermatitis to buttock and is followed by wound care company. Goals: Will have no complications from rash. The resident will have no signs or symptoms of infection. The rash will heal by next review date. Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Observe skin rashes for increased spread of infection. Seek medical attention if skin becomes bloody or infected; -1/16/25: Tracheostomy tube related to TBI. Goal: Will have no signs/symptoms of infection. Interventions: Observe for changes in level of consciousness, mental status, and lethargy. Review a sign for EBP, located on the door of another resident, showed: -Everyone must: Clean their hands, including before entering and when leaving the room; -Providers and Staff Must Also: Wear gloves and a gown for the following high-contact resident care activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting; -Device care or use: Central line, urinary catheter, feeding tube, tracheostomy; -Wound Care: Any skin opening requiring a dressing. Observation and interview on 2/24/25 at 8:56 A.M., showed personal protection equipment (PPE, gloves, gowns, masks, etc.) hanging on the outside of the room door, but no Enhanced Barrier Precautions sign on the outside of the resident's door or room. Upon entering the room, there was a sign on the inside of the door with instructions on how to remove PPE upon leaving the room. The waste can to discard PPE sat along the wall next to the first bed in the room and was not placed next to the door exit. The resident lay in bed while a family member bathed the resident. The family member wore gloves, and a face mask, but no gown. The resident had a tracheostomy tube with humidified oxygen infusing and a g-tube. When the family turned the resident onto his/her side, an uncovered stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) was noted on the resident's coccyx (tailbone). During an interview, the family member said he/she comes in every morning to bathe the resident. Observation on 2/24/25 at 11:08 A.M., showed no EBP sign on the outside of the room door. Observation and interview on 2/25/25 at 6:57 A.M., showed no EBP sign on the outside of the room door. Upon entering the room, the waste can remained along the wall next to the first bed, and the resident's family member was at the bedside, bathing the resident. The family member wore gloves and a face mask, but no gown. Certified Nursing Assistant (CNA) H entered the room and then went back outside of the room door and got two gowns, one for him/her and one for the family member. While wearing gloves and gown, CNA H helped the family member pull the resident up in the bed. The CNA told the family member whenever personal care is provided, a gown needs to be worn. The family member said he/she had been bathing the resident everyday since the resident had been at the facility, and this is the first time anyone asked him/her to wear a gown. The family member put the gown on and finished bathing the resident. During an interview on 2/28/25 at 7:20 A.M., the facility Infection Preventionist (IP) said she was not aware there was no Enhanced Barrier Precaution sign on the outside of the resident's door, but there should be. It is her and the Unit Coordinator's responsibility to ensure the signs are posted on the outside of the room. Gloves, gowns and masks are required while providing personal care to the resident. The IP had not educated the family member about the enhanced barrier precautions policy. During an interview on 2/28/25 at 9:34 A.M., the Administrator said EBP signs should be posted on the outside of the door or room for residents who meet the enhanced barrier criteria. The trash can should be next to the exit per the facility policy. He and the Director of Nursing (DON) had seen the resident's family wearing a gown before, so they are not sure why the family member said he/she had not never been asked to wear one before. They did not have any documentation showing the resident's family had been educated by the facility on why he/she should wear PPE. The Administrator said he expects staff to follow the policy by ensuring signs are posted and waste cans are next to the exit. 2. Review of Resident #29's quarterly MDS, dated [DATE], showed: -Diagnoses of congestive heart failure, muscle weakness, and toxic liver disease; -Cognitively Intact. Review of the resident's care plan, dated 2/25/25, showed: -Focus: Resident has a venous ulcer (wound caused by abnormal or damaged veins) on the right lateral (lower) leg and left lateral leg, the resident is non-compliant with wound care and is followed weekly by a wound clinic team; -Goal: The resident's ulcer will be healed by the review date; -Interventions: EBP precautions. Review of the resident's Physician's Orders Summary (POS), in use at the time of the survey, showed: -An order, dated 10/22/24, for EBP to be worn every shift during close contact care due to the resident's leg wounds. Observation on 2/24/25 at approximately 10:30 A.M., showed the resident's door did not have an EBP sign posted. The Facility Wound Nurse entered the room without PPE and informed the resident that she was there to change the resident's dressing. CNA D entered into the room without PPE. The Facility Wound Nurse, with gloved hands but no gown, removed the resident's heel protectors and dressing to both legs. While wearing gloves but no gown, CNA D assisted the Facility Wound Nurse, holding the resident's legs while the Facility Wound Nurse dressed the resident's leg wounds. At 11:25 A.M., CNA U entered the room without an isolation gown, applied gloves and said he/she was going to assist CNA D in getting the resident cleaned up. CNA U and CNA D provided perineum care (peri-care, cleansing on the genitals and rectal area) by turning the resident side to side. The resident's upper body touched CNA U's and CNA D's uniform when they turned the resident. Staff did not wear an isolation gown during resident care. Observation on 2/25/25 at 9:13 A.M., showed CNA N and CNA O entered the resident's room to transfer the resident from his/her bed to his/her wheelchair using a full mechanical lift. CNA N and CNA O both put on a pair of gloves upon entering the room. CNA N lifted the resident's feet with one hand while pulling a pillow out from under the resident's feet with his/her other hand and then placed the resident's feet back on the bed. Both CNA N and CNA O rolled the resident onto his/her left side with CNA O leaning up against the resident with his/her clothing touching the resident. The CNAs then rolled the resident to his/her left side with CNA N leaning up against the resident with his/her clothing touching the resident. While lowering the resident into his/her wheelchair from the lift, CNA O leaned against the resident while holding him/her in position with his/her clothing touching the resident. Both CNA O and CNA N did not wear a gown during the resident care During an interview on 2/28/25 at 7:26 A.M., CNA N said he/she did not know if the resident was on EBP precautions. The sign on the resident's door was an EBP sign, which means a gown and gloves needs to be worn when taking care of the resident. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed: -The resident has moderate cognitive impairment; -Diagnoses include kidney disease, pneumonia, stroke, and depression; -Requires maximum assistance from staff for toilet hygiene; -Occasionally incontinent of urine and frequently incontinent of bowels; -The resident has a feeding tube. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has an activities of daily living (ADL) self-care deficit related to hemiplegia (weakness to one side of the body), stroke, impaired balance, and limited mobility; -Interventions: Assist the resident with toilet use and hygiene. -The care plan did not address EBP. Review of the resident's POS, dated 2/24/25, showed: -An order, dated, 2/24/25, EBP for g-tube, every shift. Observation and interview on 2/24/25 at 12:15 P.M., showed an EBP sign posted on the outside of the resident's doors and a caddy filled with isolation gowns, gloves and masks. CNA S entered the resident's room without PPE. The resident said he/she was wet. CNA S applied gloves, checked the resident and changed the resident by turning the resident side to side. The resident's legs touched CNA S's uniform while being turned. During care of the resident, the resident's abdomen was exposed, and a g-tube was present. CNA S did not wear an isolation gown while providing care. During an interview on 2/27/25 at 2:25 P.M., Licensed Practical Nurse (LPN) T said EBP are required for residents who have tracheotomy tubes, urinary catheters, g-tubes and wounds. Staff should be wearing gowns and gloves when providing any type of direct care to the residents. 4. During an interview on 2/28/25 at 7:21 A.M., the IP said Resident #29 has leg wounds and Resident #45 has a g-tube which requires EBP and PPE to be worn by staff when providing direct care. Both residents should have a sign posted for EBP. She would expect staff to be following EBP policies and procedures. She said staff should be wearing a gown, gloves, and regular mask if required. 5. During an interview on 2/28/25 at 9:58 A.M., the Executive Director and DON said staff are expected to wear PPE for residents that meet the EBP criteria. They would expect staff to use PPE during care for Resident #29 and Resident #45. They would expect staff to be following the facility's EBP policy. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to treat residents with dignity when staff removed one resident's personal items without the resident's permission while he/she was out of his/her room receiving a shower (Resident #68). Furthermore, staff spoke to three residents in an unprofessional manner (Resident #68, Resident #29, and Resident #45). Staff also used their personal cell phone while assisting one resident during meal time (Resident #22). The sample was 18. The census was 86. Review of the facility's Dignity policy, reviewed, 9/26/24, showed: -Policy: Each resident has the right to be treated with dignity and respect, interactions and activities with residents by staff, temporary, agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporation of the resident goals, preferences, and choices; Staff must respect the resident's individuality as well as honor and value their input; -Procedure: -All residents will be treated with dignity and respect: Examples of treating residents with dignity and respect include, but are not limited to: -Treating all residents' possessions, regardless of their apparent value to others, with respect; -Respecting residents' private space and property (For example, changing the radio or television station only upon a resident's request, asking permission to access resident's rooms, drawers, cabinets, and closets); -Promoting resident independence and dignity while dining, such as avoiding: -Staff interacting/conversing only with each other rather than with residents while assisting with meals; -Addressing residents by the name or pronoun of the resident's choice; -Residents should not be excluded from conversations during activities or when care is being provided; -Considering the resident's lifestyle and personal choices identified through their assessment processes, to respect and accommodate his or her individual needs and preferences. Review of the facility Cell Phone policy, dated, 1/7/25, showed: -Policy: The facility will ensure the appropriate usage of cell phones to safeguard resident privacy and to ensure the provision of highest quality resident care; -Procedure: Associates should refrain from using cell phone in resident care areas at all times. 1. Review of Resident #68's, quarterly minimum data set, (MDS, a federally mandated assessment instrument completed by facility staff), dated 1/26/25, showed: -The resident is cognitively intact; -No behaviors or rejection of care; -The resident is dependent on staff for showers and bathing. Review of the resident's face sheet, undated, showed diagnoses that included: Anxiety, cognitive communication deficit, spinal stenosis (narrowing) of the lumbar region (lower back), chronic obstructive pulmonary disease (COPD, restricts airways in the lungs making it difficult to breathe). Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident is resistant to care; The resident will make false assumptions towards staff and has a manipulative perception of healthcare concerns and needs being met; The resident presents with obsessive compulsive disorder (OCD), increased anxiety, and claustrophobic like behaviors. -Interventions: Give a clear explanation of all care activities prior to and as they occur each contact; If the resident resists activities of daily living (ADL), reassure the resident, leave and return five to ten minutes later and try again; Provide the resident with opportunities for choice during care provision. Review of the resident's progress notes, showed: -On 2/17/25, at 11:14 A.M., the resident is making demands while staff are in the room to get the resident up for a shower. The resident is upset and said that the staff was taking all her things. This nurse was in room with the aide and observed the aide cleaning the resident's room and removing old linens and towels, this was explained to the resident and the resident remained upset. During observation and interview on 2/27/25 at 11:05 A.M., Certified Nursing Assistant (CNA) D propelled the resident on the shower stretcher into the spa room. The resident said he/she hoped no one takes his/her stuff in his/her room while he/she is in the shower. CNA D completed the resident's shower and propelled the resident back to his/her room using the shower stretcher. Once the resident returned to his/her room, he/she immediately looked around the room and noticed that some of his/her clothing on his/her bedside table were missing along with two towels and a bed blanket. The resident was upset and asked CNA D two times, where is my clothing? CNA D replied that he/she didn't see any clothing on the resident's nightstand. The resident said it must have been another staff member that did it. CNA S entered the room and informed the resident that he/she took the resident's towels and bath blanket off the nightstand because it was soiled. CNA S said he/she did not see the resident's clothing. The resident described to CNA S what the clothing looked like. CNA S again said he/she did not take her clothing, and only removed soiled linen that was on the resident's nightstand. CNA S said to the resident, that he/she would will try his/her best to find the clothing. The resident asked CNA S to look in the soiled linen room for his/her clothing because his/her clothing did not have his/her name on it. CNA S said again, he/she would try his/her best to locate the resident's clothing. The resident said he/she was feeling very anxious. During an interview on 2/24/25 at 9:40 A.M., the resident said he/she doesn't want to take showers anymore because when he/she is taken to the shower room by staff, another staff member goes into his/her room and removes linens and clothing without his/her permission. This makes him/her very upset and increases his/her anxiety. The resident said this has happened at least five times within the last six months. During an interview on 2/27/25 at 2:10 P.M. CNA S said he/she had taken the resident's clothing and bed linens off his/her nightstand without the resident's permission. The linens that were on top of the clothing were soiled. CNA S said the resident will not allow the staff to remove things out of his/her room and the resident becomes upset when staff try to do so. CNA S said the resident was a hoarder. He/She will discreetly remove clothing that needs to be laundered when the resident is not in his/her room. During an interview on 2/27/25 at 2:25 P.M. Licensed Practical Nurse (LPN) T said staff should not remove items out of the resident's room without his/her permission. Staff should show the resident the soiled linens and explain to him/her that the linens and clothing were soiled and that they need to be removed. If the resident refuses, then the family may have to be called. During a telephone interview on 3/3/25 at 11:31 A.M., with State Employee X and Resident #68, the resident asked CNA D if the resident was assigned to him/her and informed the CNA that he/she had a bowel movement (BM) and needed to be cleaned up. CNA D did not answer the resident but was heard speaking in the background to someone else. The resident said to State Employee X, this is what CNA D does to me, he/she assists the roommate and ignores me. The resident was heard informing CNA D that his/her light was on for a long time and that he/she has been sitting in BM and needed CNA D's help. CNA D was heard with a raised voice and said to the resident, Your light wasn't on. The resident replied, to CNA D, Yes, it was. CNA D replied with a raised voice, No it was not and said that he/she was waiting on towels. The resident said to CNA D that he/she called to the front desk at least 10 times, and the front desk hangs up on him/her. CNA D was heard with a raised voice, I don't care. You can call the front desk as many times you want. I don't care. The resident said to State Employee X he/she wanted to be treated like everyone else. During an interview on 2/28/25 at 9:34 A.M., the Administrator and the Director of Nursing (DON) said staff are expected to discuss the removal of the soiled linens and clothing prior to doing so. The staff are always professional in speaking with residents and are expected to continue to do so. 2. Review of Resident #29's quarterly MDS, dated [DATE], showed: -The resident is cognitively intact; -The resident is dependent on staff for toileting hygiene; -Diagnoses include: Cognitive communication deficit, high blood pressure, and heart failure. Review of the resident's care plan, in use of time of survey, showed: -Focus: ADL assistance and therapy services needed to maintain or attain highest level of function; -Interventions: Assist resident with mobility and ADLs as needed. During observation and interview on 2/24/25 at 11:25 AM., CNA D and CNA U provided perineum care (peri-care, cleansing the genitals and rectal area) by turning the resident side to side on his/her bed. The resident said he/she feels as though he/she is not turned very much. CNA D said to the resident, You know, things happen, and I tell all my residents they should just be happy to be alive. While washing the resident's back CNA D said to CNA U, I'm only here two days a week and I am glad. I'm a good aide, but I am reconsidering working here. During an interview on 2/24/25 at 11:35 A.M., the resident said the CNAs have a hard job. The resident heard the comments by CNA D and said he/she is happy to be alive. During an interview on 2/27/25 at 2:10 P.M., CNA S said that staff should not speak over the resident. The resident should be involved in the conversations. All interactions with the residents should be positive, upbeat, and professional. Telling the residents that they should just be happy to be alive is something that should not be said by staff. During an interview on 2/2/25 at 2:45 P.M., LPN T said the residents are to be spoken to in a professional manner and staff are not to speak over them during care. The staff should engage the resident in conversation and always be encouraging in a positive way. During an interview on 2/28/25 at 9:34 A.M., with the Administrator and the DON, the DON said she wasn't understanding the context of the conversation that the staff had with the resident related to the comment that CNA D said, I just tell all my residents that they just should be happy to be alive. In general, staff should not be talking over the resident while providing care and are expected to be professional with their conversations with residents. 3. Review of Resident #45's quarterly MDS, dated [DATE], showed: -The resident has moderate cognitive impairment; -Requires maximum assist from staff for toilet hygiene; -Occasionally incontinent of urine and frequently incontinent of bowels. Review of the resident's care plan, in use at the time of survey, showed: -Focus: The resident has ADL self-care deficit related to hemiplegia (weakness to one side of the body), stroke, impaired balance, and limited mobility; -Interventions: Assist the resident with toilet use and hygiene. During an observation and interview on 2/24/25 at 12:15 P.M., CNA S entered the resident's room and the resident said he/she was wet. CNA S checked the resident and said to the resident your diaper is dry. The resident insisted that he/she was wet. CNA S removed the resident's brief and a small amount of stool was observed on the brief. CNA S said to the resident that the resident had a small BM and his/her diaper was not wet. During an interview on 2/27/25 at 2:10 P.M., CNA S said a resident's brief can be called a diaper. He/She thought most residents wouldn't mind but guessed it depended on the resident and what they preferred. He/She didn't know what Resident #45 preferred. During an interview on 2/27/25 at 2:25 P.M., LPN T said it is not appropriate to call the resident's incontinent brief a diaper. A diaper is used on children and an incontinent brief is used on the adult residents. The term diaper is demeaning. During an interview on 2/28/25 at 2:45 P.M., with the Administrator and the DON, they said they would expect staff not to call the resident's incontinent brief a diaper while providing care to the resident. 4. Review of Resident #22's medical record, showed: -Diagnoses included dementia, diabetes, and Parkinson's disease (brain disorder causing unintended or uncontrolled movements); -Severe cognitive impairment. Review of the resident's care plan, in use at the time of the survey, showed: -Focus: ADL assistance and therapy services needed to maintain or attain highest level of function. The resident has a decline due to stroke with left sided weakness, resident is dependent with all daily living needs and transfers, resident is currently working with therapy services to increase functional mobility and strength; -Goal: Resident wishes to attain prior level of function; -Interventions: Assist with mobility and ADLs as needed. Diet is mechanical soft and resident needs to eat in the dining room. Observation on 2/26/25, of lunch in the main dining room, showed: -At 11:52 A.M., CNA M sat at the table next to the resident. CNA M held his/her cell phone in his/her lap, texting. The resident's drinks and dessert were on the table in front of the resident; -At 11:55 A.M., CNA M sat next to the resident, texting on his/her phone and not assisting the resident. The resident's food remained on the table; -At 11:57 A.M., CNA M tested on his/her phone and was not assisting the resident; -At 12: 16 P.M., CNA M texted on his/her phone. The resident's food was on the table in front of the resident, untouched; -At 12:17 P.M., CNA M was still texting on his/her phone. The resident was not eating, and his/her food remained on the table in front of him/her; -At 12:19 P.M., CNA M put his/her phone back in his/her pocket. During an interview on 2/27/25 at 12:52 P.M., Registered Nurse (RN) P said the cell phone policy is that staff are not to have cell phones out in resident care areas. It is not appropriate to be on your phone while assisting residents in the dining room. During an interview on 2/27/25 at 12:55 P.M., CNA O said staff are not to have cell phones in resident areas. He/She would expect staff to be off their phones while assisting residents due to choking risks. During an interview on 2/27/25 at 1:26 P.M., the Dietary Director said she would expect staff to be off their phones during meal service. She would expect staff to have their phones put away while assisting residents. During an interview on 2/27/25 at 1:58 P.M., the Executive Director said he would expect staff to be off their phones while assisting residents in the dining room. Staff should not be on their phones in resident areas. MO00249674 MO00248977 MO00248931 MO00250429

Based on interview and record review, the facility failed to ensure general accounting principles were followed by failing to follow up on outstanding checks during monthly resident trust fund (RTF) reconciliations. This facility identified 35 residents with funds handled by the facility. The census was 89. Review of the facility's Resident Trust Policy and Procedures, reviewed 6/15/22, showed: -In large part, these policies have been developed with the guidance of: -The Centers for Medicare and Medicaid Services (CMS) Internet-Only Manual, State Operations Manual, Appendix PP - Interpretive Guidelines for Long-Term Care Facilities; -State laws and regulations must also be followed when they are more stringent or more specific; -Each skilled nursing facility that is owned by the corporation shall: Manage a resident's personal funds via the Resident Fund Management Service (RFMS); -The policy did not provide guidance for follow-up on outstanding checks. Review of the facility's monthly RTF reconciliations from February 2024 through January 2025, showed outstanding checks as follows: -Check #1194, dated 9/30/20: $660.37; -Check #1212, dated 1/29/21: $150.00; -Check #1245, dated 6/30/21: $1,500.18; -Check #1253, dated 7/27/21: $10.00; -Check #1279, dated 9/14/21: $100.00; -Check #1292, dated 10/29/21: $50.00; -Check #1398, dated 12/23/22: $296.45; -Check #1401, dated 12/28/22: $27.26; -Check #1474, dated 8/22/23: $25.00. During an interview on 2/27/25 at 1:10 P.M., the Assistant Business Office Manager (ABOM) said she reconciles the RTF monthly and submits the reconciliations to the corporate office. She was not aware outstanding checks needed to be investigated. Following up on outstanding checks would be overseen by regional or corporate staff. During an interview on 2/27/25 at 1:16 P.M., the Regional Business Office Manger said she was not aware there needed to be routine follow-up for outstanding checks. The monthly reconciliations are reviewed by the corporate office. During an interview on 2/28/25 at 8:52 A.M., the Executive Director said he expects general accounting principles to be followed by the facility and corporate business office.

Based on interview and record review, the facility failed to designate a person to serve as the director of food and nutrition services with the appropriate certification, when a consultant Registered Dietician (RD) was not employed full-time with the facility. The census was 86. Review of the facility's certified dietary manager job description, undated, showed: -License and certification: Must have completed an approved Certified Dietary Manager course. Must maintain an active certification. During an interview on 2/28/25 at 9:53 A.M., the Dietary Director said she has her required qualifications but did not have a physical copy of the documentation. During an interview on 2/28/25 at 10:02 A.M., the Executive Director said he would expect the Dietary Director to have the required certifications. The Dietary Director did have the required certifications, but they have expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a kitchen exit door was locked and armed after one resident (Resident #1) eloped from the facility through the kitchen door during the early morning hours, and was out of the facility for approximately 30 minutes. The resident was found on the facility's premises, approximately 30 feet from the exit door. The facility census was 74. The facility was notified of past non-compliance on 12/31/24. Facility staff immediately searched for the resident, reported the incident, and began their investigation. The investigation consisted of written statements and interviews. The investigation showed the kitchen door was not locked and armed. Staff were in-serviced on elopement policy, and abuse and neglect. A second alarm was added to the kitchen door. The deficiency was corrected on 12/27/24. Review of the facility's Elopement policy, revised 11/19/24, showed: -Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle; -Upon completion of the other interdisciplinary team's admission and readmission assessments, the interdisciplinary team will review any additional unsafe wandering and/or elopement risk indicators and revise the resident's care plan as indicated; -The interdisciplinary team will review and revise the resident's unsafe wandering management care plan, if indicated, upon completion of each comprehensive, significant change and quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff) and upon an unsafe wandering or elopement event; -A specific system will be implemented to notify staff that exit doors have been opened in areas accessible to residents and may include but not be limited to: -Documented and routine testing of door alarms; -Documented and routine testing of staff's response to alarms; -Monitoring practices when door alarms are disabled or during instances of higher traffic such as holidays, special events, or tours; -Monitoring practices for exits that are not visible to staff but readily accessible to residents; -Residents will be assessed for unsafe wandering and elopement indicators upon admission, readmission, change in condition, quarterly and with any unsafe wandering or elopement event utilizing the Elopement Risk Evaluation; -During the admission and readmission process a care plan will be initiated by the admitting nurse on any residents assessed with unsafe wandering or elopement behaviors; -Associates will be provided unsafe wandering and elopement training upon hire, annually and as indicated by the Unsafe Wandering and Elopement Performance Improvement Plans (PIPs); Elopement drills will be conducted at least quarterly. Review of Resident #1 admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, gastroesophageal reflux disease (GERD, acid reflux), renal failure, diabetes, hyperlipidemia (high lipids in the blood), stroke, dementia, seizure disorder, and malnutrition; -Substantial/maximum assistance required for mobility; -Uses walker and wheelchair; -No physical or verbal behaviors; -Wandering behavior not exhibited. Review of the resident's admission elopement assessment, dated 11/28/24, showed the resident was not an elopement risk. Review of the resident's care plan, updated 12/17/24, showed: -Focus: Resident risk for elopement. Disoriented to place, impaired safety awareness, stroke with cognitive deficits, does understand others and is able to make self-understood; -Goal: The resident's safety will be maintained; -Interventions: Assess for fall risk; Complete elopement risk assessment; Encourage to participate in activities to divert from exiting seeking behavior. Review of the facility's investigation, dated 12/17/24, showed: -Approximately 6:44 A.M., Registered Nurse (RN) A contacted the Administrator regarding Resident #1. He/She informed the administrator that Resident #1 had been cared for by his/her aide at approximately 6:20 A.M. He/She performed Activity of Daily Living (ADL) care and got resident dressed for breakfast and assisted him/her to the wheelchair next to his/her bed; -RN A stated approximately 6:30 A.M. he/she noted the resident was not in his/her room so they began to search other residents rooms, and the entire facility staff continued to search. Administrator contacted Director of Nursing (DON) approximately 6:47 A.M. to update on Resident #1. DON phoned Licensed Practical Nurse (LPN) B to search the outside premises. Charge nurse observed the patient adjacent to the building near generator area. LPN B stated no acute distress noted, patient was fully clothed, and current temp of 35 degrees Fahrenheit (F) outdoors on 12/17/24. Vital signs taken and skin assessment completed with no injuries noted at this time. Patient stated he/she was trying to get back home; -Through additional investigation, it was determined that the resident had walked down the hall while the aide and nurses were performing care. Resident #1 entered the dining room area which is closed due to COVID -19 restrictions. He/She then proceeded to enter the exit corridor area by the kitchen where he/she exited the building. He/She was observed roughly 30 feet from the building away from this door near the generator area on the ground; -Approximately 10:35 A.M., upon assessment noted a hematoma (collection of blood under the skin caused by trauma) developing called to physician orders to send patient to hospital for Computed Tomography (CT) scan of the head. Daughter here at bedside. Transferred to for evaluation. Review of the resident's progress notes, showed: -On 12/17/24 at 8:57 A.M., while doing another resident's care, he/she came out, he/she noticed the resident's door was open and his/her door was to be kept closed because of residents' being COVID positive. Resident was last seen at the 6:00 A.M. round in his/her room. He/She went in to look and saw that the resident was not in the room and he/she immediately called for the Certified Nurse Aide (CNA) to begin looking for the resident. He/She thought he/she was in the bathroom but he/she was not. His/herself and the CNA began to search for resident and then the staff on the other hall. The nurse went outside in his/her car to cover the area, along with his/herself and several of the staff. LPN B got out of his/her car and saw something and realized it was the resident on the ground around 20 feet from the building. Rest of the staff was notified, a wheelchair was brought, and resident was assisted after active range of motion was applied. Inside resident was assessed for any bruising, skin tears, etc. none noted at this time. Family made aware. Physician made aware and DON made aware; -At 9:30 A.M., Nurse Practitioner (NP) here today to see resident. A full assessment was completed with normal findings, skin intact, no bruising, no scratches, no bumps, no open areas noted. Resident in room resting at this time. Vital signs within normal limits; -At 10:32 A.M., Writer place call to physician to report that a hematoma has raised on top of forehead. New order to send to emergency room (ER) for CT of head. Writer placed call to ER spoke to staff, gave report of resident, and he/she stated he/she will inform staff and await for his/her arrival. -At 10:34 A.M., Writer spoke to staff and informed them that ambulance was here and that the resident is a Elopement Risk and will let the team know, charge nurse informed 911 that resident was COVID positive when he/she placed call for resident to be transferred; -At 10:54 A.M., Resident sent to hospital for CT scan of the head. Family at bedside when Emergency Medical Service (EMS) arrived. Transferred to stretcher safely; -At 2:52 P.M., Writer informed oncoming charge nurse that resident is at hospital and upon return he/she will remain a one on one, this writer informed LPN. During an interview on 12/26/24 at 10:38 A.M., [NAME] C said he/she was told the resident got out of the kitchen door exit. He/She was there at the time, but he/she did not see or hear anything. During an interview on 12/26/24 at 10:40 A.M., Dietary Aide D said he/she was working in the kitchen at the time. He/She heard the kitchen door click. He/She did not think anything of it because employees go through the door. [NAME] C and a second dietary aide were working in the kitchen at the time. It occurred between 6:00 A.M. and 7:00 A.M. He/She did not open the door that morning or disable the door alarm. During an interview on 12/26/24 at 10:45 A.M., [NAME] C said if the door alarm is off, they can go through the door. They did not have any deliveries the morning of the elopement. He/She did not remember turning off the alarm. The delivery days are Mondays and Thursday. [NAME] C and surveyor checked the date of the elopement and confirmed it was a Tuesday morning. [NAME] C said it was possible the alarm was off and door was unlocked from the day before. They have been in-serviced. Observation and interview on 12/27/24 at 4:00 P.M., showed the door was locked and the alarm on. The red alarm box was also in place and armed. The door was pushed open and the red box alarm sound. The alarm was loud and could be heard inside the kitchen. The exit door opened outside to back of the facility. There are two large generators outside the door on the right side. There is a sidewalk/walkway on flat concrete that stretches approximately 45 feet until a slight curve where there was a wall, creating a blind spot to the exit door. The administrator said the resident was found on the ground behind the wall. Staff drove around the facility in their car and found the resident. During an interview on 12/27/24 at 3:55 P.M., the administrator said staff did 1:1 additional education for the dietary staff. He was aware the door may have been unlocked. The cook had a delivery the previous night and the door was not secured. They have added an additional alarm. It is a red box alarm. It is an additional layer. He would expect staff to ensure doors are closed and checked every shift and to set the alarm. If staff hear the alarm, they are expected to respond to it. If a resident goes through the first alarm, redirect to safety, report to nurse, and document. MO00246776

Based on interview and record review, the facility failed to ensure the rights of one resident of four sampled residents, for unrestricted visitation, when the facility prevented the resident's relative from visiting the resident due to an allegation of the relative being unruly and having erratic behavior. The facility also failed to provide alternate methods of visits via a private setting, room, or by video teleconferencing platform (Resident #1). The census was 77. Review of the facility's policy Locking Entrance and Perimeter Doors: After-Hours visitors policy, revised 07/21/23, showed: -The resident has a right to receive visitors of his or her choosing at the time of his or her choosing; -The facility must provide immediate access to a resident by immediate family and other relatives of the resident; -The facility must provide immediate access to a resident by others who are visiting with the consent of the resident. Review of the facility's policy titled, Area of Focus: Resident Rights, effective 11/27/2023, showed federal and state laws guaranteed certain basic rights while residing in a Long-Term-Care facility. The facility and its associates have the responsibility for ensuring these rights are always upheld the resident is in their care. Centers for Medicare & Medicaid Services outlines at least 48 rights the resident has that span a wide range of topics. -Resident Rights-The resident has a right to a dignified existence, self-determination, and communication, with and access to persons and services inside and outside the facility; -The facility must protect and promote the rights of the resident; -The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States; -The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility; -The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility and the exercise of his or her rights as required under this subpart. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/27/24, showed the following: -Cognitively intact; -Total dependence for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene; -Upper and lower extremity impairment on one side of the body; -No mobility devices used; -Diagnosis include anemia (low blood count), high blood pressure, diabetes, expressive aphasia (unable to speak words), stroke, hemiplegia (paralysis on one side of the body), seizure disorder or epilepsy (uncontrolled shaking) and depression. Review of the resident's progress notes, showed the visitor was the resident's relative. Review of the incident/police report, dated 3/12/24, showed officers were dispatched on 3/12/24 at 2:25 P.M. The family member was in the room with the resident. No physical altercation at this time. Review of the facility's Notice of Trespass and Notice of No Trespass and No Contact, dated 3/13/24 issued via certified mail and process server, showed the facility prohibited the relative from being on or in the parking lot, common area, buildings, or residences owned or managed by Bridgeton Medical Investors LLC. Resident does not have the right to revoke this notice of trespass. Review of the resident's care plan, dated 4/4/24, showed the following: -Limited extremity use to right upper and lower extremity; -Communication problem related to expressive aphasia; -At risk for increased depression; -The care plan did not show any documented reason for the relative's restriction inside the facility. Review of the resident's electronic medical record (EMR), showed: -No documentation or progress notes, by Social Services, nursing staff, or Administration of the allegations of aggression towards staff; -No documentation of alternative visitation accommodations; -No documentation of court order records prohibiting visitation to the facility. During an interview on 5/21/24 at approximately 7:00 A.M., the resident expressed it had been 3 months since he/she has seen his/her relative. Other people are allowed to visit, but not this relative. At 9:00 A.M., the resident expressed by nodding his/her head that he/she did want to see his/her relative and that he/she was sad because his/her relative had not been in to see him/her. During an interview on 5/21/24 at 12:20 P.M., the Administrator and Assistant Director of Nurses (ADON) said the family member was restricted due to cases on casenet for stalking patterns. The Administrator said the relative could not follow boundaries. The deal breaker was when when he/she was found under a resident's bed. He/She was asked to leave, and a police report was done. The lawyers got involved and it was discovered this was a pattern that existed out in the community before the resident came to the facility. During an interview on 5/22/24 at 7:04 A.M., the Corporate Nurse said they can arrange for the resident to visit with his/her relative if he/she chooses to do so. The use of tablets and other forms of electronics can be used if a family member is physically unable to be on campus. The facility will provide electronic access. The resident had not expressed he/she wanted to visit with his/her family member. During an interview on 5/22/24 at 10:40 A.M., the Administrator and ADON said they expected leadership to follow the process to have family members barred from the facility and document that process. Staff should inform the resident if his/her family member had been banned from the facility. Residents have the right to receive visits or visitors while in the facility. Documentation should be charted if a resident family member had threatening behavior. Leadership should have several documented conversations with an individual accused prior to them being restricted from facility. MO00235918

Based on interview and record review, the facility failed to develop and implement policy and procedures to prevent abuse and neglect neglect of residents and prevent misappropriation of resident property when the facility continued to employ staff member, Certified Nurse Aide (CNA) A who was listed on the Employee Disqualification List (EDL, a listing of individuals disqualified from working in a certified home) indicating he/she was ineligible to work in a certified long-term care facility. CNA A was hired on 12/17/14, put on the EDL list on 8/13/20 with a disqualification length of six years, and terminated from the facility on 1/12/24. The census was 74. The administrator was notified on 2/20/24, of the past non-compliance. Upon discovering CNA A was on the EDL on 1/12/24, the facility took him/her off the schedule. An audit of all current employees' background checks was completed on 1/12/24. The facility also requested their pre-hire criminal background check vendor to complete quarterly background checks on all active employees. The deficiency was corrected on 1/12/24. Review of the facility's Abuse and Neglect policy, reviewed 11/27/23, showed: -What: To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hard line, zero-tolerance approach to resident abuse. Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone; -Why: F606 Not Employ/Engage Staff with Adverse Actions. The facility must not employ or otherwise engage individuals who: Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of abuse, neglect, exploitation, misappropriation of property or mistreatment of resident property; -How: The facility has procedures in place to provide protection for the health, welfare and rights of each resident residing in the facility. These procedures include, but are not limited to: -Screening; -Identification; -Training; -Prevention. Review of CNA A's employee file, showed: -Pre-hire EDL check: 12/15/14; -Date of Hire: 12/17/14; -Date of Termination: 1/12/24; -No other background check documentation. Review of the EDL Active Report, showed: -CNA A's name and Social Security Number; -Added: 8/13/20; -Removed: 8/13/26; -Ordered Length: 6 years. During an interview on 2/20/24 at 11:36 A.M., the Administrator said she was alerted on 1/12/24 the facility should run routine background checks, including the EDL. She did not know this process should have been in place. They completed checks for all active employees and CNA A's EDL results showed he/she was on the list. The Administrator told CNA A he/she would be taken off the schedule and could not come back to work until he/she had resolved the EDL issue. CNA A never returned. During an interview on 2/20/24 at 12:48 P.M., the AP/Payroll Coordinator said she'd been in that position since 2021. She knew she needed to run background checks prior to hiring an employee, but did not know they needed to be completed routinely. She has since been educated and planned to do them quarterly. During an interview with the Administrator and Corporate Representative on 2/20/24 at 1:55 P.M., the Administrator said she was not aware screenings needed to be completed post-hire. She understood they were needed to ensure staff were not on the EDL. She was responsible to make sure routine screenings were completed. The Corporate Representative said they would have the vendor used for pre-hire background checks begin running quarterly background checks for all active staff. -

Based on record review and interview, the facility failed to ensure that residents' transfer and discharge information was communicated to the Regional State Ombudsman for one resident (R)129 of five residents sampled for hospitalization. Findings include: Interview on 01/03/24 at 1:36 PM, the Regional Ombudsman revealed that she had not received transfer/discharge notices from the facility for several months. Review of R129's admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed the resident was discharged from the facility on 08/29/23. Additional review of the resident's EMR failed to reveal any documentation of discharge information being sent to the Ombudsman. Interview on 01/04/24 at 9:30 AM with Registered Nurse (RN) 1 revealed that she completes a transfer/discharge record and gives a copy of the record to the Social Services Director (SSD) who sends that information to the Ombudsman. Interview on 01/04/24 at 10:00 AM, the SSD stated he did not know it was his responsibility to send transfer and discharge notifications to the Ombudsman. Interview with the Executive Director and the Director of Nursing (DON) on 01/04/24 at 11:10 AM revealed that it was the responsibility of the SSD to send copies of the facility's transfers and discharges to the Ombudsman. Both the Executive Director and the DON were unaware that none the residents' transfers and discharge notices had not been sent to the Ombudsman.

