**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, contracted Physical Therapy Assistant (PTA) A did not adhere to resident's rights to be informed of care or refuse care by not explaining each treatment he/she was providing for seen residents prior to providing their treatments for seven residents (Residents #1, #2, #3, #4, #5, #6 and #7) causing those residents to feel uncomfortable with the PTA A's treatments out of eleven sampled residents. The facility census was 77 residents. On 4/29/25, the facility Administration was notified of the past noncompliance which occurred on 4/21/25. Facility staff were educated on resident rights, informed care, abuse and neglect protocols and customer service. The deficiency was corrected on 4/21/25. Review of the facility's Resident Rights-Quality of Life Policy revised on May 1, 2023 showed: -The purpose of the policy was to ensure that all residents are treated with the level of dignity they are entitled to while residing at the facility. -Each resident was to have been cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality. -Facility staff was to always speak respectfully to residents, including addressing the resident by their name and pronoun of choice. -Facility staff was to have explained all procedures to residents before they were performed. -Demeaning practices and standards of care that compromised dignity were prohibited. 1. Review of Resident #1's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Non-traumatic intracerebral brain hemorrhage (also known as a brain bleed or hemorrhagic stroke, is a type of stroke where bleeding occurs within the brain tissue itself). -Generalized weakness. Review of the resident's Physician Order Sheet (POS) dated 10/9/24 showed no order for Physical Therapy (PT). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 4/4/25 showed he/she was cognitively intact. Review of the facility Investigation dated 4/14/25 showed: -The resident reported that he/she saw contract PTA A walking another resident in the dining room and stated to the PTA that he/she would like to walk like that. -Contract PTA A offered to take him/her to the therapy gym to complete a therapy screen. -The resident agreed and went with contract PTA A to the therapy gym where PTA A completed a manual muscle test (a clinical assessment used to evaluate the strength of individual muscles or muscle groups) on his/her lower legs, hip flexion (the movement where the thigh is brought towards the chest at the hip joint), knee extension (the movement of straightening the knee joint) and knee flexion (the movement that bends the knee joint, decreasing the angle between the thigh and lower leg). -He/she also completed a sit to stand transfer. -After this was completed, he/she walked the resident down to his/her room. -The Contract PTA A reported that the resident got upset with him/her because he/she stated that since the resident was recently discharged off therapy services the resident would likely not be able to get back on therapy. -Once the resident returned to his/her room he/she sat on the bed and the contract PTA A continued the assessment by touching his/her legs, stomach, shoulders and back. -At no point during this time did resident feel uncomfortable. -The resident then reported that contract PTA A touched his/her chest area where resident alleged, he/she exposed his/her breast. -The resident stated that he/she told contract PTA A to leave his/her room so contract PTA A left. -This interaction was an unwitnessed event. Resident #1 had discharged from the facility and was unable to be reached for interview after multiple attempts to contact. 2. Review of Resident #2's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Post surgical broken hip. -Generalized post-surgical weakness. Review of the resident's POS dated 4/4/25 showed PT to evaluate and treat as indicated and the resident was to have daily PT. Review of the resident's admission MDS dated [DATE] showed he/she was not cognitively intact. Review of the facility's Investigation dated 4/15/25 showed: -Resident #2 had been interviewed on 4/14/25 and denied any concerns with contract PTA A's treatment. -On 4/23/25 the resident informed the facility staff that a tall slender person with light hair was inappropriate with him/her. -The facility Administrator spoke with the resident as soon as it was reported and the resident stated the contract PTA A stared rubbing his/her arm, going down his/her side and down to his/her leg. -The resident stated the rubbing occurred on top of his/her clothing and there was no touching any private areas. -The resident did not ask him/her to stop but stated it made him/her feel uncomfortable. -The resident did state he/she felt safe at the facility and felt that staff treated him/her with dignity and respect. During an interview on 4/25/25 at 1:15 P.M., Resident #2 said: -Contract PTA A just came into his/her room and asked if he/she was ready. -Resident #2 asked, ready for what?, to which contract PTA A replied, your therapy. -The resident stated that he/she guessed so and contract PTA A began to rub and squeeze his/her legs. -Contract PTA A said nothing regarding why he/she was rubbing the resident's legs. -Contract PTA A then asked if the resident would like a massage. -The resident said he/she guessed so. -Contract PTA A then began massaging his/her shoulders and proceeded to move down to the resident's chest, not touching his/her breast, but getting near his/her right breast with his/her left hand. -He/she said something to the contract PTA like, Hey, what are you doing? and he/she stopped. -He/she did not tell anyone at the facility for over two weeks as he/she thought maybe he/she was making a big deal out of nothing. -But he/she could not get the incident out of his/her mind so he/she told staff about what happened. -The resident stated that he/she hated men, as his/her spouse had raped him/her many years ago. -The incident with contract PTA A made him/her fell crappy. -The resident stated he/she never touched his/her breast or private area but felt the therapist came too close. 3. Review of Resident #3's facility admission Record showed he/she was re-admitted on [DATE] with the following diagnoses: -Metabolic Encephalopathy (a brain dysfunction resulting from impaired cerebral metabolism due to underlying systemic diseases or condition). -Muscle weakness. Review of the resident's Annual MDS dated [DATE] showed he/she was cognitively intact. Review of the resident's POS dated 3/2/25 showed PT was to screen, evaluate and treat as indicated. Review of the facility's Investigation dated 4/15/25 showed: -Resident #3 had reported contract PTA A came into his/her room on 4/12/25 asking if he/she wanted therapy services. -The resident stated he/she did want those services, so contract PTA A started a therapy screen by touching his/her legs. -PTA A then touched his/her abdomen and under his/her breasts. -The resident did not tell him/her to stop or report the incident to anyone. -The facility staff competed an assessment and the resident showed no injuries, and the resident stated no pain. -The resident stated he/she felt safe in the facility and felt that facility staff treated him/her with dignity and respect. During an interview on 4/25/25 at 2:50 P.M., Resident #3 said: -He/she did not realize that he/she was to get therapy services and had not had therapy before. -Contract PTA A came into his/her room and began massaging his/her shoulders. -Contract PTA A also pushed on and massaged his/her legs all the way up his/her thigh. -Contract PTA A said nothing to him/her as to what he/she was doing or why he/she was doing it. -Contract PTA A did not touch his/her breast or private area, but the resident stated even so, he/she felt molested. 