Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for one resident (Resident #49) of three sampled residents who remained in the facility upon discharge from Medicare Part A services. The facility census was 109. Review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 01/09/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC - form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them his/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination. Review shoed the facility did not provide a policy pertaining to the issuance of Advance Beneficiary Notices. 1. Review of Resident #49's electronic medical record (EMR) summary page showed admission date of 10/14/24. Record review of the resident's Skilled Nursing Facility Beneficiary Notification Review, completed by facility staff on 12/05/24, showed the following: -Medicare Part A skilled services episode start date 10/14/24; -Last covered day of Medicare Part A service as 12/06/24. -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted. (Facility staff did not provide the resident or his/her legal representative the required SNFABN form CMS-10055 or alternative denial letter.) During an interview on 12/06/24, at 10:55 A.M., the resident said he/she signed the Notice of Medicare Non-Coverage (CMS-10123-NOMNC), but the facility did not provide anything showing an estimated cost of services that would not be covered after that day. The resident said he/she did his/her own research to find out the daily cost of room/board and therapy. He/she would need to stay in the facility until he/she was able to bear weight on his/her affected leg and transfer independently. During an interview on 12/06/24, at 1:30 P.M., the Social Services Director (SSD) said he/she was responsible for issuing the resident or their responsible party the Medicare Part A discharge forms. He/she was told during his/her training to only issue the SNFABN for CMS-10055 if a resident was going to stay in the facility for long-term care. The SSD did not issue the form to the resident prior to the last covered day of Medicare Part A skilled services. During an interview on 12/06/24, at 1:05 P.M., the Administrator said if a resident might potentially stay in the facility past their last covered date of Medicare Part A services, the facility should issue a CMS-10055 to show the potential cost of services not covered.

Based on record review and interview, facility staff failed to complete a quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessment for two residents (Residents #18 and #77) within 92 days of the prior assessment. The facility had a census of 109. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, Chapter 2, Assessments for the RAI, showed the following information: -The quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type; -The quarterly assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored; and -The ARD must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. Review showed the facility did not provide a policy pertaining to the completion of MDS assessments. 1. Review of Resident #18's MDS submitted reports showed the last MDS assessment ARD date was 07/24/24. Staff did not document an assessment completed since 07/24/24 (over 129 days prior). 2. Record review of Resident #77's MDS submitted reports showed the last MDS assessment ARD date was 07/29/24. Staff did not document an assessment completed since 07/24/24 (over 124 days prior). 3. During interviews on 12/05/24, at 1:40 P.M. and 1:55 P.M., the MDS Coordinator said the following: -Until recently, he/she has been the only one doing MDS assessments; -The facility had a tracking system, but there was a glitch and a couple of residents didn't have their quarterly assessments completed timely; -Resident #18 had his/her last assessment on 07/24/24; -Resident #77 had a quarterly assessment on 07/29/24; -The assessments are due every 92 days. During an interview on 12/06/24, at 11:50 A.M., the Assistant MDS Coordinator said the following: -Quarterly assessments completed every 92 days, repeat the cycle until the fourth and that's the annual; -Resident #18's quarterly was due 92 days after 07/24/24. The report omitted the next one due so it wasn't done timely; -Resident #77's quarterly was due 92 days after 07/29/24. The report omitted this resident's next assessment time so it wasn't completed timely; -He/she recently began assisting with MDS assessments and helps a couple days per week. During an interview on 12/06/24, at 1:05 P.M., the Administrator said the following: -MDS assessments are done every 90 days and have a 10 day window; -He/she isn't aware of a system the MDS Coordinator uses to track assessments; -He/she isn't aware of any MDS assessments not completed timely; -He/she expected the assessment to be completed timely.

Based on observations, record review, and interview, the facility failed to provide enteral nutrition per standards of practice when staff failed to administer tube feeding consistently as ordered and failed to ensure the orders were clear and accurate for one resident (Resident #102), out of a sample of one resident. The facility census was 109. Review of the facility policy, titled Tube Feedings, dated 11/2023, showed the following: -Tube feeding shall be administered by licensed nursing personnel upon recommendation of registered dietician and/or order by physician; -For continuous method of administration, staff should assure tubing is connected, fill the chamber one-half full and prime tubing, hang the container from the infusion pump pole, thread the tubing through the infusion pump, head of bed elevated 30 to 45 degrees at all times; -Connect the tubing to the feeding tube. Secure the connection with tape; -Set the rate as ordered and begin the infusion; -Staff should document the feeding and water flush; -Record intake and output; -Document residuals; -Document area of concern and notify physician. 1. Review of Resident #102's face sheet showed the following: -admission date of 07/09/24; -Diagnoses included nontraumatic subarachnoid hemorrhage from anterior communicating artery (a type of intracranial (inside the skull) bleeding that occurs when an aneurysm (bulge or ballooning in a blood vessel wall that's caused by a weakened area ) in the anterior communicating artery (short blood vessel that connects the left and right anterior cerebral arteries in the brain) ruptures and leaks blood into the subarachnoid space (surrounds the brain)), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), personal history of aneurysm rupture, and craniotomy (surgical opening into the skull). Review of the resident's care plan, last reviewed on 12/06/24, showed the following: -As of 08/06/24, due to the resident's poor oral intake and frequent changes in condition, the resident had restarted tube feeding; -As of 08/06/24, the resident had a pureed diet with thickened liquids; -As of 08/06/24, the resident was on a regular diet with thin liquids and tube feeding supplementation if less than 50% of oral meal is consumed; -Staff should refer to the current order for tube feeding instructions. Review of the resident's physician note, dated 11/22/24, showed the following: -Staff sent a message to the physician stating the resident was currently getting jevity (therapeutic nutrition product that provides complete, balanced nutrition for people who are unable to get enough calories and nutrients by mouth) 1.5 calories every 8 hours, sometimes did not tolerate it well, and was having residual emesis (vomiting). Speech therapy (ST) and nurse discussed continuous feeding. Could staff receive an order for continuous feeding jevity 1.5 calorie at 30 milliliter (ml) per hour for 18 hours for mostly during the night and off for 6 hours to promote eating during the day and working with speech ST and can staff continue with the flushes every 8 hours; -The physician responded let's try this and continue to observe the resident for nausea and/or vomiting and make changes if necessary. The resident is an aspiration risk, so staff need to be monitoring him/her. Review of the physician orders. dated 12/06/24, showed the following: -An order, dated 11/13/24, for tube feeding flush of 250 ml water three times per day at 5:00 A.M., 1:00 P.M., and 9:00 P.M.; -An order, dated 11/22/24, jevity 1.5 calorie, to run at 30 ml/hr every 18 hours, for duration of 33 hours and 20 minutes, with a total volume of 1,000 ml. Observations showed the following: -On 12/02/24, at 11:00 A.M., the resident was in bed with his/her eyes closed. Tube feeding attached to infusion pump running at 30 ml/hr; -On 12/03/24, at 8:58 A.M., the tube feeding was not attached to the resident or the infusion pump and not turned on. The resident was in bed with his/her eyes closed; -On 12/03/24, at 11:15 A.M., the resident was in the dining room. His/her meal included pureed meat, spinach, and mashed potatoes. The resident only ate one bite of mashed potatoes. -On 12/04/24, at 2:40 P.M., the nurse checked the resident's blood pressure. The tube feeding was running at 30 ml/hr, the nurse prepared to administer medications; -On 12/05/24, at 12:00 P.M., the resident was in the dining room, with a pureed meal. The resident was not eating and had not taken any bites; -On 12/05/24, at 12:50 P.M., the resident was in bed. The head of bed was elevated, there was no tube feeding attached or running; -On 12/05/24, at 2:54 P.M., the resident was in bed with head of bed elevated and his/her eyes closed. There was no tube feeding running or attached; -On 12/05/24, at 9:05 P.M., the resident in bed with eyes closed, the tube feeding was attached and running at 30 ml/hr. During an interview on 12/04/24, at 2:50 P.M., Registered Nurse (RN) A said the resident's tube feeding was continuous. He/she said that every 18 hours the nursing staff change the tube feeding bag and add more jevity. During an interview on 12/05/24, at 2:45 P.M., Licensed Practical Nurse (LPN) J said the tube feeding was scheduled for every 18 hours on and 6 hours off. The order did not say 6 hours off. He/she said it was a rotating schedule and there was not a set time to put on and take off. The night shift would turn on the feeding and it was turned off at 11:35 A.M. During an interview on 12/05/24, at 9:10 P.M., RN K said the tube feeding order was a little confusing. It stated to be every 18 hours and off for 8 hours. He/she said the day staff turned off the feeding at about 11:00 A.M. this day and he/she connected and turned on at 9:00 P.M. this night. During an interview on 12/06/24, at 9:27 A.M., the Assistant Director of Nursing (ADON) said staff should follow the physician orders for tube feeding and administer every 18 hours. He/she was not familiar with the resident's orders. During an interview on 12/06/24, at 11:40 A.M., Director of Nursing (DON) said staff should give tube feeding according to physician orders and if the orders were unclear, staff should obtain clarification. During an interview on 12/06/24, at 12:11 P.M., the Pharmacist said the computer system should put in the times for staff to complete tube feeding. The physician order should be correct and it should cue up every 18 hours. During an interview on 12/06/24, at 1:45 P.M., Administrator said that staff should follow physician orders and if the orders were not clear the staff should get clarification. He was made aware of tube feeding orders being unclear.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than 5% when the facility staff made two errors out of 28 opportunities resulting in an error rate of 7.14% when facility staff failed to administer medication at the specified scheduled dosing time, before a meal and separate from other medications, for two residents (Resident # 98 and Resident # 101). The facility census was 109. Review of the facility's policy titled Medication Administration and Documentation, NUR09-09, revised 12/24, showed the following: -Medications are administered in accordance with prescriber orders; -Standard administration times may be adjusted by pharmacy staff due to drug/food incompatibilities with the following agents: Thyroid preparations 6:00 A.M.; -Long Term Care (LTC) providers may exclude certain patients or medications from liberalized medication pass: Dietary and drug-drug interactions should be avoided where specifically noted in the electronic Medication Administration Record (eMAR); -Administration of medications outside their scheduled dosing times and windows will be tracked in routine reporting by the facility. 1. Review of Resident # 98's face sheet (brief resident profile sheet) showed diagnoses included Alzheimer's disease, unspecified. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 11/07/24, showed the following: -The resident entered the facility on 12/21/23; -The resident had severe cognitive impairment; -Diagnoses included thyroid disorder. Review of the resident's current physician orders showed an order, dated 12/22/23, for the following: -Administer levothyroxine (medication used for treatment of hypothyroidism (a condition in which the thyroid doesn't produce enough thyroid hormone) 75 micrograms (mcg) PO (by mouth) daily at 6:00 A.M. -Dose instructions included take on an empty stomach, 30 to 60 minutes before breakfast. -Label insturctions to administer consistently in the morning on an empty stomach, at least 30 minutes before food or other medications. Observation on 12/04/24, at 9:05 A.M., showed Registered Medication Technician (RMT) F prepared and administered levothyroxine 75 mcg tablet for the resident. RMT F administered other medications the same time as the levothyroxine. During an interview on 12/05/24, at 10:25 A.M., RMT G said breakfast is typically served between 7:00 A.M. and 8:00 A.M. and he/she normally administered the resident's thyroid medication between 8:00 A.M. to 9:00 A.M. He/she administered all of resident's medications at the same time (including levothyroxine). RMT G was aware that he/she was administering the levothyroxine to the resident at the wrong time, after breakfast, and with additional medications. He/she should have administered the medication at 6:00 A.M., before breakfast, and separate from other medications. During an interview on 12/05/24, at 1:33 P.M., Registered Nurse (RN) C said the resident's thyroid medication should be administered as ordered at 6:00 A.M., before the breakfast meal on an empty stomach and separate from other medications. 2. Review of Resident # 101's face sheet showed diagnoses included of right femur (thigh bone) fracture. Review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident entered the facility on 6/20/24; -Moderate cognitive impairment; -Diagnosis of hypothyroidism. Review of the resident's current physician orders showed the following: -Order, dated 05/03/24, for levothyroxine 88 mcg daily by mouth scheduled at 6:00 A.M. -Dose instructions included take on an empty stomach, 30 to 60 minutes before breakfast. -Label instructions to administer consistently in the morning on an empty stomach, at least 30 minutes before food or other medications. Observation on 12/05/24, at 8:57 A.M., showed RMT G prepared and administered levothyroxine 88 mcg one tablet to the resident. RMT G administered other medications at the same time. During an interview on 12/05/24, at 10:25 A.M., RMT G said he/she administered levothyroxine to the resident on 12/05/24 after he/she ate breakfast and all other medications were administered at the same time as the levothyroxine. It was impossible to administer the 6:00 A.M. medications before meals due to the number of residents receiving medications. He/she knew that levothyroxine was supposed to be administered on an empty stomach and separate from other medications. The resident received his/her breakfast between 7:00 A.M. to 8:00 A.M. on 12/05/24 and he/she administered all the resident's morning medications (including levothyroxine) around 9:00 A.M. this morning. During an interview on 12/05/24, at 1:33 P.M., RN C said the resident's levothyroxine should be administered before the breakfast meal and on an empty stomach. 3. During an interview on 12/05/24, at 10:25 A.M., RMT G said breakfast was typically served between 7:00 A.M. and 8:00 A.M. and he/she normally administered the morning medications between 8:00 A.M. and 9:00 A.M. All the morning medications for each resident are administered at the same time (including levothyroxine) because there is not enough time to administer medications separately due to the number of residents he/she was responsible for administering medications to. RMT's start their shift at 6:00 A.M. and finish their medication pass for all residents between 10:00 A.M. to 11:00 A.M. He/she was aware that he/she was administering levothyroxine to residents at the wrong time and it should be administered at 6:00 A.M., before breakfast, and separate from other medications. 4. During an interview on 12/05/24, at 1:33 P.M. RN C said the facility policy allowed staff a liberal three hour window to pass medications from the time they are due. He/she did not know of any specific medications per facility policy that needed to be administered at a specific time except medications ordered with a status to be given now. The levothyroxine should be given before the meal, on an empty stomach, and he/she would expect the night shift staff to administer the levothyroxine at 5:00 A.M., but that had not been happening. 5. During an interview on 12/06/24, at 9:23 A.M. the Director of Nursing (DON) said staff have time allowances of 30 minutes to two hours to pass medications beyond the time they are due. Some medications have exact times that they should be administered. The DON said staff should not be administering a medication after breakfast that has been ordered to be administered before breakfast. Medications that are required to be administered on an empty stomach should be administered on an empty stomach. If medications are ordered to be given without other medications they should be administered separately. The facility has a liberalized three hour window of time to give medications that are ordered in the A.M. or P.M. without a specific time listed. Staff are expected to follow parameters for medications ordered with specific instructions. It was brought to his/her attention that levothyroxine was not being administered prior to breakfast per physician orders. The DON said the medication technicians are scheduled from 6:00 A.M. to 2:00 P.M. and 2:00 P.M. to 10:00 P.M. or until all evening medications are passed. The facility has 42 residents diagnosed with hypothyroidism and his/her expectation is for staff to administer thyroid medication as ordered at 6:00 A.M. per physician orders, prior to breakfast and separate from other medications. 6. During an interview on 12/06/24, at 1:43 P.M., the Administrator said staff are expected to administer medications within the window they are ordered to be administered in. He/she is aware of the medication timing issue with the thyroid medication.