Based on record review, interview, and facility policy review, the facility failed to ensure two (Residents (R) 18 and R29) of two residents reviewed for Pre-admission Screening and Resident Review (PASARR) (an assessment performed to determine underlying mental health issues) had a Level I PASARR completed as required to determine if the residents require additional assessment and PASARR level II completion Findings include: Review of the facility policy titled, Pre-admission Screening and Resident Review revised on 09/25/23 revealed, The facility will ensure that potential admissions are be (sic) screening for possible serious mental disorders . The policy further indicated, Procedure 1. Ensure Level I PASARR has been completed on potential admissions prior to admission. Further review of the policy revealed, A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to a nursing facility. Review of R18's Facesheet located in the electronic medical record (EMR), under the Census tab, revealed an admission date of 12/23/22 with diagnoses including anxiety disorder and schizoaffective disorder. Review of R18's complete medical record revealed no evidence of a PASARR I. Review of R29's Facesheet located in the EMR, under the Census tab, revealed an admission date of 12/01/22 with diagnoses including bipolar disorder, psychotic disturbance, anxiety, and mood disturbance. Review of R29's complete medical record revealed no evidence of a PASARR I. An interview conducted with the Executive Director and the Regional [NAME] President on 01/05/24 at 9:51 AM confirmed the facility failed to provide evidence of a completed PASARR Level I prior to the R18's and R29's readmission or previous admissions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and document review, the facility failed to provide Activities of Daily Living (ADLs) to residents unable to carry out the necessary service for two (Resident (R) 20 and R24) of two residents reviewed for personal hygiene. Specifically, the facility staff failed to provide showers and/or bed baths to R20 and R24 twice per week. Findings include: Review of R20's Face Sheet located in electronic medical record (EMR) under the Profile tab, revealed the resident was admitted on [DATE] with a diagnosis of chronic respiratory failure. Review of R20's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 11/06/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R20 was cognitively intact. Further review of this MDS revealed R20 was totally dependent upon staff for assistance with bathing. During an interview on 01/02/24 at 10:54 AM, R20 stated he was supposed to get bed baths two times and week but has not been getting them. Review of the facility's Shower Schedule revealed R20's shower days are scheduled for Tuesday and Fridays. The certified nursing assistant (CNA) Bath sheet/Skin Check revealed resident had a bed bath on 12/12/23 and again on 12/22/23. No additional bed baths or showers were documented for the remainder of the month of December. Review of R24's Face Sheet located in the EMR under the Profile revealed the resident was admitted on [DATE] with a diagnosis of dysphagia. Review of R24's quarterly MDS, located in the EMR under the MDS tab, with an ARD of 11/17/23, revealed a BIMS score of 15 out of 15 indicating R24 was cognitively intact. Further review of this MDS revealed R24 was totally dependent upon staff for assistance with bathing. During an interview on 01/02/24 at 12:43 PM, R24 stated she does not receive showers on a regular basis. Review of the facility's Shower Schedule revealed R24's shower days are scheduled for Monday and Thursdays. The CNA Bath Sheet/skin check revealed resident refused on 12/18/23 and received a bed bath on 12/29/23. No additional bed baths or showers were documented for the remainder of the month of December. During an interview on 01/03/24 at 04:37 PM, the Director of Nursing (DON) stated, CNA's have a shower schedule they use which identifies by room number what days residents are scheduled for shower. The DON would not confirm that R20 and R24 did not receive showers as required and no other documentation was presented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy, the facility failed to ensure that one resident (R)8 of two residents with an indwelling urinary catheter was secured to the resident's thigh to prevent trauma to the resident urethra and failed to position for the urinary drainage bag to allow for adequate drainage and prevent contamination. The failure has the potential to contribute to reoccurrence of urinary tract infections for this resident. Findings include: Review of the facility policy titled Indwelling Catheter (Foley) Management) revised 08/24/23 indicated Keep the catheter and collecting tube free from kinking. b. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter; and securing the catheter to facilitate flow of urine, preventing kinking of the tubing . Observation 01/03/24 at 10:30 AM revealed R8 had an indwelling urinary catheter connected to a drainage bag that was touching the floor. Observation on 01/03/24 at 2:45 PM revealed R8's indwelling urinary catheter was not secured to his thigh. Review of R8's admission Sheet located in the electronic medical record (EMR) section Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury and quadriplegia. Review of R8's Significant Change Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 12/21/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating the resident was severely cognitively impaired. During an interview on 01/03/24 at 4:30 PM, Registered Nurse (RN)1 stated the resident's catheter should not be touching the floor due to the potential for the resident to be exposed to infection. RN1 confirmed the resident's catheter was not secured to his thigh to prevent the catheter from becoming dislodged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to ensure resident's medical record reflected the resident's accurate weight for one (Resident (R) 20) of five residents reviewed for nutrition. Findings include: Review of facility policy titled Weights and Heights revised August 2023, indicated All residents are weighed within 24 hours of admission and weekly for 4 weeks and as needed thereafter Review of R20's Face Sheet located in electronic medical record (EMR) under the Profile tab, revealed the resident was admitted on [DATE] with a diagnosis of chronic respiratory failure. Review of R20's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) date of 11/06/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R20 was cognitively intact. Review of R20's Weights located in the EMR under the Weights and Vitals tab revealed resident's weight on 10/25/23 was 387.8 pounds and on 12/06/23 was 288.6 pounds. During an interview on 01/03/23 at 2:44 PM, the Executive Director and Director of Nursing (DON) revealed the weight listed in R20's chart was inaccurate due to lack of calibrated scales. During an interview on 01/04/24 at 10:06 AM, the Registered Dietician (RD) stated she was aware of the inaccuracy and the inconsistency of the residents' weights. The RD stated the issue had been discussed with administration.

Based on observations, interviews, and review of facility policy, the facility failed to maintain a clean and home-like environment for residents in the facility's common areas and in resident rooms. Specifically, six of six residents (R)8, R25, R29, R46, R59, and R68) that receive enteral feeding had residue buildup on the feeding pump and feeding tube pole; debris under R1's bed; R1, R10 and R49's over bed tables had peeling veneer around the edges; R4 and R12's footboard on their beds were loose; R8's specialty mattress had yellow and brown stains and torn covering; R12's drawer in the resident's nightstand was off the track; R59's room had dried beige residue on the floor next to the resident's tube feeding pole and six residents (R8, R25, R29, R46, R59, and R68) receiving enteral feeding had dried beige; brown splatter on the feeding pump and intravenous (IV) poles and, the upholstered chairs and a couch in the lobby area were stained and in need of cleaning. Findings include: Review of facility policy titled, Daily Room Cleaning with a revision date 07/19/23 indicated The cleanliness of each resident's room is maintained daily by the housekeeping staff to provide a fresh, clean, and sanitary environment and reduce the potential for nosocomial infections Observations during the initial tour on 01/02/24 at 10:00 AM revealed the following: R 1's room had trash and paper under the resident's bed. R1, R10 and R49's over bed tables had peeling veneer around the edges. R4 and R12's footboard on their beds was loose. R8's specialty mattress had yellow and brown stains and had a lengthwise tear in in the mattress that covered half of the mattress. The floor by the head of R8's bed had dried light brown formula residue. R10's overbed table had a splintered wood frame. R12's drawer in the resident's nightstand was off track. R59's room had dried beige residue on the floor next to the resident's tube feeding pole. During an interview on 01/02/24 at 10:00 AM, R4 revealed the board at the foot of her bed had been loose for some time. Resident stated that she had been asking for someone to repair the bed with no response. During an observation on 01/03/24 at 12:30 PM, the common seating area had two upholstered chairs and an upholstered couch. One of the chairs was heavily stained and had a baseball size area of white dried debris. The other upholstered chair and the couch were heavily soiled with dried spills and stains. During an interview on 01/03/24 at 12:42 PM, the Executive Director (ED) confirmed the presence of the stains and debris, and confirmed the surface appeared unclean to sit upon. The ED stated the room was used by residents and that the soiled chairs and couch were not homelike. Review of R4's Quarterly Minimum Data Set (MDS) located in the electronic medical record (EMR) under the MDS tab with an Assessment Reference Date (ARD) of 11/25/23 revealed a Brief Interview for Mental Statues (BIMS) score of 15 out of 15 indicating that R4 was cognitively intact. During an observation on 01/03/24 at 10:45 AM, on the 200 unit, revealed the following: six residents (R8, R25, R29, R46, R59, and R68) who received enteral feeding had dried beige and brown color splatter on the feeding pump and intravenous (IV) poles. During an observation and concurrent interview on 01/04/24 at 3:45 PM, Licensed Practical Nurse (LPN)2 confirmed R8's specialty mattress was in disrepair, and the residue buildup on R8's feeding pump. Interview on 01/05/24 at 4:45 PM, the Maintenance Director revealed that he makes environmental rounds on a weekly basis, however he did not identify any of the concerns that have been brought to his attention during this survey. The Maintenance Director acknowledged that most of the residents' furniture was in disrepair. During an interview on 01/06 24 at 3:37 PM, the Executive Director revealed the environmental rounds are conducted weekly. However, the Executive Director stated that she never identified any concerns during the environmental rounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to serve food that was palatable. This failure affected five residents (R20, R42, R54, R48 and R39) who consume the fish from the kitchen. Findings include: Review of the undated facility policy titled Food and Nutrition Services, revealed, The facility provides each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. During initial screening on 01/02/24 at 10:54 AM, R20 complained the food was hard to eat and cold. Review of R20's Face Sheet located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted on [DATE]. Review of R20's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/06/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R20 was cognitively intact. During initial screening on 01/02/24 at 12:43 PM, R24 complained about the food being cold and too hard to eat. Review of R24's Face Sheet located in the EMR under the Profile tab, revealed the resident was admitted on [DATE]. Review of R24's quarterly MDS, located in the EMR under the MDS tab with an ARD of 11/17/23 revealed a BIMS score of 15 out of 15 indicating R24 was cognitively intact. On 01/04/24 at 01:08 PM, a test tray was sampled with the Food Service Director (FSD). When attempting to put the thermometer into the fried fish, the surface of the fish was so hard that the thermometer would not initially go into the fish. The FSD was finally able to get the thermometer into the fish and the temperature was 112 degrees Fahrenheit. The FSD confirmed the fish was too hard to eat. During the group meeting on 01/04/24 at 2:06 PM, 11 residents attended. When asked about the residents' lunch, four of the residents (R42, R54, R48, and R39) stated the fish was too hard to eat. Review of R42's Face Sheet located in the EMR under the Profile tab revealed an admission date of 01/01/20. Review of R42's quarterly MDS located in the EMR under the MDS tab with an ARD of 10/16/23 revealed a BIMS of 13 out of 15 which indicated R42 was cognitively intact. Review of R54's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed an admission date of 03/31/23. Review of R54's quarterly MDS located in the EMR under the MDS tab with an ARD of 11/11/23, revealed BIMS score of 10 out of 15 which indicated R54 was moderately cognitively impaired. Review of R39's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed an admission date of 07/23/19. Review of R39's quarterly MDS located in the EMR under the MDS tab with an ARD of 11/12/23, revealed BIMS score of 14 out of 15 which indicated R39 was cognitively intact. Review of R38's Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed an admission date of 01/12/22. Review of R38's quarterly MDS located in the EMR under the MDS tab with an ARD of 10/25/23, revealed BIMS score of 15 out of 15 which indicated R38 was cognitively intact.

Based on observation, interview, and policy review, the facility failed to ensure staff were wearing hair restraints in accordance with facility policy while serving food to the residents during one of four meal observations. Findings include: Review of the facility policy titled, Sanitation and Maintenance, revised on 04/06/23, revealed, The Director of Food and Nutrition Service is responsible for ensuring that the department is maintained according to the standards of sanitation and in compliance with the federal .requirements. During an observation on 01/02/24 at 12:35 PM, the Food Service Director (FSD) and Infection Preventionist (IP) were observed in the kitchen with a bouffant cap on the top of their head with their hair exposed from under the cap, while serving food and condiments to the residents during meal tray line service. Interview on 01/02/24 at 12:35 PM with IP confirmed her hair was not covered completely while assisting with meal service. Interview on 01/02/24 at 7:22 PM, the FSD revealed, It is important to have all of your hair covered not just the top, none should be hanging down. The FSD confirmed her hair was not completely contained in her cap.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, manufacturer's guidelines review and policy review, the facility failed to disinfect the glucometer between residents' uses as directed by the glucometer's manufacturer's instructions and facility policy for two residents (Resident (R) 44 and R52) of eight residents who received blood glucose monitoring. The facility's practice of inadequate cleaning of the glucometer between residents use places residents with blood glucose monitoring at risk for blood borne illnesses. Additionally, the facility staff failed to don a face mask or goggles when entering a COVID positive resident's (R130) room; failed to perform hand hygiene when passing trays between 11 resident rooms; failed to maintain a clean environment for one of one laundry room; four of four pill crushers were soiled with residue buildup; lift chairs on two of two units had dirt on the metal base of the chairs; bladder scan machine had dust and dirt on the screen and machine. Findings include: 1. Review of the facility policy, Cleaning and Disinfection of the Glucometer revised on 08/03/21, revealed an EPA [Environmental Protection Agency] registered disinfectant is to be used and specifically 5. Cleaning .Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette 6 Disinfecting- Obtain a second EPA-registered disinfectant wipe/towelette . The policy further indicated, Wipe the entire surface of the meter 3 times horizontally and three times vertically to remove blood-borne pathogens. Review of the User's Guide for Assure Prism glucometer revealed the glucometer is to be cleaned EPA registered disinfectant and directs that alcohol wipes are not an EPA registered disinfectant. During an observation and interview on 01/04/24 at 8:10 AM, Registered Nurse (RN)1 was observed exiting R44's room after performing blood glucose monitoring. RN1 was observed obtaining an alcohol wipe from the top drawer of the medication cart and wiped the glucometer. RN1 then proceeded to R52's bedside and performed blood glucose monitoring with the same glucometer used for R44. RN1 confirmed the glucometer was cleaned with an alcohol wipe between uses for the two residents. RN1 stated she was trained to clean the glucometers with alcohol wipes. During an interview on 01/04/24 at 8:30 AM, Licensed Practical Nurse (LPN) 2 stated the glucometer was to be cleaned with an alcohol wipe between residents' use. Interview with LPN3 on 01/04/24 at 8:35 AM, LPN3 stated to use an alcohol wipe to clean the glucometer between residents' uses. Interview on 01//04/24 at 10:10 AM, the Director of Nursing (DON) stated alcohol wipes are not to be used to clean the glucometer, and that staff should be using the Bleach Sani-Cloths, which are available on the medication carts, to disinfect the glucometer between residents' uses. 2. During an interview on 01/04/24 at 10:25 AM, the Infection Control Preventionist (IP) stated that new admissions that test positive for COVID are placed on droplet/contact isolation for 10 days. The IP further stated that staff are expected to perform hand hygiene upon entering and exiting the resident's room. During an observation on 01/06/24 at 10:00 AM, R130, admitted to the facility on [DATE], was placed on Droplet/Contact Precautions due to testing positive for COVID one day after admission. Signage on the resident's door indicated: Perform hand hygiene. [NAME] isolation gown, N95 face mask; face shield or goggles and gowns . The isolation cart outside the resident's room contained isolation gowns, gloves, N95 face masks, and shoe coverings. The cart did not contain face shields or goggles. During an observation on 01/06/24 at 12:15 PM, CNA4 was observed entering R130 to pass a meal tray. CNA4 did not perform hand hygiene before donning gown and gloves. CNA4 did not don a face shield or goggles before entering the resident's room. During an interview on 01/06/24 at 12:30 PM, Certified Nursing Assistant (CNA)4 acknowledged that she did not perform hand hygiene before entering the room and did not wear a face shield or goggles while in the resident's room. CNA4 stated there were no face shields or goggles on the isolation cart. 3. Review of facility policy titled Hand Hygiene revised 06/23/23 indicated part .The hand hygiene procedures to be followed by staff involved in direct resident contact. Before and after contact with the resident, After contact with blood, body fluids, or visibly contaminated surfaces; After contact with objects and surfaces in the resident's environment. After removing personal protective equipment (e.g., gloves, gown, eye protection, facemask); and. Before performing a procedure such as an aseptic task (e.g., insertion of an invasive device such as a urinary catheter, manipulation of a central venous catheter, and/or dressing care . During an observation on 01/04/24 at 5:41 AM, CNA2 was carrying a bag soiled linen to the dirty utility room, dropped off the linen and immediately exited the room. CNA2 did not perform hand hygiene after leaving the soiled linen in the soiled utility room. CNA2 stopped to talk to another staff member and then proceeded to R1s room to answer the resident's call light. During an observation on 01/04/24 at 5:47 AM, CNA1 was carrying a bag of soiled linen to the dirty utility room. After leaving the soiled linen in the soiled utility room CNA1 was observed to go into dayroom, retrieve a personal water bottle. CNA1 did not perform hand hygiene and proceeded to R228's room to provide care. The CNA donned a pair of gloves upon entering the room but did not perform hand hygiene. During an interview on 01/04/24 at 6:05 AM, CNA1 stated that hand hygiene should be performed after handling soiled linen. During an observation on 01/04/24 at 8:05 AM, RN1 was observed passing breakfast trays on the North unit. RN1 passed breakfast trays from room [ROOM NUMBER] to room [ROOM NUMBER] without performing hand hygiene between rooms. When RN1 entered the residents' rooms she arranged items on residents' overbed table, set up the meal tray, and assisted the residents in positioning them to be able to sit upright when eating. During an interview on 01/04/24 at 10:25 AM, the IP stated that it was the expectation that staff perform hand hygiene between resident contact. The IP stated hand hygiene should be done before handling the residents' meal trays. The IP stated hand hygiene should also be performed when handling residents' soiled linen. During an interview on 01/04/24 at 2:20 PM, RN1 revealed that she failed to perform hand hygiene while passing breakfast trays that morning. 4. Review of facility policy titled Daily Laundry Room Cleaning revised 12/05/23 indicated .The facility promotes the cleanliness of the laundry room, provides a clean and fresh environment for residents, visitors and staff, and reduces the potential for infection control issues by adhering to a daily laundry room cleaning regimen .Remove all lint from lint traps .Using the duster start a one side of the room and work your way around the room dusting every ledge, light and vent. Use facility approved cleanser and pad to scrub sink and wipe dry. Sweep up dust and dirt debris . During tour of the laundry room with the Housekeeping Supervisor on 01/05/24 at 2:45 PM, the following was observed: 1. There were three washing machines in the laundry room, and all had dirt and trash (paper towels, old remote unit, and used wrappers). on top of the washer. One of the washing machines also had residue and rust along the door of the machine. 2. The eye wash station located in the soiled section of the laundry had yellow green liquid sediment in the bottom of the bowl. 3. The sink had signage Do Not Use; the sink was covered with brown dirt and grime. The stainless sink was covered with white dried residue. 4. There were cobwebs on the pipes in the laundry room's soiled side. Trash was on the floor in the soiled section of the laundry room. During an interview on 01/05/24 at 3:15 PM, the Maintenance Assistant/ Housekeeping Supervisor (MA) stated the laundry areas was not clean and that the dayshift staff person was responsible for cleaning the area. The MA stated the sink in the dirty laundry area and the eye wash station required repair. 5. Review of facility policy titled Cleaning and Disinfection of Non-Critical Patient Care Equipment revised 06/03/23 indicated .Equipment will be cleaned and disinfected prior to storage. All other equipment that is not clean or cannot be cleaned immediately after use shall be placed in the soiled utility room until cleaned .Any equipment that cannot be identified as clean or soiled should be presumed dirty, and the complete cleaning process should be performed. Then, the equipment should be stored in appropriate location . During an observation on 01/04/24 at 5:50 AM, four of four pill crusher units had residue buildup along joints and dust on the vents located on the back of the pill crushers units. During an observation on 01/04/24 at 6:15 AM two resident lift chairs on the North unit had dirt and residue buildup on the metal base part of the stand. Two pill crushers had residue buildup along joints and vents of the unit. During an observation on 01/04/24 at 6:30 AM, a bladder scan machine on the South unit had dust and dirt on the monitor screen, on the frame and base of the machine. Two pill crushers had dirt and dust. The lift chair had dirt and dust on the framework. During an interview on 01/04/24 at 6:30 AM, RN2 revealed that she did not know if there was a cleaning schedule for the resident care equipment like the chair lifts. RN2 observed the bladder scan machine and the pill crushers and confirmed they needed to be cleaned. During an interview on 01/04/24 at 1:15 PM, the DON revealed there was a cleaning schedule for the resident care equipment. The DON stated the night shift was responsible for cleaning the resident care equipment. The DON stated any staff member can clean the resident care equipment they observe needs cleaning. During an interview on 01/05/24 at 4:45 PM. the Maintenance Director stated he was not aware of the schedule for cleaning the resident care equipment. The Maintenance Director stated he occasionally cleans wheelchairs and lift chairs when requested.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the scales were in proper working condition for two of two scales in the facility. Findings include: Review of R20's Face Sheet located in electronic medical record (EMR) under the Profile tab, revealed the resident was admitted on [DATE]. Review of R20's Weights located in the EMR under the Weights and Vitals tab revealed resident's weight on 10/25/23 was 387.8 pounds and on 12/06/23 was 288.6 pounds. During an interview on 01/03/23 at 2:44 PM, the Executive Director (ED) revealed that it was noticed in October 2023 that the scales needed to be calibrated. During an interview on 01/04/24 at 10:06 AM, the Registered Dietician stated the scales were not calibrated which caused the resident's weights to be documented incorrectly. During an interview on 01/06/24 at 9:26 AM, the Director of Nursing (DON) revealed the facility had been without scales to weigh residents since October 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow acceptable nursing standards when facility staff failed to check the Pyxis (a machine that has some medications available, to use when medication is not available from the managing pharmacy in sufficient time to prevent risk of harm to the patient that might result from a delay in obtaining such drug) to ensure one resident received his/her medication per physician orders (Resident #6) and failed to ensure one resident went out for his/her post-operative (post-op, after surgery) follow up appointment (Resident #3). The sample was 11. The census was 72. Review of the facility's Administration of Medications Policy, dated reviewed 8/25/22; showed it did not address what staff should do if a medication was unavailable. 1. Review of Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/17/22, showed: -Cognitively intact; -No behaviors and no rejection of care; -Diagnoses included fractures, atrial fibrillation (irregular heart rhythm) or other dysrhythmias (heart beat that has an abnormal speed or rhythm). Review of the facility's Pyxis list of medications, dated 7/19/22, showed: -Enoxaparin (blood thinner) 40 milligrams (mg)/0.4 milliliters (mL) syringe listed as a medication that was available. Review of the progress notes, dated 11/28/22 at 9:25 P.M., showed the nurse went into resident's room to explain to him/her that the Enoxaparin injection had to be reordered and he/she had done this. Upon entry, the resident was on a call. The nurse stated that he/she would return. The nurse got busy and didn't immediately return to resident's room. The resident came down to the nursing station and asked who was supposed to give the injection, the nurse explained that he/she was responsible to give injection. The injection wasn't available (in) and had been reordered and he/she would leave a note for the morning staff to administer injection as soon as possible. Review of the order summary report, dated 12/1/22 , showed an order for enoxaparin sodium solution prefilled syringe 40 mg/0.4 mL, inject 40 mg subcutaneously (under the skin) once daily for prophylaxis until 12/23/22. The start date was 11/19/23. During an interview on 12/1/22 at 2:23 P.M., the resident said he/she usually gets his/her injection in the evening. The other day, a staff member came into his/her room and gave him/her his/her medications but did not give the injection. It was around 9:30 P.M., when he/she realized he/she had not received the injection. The resident went to the nurse's station to ask for his/her injection and the nurse told him/her there were no more injections and he/she would leave a note for the next shift to give the injection when it comes in from the pharmacy. During an interview on 12/2/22 at 11:28 A.M., Registered Nurse (RN) A said if a medication was not available, he/she would check the Pyxis to see if the medication was available and if the medication was available, he/she would pull the medication and administer it. During an interview on 12/2/22 at 1:04 P.M., Licensed Practical Nurse (LPN) B said if a medication was not available, he/she would check the Pyxis to see if the medication was available. If the medication was available, he/she would pull the medication and administer it. If the medication was not available, he/she would document the medication was not available, reorder the medication from the pharmacy and notify the medical doctor (MD). During an interview on 12/5/22 at 12:31 P.M., the Director of Nursing (DON) said if a medication was not available, she expected staff to reorder the medication and to check to see if the medication was available in the Pyxis. If the medication was not available, she expected staff to notify the MD. Agency staff do not have access to the Pyxis, so she expected agency staff to ask a house nurse to check the Pyxis. On 11/29/22, the DON was made aware the resident did not receive his/her injection. The DON notified the MD and made sure the medication had been reordered. Once the medication came in, the injection was administered. 2. Review of Resident #3's admission MDS, dated [DATE], showed: -Cognitively intact; -No behaviors and no rejection of care; -Resident had a surgical wound and received surgical wound care. Review of the After Visit Summary, dated 5/29/22 through 6/10/22, showed: -Your discharge diagnosis was: osteomyelitis (inflammation of bone and bone marrow) of second toe of left foot; peripheral vascular disease (PVD, poor circulation); -Your next steps, go to post-op office visit on 6/21/22. Review of the progress notes, dated 6/10/22 through 6/23/22, showed: -On 6/10/22 at 7:44 P.M., patient arrived on the unit at 5:40 P.M. and was admitted with a diagnosis of amputation of the second toe of the left foot. Patient had a dressing over the affected toe. Patient is alert and orientated times three (person, place and time); -No documentation the resident went out for his/her post-op appointment, the appointment was rescheduled and/or of resident refusing to go out for the appointment. During an interview on 12/2/22 at 11:28 A.M., RN A said when a resident is admitted to the facility, the nurse reviews the paperwork received from the hospital and enters the orders into the computer. If a resident had a doctor's appointment already scheduled, the nurse would write the information down on a sheet of paper and give it to the front desk for transportation. During an interview on 12/6/22 at 12:31 P.M., the DON said the process for a resident to go out for a doctor's appointment was the nurse would schedule the appointment, if needed and notify transportation. If the resident already had an appointment scheduled, the nurse would notify transportation. The DON said the resident did not go out for the appointment. She did not know why the resident did not go or if the appointment was rescheduled. The DON expected residents to go out for their follow up appointments as scheduled. During an interview on 12/6/22 at 9:45 A.M., the doctor's office representative said on 6/21/22, the resident was a no show for his/her appointment. The appointment was a post-op appointment. It is important for patients to come for their appointments because they recently had surgery and to manage the recovery process. MO00210599 MO00207394 MO00207371