4. Review of Resident #4's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Heart Attack. -Left and Right sciatic lumbago (pain in the lower back that also radiates down into the legs and feet). -Muscle Weakness. Review of the resident's quarterly MDS dated [DATE] showed he/she was cognitively intact. Review of the resident's POS dated 3/8/25 showed PT was to evaluate and treat. Review of the facility's Investigation dated 4/15/25 showed: -Resident #4 had been treated by contract PTA A on 4/12/25. -The resident reported PTA A came into his/her room and began the resident's scheduled therapy session by touching his/her legs, thighs and mid abdomen. -The resident reported PTA A having treated him/her previously with no concerns. -The resident reported he/she did not tell contract PTA A to stop on 4/12/25 and did not report the incident to anyone. -Resident #4 stated having watched his/her roommate's therapy session as well and contract PTA A had provided therapy to his/her roommate's legs. -Resident #4 was assessed and no issues were found. -The resident reported no pain and stated he/she felt safe as facility staff always treated him/her with dignity and respect. -During an interview on 4/25/25 at 2:25 P.M., Resident #4 said: -He/she watched what happened with his/her roommate, Resident #3 and what happened to him/her was not like that. -Contract PTA A got a little fresh with him/her massaging his/her shoulders and touching his/her chest, but nothing more than that. -The resident stated that he/she did not like what contract PTA A did at all. 5. Review of Resident #5's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses showed: -Post surgical amputation- (the period following a surgical procedure to remove a limb or part of a limb). -Stroke. Review of the resident's quarterly MDS dated [DATE] showed he/she was moderately cognitively intact. Review of the resident's POS dated 4/1/25 showed PT was to evaluate and treat as indicated. Review of the facility's Investigation dated 4/15/25 showed: -Resident #5 was interviewed by facility staff as he/she had been a roommate of a resident on therapy services and treated by contract PTA A. -The resident reported contract PTA A came into the room and asked if he/she wanted his/her necked and shoulders rubbed. -The resident said he/she said yes and that the shoulder rub felt good. -The resident stated contract PTA A, while massaging his/her shoulders contract PTA A's hand began to go own toward his/her shirt. -The resident reported his/her breasts were not touched and he/she did not tell contract PTA A to stop even though it made the resident feel uncomfortable. -Resident #5 did not report the incident to anyone and his/her skin assessment showed no concerns. -The resident reported feeling safe in the facility and that facility staff had treated him/her with dignity and respect. During an interview on 4/25/25 at 3:23 P.M., Resident #5 said: -He/she had not had therapy and did not know contract PTA A prior to the incident. -Contract PTA A did not say anything to the resident, instead he/she just began massaging his/her shoulders. -The therapist then touched the resident's chest, near but not touching his/her breast. -The therapist did not touch him/her under his/her shirt. -The resident was seated in his/her wheelchair while the therapist worked with him/her. -He/she had spoken to his/her roommate, Resident #6 about what happened and his/her roommate said the same thing happened to Resident #6. -He/she felt creepy after the incident, and it made him/her nervous. -He/she did not say anything to any staff after it happened, until they asked him/her questions about contract PTA A. 6. Review of Resident #6's facility admission Record showed he/she was re-admitted [DATE] with the following diagnoses: -Cervical spondylosis- (a degenerative condition that affects the bones and discs in the neck (cervical spine). -Generalized weakness. -Muscle wasting and atrophy- (both refer to the decrease in muscle mass and strength). Review of the resident's POS dated 11/27/24 showed PT was to evaluate and treat as indicated. Review of the resident's annual MDS dated [DATE] showed he/she was cognitively intact. Review of the facility's Investigation dated 4/15/25 showed: -Resident #6 was treated by contact PTA A over the previous weekend and stated he/she came into the residents' room asking if the resident wanted to walk down the hall. -The resident stated he/she sat down on the bed and contract PTA A rubbed his/her shoulders with contract PTA A's hand reaching down to his/her mid abdomen over his/her clothes. -The resident expressed discomfort and contract PTA A left. -The resident had not reported the incident to anyone, and a skin assessment showed no concerns. -The resident reported no pain and stated he/she felt safe and the facility staff had always treated him/her with dignity and respect. During an interview on 4/25/25 at 1:50 P.M., the resident showed: -About two to three weeks ago on a Saturday, contract PTA A came into his/her room and said, I am ready for you. -He/she asked the therapist what was going to happened and the therapist said he/she could give the resident a massage. -Contract PTA A then began to massage the resident's shoulders and while doing so, he/she moved his/her hands down towards the resident's right breast, not touching the breast, but getting close. -The resident knocked the therapist's hand away and said, what are you doing. -Contract PTA A just said he/she was giving a massage and the resident told him/her to stop and leave the room. -Contract PTA A lingered for a short time, watching the resident television near the foot of the bed and then left the room, saying nothing. -Contract PTA A had never treated the resident before that day and ha not treated him/her since. -The incident made him/her mad. 7. Review of Resident #7's facility admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Lumbar spondylosis with myelopathy. -Stroke. Review of the resident's POS dated 1/3/24 showed PT was to evaluate and treat. Review of the resident's quarterly MDS dated [DATE] showed he/she was cognitively intact. Review of the facility's Investigation dated 4/15 25 showed: -Resident #7 was spoken with initially on 4/14/25 and