Based on interview and record review, the facility failed to give ensure all residents received bed hold information upon transfer when staff failed to provide the facility's bed hold policy to the resident and/or resident's representative for five residents (Residents #32, #35, #261, #31, and #68) who were transferred out to the hospital. The facility census was 109. Review of the facility's policy entitled Bed Hold and Re-Admission, dated 2024, showed the following information: -Residents and their family members or legal representatives will be informed of the bed hold policy in writing upon admission as part of the admission contract; -In the case of an emergency, a written notification will be made within 24 hours of the transfer. Review of the facility's bed hold policy card showed the following: -The facility is required by Centers for Medicare and Medicaid Services (CMS) to notify residents of the bed hold policy upon any transfer or discharge from the facility. 1. Review of Resident #32's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 03/22/24; -Diagnoses included vitamin D deficiency, renal failure (when the kidneys are no longer able to filter waste and toxins from the blood), diabetes (the body doesn't produce enough insulin or use the insulin properly), and dementia (decline in thinking, memory and reasoning skills). Review of the resident's nurses' notes, dated 11/21/24, showed the following: -Resident found on floor next to bed in resident's room; -Resident sent to the emergency room (ER) for multiple head lacerations. Review of the resident's medical record showed the facility did not have a copy of the bed hold policy sent, or document sending a bed hold policy, with the resident or to the resident's representative. 4. Review of Resident #31's face sheet showed the following information: -admission date of 10/01/24; -Diagnoses included congestive heart failure (CHF - condition in which the heart can't pump enough blood to the body's other organs), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)) , and chronic anxiety; -Resident was not self-responsible. Review of the resident's EMS Transfer Report, dated 11/06/24, showed the following: -Resident transferred to emergency room via ambulance with complaints of right wrist pain, back pain, and left side of head pain; -Phone message was left for family member; -Medication list and face sheet sent with resident; -Bed hold was not checked as provided. Review of the resident's medical record showed the facility did not send a bed hold policy with the resident, or to the resident's representative. 5. Record review of Resident #68 face sheet showed the following information: -admission date of 04/28/23; -Diagnoses included coronary artery disease (CAD - common heart disease in which there is narrowing or blockage of the coronary arteries), hypertension (high blood pressure), peripheral vascular disease (PVD - a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm, or become blocked), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions); -Resident was not self-responsible. Review of the resident's nurses' notes showed staff documented the following: -On 11/10/24, at 1:28 P.M., staff called the nurse to the resident's room after lunch. The resident complained of pain to right chest that radiated to the back with breathing. Vital signs obtained. Contacted on-call physician and received order to send to emergency room. EMS arrived and the resident was transferred to the gurney. Family notified by phone. Review of the facility transfer letter showed the resident was sent to the emergency department on 11/10/24. Review of the resident's medical record shows the facility did not send a bed hold policy with the resident, or to the resident's representative. 6. During an interview on 12/05/24, at 8:22 A.M., the Business Office Manager (BOM) said the following: -He/she sends out hospital transfer letters when a resident goes to the hospital; -He/she doesn't know anything about bed hold policies. During interviews on 12/05/24, at 11:25 A.M. and 11:40 A.M., the Social Services Director (SSD) said the following: -The nursing staff notify resident families of bed hold by phone and ask if they want to hold the bed when transferred to the hospital. There was no written notification of the bed hold policy sent to the resident or resident's representative. -He/she was responsible for completing the admissions paperwork and it included the bed hold policy; -He/she didn't have anything to do with sending out bed hold policies when a resident is sent out on therapeutic leave; -There is a section in the medical record where therapeutic leaves of absence are documented, but He/she doesn't know about a form to send with the resident or the resident's representative. During an interview on 12/05/24, at 3:00 P.M., Registered Nurse (RN) A said bed holds are done up to 30 days on admission and up to 30 days after readmission. He/she doesn't do anything with bed holds or give residents a form when they go out on a hospital leave. During an interview on 12/05/24, at 3:12 P.M., RN C said the following: -When a resident was transferred to the hospital, he/she sent a message to leadership and they put a bed hold in the record; -If it's in the middle of the night when a resident is sent out, he/she goes in the computer and puts in the medical record a bed hold; -He/she didn't know anything about a form that is sent out with the resident or to the resident's representative. During an interview on 12/06/24, at 9:28 A.M., the Assistant Director of Nursing (ADON) said the following: -When a resident goes out to the hospital, the bed hold is included in the other paperwork sent with the resident; -The BOM sends out a hospital transfer letter that also includes the bed hold. During an interview on 12/06/24, at 11:40 A.M., the Director of Nursing (DON) said -Staff send a bed hold policy with the residents upon transfer to the hospital; -The policy is also mailed to the resident's representative, power of attorney or guardian. During an interview on 12/06/24, at 1:05 P.M., the Administrator said they have bed hold cards that are supposed to go out with the residents when they're transferred to the hospital. The BOM sends out the bed hold policy to the family. 2. Review of Resident #35's face sheet showed the following: -admission date of 05/19/24; -Diagnoses included sepsis (infection in the bloodstream), deficiency of vitamins B12 and D, low thyroid function, obesity, high cholesterol, low magnesium level, dementia, major depressive disorder, anxiety disorder, restless legs syndrome, degenerative disease of the nervous system, insomnia, chronic pain, metabolic encephalopathy (brain dysfunction due to a chemical imbalance elsewhere in the body), chronic kidney disease, atrial fibrillation (irregular heart function), history of mini-stroke, low blood pressure, and osteoarthritis. Review of the resident's nurse's notes, dated 08/14/24, at 1:11 P.M., showed the resident's roommate used his/her call light. On entry to the room, staff found the resident on the floor next to his/her bed. The resident said his/her head hurt and a laceration was noted to the side of his/her head. Review of the Emergency Medical Service (EMS) Transfer Report, dated 08/14/24, showed the following information: -Reason for ER visit: recent fall, decreasing blood pressure, episode of bleeding with three golf ball sized blood clots; -Facility checklist indicated: med list printed, face sheet printed, resident elected a status of Do Not Resuscitate (DNR), Staff did not indicate bed hold Information provided. Review of a transfer letter, dated 08/14/24, showed staff did not document information regarding a bed hold policy given to the resident or mailed to his/her responsible party. 3. Review of Resident #261's face sheet showed the following: -admission date of 10/11/24; -Diagnoses included prostate cancer, iron deficiency, deficiency of vitamins B group and D, high cholesterol, high potassium, major depressive disorder, anxiety disorder, insomnia, chronic pain, metabolic encephalopathy, high blood pressure, heart disease, history of stroke, circulatory disease, and gastro-esophageal reflux disease (GERD - stomach acid backs up into the chest and throat). Review of nurses' notes, dated 10/30/24, showed the resident left the facility via emergency medical services (EMS). Review of the EMS Transfer Report, dated 10/30/24, showed the following information: -Reason for ER visit: low blood pressure, high pulse, low oxygen saturation level, positive for COVID-19, and lethargy; -Facility checklist did not show indication of med list printed, face sheet printed, or bed hold Information given. Review of a Transfer Letter, dated 10/30/24, showed staff did not document information pertaining to a copy of the bed hold policy given or sent to the responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure catheter (sterile tube inserted into the bladder to drain urine) usage and care per standards of practice when staff failed to obtain physician's orders regarding placement of a catheter and catheter care for two residents (Resident #29 and Resident #33) in a sample of size of 3. The facility census was 109. Review of a facility's policy entitled Urinary Catheterization, dated 2024, showed urinary catheters should be placed only under the direction of a physician's order. 1. Review of Resident #29's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 08/24/23; -Diagnoses included obstructive and reflux uropathy (condition in which the flow of urine is blocked), retention of urine (condition that makes it difficult to empty the bladder, either partially or completely), and acute kidney failure (condition where the kidneys suddenly lose their ability to filter waste from the blood). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated 10/15/24, showed the following: -Severe cognitive impairment; -Resident had an indwelling catheter; -Resident dependent on staff for toileting hygiene and personal hygiene. Review of the resident's care plan, last reviewed 12/02/24, showed the following: -Due to urethral stricture (narrowing of the urethra (tube through which urine leaves the body) caused by scar tissue) the resident had a long term foley catheter (thin, flexible tube that drains urine from the bladder into a collection bag when a person is unable to urinate on their own). The catheter was to be changed by urology (medical and surgical specialty that treats conditions of the urinary tract) as it had to be surgically placed; -Staff should assess indwelling urinary catheter; -Staff should provide urinary catheter care; -No longer seeing urology, may change catheter every month. Review of the physician's order sheet, dated 12/02/24, showed no orders for indwelling catheter or catheter care. Observation on 12/02/24 showed the following: -At 10:00 A.M., the resident was seated in a wheelchair in the common area near the nursing desk with a catheter bag in a dignity bag located under his/her wheelchair; -At 12:00 P.M., the resident was seated in the dining room with a catheter bag located under his/her wheelchair. 2. Review of Resident # 32's face sheet, showed the following: -admission date of 03/22/24; -Diagnoses included renal failure (when the kidneys are no longer able to filter waste and toxins from the blood). Review of the resident's quarterly MDS, dated [DATE], showed staff did not indicate the resident had an indwelling catheter. Review of the resident's family nurse practitioners's note, dated 11/25/24, showed the following: -Resident was hospitalized due to a fall on 11/21/24; -Resident was found to have urinary retention, a foley catheter was placed and returned thick, purulent (containing puss) discharge. Observation on 12/02/24, at 11:44 A.M., showed the resident in the dining room eating with catheter bag attached to the bottom of his/her wheelchair. Review of the resident's physician orders showed staff did not document orders for a catheter placed or catheter care prior to 12/03/24. Review of the resident's care plan, updated of 12/03/24, showed staff to manage urinary catheter and continue foley catheter care. Review of the resident's December 2024 Physician Order Sheets showed the following: -An order, dated 12/03/24, to insert urinary catheter; -An order, dated 12/03/24, to continue foley catheter care. During an interview on 12/05/24, at 3:00 P.M., Registered Nurse (RN) A said the following: -The resident came back from the hospital with a catheter; -Orders for a catheter would come from the hospital; -Usually facility staff ask for a catheter to be removed after a resident is admitted from the hospital, but the resident has acute urinary retention; -He/she pulled up the resident's record and it showed on his/her work list the resident has a catheter; -He/she looked at the resident's online medical record and saw an order for a catheter on 12/03/24. During an interview on 12/05/24, at 3:12 P.M., Certified Nurse Aide (CNA) B said the resident came from the hospital with a catheter. During an interview on 12/05/24, at 3:12 P.M., RN C said he/she looked at the resident #32's orders and he/she had an order for a catheter beginning 12/03/24. 3. During an interview on 12/05/24, at 3:00 P.M., RN A said the following: -Orders are usually put in by the nurse or the doctor; -Aides have work lists and the catheter care comes up on the list; -Aides also document urine output; -He/she said all residents with a catheter should have an order. During an interview on 12/05/24, at 3:12 P.M., CNA B said the following: -He/she knew which residents had catheters as he/she learned about each resident; -He/she documents catheter cares in the medical record; -He/she also documents output of urine. During an interview on 12/05/24, at 2:45 P.M., Licensed Practical Nurse (LPN) J said the following: -Catheter care would show on the nursing staff work list interventions in the computer. The information would include when the catheter change was due and the pertinent size information. -He/she did not know what the care plan said. -He/she said that facility policy was to change any catheters every 30 days. -The information would not populate the due date, the nurses just were aware to check that 30 days had occurred. During an interview on 12/05/24, at 3:12 P.M., RN C said the following: -Staff know which residents have catheters as the work order pops up on the status board; -The aides have different work orders for documenting cares and urine output; -Every resident with a catheter should have an order; -Nurse's are responsible for putting in the orders. During an interview on 12/06/24, at 9:28 A.M., the Assistant Director of Nursing (ADON) said residents with catheters should have an order to insert, insert/remove, and manage or continue. He/she wasn't sure if the orders would say all of this, but it would be on the staff's work list. During an interview on 12/06/24, at 11:40 A.M., the Director of Nursing (DON) said any resident with a catheter should have an order and the admitting nurse was responsible for putting in the order. During an interview on 12/06/24, at 1:05 P.M., the Administrator said nurses should be putting in orders for catheters, and all residents should have an order.

Based on observation, interview, and record review, the facility failed to have pharmacy services in place to ensure a consistent counting, reconciliation, and destruction of controlled substances when staff failed to consistently document the number of medication packages and doses of controlled medications at the change of shift on the controlled substance shift change log and failed document administration on individual resident controlled drug record logs for three residents (Resident #13, #34, and #35) located in one of four medication carts in the facility. The facility census was 109. Review of the facility's policy titled Controlled Substances, PHA04-02, revised 09/24, showed the following: -Pharmacy services is responsible for the proper safeguarding of controlled substances throughout all the hospital and facilities connected to the facility; -The purchase, storage, distribution and accounting of controlled medications will be done in accordance with all federal and state laws and standards of professional practice; -Nursing units are responsible for routine inventories of controlled substances kept in their automated dispensing cabinets (ADCs); -Nursing units will conduct narcotic counts at least weekly or per department guidelines; -Controlled substance discrepancies will be reported to the charge nurse immediately; -If the count is incorrect, licensed nursing personnel from the off-going shift will stay until the discrepancy has been resolved; -Resolution of the discrepancy must be documented in the ADC and witnessed by a second nurse; -Any controlled substances not stored in the ADC will be counted at the change of shift by both the licensed nurse leaving the shift and the nurse coming on duty. Both nurses must sign the narcotic inventory sheet thereby verifying that the count is correct; -Narcotic prescriptions are secured in a designated medication cart in each long term care facility; -Long term care facilities much establish a resident specific control sheet for each narcotic prescription delivered for resident use; -Directors of Nursing (DONs) are provided a daily report for all narcotics pulled from the e-kit. DONs are responsible for confirming all dispensing, administration, and waste records align; -Waste/destruction of controlled substances shall be done in the presence of two licensed individuals who are authorized to handle and control these drugs. 1. Review of the Control Medication Shift Count Sheet and Continuous Package Count: Cart/Cabinet log, dated 11/27/24 to 12/05/24, for the 100 hall/small unit medication cart, showed the following: -On 11/27/24, at 10:00 P.M., one staff signed the shift count sheet; -On 11/28/24, at 6:00 A. M., one staff signed the shift count sheet; -On 11/28/24, at 2:00 P.M., one staff signed the shift count sheet; -On 11/30/24, at 2:00 P.M., one staff signed the shift count sheet; -On 11/30/24, at 10:00 P.M., one staff signed the shift count sheet; -On 12/2/24, at 10:00 P.M., one staff signed the shift count sheet; -On 12/3/24, at 2:00 P.M., one staff signed the shift count sheet when four controlled medication packages were removed/destroyed; -On 12/04/24, at 6:00 A.M., one staff signed the shift count sheet; -On 12/04/24, at 2:00 P.M., one staff signed the shift count sheet; -On 12/05/24, at 6:00 A.M., one staff signed the shift count sheet and no further counts were documented for the day; -On 12/06/24 staff did not document narcotic counts. During an interview on 12/06/24, at 10:30 A.M., Registered Nurse (RN) C said the following: -The last count documented on the List for Narcotics sheet showed 12/04/24 for the 7:00 A.M. to 3:00 P.M. shift signed by Registered Medication Technician (RMT) F. -Staff did not document a count for 12/05/2024, but RMT G should have counted and documented. -RMT F also did not count or document on the List for Narcotics sheet when he/she left the facility during his/her shift at 8:00 A.M. on 12/06/24 to attend an appointment. During an interview on 12/06/24, at 11:25 A.M., RMT F said this morning Licensed Practical Nurse (LPN) I left the night shift, gave him/her the narcotic keys and left without counting. He/she has two medication carts to manage during his/her shift. 