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent staff neglect from occurring when a staff member transferred one resident (Resident #10) using a sit to stand lift (mechanical lift) without assistance. The resident required a Hoyer lift (mechanical lift) with assistance of two staff members for all transfers. The resident fell and sustained a hematoma (a collection of blood outside of blood vessels) to the back of his/her head. The sample was 20. The census was 82. Review of the facility's Protection of Residents: Reducing the Threat of Abuse & Neglect Policy, dated Revised: 1/21/19; Reviewed 4/15/19, showed: - Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone; -Residents must not be subjected to abuse by anyone. This includes but is not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals; - It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation; -Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person; -It is the policy of this facility to develop, implement, and maintain an effective training program on abuse prohibition including but not limited to the following topics: --Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property and exploitation, including sexual abuse; --Identifying what constitutes abuse, neglect, exploitation and misappropriation of resident property; --Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychosocial indicators; --Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; -The facility must: --Identify, correct and intervene in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur to include trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms, if any; --Assure that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which includes, but is not limited to, the provision of a facility assessment to determine what resources are necessary to care for its residents competently. --Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect, such as: ---Residents that require extensive nursing care and/or are totally dependent on staff for the provision of care. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/10/20, showed: -Brief Interview for Mental Status (BIMS, a brief screener of cognition) score of 12, indicating the resident was mildly cognitively impaired; -Hearing, adequate, no difficulty in normal conversation, social interaction; -Speech, ability to understand others: understands/clear comprehension; makes self-understood: understood; -Required extensive assistance from staff for bed mobility, transfers, toileting, dressing and personal hygiene and supervision with eating; -Required a wheelchair for mobility; -No falls since admission; -Diagnoses included high blood pressure, stroke, and end stage renal disease. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognition not assessed; -Hearing, adequate, no difficulty in normal conversation, social interaction; -Speech, ability to understand others: understands/clear comprehension; makes self-understood: understood; -Dependent on two staff for bed mobility, transfers and bathing; -Required extensive assistance from staff for toileting, dressing and personal hygiene and supervision with eating; -Required a wheelchair for mobility; -No falls since admission. Review of the resident's comprehensive care plan, in use at the time of the incident, showed: -Focus: Has an activity of daily living (ADL) self-care performance deficit related to residual cerebrovascular accident (CVA, stroke) effects; -Goal: Maintain current level of function requiring extensive/total assistance with ADLs through the review date; -Interventions: --Transfer: the resident is totally dependent on two (2) staff for transferring; --Transfers via Hoyer lift (initiated 12/11/18, revised 3/18/19); -Focus: Resident is at risk for falls. 7/27/20, the resident had a fall from a lift, hematoma noted to the back of the head, transferred to the hospital for observation; -Goal: Will not sustain serious injury requiring hospitalization through the review date; -Interventions: --Ensure that staff uses appropriate equipment for transfers (Hoyer lift), dated 7/28/20; --Mechanical lift, dated 12/11/18. Review of the resident's July 2020 and August 2020, physician's order sheet (POS), showed: -Fall precautions every shift for safety; -No order for Hoyer lift for transfers. Review of the resident's event nursing note, dated 7/27/20 at 7:45 P.M., showed: -Certified nurse aide (CNA) X presented to this nurse and reported that resident sustained a fall. This nurse presented to room and observed the resident lying in bed on back. CNA times 2 assisted resident to bed via gait belt transfer. Observation shows resident alert and oriented to baseline before incident. Resident sustained hematoma to the posterior right base of skull with abrasion to hematoma. Resident reports pain to area, yet denies as needed (PRN) analgesic upon administration request by this nurse. Further observation shows no other areas of skin concern. Neurological assessment initiated per facility protocol. Resident tongue is midline with demonstration request to resident by this nurse. Resident denies symptoms of nausea, vertigo (a sudden internal or external spinning sensation), nor ringing in the ears; -7:05 P.M., call placed to the resident's physician and reported incident, findings, interventions, neurological assessment, and resident present state. Orders received to send the resident to the hospital for evaluation and treatment; -7:08 P.M., call placed to emergency medical services (EMS) and reported orders for 911 dispatch to the hospital; -7:10 P.M., call to resident power of attorney (POA), this nurse spoke with spouse of POA. Spouse stated to this nurse that POA was in route to facility; -7:11 P.M., call placed to the Director of Nursing (DON) and reported incident, findings, interventions, resident present state, neurological assessments initiated per facility protocol, orders for discharge from the resident's physician; -7:10 P.M., POA arrived to facility this nurse reported incident to POA assessment findings, resident present state, orders to discharge to the hospital, DON notification and follow up assessments per facility protocol. POA verbalized understanding; -7:15 P.M., EMS transport times 2 present at facility for discharge. This nurse reported incident, assessment findings, interventions, resident present state, neurological assessment, current vitals. Resident transfer orders, code status, and medication orders sent with EMS; -7:28 P.M , EMS exited facility with resident. Review of the facility's undated Investigation Form, showed: -Department of Health and Senior Services (DHSS) notification: not applicable (NA); -Physician notified 7/27/20 at 7:05 P.M.; -Family member notified 7/27/20 at 7:10 P.M.; -Timeline: --7/27/20 at 7:11 P.M., the Administrator was contacted by the resident's Licensed Practical Nurse (LPN) whom stated the resident fell from sit to stand lift while being transferred by the assigned CNA. CNA X stated he/she was transferring the resident with sit to stand lift and resident let go. CNA X said he/she tried to stop him/her but he/she couldn't. The administrator asked CNA X what the resident's transfer ability was and he/she replied a Hoyer''. The CNA was then asked why he/she attempted to transfer the resident with a sit to stand lift. CNA X replied I don't know. The Administrator asked CNA X if he/she was aware of the facility policy when using a mechanical lift. CNA X immediately said yes, you use two people. The Administrator asked CNA X why he/she did not seek assistance with the transfer. CNA X said I didn't see anyone; --7/27/20 at 7:05 P.M., LPN W contacted the resident's physician and received an order to transfer the resident to the hospital via 911 due to the resident being on Eliquis (blood thinner); --7/27/20 at 7:08 P.M., LPN W called 911 and returned to the resident's room. The resident was on the phone with his/her family member; --7/27/20 at 7:10 P.M., the LPN called resident's family member with the number listed on the face sheet. A women answered the phone and said the resident's family member was on the way up there and hung up; --7/27/20 at approximately 7:15 P.M., EMS and the resident's family member arrived at the facility and the resident was transported to the hospital; --7/28/20 at 12:55 A.M., the resident returned from the hospital. -Conclusion or Findings: --CNA did not follow the resident's plan of care to transfer with a Hoyer lift transfer; --CNA admitted that he/she was aware and did not ask the nurse or other CNA for help; --Resident was sent out to hospital for further evaluation; -Corrective action taken by the facility: --The CNA was terminated and staff were re-educated on following resident specific plan of care/safety. Review of CNA X's undated written statement, showed: -He/she went into the resident's room to put him/her to bed; -The resident required a Hoyer lift for transfers but did not have a Hoyer lift pad under him/her; -CNA X hooked the resident up to the sit to stand lift to put the him/her in bed; -CNA X did not have a spotter and as he/she was lifting the resident, the resident let go of the lift; -CNA X tried to catch the resident to lower him/her to the ground; -In the process, the resident bumped his/her head on the wheelchair; -CNA X notified the nurse and transferred the resident to bed from the floor. Review of the facility's undated Investigation Summary, showed: -Resident is [AGE] year old with the original admission date of 1/21/2019; -He/she has multiple diagnosis including abnormal posture, angina (symptom of coronary artery disease, and feels like squeezing, pressure, heaviness, tightness, or pain in the chest), CVA and atrial fibrillation (A-fib,an irregular and often rapid heart rate) as well as several co-morbidities; -Resident is alert with mild confusion, and is able to make his/her needs known; -Requires assist with ADLs at moderate to maximum level; -Requires transfers per two staff and a Hoyer lift and utilizes a wheelchair for mobility; -On 7/27/20, 911 was contacted by the LPN W whom said the resident fell from a sit to stand lift while being transferred by CNA X. CNA X said he/she was transferring the resident with a sit to stand lift and resident let go. CNA X said he/she tried to stop him/her but he/she couldn't. The Administrator asked CNA X what the resident's transfer ability was and CNA X said a Hoyer''. CNA X was then asked why he/she attempted to transfer the resident with a sit to stand lift. CNA X replied I don't know. The Administrator asked CNA X if he/she was aware of the facility policy when using a mechanical lift. CNA X immediately said yes, you use two people. The Administrator asked CNA X why he/she did not seek assistance with the transfer. CNA X said I didn't see anyone. -LPN W contacted the resident's physician at 7:05 P.M., and received an order to transfer the resident to the hospital via 911 due to the resident being on Eliquis (an anticoagulant medication); -At 7:08 P.M., LPN W called 911 and returned to the resident's room. The resident was on the phone with her family member; -Resident did not have a change in his/her baseline neurological assessment, however, he/she did have an intact golf ball sized hematoma to the back of his/her head; -At 7:10 P.M., LPN W called the resident's family member with the number listed on his/her face sheet. A women answered the phone and said the family member was on his/her way up there and hung up; -At approximately 7:15 P.M., EMS and family member arrived that the facility and the resident was transported to the hospital; -Resident returned from the hospital at 12:55 A.M.; -Per hospital discharge summary, the resident's computerized tomography (CT, scan combines a series of x-ray images taken from different angles around your body and uses computer processing to create cross-sectional images (slices) of the bones, blood vessels and soft tissues), and cervical spine x-ray were negative; -Family was contacted and notified of the hospital testing results and resident's return to the facility. Review of CNA X's written statement showed: -He/she went into the resident's room to put him/her to bed; -The resident required a Hoyer lift for transfers but did not have a Hoyer lift pad under him/her; -CNA X hooked the resident up to the sit to stand lift to put the him/her in bed; -CNA X did not have a spotter and as he/she was lifting the resident, the resident let go of the lift; -CNA X tried to catch the resident to lower him/her to the ground; -In the process, the resident bumped his/her head on the wheelchair; -CNA X notified the nurse and transferred the resident to bed from the floor. Further review of the facility's investigation documentation, showed no resident statement provided by the facility. During an interview on 6/8/20 at 1:20 P.M., the resident said: -He/she did not remember much about the incident; -The CNA used a different lift and the resident could not hold on and fell; -He/she hit his/her head and had to go to the hospital; -He/she thinks it did hurt some. During an interview on 6/11/21 at 11:11 A.M., the Administrator said: -She was not the Administrator at the time of the incident, she did not start until May, 2021; -She did not have any personal knowledge of the incident, would review the investigation and get back with this surveyor. During an interview on 6/11/21 at 1:33 P.M., the Administrator said: -The staff member transferred the resident via sit to stand lift instead of Hoyer lift, without assistance, and dropped the resident; -The resident fell to the floor, hitting his/her head on the bed rail, resulting in a hematoma; -The staff member did not follow policy and should have known not to use the Hoyer lift by him/herself; -The Administrator acknowledged the state regulation that she must report all and any allegations to DHSS within two hours and the previous Administrator did not report the allegation; -The facility should have reported the incident to DHSS within the required time frame due to the nature of the injury and suspected abuse and/or neglect. MO00173432

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an alleged violation of abuse to the Department of Health and Senior Services (DHSS) promptly, no later than 2 hours after the allegation was brought to the facility's attention, for two of 20 sampled residents (Residents #10 and #44). The census was 82. Review of the facility's Protection of Residents: Reducing the Threat of Abuse & Neglect Policy, revised: 1/21/19 and reviewed 4/15/19, showed: -Each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone; -Residents must not be subjected to abuse by anyone. This includes but is not limited to: staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals; -It is the policy and practice of this facility that all residents will be protected from all types of abuse, neglect, misappropriation of resident property, and exploitation; -It is the policy of this facility to develop, implement, and maintain an effective training program on abuse prohibition including but not limited to the following topics: --Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property and exploitation, including sexual abuse; --Identifying what constitutes abuse, neglect, exploitation and misappropriation of resident property; --Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, such as physical or psychosocial indicators; --Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when staff and others must report their knowledge related to any alleged violation without fear of reprisal; -Facilities must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Failure to do so will mean that the facility is not in compliance with the federal regulations; -The 5-day report: Facilities must satisfy the federal requirement to report the results of an investigation within 5 working days from the date of the incident (or knowledge of the incident). Any report after that time will be considered out of compliance with regulation. 1. Review of Resident #10's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 6/10/20, showed: -Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, indicating the resident was mildly cognitively impaired; -Hearing, adequate, no difficulty in normal conversation, social interaction; -Speech, ability to understand others: understands/clear comprehension; makes self-understood: understood; -Required extensive assistance from staff for bed mobility, transfers, toileting, dressing and personal hygiene and supervision with eating; -Required a wheelchair for mobility; -No falls since admission; -Diagnoses included high blood pressure, stroke and end stage renal disease. Review of the resident's quarterly MDS, dated [DATE], showed: -Cognition not assessed; -Hearing, adequate, no difficulty in normal conversation, social interaction; -Speech, ability to understand others: understands/clear comprehension; makes self-understood: understood; -Dependent on two staff for bed mobility, transfers and bathing; -Required extensive assistance from staff for toileting, dressing and personal hygiene and supervision with eating; -Required a wheelchair for mobility; -No falls since admission. Review of the resident's Comprehensive Care Plan, in use at the time of the incident, showed: -Focus: Has an activity of daily living (ADL) self-care performance deficit related to residual cerebrovascular accident (CVA, stroke) effects; -Goal: Maintain current level of function requiring extensive/total assistance with ADLs through the review date; -Interventions: --Transfer: the resident is totally dependent on two (2) staff for transferring; --Transfers via Hoyer (mechanical) lift (initiated 12/11/18, revised 3/18/19); -Focus: Resident is at risk for falls. 7/27/20, the resident had a fall from a lift, hematoma noted to the back of the head, transferred to the hospital for observation; -Goal: Will not sustain serious injury requiring hospitalization through the review date; -Interventions: --Ensure that staff uses appropriate equipment for transfers (Hoyer lift), dated 7/28/20; --Mechanical lift, dated 12/11/18. Review of the resident's July 2020 and August 2020, physician's order sheets (POS) showed: -Fall precautions every shift for safety; -No order for Hoyer lift for transfers. Review of the resident's event nursing note, dated 7/27/20 at 7:45 P.M., showed: -The certified nurse's aide (CNA) presented to this nurse and reported that resident sustained a fall. This nurse presented to room and observed the resident lying in bed on back. CNA times 2 assisted resident to bed via gait belt transfer. Observation shows resident alert and oriented to baseline before incident. Resident sustained hematoma (an abnormal collection of blood outside of a blood vessel) to the posterior right base of skull with abrasion to hematoma. Resident reports pain to area, yet denies as needed (PRN) analgesic upon administration request by this nurse. Further observation shows no other areas of skin concern. Neurological assessment initiated per facility protocol. Resident tongue is midline with demonstration request to resident by this nurse. Resident denies symptoms of nausea, vertigo (a sudden internal or external spinning sensation), nor ringing in the ears; -7:05 P.M., call placed to the resident's physician and reported incident, findings, interventions, neurological assessment and resident present state. Orders received to send the resident to the hospital for evaluation and treatment; -7:08 P.M., call placed to emergency medical services (EMS) and reported orders for 911 dispatch to the hospital; -7:10 P.M., call to resident's power of attorney (POA), this nurse spoke with spouse of power of attorney (POA). Spouse stated to this nurse that POA was in route to facility; -7:11 P.M., call placed to the Director of Nursing (DON) and reported incident, findings, interventions, resident present state, neurological assessments initiated per facility protocol, orders for discharge from the resident's physician; -7:10 P.M., POA arrived to facility this nurse reported incident to POA assessment findings, resident present state, orders to discharge to the hospital, DON notification and follow up assessments per facility protocol. POA verbalized understanding; -7:15 P.M., EMS transport by 2 present at facility for discharge. This nurse reported incident, assessment findings, interventions, resident present state, neurological assessment, current vitals. Resident transfer orders, code status, and medication orders sent with EMS. 7:28 P.M., EMS exited facility with resident. Review of the facility's undated Investigation Form, showed: -DHSS notification: NA (not applicable); -Physician notified 7/27/20 at 7:05 P.M.; -Family member notified 7/27/20 at 7:10 P.M. Review of the facility's undated Investigation Summary, showed no documentation of DHSS notification. During an interview on 6/11/21 at 11:11 A.M., the administrator said: -She was not the administrator at the time of the incident, she did not start until May, 2021; -She did not have any personal knowledge of the incident, would review the investigation. During an interview on 6/11/21 at 1:33 P.M., the administrator said: -The staff member transferred the resident via sit to stand lift instead of Hoyer lift, without assistance, and dropped the resident; -The resident fell to the floor, hitting his/her head on the bed rail, resulting in a hematoma; -The staff member did not follow policy and should have known not to use the Hoyer lift by himself/herself; -The administrator acknowledged the state regulation that she must report all and any allegations to DHSS within two hours and the previous administrator did not report the allegation; -The facility did not follow policy and should have reported the incident to DHSS within the required time frame due to the nature of the injury and suspected abuse and/or neglect. 2. Review of Resident #44's medical record, showed: -admitted to the facility on [DATE]; -Diagnoses included high blood pressure, diabetes and dementia. Review of the resident's admission MDS, dated [DATE], showed: -Moderately impaired cognition; -Clear speech; -Able to make self-understood and able to understand others; -No behaviors or rejection of care; -Required limited assistance of staff for dressing and personal hygiene; -Required extensive assistance of staff for bed mobility and transfers; -Always incontinent of bowel and had a urinary catheter (a sterile tube inserted into the bladder through the urinary tract to drain urine). Review of the resident's progress notes, dated 5/26/21 through 6/3/21, showed: -On 6/1/21 at 8:39 A.M., at approximately 5:45 A.M., a CNA reported that resident wanted to speak to a supervisor regarding care received yesterday on dayshift. This nurse had just been in resident's room to do accu check (blood sugar check) with no concerns voiced at this time. This nurse went to resident room to speak with resident. Resident stated that at 10:30 exactly, he/she requested to be changed. The CNA told him/her that he/she was busy but would come back to him/her as soon as he/she was finished. Resident stated that at 1:00 P.M., the nurse came to give medication and he/she reported not getting care yet. Resident reported that at 2:30 P.M., the CNA came back to give care and had bad attitude while giving care. Resident stated that when he/she was turned on the side, he/she felt something hit the back of his/her head. Further stated It didn't hurt, but it was enough that I felt it. Resident stated he/she had reported this CNA before, Also, stated that his/her daughter had spoken to social worker regarding previous issues with care. This nurse did head to toe assessment with no unusual findings. Skin assessment completed with no issues noted. Vital signs (VS) are within normal limits. This nurse called the Executive Director (ED) to report concerns immediately after resident interview. Resident appreciative of attention to concerns; -At 2:14 P.M., care plan meeting held in resident's room with resident, resident's daughter, ED, Director of Social Services (DSS), Assistant Director of Nursing (ADON), dietary director and therapy representative. Discussed plan of action for resident's immediate concerns. ED and DSS gave resident contact information for general questions or concerns. DSS has scheduled weekly care plan follow-up meetings for 3 weeks to ensure all areas of concerns have been addressed. No concerns at this time. Social Services (SS) will continue to assist as needed. Review of the facility's interview with resident by the administrator on 6/1/21, showed the initial interview was conducted on 6/1/21 at 8:00 A.M. Review of the facility's Investigation Form, showed DHSS was notified on 6/2/21 at 12:45 P.M. by on-line portal. During an interview on 6/2/21 at 2:21 P.M., the administrator apologized for being late with the report and said it was investigated and completed yesterday morning. During an interview on 6/6/21 at 10:05 A.M., the administrator said all allegations of abuse and neglect should be reported to DHSS within two hours after the allegation is made. MO00173432 MO00186100

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a preadmission screening for individuals with a mental disorder and individuals with intellectual disability by failing to ensure a resident had a DA-124 Level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASARR) Level II screen is required) as required, for one of 20 sampled residents (Resident #67) The census was 82. Review of Resident #67's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/18/21, showed the following: -Date of admission on [DATE]; -No screening information regarding PASARR, Level II PASARR, or conditions related to serious mental illness/intellectual disabilities/related conditions; -Diagnoses included dementia, depression and schizophrenia (a mental condition that causes both psychosis (a loss of contact with reality) and mood problems). Review of the resident's medical record, showed no documentation of a DA-124 Level I screen and no documentation of a PASARR Level II screen. During an interview on 6/11/21 at 11:00 A.M., the administrator confirmed that the facility admitted the resident without a DA-124 Level I screen. He/she would have expected a DA-124 level screen to have been completed. The social worker or admissions coordinator is responsible completing the DA-124.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow appropriate discharge procedures and complete discharge and/or transfer documentation. This affected three of three reviewed closed records (Residents #276, #373 and #376). The census was 82. Review of the facility's Transfer and Discharge Policy, dated 5/6/19, showed: -Transfers and discharges will be handled appropriately to ensure proper notification and assistance to residents and families in accordance with federal and state-specific regulations; -The facility will provide equal care regardless of diagnosis, severity of condition, or payment source. Transfer and discharge policies are the same for residents regardless of payer source; -Documentation: When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(l )(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider; -Documentation in the resident's medical record must include: --The basis for the transfer, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). -A discharge summary must be completed for discharges; -Educate resident on and complete applicable sections of the discharge summary and post discharge plan of care for discharge to home, lower level of care, or other long-term care facility. -Educate resident on key points: -Have resident and/or representative/person responsible for care sign discharge summary and post discharge care form. This includes release of medications. -Give copy of form to the resident and/or representative/person responsible for care. Place signed original of form in the medical record. -Other Nursing Documentation related to Transfer or Discharge may also include: --Condition of the resident on discharge or transfer; --Date. Time, individual accompanying resident; --Type of transportation; --Whether or not the resident took medication; --Whether or not resident wishes to have bed held; --A receipt for medications and equipment sent with the resident is recommended. 1. Review of Resident #276's closed record, showed the following: -admitted on [DATE]; -discharged to hospital emergency room on 6/16/20; -Diagnoses included dysphasia (loss of or deficiency in the power to use or understand language as a result of injury to or disease of the brain), aphasia (loss of ability to understand or express speech) and Parkinson's disease (a progressive nervous system disorder that affects movement). Review of the resident's nursing note, dated 6/16/20, showed: -The resident experienced a change in condition; -The resident's physician was notified and a physician's order was obtained to send the resident to the emergency room; -The resident left for the emergency room via ambulance; -The note included no recapitulation of the resident's stay, no final summary of the resident's status and no reconciliation of pre- and post-discharge medications. Further review of the resident's closed record, showed no discharge summary located. The facility was unable to provide a discharge summary for the resident upon request. The administrator wrote on this surveyor's list of requested documents that the discharge summary was unavailable. During an interview on 6/16/21 at 1:00 P.M., the administrator said that if a document was said to be unavailable, it meant the facility did not have that specific document. 2. Review of Resident #373's medical record, showed the following: -admission date of 2/11/20; -Diagnoses included muscle weakness, osteonecrosis (death of bone tissue due to lack of blood supply), depression and cognitive communication deficit. Review of the resident's physical therapy Discharge summary, dated [DATE], showed the discharge recommendation for home health services and home exercise program. Further review of the resident's medical record, showed the following: -Physician order sheet, active at time of discharge, did not include a discharge order; -A progress note, dated 3/30/20 at 11:38 P.M., showed resident discharged home with medications; -The note included no recapitulation of the resident's stay, no final summary of the resident's status and no reconciliation of pre- and post-discharge medications; -A Discharge summary, dated [DATE] at 4:20 P.M., showed the resident was discharged home via automobile with family; -The discharge summary did not include recapitulation of the resident's stay, a physical assessment and instructions on discharge, or identification of the home health provider. -There was no note showing the facility contacted a home health provider to set up services or if durable medical equipment was needed or ordered at discharge. 3. Review of Resident #376's medical record, showed the following: -admission date of 2/14/20; -Diagnoses included stroke, speech and language deficits and muscle weakness; -Physician order sheet, active at time of discharge, did not include a discharge order; -A Discharge summary, dated [DATE] at 1:48 P.M., showing the vital signs of the resident; -The discharge summary did not include discharge information (where, how, with whom discharged ), recapitulation of the resident's stay, a physical assessment and instructions on discharge, or identification of the home health provider; -A social services progress note, dated 4/13/20, at 1:55 P.M., showed spoke with resident's responsible party who gave information for the pharmacy for discharge; - The note included no recapitulation of the resident's stay, no final summary of the resident's status and no reconciliation of pre- and post-discharge medications. During an interview on 6/11/20 at 11:02 A.M., the administrator said there was no discharge information found in the resident's medical file. 4. During an interview on 6/9/20 at 10:43 A.M., the Director of Nursing (DON) said the following: -She expected staff to follow facility policies; -Discharge planning began at admission and was ongoing throughout a resident's stay -She expected nursing staff, upon discharge, to provide the following information to the resident and/or the resident's responsible party: review all physician orders, provide education, review any upcoming physician appointments, and detail home health services, if applicable; -She expected nursing staff to complete the discharge summary, including recapitalization of stay for the last three months, write a progress note detailing what education was provided and what medications were released to the resident upon discharge, when the resident left and where they were discharged to along with notification of who provides services next (i.e. hospital, home health care provider, another facility) in order to provide continuity of care; -She expected nursing staff to complete a skin assessment prior to discharge, include findings on the discharge summary, and document findings in a progress note. It was important to know the condition of the resident's skin prior to discharge to see if any additional treatment orders were needed and to educate the resident and/or responsible party; -She expected a discharge order in the physician orders prior to discharge; -She expected social services to meet with the resident and resident's responsible party prior to discharge to discuss discharge plans, including any additional services they may need at discharge, and write a progress note in the medical record detailing the meeting. MO00168526 MO00171788