denied any issues. ` -On 4/15/25 the resident then reported he/she wanted to inform the facility that a therapist with gray hair came into his/her room. -The resident stated he/she asked contract PTA A to rub his/her arm to which contract PTA A began rubbing his/her arm as requested. -The resident stated that at some point, contract PTA A then touched his/her right breast over his/her shirt. -Resident #7 told him/her to stop to which contract PTA A said he/she would not do that again. -The resident did not report the incident to anyone and also that he/she had provided therapy for the resident on the previous weekend and felt the therapist did a good job. -The resident expressed feeling safe in the facility and that facility staff had always treated him/her with dignity and respect. During an interview on 4/25/25 at 3:38 P.M., Resident #7 said: -Contract PTA A had treated the resident on 4/12/25 and he/she had no issues with the treatment. -Then, the following day, he/she touched his/her breast on the outside of his/her clothing. -The therapist massaged the resident's shoulders and just got too low on his/her chest. -The resident was in his/her wheelchair during the treatment and contract PTA A also massaged the resident's arms. -Contract PTA A said nothing the whole time he/she was with the resident. -The resident did not say anything to any staff after the incident but felt he/she should have. -The incident made the resident feel not good. During an interview on 4/25/25 at 4:39 P.M., contract PTA A said: -He/she had two weeks to reflect on the accusations and felt completely blindsided. -He/she felt as thought he/she did nothing wrong and followed the treatment plans as they were supposed to be done. -He/she spoke to all the residents throughout the treatments, always telling the residents what he/she was doing and why he/she was doing it. -He/she did not use massage as part of the resident's treatment plans. -The only thing he/she could think of what that when he/she was palpating their muscles to check for muscle tone, the resident's could have thought that felt like a massage. -He/she ran his/her hands up and down their arms and legs, pressing throughout to see how their muscles felt. -At no point did he/she feel that he/she touched the residents inappropriately or varied the treatments from the treatment plans. -There were some residents whom he/she treated who were upset that after evaluation, he/she was unable to continue with any more therapy for one reason or another. -He/she felt that for some reason, the residents misinterpreted his/her treatments as something inappropriate when that was not his/her intention. 8. During an interview on 4/29/25 at 10:56 A.M., Social Worker A said: -It was reported to him/her on 4/14/25 by some residents who had all been out smoking together that contract PTA A had allegedly inappropriately touched Resident #1 the day before during a therapy treatment. -He/she immediately went and report the allegation to the facility Administrator. During an interview on 4/29/25 at 1:07 P.M., Contract Therapy Agency Director A said: -It would have been appropriate therapy treatment for contract PTA A to have taken a hold of the residents' arm and while completing range of motion (ROM), placed his/her hand on the resident pectoral muscle located in the chest to evaluation how that muscle reacted to the movement. -It would have been appropriate therapy practice for contract PTA A to have taken a hold of the residents' leg and while performing ROM on the leg, to have placed his/her hand on the inner thigh to evaluate how the leg muscles were performing during ROM. -He/she would have expected that prior to contract PTA A beginning treatment for the residents to have explained to the resident exactly where he/she was going to touch them and why. -He/she would have expected contract PTA A to have explained everything being done for each resident, so the resident was not confused or surprised by what was happening. -He/she would have expected contract PTA A to have ensured the resident was able to hear what the therapist was saying before any explanations were made. -He/she could understand how a resident might believe massage was being completed by the therapist, especially if the therapist did not explain what was being done during treatment. During an interview on 5/2/25 at 3:00 P.M., the Director of Nursing (DON) and facility Administrator said: -He/she would have expected that any staff member whether contract or regular staff to have maintained the resident's dignity and never made them feel uncomfortable. -He/she would have expected contract PTA A to have fully explained each portion of the therapy treatment prior to performing the therapy. -He/she would have expected contract PTA A to have made sure each resident could hear the therapist well. -He/she would have hoped the residents all felt they could always come and report any issues or negative experiences to a facility staff member. MO00252818 MO00253280

Based on interview and record review, the facility failed to develop a spend down plan for two sampled residents (Resident #13 and #18) out of two residents sampled for the resident fund review process, who maintained a balance of more than $5,726.00 (the legal Missouri Medicaid limit) in their account for more than one month. The total facility census was 56 residents. Review of the facility's policy titled Resident's Funds Handling and Recording revised 10/24/22 showed: -The facility would notify the resident if his/her Resident Trust Fund (RTF) account was within $200.00 of the Social Security Income (SSI-Medicaid) legal limit. 1. Review of Resident #13's RTF statements showed: -On 9/1/23 the resident's balance was $8049.94. -On 10/3/23 the resident's balance was $8806.38. -On 11/3/23 the resident's balance was $8993.86. -On 12/30/23 the resident's balance was $9303.54. -On 1/3/24 the resident's balance was $9656.71. -On 2/2/24 the resident's balance was $11044.75. -On 3/1/24 the resident's balance was $10800.34. 2. Review of Resident #18's RTF statements showed: -On 9/5/23 the resident's balance was $8965.12. -On 10/3/23 the resident's balance was $8634.71. -On 11/2/23 the resident's balance was $8857.69. -On 12/30/23 the resident's balance was $9303.54 -On 1/3/24 the resident's balance was $9656.71. -On 2/7/24 the resident's balance was $10944.75. -On 3/12/24 the resident's balance was $9441.64. 