2. Observation on 12/06/24, at 10:30 A.M., of the narcotics and the controlled drug record documents located on the 100 hall/small unit medication cart showed the following: -Resident #13's oxycodone HCL (a controlled pain medication used to treat moderate to severe pain) 5 milligram (mg) tablet package contained 61 tablets. The controlled drug record showed 62 tablets available. -Resident #34's tramadol HCL (a controlled pain medication used to treat moderate to severe pain and chronic pain) 50 mg tablet package contained 68 tablets. The controlled drug record showed 69 tablets available. -Resident #35's oxycodone IR 5 mg tablet package contained 26 doses. The controlled drug record showed 27 tablets available. During an interview on 12/06/24, at 12:56 A.M., RMT F said the following: -Resident #13's oxycodone HCL 5 mg package had 61 tablets. -Resident #35's oxycodone IR 5 mg package had 26 tablets. -Resident #'34's tramadol HCL 5 mg package had 68 tablets. During an interview on 12/06/24, at 12:50 P.M., RN C said he/she administered tramadol to Resident #34 at 9:24 A.M. and oxycodone to Resident #35 at 9:46 A.M. He/she did not document the medication on either resident's controlled drug record at the time administered. He/she wrote the date and time administered on a sticky note. During an interview on 12/06/24, at 1:01 P.M., the Director of Nursing (DON) reviewed the electronic narcotic administration record at the nurses' station with RN C for Resident #13 , Resident #35, and Resident #34. The DON said RMT G documented that he/she administered tramadol to Resident #34 on 12/05/24, at 6:39 P.M., but did not document the dose on Resident #34's controlled drug record. On 12/04/24, RMT G documented administering oxycodone to Resident #13 at 8:52 A.M., but he/she did not document the dose on Resident #13's controlled drug record. 2. During an interview on 12/06/24, at 11:17 A.M., RMT H said he/she completed narcotic counts with a nurse in the morning, with another RMT when he/she leaves for the evening, and with any medication cart changes. During an interview on 12/06/24, at 11:19 A. M., RN A. said he/she would not accept responsibility for administering narcotics without counting with other staff first. For discrepancies, he/she checked to see if the discrepancy was something he/she did not document, then he/she checked with other staff that recently passed narcotics. With unresolved discrepancies, he/she contacted the DON. During an interview on 12/06/24, at 11:25 A.M., RMT F said he/she occasionally completed narcotic counts with other staff. He/she has two medication carts to manage during his/her shift. If he/she does not get to count the narcotics, he/she goes ahead and passes the narcotics, but tries to count them and sign the narcotic sheet as the medications are passed even though he/she is the only one counting and signing. With discrepancies, he/she talks with the staff that narcotic keys were obtained from or to the DON. He/she counted narcotics with a RMT or nurse when they were available. He/she documented on a shift sheet and a narcotic card count sheet. During an interview on 12/06/24, at 10:45 A.M., the DON said his/her expectation was for the nurses and RMTs to do narcotic counts at shift change and with every exchange of narcotic keys. If narcotics are missing or there is a discrepancy, he/she would expect staff to notify him/her and he/she would investigate it and report to the Administrator. When staff that administer narcotics leave the building even for a temporary amount of time, the expectation was for the narcotic count to be completed prior to the staff leaving. If there was a narcotic discrepancy that he/she cannot rectify, the staff would be held in the facility until the issue is resolved. During an interview on 12/06/24, at 10:55 A.M., the Administrator said he/she expected staff to complete narcotic counts with each shift change, any change of staff and if staff leave the facility during their shift. He/she would hold staff in the facility until discrepancies are resolved. At 1:43 P.M., the Administrator said the narcotic count should be completed every shift with two staff and every time the narcotic passing role changes hands. Discrepancies in narcotics need to be taken care of immediately.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner that prevent possible contamination when the ice machine has a black substance on the deflector shield, a dented can was on the shelf for use, and scoops were left in the sugar and cornstarch. This has the potential to affect all residents who consumed food from the facility kitchen. The facility census was 109. 1. Review of the 2013 Missouri Food Code showed equipment food-contact surfaces and utensils shall be clean to sight and touch. Review of the facility's policy Ice Machines, dated 2024, showed the following: -Ice machine bins shall be cleaned on a quarterly schedule by departments utilizing cubers with bins; -Ice machines shall be cleaned using the wash, rinse, and sanitize process by removing all ice and water from the bin; -Using a cleaning solution or a solution with detergent and sanitizer combined wash interior of ice bin, rinse with clear water and town dry; -Inspect the ice chute for microbial growth, and clean as needed. Review of the preventative maintenance work order shows the ice machine was cleaned last on 07/31/24. Observation on 12/02/24, beginning at 9:27 A.M., of the ice machine showed the deflector shield, located over the ice, had multiple black spots over the entire shield. Observation on 12/04/24, beginning at 9:37 A.M., of the ice machine showed the deflector shield, located over the ice, had multiple black spots over the entire shield. During an interview on 12/04/24, at 2:14 P.M., Dietary Aide (DA) D said maintenance was responsible for cleaning the inside of the ice machine. The ice machine shouldn't have a black substance in it. During an interview on 12/04/24, at 2:19 P.M., DA E said he/she didn't know who was responsible for cleaning the inside of the ice machine. It should not have black spots on the inside. During an interview on 12/04/24, at 2:23 P.M., the Assistant Dietary Manager said they have a company that takes care of the ice machine, but they don't do anything with the inside. He/she wasn't sure who cleans the inside, but it shouldn't have black spots on the inside. During an interview on 12/04/24, at 3:50 P.M., Maintenance Director said the following: -He/she cleaned the inside of the ice machine; -He/she had a program called preventative maintenance and the program told him/her when to clean the ice machine; -He/she was not aware the deflector shield had black spots. There shouldn't be black spots in the ice machine. During an interview on 12/04/24, at 2:50 P.M., the Administrator said the following: -Maintenance cleans the inside of the ice machine; -The system generates preventative maintenance schedules and the tasks are completed as scheduled; -He/she was not aware there were black spots on the deflector shield. 2. Review of the Food and Drug Administration (FDA) 2022 Food Code FDA showed the following: -Depending on the circumstances, rusted, and pitted or dented cans may present a serious potential hazard. -Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. Observation on 12/02/24, beginning at 9:27 A.M., showed a 105 ounce can of pumpkin, with a large dent on the side, located by several other cans of pumpkin on the shelf. Observation on 12/04/24, beginning at 9:37 A.M., showed a 105 ounce can of pumpkin, with a large dent on the side, located by several other cans of pumpkin on the shelf. During an interview on 12/04/24, at 2:14 P.M., DA D said they do not use cans with dents on them. They put them away from the other cans. During an interview on 12/04/24, at 2:19 P.M., DA E said they do not use cans with dents. They put them in a bucket. During an interview on 12/04/24, at 2:23 P.M., Assistant Dietary Manager said the following: -They have two cans of pumpkins with dents; -If the dents are minor, or if the staff sometimes drop them and they have a dented rim they will use them; -If the cans come in with dents they will send them back. During an interview on 12/04/24, at 2:50 P.M., the Administrator said if dented cans come in from the truck dented, they should be returned. If staff cause the dent, they should be disposed of and not used. 3. Observation on 12/02/24, beginning at 9:27 A.M., showed the following: -Large plastic container of sugar with a scoop halfway in the sugar; -Large plastic container of cornstarch with the scoop partially in the cornstarch. (The scoop handles could come in contact with the sugar or cornstarch causing potential contamination.) Observation on 12/04/24, beginning at 9:37 A.M., showed the following: -Large plastic container of sugar with a scoop halfway in the sugar; -Large plastic container of cornstarch with the scoop partially in the cornstarch. During an interview on 12/04/24, at 2:14 P.M., DA D said as far as he/she knew the scoops are okay to be down inside of the containers of sugar and cornstarch. During an interview on 12/04/24, at 2:19 P.M., DA E said scoops should not be left in the plastic containers. They should be stored elsewhere. During an interview on 12/04/24, at 2:23P.M., the Assistant Dietary Manager said he/she didn't know if scoops could be left down in the containers of food. During an interview on 12/04/24, at 2:50 P.M., the Administrator said scoops should not be left in containers with food such as sugar and cornstarch.

Based on observation and interview, the facility failed to maintain a sanitary environment for all residents and staff when staff failed to ensure the fans located in the walk-in refrigerator and walk in freezer were kept clean. The facility census was 109. Review showed the facility did not provide a policy that addressed maintenance of the refrigerator or freezer fans. 1. Review of the facility's weekly cleaning schedule showed the staff responsible for cleaning the fans in the freezer or refrigerator was not listed. Observation on 12/02/24, beginning at 9:27 A.M., showed the following: -Black and brown substances on the plastic casing on the refrigerator fans; -Black and brown substance on the plastic casing covering the fans in the freezer. Observation on 12/04/24, beginning at 9:37 A.M., showed the following: -Black and brown substances on the plastic casing on the refrigerator fans; -Black and brown substance on the plastic casing covering the fans in the freezer. During an interview on 12/04/24, at 2:14 P.M., Dietary Aide (DA) D said maintenance is responsible for cleaning the fans in the refrigerator and freezer. He/she hasn't noticed them being dirty or he/she would have told maintenance. During an interview on 12/04/24, at 2:19 P.M., DA E said he/she had not been at this facility long, but in other facilities the maintenance person has been responsible for cleaning the fans in the walk in freezer and refrigerator. He/she had not noticed them being dirty. During an interview on 12/04/24, at 2:23 P.M., the Assistant Dietary Manager said he/she didn't know how to turn the fans off to clean them. He/she wasn't sure if maintenance or dietary staff were supposed to be cleaning the fans. He/she had not noticed the fans being dirty. During an interview on 12/04/24, at 3:50 P.M., the Maintenance Director said the following: -Normally the task of cleaning the fans inside of the freezer and refrigerator would generate on the preventative maintenance; -He/she didn't know when they were cleaned last, but he/she should be getting reminders; -The fans shouldn't' have black or brown substances on them. During an interview on 12/04/24, at 2:50 P.M., the Administrator said maintenance is responsible for cleaning the fans in the walk in refrigerator and freezers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed implement an abuse/neglect policy that ensured all reported allegations of possible abuse were reported to the State Survey Agency (Department of Health and Senior Services - DHSS) within two hours when staff failed to reported a documented allegation of touching of genitalia between two residents (Resident #1 and #2). The facility census was 105. Review of the facility policy titled, Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, ADM03-03, last revised August 2021, showed the following: -Staff, employees, and physicians will follow regulations and standards in identification of and procedures for handling alleged victims of abuse; -In the event a person with responsibility for care of a person sixty years of age or older or adults with disabilities ages 18-59 has reasonable cause to suspect that an individual has been subjected to abuse or neglect, receives an allegation of abuse or neglect, or observes this individual being subjected to conditions or circumstances which would reasonably result in abuse or neglect, that individual shall immediately make a report to the DHSS or the appropriate facility designee; -The designee will report or assist the person with direct knowledge of the concern to report immediately, within two hours of the allegation is for mental, physical, verbal, or sexual abuse or there has been bodily injury related to abuse. If not abuse and there is no injury, the designee should report within 24 hours of the observation or allegation, to DHSS at the hotline or in cases involving LTC (Long Term Care), the report shall be made first to the regional DHSS office during business hours or the hotline after hours. A fax notice or email to the regional DHSS during hours the hotline is closed is acceptable for the two-hour notice, but a follow up call is required; -In LTC, the designee is the facility Administrator, Administrator On-Call, Director of Nursing (DON) or registered nurse (RN) that shall be responsible for reporting suspected abuse or neglect; -Any concern, complaint, or allegation of patient/resident abuse/neglect (sexual, physical, or verbal) by another resident, employee, vendor or visitor shall be verbally reported immediately to the facility Administrator. 1. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admission date of 08/04/21; -Resident had a guardian; -Diagnoses included bi-polar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and dementia. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 07/02/24, showed the following: -Cognitively intact; -Resident had a guardian; -No behaviors exhibited. Review of the resident's care plan, last revised 09/25/24, showed the following: -Resident had a history of bi-polar disorder, unspecified mood disorder, conversation disorder with motor symptoms and deficits, insomnia, altered mental status, and Parkinson's disease; -Mood interventions included to encourage expression of feelings, acknowledge/validate feelings, assist with coping skills, maintain a non-defensive stance, implement diversional activity, and assess for trigger situation such as pain, personal loss, relocation, conflict or prior history; Review of the resident's nursing note dated 08/08/24, at 9:51 P.M., showed the following: -The resident was found outside in courtyard with another resident. Resident #1 was touching the Resident #2's genitalia with his/her hand; -Residents were separated and put on 15-minute checks; -Resident was educated that his/her actions were inappropriate; -Staff notified the resident's guardian. The guardian advised he/she did not know what to do about the situation, but would be at the facility the following day to talk to the resident and the Administrator; -Staff notified the DON and who gave direction to place residents on 15-minute checks. During an interview on 09/26/24, at 10:52 A.M., the resident said the following: -He/she had been in a relationship with Resident #2 for over a year; -He/she touched Resident #2's genitalia and rubbing it in the courtyard. During an interview on 09/26/24, at 1:15 P.M., the resident's guardian said the following: -A nurse notified him/her the resident was playing with Resident #2's genitalia on the back patio; -He/she advised the nurse to separate the residents and he/she would be at the facility the following day to speak to the Administrator; -The Administrator told the resident during the meeting the next day it is not appropriate for him/her to touch residents' in the private parts. Review of the resident's record showed staff did not document reporting the allegation abuse to DHSS. 2. Review of Resident #2's face sheet showed the following: -admission date of 11/25/22; -Resident had a Durable Power of Attorney (DPOA); -Diagnoses included major depressive disorder (persistently depressed mood or loss of interest in activities) and a history of stroke. Review of the resident's care plan, last reviewed on 02/27/24, showed the following: -Resident had a history of combat experience and has received professional treatment in the past, but does not wish to receive counseling or professional services; -Resident will not be exposed to triggers that may cause re-traumatization; -Observe for signs of adjustment difficulties such as inability to pursue interests or activities, sad or anxious mood, behavioral symptoms, impaired communication, sleep problems, and spiritual distress. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No behaviors exhibited. Review of the resident's nursing note dated 08/08/24, at 11:23 P.M., showed the nurse was informed by aide that resident was outside in the courtyard receiving stimulation to his/her private area by another resident's hand. Residents were brought back into the building and remained in the dining room. Around 7:50 P.M., nurse called the resident's DPOA to notify of the incident. This nurse explained that the resident was found outside in the courtyard with another resident engaging in adult activity. The residents were separated and placed on 15-minute checks. Staff notified the DON of the situation. During an interview on 09/26/24, at 11:59 A.M., the resident said the following: -He/she does not remember traumatic events at times and would consider someone touching his/her genitalia to be a traumatic event because he/she would not want another resident to be doing that to him/her at the facility. Review of the resident's record showed staff did not document reporting the allegation abuse to DHSS. 3. Review of facility records showed staff did not provide documentation of reporting the allegation of possible abuse to DHSS. Review of DHSS records show DHSS did not have record of the facility reporting the allegation of sexual contact between Resident #1 and Resident #2. 4. During interviews on 09/26/24, at 12:15 P.M. and 2:03 P.M., Certified Nurse Assistant (CNA) A said the following: -Staff should separate residents engaging in sexual touching and report to the Administrator immediately because staff may not know what the guardian's expectations are if the resident has a guardian; -The facility has 24 hours to report any abuse allegations to the state; -He/she would consider the incident of touching between Resident #1 and Resident #2 to be potential abuse and would have reported to the charge nurse. 5. During interviews on 09/26/24, at 12:19 P.M. and 2:10 P.M., License Practical Nurse (LPN) B said the following: -Staff should separate residents with guardians engaging in sexual activity and contact the guardian and DON for further guidance; -Staff would not necessarily report residents with guardians engaging in sexual activity to the state agency if no harm or force was involved. 6. During an interview on 09/26/24, at 12:31 P.M., CNA C said the following: -The guardian of a resident makes decisions regarding sexual activity with another resident, and staff should follow the guardian's decisions; -Resident #1's guardian did not want him/her engaging in sexual activity; -He/she did not know if Resident #2 consented; -Staff should have reported to the state agency because it could have been considered abuse. 