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide necessary services to maintain personal hygiene for a resident who was unable to use a urinal and/or stand over a bedside commode or toilet (Resident #36). In addition, the facility failed to ensure residents were shaved and their fingernails were cleaned/trimmed as needed. (Residents #71, #54 and #73). The sample was 20. The census was 82. Review of the facility Activities of Daily Living (ADLs) policy, reviewed on 5/5/21, showed: -Purpose, to ensure facilities identify and provide needed care and services that are resident centered, in accordance with the resident's physical, mental and psychosocial needs; -A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living; -Hygiene, bathing, dressing, grooming and oral care; -A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Review of the facility Bed Rail-Safe and Effective Use of Bed Rails policy, reviewed on 5/12/21, showed: -To prevent entrapment and other safety hazards associated with bed rail use; -The use of bed rails as restraints is prohibited unless they are necessary to treat a resident's medical symptoms. All alternatives should be considered and bed rails should only be used when identified need outweighs potential risks; -Residents will be assessed upon admission, readmission, quarterly and change of condition utilizing the Evaluation for Use of Bed Rails Form. 1. Review of Resident #36's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/17/21, showed: -Cognitively intact; -Two staff person assistance for bed mobility, transfers, dressing, toileting and personal hygiene; -One person assistance for eating; -Walker/Wheelchair for mobility; -Behaviors, not towards others, such as hitting, scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, screaming, disruptive sounds, occurred daily; -Oxygen therapy; -Medications; diuretic (medications designed to increase the amount of water and salt expelled from the body as urine) (7) days a week; -Diagnoses included anemia (a condition in which the blood doesn't have enough healthy red blood cells), heart failure, high blood pressure, kidney failure (a condition in which the kidneys lose the ability to remove waste and balance fluids), chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breath), diabetes, high cholesterol and respiratory failure. Review of the resident's care plan, in use during the survey, showed: -Problem, non-compliant with using the urinal, he/she prefers to use the bath basin, and urinate on the floor. Also refuses to bathe at times, he/she is encouraged to use the urinal. He/she is encouraged to bathe, interdisciplinary team will continue to monitor for new or worsening behaviors; -Approach, anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Observe for behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Praise any indication of the resident's progress/improvement in behavior. Provide a program of activities that is of interest and accommodates resident's status. Reward the resident for appropriate behavior by (SPECIFY rewards), as indicated; -No direction for staff as to specification of rewards; -Problem, at risk for falls; -Approach, assist with ADLs as needed. Call light within reach. Review of the resident's nurse's progress notes, showed: On 5/13/2021 at 2:38 P.M., Care Management Note Text: DSS (Department of Social Services), Ombudsman, Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), resident, and resident's family member had meeting in resident's room to discuss personal hygiene and self-care. DSS explained the importance of self-care and good hygiene habits. Resident agreed to try a different type of urinal and to utilize call light for assistance when needing to use the restroom. Review of the resident's Behavioral Agreement, signed on 5/13/21, showed: -To make your stay at our facility as agreeable as possible and to prevent any misunderstandings, we have developed a list of resident responsibilities and expectations; -Compliance with keeping up with good hygiene and self-care in order for room to be a safe and clean space for the resident and roommate; -Resident will not urinate on floors; if needing assistance with using the restroom resident will utilize call light to ask staff for assistance to the restroom. Further review of the resident's nurse's progress notes, showed: -On 5/15/21 at 12:20 P.M., Note Text: Resident is at 527.8 pounds with weight fluctuations noted, but overall change for 6 months is 2 pounds. Diet order remains appropriate. Noted diuretic therapy; -On 5/18/21 at 6:10 A.M., Behavior note, resident continues to urinate in wash basin, this nurse educated resident on importance in asking for assistance; -On 5/18/21 at 1:37 P.M., Behavior note, resident offered urinal instead of urinating in pink color basin. Resident continued with multiple excuses of afraid of making a mess, nurse offered assistance x 2 resident continued to refuse, nurse questioned if resident minded emptying the pails after use to help with odor or any possible pest control, resident went on to voice not able to. Nurse asks resident of resident input he had none, voiced he would continue use of pail basin, voiced it was easier. Review of the resident's Occupational Therapy notes, showed: On 5/19/21, no time noted, summary, patient instructed in utilizing bed side commode with one handle for urination in efforts to increase independence and decrease fall risk. Patient performed simulation and is to trial bed side commode bucket. Further review of the resident's nurse's progress notes, showed: -On 5/27/21 at 4:18 P.M., Behavior Note, resident continues to use pail in room for urination, staff has reported that resident also spits on the wall. Nurse has resident to call staff down for urination needs resident refused voiced does not want to when needs to go, resident voiced okay with pail he uses. Resident is up during the day, resident encouraged activities resident refuses. Resident able to make all needs known alert orientated x 4 and understands teaching, and educated on infection control. Noted urine over the room floor daily when offered routine toileting's resident refused resident voiced nothing he/she can do about it. Resident uses call light for pain medication and when he/she needs extra bed padding, or staff to assist with wiping buttock after bowel movement; -On 5/31/21 at 7:50 P.M., Behavior Note, resident has been compliant with using pail to void in and has emptied pail him/herself. This nurse gave resident positive feedback; -On 6/1/21 at 3:03 P.M., Behavior Note, resident continues to use provided basin for urination, resident does call staff for emptying. Resident also calls for extra bed padding to urinate on. Resident educated on calling staff, routine toileting to help decrease episodes of urinating on extra pads and placing them on floor for staff, resident voices understanding and request PRN (as needed) pain medication; -On 6/2/2021 at 3:27 P.M., Behavior Note, resident continues to urinate on floor, resident redirected to use toilet and ask for help. Resident verbalized understanding but continues to urinate on floor; -On 6/2/2021 at 10:32 P.M., Behavior Note, guest continues to use basin to urinate in, this nurse redirected to use rest room, resident stated he/she could not; -On 6/3/2021 at 9:40 P.M., Behavior Note, this nurse observed resident's continued use of basin on floor to urinate in. This nurse asked resident if he/she would like assistance to his/her bathroom or the larger bathroom in the shower room, resident declined; -On 6/4/2021 at 1:51 P.M., Behavior Note, resident observed sitting on side of bed, by nurse, attempting to urinated in pail provided. Urine puddle on floor, nurse offered to help to commode to avoid any more duration on floor or possible fall if resident attempted to transfer self, resident refused voiced he/she does that all the time he/she just needs a pad. And the housekeepers comes in to clean and ask if the nurse could send someone in to empty pail. Nurse educated resident of wet floor and fall risk, resident voiced understanding, resident call light in reach resident educated on moving to different room, resident understands no concerns noted; -6/4/21 at 9:08 P.M., Behavior Note, at beginning of shift, social worker informed writer that a meeting had been held with resident and he/she was no longer allowed to urinate in a bath basin. Resident is to use toilet. Resident continues to yell out and cuss for no apparent reason while sitting in his/her room alone. Further review of the resident's occupational therapy notes, showed: On 6/4/21, no time noted, summary, patient stated he/she is unable to perform toilet hygiene with use of toileting aid due to difficulty reaching. Patient states he/she is able to use bucket as a urinal and will walk to the bathroom to empty bucket. Further review of the resident's nurse's progress notes, showed: On 6/5/2021 at 6:32 P.M., Note Text: Resident stays in bed. Yells out when he/she went to use the bathroom but denies any pain. Ambulates with a walker. Observation and interview on 6/7/21 at 10:50 A.M., showed the resident sat up in a bariatric bed (extra wide bed) with a sheet laid across his/her body, his/her bare upper chest and feet visible. He/she said his/her walking has gotten worse. This bed does not have rails on it and he/she really needs it for positioning. They said side rails restrain people and he/she couldn't have them. He/she was using a bucket (bedside commode bucket) to urinate in, they told him/her he/she has to get up and use the toilet, although its hard for him/her. He/she guessed they are tired of emptying the bucket. He clarified they as nursing staff. Urine was observed on the floor around the base of the toilet. During an interview on 6/7/21 at 11:02 A.M., the resident's family member said the resident is unable to clean him/herself. His/her arms are too short and he/she is afraid he/she is going to urinate on the floor. Staff used to give him/her a pan to urinate in, but they said he/she can't use the pan now and told him/her to keep his/her room clean. Further review of the resident's occupational therapy notes, showed: On 6/8/21, no time noted, summary, patient verbalizes 9 out of 10 (#1 lowest to #10 highest) level low back pain. Patient states prior to therapist arrival he/she walked to the bathroom. Nurse informed of patient's pain levels. Patient states in his/her new room, he/she is able to stand over the toilet to urinate however does experience urinary urgency. Requires maximum assist for hygiene. Patient states he/she is unable to use toilet aid due to difficulty reaching. Educated patient to utilize pads on bed for hygiene, patient verbalizes understanding. Observation and interview on 6/9/21 at 1:02 P.M., showed the resident sat up in bed with a sheet laid across his/her body, his/her bare upper chest and feet visible. He/she said he/she is taking a water pill and is always having to urinate. He/she sits naked in his bed all day without any clothing on because he/she doesn't want to mess up his/her clothing. He/she said staff told him/her he/she is supposed to get up and use the bathroom. Observation and interview on 6/10/21 at 12:58 P.M., showed upon entering the resident's room, a strong odor of urine was noted. The resident said he/she was yelling earlier because he/she couldn't get out of bed, he/she said they are supposed to be getting him/her bed railings, but ever since he/she had been here, he/she has not gotten railings. During an interview on 6/10/21 at 1:14 P.M., the resident's family member said the resident had asked for bed rails and didn't get them. That is the way he/she moves, it helps him/her maneuver. The family member said to the surveyor, It looks like your really helping, (he/she) had gotten a call today to get him a bed rail, and that's really good! If he/she sits on or straddles the commode, he/she is going to miss and wet his/her clothing. Review of the resident's Evaluation for use of Bed Rails, signed and dated 6/11/21, showed assist rail X 1, exit side of bed, recommended for assistance. During an interview on 6/11/21 at 10:36 A.M., Licensed Practical Nurse (LPN) U said the resident doesn't normally yell out, he/she refrains from using the urinal. He/she urinates in a bucket and refuses to wear clothing. Some staff are not comfortable with his/her nudity. He/she can get around with a walker and wheelchair, and can use a urinal. He/she urinates on the floor. During an interview on 6/11/21 at 10:48 A.M., Certified Nurse Aide (CNA) V said they are weaning the resident from using the bucket to urinate. He/she doesn't use the urinal, he/she walks to the bathroom. During an interview on 6/15/21 at 9:15 A.M., the Assistant Therapy Director said the resident was seen by physical therapy and was independent with bed mobility and needed assistance with transferring. A raised toilet seat was provided with a grab bar. The resident was able to urinate in a bucket and insisted on using it. He/she would place pads around it and aim over it. Therapy tried to educate, hygiene wise. Therapy tried to work on getting to the bathroom, he/she had difficulty aiming due to his/her weight. Therapy felt it was better and more hygienic to use the toilet. Therapy tried to educate for a bedside commode, but he/she said it didn't work, we were trying to find a more sanitary way, but he/she was resistant. He/she still wanted to use the bucket due to urgency. He/she would dribble on the way to the bathroom, which could be a fall risk. He/she was unable to use the urinal due to his/her weight and he/she was given a bucket to hold underneath him/herself. Observation and interview on 6/15/21 at 9:30 A.M., showed the room reeked of urine and the resident sat upright in his/her bed, a sheet covered his/her body, exposing his/her chest and lower legs. At his/her calves, a large yellow ring with a darker exterior ring, ran from one side of his/her body to the other. He/she said nursing told him/her that he/she couldn't use the bucket to urinate in and he had to go to the bathroom. Urine gets on the floor because he/she couldn't get to the bathroom fast enough. They complain about dumping the bucket. If they would just give him/her pads, he/she would use them, but they just took the bucket away. Alongside the resident's bed, was a trail of urine which extended to the from the side of the bed to the restroom. During an interview on 6/15/21 at 9:49 A.M., the social workers said when the resident returned from the hospital in January, he/she had a bed rail. He/she moved off of the quarantine hall and was supposed to be getting assessed for a bed rail. He/she had expressed to nursing either Monday to Tuesday that he/she had difficulty getting up and asked nursing about getting a bed rail assessment. During an interview on 6/15/21 at 10:19 A.M., the resident said when he/she returned from the hospital for therapy, he/she did not have a bed rail. He/she asked for his/her old bed because it had a rail, he/she didn't know what happened to it, he/she never heard anything more. During an interview on 6/16/21 at 10:45 A.M., the DON, said the resident had been using a bath basin for urination. Therapy worked with him/her with positioning and he/she refused to use a female urinal. He/she would put the basin on the floor and urinate, then get back in bed. He/she said the restroom was too far to walk. Staff tried a female urinal, bedside commode, personal care, and just put in an order for an assist rail. His/her yelling out has been ongoing since admission. During an interview on 6/16/21 at 11:11 A.M., the administrator said she was not aware of him/her using a bedside commode bucket to urinate in and said if he/she can get up and into a wheelchair to go to the kitchen for a free meal, he/she can make his/her way to the restroom. 2. Review of Resident #71's medical record, showed: -An admission face sheet, showed an original admission date of 12/31/19 and a readmission date of 5/13/21; -Diagnoses included muscle weakness and dementia. Review of the resident's significant change MDS, dated [DATE], showed: -Severely impaired cognition; -Required extensive assistance from staff for bed mobility, transfers, dressing, toilet use and personal hygiene; -Required total assistance from staff for eating and bathing; -Incontinent of bowel and bladder. Review of the resident's care plan, dated 5/19/20 and in use during the survey, showed: -Problem: Resident has ADL self-care performance deficit related to impaired balance; -Goal: Resident will improve current level of function through next review; -Intervention: Staff to provide moderate assistance with bathing. Review of the resident's CNA bath sheet/skin check sheets, showed: -On 6/1/21, type of bath performed, marked shower and no nail or toenail care documented as provided; -On 6/4/21, type of bath performed, marked shower and no nail or toenail care documented as provided; -On 6/8/21, type of bath performed, marked shower and no nail or toenail care documented as provided; -On 6/11/21, type of bath performed, marked shower and no nail or toenail care documented as provided. Observations during the survey, showed: -On 6/7/21 at 11:05 A.M., the resident sat in his/her Geri-chair (reclining wheeled chair) with long, untrimmed dirty fingernails; -On 6/8/21 at 9:26 A.M., the resident sat in his/her Geri-chair with long, untrimmed dirty fingernails; -On 6/9/21 at 7:04 A.M., the resident sat in his/her Geri-chair with long, untrimmed dirty fingernails; -On 6/10/21 at 6:53 A.M., the resident sat in his/her Geri-chair with long, untrimmed dirty fingernails; -On 6/11/21 at 6:26 A.M., the resident lay in bed with long, untrimmed dirty fingernails; -On 6/14/21 at 8:41 A.M., the resident lay in bed with long, untrimmed dirty fingernails; -On 6/15/21 at 8:30 A.M., the resident lay in bed with long, untrimmed dirty fingernails. 3. Review of Resident #54's admission MDS, dated [DATE], showed: -An admission date of 5/5/21; -Moderate cognitive impairment; -Required extensive assistance from staff for transfers, toileting, personal hygiene and dressing. Required supervision for eating; -Diagnoses included heart failure, end stage renal disease (ESRD, is the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), stroke and Parkinson's disease (A disorder of the central nervous system that affects movement, often including tremors). Observations and interview of the resident, showed: -On 6/7/21 at 10:13 A.M., dark debris was visible under the resident's nails. The resident's nails were untrimmed and extended past the end of his/her fingers. The resident also had numerous whiskers on his/her cheeks and chin. The resident said he/she has had one bath since being at the facility. He/she prefers to have clean, trimmed nails and to be clean shaven; -Further observations of the resident on 6/8/21 at 2:19 P.M., 6/9/21 at 1:10 P.M., 6/10/21 at 6:50 A.M., 6/11/21 at 8:20 A.M., 6/14/21 at 11:04 A.M., 6/15/21 at 2:03 P.M. and 6/16/21 at 8:00 A.M., showed the dark debris remained under the resident's untrimmed nails. The facial hair also remained on the resident's face. Review of the resident's shower sheets, showed since his/her readmission on [DATE]: -Staff documented providing the resident a shower or bed bath on 5/28/21, 6/2/21, 6/8/21 and 6/12/21; -Staff failed to document trimming or shaving the resident's facial hair or providing nail care. 4. Review of Resident #73's admission MDS, dated [DATE], showed: -Cognitively moderately impaired; -One staff person assistance for dressing, toileting and personal hygiene; -Two person assistance for bed mobility or eating; -Wheelchair for mobility; -Oxygen therapy; -Dialysis; -Diagnoses included anemia, heart failure, high blood pressure, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and ESRD. Review of the resident's care plan, in use during the survey, showed: -Problem, has a decline in mobility and strength due to a recent stroke with left sided weakness, has a right below the knee amputation, and requires assist with all daily living needs and transfers. He/she is currently working with therapy services to increase functional mobility and strength; -Approach, assist with ADLs as needed. Call light within reach. Mechanical lift. Observation and interview on 6/14/21 at 7:33 A.M., showed the resident with long dirty fingernails. He/she said he/she just gets bed baths and his/her nails need trimmed. During an interview on 6/16/21 at 7:41 A.M., LPN C said only nurses can trim the resident's nails. They should be trimmed during baths and/or showers. Review of the resident's shower sheets, showed since his/her readmission on [DATE]: -Staff documented providing the resident a shower or bed bath on 5/28/21, 6/1/21, 6/5/21 and 6/12/21; -Staff failed to document nail care as provided. 5. During an interview on 6/16/21 at 10:00 A.M., the DON said CNAs are responsible to ensure when residents received showers or baths, their fingernails and/or toenails are trimmed and cleaned. When the resident's shower/bath sheets are left blank for fingernails or toenail care, that means the resident's fingernails not were trimmed and cleaned. MO00178024 MO00178805 MO00169616 MO00168954 MO00168838

Based on observation, interview and record review, the facility failed to maintain proper placement of indwelling urinary catheters (a tube inserted into the bladder for purpose of continual urine drainage). The facility identified four residents as having indwelling urinary catheters. Of those four, one was chosen for the sample and issues were found (Resident #61). The sample size was 20. The census was 82. Review of the facility's Indwelling Urinary Catheter and Management Policy/Procedure, dated November 20, 2020, showed the following: -Critical Notes: Life Care Centers of America has approved the following information as an addendum to the Lippincott procedure: 1). Conduct a comprehensive, interdisciplinary review and assessment of the resident's continence status on admission, quarterly and with significant change of urinary function including factors that predispose the resident to the development of urinary incontinence and the use of an indwelling catheter; 2). Monitor the catheter daily and assess for complications resulting from the use of an indwelling catheter such as symptoms of blockage with associated bypassing of urine, catheter-associated urinary tract infection (UTI), pain, discomfort and bleeding; 3). Develop an individualized care plan based on assessment findings and revise as needed; -Clinical Alert: -Keep the catheter and drainage tubing free from kinks and avoid dependent loops to allow the free flow of urine; -Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of infections; -Don't place the drainage bag on the floor to reduce the risk of contamination and subsequent infection. Review of Resident #61's medical record, showed: -An admission face sheet, showed admission date of 2/4/20 and readmission date of 6/4/21; -Diagnoses included urinary retention (inability to completely empty the bladder of urine), renal insufficiency (partial kidney function failure characterized by less than normal urine excretion) and chronic kidney disease (gradual loss of kidney function). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/9/21, showed: -Alert and oriented; -Required limited assistance from staff for activities of daily living (ADLs); -Indwelling urinary catheter. Review of the resident's care plan, dated 3/26/21 and in use during the survey, showed: -Problem: Resident has indwelling urinary catheter for urinary retention; -Interventions: Position the catheter tubing/bag below the resident's bladder, check catheter tubing for kinks every shift, educate the resident/family regarding indwelling urinary catheter/care, intake/output as per facility policy, observe for signs/symptoms of pain/discomfort to catheter, observe/report signs of UTI to the physician, observe for pain, blood tinged urine, cloudiness, no urine output, frequent chills and fever; -Goals: Resident will have no complications related to urinary catheter. Review of the resident's physician's order sheet (POS), dated June 2021, showed an order dated 6/4/21, indwelling urinary catheter, size 16 French (brand),10 cubic centimeters (cc) balloon (the balloon portion of the catheter is inflated with saline solution to keep the catheter in the bladder), change catheter for leakage or obstruction, change catheter bag every fourteen days, catheter care every shift and keep catheter bag below the resident's bladder. Observations of the resident during the survey, showed: -On 6/7/21 at 10:46 AM, the resident sat in his/her wheelchair in his/her room. Approximately 20 to 24 inches of the catheter tubing and collection drainage bag (not inside of a privacy bag) lay directly on the floor underneath the resident's wheelchair. The resident stepped on the catheter tubing and drainage bag while he/she self-propelled his/her wheelchair in the room; -On 6/8/21 at 9:28 A.M., the resident lay in the bed on his/her right side with approximately 12 inches of catheter tubing directly underneath his/her right upper thigh. The catheter tubing contained yellow colored urine and no urine drained from the tubing into the collection drainage bag. Approximately 14 inches of the catheter tubing and collection drainage bag (not inside a privacy bag) lay directly on the floor next to the bed; -On 6/8/21 at 10:00 A.M., the resident lay in the bed with the urinary catheter collection drainage bag (not inside a privacy bag) directly on the floor, and approximately 12 to 14 inches of the catheter tubing also directly on the floor next to the bed. No urine drained from the catheter tubing into the collection drainage bag. During an interview on 6/10/21 at 11:00 A.M., the Director of Nurses (DON) said the catheter tubing should be positioned to allow urine to drain per gravity from the tubing into the collection drainage bag, should not be on the floor, and the collection drainage bag should not be directly on the floor due to infection control and prevention of UTI. The catheter tubing and collection drainage bag should be positioned below the resident's bladder at all times to prevent infection and UTI. The DON said she expected nursing staff to follow the facility's policy regarding catheter positioning. It is the charge nurses' responsibility to ensure the resident's catheter tubing and collection drainage bag are positioned correctly.

Based on observation, interview, and record review, staff failed to execute appropriate technique while administering medications via gastrostomy (g-tube, a surgical opening into the stomach from the abdominal wall for the insertion of food and fluids) to one resident observed (Resident #23). Staff failed to follow standard, recommended practice when checking for g-tube placement and did not raise the head of bed (HOB) while administering medications to the resident via g-tube. The sample was 20. The census was 82. Review of the facility's Medication Administration through an Enteral Tube policy, effective date 4/4/19, showed: -Purpose is to set forth the procedures for medication administration through an enteral tube; -Check gastric residual volume (GRV, the amount of liquid drained from stomach following the administration of enteral feed) and observe the external length of the tubing for changes in size to verify g-tube patency prior to the administration of medications; -Adjust head of bed. Review of the facility's Enteral Nutrition Therapy policy, revised on 5/19/20, showed: -Facility will utilize the Lippincott procedures for Enteral tube feeding. Review of the undated Lippincott procedure for Enteral tube feeding, showed: -Assess the patient's gastrointestinal (GI) status and risk for aspiration; -Position the head of the bed at least 30 degrees. Review of Resident #23's electronic medical record (EHR), showed: -Diagnoses included dysphagia (difficulty swallowing foods or liquids), gastronomy status, pneumonitis (inflammation of lung tissue) due to inhalation of food and vomit, pneumonitis due to inhalation of other solids and liquids, acid reflux disease, quadriplegia (paralysis of all four limbs), muscle weakness, history of traumatic brain injury (TBI), and contracture (shortening and hardening of connective tissues resulting in deformed, rigid joints); -The Medication Administration Record (MAR), dated 6/2021, showed: -An order dated 4/1/21, to check residual at the beginning of every shift and record; -An order dated 4/1/21, for the head of the bed to be elevated at least 30 degrees every shift; -An order dated 4/1/21, to verify g-tube placement every shift by checking GRV. Observation on 6/9/21 at 12:55 P.M., showed Licensed Practical Nurse M (LPN) administered medications via g-tube to the resident. He/she verified the resident's medication orders. The head of the resident's bed was elevated approximately 15 degrees. LPN M connected a 60 milliliter (mL) syringe with plunger to the resident's g-tube and administered approximately 20mL of air into it to check placement. He/she administered medications to the resident as ordered. He/she administered an additional 5mL of air via g-tube before he/she flushed the tubing for the final time, with water. During an interview on 6/15/21 at approximately 9:15 A.M., the Director of Nursing (DON) said that using an air bolus to check g-tube placement was no longer a recommended standard of practice. This is in their policy. She expected staff to follow their policies for enteral feedings and g-tube placement. The HOB should be elevated approximately 45-50 degrees during g-tube medication administration. On 6/16/21 at approximately 10:30 A.M., the DON stated that she expected staff to follow physician orders.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 31 opportunities observed, 2 errors occurred, resulting in a 6.45% error rate (Resident #38). The sample was 20. The census was 82. Review of the facility's Administration of Medications policy, revised on 5/6/20, showed: -All medications to be administered as ordered; -A physician order includes dosage, route, frequency, duration, and other required considerations; -Federal regulation is to have less than 5% error rate. Review of the facility's Reordering, Changing, and Discontinuing Orders, policy revised on 10/31/16, showed: -Facilities are encouraged to reorder medications electronically. Review of Resident #38's Electronic Health Record (EHR), showed: -Diagnoses included multiple sclerosis (MS, a disease in which one's immune system attacks the protective barrier of nerves), atrial fibrillation (an irregular heart beat), depression, muscle weakness, cognitive communication deficit, convulsions, high cholesterol, obesity and bladder disorder; -A care plan, in use at the time of survey, showed: -Requires assistance with Activities of Daily Living (ADLs), transferring and mobility; -On anticoagulant (blood thinner) therapy; -Has a seizure disorder; -Has high blood pressure; -Diagnosis of depression requiring anti-depressant medication; -Interventions included administering medications as ordered; -The Medication Administration Record (MAR), showed: -An order dated 5/27/21, for Mucinex 600 milligrams (mg) extended release (ER) tablet twice daily at 8:00 A.M. and 8:00 P.M.; -An order dated 4/15/21, for Vitamin D 125 mcg tablet daily at 8:00 A.M. Observation on 6/10/21 at 9:05 A.M., showed Licensed Practical Nurse (LPN) C administered medications to the resident. He/she verified each medication order as he/she removed them from their packaging. During an interview with LPN C at this time, he/she said that the resident was actively scheduled to receive Mucinex, but that he/she could not locate this medication. Mucinex was a facility-stocked medication. He/she did not administer Mucinex to the resident. LPN C said the resident was also scheduled to receive Vitamin D that was not available. Vitamin D was not kept in the facility's stock and the dose was not available in the facility's emergency medication supply. LPN C did not administer Vitamin D to the resident. LPN C told the resident that he/she did not receive his/her Mucinex and Vitamin D due to it was not available. During an interview on 6/15/21 at approximately 9:15 A.M., the Director of Nursing (DON) said that the facility reorders medications, on demand when residents are down to their last 5 doses of a medication. If a resident receives a medication three times daily, staff should reorder it when there are 15 pills remaining. Staff are able to reorder most medications electronically through their system. Narcotics are ordered via telephone route because the physician may need to provide a new script. Staff are expected to reorder medications before they are exhausted. Medications are expected to be administered as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility to maintain medical records that are complete, accurately documented, readily accessible and systematically organized for four of 20 sampled residents (Residents #379, #56, #227 and #12). The census was 82. 1. Review of Resident #379's medical record, showed the following: -admission date [DATE], discharged to county medical examiner on [DATE]; -Diagnoses included Stage 4 Pressure Ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough (dead tissue separating from living tissue) or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling) located at the sacrum (triangle shaped bone located above the coccyx (tailbone), end stage kidney disease, elevated white blood count, metabolic encephalopathy (brain function is disturbed due to different diseases or toxins in the body) and dementia; -A progress note, dated [DATE] at 12:44 P.M., showed the resident had an elevated temperature, was sweating profusely and yelling out in pain. The resident's wound located on his/her buttock had a large amount of foul smelling drainage. The nurse notified the physician who gave orders to send the resident out to the hospital. Review of the resident's hospital Discharge summary, dated [DATE], showed the following: -COVID-19 test positive on [DATE]; -Discharge diagnoses include severe sepsis (blood infection) to infected sacral decubitus ulcer (pressure ulcer) down to the coccyx, infected sacral decubitus ulcer down to the bone Stage 4, end stage kidney disease, acute pulmonary embolism (new condition in which one or more arteries in the lungs was blocked by a blood clot) and recent COVID-19 infection; -Indication for admission: admitted with a huge infected Stage 4 sacral ulcer; -Hospital Course: Discussed the resident's very poor prognosis with the family and switched to hospice care. Stopped all medications and started comfort measures; -Facility admission: Admit to facility on hospice. Further review of the resident's medical record, showed the following: -No admission note when the resident was readmitted to the facility on [DATE] detailing new diagnoses, new orders, reconciliation of hospital discharge orders with the physician, or notification to the resident's responsible party of the change of condition; -A progress note, dated [DATE] at 6:46 P.M., showed the resident was yelling out in pain, the nurse administered as needed (PRN) narcotic pain medication, administered a treatment to the resident's coccyx, discontinued insulin orders, no complications noted at the time of the note. The physician approved skilled therapy for seven days. The resident was alert, needed assistance of one staff member for activities of daily living (ADLs) and transfers, incontinent of bowel and bladder, care provided as needed. No distress noted and call light within reach; -A progress note, dated [DATE] at 2:46 P.M., showed the resident was in bed with call light within reach, alert and oriented to self, comfort care, appetite poor, no shortness of breath or cough noted; -A physician's progress note, dated [DATE], seen today for follow-up, showed the resident was alert and oriented to self with significant memory impairment, looked comfortable and was not in pain. The resident said he/she was hungry and that he/she was okay. Vital signs normal, no shortness of breath, lungs sounded clear, regular bowel sounds noted, slight edema (fluid accumulation) in right and left legs. Continue comfort care, pain management, wound care, do not resuscitate, and comfort measures only; -Physician orders for [DATE], showed no order for comfort measures; -A progress note, dated [DATE] at 2:52 P.M., showed the resident was resting in bed with call light in reach, alert and oriented to self, able to voice needs, appetite poor, dressing clean, dry and intact. No shortness of breath or cough noted; -A discharge summary note, dated [DATE] at 1:28 P.M., showed the Certified Nurse Assistant (CNA) notified the nurse that the resident showed no signs of life. Carotid pulse not felt. No respirations noted. Verified with a second nurse. Do not resuscitate. Time of death was 1:10 P.M. Notified family. Family will call back with funeral home information once it is decided where remains will be transported; -There was no documentation of a change of condition leading up to the resident's death. During an interview on [DATE] at 10:34 A.M., the Director of Nursing (DON) said the following: -When a resident returns from the hospital, the charge nurse on the floor who does the admission was responsible for reconciling hospital orders and then the clinical team reviews in the daily morning meeting to double check; -The admitting nurse was also responsible for writing a progress note detailing the resident's admission to the facility with new diagnoses, notification of physician and reconciliation of orders and any new orders; -The clinical team read the discharge transfer orders during daily utilization review, to determine why residents were there, what the overall stay was in hospital and to determine the plan to treat and/or discharge the resident, if appropriate; -She expected social services to meet with the resident and/or family and get an order for hospice to evaluate and treat from the physician and then initiate with a hospice service if a hospital discharge transfer orders said resident is to be admitted to the facility on hospice, and document all details in the resident's medical record; -She expected nurses to contact the hospice team and coordinate care if the resident was discharged from the hospital with a hospice team already in place, and document all details in the resident's medical record; -She did not know why the resident was on comfort care or why the resident died; -She expected a note from the social worker, nurse, or the interdisciplinary team showing a meeting was held with the family and the resident discussing end of life care, with services from therapy for wound management and pain; -She expected the physician to evaluate the resident within seven days of readmission. 2. Review of Resident #56's medical record, showed the following: -admitted on [DATE]; -Diagnoses included heart failure, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), muscle weakness and cognitive communication deficit; -A progress note, dated [DATE] at 8:00 P.M., the DON wrote the physician was updated on the resident's statements of alleged abuse and interventions/actions currently in place. The physician was notified the resident did not have any bruising/scratches or areas of concern on skin per charge nurse evaluation; -A progress note, dated [DATE] at 10:30 P.M., showed the Infection Preventionist (IP), also a licensed practical nurse (LPN), was alerted by an aide that the resident stated he/she was beat up by my aide yesterday. The resident stated the aide hit his/her head several times. The IP completed a body and skin assessment and wrote This nurse noted to bruising of hematomas (collection of blood outside of a blood vessel) of the head, no bruising to the body or shoulders. The IP informed the DON and the administrator of the situation. Review of the investigation report, dated [DATE], showed the following: -No written statement from the IP; -No skin assessment from [DATE]. During an interview on [DATE] at 9:15 A.M., the resident said the following: -He/she was treated well by staff except that time an aide came into my room and slapped me across my head; -He/she did not remember what happened to the aide except that the aide never worked with him/her again. During an interview on [DATE] at 10:23 A.M., the IP said the following: -If a resident alleged abuse, he/she would make sure the resident was safe, get a statement from the resident and complete a full head to toe body assessment, focusing on the areas where the resident alleged they were hit; -If a bruise or hematoma was found to the resident's head, he/she would notify the physician for new orders and start neurological checks to ensure the resident did not have any changes in cognition; -He/she could not remember much of what happened in regards to the resident's allegations of abuse on [DATE]; -He/she could not remember if the resident had bruising or a hematoma to his/her head when he/she completed the skin assessment on the resident on [DATE]; -When writing a progress note explaining a bruise or hematoma was found, the nurse used the verbiage This nurse noted .; -If he/she had found bruising or a hematoma on the resident's head, it would have given validity to the resident's allegations of abuse. During an interview on [DATE] at 11:31 A.M., the DON said the following: -She expected nurses to complete a full head to toe body assessment and note any discolorations, bruises, marks, anything out of the ordinary when a resident makes an allegation of abuse and say a specific area was hit; -She expected nurses to document if they found anything unusual and notify the physician, the resident's responsible party, the DON and administrator; -If a nurse found a bruise or hematoma on a resident's head, she expected the nurse to notify the physician to get orders, notify the responsible party, the DON and administrator and document in the progress notes; -The DON immediately investigates all allegations of abuse by reviewing all medical notes made prior to the incident, all written statements from staff and residents and the head to toe skin assessment completed by the nurse; -If there was a note about discoloration found in the progress note or skin assessment completed by the nurse, the DON would personally complete a head to toe skin assessment of the resident; -There was no documentation found in the final summary of the investigation that the DON completed a head to toe skin assessment of the resident; -The event took place a few days after the DON was hired; -After asking the DON why the nurse's note which said this nurse noted to bruising of hematoma of the head wasn't addressed in her investigation, as the resident stated the aide slapped her head several times, she said she must have missed it. During an interview on [DATE] at 12:59 P.M., the DON and the IP said in the progress note, written on [DATE] at 10:38 P.M., the word to was actually no, it was a typo. The IP was documenting the resident had no bruising or hematoma. During an interview, on [DATE] at 10:20 A.M., the DON said the following: -She expected medical records to be correctly and accurately documented so they don't have to depend on staff to clarify records; -An employee's recall of the event would be influenced by what the note said in the medical record; -An employee would not be able to determine what happened over a year ago if there was no note, their recall wouldn't be accurate; -If they are not able to speak with the former employee, then the record is incomplete because we cannot get the appropriate information; -Documentation found in residents' medical records is used to determine plan of care, if current treatments are effective, and what occurred during a significant change of condition. 3. Review of Resident #227's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -admission date of [DATE]; -Cognitively intact; -Weight: 186 pounds (lbs); -Independent with eating; -Diagnoses included medically complex conditions, high blood pressure, diabetes and anxiety disorder. Review of the resident's weights at the facility, showed: -On [DATE], 186 lbs; -On [DATE], 157.8 lbs; -On [DATE], 157.8 lbs; -Staff documented a 15.16% weight loss in 12 days. Review of the resident's progress notes, showed: -No documentation regarding the resident's significant weight loss; -A discharge date of [DATE]; -A registered dietician nutrition assessment, completed on [DATE], showed weight loss from 186 lbs to 157 lbs within month of admission; -A progress note, written by the DON, dated [DATE] at 1:10 P.M., spoke with admission nurse regarding admission weight. Nurse stated weight was typo, he/she hit the number 8 instead of the number 5. Weight should have been 156.0. During an interview on [DATE] at 10:00 A.M., the DON said medical records should be accurately documented so staff don't have to clarify. 4. Observation on [DATE] at 8:11 A.M., showed LPN S administered medications to Resident #12. During an interview with LPN S at this time, he/she said that Loratadine (an antihistamine) was not available to administer to the resident and that he/she would have to come back to administer it. Review of Resident #12's medical record on [DATE] at 9:14 A.M., showed: -LPN S signed Loratadine 10 milligrams (mg) out as given on the medication administration record (MAR). During an interview on [DATE] at 9:30 A.M., LPN S said he/she had not yet administered Loratadine to the resident and that he/she would go find it in the facility's stock supply. At 9:37 A.M., he/she returned to the medication cart with a stock bottle of Loratadine 10 mg tablets. He/she logged into the laptop on top of the medication cart and stated staff should not sign the medication as administered until it is administered. He/she then administered one tablet of Loratadine 10 mg to the resident. During an interview on [DATE] at approximately 10:30 A.M., the DON said staff should not sign out medications that have not yet been given, as administered on the MAR. MO00175002

Based on interview and record review, the facility failed to promptly, upon the grievances and recommendations of the resident council, demonstrate their response and rationale for such response concerning issues of quality of life. The resident council reported concerns with activities during the three most recent meetings and the facility failed to document a follow-up with the concerns, act upon the recommendations and/or document a rationale as to why the facility could not act upon the concerns. The census was 82. Review of the resident's bill of rights, provided to residents upon admission to the facility, showed: -The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident; -The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal; -The resident has a right to prompt efforts by the facility to resolve grievances, including those with respect to the behavior of other residents. Review of the resident council notes, showed: -March 2021, residents are happy the new activity director is at the facility. When can residents go back outside in the courtyard, bus trips to store and out to eat? Activities was shut down before COVID-19 and it is unfair. No documented follow-up; -April 2021, all residents want outside activities. No documented follow-up; -No May 2021 resident council minutes provided; -June 2021, all residents need outdoor activities like out to eat in store runs. Not enough activities. No documented follow-up. During an interview on 6/14/21 at 1:19 P.M., the administrator said there was no resident council meeting held in May 2021. Review of the facility's activity calendars, showed a decrease in scheduled group activities from March 2021 to June 2021: -March 2021: Three to four activities scheduled daily during week days. Two activities scheduled daily during the weekend. 100 activities total scheduled for the month; -April 2021: Two to three activities scheduled daily. 63 activities total scheduled for the month; -May 2021: One to three activities scheduled daily. 66 activities total scheduled for the month; -June 2021: One to two activities scheduled daily. 65 activities total scheduled for the month. During a group interview on 6/8/21 at 10:55 A.M., four residents identified by the facility as being alert and oriented, who represented the resident council, said: -Resident #13 said when COVID-19 started, the facility said residents cannot smoke anymore. That was a form of enjoyment and time to socialize. They just took that away. Since COVID-19, residents haven't seen anything but the four walls in their room. They don't see anyone anymore. Residents cannot even go up to the front lobby to get money anymore, they have to have it brought to them. Residents have to stay close to their rooms, can't sit in the halls, and if they leave their rooms, they are told to go back to their room. Activities has been almost non-existent. With bingo, they can only have one resident at a table, so only a couple residents can go; -Resident #32 said he/she has been wanting to go outside. He/she wants to go shopping. During an interview on 6/10/21 at 1:07 P.M., the activity director said she is the only activity staff person at the facility. She usually has the same eight residents that come to activities. She is aware of activity concerns brought up by the resident council. They want to go on outings, go outside, smoke and have more activities. She started working at the facility four months ago and there has been no activities in the courtyard or smoking. She has not been able to use the courtyard for activities because it is so overgrown with weeds. The residents are not allowed to go out there. Nothing has been done to address the resident council concerns because there is not enough activity staff and she has not been given permission for outdoor activities or outings. The March activity calendar was the first one she created after starting at the facility. Due to having no activity staff to help, she was not able to do all the activities that were listed and residents were complaining that the scheduled activities were not taking place. To fix this, she scheduled less activities. During an interview on 6/11/21 at 9:22 A.M., the social service director said she is the person responsible for grievances. This includes concerns brought from the resident council. The person running the resident council group meeting fills out grievance forms and the appropriate department head follows-up on the concerns. She has not been provided any concerns from the resident council in a couple of months. None since March. The person running the meeting has not provided these grievances. She is not sure how the person running the resident council follows-up with resident council concerns. During an interview on 6/11/21 at 1:56 P.M., the administrator said she is not sure how many activity staff there were prior to the pandemic, but she does feel one activity staff, if qualified, is sufficient for the number of residents at the facility. She is aware of resident council concerns regarding activities. She does not know what follow-up the activity director has provided to the resident council.