3. During an interview on 4/3/24 at 1:40 P.M. the Business Office Manager (BOM) said: -He/she was responsible for the RTF accounts. -He/she did tell the residents they were over the legal limit. -The legal limit was $5000.00. -He/she did not tell the residents they could lose their Medicaid benefits since they were over the legal limit. -He/she just told the residents to spend their money. -He/she did not assist with a plan to help spend their RTF money to ensure they did not lose Medicaid services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to properly and accurately document a resident's advanced directives (wishes for what procedures, if any, a person would like to have should the heart stop beating and/or they stopped breathing) by reporting full code (giving the resident Cardiopulmonary Resuscitation CPR- An emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) and Do Not Resuscitate (DNR-do not provide life-saving measures) on the resident's care plan for one sampled resident (Resident #27) out of 15 sampled residents. The facility census was 56 residents. Review of the facility's Advance Directives Policy, dated [DATE], showed: -The facility respected a resident's advance directive and complied with the resident's wishes expressed in the advance directive. -Upon admission the admission staff obtained a copy of a resident's advance directive. -A copy of the resident's advance directive was included the resident's medical record. -Advance directive was a written preference regarding treatment options. -If the resident had an advance directive the facility obtained a copy of the document and put it in the resident's medical record. -The Interdisciplinary Team (IDT) reviewed advance directives with the resident or responsible party on an annual basis, to ensure the directive still reflected the wishes of the resident. -Changes or revocations of the advance directive was communicated to the attending physician. -The resident's care plan was updated to reflect the changes. 1. Review of Resident 27's face sheet, undated, showed: -The resident was diagnosed with Chronic Obstructive Pulmonary Disease (COPD- a condition involving constriction of the airways and difficulty or discomfort in breathing), chronic kidney disease (a gradual loss of kidney function over time) and major depressive disorder (a mood disorder that caused a persistent feeling of sadness and loss of interest). -The resident had a legal guardian (a person who looked after and was legally responsible for someone who was unable to manage their own affairs). -The resident was a full code. Review of the resident's electronic health record (EHR) uploaded documents showed the resident had a DNR dated [DATE]. Review of the resident's Full Code cover sheet, dated [DATE], showed: -The resident wished to have CPR performed. -There was verbal consent obtained from the resident's guardian. Review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated [DATE], showed: -The resident scored a 15 on the Brief Interview for Mental Status (BIMS --This showed that the resident was cognitively intact. Review of the resident's care plan, dated [DATE], showed: -DNR at resident's request would be honored. -The resident wished to be a full code. -Paper placed in the chart reflected the wishes for a full code. Review of the resident's physician orders showed: -On [DATE] at 2:27 P.M. the resident was shown as full code. -On [DATE] at 9:43 A.M. the resident was shown as DNR. -On [DATE] at 2:40 P.M. the resident was shown as full code. During an interview on [DATE] at 9:00 A.M., Certified Nurse's Assistant (CNA) A said: -He/She checked the physician orders or the EHR for a resident's code status. -He/She was unaware if the resident was a full code or not. During an interview on [DATE] at 9:12 A.M., Registered Nurse (RN) A said: -He/She was pretty sure the resident had a DNR. -He/She had to look it up in the computer. -He/She went by the physicians order. -Every care plan meeting the team addressed the residents code status. -They also ensured the code status still met the wishes of the guardian or resident. -Code status was in the care plan. -Every resident had a code status. During an interview on [DATE] at 10:55 A.M., the resident said: -He/She was a full code and wanted CPR performed. -He/She clarified he/she wanted CPR and was not to be considered DNR. During an interview on [DATE] at 10:45 A.M., the MDS coordinator said: -When the resident was readmitted after a hospital stay, he/she had to have the code status updated. -The care plan was reviewed and updated as well. -There was a whole care plan meeting when he/she returned to the facility. -The social worker or the Director of Nursing (DON) updated him/her then he/she updated the care plan. -He/She verified code status on the physician orders. -He/She reviewed and agreed the resident's care plan had both full code and DNR during the interview. -He/She called the guardian yesterday and found out the resident was a full code. -He/She was going to revise the care plan immediately. During an interview on [DATE] at 12:04 P.M., the DON said: -He/She found a resident's code status in the top ribbon of the EHR face sheet screen. -It should also be in the care plan. -Code status documents were also to be uploaded under documents in the EHR. -Code status was reviewed quarterly or with care plan meetings. -If a resident was a full code status, they should not have an uploaded DNR. -He/She would expect staff to go by physician orders for code status. -He/She would not expect the care plan to say the resident was a full code and a DNR. -When a DNR was revoked then a document stating the revocation was uploaded in documents. -When uploaded they were titled a revoked DNR. -The resident had a revoked DNR and now wished to be a full code.

Based on interview and record review the facility failed to follow their policy to conduct Criminal Background Checks (CBC) for new employees, not having on the policy to check the Nurses Aide (NA) Registry (a data base that provided the list of eligible nursing assistants who can be employed by long-term care facilities as health workers) for all employees prior to hire, and not completing a check of the NA Registry for two sampled employees (Employee B and Employee F) out of ten sampled new employees. The facility census was 56 residents. Review of the facility's Staff Screening policy, dated 10/24/22, showed: -Prior to employment the facility verified and documented or obtained a copy of the following information: --Previous/current employer regarding work history, allegations of abuse against residents, employees, or others. --Criminal Background Checks. --National Sex Offender Public Website. --Office of Inspector General Exclusion Screening. --State exclusion screening, if applicable. --Current licenses and certifications. --References and disclosure of information. -The facility did not employee an individual who was found guilty of abuse, neglect, exploitation or mistreatment or misappropriation of property by a court of law or who had a finding in the state nursing aide registry concerning abuse, neglect or exploitation or mistreatment or misappropriation of property, or had a disciplinary action in effect taken against his/her professional license. 1. Review of the facility's list of employees hired since the facility's last annual survey showed: -Employee B was hired on 12/18/23. -Employee F was hired on 7/17/23. 2. Review of Employee B's Federal Indicator tracking sheet showed he/she did not have a NA registry check completed. 