7. During interviews on 09/26/24, at 12:48 P.M., and 1:48 P.M., Licensed Practical Nurse (LPN) D said the following: -The guardian of a resident makes decision regarding sexual activity with another resident, and staff should follow the guardian's decision; -If a guard of a resident does give permission to engage in sexual activity, the facility should provide a safe and private setting; -Staff should consider residents engaging in sexual activity without the permission of the guardian to be abuse and should report immediately to the guardian, DON, Administrator, and the state agency within 24 hours; -An aide reported observing Resident #1's hand on Resident #2's genitalia to another charge nurse who then reported to her/him; -He/she ensured the residents were separated; -He/she reported the incident to the guardian and the DON; -The guardian wanted the residents completely separated; -The DON advised to separate the residents and start 15-minute checks; -He/she did not report the incident to the state agency. 8. During an interview on 09/26/24, at 2:17 P.M., the DON said the following: -Staff should immediately separate residents engaged in abusive behavior and report the incident to the charge nurse. The charge nurse reports to management; -Staff should immediately notify the responsible party and physician of any abuse allegation and the state agency within two hours; -Guardians and DPOA's make decisions regarding residents engaging in sexual relations with other residents; -The facility should take steps to honor decisions to now allow residents to engage in sexual relations by providing monitoring; -An aide reported observing Resident #1 touching Resident #2's genitalia while outside in the courtyard; -He did not feel this incident needed to be reported to the state agency as there was no allegation of abuse or neglect; -The facility did not have prior permission from Resident #1's guardian or Resident #'2 DPOA to engage in sexual relations; -Residents should not be engaging in sexual relations outside at the facility; -Staff should have treated the incident as an abuse situation if Resident #2 had said he/she did not consent, but to his knowledge, no staff had this conversation with either resident. 9. During an interview on 09/26/24, at 3:22 P.M., the Administrator said the following: -Staff should separate residents following a resident-to-resident abuse allegation; -Staff should immediately report any abuse allegation to the charge nurse, DON, Administrator, and state agency within two hours; -The guardian of a resident makes decision regarding sexual activity with another resident, and staff should follow the guardian's decision; -If staff are unsure of a guardian's wishes regarding a resident engaging in sexual relations, staff should separate until a determination is made; -Staff found the residents outside and Resident #1 was touching Resident #2's genitalia; -Residents should not be touching one another's private parts outside at the facility; -The guardian of Resident #1 and DPOA of Resident #2 were contacted almost immediately; -The guardian of Resident #1 did not want him/her engaging in sexual behavior and the DPOA of Resident #2 did not have a preference; -He did not ask Resident #2 if he/she wanted to be touch and is unsure if any other staff asked; -Staff did not report to the state agency because they believed this was a mutual issue. MO00242275

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed implement an abuse/neglect policy that ensured staff completed and documented a timely investigation of all reported allegations of possible abuse when staff failed to complete a documented investigation of a documented allegation of touching of genitalia between two residents (Resident #1 and #2). The facility census was 105. Review of the facility policy titled, Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, ADM03-03, last revised August 2021, showed the following: -All complaints will be reviewed by the department director or facility administrator to determine the need for investigation; -The investigation party will determine the protocol for presenting the results of individual investigations to the Department of Health and Senior Services (DHSS) and may recommend changes to preclude recurrence of non-complaint activity; -The organization's designee will be responsible for immediately initiation and conducting an investigation of the alleged abuse/neglect; -During the investigation, residents will be protected from harm by interrupting the source of activity relating to the suspected abuse or neglect, providing education on appropriate behavior, and redirecting the resident as appropriate; -Residents will be removed from the area or distanced from the individual suspected of abuse/neglect; -In long-term care (LTC), the investigation will be completed by the administrator or designee and a summary submitted to the DHSS within five working days. 1. Review of Resident #1's face sheet (a brief resident profile) showed the following: -admission date of 08/04/21; -Resident had a guardian; -Diagnoses included bi-polar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and dementia. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 07/02/24, showed the following: -Cognitively intact; -Resident had a guardian; -No behaviors exhibited. Review of the resident's care plan, last revised 09/25/24, showed the following: -Resident had a history of bi-polar disorder, unspecified mood disorder, conversation disorder with motor symptoms and deficits, insomnia, altered mental status, and Parkinson's disease; -Mood interventions included to encourage expression of feelings, acknowledge/validate feelings, assist with coping skills, maintain a non-defensive stance, implement diversional activity, and assess for trigger situation such as pain, personal loss, relocation, conflict or prior history. Review of the resident's nursing note dated 08/08/24, at 9:51 P.M., showed the following: -The resident was found outside in courtyard with another resident. Resident #1 was touching the Resident #2 genitalia with his/her hand; -Residents were separated and put on 15-minute checks; -Resident was educated his/her actions were inappropriate; -Staff notified resident's guardian and the guardian advised he/she did not know what to do about the situation, but would be at the facility the following day to talk to the resident and the Administrator; -Staff notified the Director of Nursing (DON) who gave direction to place residents on 15-minute checks. During an interview on 09/26/24, at 10:52 A.M., the resident said the following: -He/she had been in a with Resident #2 for over a year; -He/she touched Resident #2's genitalia and was rubbing it in the courtyard. and Resident #2 are only allowed to hold hands now and can only go outside together during the day; During an interview on 09/26/24, at 1:15 P.M., the resident's guardian said the following: -A nurse notified him/her the resident was playing with Resident #2's genitalia on the back patio; -He/she advised the nurse to separate the residents and he/she would be at the facility the following day to speak to the Administrator; -The Administrator told the resident during the meeting the next day it is not appropriate for him/her to touch residents in the private parts. 2. Review of Resident #2's face sheet showed the following: -admission date of 11/25/22; -Resident had a Durable Power of Attorney (DPOA); -Diagnoses included major depressive disorder (persistently depressed mood or loss of interest in activities) and a history of stroke. Review of the resident's care plan, last reviewed on 02/27/24, showed the following: -Resident had a history of combat experience and has received professional treatment in the past, but does not wish to receive counseling or professional services; -Resident will not be exposed to triggers that may cause re-traumatization; -Observe for signs of adjustment difficulties such as inability to pursue interests or activities, sad or anxious mood, behavioral symptoms, impaired communication, sleep problems, and spiritual distress. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -No behaviors exhibited. Review of the resident's nursing note dated 08/08/24, at 11:23 P.M., showed the nurse was informed by aide that resident was outside in the courtyard receiving stimulation to his/her private area by another resident's hand. Residents were brought back into the building and remained in the dining room. Around 7:50 P.M., nurse called the resident's DPOA to notify of the incident. This nurse explained that the resident was found outside in the courtyard with another resident engaging in adult activity. The residents were separated and placed on 15-minute checks. Staff notified the DON of the situation. During an interview on 09/26/24, at 11:59 A.M., the resident said the following: -He/she does not remember traumatic events at times and would consider someone touching his/her genitalia to be a traumatic event because he/she would not want another resident to be doing that to him/her at the facility. 3. Review showed the facility did not provide a written investigation into the allegation of possible abuse. Review of DHSS records showed a written investigation into the allegation of possible abuse was not received. 4. During interviews on 09/26/24, at 12:15 P.M. and 2:03 P.M., Certified Nurse Assistant (CNA) A said the following: -Staff should separate residents engaging in sexual touching and report to the Administrator immediately because staff may not know what the guardian's expectations are if the resident has a guardian; -He/she would consider the incident between Resident #1 and Resident #2 to be potential abuse. 5. During interviews on 09/26/24, at 12:19 P.M. and 2:10 P.M., License Practical Nurse (LPN) B said staff should separate residents with guardians engaging in sexual activity and contact guardian and DON for further guidance. 6. During an interview on 09/26/24, at 12:31 P.M., CNA C said the following: -The guardian of a resident makes decisions regarding sexual activity with another resident, and staff should follow the guardian's decisions; -Resident #1's guardian did not want him/her engaging in sexual activity; -He/she did not know if Resident #2 consented. 7. During interviews on 09/26/24, at 12:48 P.M. and 1:48 P.M., LPN D said the following: -The guardian of a resident makes decision regarding sexual activity with another resident and staff should follow the guardian's decision; -If a guard of a resident does give permission to engage in sexual activity, the facility should provide a safe and private setting; -Staff should consider residents engaging in sexual activity without the permission of the guardian to be abuse and should report immediately to the guardian, DON, Administrator, and the state agency within 24 hours; -An aide reported observing Resident #1's hand on Resident #2's genitalia to another charge nurse who then reported to her/him; -He/she ensured the residents were separated; -He/she reported the incident to the guardian and the DON; -The guardian wanted the residents completely separated; -The DON advised to separate the residents and start 15-minute checks. 8. During an interview on 09/26/24, at 2:17 P.M., the DON said the following: -Staff should immediately separate residents engaged in abusive behavior and report the incident to the charge nurse. The charge nurse reports to management; -Staff should place residents on 15-minute checks; -Management completes investigations regarding abuse allegation, which includes resident and staff interviews and resident assessments; -Guardians and DPOA's make decisions regarding residents engaging in sexual relations with other residents; -The facility should take steps to honor decisions to now allow residents to engage in sexual relations by providing monitoring; -An aide reported observing Resident #1 touching Resident #2's genitalia while outside in the courtyard; -He did not know if staff asked Resident #2 if he/she consented to being touched; -The facility did not complete an investigation regarding the incident because there was no allegation of abuse or neglect; -The facility did not have prior permission from Resident #1's guardian or Resident #'2 DPOA to engage in sexual relations. -Staff should have treated the incident as an abuse situation if Resident #2 had said he/she did not consent, but to his knowledge, no staff had this conversation with either resident. 9. During an interview on 09/26/24, at 3:22 P.M., the Administrator said the following: -Staff should separate residents following a resident-to-resident abuse allegation; -The facility should complete an investigation with any abuse allegation, including interviewing residents and staff and completing resident assessments; -The guardian of a resident makes decision regarding sexual activity with another resident, and staff should follow the guardian's decision; -If staff are unsure of a guardian's wishes regarding a resident engaging in sexual relations, staff should separate until a determination is made; -Staff found the residents outside and Resident #1 was touching Resident #2's genitalia; -Residents should not be touching one another's private parts outside at the facility; -The guardian of Resident #1 did not want him/her engaging in sexual behavior and the DPOA of Resident #2 did not have a preference; -He did not ask Resident #2 if he/she wanted to be touch and is unsure if any other staff asked; -An investigation was not completed. MO00242275

Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of one resident's (Resident #71) needs when the resident was unable to safely toilet due to a large commode kept in the resident's bathroom. The facility census was 108. Record review of the facility's admission agreement, revised 8/15/18, showed the following: -Room and roommate transfers - The facility reserves the right of room and roommate transfer at its discretion. The facility agrees to allow resident to designate a roommate of his or her choice at any time, so long as accommodation of the resident's designation is practicable, both residents live at the facility, both residents consent to the arrangement, and the request does not infringe upon the rights of another resident; -Right to keep and use personal belongings and property as long as they do not interfere with the rights, health or safety of others; -The right to retain your personal possessions as space permits; -Residents are expected to keep their personal belongings in a manner so as not to cause a safety hazard. 1. Record review of Resident #71's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/28/22, showed the following: -Moderately impaired cognition; -Transferred with extensive assistive with one staff; -Extensive assistance with one staff for toilet use -Diagnoses that included stroke (when blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), pneumonia (lung infection), chronic obstructive pulmonary disease (COPD - lung disease that blocks air flow and makes it difficult to breathe), high blood pressure, and heart failure. Record review of the resident's care plan, reviewed 1/2/23, showed the following: -Sometimes forgetful; -Ambulates in room with no staff assistance; -Primarily uses a wheelchair for locomotion and able to propel self in wheelchair; -Occasionally incontinent of bowel and bladder and able to take self to the restroom. Resident will ask for staff assistance if needed; -At high risk for falls related to generalized weakness with reduced mobility. Resident has a history of falling; -Staff to encourage and remind to request assistance. Observation and interviews on 1/17/23, at 11:09 A.M., and 1/19/23, at 11:55 A.M., showed the following: -The resident was unable to access the toilet due to the extra-large commode in the bathroom that his/her roommate used; -The resident uses the wheelchair to get to the bathroom and then has to climb over the commode to use the toilet; -The resident said the extra-large commode stays in the bathroom. He/she brings the wheelchair up to the commode in the bathroom and then he/she gets up and goes to the toilet; -There was an extra-large commode near the door inside the bathroom that was approximately two and a half feet between the side of the commode to the toilet seat. During an interview on 1/19/23, at 1:45 P.M., Certified Nurse Aide (CNA) B said the following: -The resident can bear his/her own weight and can use a walker; -The resident was to call for staff assistance to use the toilet in the bathroom; -The resident had several falls; -The resident takes the wheelchair to the door of the bathroom and then walks over to the toilet to sit down on it; -The commode is too big for the bathroom. Observation and interview on 1/20/22, at 10:29 A.M., showed the following: -The resident had difficulty getting into the bathroom with the bed side commode in there; -A nurse (he/she could not remember which one) mentioned how dangerous it was for him/her to transfer to the toilet with that bedside commode in the bathroom; -After staff placed the bedside commode in the bathroom, the transfer to the toilet was scary, but he/she just got used to it; -He/she thought it would be safer for him/her to transfer to the toilet if the bedside commode was not in his/her way; -He/she wheeled self into the bathroom as far as he/she could. He/she could not get his/her wheelchair past the bedside commode and had to park his/her wheelchair approximately two feet away from the toilet with the left front wheel of his/her wheelchair behind the leg of the bedside commode. He/she stood up from that position and needed to step around the leg of the bedside commode to attempt to transfer to the toilet. During an interview on 1/20/23, at 12:13 P.M., Occupational Therapist (OT) D said the following: -The resident currently received physical and occupational therapy; -The resident was not safe with his/her transfers and required moderate assistance; -It was not safe for the resident to step around the bedside commode in the bathroom; -The therapists discussed this with each other; -He/she felt it would be safer for the resident if staff stored the bedside commode elsewhere when it was not in use. During an interview on 1/20/23, at 12:21 P.M., Physical Therapist (PT) E said the following: -The resident was not safe to transfer him/herself to the toilet, but he/she still tried; -He/she and OT discussed the bedside commode in the bathroom and felt it was safer if staff stored it elsewhere when not in use; -The resident currently received physical therapy for strengthening of his/her legs. During an interview on 1/20/23, at 12:26 P.M., Licensed Practical Nurse (LPN) C said the following: -The resident had a large commode in his/her bathroom which the roommate would use; -The resident wheels him/herself in the wheelchair to the bathroom and transfers self in the bathroom; -Staff can see a little of the wheelchair from the door when the resident toilets him/herself; -The large commode is stored in the bathroom since they would not be able to store the commode in a closer area. Staff would have to go up and down the hall to get the commode. During an interview on 1/20/23, at 3:45 P.M., the Director of Nursing (DON) said the following: -They determine residents as roommates if they get along well with another resident, such as seeing them visiting in the dining room; -If a resident is a new admission, they discuss where it will work the best for that resident in the facility; -They do look at space, such as if the resident is a bariatric (treatment for someone with obesity) and had a bariatric and adaptive equipment, like their wheelchair for their bathroom. Is this case they would not be able to have another resident in the room; -Staff were to move the commode out of the bathroom each time the resident needed to use the toilet and put the commode over by the roommate's closet; -There was a space problem in the resident's room; -The resident was considered a high risk for falls. During interview on 1/20/23, at 5:40 P.M., the Administrator said the following: -She was unaware of the resident's toileting situation; -The commode was not to remain in the bathroom.