Based on observation, interview and record review, the facility failed to ensure residents were aware of available hours to receive their money during the week or to have money available to residents on the weekends. The census was 82. Review of the facility's Resident Trust Policy and Procedures, showed: -Cash on hand shall be held in a cash box clearly marked Personal Needs in a secure location; -Personal needs cash on hand is operations funds made available to advance cash to residents requesting withdrawals from their respective accounts; -The policy did not have times as to when residents' money was available. Review of the Authorization and Agreement to Handle Resident Funds form signed by the resident, did not show when their money was available to them or how to obtain funds on the weekends. Observations of the facility throughout the survey, showed no hours posted for when residents could have access to their money. During an interview on 6/10/21 at 11:00 A.M., Resident #35 said he/she can call ahead to get money during weekdays, but not on weekends. During an interview on 6/8/21 at 10:55 A.M., Resident #13 said they can't go up front to get money. They have to call the staff up front to bring it to them. During an interview on 6/10/21 at 12:06 P.M., the business office manager (BOM) said hours are discussed upon admission, however, petty cash for the residents is locked up in a safe on the weekends in his office. The weekend supervisors do not have access to his office or the safe on the weekends.

Based on interview and record review, the facility failed to perform a yearly review of code status for full code (if the heart stops beating or breathing ceases, all life saving methods are performed) or no code (do not resuscitate (DNR), no life prolonging methods are performed) and obtain a signed code status form upon admission to the facility (Residents #13, #71, #61 and #227). In addition, the facility failed to ensure two witnesses signed a code status form for a resident who could not sign their name (Resident #324). The sample was 20. The census was 82. 1. Review of Resident #13's medical record, showed: -An admission face sheet, showed an admission date of 10/13/12; -A signed code status form, dated 9/22/17, for full code; -A physician's order sheet (POS), dated June 2021, showed an order dated 10/8/18, for full code status; -No updated code status form found since 9/22/17. Review of the resident's current signed code status form, provided by the facility on 6/14/21, showed signed code status form, dated 9/22/17, for full code. 2. Review of Resident #71's medical record, showed: -An admission face sheet, showed an admission date of 12/31/19 and a readmission date of 5/13/21; -A signed code status form, dated 1/3/20, for full code; -A POS, dated June 2021, showed an order dated 5/20/21, for full code; -No updated code status form found since 1/3/20. Review of the resident's current signed code status form, provided by the facility on 6/14/21, showed a signed code status form, dated 1/3/20, for full code. 3. Review of Resident #61's medical record, showed: -An admission face sheet, showed an admission date 4/29/20 and a readmission date of 6/4/21; -A signed code status form, dated 2/4/20, for full code; -A POS, dated June 2021, showed an order dated, 6/4/21, for full code status -No updated code status form found since 2/4/20. Review of the resident's current signed code status form, provided by the facility on 6/14/21, showed a code status form, dated 2/4/20, for full code. 4. Review of Resident #227's medical record, showed: -An admission date of 5/27/21; -An order, dated 5/27/21, for full code; -No signed code status form; -An out of hospital do not resuscitate form (OHDNR), left blank. On 6/14/21 at 1:23 P.M., the administrator said they do not have a signed code status form for the resident. 5. Review of Resident #324's medical record, showed: -An admission date of 5/19/21; -A code status form, signed with an X on 5/20/21, for full code, no other signatures; -Review of the physician's orders on 6/8/21, showed no documented code status. During an interview on 6/16/21 at 10:06 A.M., the Director of Nurses (DON) said if someone is unable to sign their code status form, two witnesses are required to sign the form. She would have expected the admission nurse to get another nurse to witness the X signature for the resident. 6. During an interview on 6/16/21 at 10:00 A.M., the DON said she expected the admitting nurse to obtain a signed code status form from either the resident or representative. Each resident should have a signed code status form. The social service designee is responsible for reviewing and updating the resident's code status form annually or when there is a change in the resident's condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents could retain personal property safely from loss or theft, when they failed to complete an inventory sheet for 6 of 20 sampled residents (Residents #426, #378, #376, #373, #425 and #276). The census was 82. Review of the facility's admission packet, provided on 6/7/21, showed: -Section 12 Resident Funds, Valuables and Possessions: -You or your representative agree to inform the facility of all valuable property upon admission, and at any time new items are added to your possession. Upon admission, a detailed inventory of your possessions will be done; -The facility will attempt to reasonably safeguard your non-monetary personal property and belongings left in the facility, to the extent required by law. The facility will dispose of any non-monetary personal property and belongings that remain unclaimed 14 days after your discharge from the facility. 1. Review of Resident #426's medical record, showed: -admitted : 11/13/20; -Diagnoses included: deaf- non-speaking, communication deficit, diabetes, high blood pressure and hypothyroidism (the thyroid is not making enough thyroid hormone); Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/28/21, showed: -Cognitively intact; -Unclear speech-slurred or mumbled words; -Makes self-understood and ability to understand others. During an interview on 6/7/21 at 2:00 P.M., the resident said a certified nurse aide (CNA) threw his/her Iphone into a pan of water. The resident said he/she reported it to the facility and was told the facility would pay for it but it never happened. The resident said the incident took place in November, 2020. Further review of the resident's hard chart, showed: -No inventory sheet was completed. During an interview on 6/9/21 at 1:30 P.M., the administrator said no inventory sheets were available for Resident #426. During an interview on 6/11/21 at 9:45 A.M., the social worker (SW) said she has been at the facility since March. She was the grievance officer. Once she gets a grievance (blue card), she will log the grievance into the computer and the department heads are made aware. Grievances are discussed in the daily morning meeting. The goal is to have the issue resolved within 48-72 hours or as soon as possible. Residents are notified of the outcome and it is logged if the resident was satisfied with the outcome or not. The SW maintains all the grievances. The SW was aware the resident had issues with a phone prior to moving into this facility. The SW was not aware of an issues with the resident's phone at this facility. During observation and interview on 6/11/20 at 11:30 A.M., the resident said he/she purchased the Iphone in September and moved to the facility in November. The resident said his/her phone was working when he/she moved into the facility, then a CNA dropped the phone into a pan of water while he/she washed his/her face . The CNA said to the resident, oops, accident. The resident told the facility, and he/she was told the CNA quit. The resident let the phone dry out for a month and another CNA tried to turn the phone on and the phone began to smoke and the screen broke. Observation of the Iphone showed the screen was cracked. The resident said the phone did not work. During an interview on 6/14/21 at 2:00 P.M., the Director of Nursing (DON) said when a resident is admitted to the facility, the families are encouraged to label the residents' personal belongings and complete the inventory sheet. If the resident's items are not labeled by the resident/resident's representative, the CNAs would be responsible for labeling the items and completing the inventory sheets. All residents should have an inventory sheet in the resident's hard chart. If a resident cannot find an item, the facility will look for the item, notify the administration, and complete a purple packet. The police, family and Department of Health and Senior Services (DHSS) would be notified, if needed. If a family is unable to locate an item, they would complete a blue card. If an item is broken by the staff, staff should notify the facility and complete a blue card. The blue cards go to administration and administration would distribute the card out to the department that is involved. Social Services would log the blue card on the grievance log. Then, the item would be discussed in the morning meeting. Residents know they can report anything to anyone or complete a blue card. Blue cards are located in various places throughout the building, or the staff can get the resident a blue card. If a staff member breaks a resident's item, the DON expected the staff member to report it. The DON was unaware the resident's iPhone did not work and the resident alleged a CNA dropped his/her phone in a pan of water or got water on the resident's phone. The DON said the resident never reported it. The DON said he/she would complete a blue card and check into it. 2. Review of Resident #378's admission MDS, dated [DATE], showed: -admission date of 7/2/20; -Moderate cognitive impairment; -Diagnosis included dementia. Review of the resident's medical record, showed the following: -A progress note dated 8/28/20, at 4:38 P.M., social service department met with the resident and explained that with the current COVID restrictions, residents were not able to visit with family outside of facility at this time; -A progress note dated 8/29/20 at 11:04 A.M., the resident was alert and oriented to his/her name and knows where he/she was, with confusion. The resident was walking, pushing his/her wheelchair with all personal items packed. Resident's responsible party said the resident was going to look for an apartment and would return in the evening or the next morning. The responsible party was made aware if the resident did not return within 24 hours, the facility would discharge the resident against medical advice (AMA). The responsible party said he/she was aware of the possible discharge of AMA and would have the resident back at the facility within 24 hours; -A progress note, dated 8/30/20, time unknown, showed the resident did not return to the facility and was discharged leave of absence (LOA) AMA; -There was no documentation showing the resident's personal belongings were collected from his/her room and packed up by the facility staff; -There was no documentation showing the facility notified the resident or the resident's representative to pick up his/her personal belongings after discharge; -There were no inventory sheets found in the medical record showing the resident's personal belongings during time of stay; -The facility was unable to provide an inventory upon request. The administrator wrote No inventory sheets were found for the resident on this surveyor's list of requested items. During an interview on 11/10/20 at 8:15 A.M., a representative for the resident said he/she called the facility to report the resident came home without his/her personal belongings, and instead had packed other resident's clothes. The facility told the representative they would try to locate the resident's belongings but never followed up. During an interview on 6/10/21 at 10:49 A.M., Licensed Practical Nurse (LPN) C said the following: -The resident's responsible party took the resident out of the building to view an apartment and never brought the resident back; -The resident was often confused and probably would not have been able to pack him/herself up with his/her own belongings; -He/she did not know if anyone packed up the resident's belongings. During an interview on 6/10/21 at 11:00 A.M., the accounting clerk said the following: -She worked in social services at time of the resident's discharge and the resident was on her caseload; -If a resident was discharged AMA, the staff from housekeeping or maintenance would pack the resident's belongings and notify social services, who would then notify the resident and/or resident's family to come and pick up the items; -She would make a note in the resident's medical record after she notified the resident and/or the resident's family to come and pick up personal belongings; -The last note she wrote in the resident's medical record was on 8/28/20 at 4:38 P.M.; -She did not know what happened to the resident's belongings. During an interview on 6/11/21 at 10:59 A.M., the accounting clerk said the following: -She checked with the maintenance department who said they could not locate a box of the resident's personal property; -She knew the resident didn't have any belongings, even though there was not an inventory sheet, because no one asked her about the resident's belongings and no one told her they boxed up any of the resident's personal property. 3. Review of Resident #376's medical record, showed the following: -admission date of 2/14/20; -Diagnoses included stroke, speech and language deficits and muscle weakness; -discharge date of 4/13/20 at 2:20 P.M.; -No inventory sheets found in the medical record showing the resident's personal belongings during time of stay. Review of a note written by the administrator showed, No inventory sheets were found for the resident on this surveyor's list of requested items. 4. Review of Resident #373's medical record, showed the following: -admission date of 2/11/20; -Diagnoses included depression and cognitive communication deficit; -A progress note, dated 3/30/20 at 11:38 P.M., showed the resident discharged home with medications; -No inventory sheets found in the medical record showing the resident's personal belongings during time of stay. Review of a note written by the administrator showed, No inventory sheets were found for the resident on this surveyor's list of requested items. 5. Review of Resident #425's medical record, showed: -admitted : 3/30/20; -Diagnoses included amputation, high blood pressure, high cholesterol, diabetes, end stage renal disease (ESRD, chronic irreversible kidney failure) and dependence on dialysis; -No inventory sheet. During an interview on 4/9/20 at 9:19 A.M., a representative for the resident said he/she had sent numerous pieces of clothing, many which had gone missing. During an interview on 6/9/21 at 1:30 P.M., the administrator said no inventory sheets were available for Resident #425. 6. Review of Resident #276's medical record, showed: -admission date of 6/3/20; -Diagnoses included dysphasia (loss of or deficiency in the power to use or understand language as a result of injury to or disease of the brain), aphasia (loss of ability to understand or express speech) and Parkinson's disease (a progressive nervous system disorder that affects movement); -No inventory sheet of personal belongings. Review of a note written by the administrator showed, No inventory sheets were found for the resident on this surveyor's list of requested items. 7. During an interview on 6/11/21 at 7:55 A.M., CNA Q said if an item was lost, he/she would look for the item and report it to the nurse. If a resident's item was broken or got broken, he/she would report it to the nurse and the nurse would document it. Sometimes when a resident is admitted to the facility, the family will label the resident's items. If the items are not labeled, the aides will label them. The aides complete the inventory sheets. If a family member brings items into the facility after admission, the items are added to the inventory sheet. 8. During an interview on 6/11/21 at 7:50 A.M., LPN P said if a resident has an item that is lost, the staff would look for the item. If the lost item was not found, staff would notify the social worker and call the family, because a family member might have taken something home and the resident forgot. When a resident is admitted to the facility, either the family or the aides label the resident's personal items with the resident's name. If the resident is alert, they will complete their own inventory sheet. If the resident or resident's representative does not complete the inventory sheet, the nurse aides will complete the inventory sheet. Inventory sheets are updated if items are brought in after admission. 9. During an interview on 6/10/20 at 11:20 A.M., the DON said the following: -Nursing staff were expected to fill out inventory sheets with resident's personal property at admission and keep it updated; -The inventory sheets were used to track items; -She expected maintenance or housekeeping staff to box up and secure resident's personal property and notify social services during the daily interdisciplinary team meeting; -She expected nursing staff to write a note in the resident's medical record, stating their personal belongings were boxed up and secured; -She expected social services to document when family was notified to pick up the resident's personal property, where it was secured, and if the belongings were picked up or not. 10. During an interview on 6/16/21 at 1:00 P.M., the administrator said that if a document was said to be unavailable, it meant the facility did not have that specific document. MO00177882 MO00168838 MO00183799

Based on interview and record review, the facility failed to disclose and provide to a resident or potential resident prior to time of admission, notice of service limitations of the facility. The facility is a smoking facility and the admission packet provided to residents identify the smoking area and smoking times. During the COVID-19 pandemic, the facility stopped allowing smoking at the facility, failed to grandfather in the current residents admitted prior to the rule change and failed to provide in writing to newly admitted residents the new rule that smoking was no longer allowed in the facility. The facility identified one resident who smoked (Resident #13). The survey team identified an additional two residents who smoked prior to being admitted to the facility and voiced the desire to smoke while at the facility (Residents #227 and #36). The facility also failed to ensure residents who signed the admission agreement were cognitively intact enough to sign a contract (Resident #232). The sample was 20. The census was 82. Review of the resident's bill of rights, provided to residents upon admission to the facility, showed: -The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; -The resident has the right to exercise his or her rights as a resident of the facility and as a citizen of the United States; -The resident has the right to be free from interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required; -The resident has the right to be informed, in advance, of changes to the plan of care. Review of the facility's admission packet, provided on 6/7/21 as the information provided to residents who admit to the facility, showed: -Section 10 Rules and regulations: -Resident responsibilities: You or your representative agree to comply with the current rules, regulations, policies and procedures of the facility. The facility will notify you or your representative of any changes to these responsibilities are required by law; -Smoking: Refer to the facility smoking procedures and smoking attachment incorporated into this agreement; -Smoking Facility: This facility strives to protect the public health and welfare of its residents, staff, and visitors by restricting smoking to designate areas on the grounds of this property; -This facility must ensure a resident's environment remains free of accidents as is possible and each resident receives supervision to prevent accidents including accidents related to cigarette smoking. This also includes the use of e-cigs which are considered the same as any tobacco product; -Therefore, while you are under our care, you and/or your representative agree to smoke supervised in the designated smoking area for your individual safety, as well as the safety of others in this facility, you may never smoke in your room or any other areas not specifically designated as a smoking permitted area you and or your representative agree that the facility may impose additional smoking procedures and/or restrictions as required by law; -You and or your representative understand that upon identification of any non-compliance to the smoking policy may result in your involuntary discharge due to potential harm to self and or others. You also understand in the event of any non-compliance by a family member or visitor, the facility will consider supervised visitation and or revocation of visiting privileges; -Smoking use protocol: -Within the facility, we strive to be smoke-free, therefore, smoking is prohibited in all areas of the facility; -Accommodations for resident smoking will be provided outside of the building, in the designated smoking location. Separate smoking areas will be maintained for residents and staff; -No-smoking signs will be posted in applicable areas within in the facility; -Residents who desire to use tobacco and/or e-cigs will only be permitted to do so based on clinical assessment and are deemed safe to do so; -Oxygen and its use is prohibited in smoking areas; -All residents desiring to smoke must do so in a supervised, designated area, at designated times; -Supervised smoking is scheduled as follows: 9:45 A.M.-10:00 A.M., 1:00 P.M.-1:15 P.M., 3:30 P.M.-3:45 P.M., 6:30 P.M.-6:45 P.M. and 8:30 P.M.-8:45 P.M.; -Two cigarettes and/or 15 minutes, whichever comes first will be the designated time frame for each smoking time; -Residents desiring to smoke must utilize safety equipment as deemed necessary by the smoking assessment such as smoking aprons, etc. failure to comply with, utilize of safety equipment as necessary will be deemed a violation of this protocol; -Smoking is not permitted, at any times, in any facility vehicle or mode of transportation; -Residents will not be permitted to maintain smoking paraphernalia on their person or in their room while residing at this facility. Examples include, but are not limited to: lighters, matches, cigarettes and e-sigs; -Smoking cessation programs are available at the request of the resident/representative; -Education regarding the facility's smoking policy will take place upon admission an as needed and upon change in protocol; -Upon identification of non-compliance to this protocol, the resident/representative will be reeducated regarding the smoking policy and smoking paraphernalia will be confiscated and the resident may be issued and immediate discharge; -Inclement weather may cancel a scheduled smoke time and will be made at the digression of the executive director. The designated smoke area may be changed at the direction of the executive director; -Residents are responsible for purchasing their own smoking materials; -Family, visitors, responsible parties and guests will be allowed to take residents to smoke in designated areas. Visitor must follow all established protocols for smoking safety, including use of adaptive smoking equipment; -Facility smoking schedule: -Dietary department 9:45 A.M. to 10:00 A.M.; -Activities department 1:00 P.M. to 1:15 P.M.; -Business office 3:30 P.M. to 3:45 P.M.; -Housekeeping 6:30 P.M. to 6:45 P.M.; -Laundry department 8:30 P.M. to 8:45 P.M.; -On the weekend, the weekend manager will fill the 1:00 P.M. to 1:15 P.M. and 3:30 P.M. to 3:45 P.M. time slot. 1. Observation on 6/9/21 at 5:35 P.M., of the courtyard, located just outside of the dining room, showed weeds grew up between the concrete. Trees and bushes overgrown and hung over and onto to walkways. A shade umbrella lay across the patio walkway. One weed grew between the concrete waist high and one chest high. Several other smaller weeds grew up between the concrete. During an interview on 6/7/21 at 8:48 A.M., the administrator said there was smoking at the facility pre-COVID. She was told when she started that staff were not able to socially distance with the residents who smoked and that is why the facility stopped allowing the residents to smoke. On 6/11/21 at 1:56 P.M., the administrator said the smoking area was in the courtyard. On 6/14/21 at 2:20 P.M., the administrator said she was not able to find documentation to show the residents were notified in writing that the facility stopped allowing smoking during the COVID-19 pandemic. 2. Review of the list of residents who smoke, dated 6/11/21, showed one resident, Resident #13 listed. Review of Resident #13's smoking safety evaluation, dated 3/25/21, showed: is the resident receptive to smoking cessation options: Undecided at this time. During an interview on 6/8/21 at 10:55 A.M., the resident said when COVID-19 started, the facility said residents cannot smoke anymore. That was a form of enjoyment and time to socialize. They just took that away. 3. Review of Resident #227's medical record, showed no smoking assessment completed. During an interview on 6/7/21 at 2:53 P.M., the resident said he/she is a smoker and wished he/she could smoke now. He/she was told when admitted that smoking is not allowed. He/she wished he/she could just go outside. He/she had not been outside since being admitted . 4. Review of Resident #36's smoking safety evaluation, dated 10/9/20, showed: is the resident receptive to smoking cessation options: No. During an interview on 6/9/21 at 1:02 P.M., the resident said staff tell him/her that he/she cannot smoke, but employees who work at the facility are allowed to smoke. They go outside and smoke. He/she can see them. 5. Observation on 6/9/21 at 1:14 P.M., showed two employees smoked cigarettes in the employee smoking area located outside the kitchen. Observation on 6/9/21 at 3:41 P.M., showed two staff outside the conference room window at the end of the administration hallway, smoking. The area was not identified as a designated smoking area during the life safety/fire safety tour. 6. During an interview on 6/14/21 at 8:53 A.M., admission Director B said she was the admissions director at the facility until just recently. He/she could not recall what information was provided to residents upon admission. 7. During an interview on 6/14/21 at 1:56 P.M., the administrator said when a resident is admitted , it is the responsibility of the admissions director to determine if the resident smoked. In addition, the social services director and nursing staff will assess this. A smoking assessment should be completed on any resident admitted that smokes. The smoking area for staff is outside near the kitchen area. When she first arrived to the facility approximately a month ago, she was told residents could not smoke because staff were not able to monitor them while social distancing. The resident smoking area is in the courtyard. If staff are able to smoke onsite, it would be appropriate for the residents to smoke as well. She is not sure how the decision was made to not allow smoking for the residents. She is not sure if residents who resided at the facility prior to the COVID-19 pandemic were provided written and verbal notification of the rule change or if residents admitted since the rule change were notified in writing, she will check. The admission packet provided is the admission packet provided to the residents. She is not sure what the plan is for allowing the residents the right to smoke. Corporate has been discussing this but no final word has been passed down. At 2:20 P.M., the administrator said she was not able to find any written notification provided to residents regarding smoking not being allowed. 8. Review of the facility's Resident admission Agreement, last revised in 2018, showed: -The Resident admission Agreement is a binding legal contract. Please read it carefully before signing to make sure you fully understand its terms and the obligations you are assuming; -This document includes the agreement, which explains the services, charges, rules and regulations understood and agreed upon by the nursing facility, resident and any other parties involved. Also included are various attached materials, which must be signed by the parties, as indicated. 9. Review of Resident # 232's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/3/21, showed: -An admission date of 2/24/21; -Severe cognitive impairment; -Diagnoses included dementia, cognitive communication disorder and hypothyroidism. Review of the resident's medical record, showed: -A signed Durable Power of Attorney for Health Care (DPOA, a document that lets an individual name someone else to make decisions about their health care in case the individual is not able to make those decisions) dated 3/13/18, naming the resident's family member as the DPOA for health care decisions; -A nurse's note, dated 2/25/21 at 4:00 A.M., resident alert and very confused/disoriented to place and time and requires frequent redirecting; -A physician's history and physical note, dated 2/25/21 at 12:04 P.M., showed the resident was alert to self only; -An undated Intake Report, showed the resident's neurological status was confused. Review of the resident's admission Agreement, dated 2/25/21, completed by admission Director B, showed the resident's initials on the following documents: -Treatment and Financial Responsibility Agreement; -Mail Handling; -Authorization for Release of Information; -Transfer within the Facility; -Medicaid Referral form; -Privacy Act Statement-Health Care Records; -Notice of Privacy Practices; -Informed Decision Regarding Nursing Facility admission and Acknowledgements of admission Agreement; -All areas to be signed by the resident's representative were left blank. During an interview on 3/19/21, the resident's representative said he/she never signed any admission paperwork. During an interview on 6/11/21 at 8:45 A.M., the Director of Nursing (DON) said the resident was very confused. During an interview on 6/11/21 at 9:22 A.M., the facility social worker (SW) said the resident was not appropriate to sign paperwork. The resident was alert and oriented to person and sometimes place. The resident would have been too confused to understand what he/she was signing. Admissions Director B was the admission counselor at the time when the resident was admitted . During an interview on 6/11/21 at 12:11 P.M., Admissions Director B said he/she was the admission counselor in February 2021. He/she could not remember the specific resident. He/she assesses residents to determine comprehension before completing the Resident admission Agreement. If they are not able to comprehend, she will reach out to the family to complete the paperwork. Sometimes a resident is more cognitively intact initially and declines over time. He/she can assess comprehension based on if a resident is able to understand and say Yes they want to do the paper work, even if they are only alert and oriented to self. If a resident is able to answer hello, how they are doing and if they want to quickly complete paper work, he/she will proceed with completing the packet. If a resident does not acknowledge him/her or just stares at him/her, then he/she will not proceed with the paperwork. During an interview on 6/16/21 at approximately 10:10 A.M., the administrator said it was not acceptable to have the resident fill out the admission paperwork. Admissions Director B should have reached out to the DPOA or next of kin. The facility did not do their due diligence in this matter. MO00182981