3. Review of Employee F's Federal Indicator tracking sheet showed: -He/She had a NA registry check completed 7/19/23. --This was two days after his/her hire date. 4. During an interview on 4/5/24 at 9:00 A.M., the Business Office Manager (BOM)/Human Resources (HR) said: -He/She was responsible for completing the NA registry for new hires. -He/She was responsible for completing the background checks for new hires. -He/She started the background checks when he/she received notification of a new employee. -Employees were not supposed to start working until all background screenings including EDL checks and NA Registry checks were completed. -Employee B had interviewed and was available to start work immediately and the facility started Employee B before he/she had the chance to complete the background process. -He/She normally did NA registry checks before new employees started working. -He/She had a checklist to follow to be sure all backgrounds were completed before they started working on the floor. -Sometimes they slipped through the cracks. -Employee F started working on 11/1/23. During an interview on 4/5/24 at 12:01 P.M., the Director of Nursing (DON) said: -The NA registry check should be completed before new employees started working. -The BOM/HR was responsible for completing the NA registry backgrounds. -All staff should have a NA registry screening.

Based on observation, interview and record review, the facility failed to provide treatment/services, equipment, supplies or assistance to maintain and improve range of motion (ROM) and mobility for one sampled resident (Resident #38) reviewed for ROM out of 15 sampled residents. The facility census was 56 residents. Review of the facility policy titled Range of Motion Exercises dated 10/24/22 indicated: -Staff used a physician order to deliver ROM exercises to residents. -The exercises were used to prevent/decrease contractures and increase ROM for a joint. 1. Review of Resident #38's undated face sheet indicated he/she had the following diagnoses: -Cerebral infarction (stroke). -Dysphasia (impairment in the production of speech resulting from brain disease or damage). -Hemiplegia and hemiparesis following cerebral infarction affecting the left side (paralysis of the left side of the body). -Muscle weakness. Review of the resident's admission orders showed an order for a left arm splint dated 2/1/24 with no end date. Review of the resident's Interdisciplinary Rehabilitation Screening form dated 2/14/24 signed by the Director of Rehabilitation (DOR) lacked documentation of functional joint motion and contractures. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) 2/21/24 showed the resident had: -A limited range of motion. -Received no physical or occupational therapy during the look back period. -Received no restorative therapies. Review of the resident's admission MDS Care Area Assessment (CAA) for pain dated 2/27/24 listed the resident as having contractures. Review of the resident's Physician Order Sheet (POS) dated April 2024 indicated a lack of orders for services, equipment, or assistance that would maintain or improve the resident's ROM status. Review of the resident's current, undated care plan showed a lack of documentation for ROM status or interventions. Observation on 4/1/24 at 10:14 A.M., showed the resident had: -A dependent left hand with fingers contracted toward the wrist. -No devices or equipment in place to maintain a neutral hand position. -An inability to move the left side of his/her body. During an interview on 4/1/24 at 10:14 A.M., the resident said: -He/she did not receive any therapy or exercise by facility staff. -He/she once had a splint to keep the left hand in a neutral position and prevent worsening of contracture, but the splint never came from his/her previous facility. Observation on 4/4/24 at 8:12 A.M., showed the resident had: -A dependent left hand with fingers contracted toward the wrist. -No devices or equipment in place to maintain a neutral hand position. -An inability to move the left side of his/her body. During an interview on 4/4/24 at 11:35 A.M., the DOR said: -The resident was not on therapy services. -A resident with contractures would have benefited from a splinting device or restorative therapies to prevent worsening of contractures. -A resident with hemiplegia should have had therapies for ROM. -A previously ordered medical device should have been continued after admission. During an interview on 4/5/24 at 12:11 P.M., the Director of Nursing (DON) said: -He/she expected orders from the previous facility to be reviewed by a physician and continued if appropriate. -He/she expected the resident would have been evaluated and treated by the therapy department upon admission. -He/she expected a resident with hemiplegia and/or contractures would have received treatment to maintain or improve ROM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's monthly pharmacy Drug Regimen Review (DRR) recommendations were reviewed and acted upon by the physician, for one sampled resident (Resident #29), out of 15 sampled residents. The facility census was 56 residents. Review of the facility's policy titled Drug Regimen Review dated 10/24/22 showed: -The pharmacist was responsible for reviewing each resident's medication regimen at least once a month to identify irregularities and to identify clinically significant risks and/or actual or potential adverse consequences which may result from or be associated with medications. -The pharmacist was responsible for reporting any irregularities to the Attending Physician, the facility's Medical Director, and the Director of Nursing (DON), and these reports must be acted upon. -The pharmacist performing the Drug DRR will review the residents' medical records to appropriately monitor the medication regimen and verify the medication each resident is taking is clinically indicated. -The pharmacist will note in the residents' medical records that the pharmacy medication review regimen was completed. -If no irregularities were identified during the review, the pharmacist included a signed and dated statement to that effect. -The pharmacist will report any irregularities such as unnecessary drugs (which include but are not limited to excessive dosage, excessive duration, inadequate monitoring, inadequate indications for use or adverse consequences of use) to the facility's Medical Director, Director of Nursing, and the Attending Physician. -Irregularities must be addressed in a separate, written report. The report will include the resident's name, the relevant drug, and the irregularity the pharmacist identified. -The report will be submitted within three business days of review, unless the irregularity is an emergent issue requiring immediate action. If the irregularity is emergent, the Attending Physician will be contacted as soon as practicable from the time the irregularity is identified. -The Attending Physician will respond to any irregularities reported by the pharmacist by reviewing the irregularities and documenting in the resident's medical