Based on observation, interview, and record review, the facility failed to provide necessary services to identify pressure ulcers (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) timely when staff failed to accurately monitor skin during showers and failed to complete a weekly assessment for one resident (Resident #28) who was at risk for pressure ulcers. The facility census was 108. Record review of the facility policy titled, Pressure Ulcer/Wound Assessment and Treatment, revised January, 2023, showed the following: -Residents will be assessed per Braden scale (a measured assessment to determine pressure ulcer risk based on predetermined criteria) by licensed nursing professional for the potential to develop and the presence of a pressure ulcer/wound upon admission to the facility/program; -Reassessment will be done according to the resident individual needs; -Skin Assessment Procedure: In long term care (LTC), the skin risk assessment score will be documented by nursing on the admission assessment and then weekly for the first four weeks; -Basic skin assessment is completed on the residents weekly. The MDS, care planning process, change in cognition or functional abilities, or health status changes may trigger extra skin risk assessments; -Skin Risk Scoring- A score will be correlated with assessment. This score will identify prevention intervention recommendations for the identified risk level. Initiate the appropriate prevention interventions, a physician order is not necessary to initiate prevention interventions; -Residents with a cast or other treatment device may be difficult to assess for pressure ulcers. Routine assessment to check for adequate circulation, movement, and sensation may fail to detect pressure ulcers beneath casts of devices; -Determine whether treatment devices need to be altered or replaced, to relieve pressure; -Remove device if appropriate, to assess the skin. 1. Record review of Resident #28's face sheet showed the following: -admission date of 12/2/22. Record review of the resident's current diagnoses list showed the following: -Diagnoses included post intertrochanteric (upper thigh/femur) fracture of the left hip with surgical repair, foot callus, decubitus ulcer (pressure sore), cerebrovascular vascular accident (CVA - stroke) with left sided hemiparesis (weakness or partial paralysis of one side of the body), peripheral vascular disease (PVD - a progressive circulatory disorder, most commonly affecting the legs and feet), edema (swelling), and limited mobility. Record review of the resident's nurse's note dated 12/2/22, at 5:59 P.M., showed the following: -admitted to the facility on skilled services related to a displaced intertrochanteric fracture of the left femur; -Alert and oriented and able to make his/her needs known; -Resident had a previous stroke with left sided weakness; -Resident was non-weight bearing to the left leg related to surgical repair; -Staff observed a 6 x 5 centimeter (cm) dark, soft, boggy (spongy textured) area to the resident's left heel; -Staff entered a treatment order, placed pressure relief boots on the resident, and staff to float the resident's heels off the bed. Record review of the resident's skin risk assessment scale (Braden scale), dated 12/2/22, showed the resident at risk for the development of pressure ulcers. Record review of the resident's physician order sheet, dated 12/2/22, showed the following: -An order for protective pressure relief, heel boot(s); -Special instructions to keep heel boots in place to bilateral (both sides) lower extremities at all times. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/8/22, showed the following: -Cognitively intact; -At risk for the development of pressure ulcers; -Presence of one or more unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured) suspected deep tissue injury (DTI - intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) pressure ulcers on admission; -Pressure reducing device for chair; -Pressure ulcer care; -Application of dressing to feet; -Totally dependent on two or more staff for bed mobility and transfers; -Wheelchair for mobility device. Record review of the resident's current care plan showed the following: -Dated 12/2/22, skin risk assess scale every seven days for four weeks; -Dated 12/10/23, risk of impaired skin integrity due to decreased mobility, weakness, left sided hemiparesis, diabetes, PVD, protein calorie malnutrition. Resident needs staff assist to make major position changes. Resident had a deep tissue injury (DTI) when the resident came to the facility; -Dated 12/10/22, impaired skin integrity with unstageable injury to the left heel that was a deep tissue injury (DTI) upon admission. Interventions will be in place to promote wound healing, to the extent possible related to disease process throughout next review; -Dated 1/5/23, skin treatment. Record review of a message from facility staff to the resident's physician, dated 1/5/23, showed the following: -The resident's left heel suspected deep tissue injury, the hardened skin peeled off, a dark firm area remains under that area as well as a light red area along with slight drainage; -A new order placed for treatment with wound cleanser, apply Maxorb (a wound dressing) to wound bed, cover with a dry dressing wrap, staff to change every other day and as needed; -The resident continued to wear heelless boots. Record review of the resident's skin assessment, dated 1/6/23, showed: -Deep tissue injury to left heel, warm, dry, color = ecchymosis (a discoloration of the skin resulting from bleeding underneath), texture = boggy; -Staff did not identify any other areas. Observation and interview on 1/16/23, at 10:10 A.M., showed the following: -The resident said he/she had a sore to his/her left heel; -The resident said he/she had a stroke that affected the left side of his/her body; -The resident sat in a wheelchair with foot rests and wore and pressure relieving (open-toe) boot to his/her left foot and had a dressing visible to the left foot. Observation and interview on 1/17/23, at 2:21 P.M., showed the following: -The resident lay on his/her back on the bed; -The resident wore a pressure relieving boot on his/her left foot; -The resident said he/she suffered a stroke in 2012 which affected his/her left arm and leg; -The resident said he/she developed a callous to his/her left heel after his/her hip surgery while in the hospital; -The resident said facility nurses changed the dressing to his/her left heel as ordered. Observation on 1/18/23, at 2:00 P.M., showed the following: -The resident laid on his/her bed on his/her back; -The resident wore a pressure relieving boot to his/her left foot. Observation of the resident's skin on 1/19/23, at 9:26 A.M., with Registered Nurse (RN) H showed the following: -The resident's left heel had an open area. The nurse described the area as between the size of a quarter and a half dollar, shallow, with black eschar (dead tissue) to approximately 50% of the wound bed and red granulation (the pink-red moist tissue that fills an open wound, when it starts to heal) tissue to 50%, no odor, with a small amount of bloody drainage; -The RN observed two (previously unidentified) areas to the resident's left foot. A brownish/black pea-sized area to the resident's lateral (side) left 5th toe with no drainage and a brownish/black dime-sized area to the base of the resident's left lateral foot with no drainage; -The resident denied pain and stated the areas were caused by the pressure relieving boot rubbing on his/her lateral foot. During an interview on 1/19/23, at 9:26 A.M. with RN H said the following: -He/she completed the resident's left heel treatment on 1/18/23, but must have overlooked the left lateral foot and toe areas; -The nurse notified the Director of Nursing (DON) of the new pressure areas. During an interview on 1/19/23, at 9:45 A.M., the DON said: -She was not aware of any pressure areas to the resident's skin, other than the resident's left heel pressure ulcer. Record review of a message from a facility nurse to the resident's nurse practitioner dated 1/19/23, at 10:24 A.M., showed the following: -During wound rounds this morning, noted a new pressure ulcer to the resident's left lateral foot and left anterior (nearer the front) toe. Left lateral foot with brown/black eschar (dead or devitalized tissue that is hard or soft in texture) area measuring 1.0 centimeter (cm) long and 1.5 cm wide. Left anterior toe measured 0.6 cm long by 0.9 cm wide with brown/black eschar covering a raised callous area. The resident said the pressure relieving boot caused the area to be sore. Assessed the boot and notes a wedge in place to keep the foot in alignment, wedge removed to eliminate pressure. Nurse added orders for Santyl (an ointment that removes dead tissue from wounds) and dry gauze daily to both areas; -Noted dry, peeling, brownish discoloration to right heel. This area measured 4.5 cm long by 2.0 cm wide and was removed with cleansing, revealed a pink blanchable non-tender area. New order for skin prep to this area twice daily. Also placed offloading boot to right foot; -Resident signed consent for a wound care company to provide care to resident. Record review of the facility message from the resident's NP to the facility nurse dated 1/19/23, at 10:41 A.M., showed the NP approved the skin treatment order recommendations. Record review of the resident's physician orders, dated 1/19/23, showed the following: -Pressure ulcer care instructions for left lateral foot pressure ulcer and left anterior toe pressure ulcer: Cleanse with normal saline, pat dry, apply Santyl, cover with dry gauze, wrap with gauze wrap, change daily and as needed if soiled/displaced. Record review of the resident's skin assessments showed the following: -Staff did not complete a weekly skin assessment after 1/6/23 until 1/19/23 (13 days later). Record review of the resident's skin assessment, dated 1/19/23, showed staff documented the following new pressure ulcers: -Pressure to left lateral foot with brown/black eschar measured 1.0 cm long by 1.5 cm wide; -Pressure ulcer to left anterior toe with brown/black eschar measured 0.6 cm long by 0.9 cm wide. Resident stated boot causing this area to be sore. Assessed boot and not a wedge placed to keep foot in alignment, staff removed wedge to eliminate pressure; -Orders for Santyl and dry gauze daily to both areas. During an interview on 1/19/23, at 12:51 P.M., Certified Nurse Assistant (CNA) I said the following: -The resident was totally dependent on staff for turning in bed; -The resident usually lays on his/her back in bed; -The resident yells at the slightest movement; -He/she had not noticed the pressure ulcers to the resident's left lateral foot and toe; -The resident wore a pressure relieving boot to his/her left foot. During an interview on 1/19/23, at 1:22 P.M., CNA K said the following: -During resident showers, the CNA observed residents' skin and documented any new areas observed on a paper and then gave the form to the nurse; -He/she assisted the resident with a shower, earlier that same day, on 1/19/23; -He/she did not see any pressure ulcers on the resident's feet, other than the existing pressure ulcer to the resident's left heel; -The resident required staff assistance to turn onto his/her side in bed. During interviews on 1/19/23, at 1:36 P.M., and on 1/20/23, at 10:03 A.M., RN H said the following: -He/she measured the resident's pressure ulcers and the DON entered the wound measurements into the resident's electronic record; -The nurses were to complete assigned weekly skin assessments, but some of the nurses had not completed their assigned resident skin assessments; -Today, 1/19/23, the facility discovered an issue with the way in which the skin assessments populated into the nurses' computer system. The task populated at a random time, instead of at the beginning of the shift; -The nurse expected the CNAs to check the resident's skin during cares and expected the shower aide to check the resident's skin during showers. If pressure ulcers or skin concerns were identified, they would notify the nurse on duty; -The shower aide could have some difficulty in seeing all of the resident's skin during a shower; -The nurse said he/she discovered a foam wedge in the resident's left pressure relief boot that was rubbing to outer portion of the resident's left foot. The nurse removed the wedge. During an interview on 1/20/23, at 10:37 A.M., CNA J said the following: -Staff had been placing a left pressure relief boot on the resident, which he/she wore all the time; -The CNA had not observed any new pressure ulcers to the resident's feet. During an interview on 1/20/23, at 3:44 P.M., the DON said the following: -He/she expected nurses to complete weekly skin assessments on all residents; -He/she discovered an issue recently with the time codes in the computer for completing weekly skin assessments. The time codes did not match the skin assessment schedule; -Failure to complete weekly skin assessments on a resident could contribute to staff not timely identifying new areas of skin breakdown. During an interview on 1/20/23, at 5:29 P.M., the Administrator said the following: -Staff should completed skin assessments weekly on each resident; -Staff should notify the DON and contact the resident's physician or nurse practitioner of any new pressure ulcers and request a treatment order by the end of their shift of the same day discovered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure services were provided to allow residents to maintain or improve range of motion when the facility failed provide a restorative nursing program for two residents (Resident #28 and Resident #53). The facility census was 108. Record review of the facility policy titled, Range of Motion Exercises, revised August 2020, showed the following: -Rehabilitation services will provide range of motion (ROM) exercises to residents as appropriate; -Purpose to maintain passive range of motion (PROM), to minimize contractures (permanent stiffening of a joint) and deformity, to increase joint mobility, to increase and stimulate circulation, to help prevent thrombosis (blood clots), to facilitate muscle re-education, to increase muscle strength, to increase independent function of extremities, to facilitate resumption of independence with activities of daily living (dressing, grooming, bathing, eating, and toileting), to facilitate provision of good hygiene by staff, and to help maintain skin integrity. 1. Record review of Resident #28's face sheet showed an admission date of 12/2/22. Record review of the resident's diagnoses list showed the following: -Diagnoses included post intertrochanteric (upper thigh/femur) fracture of the left hip with surgical repair, foot callus, cerebrovascular vascular accident (CVA - stroke) with left sided hemiparesis (weakness or partial paralysis of one side of the body), peripheral vascular disease (PVD - a progressive circulatory disorder, most commonly affecting the legs and feet), edema (swelling), and limited mobility. Record review of the resident's physician orders an order, dated 12/2/22, for occupational therapy (OT) and physical therapy (PT) to evaluate and treat. Record review of the resident's initial care plan upon admission nurse's note dated 12/2/22, at 5:57 P.M., showed the following: -Resident wishes to receive therapy and return home. Resident lived at home alone and had a caregiver come in daily and a nurse weekly; -Resident states prior to fall he/she was able to get around with the use of a quad cane; -Rehab orders entered, refer to therapy for evaluation/screening. Record review of the resident's nurse's note dated 12/2/22, at 5:59 P.M., showed the following: -Staff admitted the resident to the facility on skilled services related to a displaced intertrochanteric fracture of the left femur; -The resident was alert and oriented and able to make his/her needs known; -The resident had a previous stroke with left sided weakness; -The resident left hand was contractured (permanent shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and resident had limited ROM to the upper extremity; -Resident was non-weight bearing (NWB) to the left lower extremity related to surgical repair of a fracture; -Resident stated, prior to his/her fall, he/she drove a car and ambulated with the use of a quad cane (four footed). Record review of the resident's admission Minimum Data Set (MDS - a federally-mandated comprehensive assessment tool completed by facility staff), dated 12/8/22, showed the following: -Cognitively intact; -Did not reject care; -Totally dependent on two or more staff for bed mobility and transfers; -Functional limitation in range of motion showed no impairment to upper or lower extremities; -Functional rehab potential - resident and direct care staff believe the resident is capable of increased independence in at least some activities of daily living (ADLs - dressing, grooming, bathing, eating, and toileting); -Active discharge plan in place for resident to return to community. Record review of the resident's care plan showed the following: -Start date of 12/10/2 -Requires extensive to total assistance with ADLs. Resident working with therapy to achieve his/her goal of returning to a prior level of function in order to return home. Resident has left sided hemiparesis due to a past stroke; -Interventions were ambulation, resident not walking at this time. He/she is working with therapy to regain his/her strength, so that he/she can walk with a walker again. Record review of the resident's social services note dated 12/20/22, at 12:08 P.M., showed the following: -The resident's insurance company issued a notice of Medicare non-coverage (a notice that indicates when care is set to end), dated 12/22/22, and the resident/responsibility party requested to file an appeal; -Resident currently has weight bearing restrictions and is not safe to return home; -Social service to complete Medicaid application with resident next week to help cover co-pays and long-term care coverage, if needed. Record review of the resident's social services note dated 12/21/22, at 11:45 A.M., showed the following: -Social services, resident, and the certified occupational assistant (COTA) met; -Per therapy, the resident required extensive to total assistance of two staff due to weight bearing restrictions. Hip hardware was noted to be loose at the resident's last orthopedic appointment. The resident's weight bearing restrictions were already in place and restrictions continue due to this complication; -Discussed advanced beneficiary notice (ABN - notice to resident/responsible party of services that will not be covered) and of co-pays needed for Part B therapy, should the appeal not be approved; -All parties were in agreement with current plan of care and aware of all upcoming co-pays, charges that may vary; -For now, resident wanted to remain in the facility long-term care with part B should appeal get denied. Record review of the OT discharge note, dated 12/22/22, showed the following: -Start of care 12/6/22; -Date of discharge 12/22/22; -Discharge completed this date due to insurance limitations. Resident continues with NWB status and is limited with overall progress at this time. Resident has a co-pay for Medicare part B services. The resident to return to the orthopedic surgeon in a couple of weeks with therapy to resume therapy services to progress to prior level of functioning. Resident and family in agreement with plan. Discharge due to patient at max benefit of insurance coverage at this time. Observation and interview of the resident on 1/17/23, at 2:21 P.M., showed the following: -The resident said he/she fell off of a curb in the end of November 2022 and broke his/her hip. The resident went to the hospital and had hip surgery and then came to the facility approximately six weeks ago for rehabilitation; -The resident said, 11 years ago, he/she had a stroke affecting mobility in his/her left arm and leg, but could still walk with a cane; -The resident said he/she admitted to the facility and began physical and occupational therapy, but both had PT and OT stopped working with him/her due to insurance payment problems and he/she currently was not receiving any therapy or range of motion exercises; -The facility told the resident in order to continue exercises and therapy, he/she would have to pay a co-pay. The resident wanted to continue therapy, but decided not to continue due to the co-pay; -The facility did not offer the resident restorative exercises; -The resident would like to have some type of exercise during the day. During an interview on 1/19/23, at 12:12 P.M., Occupational Therapist (OT) P said the following: -The resident admitted to the facility after hip surgery and initially PT and OT worked with the resident; -The resident's insurance refused to cover further therapy because the resident was not making enough progress. The resident did not have full weight bearing to his/her left leg; -The facility was going to wait until the physician said the resident was able to bear full weight on his/her left leg and then try to get insurance approval to restart therapy; -The OT said, he/she would have referred the resident for restorative therapy, if the facility had a restorative program; -The facility offered Part B therapy, the resident's portion would have cost the resident per visit and the resident was either not able or willing to pay the additional cost. During an interview on 1/19/23, at 12:51 P.M., Certified Nurse Assistant (CNA) I said the following: -The resident was totally dependent on staff; -The resident required two staff to assist with turning and two staff used a Hoyer (mechanical) lift to transfer the resident from the bed to the wheelchair; -For the last couple of weeks, the resident has been staying in bed most of the time; -The aide said he/she did not do any type of range of motion with the resident. 