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure notification to the resident and the resident's representative in writing of a discharge, including the reason for the discharge, the effective date of the discharge, the location to which the resident is discharged and a statement of the resident's appeal rights. The facility also failed to follow their transfer or discharge policy for 9 of 20 sampled residents (Residents #25, #57, #227, #223, #23, #61, #71, #276, and #67). The census was 82. Review of the facility's policy for Transfers and Discharges, dated 5/16/19, showed before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move, in writing. 1. Review of Resident #25's medical record, showed: -discharged to the hospital 3/16/21; -Returned to the facility from the hospital on 3/24/21; -No transfer notice provided for the hospitalization on 3/16/21 through 3/24/21. 2. Review of Resident #57's medical record, showed: -Dscharged to the hospital 2/3/21; -Returned to the facility from the hospital on 2/5/21; -No transfer notice provided for the hospitalization on 2/3/21 through 2/5/21. 3. Review of Resident #227's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, submission history, showed: -admitted on [DATE]; -discharged on 6/9/21. Review of the resident's nurses notes, dated 6/9/21 through 6/15/21, showed no documentation the resident and/or their representative was provided a written notice and/or copy of the written notice at the time of the transfer in the resident's medical record. 4. Review of Resident #223's MDS submission history, showed: -admitted on [DATE]; -discharged on 6/8/21. Review of the resident's nurses notes, dated 6/4/21 through 6/15/21, showed no documentation the resident and/or their representative was provided a written notice and/or copy of the written notice at the time of the transfer in the resident's medical record. 5. Review of Resident #23's MDS, admission and discharge assessments, showed: -admission date of 4/21/19; -discharged to the hospital 3/28/21; -readmission to the facility 4/1/21; -No documentation the resident and/or their representative received written notice of the resident's transfer. Review of the resident's nurses notes, dated 3/28/21 through 4/31/21, showed no documentation the resident and/or their representative was provided a written notice and/or copy of the written notice at the time of the transfer in the resident's medical record. 6. Review of Resident #61's MDS admission and discharge assessments, showed: -admission date of 2/4/20; -discharged to the hospital 5/26/21; -readmission to the facility 6/4/21; -No documentation the resident and/or their representative received written notice of the resident's transfer. Review of the resident's nurses notes, dated 5/26/21 through 6/4/21, showed no documentation the resident and/or their representative was provided a written notice and/or copy of the written notice at the time of the transfer in the resident's medical record. 7. Review of Resident #71's MDS admission and discharge assessments, showed: -admission date of 12/31/19; -discharged to the hospital 3/17/21; -readmission to the facility 3/20/21; -discharged to the hospital 5/2/21; -readmission to the facility 5/13/21. Review of the resident's nurses notes, dated 3/17/21 through 3/31/21 and 5/2/21 through 5/13/21, showed no documentation the resident and/or their representative was provided a written notice and/or copy of the written notice at the time of the transfers in the resident's medical record. 8. Review of Resident #276's face sheet, showed: -admitted on [DATE]; -discharged on 6/16/20; -Diagnoses included dysphasia (loss of or deficiency in the power to use or understand language as a result of injury to or disease of the brain), aphasia (loss of ability to understand or express speech), and Parkinson's disease (a progressive nervous system disorder that affects movement). Review of the resident's nurse's notes, dated 6/16/20, showed: -The resident experienced a change in condition; -The resident's physician was notified and a physician's order was obtained to send the resident to the emergency room; -The resident left for the emergency room via ambulance. Further review of the resident's closed medical record, showed no transfer notice. Review of a note written by the administrator showed the transfer notice was unavailable. During an interview on 6/16/21 at 1:00 P.M., the administrator said that if a document was said to be unavailable, it meant the facility did not have that specific document. 9. Review of Resident #67's MDS, admission and discharge assessments, showed: -admission date of 5/5/21; -discharged to the hospital 5/12/21; -readmission to the facility 5/14/21; -No documentation the resident and/or their representative received written notice of the resident's transfer. Review of the resident's nurses notes, dated 5/12/21 through 5/31/21, showed no documentation the resident and/or their representative was provided a written notice and/or copy of the written notice at the time of the transfer in the resident's medical record. 10. During an interview on 6/16/21 at 10:00 A.M., the Director of Nursing (DON) said the following: -The person responsible for providing transfer notices would be the floor nurse who is discharging or transferring the resident to the hospital; -Transfer notices can be found under assessments if the resident had a change of condition; -Transfer notice copies are given to emergency medical services (EMS); -The transfer notice is recorded on the facility's database; -There is no documentation on the facility's database to verify written transfer notices are given to the residents or the residents' representative; -She expected a copy of transfer notices to be kept on file. 11. During interviews on 6/9/21 at 1:30 P.M and 6/11/21 at 9:14 A.M., the administrator said there was no transfer notice documentation for the above residents. She expected staff to complete them, but they currently are not being completed. She expected the notice of the resident's transfer to be completed at the time of transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform the resident and family or legal representative of the bed hold policy at the time of transfer to the hospital for various medical reasons for eight of 20 sampled residents (Residents #35, #23, #71, #57, #227, #67, #276 and #25) The census was 82. Review of the facility's Bed Hold/Reservation of Room Policy, dated 5/2/19, included the following: -The facility's bed hold policy will be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or the resident goes on therapeutic leave of absence; -The facility will provide written information to the resident or resident's representative the nursing facility policy on bed-hold periods and the resident's return to the facility to ensure that residents are made aware of the facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility; -Procedure: 1. Bed hold policies will be provided and explained to the resident or responsible party upon admission and explained to the resident before each temporary absence; 2. Before the resident transfers to a hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident and responsible party that specifies: -The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; -The reserve bed payment policy in the state plan, if any; -The facility's policies regarding bed-hold; -In cases of emergency transfer, notice at the time of transfer means that the family, surrogate or responsible party are provided with written notification within 24 hours of the transfer. 1. Review of Resident #35's medical record, showed: -discharged to the hospital 2/12/21; -Returned to the facility from the hospital on 2/16/21; -No bed hold policy provided for the hospitalization on 2/12/21-2/16/21. 2. Review of Resident #23's Minimum Data Set (MDS) admission and discharge assessments, showed: -admission date to the facility 4/21/19; -discharged to the hospital 3/28/21; -Returned to the facility from the hospital on 4/1/21. Review of the resident's medical record, showed no documentation the resident and/or resident's representative received written notice of the facility's bed hold policy at the time of the transfer. 3. Review of Resident #71's MDS admission and discharge assessments, showed: -admission date to the facility 12/31/19; -discharged to the hospital 3/17/21; -Returned to the facility from the hospital on 3/20/21; -discharged to the hospital 5/2/21; -Returned to the facility from the hospital on 5/13/21. Review of the resident's medical record, showed no documentation the resident and/or resident's representative received written notice of the facility's bed hold policy at the time of the transfers. 4. Review of Resident #57's medical record, showed: -discharged to the hospital on 2/3/21; -Returned to the facility from the hospital on 2/5/21; -No bed hold policy provided for the hospitalization on 2/3/21-2/5/21. 5. Review of Resident #227's medical record, showed: -Nurse's note, dated 6/9/21, staff sent the resident to the hospital; -Nurse's note, dated 6/11/21, the resident remains in the hospital; -Nurse's note, dated 6/14/21, the resident was discharged from the hospital to a different nursing home. Review of the resident's electronic and paper charts, showed no documentation the resident and/or their representative received information in writing of the facility's bed hold policy at the time of transfer on 6/9/21. 6. Review of Resident #67's MDS admission and discharge assessments, showed: -admission date to the facility 5/5/21; -discharged to the hospital 5/12/21; -Returned to the facility from the hospital on 5/14/21. Review of the resident's medical record, showed no documentation the resident and/or resident's representative received written notice of the facility's bed hold policy at the time of the transfer. During an interview on 6/9/21 at 1:30 P.M., the administrator said they did not have documentation that the bed hold notice was given at the time of transfer to the hospital. He/she would expect the bed hold notice to be completed at the time of the transfer. 7. Review of Resident #276's face sheet, showed: -admitted on [DATE]; -discharged on 6/16/20; -Diagnoses included dysphasia (loss of or deficiency in the power to use or understand language as a result of injury to or disease of the brain), aphasia (loss of ability to understand or express speech), and Parkinson's disease (a progressive nervous system disorder that affects movement). Review of the resident's nurse's note, dated 6/16/20, showed: -The resident experienced a change in condition; -The resident's physician was notified and a physician's order was obtained to send the resident to the emergency room; -The resident left for the emergency room via ambulance. Further review of the resident's medical record, showed the resident was expected to return. There was no letter notifying the resident and/or the resident's representative of the facility's bed hold policy. Review of the resident's medical record, showed the resident did not return to the facility. Review of the list of surveyor requested documents, showed the administrator wrote the resident's bed hold letter was unavailable. During an interview on 6/16/21 at 1:00 P.M., the administrator said that if a document was said to be unavailable, it meant the facility did not have that specific document. 8. Review of Resident #25's medical record, showed: -discharged to the hospital 3/16/21; -Returned to the facility from the hospital on 3/24/21; -No bed hold policy provided for the hospitalization on 3/16/21-3/24/21. 9. During an interview 6/16/21 at 10:00 A.M., the Director of Nursing (DON) said the following: -The person responsible for providing the bed hold policy notices would be the floor nurse who is discharging or transferring the resident; -Bed hold policy notices can be found under assessments if the resident had a change of condition; -Bed hold policy notice copies are given to emergency medical services (EMS); -The usual process is for the bed hold policy notice to be recorded on the facility's data base; -There is no documentation on the facility's data base to verify written bed hold policy notices were provided to the residents or their representatives; -She would expect a copy of bed hold policy notices to be kept on file.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain vitals and neurological checks for a resident who had fallen (Resident #425), ensure physician's orders were obtained/followed for tube feedings and oxygen, and ensure braces, splints, or palm guards were applied as ordered, for five of 20 sampled residents (Residents #67, #23, #54 and #22). The census was 80. 1. Review of the facility Fall Management Policy, dated 6/4/20, showed: -Purpose: To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patient fall indicators; -Definition: Fall: refers to unintentionally coming to rest on the ground, floor, or other lower level. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he/she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Review of the facilities Neurological Assessment Policy, dated 5/15/20, showed: -Purpose: A neurological assessment is an indispensable tool for quickly checking a resident's neurological status. This procedure supplements the routine measurement of vital signs (VS) (such as temperature, pulse rate, blood pressure and respirations) by evaluating a resident's level of consciousness (LOC), pupil activity, motor response, and orientation to time, place and person; -Policy: the neurological check list user defined assessment (UDA) in Point click care (computer program) shall be initiated by a written physician's order for neurological checks or when indicated by resident assessment (example given, post fall); -Procedure: The assessing nurse initiates the neurological check list; -The neurological check list shall remain a permanent part of the resident's medical record. Review of Resident #425's medical record, showed: -admitted : 3/30/20; -Diagnoses included: amputation, high blood pressure, high cholesterol, diabetes, end stage renal disease (ESRD, chronic irreversible kidney failure), dependence on dialysis; -Needed supervision with hygiene and extensive assistance of staff for bed mobility, locomotion, dressing, toilet use and bathing. Needed total assistance of staff for transfers. Review of the resident's progress notes, showed: -Late entry for 4/9/20 at 6:08 P.M., slid off bed, low to floor approximately 3-4 inches, sitting on floor, beside bed. Lethargic, confused doesn't respond verbally at times. No injury, Vital signs stable, message left for on call daughter. Temperature (T): 96.4; -Documentation showed: no post fall Pulse (P), Respirations (R) or Blood Pressure (B/P) documented at time of incident; -No documentation showing the medical doctor (MD) was notified; -No night shift post fall VS documented; -On 4/10/20: -Documentation showed: no day, evening or night shift post fall VS documented; -On 4/11/20: -Documentation showed: at 4 P.M., T: 98.9, no other VS was documented; - No day or night shift post fall VS documented. -Further review of the residents progress notes, showed: -On 4/13/20 at 8:46 A.M., resident on floor, he/she was assisted up. Resident's family was notified. -At 9:02 A.M., patient up in wheelchair with call light in reach. Alert and orientated times four. Denies pain or discomfort. On incident follow up due to fall this shift. No concerns with assessment; -Documentation showed: no VS or neuro (neurological) checks documented post fall; -No documentation showing MD was notified; - No evening or night shift post fall VS documented; -On 4/14/20: -Documentation showed: no night shift post fall VS documented; -On 4/15/20: -Documentation showed: no evening or night shift post fall VS documented; -On 4/16/20: -Documentation showed: at 4:50 P.M. T: 98.2 no other VS was documented; -No day shift post fall VS documented Further review of the resident's progress notes, showed: -On 4/20/20 at 3:45 P.M., resident went to his/her room and tried to transfer self into bed, made it half way into bed. Assisted the rest of the way into bed and assessed for injury. MD, Director of Nursing (DON) and family notified; -Documentation showed no VS documented time of incident; -On 4/21/20: -Documentation showed: no evening P, R, B/P documented and no night shift post fall VS documented; -On 4/22/20: -Documentation showed: no day or night shift post fall VS documented. Further review of the resident's progress notes, showed: -On 4/23/20 at 7:50 P.M., resident noted trying to turn off light, noted sliding to the floor. VS, T: 98.2, P: 72, R: 20, B/P: 115/73, call placed to the MD, awaiting call back; -No documentation showing the family was notified; -No night shift post fall VS documented; -On 4/24/20: -Documentation showed: no day, evening or night shift post fall VS documented; -On 4/25/20: -Documentation showed: no evening or night shift post fall VS documented; -On 4/26/20: -Documentation showed: no day shift post fall VS or evening P, R, B/P was documented. Further review of the resident's progress notes, showed: -On 5/1/20 at 4:32 P.M., resident noted almost out of his/her wheelchair with one knee on the floor. MD and family aware. -Documentation showed: no vital signs were documented; -On 5/2/20: -Documentation showed: no documentation for days, evening or night shift for post fall VS documented; -On 5/3/20: -Documentation showed: no documentation for days, evening or night shift for post fall VS documented; -On 5/4/20: -Documentation showed: no documentation for days, evening or night shift for post fall VS documented. During an interview on 6/11/21 at 7:50 A.M., Licensed Practical Nurse (LPN) P, said if a resident falls, the nurse would assess the resident. Vital signs and a neuro check would be completed. If the resident is ok, the resident will be transferred to the chair. The family, MD, DON and the on call person would be notified. VS are done for three days on every shift. If the fall was unwitnessed or if the resident hits their head, VS and neuro checks would be done for three days. There is a scale in the computer for completing the VS with the neuro checks. The fall would be documented in the computer and on the report sheet. During an interview on 6/14/21 at 2:00 P.M., the DON said a fall is an unintentional change of plane. If a resident was sliding to the floor, slid off a low bed to floor, was found on floor, was almost out of his/her wheelchair with one knee on the floor, these would be considered a fall. If a resident falls, staff should complete an incident packet and get statements on the floor that the fall took place. Staff would notify the family, MD, DON or the on call person. Staff would assess the resident, do a pain assessment and neuro checks if the fall was unwitnessed or if the resident hit their head, or as needed. Falls are discussed at the daily meeting and the interventions put into place at the time of the fall are reviewed. VS are checked every shift for 72 hours after a fall and documented in the resident's chart. Neuro checks have a template in the computer. Documentation after a fall should include if the resident was having pain and any new bruising. Sometimes the nurses use the skilled daily charting for the post fall documentation. The DON verified there were no neuro assessments completed for the incidents dated 4/9, 4/13, 4/20, 4/23 and 5/1/20, and there were limited VS documented in the progress notes. The DON would expect staff to document VS every shift for 72 hours and complete neuro checks if the resident hits their head or if the fall was unwitnessed. The family and the MD should be notified. 2. Review of Resident #67's medical record, showed: -admitted [DATE]; -Diagnoses included: traumatic subdural hemorrhage (bleeding that often occurs outside the brain as a result of a severe head injury) without loss of consciousness, high blood pressure, schizophrenia (a mental condition that causes both psychosis (a loss of contact with reality) and mood problems), heart failure and dementia without behavioral disturbance. Review of the Resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/18/21, showed: -Severe cognitive impairment; -Needed extensive assistance of staff for eating, dressing, toilet use, personal hygiene and total assistance for transfers and bathing; -Always incontinent of bowel and bladder; -Had a feeding tube. Review of the Resident's physician order sheet (POS), in use at time of survey, showed: -An order for Jevity 1.5 (nutritional supplement) tube feeding at 8:00 P.M., at 60 milliliters (ml)/hour in the evening for supplement, start date: 5/26/21; -An order for Jevity 1.5 tube feeding at 8:00 P.M., at 70 ml/hour, start date: 6/11/21. Review of the resident's progress notes, showed on 6/11/21, Diet order is Mechanical Soft with 70 ml Jevity 1.5 every hour times 12 hours. Receives 150 ml water (H20) Flush every (q) 4 hours. Would change flush to 240 ml four times a day (QID) to reduce frequency of flushing. Discussed with DON. Change to implemented. Observation on 6/14/21 at 6:15 A.M., showed the resident asleep in bed, with Jevity 1.5 tube feeding infusing at 60 ml/hour. Further observation, on 6/15/21 at 6:28 A.M., showed the resident lay in bed awake, with Jevity 1.5 tube feeding infusing at 60 ml/hour. During an interview on 6/16/21 at 10:00 A.M., the DON, said when the dietician makes a recommendation, the dietician e-mails the recommendation to the administrator and the DON. The doctor is notified of the recommendation. If new orders are received, the orders are entered into the computer and appear on the medication administration record (MAR). The rate on the tube feeding pump should be changed when the order is changed. The nurse on the floor is responsible to check the MAR to verify the rate of the tube feeding is correct. 3. Review of Resident #23's medical record, showed: -An admission face sheet, showed an admission date of 4/21/19 and a readmission date of 4/1/21; -Diagnoses included acute respiratory distress (condition that occurs when fluid fills up the air sacs in the lungs) and traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head). Review of the resident's current POS, dated June 2021, showed: -An order dated 5/26/21, to administer oxygen at 2 liters (L) continuously per nasal cannula (NC, device inserted into the nares to deliver oxygen); -An order dated 5/26/21, to administer oxygen at 2 L as needed (PRN). Observations during the survey, showed: -On 6/8/21 at 5:50 A.M., 9:28 A.M., and 12:40 P.M., the resident lay in the bed with oxygen infusing at 3 liters per NC per oxygen concentrator (medical device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen); -On 6/9/21 at 7:05 A.M., the resident lay in the bed with oxygen infusing at 2.5 L per NC per oxygen concentrator; -On 6/9/21 at 12:14 P.M., the resident lay in the bed with oxygen infusing at 3 L per NC per oxygen concentrator; -On 6/11/21 at 6:30 A.M. and 6:58 A.M., the resident lay in the bed with oxygen infusing at 3 L per NC per oxygen concentrator; -On 6/14/21 at 8:30 A.M., the resident lay in the bed with oxygen infusing at 3 L per NC per oxygen concentrator. During an interview on 6/16/21 at 10:00 A.M., the DON said she expected nursing staff to follow all physician's orders to direct care for the residents. The charge nurse is responsible to ensure the resident's oxygen is infused as ordered and she expected the resident's oxygen to be administered as ordered. 4. Review of Resident #54's admission MDS, dated [DATE], showed: -An admission date of 5/5/21; -Moderate cognitive impairment; -Required extensive assistance from staff for transfers, toileting, personal hygiene and dressing. Required supervision for eating; -Diagnoses included heart failure, end stage renal disease, stroke and Parkinson's disease (A disorder of the central nervous system that affects movement, often including tremors). Review of the residents medical record, showed: -A readmission date of 5/26/21; -Hospital discharge orders, dated 5/26/21, showed: Other instructions: Oxygen Saturation (the amount of oxygen circulating in the blood). Check PRN for respiratory distress or change in patient's condition per PRN assessment. Oxygen instructions: Two L (Flow rate for supplemental oxygen). Observation of the resident, showed: -On 6/7/21 at 12:54 P.M. and 2:00 P.M., on 6/8/21 at 12:38 P.M. and 2:05 P.M. and on 6/9/21 at 1:09 P.M., the resident wore a NC and it was hooked up to the wall oxygen supply. The pressure regulator showed the flow rate set at 2 L; -On 6/10/21 at 8:40 A.M., and 1:34 P.M. the resident wore the NC with the flow rate set at 3 L; -On 6/11/21 at 6:31 A.M., the resident lay in bed on his/her side with his/her eye closed. The NC laid on the floor under the resident's bed; -On 6/11/21 at 1:18 P.M., the resident wore the NC and said sometimes it falls off when he/she rolls over in bed. The flow rate was set at 1.5 L. Review of the resident's progress notes, showed: -A nurse's note on 6/7/21 at 12:14 P.M., the resident complaint of shortness of breath (SOB) and is sleepy with no further concerns. Oxygen at 2 L per NC applied. Notified resident's physician and family member; -On 6/8/21 at 11:45 A.M., 6/9/21 at 10:48 A.M., 6/10/21 at 10:34 A.M., 6/11/21 at 1:12 P.M., 6/12/21 at 11:24 P.M., 6/13 at 11:59 P.M. and 6/14/21 at 11:06 A.M., staff documented the resident wore oxygen via NC at 2 L. Review of the resident's June 2021 POS, showed no order for oxygen therapy, flow rate, route or diagnosis. During an interview on 6/11/21 at 1:56 P.M., the DON said an order is required for oxygen. The orders should include the rate, route, reason and how often. Further review of the resident's medical record, showed: -A readmission date of 5/26/21; -A Diet Order & Communication form, dated 5/26/21, for regular diet, mechanical soft texture. Further observations of the resident, showed: -On 6/8/21 at 12:55 P.M., 6/9/21 at 1:05 P.M., 6/14/21 at 8:30 A.M. and 6/15/21 at 8:19 A.M. and 12:00 P.M., the resident was served a mechanical soft textured diet; -On 6/8/21 at 11:45 A.M., 6/10/21 at 8:40 A.M. and 6/15/21 at 2:03 P.M., the resident sat up in his/her wheelchair with a foam hip abductor (used to prevent the hip from moving out of the joint) placed between his/her legs; -During an interview on 6/9/21 at 1:10 P.M., the resident said staff sometimes places the foam hip abductor between his/her legs. It is uncomfortable and he/she doesn't like it. Further review of the resident's June 2021 POS, showed: -No order or indication for a hip abductor; -An order, dated 6/14/21, for a regular textured diet. During an interview on 6/16/21 at 10:00 A.M., the DON said the admitting nurse is responsible for obtaining the diet order and transcribing it on to the POS. She expected orders to be correct. An order is required for the use of a hip abductor. 5. Review of Resident #22's medical record, showed: -Diagnoses included muscle weakness, cognitive communication deficit, Multiple Sclerosis (MS, a disease in which one's immune system attacks the protective barrier of nerves), contracture (shortening and hardening of connective tissues resulting in deformed, rigid joints) and quadriplegia (paralysis of all four limbs); - A quarterly MDS, dated [DATE], showed: -A Brief Interview for Mental Status (BIMS) score of 7 out of possible 15; -A BIMS score of 0-7 showed the resident with severe cognitive impairment; -Required extensive assistance with bed mobility, transferring, dressing, eating, toileting and personal hygiene; -Functional limitation in range of motion in bilateral (both sides) upper extremities (shoulders, elbows, wrists and hands) and bilateral lower extremities (hips, knees, ankles and feet); -Always incontinent of urine and bowel movements; -Dependent of staff for wheelchair mobility; -At risk for developing pressure ulcers (injuries to skin and underlying tissue due to prolonged pressure on the skin); -Splint or brace assistance noted as not occurring any of the 7 calendar days prior to the MDS assessment; -An occupational therapy note, dated 1/1/21, showed: -Prior therapy service 10/15 - 26/20, with treatment outcome of bilateral palm guards (protective devices made of soft material that are applied to the hands to prevent fingernails from digging into the palms) being provided; -An order, with a start date of 11/6/20, showed: -Late entry for 10/27/20: patient to wear bilateral palm guard up to 6 hours daily; -A care plan, in use at the time of survey, showed: -Need for bilateral palm guards not addressed; -The Treatment Administration Record (TAR), dated 6/2021, did not include the order for bilateral palm guards. Observation on 6/7/21 at approximately 8:55 A.M., showed the resident with a left hand contracture and not wearing palm guards. Observation on 6/7/21 at 3:22 P.M., showed the resident did not have a wedge positioned under his/her left trunk or a pillow under his/her head on the left side. Resident was not wearing palm guards. Therapy instructions hung on the wall to the right side of the resident's bed, included: -Small wedge on left side of trunk; -Pillow on left side of head; -Right upper extremity to be elevated at all times. Observations on 6/7/21 at 1:05 P.M., on 6/9/21 at 10:31 A.M. and 5:54 P.M., on 6/10/21 at 8:06 A.M. and on 6/11/21 at 6:31 A.M., showed the resident lay in bed without palm guards on his/her bilateral hands. 6. During an interview on 6/15/21 at 12:15 P.M., the DON stated she expected staff to ensure medical equipment, noted on residents' orders, are utilized by the residents. The need for said equipment should be included in the care plan so that it could roll over to the [NAME] (a filling system for orders and nursing records). The certified nursing assistants (CNAs) can see the [NAME]. CNA Q was responsible for applying braces, palm guards and hand splints to the residents; nurses were responsible for verifying the application of these devices. However, all CNAs would be responsible for applying these devices, moving forward. There was not an active process in place to communicate to staff which residents required braces, splints or palm guards, but the facility planned to add it to the point of care documentation. Application of these devices should be documented on the TAR, but this was not consistently occurring across the board. MO00168954 MO00180625 MO00180647

Based on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional. The facility's activity director had worked at the facility for approximately four months and did not meet the requirements to be the activity director. The census was 82. Review of the activity director's resume and application for employment, showed: -Education: Bachelor of Science in Wellness with an emphasis in Kinesiology (body movement and positioning); -Work experience included experience as a Maître D (food service specialist) and home services provider (cleaning, cooking and shopping); -Volunteer experience in the Month of April, 2019 at a long term care facility in the activity program; -No documentation of certification in a state approved activity director training course; -No documentation of 2 years experience in a social/recreational program with one year full time in a therapeutic activity program. During an interview on 6/10/21 at 1:07 P.M., the activity director said she is the only activity staff person in the building. She has been the activity director at the facility for four months. During an interview on 6/11/21 at 1:56 P.M., the administrator said she is not sure if the activity director had taken any activity director courses that would make her eligible for certification as an activities professional, if she had 2 years experience in a social/recreational program with one year full time in a therapeutic activity program or if she completed a training course approved by the state. She is not aware of any steps taken by the facility to ensure these qualifications are met. She would expect the activity director to be qualified if holding the position. On 6/14/21 at 2:20 P.M., the administrator said they were not able to verify the activity director is qualified to hold the position. The facility is moving forward with hiring a more qualified activity director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to adequately monitor and provide assistance to promote good nutrition and to maintain acceptable parameters of nutritional status. Staff failed to ensure a timely nutrition assessment by the Registered Dietician (RD), failed to ensure response to the RD recommendation regarding resident weight loss, failed to notify the physician of significant weight loss, failed to implement interventions regarding nutrition per the care plan (Residents #54, #227 and #235). Furthermore, staff failed to provide meal assistance as needed, ensure the resident was positioned at a 90 degree angle when eating, and provide health shakes as ordered (Resident #324). The sample was 20 and the census was 82. 1. Review of Resident #54's care plan, initiated on 5/6/21 and in use during the survey, showed: -Focus: At risk for weight fluctuation related to current health status; -Goal: Resident wishes to maintain current weight through next review; -Interventions included assistance with meals as needed, diet order (specify), educate resident and family on storage and preparation of outside food, educate resident and family on potential for weight fluctuation. Review of Resident #54's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/12/21, showed: -An admission date of 5/5/21; -Moderate cognitive impairment; -Required extensive assistance from staff for transfers, toileting, personal hygiene and dressing. Required supervision for eating; -Weight: 166 pounds; -Special treatments while a resident: Dialysis (the process of removing excess water, solutes, and toxins from the blood when the kidneys can no longer perform these functions naturally); -Diagnoses included heart failure, end stage renal disease, stroke and Parkinson's disease (A disorder of the central nervous system that affects movement, often including tremors). Review of the resident's weight summary, showed the following weights (pounds): -5/12/21, 166.0, dry weight (weight without the excess fluid that builds up between dialysis treatments).; -5/20/21, 143.0, dry weight; -5/27/21, 150.0, dry weight. Review of the resident's medical record on 6/10/21, showed: -A discharge date of 5/16/21; -A readmission date of 5/26/21; -A Diet Order & Communication form, dated 5/26/21, for regular diet, mechanical soft texture; -No physician ordered diet; -No admission nutrition assessment completed by the facility's RD; -No documentation or interventions regarding the resident's 13.8% weight loss on 5/20/21; -No documentation or interventions regarding the resident's 9.6% weight loss on 5/27/21. Observations on 6/8/21 at 12:55 P.M. and 6/9/21 at 1:05 P.M., showed the resident received a mechanical soft textured diet meal. During an interview on 6/11/21 at 9:14 A.M., the administrator said the RD should be notified upon admission of a new resident. She should be doing a weekly check and would expect a nutritional assessment to be completed within 48 hours of admission. She would expect there to be an assessment for this resident. Further review of the resident's medical record, showed a nutrition progress note completed by the RD on 6/11/21 at 12:10 P.M. included the following: Resident is at 150 pounds with weight loss then weight gain since admission. Weight fluctuations expected secondary to dialysis. Likely fluid shifts. Estimated needs met, but would add 30 milliliters (ml) liquid Prosource (protein nutrition supplement) twice a day and obtain renal labs. Would also request to post diet order on the physician's orders sheet (POS). During an interview on 6/11/21 at 12:50 P.M., the RD said she would ideally like to assess new residents within the first week of admission. Further review of the resident's medical record on 6/14/21 at 9:15 A.M., showed: -An order, dated 6/14/21, for a regular textured diet; -No orders for 30 ml Prosource twice a day or for renal labs. During an interview on 6/14/21 at 8:52 A.M., the Director of Nursing (DON) said dietary recommendations have to be approved by a resident's physician. She would expect the recommendation to be approved within 24 hours, but depending on the physician, it can take longer. Further observations of the resident, showed on 6/14/21 at 8:30 A.M. and 6/15/21 at 8:19 A.M. and 12:00 P.M., the resident received a mechanical soft textured diet meal. A weight obtained by the facility on 6/15/21, showed the resident's current weight of 141.5 pounds, a 14.8% weight loss in one month and a 5.6% loss in three weeks. During an interview on 6/16/21 at 10: 00 A.M., the DON said there should be an order for the diet. The order on the POS should match the Diet Order and Communication form. Newly admitted residents are reviewed at the daily clinical meeting. If a resident has weight loss, the charge nurse should be notified who would notify the DON. The DON would notify the RD and interventions such as supplements and weekly weights would be implemented. The resident's weight loss would also be discussed at the interdisciplinary meetings. She would expect staff to document notification to the physician about the weight loss as well. 2. Review of Resident #227's admission MDS, dated [DATE], showed: -admission date of 5/27/21; -Cognitively intact; -Weight: 186 pounds; -Independent with eating; -Number of Stage II pressure ulcers (Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater): 1; -Number of Stage III pressure ulcers (Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue): 1; -Diagnoses included medically complex conditions, high blood pressure, diabetes and anxiety disorder. Review of the resident's weight summary, showed the following weights (pounds): -On 5/27/21, 186; -On 6/4/21, 157.8; -On 6/8/21, 157.8; -Staff documented a 15.16% weight loss in 12 days. Review of the resident's medical record, showed: -A Diet Order & Communication form, dated 5/27/21, for regular diet with diet condiments; -No physician order for diet. Review of the resident's care plan, revised on 6/6/21 and in use during the survey, included: -Focus: Resident is at risk for nutritional problems, he/she has a diagnosis of diabetes, he/she takes medication to manage. He/she also receives accuchecks (blood glucose monitoring). He/she has anemia (inadequate amount of healthy red blood cells), and has high blood pressure. His/her nutritional status is further affected related to a diagnoses of schizophrenia (mental disorder involving a breakdown in thought, emotion and behavior), schizoaffective disorder (combination of schizophrenia and mood disorder symptoms) and stage II pressure ulcer to right buttock and stage III pressure ulcer to coccyx. Resident is at risk for nutritional decline; -Goals: Resident will maintain adequate nutritional status as evidenced by maintaining weight within next review; -Interventions included: Offer activities of choice to help divert attention from food. Invite resident to activities that promote additional intake. Observe and report to physician, as needed, signs/symptoms of malnutrition: emaciation (abnormally thin or weak), muscle wasting, significant weight loss: 3 pounds in one week, greater than 5 pounds in one month, greater than 7.5% in three months, greater than 10% in six months. RD to evaluate and make recommendations as needed. During an interview on 6/11/21 at 9:14 A.M., the administrator said there was not a nutrition assessment for this resident. She would expect there to be one. Review of the resident's progress notes, showed: -No documentation regarding the resident's significant weight loss; -A discharge date of 6/9/21; -An RD nutrition assessment progress note, completed on 6/11/21, included weight loss from 186 lbs to 157 lbs within month of admission. Weight loss likely related to fluid issues and was at a healthier weight with loss. Resident no longer in facility. During an interview on 6/14/21 at 9:21 A.M., the DON said when a resident admits from the hospital, the admitting nurse will take the weight. If there is a significant weight difference at the next weigh in, she'd expect staff to get an immediate reweigh. If the weight is still significantly different, then she would talk to the admitting nurse who took the weight to see if there were any reasons for variance. She agreed staff had documented a significant weight loss. There should be documentation of how staff address significant weight changes. The RD should assess a newly admitted resident within 7 days of admission. Further review of the resident's progress notes, showed a progress note, written by the DON, dated 6/15/21 at 1:10 P.M., Spoke with admission nurse regarding admission weight. Nurse stated weight was a typo. He/She hit the number 8 instead of the number 5. Weight should have been 156.0. During an interview on 6/16/21 at 10:00 A.M., the DON said medical records should be accurately documented so staff don't have to clarify. 3. Review of Resident #235's care plan, review date 8/7/20, showed the following: -Focus: Resident has potential nutritional problem related to cognitive deficits. The resident has diagnoses of diabetes and hypertension and requires a therapeutic diet. The resident needs total to extensive assistance with feeding; -Interventions included: -Administer medications as ordered; -Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain the consequences of refusal, obesity/malnutrition; -Invite the resident to activities that promote additional intake; -Provide and serve supplements as ordered; -Provide and serve diet as ordered. Monitor intake and record every meal; -RD to evaluate and make diet change recommendations as needed; -The resident needs a calm, quiet setting at meal times with adequate eating time. The resident prefers to eat in his/her room. Review of the resident's weight summary, showed the following weights (pounds): -On 8/5/20, 158.1; -On 8/14/20, 153.9; -On 9/4/20, 154.3; -On 10/3/20, 149.6; -On 10/13/20, 149.6; -On 11/6/20, 140.0 (11.4% weight loss in three months). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Extensive assistance required for eating; -Diagnoses included: anemia, hypertension, diabetes, fracture, Alzheimer's disease, dementia and depression; -Height 66 inches, weight 140 pounds; -Weight loss. Review of the resident's weight summary, showed the resident weighed 131.8 pounds on 12/3/20. Review of the progress notes, showed the resident transferred to the hospital on [DATE]. Review of the admission face sheet, showed the resident readmitted to the facility on [DATE]. Review of the physician's order sheets (POS), active orders as of 1/19/21 (date of discharge), showed a diet order, dated 12/18/20, for regular diet, regular texture, thin consistency. Further review of the resident's weight summary showed the following weights (pounds); -On 12/30/20, 124.3; -On 1/5/21, 124.3. Review of the progress notes, dated 1/6/21, showed the resident tested positive for COVID. Review of the nutrition/dietary progress note, dated 1/8/21, showed resident with decreased appetite and significant weight loss, 5.1% in one month, 16.8% in three months, 20.1% in six months. Resident is currently COVID positive; nurse states asymptomatic. Resident needs assistance and encouragement with meals. Nurse states when being fully assisted, resident eats 75% of meals. Nurse states she will continue to communicate per report for other nurses and aides to monitor resident's intake. Left voice mail with dietary that resident states meat is difficult to eat due to being too tough. Will make diet modification on diet slip to chopped/ground meat and add gravy/sauce to moisten meat as well. Provide fortified foods with meals and health shakes (provides increased calories) twice a day to help meet needs to prevent further unintentional weight loss. Review of the POS, active orders as of 1/19/21, showed the following: -An order, dated 1/12/21, for fortified foods with meals, every day and evening shift for dietary recommendation; -No orders for chopped/ground meat; -No orders for health shakes twice a day. Review of the January 2021 meal intake record, 1/1/21 through 1/19/21, showed the following meal intakes not recorded: -1/1/21, breakfast and lunch; -1/2/21 through 1/5/21, breakfast, lunch and dinner; -1/6/21 through 1/8/21, breakfast and lunch; -1/9/21 through 1/11/21, breakfast, lunch and dinner; -1/12/21, breakfast and lunch; -1/16/21 through 1/17/21, breakfast and lunch; -1/18/21, dinner. During an interview on 6/10/21 at 3:45 P.M., the DON, said the resident was experiencing a decline prior to discharge from the facility, and the physician spoke to the family about the decline. The certified nurses' aides (CNAs) should document intake for each resident at every meal. The dietician should assess the resident's nutrition upon admission, quarterly and with a significant change of condition. During an interview on 6/10/21 at 2:50 P.M., the administrator said there was no order for the resident to have the ground meat or the health shakes. The information is in the progress note, but the former dietician did not inform nursing staff of the recommendations. The usual process, at that time, was for the dietician to e-mail the recommendations to nursing management, but none of the nurses received the recommendations about the chopped meat and health shakes for this resident in an e-mail. There were communication problems with the former dietician, which was part of the reason they have a new dietician. 4. Review of Resident #324's medical records, included hospital records with a progress note, dated 5/18/21 at 8:54 A.M., which showed a recorded weight of 150.6 pounds. Review of the facility progress notes, showed an admission assessment completed on 5/20/21 at 11:54 A.M., included the following information: -The resident discharged from the hospital on 5/19/21; -No weight noted in the admission assessment. Review of the resident's Speech Therapy Evaluation and Plan of Treatment, dated 5/20/21, showed: -Intake/Diet level: Mechanical soft/chopped meats, thin liquids; -Supervision for oral intake, no supervision/assistance required; -Short term goals: Patient will utilize swallowing strategies (upright 90 degrees, alternate liquids/solids during regular diet meals with no cues provided to increase safety with upgraded diet). Review of Resident #324's admission MDS, dated [DATE], showed: -Cognitively intact; -Two staff person assistance for bed mobility, transfers and toileting; -One staff person assistance for dressing, eating and personal hygiene; -Wheelchair for mobility; -Recent surgery, fusion of spinal bones (permanently connect two or more vertebrae in the spine, eliminating motion between them); -Weight, 185 pounds; -Diagnoses included high blood pressure, diabetes, stroke (damage to the brain from interruption of its blood supply), and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Review of the resident's physician's orders, 6/1/21 through 6/20/21, showed: -An order, dated 5/28/21 for House Shake supplement with meals; -An order dated 6/8/21 for a Regular diet, Mechanical Soft texture. Review of the resident's facility weights, showed: -On 5/25/21, 184.6 pounds, (a line crossed over the weight of 184.6, with a note dated 6/4/21, of a documentation error), no other information noted; -On 6/4/21, 136.6 pounds; -On 6/8/21, 136.6 pounds; -On 6/15/21, 133 pounds. Review of the resident's care plan, in use during the survey, showed: -Problem: At risk for weight fluctuation due to current health status. Has diabetes; -Approach: Assistance with meals as needed; -Diet order (specify); -Diet order not defined and supplements not noted on care plan. Review of the resident's progress notes, showed; -On 5/28/21 at 2:37 P.M., Care Team Meeting, Note: Resident needs set up and feeding assist at times. Not eating too much and would benefit from daily health shakes. Will continue to monitor; -On 5/31/21 at 11:06 A.M., Resident has neck brace applied. Resident needs total assist with meals, resident encouraged to use dominant hand as tolerated; -On 6/1/21 at 7:45 P.M., one staff person assist with activities of daily living (ADLs), needs assistance at meals, appetite fair this shift; -On 6/6/2021 7:46 P.M., Nutrition/Dietary Note: Assessment Completed. Resident is at 184.6 pounds. Estimated needs met. Receives Mechanical Soft CCHO (consistent carbohydrate diet) with House Supplement three times a day. Would discontinue supplement and change diet to Regular. Will continue to follow for changes in weight and euglycemia (normal level of glucose in the blood). Observation and interview on 6/7/21 at 10:00 A.M., showed the resident seated in his/her bed, wearing a large neck brace, attempted to pick up a drink and said he/she is unable to put the drink to his/her mouth and needed a straw to be able to drink. No straws were available on his/her bedside table. Observation and interview on 6/9/21 at 5:49 P.M., showed the resident in his/her bed, with the bed side table across his/her lap. The bed positioned at a 45 degree angle; the neck brace preventing the resident to bend his/her head forward. He/she said he/she needed help eating. He/she had been choking on his/her food and staff did not want to help him/her. He/she said he/she did not want any more to eat. On the tray was an uneaten grilled cheese sandwich and an uneaten serving of mixed vegetables. The resident had eaten a small portion of mixed fruit. No health shake was provided on the tray. Observation and interview on 6/10/21 at 8:49 A.M., showed the resident on his/her right side; the bed at a 45 degree angle. The breakfast tray on the bedside table was positioned beside the bed. The resident's neck brace prevented him/her from bending his/her head forward. The resident said he/she feels terrible and uncomfortable in this position. He/she said he/she did not like the food and he/she did not receive a health shake. Review of the resident's occupational therapy notes, showed on 6/11/21, no time noted, patient demonstrated the ability to feed self with set up assist. Patient demonstrated decreased activity tolerance throughout task. Review of the resident's medication administration record, showed: -An order for house shakes on 5/28/21, with meals, documented as provided three times a day, from 6/1/21 through 6/14/21. Observation and interview on 6/15/21 at 8:40 A.M., showed the resident seated on his/her bed with his/her breakfast tray on the bedside table positioned across his/her lap. The resident wore a large brace on his/her neck. He/she said he/she could eat better if someone would feed him/her. He/she attempted to lift a small cup of water to his/her mouth but was unable to lift his/her head forward to drink and sat the cup back down. He/she said he/she was afraid to drink it for fear of spilling it and needed someone to help him/her. No health shake was provided on the tray. Observation and interview on 6/15/21 at 12:18 P.M., showed the resident sat in his/her bed, wearing a large neck brace, with his/her lunch tray in front of him/her. He/she said he/she couldn't feed her/himself. No health shake was provided on the tray. During an interview on 6/16/21 at 8:08 A.M., the dietary manager said she was not aware the resident had an order for health shakes. Observation an interview on 6/16/21 at 8:19 A.M., showed Licensed Practical Nurse (LPN) C stood outside the resident's doorway with a medication cart. He/she said the resident has an order for health shakes, and they are provided on his/her meal trays. LPN C walked inside the resident's room, looked at the resident's breakfast tray and confirmed no health shake was provided. During an interview on 6/16/21 at 10:11 A.M., the DON said if staff notice weight loss, they let the charge nurse know, the facility then contacts the dietician, and supplements are ordered. She said she would have expected staff to position the resident correctly at an angle where the resident could comfortably eat and assumed nursing would go to the kitchen and get a health shake if none was provided. She was not aware staff were documenting the health shakes as provided and and expected medical records to be accurately documented. She would have expected staff to make the dietician aware of weight changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the proper storage of medications in two of three medication carts observed. One medication cart contained an unidentified, pre-pulled pill in the top drawer and a tube of anti-fungal cream located inside of a box of lancets (small double-edged blades or needles used to make a puncture to obtain a blood specimen) in the bottom drawer. A second medication cart contained a box with various medications stored together, not labeled as stock or for a specific resident, a bottle of liquid Pro-source (a nutritional supplement) that lacked an opened-date, spilled over the side and into to the bottom of the medication cart and an unidentified pill on the bottom, right ledge of the cart. The facility had five medication carts. The census was 82. Review of the facility's Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles policy, revised on [DATE], showed: -Policy governs procedures relating to the storage and expiration dates of medications, biologicals, syringes and needles; -Facility to ensure medications are stored in an orderly manner in cabinets, drawers, carts and refrigerators/freezers; -Facility to ensure external use medications are stored separately from internal use medications and biologicals; -Topical (external) use medications or other medications should be stored separately from oral medications when infection control issues may be a consideration; -Once opening medications, the facility must follow the manufacturer guidelines with respect to expiration dates; -Facility staff should record the date opened on the primary medication container when the medication has a shortened expiration date once opened; -Facility should destroy and reorder medications when soiled, illegible, worn, makeshift, incomplete, damaged or missing labels or cautionary instructions are noted; -Facility is to ensure resident medication storage areas do not contain non-medication items; -Facility should ensure that medications are stored in the containers in which they were received in; -Facility should ensure that medications for expired or discharged or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider; -Facility should destroy or return all discontinues, outdated/expired, or deteriorated medications. 1. Observation on [DATE] at 4:27 P.M., of North cart two, showed a tube of anti-fungal cream dated but without a resident's name labeled, located inside of a box of lancets in the bottom, left drawer and a small, round and orange pill inside a medication cup in the right, top drawer. During an interview at that time, Licensed Practical Nurse (LPN) J said that he/she did not know what the medication was. He/she examined the unidentified pill further, then said that it was Hydralazine (antihistamine). He/she disposed of the pill. 2. Observation on [DATE] at 4:47 P.M., of South cart one, showed a bottle of Pro-source in the left bottom drawer. A dried tan fluid ran down the sides of the bottle and into the drawer of the cart, where it puddled underneath the bottle. The bottle of Pro-source was not labeled with a date opened. A tattered syringe box contained Omeprazole (an antacid), Famotidine (an antacid), Restasis (single-use eye drops) and suppositories (medications administered via the rectum) inside of the bottom drawer. During an interview with LPN L at that time, he/she said that the box was where the staff put extra stock medications that were not being used. An unpackaged and unidentified pill sat on the bottom right ledge of the cart. During an interview with LPN L on [DATE] at 5:06 P.M., he/she said that the medications inside the box would not be used for anything and would be discarded. The Pro-source was supplementation given by mouth to residents with orders for it. Further observation of the bottle of Pro-source at that time revealed that it was shelf stable, but should be discarded three months after it is opened. 3. During an interview with the Director of Nursing (DON) on [DATE] at approximately 9:15 A.M., she said that creams, including stock creams, should be labeled with the resident's name when they are opened and in use. She expected staff persons initiating treatments to label the packaging with the resident's name upon breaking the seal. Medications should not be pre-pulled, then stored on the medication cart. Medications that are no longer in use should be pulled from the medication cart to be discontinued or sent back to the pharmacy for credit; narcotics are pulled from the cart, then wasted at the facility. It was not acceptable to have a box of miscellaneous medications stored on a medication cart and left-over medications should not be maintained on the medication cart. A liquid medication bottle is expected to be kept clean to ensure the label is legible. Spilled-liquid medication inside of a medication cart is not acceptable. Staff should have cleaned it up.