record that the irregularity has been reviewed, and what, if any, action has been taken to address it. -If no action has been taken, the Attending Physician must document his/her rationale. -Documentation by the Attending Physician must occur within 30 days of issuance of the pharmacist's report, unless the irregularity is an emergent issue requiring immediate action. -The Medical Director and DON will also review the pharmacist's report if any irregularities are identified. -The DON was responsible for following up with the Attending Physician, as indicated 1. Review of Resident #29's admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with following diagnoses: -Cerebral Infarction (stroke). -Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body) following stroke affecting the left non-dominant side. -Bipolar disorder (a form of mental illness associated with episodes of mood swings ranging from depressive lows to manic highs). -Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of the resident's Pharmacist Consultant Note dated 3/22/23 at 5:31 P.M., showed: -See report for any noted irregularities and/or recommendations. -No reports were found in the resident's medical record for this note. -No physician response was found in the resident's medical record. Review of the resident's Pharmacist Consultant Note dated 4/27/23 at 6:53 P.M., showed: -See report for any noted irregularities and/or recommendations. -No reports were found in the resident's medical record for this note. -No physician response was found in the resident's medical record. Review of the resident's Pharmacist Consultant Note dated 9/1/23, no time noted, showed: -The resident was taking both Ticagrelor and Apixaban both are blood thinning medications. -Evaluate if both blood thinning medications were necessary. -Please clarify If both were to be continued. -Please have staff monitor closely for abnormal bleeding/bruising. -The Physician discontinued the Ticagrelor. -There was no order, by the Physician, to monitor closely for abnormal bleeding or bruising while on a blood thinner. Review of the resident's Physician's Order Summary (POS) dated April 2024 showed no order to monitor closely for abnormal bleeding or bruising while on a blood thinner. During an interview on for 4/5/24 at 12:03 P.M. the DON said: -The pharmacist reviewed medications monthly. -The pharmacist emailed the recommendations to him/her. -He/She would give the pharmacist recommendations report to the physician to review and sign off on. -The physician gave the report with his/her acceptance or rejection and rational back to him/her. -He/She would make sure any new orders or changes were put into the POS. -The physician should respond to the pharmacist recommendations whether he/she agreed or disagreed and sign that he/she had received it within 30 days of receiving it. -If no response then he/she kept following up with physician until a response was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two sampled residents (Resident #25 and #51) received dental services for broken teeth out of 15 sampled residents. The facility census was 56 residents. Review of the facility's policy, Dental Services dated October 24, 2022 showed: -It was the responsibility of each staff member within the nursing department to ensure good oral care for each resident. -An assessment of the oral cavity and teeth was to have been preformed upon admission and as necessary. -Observe mouth for any adverse conditions such as bleeding, swelling, unusual mouth odor or any complaint of pain or discomfort. -Note any such condition in the resident's chart. -Report problem to the charge nurse. -Refer and or assist the resident to obtain dental services as indicated for routine and emergency dental care including making appointment for the resident, if needed or requested and arranging transportation to and from the dentist's office. -Routine services include but were not limited to; -Annual inspections. -Dental cleaning, fillings, and x-ray as needed. -Smoothing of broken teeth. -Emergency dental services include but were not limited to; -Broken , damaged teeth, or dentures. 1. Review of Resident #25's face sheet showed he/she was admitted on [DATE] with the following diagnose of moderate protein-calorie malnutrition (the state of inadequate intake of food). Review of the resident's undated care plan showed: -He/She had a self care performance deficit. -He/She required set up assistance to eat. -He/She was at risk for nutritional problem or potential nutrition problem. -There were no dental related issues noted in any of the resident's care plans. Review of the resident's Dental/Oral Assessment, dated 2/15/24 showed: -He/She had his/her own teeth both upper and lower. -He/She did not have any dentures. -He/She did not have any pain or discomfort. -The form was electronically signed by the physician. Review of the resident's Dental/Oral Assessment, dated 3/8/24 showed: -He/She had his/her own teeth both upper and lower. -He/She did not have any dentures. -He/She did not have any pain or discomfort. -The form was electronically signed by the physician. Review of the resident's Dental/Oral Assessment, dated 3/12/24 showed: -He/She had his/her own teeth both upper and lower. -He/She did not have any dentures. -He/She did not have any pain or discomfort. -He/She did not have any signs of infection. -The form was electronically signed by the physician. Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment toll completed by the facility for care planning) dated 3/8/24 showed: -His/Her Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating he/she was cognitively intact. -He/She needed set up help for oral hygiene. -He/She was at risk for malnutrition. -Did not show any dental issues. Review of the resident's Physician's Order Sheet (POS) dated March 2024 showed there was no order to see a dentist. Observation on 4/1/24 at 1:34 P.M. showed: -The resident had most of his/her teeth missing. -He/She had a couple of whole teeth. -The rest of the resident's teeth were broken. During an interview on 4/1/24 at 1:35 P.M. the resident said: -Most of his/her teeth were broken. -His/Her teeth needed to be pulled and he/she needed to be fitted for dentures. -He/She had not seen a dentist since he/she had been admitted to the facility. -He/She had told the nurse he/she would like to be seen by the dentist as it hurt to chew. -No one at the facility had said anything to him/her about seeing a dentist. 