2. Record review of Resident #53's face sheet showed a readmission date of 12/20/21. Record review of the resident's diagnoses showed the following: -Elbow and hand pain, spinocerebellar ataxia (an inherited brain/spine disorder affecting physical movement of hands and legs), weakness of all extremities, chronic pain, and muscle spasms. Record review of the resident's care plan showed the following: -Dated 7/3/19, required assistance of two staff with most ADLs. He/she is able to make needs known; -ADL, required one to two staff assistance with dressing needs, required a wheelchair for locomotion, he/she used a power chair for mobility, incontinent of bowel and bladder, staff to ensure the resident is clean and dry, required a Hoyer (mechanical) lift for transfers. Record review of the resident's annual MDS, dated [DATE], showed the following: -Resident re-entered the facility on 12/20/21 from the hospital; -Cognitively intact; -Did not reject care; -Required limited assistance of one with bed mobility and personal hygiene; -Did not transfer or walk; -Functional limitation in ROM, impairment to both lower extremities; -Required a wheelchair for mobility; -Functional rehab potential = no response marked. Observation on 1/17/23, at 1:51 P.M., showed the resident sat in his/her electric wheelchair moving about the facility. Observation and interview on 1/18/23, at 2:05 P.M., showed the following: -The resident lay on his/her bed, watching television; -The resident said, he/she received restorative therapy in the past while living at another facility and his/her arm and hand sensation improved from the exercises and ROM; -He/she would like to have restorative therapy for his/her legs, because he/she does not qualify for skilled therapy due to his/her age. During an interview on 1/19/23, at 12:12 P.M., OT P said the resident would be a restorative candidate for ROM to his/her legs and strengthening to his/her arms and legs. During an interview on 1/19/23, at 12:51 P.M., CNA I said the following: -The resident was able to move his/her arms and wiggles his/her toes; -The facility had not instructed the aide to perform ROM exercises on the residents. During an interview on 1/19/23 at 1:04 P.M., Certified Medication Technician (CMT) Q said to the CMT's knowledge, staff do not assist the resident with range of motion exercises. 3. During an interview on 1/19/23, at 12:12 P.M., OT P said the following: -The facility has not had an actual restorative program for the past two to three years; -The benefit of the restorative nursing program was to maintain a resident's functional status and improve a resident's quality of life; -Restorative programs were individualized to the resident's needs by the therapists; -The facility used to have aides that were restorative certified and they would assist residents with restorative exercises and walking throughout the day; -When the facility decided to drop the restorative aides, the facility planned to have the nursing aides and nurses assist the residents with ROM exercises; -Nursing department staff did not have any specifics instructions or restorative plans for different residents; -The certified nurse aides and nurses were not currently doing restorative nursing with the residents; -If therapy did not work with a resident and the resident did not receive any type of restorative maintenance, then the residents would decline. 4. During an interview on 1/19/23, at 1:04 P.M., CMT Q said the following: -The facility used to have a restorative nursing program, but he/she did not think facility still had a program; -The facility had not given the CMT any instructions to do exercises with the residents; -He/she did not provide exercise or range of motion assistance to any of the residents. 5. During an interview on 1/19/23, at 1:22 P.M., CNA K said the following: -He/she did not do ROM exercises with the residents on a regular basis; -The facility had not had a restorative nursing program for approximately one to two years; -When the facility had a restorative nursing program, the restorative aides did exercises with the residents to improve their muscle function and assisted the residents to walk; -If the facility had restorative it would residents to maintain their mobility and ROM. 6. During an interview on 1/20/23, at 10:03 A.M., Registered Nurse (RN) H said the following: -The facility does not have an actual restorative program; -Therapy could instruct nursing staff on how to do ROM exercise, the they have not done so; -He/she did not have specific instructions for restorative therapy for any of the residents; -A restorative nursing program would perhaps help with possible resident physical declines. 7. During an interview on 1/20/23, at 3:44 P.M., the Director of Nursing (DON) said the following: -The facility does not currently have a restorative therapy program; -During the height of COVID 19 in 2020, the facility administrator decided the facility did not have adequate staffing to have restorative aides, because the staff was needed worse on the floor to provide direct cares; -In the past, a resident would see therapy and then therapy would create a resident specific restorative program for the resident to maintain the resident's functional status; -This program included providing assistance with ambulation, ROM, application of braces; -The program was beneficial to the residents; -Residents could have some decline due to not having an restorative nursing program; -Nursing staff are not trained to do the restorative program. 8. During an interview on 1/20/23, at 5:29 P.M., the Administrator said the following: -The facility does not currently have a restorative nursing program with individualized plans for residents; -The facility works hard to identify residents with declines and therapy picks up residents for therapy, when needed; -Everyone that needed therapy was getting therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents had assistance devices accessible to help prevent possible falls when staff failed to ensure the the call light and wheel chair were readily accessible for one resident (Resident #85) with a history of falls. The facility census was 108. Record review of the facility's policy titled Fall Program, revised 07/2022, showed the following: -The facility will identify resident intrinsic and extrinsic fall risk factors, identify and implement fall prevention/management interventions, and provide resident and family fall prevention/management education; -The purpose is to provide staff, resident education and resident specific interventions which promote a safe environment with the goal of preventing/ managing falls; -Universal/low risk fall prevention interventions will be implemented for residents. These include, but are not limited to: educate resident and families regarding fall prevention program; keep bed at appropriate height for safety based on resident condition; use brakes on wheelchairs, beds, and appropriately; call light within resident's reach as appropriate; assuasive devices as needed; provide and encourage assistive devices as needed; use gait belts for assisted transfers and ambulation; -Moderate risk interventions may include but are not limited to: implement universal low risk interventions; rehabilitation screening; and implement assistive devices as appropriate; -High risk interventions for residents may include, but are not limited to: implement universal low and moderate risk interventions, review medication, and referral for rehabilitation screening. 1. Record review of Resident #85's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 10/5/22; -Diagnoses included dementia. Record review of the resident's Fall Risk Assessments, dated 10/6/22, showed staff assessed the resident as a moderate fall risk. Record review of the resident's nurses' progress notes showed the following: -On 12/14/22, at 5:42 A.M., Fall Communication Form - The events prior to fall were the resident was in his/her room in recliner. The resident walked out the door of his/her room. The resident went straight forward on top of his/her walker; -On 12/19/22, at 1:12 P.M., Fall Communication Form - It was reported to this nurse from staff that resident stated he/she fell in his/her bathroom last night. The resident had bruising to the left elbow. Bruising to his/her right forehead from a previous fall was resolving. The resident reported pain to coccyx (tailbone). Resident assessed by this nurse and the nurse practitioner and weakness was noted. X-ray ordered for coccyx. Nursing to continue to monitor and report any new or worsening symptoms. Family notified, nursing manager notified, and primary care provider notified. Record review of the resident's nurses' progress notes showed the following: -On 12/26/22, at 1:36 A.M., the resident had been in bed for the night when call light rang at 1:10 A.M. Resident found [NAME] on the floor on his/her left side. He/she stated he/she fell trying to wipe a spot on the floor, lost his/her balance, grabbed a drawer, and the drawer opened and he/she fell. He/she denied injury. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 1/2/23, showed the following: -Severe cognitive impairment; -Required supervision from staff for bed mobility, transfers, walk in room and corridor, locomotion on unit, dressing, eating, toilet use and personal hygiene; -Used a walker for locomotion; -The resident had falls since admission or the prior assessment. The resident had two or more falls with no injury and one fall with injury. Record review of the resident's physical therapy (PT) evaluation dated 1/2/23, at 12:27 P.M., showed the resident reported he/she missed the chair yesterday and had to call for help because he/she could not get up off the floor. Record review of the resident's nurses' progress notes showed the following: -On 1/2/23, at 2:08 A.M., Fall Communication Form - Called to room by resident's call light on. Resident observed sitting on the floor in front of his/her recliner. Resident assessed for any visible injuries and none noted. Resident denied any pain or discomfort. Resident stated he/she attempted to sit in his/her recliner but it rocked/tilted and he/she slid down to the floor. Gait belt (a belt used for support when transferring) applied and with two person assisted to feet and into bed. Interventions for this fall included encourage resident to ask for assistance; -On 1/3/23, at 4:55 A.M., Fall Communication Form - Heard the resident calling from his/her room. Observed the resident laying on his/her back by the foot of his/her bed. Assessed the resident for any injuries and none visible. Range of motion within normal limits. Gait belt applied and two person assisted him/her to his/her feet and into his/her bed. The resident said he/she lost his/her balance. Interventions included encourage the resident to ask for assistance or help. Record review of the resident's Fall Risk Assessments, dated 1/4/23, showed staff assessed the resident as a high fall risk. Record review of the resident's care plan, reviewed 1/4/23, showed the following: -At risk for falls due to his/her history of falls; -Fall risk assessment completed every 90 days; -Rehabilitation screening as needed; -Implement appropriate fall precautions such as call light in reach, pharmacy to review high risk medications as needed, therapy to evaluate and treat as indicated, assess and evaluate for acute processes and/or change in condition, encourage/remind to request assistance, keep care areas well lighted, keep floors dry, use assistive devices as ordered, and encourage non-skid footwear; -Resident ambulated with a walker and required supervision. Record review of the resident's nurses' progress notes showed the following: -On 1/10/23, at 4:09 A.M., staff answered call light at 3:50 A.M. and noted the resident to be sitting on the floor beside his/her bed with is/her pants off and pulled up on wrong. He/she denied pain. No injury found on assessment. Assisted the resident to dress and took the resident to 100 south in wheelchair for certified nursing assistant (CNA) to do vitals; -On 1/12/23, at 10:50 A.M., Fall Team Meeting - Team reviewed falls on 12/14/22, 12/19/22, and 12/26/22. Pharmacy to review high risk medications as need. Therapy to screen, evaluate, and treat as needed. Assess for acute processes or infections, resident currently under treatment. Care plan updated; -On 1/16/23, at 6:06 A.M., Fall Communication Form - The resident's call light came on. The nurse went to his/her room and observed the resident sitting on the floor in front of his/her bed. The resident had two legs in one pant leg. Assessed the resident and no visible injuries noted. Gait belt applied and with two person assisted to his/her feet and placed in wheelchair. Interventions included encourage and remind resident to ask for assistance. Observation on 1/18/23, at 3:31 P.M., showed the following: -The resident laid in bed; -The resident's walker folded up and placed against the wall opposite the foot of his/her bed with a three drawer dresser between the walker and the foot of the bed. The walker was not within reach; -The resident's wheelchair parked up against the wall opposite the foot of the bed and was not within reach; -The residents call light laid on the floor next to his/her recliner on the left side and the right side of the recliner was next to the bed. The call light was not within reach. Observation on 1/19/23, at 9:36 A.M., showed the following: -The door to the resident's room was closed and he/she laid diagonally in his/her bed with his/her left leg hanging off the bed; -The resident's walker folded up and placed against the wall opposite the foot of his/her bed with a three drawer dresser between the walker and the foot of the bed. The walker was not within reach; -The resident's wheelchair parked up against the wall opposite the foot of the bed and was not within reach; -The resident's call light tucked into the cushion of his/her recliner on the left side and the right side of the recliner next to the resident's bed. The call light was not within reach. Observation on 1/19/23, at 2:12 P.M., showed the following: -The resident laid in bed; -The resident's walker folded up and placed against the wall opposite the foot of his/her bed with a three drawer dresser between the walker and the foot of the bed. The walker was not within reach; -The resident's wheelchair parked up against the wall opposite the foot of the bed and was not within reach; -The call light laid on the bed next to the resident. Observation on 1/20/22, at 9:06 A.M., showed the following: -The resident laid in bed; -The resident's walker folded up and placed against the wall opposite the foot of his/her bed with a three drawer dresser between the walker and the foot of the bed. The walker was not within reach; -The resident's wheelchair sat across the room between the sink and wall opposite the foot of the bed not within reach. During an interview on 1/20/23, at 9:16 A.M., CNA G said the following: -The resident had several falls and was considered a high fall risk; -The resident tripped over his/her walker frequently so nursing talked to therapy about placing him/her in a wheelchair for safety due to him/her not being able to walk to the dining room without tripping; -The resident transfers him/herself often. He/she got up at night and did not ask for assistance; -When the resident was in his/her recliner, the CNA tried to position the wheelchair close to the resident and when the resident was in bed, the CNA placed the wheelchair close to the foot of the bed so the resident had room to get out of bed and still had access to his/her wheelchair; -If staff placed the wheelchair against the wall opposite the foot of the resident's bed, the resident attempted to walk to the wheelchair and stumbled and fell at times. He/she did not think staff should place the wheelchair that far away from the resident and no staff told him/her to not place the wheelchair within the residents reach; -If he/she saw the resident's wheelchair not in reach, he/she moved the wheelchair; -He/she reminded the resident to use their call light to ask for assistance; -He/she believed it was safer to leave the resident's wheelchair within reach of the resident due to the resident transferred themselves and did not always remember to ask for assistance. During an interview on 1/20/23, at 9:51 A.M., Licensed Practical Nurse (LPN) F said the following: -The resident was a high fall risk; -Staff should place the resident's call light within reach; -The resident transferred him/herself from the bed to recliner or wheelchair, from the recliner to the bed or wheelchair and from the wheelchair to the bed or recliner; -The resident walked, but was not steady; -The resident had several falls in his/her room going to and from the bathroom and he/she forgot to take his/her walker with him/her; -The resident started urinating from his/her recliner due to difficulty getting to and from the bathroom; -Introducing the wheelchair was a good idea; -The resident used his/her walker with assistance due to him/her being unsteady. Staff folded his/her walker up out of reach against the wall to discourage the resident from using it alone; -Staff should not park the resident's wheelchair across the room out of reach and if staff saw this, they should move it closer. During an observation on 1/20/23, at 10:29 A.M., the resident laid in bed with the door open and call light within reach. His/her wheelchair was approximately five feet away from the bed close to the sink and not within reach. No staff observed in the hallway. During an interview on 1/20/23, at 3:44 P.M., the Director of Nursing (DON) said the following: -The resident was a high fall risk and had multiple falls; -The resident had a urinary tract infection and currently treated for that. This caused the resident to have more frequent trips to the bathroom; -Staff should place the resident's wheelchair next to his/her bed within reach. Sometimes the resident parked his/her wheelchair away from his/her bed, but if staff saw this, they should move the wheelchair within reach; -Staff approached him/her about moving the resident to a different hall. During an interview on 1/20/23, at 5:30 P.M., the Administrator said he/she expected staff to keep the resident's wheelchair and call light within reach due to the resident being a high fall risk. During an interview on 1/20/23, at 9:16 A.M., CNA G said the following: -Staff should place residents' call lights within reach and if he/she saw a call light not within reach, he/she moved it within reach and let the other CNA know the call light was not placed properly; -Staff should place adaptive equipment such as wheelchairs and walkers within reach of the resident when they are in bed. During an interview on 1/20/23, at 9:51 A.M., LPN F said the following: -If a resident had frequent falls, staff were on their toes and provided interventions such as ensuring the resident had appropriate footwear on, frequent monitoring, low beds and floor mats. They also kept adaptive equipment and call lights within reach if they thought a resident knew how to use them; -If a resident was in bed, the call light should not be on the opposite side of their recliner because it would not be within reach; -Staff should leave a residents wheelchair within reach when a resident was in bed. Sometimes she believed the aides think it would be safer for a resident for it to not place it closer to a resident, but in reality, a resident would still try to get to the wheelchair. During an interview on 1/20/23, at 3:44 P.M., the DON said the following: -He/she expected a resident have access to the restroom, rooms be free of clutter, access to their wheelchair, and call lights placed within reach; -If staff had a concern about a resident, they told the charge nurse, him/herself or the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to consistently provide nutritional interventions and nutritional supplements for two residents (Resident #40 and Resident #74 ) with identified weight loss. The facility census was 108. Record review of the facility policy, titled Supplemental Feedings, revised 10/2021, showed the following: -It is the policy of Nutritional Services and nursing to provide supplemental feedings to residents that need additional nutrition; -The purpose is to provide additional nutritional support for residents that cannot receive it just by eating three meals a day; -The doctor may request that a resident receive supplemental feedings in addition to their regular diet; -The doctor may order a specific nutritional supplement, or indicate that a supplement is needed and allows the dietician/dietary manager to select the appropriate supplement. The nursing department is responsible for notifying the dietician and Nutritional Services of the doctor's order; -Nutritional Services is responsible for the preparation and delivery of the supplement to the area. Nutritional Services is responsible for ordering and storage of the nutritional supplements; -A small supply of nutritional supplements is kept at the nurses' stations; -A nutritional supplement will be included with pureed trays except those patients who receive tube feedings. Record review showed the facility did not provide a policy related to weight loss and weight loss interventions. 