Based on observation, interview and record review, facility staff failed to maintain kitchen equipment, walls, ceiling tiles and floors in a clean and sanitary manner to prevent to the growth of bacteria and potential harborage of pests. Facility staff failed to ensure the meat slicer remained covered when not in use to prevent cross contamination and failed to ensure the inside perimeter of the mop bucket was clean. The census was 82. Observations on 6/7/21 at 8:28 A.M., 6/8/21 at 11:39 A.M., 6/9/21 at 8:05 A.M., 6/10/21 at 1:01 P.M., 6/11/21 at 10:16 A.M., 6/14/21 at 11:05 A.M., 6/15/21 at 1:57 P.M. and 6/16/21 at 7:03 A.M., showed the following: -The uncovered meat slicer positioned next to a food preparation sink; -The convection oven had a layer of grease and dust on top. The interior walls and the racks had a heavy carbon build up; -The vat walls of the deep fat fryer had caked on food particles extending 3 inches above the oil. Sediment floated on top of the oil. The oil was very dark in color and the bottom of the vat was not visible; -The metal cabinet housed underneath the fryer, showed a build up of caked on oil on the various mechanisms. A solid build up of oil pooled on the floor underneath the deep fat fryer; -Several dark sticky circular spots on the floor in the dry goods storage room, as well as an accumulation of food and other debris along the baseboards of the walls; -An accumulation of dust particles on the ceiling tiles above the steam table and on the wall behind the ice maker; -Several dark splatter marks on the ceiling tile in the dish washing area; -A build up of dust on the vent slats on the ceiling vent near the ice machine and main entrance; -A black-colored build up of dirt on the interior of the mop bucket used to mop the kitchen floors. Review of the June 2021 Kitchen Sanitation schedule, showed: -Ceiling vents scheduled to be cleaned once a week; -Convection oven scheduled to be cleaned once a week; -Fryer scheduled to be cleaned once a week; -Walls scheduled to be cleaned once a week. During an interview on 6/16/21 at 8:03 A.M., the dietary manager (DM), said they haven't had a maintenance person for awhile, and she can't get up to clean the ceiling/vents, which is her responsibility. The slicer should be covered to keep it clean from dust, and that is her fault. She was aware of the dust on the ceiling above the steam table, on the walls and the vent above the ice machine, as well as the spots on the tile in the dish room. They should be cleaned. The deep fat fryer is cleaned three times a week. The oil should be changed as needed. There should not be any build up around the interior of the fryer vat. She was not aware of the last time the mechanisms inside the metal cabinet of the fryer had been cleaned, nor was she aware of the solid oil accumulation on the floor. Since this is grease, it is a safety concern and agreed it is also not hygienic. The racks in the oven and the inside of the oven should be cleaned three times a week and as needed. There should not be any build up. The dry storage floor is cleaned twice a week when they have deliveries and as needed. There should not be food debris such as flour, chips, caked on spots on the floor. The inside of the mop bucket needs to be replaced. The mop water cannot be clean if the inside is dirty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility failed to address the activity services required by the resident population considering the need for quarantine, the activity director staff competencies and the physical plant considerations such as the family dining room and courtyard utilized for meals and activities. In addition, the facility assessment failed to identify the smoking resident population and/or the location of the resident smoking area in the court yard. The facility identified one resident who smoked (Resident #13). The survey team identified an additional two residents who smoked prior to being admitted to the facility and voiced the desire to smoke while at the facility (Resident #227 and #36). The census was 82. 1. Review of the facility assessment tool, dated 6/5/20, showed: -Average daily census: 78; -List common diagnoses or conditions for the facility: Respiratory infections, including COVID-19; -Describe other pertinent facts or descriptions of the resident population that must be taken into account when determining staffing and resource needs: Blank; -Person centered/directed care; psycho/social/spiritual support: Provide opportunities for social activities/life enhancement (individual, small group, community); -Identify the types of staff members, other health care professionals and medical practitioners that are needed to provide support and care for residents: Activity services- Activity director and assistant; -Staffing plan: Based on the resident population and their needs for care and support, describe the general approach to staffing to ensure sufficient staff to meet the needs of the residents at any given time: (Activity staff not identified as a position in the staffing plan); -Staff training/education and competencies: (the qualifications, training, and competencies of the activity director and/or activity staff not identified); -Physical environment and building/plan needs: Building and/or building layout attached; -The 14 day quarantine for new admissions not identified as a resident condition; -The need for one on one activities for residents in quarantine not identified; -The residents smoking population not identified. Observation on 6/7/21 at 9:19 A.M., showed a large open room located between the 100 and 200 halls and near the kitchen. The room contained 11 tables socially distanced. A large picture window the length of the room with a door on either side that led to a courtyard area. In the 100 hall, just next to room [ROOM NUMBER], a medium sized room identified with a plaque as the family dining room. Review of the facility layout, showed the large room located between the 100 and 200 hall identified as the dining room. Neither the courtyard nor family dining room identified on the layout. Further review of the facility assessment, showed physical environment and building/plan needs: -The courtyard and family dining room not identified; -The resident smoking area not identified. 2. Review of the facility's resident roster, dated 6/6/21, showed 15 residents resided in the yellow zone (isolation area). Observation on 6/8/21 at 11:54 A.M., showed a group activity occurred in the dining room. Five residents in attendance. During an interview on 6/7/21 at 8:48 A.M., the administrator said they have no positive COVID-19 cases. Yellow zone rooms are for residents on isolation due to being a recent admission. They are moved to a green zone after the 14 day quarantine. On 6/11/21 at 1:56 P.M., the administrator said the COVID-19 pandemic increases the need for activities. Residents in the yellow zone should receive one on one activities. She is not sure if the activity director had taken any activity director courses that would make her eligible for certification as an activities professional, if she had 2 years experience in a social/recreational program with one year full time in a therapeutic activity program or if she completed a training course approved by the state. She is not aware of any steps taken by the facility to ensure these qualifications are met. She would expect the activity director to be qualified if holding the position. The facility will allow one resident per table in dining room for activities. The facility can only have one resident per table due to social distancing while eating in the dining room. On 6/14/21 at 2:20 P.M., the administrator said they were not able to verify the activity director is qualified to hold the position. The facility is moving forward with hiring a more qualified activity director. 3. Review of list of residents who smoke, dated 6/11/21, showed one resident, Resident #13 listed. Observation on 6/9/21 at 5:35 P.M., of the courtyard, located just outside of the dining room, showed weeds grown up between the concrete. Trees and bushes overgrown and hung over and onto to walkways. A shade umbrella lay across the patio walkway. One weed grew between the concrete waist high and one chest high. Several other smaller weeds grew up between the concrete. During an interview on 6/7/21 at 8:48 A.M., the administrator said there was smoking at the facility pre-COVID. She was told when she started that staff were not able to socially distance with the residents who smoked and that is why the facility stopped allowing the residents to smoke. On 6/11/21 at 1:56 P.M., the administration said the smoking area was in the courtyard. On 6/14/21 at 2:20 P.M., the administrator said she was not able to find documentation to show the residents were notified in writing that the facility stopped allowing smoking during the COVID-19 pandemic. Review of the facility's admission packet, provided to residents admitted to the facility both before and during the COVID-19 pandemic, showed the smoking identified as a service provided at the facility. 4. Review of Resident #13's smoking safety evaluation, dated 3/25/21, showed is the resident receptive to smoking cessation options: Undecided at this time. During an interview on 6/8/21 at 10:55 A.M., the resident said when COVID-19 started, the facility said residents cannot smoke anymore. That was a form of enjoyment and time to socialize. They just took that away. 5. Review of Resident #227's medical record, showed no smoking assessment completed. During an interview on 6/7/21 at 2:53 P.M., the resident said he/she is a smoker and wished he/she could smoke now. He/she was told when admitted that smoking is not allowed. He/she wished he/she could just go outside. He/she had not been outside since being admitted . 6. Review of Resident #36's smoking safety evaluation, dated 10/9/20, showed is the resident receptive to smoking cessation options: No. During an interview on 6/9/21 at 1:02 P.M., the resident said staff tell him/her that he/she cannot smoke, but employees who work at the facility are allowed to smoke. They go outside and smoke. He/she can see them. 7. During an interview on 6/14/21 at 2:20 P.M., the administrator said the availability of the courtyard and the family dining room should be identified on the facility assessment as space used for communal dining, activities and/or gatherings. The resident smoking population and the smoking area should be on the facility assessment. The activity needs of the residents and staff qualifications should be included as part of the facility assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents have the right to make choices about aspects of their life in the facility that are significant to the resident. During the COVID-19 pandemic, the facility stopped allowing smoking at the facility, failed to permit the current residents admitted prior to the rule change and failed to provide in writing to newly admitted residents the new rule that smoking was no longer allowed at the facility. The facility identified one resident who smoked (Resident #13). The survey team identified an additional two residents who smoked prior to being admitted to the facility and voiced the desire to smoke while at the facility (Resident #227 and #36). The facility failed to allow residents who voiced a desire to eat in the dining room the right to eat in the dining (Resident #10 and #13). In addition, the facility failed to allow residents who voiced the desire to go outside the right to go outside to an enclosed courtyard (Resident #38, #227, #44, #173, #32 #48, and #325). This had the potential to affect all residents who eat at the facility, who would choose to go outside and/or who would like to smoke. The sample was 20. The census was 82. Review of the resident's bill of rights, provided to residents upon admission to the facility, showed: -The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility; -The resident has the right to exercise his or her rights as a resident of the facility and as a citizen of the United States; -The resident has the right to be free from interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required; -The resident has the right to be informed, in advance, of changes to the plan of care; -The resident has the right to be treated with respect and dignity; -The resident has the right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessment, and plan of care; -The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident; -The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility; -The resident has the right to participate in other activities, including social, religious and community activities that do not interfere with the rights of the residents in the facility. 1. During an interview on 6/7/21 at 8:48 A.M., the administrator said residents are not currently allowed to smoke. There was smoking pre-COVID. There are no positive cases for COVID-19 currently in the facility. Yellow rooms are on isolation due to being a recent admission and then the residents are moved to green rooms after 14 days. 2. Review of the facility's admission packet, provided on 6/7/21 as the information provided to residents who admit to the facility, showed: -Section 10 Rules and regulations: -Resident responsibilities: You or your representative agree to comply with the current rules, regulations, policies and procedures of the facility. The facility will notify you or your representative of any changes to these responsibilities are required by law; -Smoking: Refer to the facility smoking procedures and smoking attachment incorporated into this agreement; -Smoking Facility: This facility strives to protect the public health and welfare of its residents, staff, and visitors by restricting smoking to designate areas on the grounds of this property; -This facility must ensure a resident's environment remains free of accidents as is possible and each resident receives supervision to prevent accidents including accidents related to cigarette smoking. This also includes the use of e-cigs which are considered the same as any tobacco product; -Therefore, while you are under our care, you and/or your representative agree to smoke supervised in the designated smoking area for your individual safety, as well as the safety of others in this facility, you may never smoke in your room or any other areas not specifically designated as a smoking permitted area you and or your representative agree that the facility may impose additional smoking procedures and/or restrictions as required by law. During an interview on 6/14/21 at 8:53 A.M., admission Director B said he/she was the admissions director at the facility until just recently. He/she could not recall what information was provided to residents upon admission. Observation on 6/9/21 at 5:35 P.M., of the courtyard located just outside of the dining room, showed weeds grown up between the concrete. Trees and bushes overgrown and hung over and onto to walkways. A shade umbrella lay across the patio walkway. One weed grew between the concrete waist high and one chest high. Several other smaller weeds grew up between the concrete. During an interview on 6/11/21 at 1:56 P.M., the administrator said the resident smoking area was in the courtyard. On 6/14/21 at 1:56 P.M., the administrator said when a resident is admitted , it is the responsibility of the admissions director to determine if the resident smoked. In addition, the social services director and nursing staff will assess this. A smoking assessment should be completed on any resident admitted that smokes. The smoking area for staff is outside near the kitchen area. When she first arrived to the facility approximately a month ago, she was told residents could not smoke because staff were not able to monitor them while social distancing. The resident smoking area is in the courtyard. If staff are able to smoke onsite, it would be appropriate for the residents to smoke as well. She is not sure how the decision was made to not allow smoking for the residents. She is not sure if residents who resided at the facility prior to the COVID-19 pandemic were provided written and verbal notification of the rule change or if residents admitted since the rule change were notified in writing, she would check. The admission packet provided to the survey team is the admission packet provided to the residents. She is not sure what the plan is for allowing the residents the right to smoke. Corporate has been discussing this, but no final word has been passed down. At 2:20 P.M., the administrator said she was not able to find any written notification provided to residents regarding smoking not being allowed. 3. Review of the resident council notes, showed: -March 2021, when can residents go back outside in the courtyard, bus trips to store and out to eat? Activities was shut down before COVID-19 and it is unfair. No documented follow-up; -April 2021, all residents want outside activities. No documented follow-up; -No May 2021 resident council minutes provided; -June 2021, all residents need outdoor activities like going out to eat and store runs. Not enough activities. No documented follow-up. During an interview on 6/14/21 at 1:19 P.M., the administrator said there was no resident council meeting held in May 2021. During a group interview on 6/8/21 at 10:55 A.M., held with four residents identified by the facility as being alert and oriented, who represented the resident council, said: -Resident #13 said when COVID-19 started, the facility said residents cannot smoke anymore. That was a form of enjoyment and time to socialize. They just took that away. Since COVID-19, residents haven't seen anything, but the four walls in their room. They don't see anyone anymore. Residents cannot even go up to the front lobby to get money anymore, they have to have it brought to them. Residents have to stay close to their rooms, can't sit in the halls, and if they leave their rooms, they are told to go back to their room; -Resident #32 said he/she has been wanting to go outside. He/she wants to go shopping. During an interview on 6/10/21 at 1:07 P.M., the activity director said she is the only activity staff person at the facility. She is aware of activity concerns brought up by the resident council. They want to go on outings, go outside, smoke and have more activities. She started working at the facility four months ago and there has been no activities in the courtyard or smoking. She has not been able to use the courtyard for activities, because it is so overgrown with weeds. The residents are not allowed to go out there. 4. Observation on 6/7/21 at 9:19 A.M., showed a large room located between the 100 and 200 halls and near the kitchen. The room contained 11 tables socially distanced. A large picture window the length of the room with a door on either side that led to a courtyard area. In the 100 hall, just next to room [ROOM NUMBER], a medium sized room identified with a plaque as the family dining room. Review of the facility layout, showed the large room located between the 100 and 200 hall identified as the dining room. Neither the courtyard nor family dining room identified on the layout. 5. Review of list of residents who smoke, dated 6/11/21, showed one resident, Resident #13 listed. Review of Resident #13's significant change Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/17/19, showed current tobacco use: Yes. Review of the resident's annual MDS, dated [DATE], showed: -Cognitively intact; -How important is it to you to do things with groups of people: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -Locomotion on the unit: Limited assistance required; -Locomotion off the unit: Activity did not occur; -Supervision required with eating; -Diagnoses included stroke and seizure disorder; -Current tobacco use: No. Review of the resident's care plan, in use at the time of the survey, showed: -The resident is a smoker: -Goal: The resident will not smoke without supervision; -Interventions: Complete the smoking safety evaluation; instruct resident about smoking risks and hazards and about smoking cessation aids that are available; instruct resident about the facility smoking policy, locations, times, and safety concerns; -At risk for change in mood or behavior due to medical condition depression and anxiety: -Goal: The resident will allow staff to assist with basic care needs; -Interventions: Consult with resident on preferences regarding customary routines; -At risk for impaired psychosocial well-being related to depression and anxiety: -Goal: The resident will not have impaired psychosocial well-being; -Encourage participation from resident who depends on others to make own decision; observe for usual response to problems; when conflict arises, remove resident to a calm safe environment and allow to vent/share feelings; -The resident is at risk for alteration in psychosocial well-being due to visitation restrictions related to COVID-19 precautions. He/she is on the green hall. He/she prefers to have his/her door open and not to wear a mask during care: -Goal: Will not experience any adverse effects of visitation restrictions: -Encourage or facilitate alternative ways of communication with friends and family; observe for changes in mental status caused by situational stressors and report to physician as appropriate; provide opportunities to express feelings related to situational stressors. Review of the resident's smoking safety evaluation, dated 3/25/21, showed is the resident receptive to smoking cessation options? Undecided at this time. During an interview on 6/8/21 at 10:55 A.M., the resident said when COVID-19 started, the facility said residents cannot smoke anymore. That was a form of enjoyment and time to socialize. They just took that away. They are not eating in the dining room anymore. It would be nice to go to the dining room so they could socialize and talk. Since COVID-19, residents haven't seen anything but the four walls in their room. They don't see anyone anymore. Residents cannot even go up to the front lobby to get money anymore, they have to have it brought to them. Residents have to stay close to their rooms, can't sit in the halls, and if they leave their rooms, they are told to go back to their room. Activities has been almost non-existent. With bingo, they can only have one resident at a table, so only a couple residents can go. 6. Review of Resident #227's medical record, showed no smoking assessment completed. Review of the resident's physician/physician assistant/nurse practitioner admission history and physical, dated 5/28/21 at 11:07 A.M., showed: -Prior to admission he/she lived by him/herself and ambulates without use of assistance device; -Social History: Smokes one pack of cigarettes daily, drinks alcohol perhaps twice a year. Review of the resident's admission MDS, dated [DATE], showed: -Cognitively intact; -How important is it to you to do your favorite activities: Very important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -Supervision required for locomotion on the unit; -Independent with locomotion off the unit; -Diagnoses included medically complex conditions and anxiety disorder; -Current tobacco use: No. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for altercations in psychosocial well-being due to visitation restrictions related to COVID-19 precautions. He/she is on isolation precautions on the yellow hall per guidelines. He/she prefers to have his/her door open and prefers not to wear a mask during care: -Goal: Have no indications of psychosocial well-being problems while in quarantine/isolation; -Interventions: Educate on the purpose of the quarantine period; observe for changes in mental status caused by situational stressors and report to physician as appropriate; observe for increased anxiety or change in mood/behavior that are related to quarantine and notify physician as appropriate; provide resident with in room activities; -The resident's desire to smoke not listed on the care plan. During an interview on 6/7/21 at 2:53 P.M., the resident said he/she is a smoker and wished he/she could smoke now. He/she was told when admitted that smoking is not allowed. He/she wished he/she could just go outside. He/she had not been outside since being admitted . 7. Review of Resident #36's smoking safety evaluation, dated 10/9/20, showed is the resident receptive to smoking cessation options: No. Review of the resident's admission MDS, dated [DATE], showed: -Moderately impaired cognition; -How important is it to you to do your favorite activities: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Somewhat important; -Supervision required for locomotion on the unit; -Locomotion off the unit: Activity did not occur; -Diagnoses included medically complex conditions; -Current Tobacco use: No. Review of the resident's physician/physician assistant/nurse practitioner admission history and physical, dated 1/14/21 at 11:51 A.M., showed: -Social history: Former smoker up until 3 months ago, smoked up to two packs per day. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for alterations in psychosocial well-being due to visitation restrictions related to COVID-19 precautions. He/she is on a green hall: -Goal: Not experience any adverse effects of visitation restrictions; -Interventions: Encourage to facility alternative ways to communicate with friends and family; observe for changes in mental status caused by situational stressors; provide opportunities to express feelings related to situational stressors; -The resident's desire to smoke not listed on the care plan. During an interview on 6/9/21 at 1:02 P.M., the resident said staff tell him/her that he/she cannot smoke, but employees who work at the facility are allowed to smoke. They go outside and smoke. He/she can see them. 8. During an interview on 6/16/21 at 10:00 A.M., the Director of Nursing (DON) said residents' MDS should be accurate. If a resident smoked when admitted , the MDS should indicate that they smoke. The nurse doing the assessment is responsible to ensure this is accurate. 9. Observations of meal service during the survey, showed: -On 6/7/21 at 9:19 A.M., 11 tables socially distanced located in the dining room, no resident in the dining room. Observation on the resident halls, showed residents ate in their rooms; -On 6/7/21 at 12:19 P.M., dietary staff brought a hall tray cart out of the kitchen and brought it to the 100 hall. At 12:23 P.M., dietary staff brought a second cart out from the kitchen and to the 100. At 12:39 P.M., dietary staff brought a cart out of the kitchen and to the 200 hall. At 12:47 P.M., dietary staff brought a second cart from the kitchen and to the 200 hall. No residents in the dining room. During an interview at 12:48 P.M. dietary staff said that was the last of the trays to be served to the resident; -On 6/8/21 at 8:30 A.M., no residents in the dining room as staff passed hall trays; -On 6/8/21 at 12:41 P.M., no residents in the dining room as staff passed hall trays; -On 6/9/21 at 12:23 P.M., no residents in the dining room as staff passed hall trays; -On 6/9/21 at 5:27 P.M., hall trays sent to the 100 hall. No residents in the dining room. At 5:46 P.M., the admissions director told maintenance staff that the dining room is closed off. At 5:50 P.M., hall trays sent to the 200 hall. At 6:09 P.M., a second cart sent to the 200 hall. The dietary staff said it is the last of the trays. No residents in the dining room; -On 6/10/21 at 7:58 A.M., hall trays arrived to the 200 hall. No residents in the dining room. 10. Review of Resident #10's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Interview for activity preferences not assessed; -Extensive assistance required for locomotion on the unit; -Limited assistance required for locomotion off the unit; -Diagnoses included orthopedic conditions and stroke. Review of the resident's care plan, in use at the time of the survey, showed: -Impaired cognitive ability/impaired thought process, has moderate cognitive impairment: -Goal: Be able to communicate basic needs; -Interventions: Ask yes/no questions in order to determine the resident's needs; communicate with the resident/family/caregivers regarding capabilities and needs; resident understands consistent, simple, direct sentences; engage the resident in simple, structured activities that avoid overly demanding tasks; -At risk for impaired nutrition/weight changes related to anorexia. Currently taking an appetite stimulant: -Goal: Be free from significant weight changes: -Interventions: Assist the resident with developing a support system to aid in weight loss efforts, including friends, family, other residents, volunteers, etc.; develop an activity program that includes exercise, mobility. Offer activities of choice to help divert attention from food; explain and reinforce the importance of maintaining the diet ordered; invite the resident to activities that promote additional intake; -At risk for alteration in psychosocial well-being due to visitation restrictions related to COVID-19 precautions. He/she is on the green hall: -Goal: Not experience any adverse effects of visitation restrictions; -Interventions: Observe for changes in mental status caused by situational stressors and report to physician as appropriate. During an interview on 6/7/21 at 2:48 P.M., the resident said he/she is bored with sitting in front of the television all day. He/she used to be able to sit in the hall and watch people come and go, but not anymore. On 6/8/21 at 5:40 A.M., the resident asked if he/she will ever be able to eat in the dining room. During an interview on 6/8/21 at 5:56 A.M., Licensed Practical Nurse (LPN) C said the resident is a sociable person. 11. Observation of the enclosed courtyard, showed: -On 6/9/21 at 5:35 P.M., the courtyard located outside dining room, weeds grew up between the concrete. Trees and bushes overgrown and hung over onto to walkways. A shade umbrella lay across the patio area. One weed that grew between the concrete waist height and one chest height. Other weeds grew through the concrete at various heights; -On 6/10/21 at 2:51 P.M., weeds removed, grass cut, trees and bushes trimmed. Umbrella picked up and placed on the patio furniture. No residents observed in the courtyard. 12. Review of Resident #38's admission MDS, dated [DATE], showed: -Cognitively intact; -How important is it to you to do your favorite activities: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -Locomotion on and off the unit: Activity did not occur; -Diagnoses included medically complex conditions and depression. Review of the resident's care plan, in use at the time of the survey, showed: -The resident is at risk for alterations in psychosocial well-being due to visitation restrictions related to COVID-19 precautions: -Goal: Have no indications of psychosocial well-being problem while in quarantine/isolation; -Interventions: Educate on the need and purpose of the quarantine period; observe for increased anxiety or changes in mood/behavior that are related to quarantine; provide residents with in room activities. During an observation and interview on 6/8/21 at 1:40 P.M., showed the resident sat in a wheelchair in the hall, at the door to the outside as he/she looked outside. He/she said he/she cannot wait until he/she can go outside again and hopes it is soon. The last time he/she was outside was about six months ago when he/she left the hospital to come to the facility. He/she is an outdoors person and loves hunting, fishing, and yard work. He/she misses fresh air. 13. Review of Resident #44's admission MDS, dated [DATE], showed: -Moderately impairment; -How important is it to do your favorite activities: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -Extensive assistance required for locomotion on the unit; -Locomotion off the unit: Activity did not occur; -Diagnoses included medically complex conditions, dementia and depression. Review of the resident's care plan, in use at the time of the survey, showed: -Behavior problems at times, has cognitive deficits, moderate cognitive impairment: -Goal: Not express behaviors that are harmful to self and others; -Interventions: Provide a program of activities that is of interest and accommodates resident's status; -At risk for alteration in psychosocial well-being due to visitation restrictions related to COVID-19 precautions: -Goal: Have no indications of psychosocial well-being problem while in quarantine/isolation; -Interventions: Educate on the need and purpose of the quarantine period; observe for changes in mental status caused by situational stressors; observe for increased anxiety or changes in mood/behavior that are related to quarantine; provide resident with in room activities. During an observation and interview on 6/9/21 at 1:07 P.M., showed the resident lay in bed. The resident said he/she wants to go outside, but is not allowed to because the courtyard is overgrown. He/she wants more activities. 14. Review of Resident #173's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -How important is it to you to do your favorite activities: Very important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -Limited assistance required for locomotion on the unit; -Extensive assistance required for locomotion off the unit; -Diagnoses included medically complex conditions, stroke and malnutrition. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for alterations in psychosocial well-being due to visitation restrictions related to COVID-19 precautions: -Goal: No indications of psychosocial well-being problem while in quarantine/isolation; -Interventions: Educate on the need and purpose of the quarantine period, observe for increased anxiety or changes in mood/behavior that are related to quarantine; provide with in-room activities. During an observation and interview on 6/8/21 at 12:08 P.M., showed the resident up in a wheelchair. He/she said he/she has asked the staff if he/she can go outside and they did not answer. 15. Review of Resident #32's annual MDS, dated [DATE], showed: -Cognitively intact; -How important is it to you to do your favorite activities: Very important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -Independent with locomotion on and off the unit; -Diagnoses include medically complex conditions, dementia and depression. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for impaired psychosocial well-being related to visitor restriction secondary to COVID-19 pandemic: -Goal: Be free from negative outcomes related to visitor restrictions; -Interventions: Encourage participation from resident who depends on others to make own decisions; monitor for psychosocial distress, offer and encourage daily activities to keep the resident entertained and stimulated. During an interview on 6/8/21 at 2:01 P.M., the resident said he/she has been wanting to go outside. He/she wants to go shopping, to go get what he/she wants, not have to tell someone to do it for him/her. 16. Review of Resident #48's annual MDS, dated [DATE], showed: -Cognitively intact; -How important is it to you to do your favorite activities: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Somewhat important; -Supervision required for locomotion on and off the unit; -Diagnoses included stroke. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for alterations in psychosocial well-being due to visitation restrictions related to COVID-19 precautions: -Goal: Not experience any adverse effects of visitation restrictions; -Interventions: Observe for changes in mental status caused by situational stress; provide opportunities to express feelings related to situational stressors. During an interview on 6/14/21 at 10:04 A.M., the resident said he/she cannot go outside because he/she is not allowed to. He/she would go outside to get exercise if he/she could. 17. Review of Resident #325's admission MDS, dated [DATE], showed: -Cognitively intact; -How important is it to you to do your favorite activists: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -Supervision required for locomotion on the unit; -Extensive assistance required for locomotion off the unit; -Diagnoses include amputation and high blood pressure. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for alteration in psychosocial well-being due to visitation restrictions related to COVID-19 precautions; -Provide resident with in room activities; provide psychosocial support when in resident's rooms. During an interview on 6/8/21 at 12:28 P.M., the resident said he/she wants to eat in the dining room, but the facility does not allow them to do that anymore. The courtyard is so pretty, but residents do not get to go out there. 18. During an interview on 6/10/21 at 1:07 P.M., the activity director said she is aware that residents want to go on outings and want more activities. The residents cannot go in the courtyard or smoke. Residents complain about this as well. The administrator said staff cannot go outside. He/she believes it is probably because of the long grass. 19. During an interview on 6/10/21 at 1:11 P.M., Certified Nursing Assistant (CNA) H said no activities are available for the residents because of the pandemic. There are really no gatherings due to social distancing. He/she does not know where the resident smoking area is and does not know if there is a place that residents can go if they want to go outside. If a resident would ask to go outside, he/she would tell them they cannot go due to social distancing. He/she does not know if residents are allowed to eat in the dining room. 20. During an interview on 6/10/21 at 1:16 P.M., CNA G said prior to the pandemic, staff would go room to room to invite residents to activities, but not now. Residents are not allowed to smoke. If a resident were to ask, they would just tell them no. He/she is not sure if a residents are allowed outside or if they are allowed to eat in the dining room. 21. During an interview on 6/10/21 at 1:24 P.M., Licensed Practical Nurse (LPN) C said there are too little activities available to residents. If residents tell staff they want to attend an activity, staff will take them. One resident told their family that they were bored so the family brought in some things for them to do. The resident smoking area was in the courtyard prior to the pandemic, now residents don't smoke. If a resident asked to smoke, he/she would refer them to the social worker. Prior to COVID-19, residents could go sit in front of the building to get some fresh air. He/she is not sure if residents can eat in the dining room. 22. During an interview on 6/11/21 at 1:56 P.M., the administrator said residents have the right to make choices about their lives that are important to them. The facility is following Centers for Disease Control and Prevention (CDC) guidelines as well as directives from corporate regarding allowing communal dining and smoking. She started at the facility May 17, 2021. At that time, the facility was still following guidance that only one resident per table could be in the dining room for social distancing. When a resident is admitted , it is the responsibility of admissions to determine if they smoke. The social worker and nurse also follow up with the resident. If a resident smoked prior to admission the smoking assessment should be completed. The staff smoking area is outside the kitchen. If staff are able to smoke onsite at the facility, it would be appropriate to allow residents to smoke. She is not sure how the decision was made to not allow smoking. She does not know the plan to start allowing residents to smoke, but there has been some talk at the corporate level. No final word has been passed down yet. Residents are not allowed to use the outdoor area. The facility has a landscaping company to take care of the overgrowth in the courtyard. They were not able to come in due to the pandemic. They just came in yesterday, but she is still not happy with the results because the grass is too long. Maintenance could have done the upkeep if the facility had consistent maintenance staff. Residents should be allowed to smoke again once the facility receives direction from corporate. 23. During an interview on 6/14/21 at 9:30 A.M., the infection preventionist, said the last positive COVID-19 case was in either February or March, 2021. Currently, residents who need assistance with eating may eat in the main dining room or their rooms. Residents who do not require assistance with eating are still required to eat in their rooms. 24. Review of the Centers for Disease Control and Prevention (CDC) website, Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, Nursing Homes & Long-Term Care Facilities, and last updated March 29, 2021, showed: -The following