2. Review of Resident #51's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis need for assistance with personal cares. Review of the resident's Dental/Oral assessment dated [DATE] showed: -He/She had his/her own teeth. -He/She had one tooth on the top. -He/She had two teeth on the bottom. -He/She did not have dentures. -The assessment was electronically signed by the physician. Review of the resident's quarterly MDS dated [DATE] showed: -His/Her BIMS score was 15 out of 15 indicating he/she was cognitively intact. -He/She had no dental issues. -He/She was independent with oral cares. Observation on 4/1/24 at 11:44 A.M. during initial tour showed the resident: -Was missing most of his/her teeth. -Had many teeth that were broken. During an interview on 4/1/24 at 11:44 A.M. the resident said: -He/She would like to see a dentist. -He/She has been afraid of the dentist in the past but now it was time to do something. -He/She would like to have his/her teeth pulled. -He/She would like to have dentures. Review of the resident's undated care plan showed he/she required supervision/limited assistance with oral cares. During an interview on 4/2/24 at 11:59 A.M. Certified Medication Technician (CMT) A said: -He/She had watched the resident take his/her medications. -He/She did not know if the resident had any problems with his/her teeth. -The Social Service Director (SSD) was responsible for making appointments for residents to see the dentist. -If a resident had broken teeth, they should see a dentist. During an interview on 4/2/24 at 12:01 P.M. the Assistant Director of Nursing (ADON) said: -He/She did not know if the resident had any problems with his/her teeth. -He/She had not looked in the resident's mouth. -The charge nurse would have been responsible to make an appointment for the resident to see the dentist. -The residents should see a dentist every three months. -A dentist was at the facility last month. -The resident had not seen the dentist. -He/She did not know anything about the resident having broken teeth or wanting dentures. During an interview on 4/2/24 at 12:04 P.M. Certified Nursing Assistant (CNA) E said: -There used to be a place on the computer to chart oral cares or any issues with someone's teeth. -If a resident had missing teeth the staff should have charted it. -If staff did oral hygiene with the resident it should have been charted. -Last year in July a new company took over with a new computer system. -The corporate staff was still working on the computer system. -The admission assessment had a place to chart an assessment but it is not there now. -There was no documentation about missing or broken teeth on the resident's chart. -The resident did not have any teeth. -Currently there was no where on the chart to document oral cares or tooth issues. -He/She had spoke to the new company maybe two months ago about charting dental or oral cares. During an interview on 4/2/24 at 1:40 P.M. the SSD said: -He/She had been working on getting a dental visit with a new company for the residents for the last few months. -There was no date for the resident to see a dentist at this time. During an interview on 4/5/24 at 12:00 P.M. the Director of Nursing (DON) said: -He/She would have expected nursing staff to know if a resident had dentures or missing any teeth. -The CNAs when they were doing oral cares should have assessed the resident's teeth daily. -A resident's teeth should have been assessed quarterly for the care plan. -If a resident had broken teeth they should have been seen by a dentist. -If a resident would like to have dentures a referral to a dentist should have been made. -A dentist had been to the facility twice in the last six months. -Social Services would put the resident on a list to see the dentist. -A resident should have been reviewed at least quarterly for cares. -The DON was responsible to audit to ensure the physicians see the residents. -If a resident had dental issues it should have been in the resident's care plan. -The Interdisciplinary Team should have ensured the resident's care plans were updated quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #38's admission MDS dated [DATE] showed he/she: -admitted with an amputation of the left leg above the knee. -Received scheduled and as needed pain medications during the lookback period. -Reported pain almost constantly. -Frequently had pain that effected sleep and day to day activities. Review of the resident's MDS Care Area Assessment (CAA) for pain dated 2/27/23, showed he/she: -Had diseases and conditions that may cause pain including heart conditions, peripheral vascular disease (reduced blood flow in the arms and legs), neurological conditions, musculoskeletal conditions, and gastrointestinal conditions. -Would have pain addressed in the care plan to slow or minimize decline. Review of the resident's POS 4/4/24 showed orders for: -Acetaminophen (a medication for pain) 650 milligrams (mg) by mouth every six hours as needed for pain. -Gabapentin (a medication to treat nerve pain) 100 mg three times daily. -Lidocaine patch (a patch that is applied to the skin for pain) daily to the amputation site. -Hydrocodone (A narcotic pain medication) 5-325 mg three times a day for pain. -Hydrocodone 5-325 mg every six hours as needed for pain. -Voltaren (a gel applied to the skin to relieve pain) apply to the amputation site at bedtime and every 6 hours as needed for pain. Review of the resident's current, undated care plan accessed 4/4/24, showed: -The resident was at risk for pain. -Interventions included administering analgesia per orders and anticipating the resident's need for pain relief. -A lack of documentation related to the resident's current pain status including frequency, type and location of pain, non-pharmacological pain interventions and history of chronic pain. 4. Review of Resident #47's Quarterly MDS 2/28/24 showed he/she: -Had pressure ulcers to the feet. -Was at risk for developing pressure ulcers. -Was being treated with: --A pressure reducing device for chairs. --A pressure reducing device for bed. --A turning/repositioning program --Nutrition/hydration supplementation --Pressure ulcer care including application of dressings and ointments. Review of the resident's Weekly Wound Observation Tool dated 3/25/24, showed he/she had: -A pressure ulcer to the left lateral/medial (outer) 5th toe acquired 2/24/24. -A pressure ulcer to the right heel acquired 2/24/24. -A pressure ulcer to the left heel acquired 1/30/24. -A pressure ulcer to the left great toe acquired 1/30/24. Review of the resident's POS dated 4/4/24 showed orders for: -An air loss mattress for prevention of pressure ulcers. -Nutritional supplementation for prevention/healing of pressure ulcers. -Pressure ulcer skin treatments to both heels, the left great toe, and the left outer foot. Review of the resident's current, undated care plan accessed 4/4/24, showed: -The resident had a potential impairment to skin integrity. -The resident had three unstageable ulcers to the left foot. -A lack of documentation for the pressure ulcer to the right heel. 5. During an interview on 4/5/24 at 12:04 P.M., the DON said: -The IDT was responsible for updating care plans. -Care plans should have been updated quarterly with MDS completion and on an as needed basis. -The MDS Coordinator audited care plans for accuracy. -Regarding Resident #29: --He/She should have had a care plan that indicated the resident had a pressure ulcer and showed the location(s), treatment(s), and been updated to reflect changes as they were made. -Regarding Resident #18: --He/She was his/her own person and checked himself/herself out and left to smoke outside on his/her own. --He/She was supposed to be supervised while on facility grounds. --He/She should not be helped by another resident while smoking. --His/Her care plan should indicate if he/she was educated on safe smoking and if he/she was non-compliant with who assisted him/her. --He/She would expect his/her most recent smoking assessment and the care plan to have the same information. -Regarding Resident #38: --He/She should have had a care plan that addressed his/her pain status, location, frequency, treatment, and response to treatment. 