1. Record review of Resident #40's face sheet (a document that gives a patient's information at a quick glance), showed the following: -admission date of 12/12/14; -Diagnosis included Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Record review of the resident's care plan, reviewed 2/2/22, showed the following: -Consider diet as ordered (regular no added salt diet); -Nutritional supplements as ordered; -Fortified foods, super cereal (a recipe that combines different ingredients and nutrients that when combined, makes a high-calorie, nutritious, and fortified cereal), snack between meals, or Compact (nutritional supplement) 118 milliliters (ml), use of adaptive equipment as ordered; -Interventions included soft music and snacks; -Encourage and assist him/her with meals, as tolerated, to promote adequate intake; -Give supplements as ordered and tolerated; -Offer snacks between meals; -Offer snacks at 10:00 A.M., 2:00 P.M. and 8:00 P.M. Record review of the resident's weight record, dated 8/19/22 to 12/19/22, showed the following: -On 8/19/22, the resident weighed 117 pounds (lbs) 6.4 ounces (oz).; -On 12/1/22, the resident refused staff to weigh him/her; -On 12/8/22, the resident refused staff to weigh him/her; -On 12/12/22, the resident weighed 111 lbs. 2 oz. (loss of 6 lbs, 4.4 oz); -On 12/19/22, the resident weighed 115 lbs. 4 oz Record review of the resident's progress note dated 12/19/22, at 3:40 P.M., showed the following: -Weight change nutritional review completed. The resident's current weight was 111 lbs 2 oz which reflected a 3.5% weight loss in one month, a 4.3% weight loss in three months and a significant 10.5% weight loss in six months. His/her body mass index (BMI - a weight-to-height ratio) 19.5 was within normal limits; -Current diet was regular, thin liquids, super cereal with breakfast. His/her five day intake average was 55% with 0 to 240 ml per meal; -Nutritional interventions included Ensure Enlive (nutritional supplement) with lunch and dinner. His/her nutritional needs were being addressed; -Recommended snacks in between meals and assist with food and fluid intake to promote adequate intake; -Give supplement as ordered and tolerated by the resident; -Monitor the resident. Record review of the resident's weight record, dated 12/20/22 to 12/31/22, showed the following: -On 12/26/22, the resident weighed 108 lbs 12.8 oz (loss of over 6 lbs); Record review of the resident's weight record, dated 1/1/23 to 1/2/23, showed the following: -On 1/2/23 the resident weighed 109 lbs. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 1/4/23, showed the following: -Severe cognitive impairment; -Required supervision of staff for eating; -The resident did not have a swallow disorder; -The resident's weight was 109 pounds (lbs); -The resident had a weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Record review of the resident's progress notes showed the following: -On 1/5/23, at 3:48 P.M., care plan review for 1/5/23. Resident and/or family attended by phone. Continued with current care plan. The resident's current weight was 109 lbs, diet was regular with modifiers of super cereal, thin liquids, and Ensure Enlive. He/she ate 25% to 75% of his/her meals. Family had concerns about the resident not taking his/her medications and how much he/she was eating. Discussed with the family member that staff were continuing to try different interventions to get the resident to eat and take medications. The family member offered to bring the resident's favorite juice if that would help him/her with medications and staff stated they would try. All questions and concerns were addressed at this time. Record review of the resident's January 2023 POS showed the following: -An order, dated 1/9/23, for a regular diet with diet modifiers of super cereal, thin liquids and Ensure Enlive (21 days after note that resident was receiving Ensure Enlive). -An order, dated 1/11/23, for speech therapy (ST) to evaluate and treat. Record review of the resident's weight record from 1/3/22 through 1/16/23, showed the following: -On 1/16/23 the resident weighed 108 lbs. 4 oz. Record review of the resident's progress notes showed the following: -On 1/16/23, at 3:07 P.M., weight change nutritional review completed. The resident's current weight was 108 lbs 4 oz which reflected a 2.7% loss in one month. His/her BMI of 19 was within normal limits. His/her current diet was regular, thin liquids, and super cereal with breakfast. His/her five day intake was 25% to 50% with 120 to 240 ml per meal. Nutritional interventions included Ensure Enlive with lunch and dinner. His/her nutritional needs addressed. He/she had an unavoidable weight loss related to disease progression and variable intake and continued weight loss with nutritional interventions in place. No recommendations for him/her. Continue to encourage and assist the resident with meals as tolerated. Supplement as ordered and tolerated by the resident. Monitor the resident. Record review of the supplement list in the kitchen showed the resident not listed. During an observation on 1/16/23, at 11:09 A.M., the resident sat in his/her room with his/her lunch tray. Certified Nursing Assistant (CNA) L went in and out of the resident's room and the dining room. The resident took what appeared to be a couple bites of his/her meal. The CNA offered the resident a banana and took the resident's tray away. The CNA did not offer the resident an alternative hot meal. Observation on 1/17/23, at 11:22 A.M., showed the resident sat on the edge of his/her bed with his/her lunch on the bedside table. The resident ate his/her dessert and drank his/her protein shake. Observation on 1/19/23, at 11:22 A.M., showed the following: -The resident sat in the dining room; -At 11:30 A.M., the resident received his/her food and he/she pushed the plate away and CNA M asked the resident if he/she did not want it and the resident did not say anything. The resident's tray did not include Ensure Enlive; -After serving the residents in the SCU, the CNA sat at the computer and grabbed the clipboard to document resident food intakes; -The resident ate 100% of his/her pudding and when he/she finished it, he/she sat back in his/her chair and crossed his/her arms; -The resident then took a drink of his/her milk and a bite of his/her cooked carrots. He/she then picked up the container the pudding was in and scraped the bottom and sides with his/her spoon attempting to get more and then put the container down; -The CNA sat in the chair at the computer across the dining room from the resident, had not offered to assist the resident or offered any encouragement to the resident to eat; -The CNA got up and cleared other residents plates from their tables and the resident whispered something to the CNA and the CNA stated ok and continued to clear other residents plates; -The resident again picked up the empty pudding container and scraped the sides and bottoms attempting to get more but the container was empty. He/she put the container back on the table; -The CNA asked the resident if he/she was ready to go back to his/her room, did not offer any encouragement to eat, did not offer more pudding and did not offer the resident an alternative and cleared the resident's plate from the table; -The resident ate ½ of his/her carrots, one bite of potatoes, none of the pork chop and all of the pudding. He/she drank half of the milk and none of the water. The resident did not have an Ensure Enlive served with his/her lunch. Record review of the resident's January 2023 POS showed an order, dated 1/19/23, for Ensure Plus high protein (a nutritional supplement), 237 ml daily as needed. During an observation and record review on 1/20/23, at 11:31 A.M., showed the following: -CNA L delivered the resident's tray to him/her in his/her room and explained what was on the tray; -No Ensure was on the resident's tray; -No Ensure delivered on the drink cart; -Ensure Enlive written on the resident's diet card. During an interview on 1/19/23, at 2:24 P.M., CNA M said the following: -The resident had a weight loss; -The resident received a protein cup at lunch. It was like a pudding cup but he/she did not eat them often. He/she did not get one today. The kitchen sent them down with the meals. He/she did not think to call the kitchen to ask for one; -The resident was not supposed to get Ensure Enlive with lunch; -If he/she saw the resident not eating, he/she should encourage the resident to eat; -He/she had tried to feed the resident, but the resident would not allow it; -If the resident did not eat well, he/she informed the charge nurse; -He/she encouraged the resident to eat several times during lunch today; -The resident did well with a sandwich and chips, but last week on 1/11/23, the physician sent the resident to the hospital with a stroke and since then his/her diet was changed; -This morning the resident ate two bowls of cereal. He/she got raisin bran and super cereal for breakfast; -At lunch today, he/she cut up the residents food and the resident shoved the plate back and only ate his/her pudding. He/she attempted to get the resident to eat before he/she picked up the resident's plate; -He/she could have offered an alternative or requested more pudding for the resident but did not; -The resident got in moods at times like today and shoved his/her food out. He/she did not offer more pudding because the resident would just shove it away; -He/she did not notice the resident kept picking up their container of pudding and attempting to get more out of the container. The resident may have ate more pudding if he/she offered it to them; -He/she offered the resident snacks in the morning, afternoon and when the resident requested one. He/she gave the resident a snack this afternoon and the resident ate it. During an interview on 1/19/23, at 2:47 P.M., CNA L said the following: -The resident had a significant weight loss; -When he/she passed the resident's room, he/she offered the resident drinks and snacks; -He/she encouraged the resident to come to the dining room for meals and at times sat with the resident and assisted the resident to eat when the resident let him/her; -He/she allowed the resident to take as much time to eat as they wanted; -If the resident pushed their plate away, he/she introduced the resident to what was on their plate. If the resident still did not want what was on their plate, he/she offered the resident something else to eat. The other day the resident ate three bananas; -If the resident ate all their dessert, he/she encouraged the resident to drink their milk. If the resident only wanted the dessert and kept attempting to get more dessert from the empty container, he/she called the kitchen to get the resident more dessert; -The resident received a protein supplement but he/she could not remember which one. The resident also received super cereal from breakfast. During an interview on 1/29/23, at 3:00 P.M., Licensed Practical Nurse (LPN) N said the following: -The resident had a weight loss; -The resident received super cereal at breakfast, Ensure Enlive with lunch and dinner. Dietary services sent these items down with the meal cart; -If dietary services did not send these items, staff should call them and they would bring them to the SCU; -The resident received Remeron at bed time to help stimulate his/her appetite; -At meals, the resident was particular and staff should offer him/her a selection of food. A lot of times, the resident would just eat cereal; -Staff should encourage the resident to eat when he/she was not; -If the resident pushed his/her plate away, staff should offer an alternative; -If the resident continued to try to get more pudding out of an empty bowl after he/she finished it, staff should offer more pudding. If the resident ate a certain food item, they should offer more of that food item because something is better than nothing; -Staff should not just remove the resident's plate and not offer an alternative if the resident did not eat the food because the resident had a weight loss. During an interview on 1/19/23, at 3:44 P.M., the Dietary Manager (DM) said the following: -The resident did not have any ordered supplements; -The resident was not on the supplement list he/she updated today; -The DM looked at the resident's chart and stated the resident was supposed to get Ensure Enlive. The order was in the resident's physician's orders, but not on his/her diet modification report. He/she did not know the date of the order; -He/she assumed the resident should receive the Ensure Enlive two meals a day; -He/she could not say if he/she received an order from nursing for the resident's supplement. During an interview on 1/20/23, at 9:16 A.M., CNA G said the following: -The resident had a weight loss; -A lot of the time, the resident did not like to come out of his/her room to eat but staff should encourage the resident to come out of his/her room to the dining room because he/she ate more in the dining room; -If the resident stayed in his/her room, staff tried to do one on one with him/her to try to get the resident to eat and if she did not eat, staff offered him/her a snack or Ensure; -The resident received super cereal for breakfast and received Ensure for a while but he/she did not know if the resident still received Ensure; -If the resident only ate the dessert, staff could call the kitchen to get more or ask for bran flakes because the resident would eat them. The resident would eat bran flakes for all meals; -He/she offered the resident encouragement to eat and offered snacks or an alternative if the resident would not eat the regular meal; -If he/she saw the resident scraping an empty bowl of pudding attempting to get more, he/she called the kitchen for them to send more; -The resident was on a regular diet and would do well with finger foods such as sandwiches, her cereal and he/she liked shakes or Ensure. During an interview on 1/20/23, at 9:52 A.M., LPN F said the following: -The resident had a weight loss; -Staff offered the resident snacks between meals and throughout the day; -The resident was not a big eater and since he/she went out to the hospital for a mild stroke, he/she ate even less; -Staff should cue the resident to eat if he/she was not eating; -Staff offered the resident supplements throughout the day; -The resident received Ensure with meals and with medications; -The resident loved cereal, bran flakes or raisin bran, and staff offered this to him/her. The resident liked ice cream too; -Staff should offer the resident anything he/she wanted; -If the resident had a day where he/she would not eat, staff offered an alternative that he/she may eat such as sandwiches or Dr. Pepper. The resident's family used to bring him/her protein bars but the resident had a lot of nausea and was on multiple anti-nausea medications; -Staff encouraged the resident to get out of bed and up for meals, but would not argue with the resident if he/she chose not to. Sometimes the resident did and sometimes he/she did not; -If the resident ate all of his/her pudding and continued to scrape the bowl for more, staff should ask the resident if he/she wanted more. If the resident said no, staff should call the kitchen to get more and place it in front of him/her to see if he/she ate it; -Staff tried finger foods but had the same response of sometimes he/she ate them and sometimes not; -If the resident was supposed to receive a supplement, he/she should get the supplement. If the order was for lunch and dinner, staff should give the resident the supplement; -The resident had an order dated 1/20/23 for Ensure High Protein, 237 ml, by mouth daily and staff placed that order under the medication pass. That amount was a full bottle and staff should have put the order under dietary; -The resident had an order dated 1/9/23 for Ensure Enlive daily; -The resident received super cereal for breakfast and an order for Remeron at bedtime for appetite stimulation; -The resident was on a regular diet; -Staff should offer the resident supplements, snacks, alternatives and encouragement because the resident did not need to lose more weight. The resident could afford to gain some weight. He/she wanted the resident to feel good and have a good quality of life; -He/she considered the resident high risk for weight loss. During an interview on 1/20/23, at 11:52 A.M., the Registered Dietician said the following: -The resident had a weight loss in December 2022; -The resident's weight was stable around 115 lbs. to 120 lbs. for about six months and then he/she had a weight loss; -He/she recommended super cereal with breakfast and Ensure Enlive with lunch and dinner; -On 1/16/23, when he/she reviewed the resident's chart, he/she noticed the residents Ensure intake was patchy as to when the resident would drink them; -The resident was finicky and staff tried new interventions; -He/she wrote the diet order for Ensure Enlive a long time ago, but he/she could not remember when; -If the resident had an order for a supplement, staff should give the resident the supplement; -The DM should be aware the resident received a supplement and should review diet orders regularly; -The resident should have been on the supplement list in nutritional services; -The resident should receive his/her supplement whether he/she drank it or not and staff should offer it with meals. During an interview on 1/20/23, at 3:44 P.M., the Director of Nursing (DON) said the following: -The resident had a significant weight loss; -Staff tried multiple interventions in the past such as snacks between meals, protein bars and medications for upset stomach. Staff tried Ensure Compact with medications but he/she would not take the Ensure Compact and refused medications at times; -He/she expected staff to cue the resident to eat and if the resident enjoyed the dessert, staff should call the kitchen to get more; -The resident was particular and shut-down, but staff should still offer encouragement for the resident to eat; -If the resident had Ensure Enlive ordered, he/she expected the dietary staff to send it to the unit and staff to give it to the resident. During an interview on 1/20/23, at 5:30 P.M., the Administrator said the following: -He/she expected staff give ordered supplements to the resident and staff should follow his/her interventions for weight loss. 2. Record review of Resident #74's face sheet showed: -admission date of 12/1/22. Record review of the resident's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Required supervision - oversight, encouragement, or cueing with meals; -No swallowing or dental concerns identified; -Resident on hospice services. Record review of the resident's weight record documentation showed on 12/7/22 the resident's nutritional assess weight of 107 lbs. Record review of the resident's initial nutritional assessment note, dated 12/8/22, showed resident's nutritional needs were being addressed, staff to monitor intake and weights. Record review of the resident's nutritional status care plan, dated 12/8/22, showed: -Resident on a regular diet and usually eats 50-100%; -Diet as ordered, regular; -Nutritional supplements as ordered; -Use of adaptive equipment as ordered; -Staff to monitor the resident's weight monthly, as ordered; -Staff to monitor the resident's nutritional intake; -Obtain nutritional history, obtain the resident's weight, offer bedtime snack, and complete a nutritional assessment. Record review of a message from the facility to the resident's physician, dated 12/27/22, showed: -Resident with documented weight loss of 5 pounds in 14 days, requesting order to add Ensure Compact 118 ml two times daily; -Physician agreed to the recommendation. Record review of the resident's physician orders showed the following order: -An order for Ensure compact twice daily started on 12/27/22 and order discontinued on 1/16/23. Record review of the resident's January 2023 Medication Administration Record (MAR) for January 2023, showed the following: -An order for Ensure Compact 118 milliliters (ml) administer two times daily; -From 1/1/23 to 1/16/23, staff documented the supplement was not available a total of 17 times. Record review of the resident's nutritional note, dated 1/16/23, showed: -Resident had weight change, his/her current = 101 pounds, a severe 