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of each resident. The facility failed to employ an activity director qualified for the position, failed to employ sufficient numbers of activity staff based on the facility assessment, failed to ensure scheduled activities occurred as scheduled, failed to provide outdoor activities per residents request, failed to provide activities per residents choice as identified in grievances and resident council, failed to ensure residents on quarantine were provided with in room activities and failed to ensure group activities occurred in sufficient numbers to ensure residents who wanted to attend were able to attend for nine of 12 residents investigated for activities (Resident #73, #227, #13, #38, #44, #52, #36, #22 and #523). These failures had the potential to affect all residents in the facility, both residents able to attend group activities and those who require in room and/or one on one activities. The sample was 20. The census was 82. 1. Review of the resident's bill of rights, provided to residents upon admission to the facility, showed: -The resident has the right to participate in establishing and expected goals and outcomes of care, the type, amount, frequency and duration of care, and any other factors related to the effectiveness of the plan of care; -The resident has the right to receive the services and/or items included in the plan of care; -The resident has the right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessment, and plan of care; -The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident; -The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility; -The resident has the right to participate in other activities, including social, religious and community activities that do not interfere with the rights of the residents in the facility. 2. Review of Review of the activity director's resume and application for employment, showed: -No documentation of certification in a state approved activity director training course; -No documentation of 2 years experience in a social/recreational program with one year full time in a therapeutic activity program. During an interview on 6/10/21 at 1:07 P.M., the activity director said she is the only activity staff person in the building. She has been the activity director at the facility for four months. During an interview on 6/11/21 at 1:56 P.M., the administrator said she is not sure how many activity staff there were prior to the pandemic, but she does feel one activity staff, if qualified, is sufficient for the number of residents at the facility. On 6/14/21 at 2:20 P.M., the administrator said they were not able to verify the activity director is qualified to hold the position. The facility is moving forward with hiring a more qualified activity director. Review of the facility assessment tool, dated 6/5/20, showed: -Average daily census: 78; -Person centered/directed care; psycho/social/spiritual support: Provide opportunities for social activities/life enhancement (individual, small group, community); -Identify the types of staff members, other health care professionals and medical practitioners that are needed to provide support and care for residents: Activity services- Activity director and assistant; -Staffing plan: Based on the resident population and their needs for care and support, describe the general approach to staffing to ensure sufficient staff to meet the needs of the residents at any given time: (Activity staff not identified as a position in the staffing plan); -Staff training/education and competencies: (the qualifications, training, and competencies of the activity director and/or activity staff not identified). 3. Review of the facility's activity calendars, showed: -March 2021: Three to four activities scheduled daily during week days. Two activities scheduled daily during the weekend. 100 activities total scheduled for the month; -April 2021: Two to three activities scheduled daily. 63 activities total scheduled for the month; -May 2021: One to three activities scheduled daily. 66 activities total scheduled for the month; -June 2021: -65 activities total scheduled for the month. -One to two activities scheduled daily; -No outdoor activities scheduled; -No outings scheduled; -No activities scheduled after 3:00 P.M. on any day. During an interview on 6/10/21 at 1:07 P.M., the activity director said the March activity calendar was the first one she created after starting at the facility. Due to having no activity staff to help, she was not able to do all the activities that were listed and residents were complaining that the scheduled activities were not taking place. To fix this, she scheduled less activities. Not all activities scheduled were actually completed. 4. Observation on 6/9/21 at 5:35 P.M., of the courtyard located just outside of the dining room, showed weeds grew up between the concrete. Trees and bushes overgrown and hung over and onto to walkways. A shade umbrella lay across the patio walkway. One weed grew between the concrete waist high and one chest high. Several other smaller weeds grew up between the concrete. During an interview on 6/10/21 at 1:07 P.M., the activity director said she is aware of activity concerns brought up by the resident council. They want to go on outings, go outside, smoke and have more activities. She started working at the facility four months ago and there has been no activities in the courtyard or smoking. She has not been able to use the courtyard for activities because it is so overgrown with weeds. The residents are not allowed to go out there. There are no activities scheduled outside and they currently do not have any outings. 5. Review of the resident council notes, showed: -March 2021, when can residents go back outside in the courtyard, bus trips to store and out to eat? Activities was shut down before COVID-19 and it is unfair. No documented follow-up; -April 2021, all residents want outside activities. No documented follow-up; -No May 2021 resident council minutes provided; -June 2021, all residents need outdoor activities like going out to eat and store runs. Not enough activities. No documented follow-up. During an interview on 6/14/21 at 1:19 P.M., the administrator said there was no resident council meeting held in May 2021. During a group interview on 6/8/21 at 10:55 A.M., held with four residents identified by the facility as being alert and oriented, who represented the resident council, said: -When COVID-19 started, the facility said residents cannot smoke anymore. That was a form of enjoyment and time to socialize. They just took that away. Since COVID-19, residents haven't seen anything but the four walls in their room. They don't see anyone anymore. Residents cannot even go up to the front lobby to get money anymore, they have to have it brought to them. Residents have to stay close to their rooms, can't sit in the halls, and if they leave their rooms, they are told to go back to their room; -One resident said he/she has been wanting to go outside. He/she wants to go shopping. During an interview on 6/10/21 at 1:07 P.M., the activity director said nothing has been done to address the resident council concerns, because there is not enough activity staff and she has not been given permission for outdoor activities or outings. During an interview on 6/11/21 at 1:56 P.M., the administrator said she is aware of resident council concerns regarding activities. She does not know what follow-up the activity director has provided to the resident council. 6. Review of the facility's resident grievance log, for the months of April through June, 2021, showed: -On 4/27/21: Department- activities: Activity department isn't doing activities; -On 5/1/21: Department- activities: Resident is bored. During an interview on 6/11/21 at 9:22 A.M., the social worker said she is the grievance official. When a resident voices a grievance, it is discussed during morning meeting and the appropriate department head is informed. The information is then provided to the administrator to be signed off. If the grievances are voiced during resident council, the activity director would provide that information to her for the grievance log, but the current activity director has provided no group grievances since she started in March. 7. Review of the facility's resident room roster, dated 6/6/21, showed 15 residents resided in rooms designated as yellow rooms. During an interview on 6/7/21 at 8:48 A.M., the administrator said yellow rooms are on isolation due to being a recent admission and then the residents are moved to green rooms after 14 days if they do not show symptoms of COVID-19 during the quarantine timeframe. During an interview on 6/10/21 at 1:07 P.M., the activity director said one on one activities are only provided to residents in yellow rooms since they are on isolation. Review of the facility's June 2021 one on one activity schedule, titled yellow room visits, showed six residents scheduled to receive one on one room visits for the month, total. Each of the six residents listed only scheduled to receive one visit during the month. 8. During an interview on 6/10/21 at 3:54 P.M., the activity director said activity participation is documented under progress notes. If the resident attended a group activity or was provided one on one activities, this is where it would be documented. If there is no documentation, the resident did not attend the activity. 9. Review of Resident #73's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/28/21, showed: -Severe cognitive impairment; -Should interview for daily and activity preferences be conducted: Yes; -How important is it to you to have books, newspapers and magazines to read: Somewhat important; -How important is it to you to listen to music you like: Somewhat important; -How important is it to you to keep up with the news: Very important; -How important is it to you to do things with groups of people: Somewhat important; -How important is it to you to do your favorite activities: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -Extensive assistance required with locomotion on and off the unit; -Primary medical condition category: Medically complex conditions. Review of the resident's undated activity preferences, provided by the activity director, showed: -Things I enjoy doing: Playing cards, playing pool; -Things I dislike doing: Blank; -Favorite snacks: Popcorn, ice cream; -Other information: Blank. Review of the resident's care plan, in use at the time of the survey, showed: -Dehydration or potential for fluid deficit related to vomiting: -Goal: Be free of symptoms of dehydration and maintain moist mucous membranes and good skin turgor; -Intervention: Invite the resident to activities that promote additional fluid intake. Offer drinks during one to one visits. Provide beverages that comply with diet/fluid restrictions and consistency requirements; -Risk for alteration in psychosocial well-being due to visitation restrictions related to COVID-19 precautions. Resident is on isolation precautions on the yellow hall per guidelines: -Goal: Have no indications of psychosocial well-being problems while in quarantine/isolation; -Interventions: Provide resident with in room activities; -The care plan did not address the resident's activity preferences or type/frequency of in room activities during quarantine. Review of the resident's admission activities evaluation, dated 6/1/21, showed the following preferences: -Frequency of activities: Daily; -Preferred location: Day/activity room. Review of the resident's progress notes, showed: -On 6/8/21 at 8:17 A.M., activity participation note: The resident received a room visit for the activity director yesterday. The resident was happy to have company just so he/she could have a conversation. They talked about his/her activity interests and some personal information to get to know him/her; -No further documentation of activities provided or activity attendance. Observations on 6/7/21 at 2:01 P.M. and 2:51 P.M., 6/9/21 at 12:01 P.M., 6/11/21 at 10:54 A.M. and 6/14/21 at 12:31 A.M., showed the resident in his/her room. During an interview on 6/9/21 at 10:59 A.M., the resident said there are no activities. He/she just watches TV. There is nothing to do except watch TV. He/she would like for someone to visit with him/her or do puzzles, anything. 10. Review of Resident #227's admission MDS, dated [DATE], showed: -Cognitively intact; -Should interview for daily and activity preferences be conducted: Yes; -How important is it to you to listen to music you like: Somewhat important; -How important is it to you to keep up with the news: Very important; -How important is it to you to do things with groups of people: Very important; -How important is it to you to do your favorite activities: Very important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -How important is it to you to participate in religious services or practices: Very important; -Supervision required with locomotion on the unit; -Independent with locomotion off the unit; -Primary medical condition category: Medically complex conditions. Review of the resident's undated activity preferences, provided by the activity director, showed: -Things I enjoy doing: Playing cards, being with family; -Things I dislike doing: Blank; -Favorite snacks: Chips, cookies; -Other information: Blank. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for potential nutritional problems. He/she has a diagnosis of diabetes: -Goal: Maintain adequate nutritional status; -Interventions: Invite to activities that promote additional intake; -At risk for alteration in psychosocial well-being due to visitation restrictions related to COVID-19 precautions. He/she is on isolation precautions on the yellow hall per guidelines: -Goal: Have no indications of psychosocial well-being problem while in quarantine/isolation; -Interventions: Observe for increased anxiety or changes in mood/behavior that are related to quarantine; provide with in-room activities; -The care plan did not address the resident's activity preferences or type/frequency of in room activities during quarantine. Review of the resident's admission activities evaluation, dated 6/3/21, showed the following preferences: -Frequency of activities: daily; -Preferred location: Outside the facility. Review of the resident's progress notes, showed: -On 6/8/21 at 8:23 A.M., activity participation note: The resident received a room visit yesterday from the activity director. He/she expressed how he/she would like to join activities and go outside. He/she also was happy to have a long conversation with someone at the facility; -No further documentation of activities provided or activity attendance. During an interview on 6/7/21 at 1:01 P.M., the resident said he/she would like to have more to do. He/she has not been outside since he/she arrived to the facility. Observation and interview on 6/7/21 at 1:24 P.M., showed the resident in his/her room and said he/she has not had lunch yet and would like to eat. At 2:57 P.M., the resident sat in his/her room and said he/she got his/her lunch about three minutes ago. Observation on 6/8/21 at 1:13 P.M., showed the resident in his/her room. He/she wore the same clothes he/she had on the day prior. At 2:20 P.M., the resident lay across the bed with his/her head on his/her hand and stared at the wall. His/her lunch tray at his/her bedside. 11. Review of Resident #13's annual MDS, dated [DATE], showed: -Cognitively intact; -Should interview for daily and activity preferences be conducted: Yes; -How important is it to you to have books, newspapers and magazines to read: Very important; -How important is it to you to listen to music you like: Very important; -How important is it to you to keep up with the news: Very important; -How important is it to you to do things with groups of people: Somewhat important; -How important is it to you to do your favorite activities: Very important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -Limited assistance required with locomotion on the unit; -Locomotion off the unit: Activity did not occur; -Primary medical condition category: Stroke. Review of the resident's undated activity preferences, provided by the activity director, showed: -Things I enjoy doing: Reading books, watching movies; -Things I dislike doing: Public speaking; -Favorite snacks: Jolly ranchers; -Other information: Blank. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for impaired fluid intake related to depression: -Goal: be free of symptoms of dehydration; -Interventions: Invite to activities that promote additional fluid intake. Offer drinks during one to one visits; -At risk for falls: -Goal: Not sustain serious injury; -Interventions: Encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility; -The care plan did not address the resident's activity preferences. Review of the resident's admission activities evaluation, dated 7/30/20, showed the following preferences: -Frequency of activities: Daily; -Preferred location: Day/activity room. Review of the resident's progress notes, from 1/1/21 through 6/9/21, showed: -On 6/2/21 at 4:00 P.M., activity participation note: Attended resident council meeting; -On 6/8/21 at 5:42 P.M., activity participation note: Resident attended resident council meeting today which he/she participated with no issues (this group meeting was held between the state surveyors and resident and was not a facility provided activity); -No further documentation of activities provided or activity attendance. During a group interview on 6/8/21 at 10:55 A.M., the resident said when COVID-19 started, the facility said residents cannot smoke anymore. That was a form of enjoyment and time to socialize. They just took that away. Since COVID-19, residents haven't seen anything but the four walls in their room. They don't see anyone anymore. Residents cannot even go up to the front lobby to get money anymore, they have to have it brought to them. Residents have to stay close to their rooms, can't sit in the halls, and if they leave their rooms, they are told to go back to their room. 12. Review of resident #38's admission MDS, dated [DATE], showed: -Cognitively intact; -Should interview for daily and activity preferences be conducted: Yes; -How important is it to you to have books, newspapers and magazines to read: Somewhat important; -How important is it to you to listen to music you like: Somewhat important; -How important is it to you to keep up with the news: Very important; -How important is it to you to do things with groups of people: Somewhat important; -How important is it to you to do your favorite activities: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -How important is it to you to participate in religious services or practices: Somewhat important; -Locomotion on and off the unit: Activity did not occur; -Primary medical condition category: Medically complex conditions. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for alterations in psychosocial well-being due to visitation restrictions related to COIVD-19 precautions. Is on the green hall: -Goal: Have no indications of psychosocial well-being while in quarantine/isolation; -Interventions: Provide resident with in room activities; -Activity preferences not included on the care plan. Review of the resident's admission activities evaluation, dated 4/22/21, showed the following preferences: -Frequency of activities: Daily; -Preferred location: Day/activity room. Review of the resident's progress notes through 6/7/21, showed no activity participation notes. During an observation and interview on 6/8/21 at 1:40 P.M., the resident sat in a wheelchair in the hall, at the door to the outside as he/she looked outside. He/she said he/she cannot wait until he/she can go outside again and hopes it is soon. The last time he/she was outside was about six months ago when he/she left the hospital to come to the facility. He/she is an outdoors person and loves hunting, fishing and yard work. He/she misses fresh air. Further review of the resident's progress notes, showed on 6/8/21 at 5:40 P.M., the resident had a one on one visit outside with the activity director that he/she requested to get some fresh air. Conversation occurred about how he/she was processing overall with his/her and how happy he/she was to come to this facility. 13. Review of Resident #44's admission MDS, dated [DATE], showed: -Moderately impairment; -Should interview for daily and activity preferences be conducted: Yes; -How important is it to you to have books, newspapers and magazines to read: Somewhat important; -How important is it to you to listen to music you like: Very important; -How important is it to you to keep up with the news: Very important; -How important is it to you to do things with groups of people: Somewhat important; -How important is it to you to do your favorite activities: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -Extensive assistance required for locomotion on the unit; -Locomotion off the unit: Activity did not occur; -Primary medical condition category: Medically complex conditions. Review of the resident's undated activity preferences, provided by the activity director, showed: -Things I enjoy doing: Read, chess, socialize; -Things I dislike doing: Being idle; -Favorite snacks: Chips, apples; -Other information: Blank. Review of the resident's care plan, in use at the time of the survey, showed: -Resident has behavioral problems at times, he/she has moderate cognitive impairment: -Goal: Not experience behaviors that are harmful to self and others; -Interventions: Provide a program of activities that is of interest and accommodates resident's status; -Resident has impaired cognitive ability: -Goal: Be able to communicate basic needs; -Interventions: Provide a program of activities that accommodates the resident's abilities (SPECIFY); -At risk for alteration in psychosocial well-being due to visitation restrictions related to COVID-19. Resident is on a green hall: -Goal: No indications of psychosocial well-being problems while in quarantine/isolation; -Approach: Provide resident with in room activities; -The care plan did not address activity preferences. Review of the resident's admission activities evaluation, dated 5/3/21, showed the following preferences: -Frequency of activities: Daily; -Preferred location: Day/activity room. Review of the resident's progress notes, showed: -On 6/8/21 at 4:54 P.M., activity participation note: The resident engaged in a conversation with the activity director during a room visit. He/she stated some things he/she enjoyed regarding activities and some snacks he/she liked to eat; -No further documentation of activities provided or activity attendance. During an interview on 6/8/21 at 1:40 P.M., the resident said no one ever asks him/her about activities or tells him/her about activities going on. He/she does not have an activity calendar and does not know where one is posted. When asked if there was an activity cart that comes around, he/she said no. He/she asked to go outside once, it never happened. Observation and interview on 6/14/21 at 12:05 P.M., showed the resident lay in bed. The resident said there are no activities. He/she enjoys playing chess and cards but does not know if anyone else here does. 14. Review of Resident #52's annual MDS, dated [DATE] showed: -Rarely/never understood; -Should interview for daily and activity preferences be conducted: Yes; -How important is it to you to listen to music you like: Somewhat important; -How important is it to you to keep up with the news: Somewhat important; -How important is it to you to do things with groups of people: Somewhat important; -How important is it to you to do your favorite activities: Somewhat important; -How important is it to you to participate in religious services or practices: Somewhat important; -Extensive assistance required with locomotion on the unit; -Locomotion off the unit: Activity did not occur; -Primary medical condition category: Other neurological conditions. Review of the resident's undated activity preferences, provided by the activity director, showed: -Things I enjoy doing: Watching movies; -Things I dislike doing: Blank; -Favorite snacks: Cookies, M&Ms; -Other information: Blank. Review of the resident's care plan, in use at the time of the survey, showed: -Communication problem due to stroke: -Goal: Make basic needs known; -Interventions: Be conscious of resident position when in groups, activities, dining room to promote proper communication with others; -The care plan did not address activity preferences or needs. Review of the resident's medical record, showed no activities evaluation completed. Review of the resident's progress notes, from 1/1/21 through 6/9/21, showed: -On 6/4/21 at 3:07 P.M., the resident attended the doughnuts day activity which he/she was alert and ate doughnuts happily; -No further documentation of activities provided or activity attendance. During a resident representative interview on 6/8/21 at 7:58 A. M, the resident's family member said activities dwindled after COVID-19 hit. There were many activities prior to COVID-19. When he/she visits, they play cards, but he/she can only visit for one hour. He/she thought restrictions for COVID-19 were loosening up, but guesses they are not at this facility. 15. Review of Resident #36's admission MDS, dated [DATE], showed: -Moderately impaired cognition; -Should interview for daily and activity preferences be conducted: Yes; -How important is it to you to keep up with the news: Somewhat important; -How important is it to you to do your favorite activities: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Somewhat important; -Supervision required with locomotion on the unit; -Locomotion off the unit: Activity did not occur; -Primary medical condition category: Medically complex conditions. Review of the resident's undated activity preferences, provided by the activity director, showed: -Things I enjoy doing: Having visits from parent; -Things I dislike doing: Being ignored; -Favorite snacks: Chips; -Other information: Blank. Review of the resident's care plan, in use at the time of the survey, showed: -At risk for alterations in psychosocial well-being due to visitation restrictions related to COVID-19 precautions. He/she is on a green hall: -Goal: Not experience any adverse effects of visitation restrictions; -Interventions: Encourage to facilitate alternative ways to communicate with friends and family; observe for changes in mental status caused by situational stressors; provide opportunities to express feelings related to situational stressors; -Activity preferences not listed on the care plan. Review of the resident's admission activities evaluation, dated 10/20/20, showed the following preferences: -Frequency of activities: Daily; -Preferred location: Prefers own room. Review of the resident's progress notes, showed no activity participation notes. During an interview on 6/7/21 at 10:50 A.M., the resident said there are no activities. He/she would at least like to go play bingo. 16. Review of Resident #22's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Should interview for daily and activity preferences be conducted: Yes; -How important is it to you to listen to music you like: Very important; -How important is it to you to keep up with the news: Very important; -How important is it to you to do things with groups of people: Somewhat important; -How important is it to you to do your favorite activities: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Somewhat important; -Total dependence with locomotion on and off the unit; -Primary medical condition category: Other neurological conditions. Review of the resident's undated activity preferences, provided by the activity director, showed: -Things I enjoy doing: Having conversations; -Things I dislike doing: Blank; -Favorite snacks: Pies; -Other information: Blank. Review of the resident's care plan, in use at the time of the survey, showed: -Impaired mobility related to multiple sclerosis (an autoimmune disease that attacks the nerve endings). Relies on staff for all feedings, appetite and nutritional needs may be affected by episodes of pain and depression. At risk for impaired nutrition and weight changes: -Goal: Be free from significant weight changes; -Interventions: Develop an activity program that includes exercise, mobility. Offer activities of choice to help divert attention from food; invite to activities that promote additional intake; -The care plan did not address activity preferences. Review of the resident's progress notes, from 1/1/21 through 6/9/21, showed no activity participation notes. Review of the resident's admission activities evaluation, dated 11/10/20, showed the following preferences: -Frequency of activities: Daily; -Preferred location: Prefers own room. Observation and interview on 6/8/21 at 1:05 P.M., showed the resident lay in bed. The resident said he/she did not participate in activities today. 17. Review of Resident #523's admission MDS, dated [DATE], showed: -Cognitively intact; -Should interview for daily and activity preferences be conducted: Yes; -How important is it to you to have books, newspapers and magazines to read: Somewhat important; -How important is it to you to keep up with the news: Very important; -How important is it to you to do things with groups of people: Somewhat important; -How important is it to you to do your favorite activities: Somewhat important; -How important is it to you to go outside to get fresh air when the weather is good: Very important; -Extensive assistance required for locomotion on the unit; -Locomotion off the unit: Activity did not occur; -Primary medical condition category: Fractures and other multiple trauma. Review of the resident's undated activity preferences, provided by the activity director, showed: -Things I enjoy doing: Casino, watching TV, and computer; -Things I dislike doing: Blank; -Favorite snacks: Ice cream, popcorn and cookies; -Other information: Blank. Review of the resident's care plan, in use at

Based on interview and record review, the facility failed to ensure the quality assurance and performance improvement (QAPI) program committee developed and implemented appropriate plans of action to correct identified quality of life deficiencies related to activities provided. In addition, the facility failed to develop policies specific to the facility to address feedback, data collection systems and monitoring, including adverse event monitoring; to address how the facility will use a systematic approach to determine underlying causes of problems, how the facility will develop corrective actions, or how the facility will monitor the effectiveness of its performance improvement activities. This had the potential to affect all residents in the facility. The census was 82. Review of the facility's Quality Assurance and Performance Improvement Program Framework, dated 12/20/19, showed: -Purpose: To provide guidance in the development and implementation of an effective QAPI program that takes a systematic, interdisciplinary, comprehensive and data-driven approach to maintaining and improving safety and quality while involving resident, families and associates in practical and creative problem solving; -The focus of the QAPI program is to promote excellence in quality of care, quality of life, resident choice and person centered care. All QAPI activities will be collaborative and interdisciplinary, including the involvement of all appropriate associates. Any system that affects the satisfaction of residents, families and associates will be considered an area for improvement; -Each long term care facility, including a facility that is part of a multiunit chain, must develop, implement and maintain an effective, comprehensive, data-drive QAPI program that focuses on indicators of the outcomes of care and quality of life. The facility must: -Maintain documentation and demonstrate evidence of its ongoing QAPI program. This may include but is not limited to documentation demonstrating the development, implementation and evaluation of corrective actions or performance improvement activities; -Program feedback, data systems and monitoring: A facility must establish and implement written policies and procedure for feedback, data collection systems and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following: -Facility maintenance of effective system to obtain and use the feedback and input from direct care staff, other staff, residents and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone and opportunities for improvement; -Facility maintenance of effective systems to identify, collect and use data and information from all departments, including but not limited to the facility assessment and including how such information will be used to develop and monitor performance indicators; -Facility development, monitoring and evaluation of performance indicators, including the methodology and frequency for such development, monitoring and evaluation; -Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events; -Program systematic analysis and systemic action: The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained. The facility will develop and implement policies addressing: -How they will use a systematic approach to determine underlying causes of problems impacting larger systems; -How they will develop corrective actions that will be designated to effect change at the systems level to prevent quality of care, quality of life, or safety problems; -How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained. During an interview on 6/14/21 at 1:55 P.M., the administrator said she does not have any QAPI policy specific to the facility to address feedback, data collection systems and monitoring, including adverse event monitoring. There are also no facility specific QAPI policies to address how the facility will use a systematic approach to determine underlying causes of problems, how the facility will develop corrective actions, or how the facility will monitor the effectiveness of its performance improvement activities. The facility does not have any QAPI policies outside of the QAPI framework provided. Review of the facility's activity calendars, showed a decrease in scheduled group activities from March 2021 to June 2021: -March 2021: Three to four activities scheduled daily during week days. Two activities scheduled daily during the weekend. 100 activities total scheduled for the month; -April 2021: Two to three activities scheduled daily. 63 activities total scheduled for the month; -May 2021: One to three activities scheduled daily. 66 activities total scheduled for the month; -June 2021: One to two activities scheduled daily. 65 activities total scheduled for the month. Review of the resident council notes, showed: -March 2021, residents are happy the new activity director is at the facility. When can residents go back outside in the courtyard, bus trips to store and out to eat? Activities was shut down before COVID-19 and it is unfair. No documented follow-up; -April 2021, all residents want outside activities. No documented follow-up; -No May 2021 resident council minutes provided; -June 2021, all residents need outdoor activities like out to eat in store runs. Not enough activities. No documented follow-up. During an interview on 6/14/21 at 1:19 P.M., the administrator said there was no resident council meeting held in May 2021. During a group interview on 6/8/21 at 10:55 A.M., four residents identified by the facility as being alert and oriented, who represented the resident council, said: -Resident #13 said, when COVID-19 started, the facility said residents cannot smoke anymore. That was a form of enjoyment and time to socialize. They just took that away. Residents are not eating in the dining room since COVID-19. It would be nice to go to the dining room, which is where residents socialized and talked. Since COVID-19, residents haven't seen anything but the four walls in their room. They don't see anyone anymore. Residents cannot even go up to the front lobby to get money anymore, they have to have it brought to them. Residents have to stay close to their rooms, can't sit in the halls, and if they leave their rooms, they are told to go back to their room. Activities has been almost non-existent. With bingo, they can only have one resident at a table, so only a couple residents can go; -Resident #32 said he/she has been wanting to go outside. He/she wants to go shopping; -Resident #35 said his/her room is by the court yard and since COVID-19, he/she has not seen anyone go out to smoke. During an interview on 6/10/21 at 1:07 P.M., the activity director said she is the only activity staff person at the facility. She usually has the same eight residents that come to activities. There are a few residents who receive one on one activities. They are scheduled on a printed calendar. She will provide a copy of the schedule for this month. Activity participation is documented in the electronic medical record under progress notes. Residents on isolation, in the yellow zone, and cannot come out of their rooms would benefit from one on one activities. She is aware of activity concerns brought up by the resident council. They want to go on outings, go outside, smoke and have more activities. She started working at the facility four months ago and there has been no activities in the courtyard or smoking. She has not been able to use the courtyard for activities because it is so overgrown with weeds. The residents are not allowed to go out there. Nothing has been done to address the resident council concerns because there is not enough activity staff and she has not been given permission for outdoor activities or outings. The March activity calendar was the first one she created after starting at the facility. Due to having no activity staff to help, she was not able to do all the activities that were listed and residents were complaining that the scheduled activities were not taking place. To fix this, she scheduled less activities. Review of the facility's resident roster, dated 6/6/21, showed 15 residents resided in the yellow isolation zone. Review of the activity one on one schedule, showed only six one on one activities scheduled. During an interview on 6/11/21 at 1:56 P.M., with the administrator and director of nursing (DON), the administrator said she started at the facility a little over a month ago. The facility has had one QAPI meeting since she started. The process to identify areas of concern include looking into areas of high risk, falls, complaints from residents, risk factors etc. An example of information used to identify concerns includes the grievance log. She has identified activities as an area of concern. She is not sure how many activity staff there were prior to the pandemic, but she does feel one activity staff, if qualified, is sufficient for the number of residents at the facility. The COVID-19 pandemic increases the need for activities. She is aware of resident concerns regarding activities. She does not know what follow up the activity director has provided to the resident council. During an interview on 6/14/21 at 2:20 P.M., the administrator said her first QAPI meeting with the facility was in June. Activities had been an ongoing concern, but she is not sure if it was selected as a QAPI project or what had been done to correct the concern.