6.5% loss in one month; -The resident's base metabolic index (BMI) = 19.7 was within normal limits; -The resident was not choosing to eat 100%; -Ordered dietary supplement, Ensure Compact 118 milliliters (ml) twice daily, this has been unavailable related to distributor issues, discussed with the DON; -Resident nutritional needs were being addressed; -Discontinue Ensure compact and recommend Ensure plus high protein, 237 ml, twice daily; -Update the resident's diet order to include International Dysphagia Diet Standardization Initiative (IDDSI - a global standard describing modified texture foods and thickened liquids for individuals with dysphagia) liquid level; -Staff to encourage clear fluids as tolerated. Record review of the resident's weight record documentation showed: -On 1/16/23, the resident's weight = 101 pounds. Record review of the resident's physician orders showed the following order: -An order for Ensure compact twice daily discontinued on 1/16/23; -An order for Ensure high protein 237 milliliters started on 1/17/23. Observation on 1/19/23 at 11:31 A.M., showed the resident sat in the dining room slowly eating his/her food. During an interview on 1/19/23, at 1:22 P.M., CNA K said the following: -The resident's appetite varied day to day, but he/she usually had a good appetite at breakfast; -The resident did not need help with meals, but did need encouragement to eat; -The CNA was unsure if the resident had lost any weight since admission. During an interview on 1/19/23 at 1:36 P.M., RN H said the following: -The resident was a very light eater; -The resident drank Ensure at times; -The resident frequently refused help with meals. During an interview on 1/20/23, at 9:35 A.M. and at 11:21 A.M., the Dietary Manager (DM) said the following: -The facility had a weight loss meeting every Friday for residents with a 5% or greater weight loss over the past 30 days; -The DM said he/she was not always able to attend the weight loss meetings due to working in the kitchen preparing meals; -Staff review resident diets and determine if residents need added supplements or other interventions; -The DM was not aware the resident had a weight loss; -The DM said the resident was on an Ensure supplement. -The Registered Dietitian (RD) usually comes to the facility weekly and reviews residents with weight loss and makes needed recommendations for weight loss interventions; -The DON usually compiles the list of resident's with weight loss. -The nursing department distributes the Ensure Compact; -The front office manager ordered the Ensure Compact from the distributor; -The DM was not aware of any issue in obtaining the Ensure Compact from the distributor. -Prior to this week, he/she was not giving the resident any nutritional supplements; -The RD recommended to start the Ensure with meals on 1/16/23 or 1/17/23 and that was when he/she began giving the resident Ensure in the dining room. During an interview on 1/20/23, at 9:58 A.M., the office manager said the following: -He/she was in charge of ordering nutritional supplements from the distributor for the residents; -The distributor was not able to send the full orders; -This lead to the facility running out of the Ensure Compact; -He/she informed the DON this week and they are working to change the resident orders to a supplement that is more readily available. During an interview on 1/20/23, at 10:03 A.M., RN H said the following: -He/she was aware of the resident's weight loss; -Staff encourage the resident to eat, but the resident was a light eater and would often refuse to eat; -The resident had an order for Ensure Compact, dated 12/27/22, but the facility was out of the Ensure Compact for a few days; -He/she thought the resident was now on a different supplement as of 01/16/23 or 01/17/23; -The certified medication technician gave the resident the Ensure Compact when available; -The CMT gave the nurse a non-administration report that listed the Compact when it was not available to give to the resident; -Upon reviewing the CMT's for Resident #74, from 01/01/23 and 01/16/23, the CMT did not administer the resident's Ensure Compact on 17 occasions. During an interview on 1/20/23, at 10:37 A.M., CNA J said the following: -Beginning today, 1/20/23, RN H said, if the resident did not eat, staff should give the resident an Ensure to drink; -Prior to today, CNA J had not been instructed to offer the resident a supplement. During an interview on 1/20/23, at 11:09 A.M., CMT Q said the following: -During January 2023, there were several times, when the Ensure Compact was not available from the distributor; -When this occurred, the CMT documented on the back of the resident's MAR and gave a non-administration list to the nurse each day of the resident items when not available; -The CMT said he/she was not giving the resident a substitute supplement in place of the Ensure Compact. During an interview on 1/20/23, at 3:44 P.M. the DON said the following: -He/she was not aware the facility was running out of Ensure Compact until 1/16/23; -Staff were reviewing the resident's MAR and discovered that staff were not consistently administering the Ensure Compact as ordered during the month of January 2023; -The DON spoke with the RD, who then made recommendations to substitute Ensure plus high protein; -The DON then asked the nurse practitioner for orders to change the resident supplement; -The failure to administer the ordered Ensure Compact could contribute to resident weight loss -If the Ensure Compact was not available as ordered, the CMT should notify the nurse and the nurse should notify the DON, but this did not happen. During an interview on 1/20/23 at 5:29 P.M., the administrator said: -He/she was not aware the facility was out of Ensure Compact until 01/16/23. 3. During an interview on 1/19/23, at 2:47 P.M., CNA L said the following: -If a resident's weight went down three pounds, they offered supplements or snacks; -The physician ordered supplements for the residents and some protein shakes given liberally. 4. During an interview on 1/19/23, at 3:00 P.M., LPN N said the following: -If a resident started to have weight loss, he/she assessed the resident for physical reasons such as oral issues, sores in mouth, denture fitment, problems with their teeth, if the resident was sick recently or recent exacerbation of congestive heart failure (CHF - breathing problems from fluid in and around your lungs). He/she asked the resident about their appetite and looked at medications to see if they affected the resident's appetite. He/she also notified the resident's physician. 5. During an interview on 1/19/23, at 3:44 P.M., the DM said the following: -The dietary aides gave supplements to residents that ate in the dining room and the aides delivered them to the residents on the hall carts and in the SCU's; -The dietary aide placed the supplement on the drink cart delivered to the 100 south SCU and if they forgot the aides in the SCU called the kitchen and the dietary aide delivered it; -He/she made a list for each cart with residents who had ordered supplements; -He/she knew which residents received supplements when the nurses gave him/her an order; -The nurse received an order from the physician or dietician and gave him/her a copy of the order. He/she then updated his/her list. 6. During an interview on 1/20/23, at 9:52 A.M., LPN F said the following: -If a resident had a weight loss, he/she reweighed the resident, documented their weight and notify the nurse practitioner and DON about the weight loss; -He/she believed nursing management did weight loss meetings weekly. They called and had the nurse obtain a current weight before their meeting; -When the physician ordered a supplement for a resident, the nurse put the order under dietary and called the DM to let them know; -The DM did not receive a print out of the order and the facility did not have a process for this; -The DM wrote the supplement down when the nurse called and added the supplement to their diet card. 7. During an interview on 1/20/23, at 11:52 A.M., the Registered Dietician said the following: -Nutritional services stocked supplements and stocked them in each of the units as well; -If the 100 south SCU did not have a stock of supplements, nutritional services sent the supplement to that SCU on the drink cart with meals; -He/she gave the DM, Administrator, and DON a report every time he/she visited; -The DM kept a list of resident's who received supplements either on his/her door or by the hand washing sink; -The DM added the supplements to the residents' diet cards so staff could deliver the supplement to the residents; -The DM should attend the weight loss meeting. 8. During an interview on 1/20/23, at 3:44 P.M., the DON said the following: -Staff weighed all residents monthly and if they notice a weight loss, staff weighed them weekly; -Staff tried interventions such as supplements, super cereal, snacks between meals, Ensure, talked to the Registered Dietician and SLP about concerns and looked to see if the resident got up for meals; -He/she, the MDS Coordinator, and the DM completed weekly weight meetings. The DM could not always attend and he/she could not say how often the DM did attend; -The RD did not attend the weekly weight meetings, but vi

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow policies and procedures for immunization of residents against influenza in accordance with national standards of practice when staff administered two annual influenza shots less than a month apart for two residents (Resident #45 and #78). The facility had a census of 108. Record review of the facility's policy titled Nursing Protocol: Adult Outpatient Vaccine Schedule, revised 10/2022, showed the following: -The purpose of the policy is to outline an adult vaccine schedule for long-term care (LTC) facilities to follow. Utilizing a standardized process for vaccinating adults promotes clinical staff competency and patient safety. This practice also facilitates an easy to follow schedule in Health Maintenance in the patient Electronic Medical Record (EMR); -Registered Nurses in the LTC facilities may also initiate the protocol; -Identify adults in need of vaccination based on the following criteria: Influenza, inactivated or recombinant (DNA, proteins, cells, or organisms that are made by combining genetic material from two different sources), age [AGE] and up, annually; screen patients for contraindications and precautions to vaccine; provide patient/resident/guardian with a copy of the most current federal Vaccine Information Statement (VIS) and get consent for immunization; administer the vaccine per package instructions; and be prepared for management of a medical emergency related to the administration of the vaccine per Nursing Protocol: Anaphylaxis Management; -Place an order on the eMAR with order source protocol and complete the vaccination intervention if applicable. Documentation will include the date, manufacture, lot number, vaccine expiration date, vaccination site, and route. Record review of the Centers for Disease Control and Prevention (CDC) web-site, updated 8/24/22, showed the Advisory Committee on Immunization Practices (ACIP) recommended that adults of 65 years or older should preferentially receive any one of the following higher dose or adjuvanted influenza vaccines: quadrivalent high-dose inactivated influenza vaccine (HD-IIV4), quadrivalent recombinant influenza vaccine (RIV4), or quadrivalent adjuvanted inactivated influenza vaccine (aIIV4). If none of these three vaccines are available at an opportunity for vaccine administration, then any other age-appropriate influenza vaccine should be used. 1. Record review of Resident #45's face sheet (a document that gives a patient's information at a quick glance) showed the following -admission date of 2/23/21; -Diagnoses included Alzheimer's disease. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/21/22, showed the following: -The resident received the influenza vaccine on 9/28/22. Record review of the resident's physician order sheets (POS), dated September 2022 and October 2022, showed the following: -An order, dated 9/28/22, for Influenza QV2022-23 (influenza vaccine), .5 milliliters (ml) inject into the muscle (IM) once; -An order, dated 10/25/22, for Influenza QV2022-23, .5 milliliters (ml) inject IM once. Record review of the resident's Medication Administration Record (MAR), dated September 2022 and October 2022, showed the following: -On 9/28/22, staff administered .5 ml Influenza QV 2022-23 IM; -On 10/25/22, staff administered .5 ml influenza QV 2022-23 IM. Record review on the resident's nurses' progress notes showed the following: -On 9/28/22, at 3:47 P.M., education and VIS provided to the resident and guardian/durable power of attorney (DPOA) for annual influenza vaccine. Resident and guardian/DPOA agrees to receive influenza vaccine and consent form signed. Resident afrebile (without fever) prior to administration. Vaccine administered without difficulty. The resident tolerated it well. -On 10/25/22, at 3:48 P.M., education and VIS provided. Flu vaccine administered after consent was given. Post injection without adverse reactions or complaints of pain or discomfort to injection site. Record review of the resident's vaccination record showed staff administered the influenza vaccination to the resident on 9/28/22 and 10/25/22. During an interview on 1/20/23, at 10:52 A.M., the Infection Preventionist said the following: -The resident received an influenza vaccination on 9/28/22 and 10/25/22. The MDS Coordinator gave the vaccination in September and he/she gave the vaccination in October; -He/she should have noticed that the resident already received the vaccination and should not have administered the second vaccination. Giving the second vaccination was a medication error on his/her part; -The resident should not have received two influenza vaccinations. During an interview on 1/20/23, at 11:46 A.M., the MDS Coordinator said the following: -He/she did not remember giving the resident the influenza vaccination in September, but if he/she documented the vaccination given and site administered, he/she or another nurse gave the vaccination; -Staff should not have administered another influenza vaccination to the resident in October; -He/she did not know of a reason the resident should receive two influenza vaccinations. During an interview on 1/20/23, at 3:44 P.M., the Director of Nursing (DON) said the following: -Staff should not have administered two influenza vaccinations to the resident; -The resident did not have any adverse reactions that he/she was aware of. During an interview on 1/20/23, at 5:30 P.M., the Administrator said the following: -Staff should not have administered two influenza vaccinations to the resident this year. 2. Record review of Resident #78's face sheet showed the following: -admission date of 6/12/20; -Diagnosis included major depressive disorder. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -The resident received the influenza vaccination on 10/7/22. Record review of the resident's POS, dated October 2022, showed the following: -An order, dated 10/13/22, for Influenza QV2022-23, .5 ml inject IM once; -An order, dated 10/24/22, for influenza QV2022-23, .5 ml inject IM once. Record review of the resident's MAR, dated October 2022. showed the following: -On 10/14/22, .5 ml influenza QV 2022-23 given IM; -On 10/25/22, .5 ml influenza QV 2022-23 given IM. Record review of the resident's nurses' progress notes showed the following: -On 10/14/22, at 3:21 P.M., education and VIS provided. Flu vaccine administered after consent was given. Post injection without adverse reactions or complaints of pain or discomfort to injection site; -On 10/25/22, at 3:30 P.M., education and VIS provided. Flu vaccine administered after consent given. Post injection without adverse reactions or complaints of pain or discomfort to injection site. Record review of the resident's immunization record showed staff administered the influenza vaccination to the resident on 10/14/22 and 10/25/22. During an interview on 1/20/23, at 10:52 A.M., the Infection Preventionist said the following: -The resident received the influenza vaccination on 10/14/22 and 10/25/22 and he/she administered both of those vaccinations; -He/she did not remember administering two influenza vaccinations to the resident and believed the first documentation was an error. If he/she did not administer the vaccination, he/she should not document this in the resident's record. During an interview on 1/20/23, at 3:44 P.M., the DON said the following: -Staff should not have administered two influenza vaccinations to the resident; -The resident did not have any adverse reactions that he/she was aware of. During an interview on 1/20/23, at 5:30 P.M., the Administrator said the following: -Staff should not have administered two influenza vaccinations to the resident this year. 3. During an interview on 1/20/23, at 10:52 A.M., the Infection Preventionist said the following: -He/she offered the influenza vaccine to residents yearly. He/she received consent from the resident or their responsible party and if they gave consent, he/she or another nurse administered the vaccine; -He/she only gave one influenza vaccine to a resident unless the physician ordered more; -He/she tracked the vaccinations on a spreadsheet and looked in the residents' charts and pulled reports also. At the time, he/she was learning how to use the reports in the EMR. 4. During an interview on 1/20/23, at 11:46 A.M., the MDS Coordinator said the following: -The Infection Preventionist gathered consents for the influenza vaccination in early to mid-September yearly; -If the resident or their responsible party consented, a nurse administered the vaccination and if they declined, they did not get the vaccination; -If a resident had the influenza vaccination prior to admission that season, they did not receive the vaccination in the facility; -Staff should not administer two influenza vaccinations to a resident in a year; -The EMR had immunization reports that staff pulled to see if a resident had a vaccination already and the Infection Preventionist kept a spread sheet to track the immunizations as well. 5. During an interview on 1/20/23, at 1:01 P.M., the Medical Director said the following: -Staff should not administer two influenza vaccination in a year; -If staff administered an influenza vaccination, they should enter this into the health maintenance tracker; -The facility needed to improve tracking to be easier and more visible; -If a resident received two influenza vaccinations in a year, it could cause a hyperimmune (a high concentration of antibodies (a blood protein produced in response to and counteracting a specific antigen (a toxin or other foreign substance which induces an immune response in the body)) produced in reaction to repeated injections of an antigen) to the vaccination such as a rash, swollen lymph nodes (a small bean-shaped structure that is part of the body's immune system) or worst case scenario, Guillian-Barre syndrome (a rare disorder in which your body's immune system attacks your nerves). 6. During an interview on 1/20/23, at 3:44 P.M., the DON said the following: -When a resident admitted to the facility, the Infection Preventionist checked to see if the resident received an influenza vaccination. He/she emailed their provider, spoke with family members, and had access to Show Me Vax; -If the resident was already in the facility, the Infection Preventionist checked all residents' records to ensure not already vaccinated that influenza season; -Staff should not administer two influenza vaccination in the same year to any resident; -Receiving two influenza vaccinations in a year could cause adverse reactions such as influenza like symptoms, redness of the arm and myasthenia gravis (a chronic autoimmune, neuromuscular disease that causes weakness in the skeletal muscles that worsens after periods of activity and improves after periods of rest); -He/she expected the nurse to check the residents chart to ensure they had not received the vaccination; -The EMR had a report to pull all the vaccinations given and the nurse should audit this. If he/she administered the vaccination, he/she checked the resident's record him/herself; -The Infection Preventionist placed the vaccinations given in a spread sheet; -The nurse managers (Administrator, DON, MDS Coordinator and Infection Preventionist) worked together during influenza season to administer the vaccinations and the Infection Preventionist took care of new admissions; -They (nurse managers) took a census sheet and used it as a master list when they started giving vaccinations. They looked to see who needed the influenza vaccination prior to their MDS date and gave those vaccinations. If they did not capture the influenza vaccination during their MDS look back period (seven days before the MDS due date) they did not get credit for giving the vaccination; -They started giving influenza vaccinations in September and October and did not give them all at a time. They highlighted the residents name on the master list when they administered the vaccination.