2. Review of Resident #18's quarterly MDS dated [DATE], showed: -The resident scored a 15 on the Brief Interview for Mental Status (BIMS). --This showed that the resident was cognitively intact. -The resident's diagnoses included: Multiple Sclerosis (MS- a potentially disabling disease of the brain and spinal cord causing communication problems between the brain and the rest of the body), lack of coordination and reduced mobility. -NOTE: Section J of the MDS did not indicate the resident smoked. Review of the resident's Smoking assessment dated [DATE], showed the resident required supervision while smoking. Review of the resident's Smoking Assessment, dated 1/2/24, showed the resident required supervision while smoking. Review of the resident's comprehensive care plan, dated 1/4/24, showed: -The resident was a smoker. -The resident required supervision while smoking. -The resident needed assistance with putting out cigarettes. -The resident needed assistance with ashes. Review of the resident's Smoking Assessment, dated 3/28/24, showed the resident was safe to smoke without supervision. Observation on 4/1/24 at 11:12 A.M., showed the resident was in his/her wheelchair with a cigarette in his/her mouth. Another resident took the cigarette out of his/her mouth. A staff person lit a new cigarette and placed it in the resident's mouth. Another resident then took the cigarette out of the resident's mouth again and threw it away. Observation on 4/3/24 at 11:11 A.M., showed: -The resident was smoking on the smoking patio. -A staff person lit a cigarette for the resident. -The resident was in his/her wheelchair with a cigarette hanging out of his/her mouth with approximately an inch long ash on the end. --No ashes observed on the residents sweatshirt. -A staff person came to up to the resident and removed the cigarette butt from the resident's mouth then assisted him/her in lighting a second cigarette. -The resident smoked most of the cigarette without handling it with his/her fingers, using just his/her lips. -Another inch long ash fell on the resident's shirt. --He/She did not brush it off, no staff or residents assisted. -The resident continued to smoke the second cigarette showing no signs of distress, again not handling it with his/her fingers. -Ashes from second cigarette fell on the shirt again. -Another resident came over to the resident and took the cigarette out of his/her mouth. During an interview on 4/3/24 at 9:00 A.M., Certified Nurse's Assistant (CNA) A said: -The resident was a smoker. -He/She was unaware if the resident needed assistance with smoking. -The resident received assistance with eating because his/her hands and arms did not work well enough to feed himself/herself. -Staff supervised the smokers in the smoking area but they were not CNA's. -The resident had MS and received assistance eating. -He/She was unaware of what staff supervised the smokers. During an interview on 4/3/24 at 9:12 A.M., Registered Nurse (RN) A said: -The resident was a smoker. -The resident was his/her own person and chose to smoke on his/her own and was allowed to smoke on his/her own outside of the facility. -He/She told the resident it was not safe to smoke without supervision. -He/She had seen holes on the resident's shirts, and he/she had educated the resident on the safety aspect. -The resident chose to have other residents help him/her while smoking. -The resident refused to wear a smoking apron. -Designated smoke times were all supervised, but the residents were able sign out and go outside and to smoke on their own. During an interview on 4/4/24 at 8:31 A.M., the Medical Records/CNA said: -The resident required assistance with eating because his/her hands and arms did not work well enough to feed himself/herself. During an interview on 4/4/24 at 8:40 A.M., the resident said: -His/Her left arm was dead and he/she had no ability to move it. -His/Her right arm had some mobility, but he/she was unable to move his/her hand and had no gripping strength. -He/She needed assistance smoking and sometimes resident's helped him/her. During an interview on 4/4/24 at 10:17 A.M., the Activities Director said: -There was a smoking schedule and staff were assigned to supervise. -Nursing was assigned in the evening, during the day it was dietary, activities, and housekeeping. -Staff were in-serviced on the smoking procedure, which included monitoring the residents. -Each department also trained their staff who supervised smoking. -There was no list of residents who required additional supervision. -Everyone watched everyone. -There was no list of residents who required a smoking apron. --He/She thought there were two residents who were to wear a smoking apron, the resident was one of the two. -The resident refused the smoking apron 98% of the time but it was offered. -Smoking aprons were kept at the nurses station. During an interview on 4/4/24 at 10:45 A.M., the MDS Coordinator said: -They tried to make care plans specific. -The resident was independent with smoking. -He/She had not done a MDS on the resident yet. -Corporate was aware of discrepancies between care plans and the MDS. -If there was conflicting information on the care plan then staff looked at the physician orders, or asked the Director of Nursing (DON). Based on interview and record review, the facility failed to ensure one sampled resident's (Resident #29) care plan was updated to reflect an unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed); failed to ensure one sampled resident's (Resident #18) care plan was updated to reflect requiring assistance / supervision with smoking; failed to ensure one sampled resident's (Resident #38) care plan was updated to reflect his/her current pain level, frequency, and interventions; failed to ensure one sampled resident's (Resident #46) care plan reflected all pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) were addressed with current status and interventions/treatments out of 15 sampled residents. The facility census was 56 residents. Review of the facility's policy titled Care Planning dated 10/24/22 showed: -The Facility's Interdisciplinary Team (IDT) would develop a Baseline and/or Comprehensive Care Plan for each resident. -The care plan served as a course of action where the resident (resident's family and/or guardian or other legally authorized representative), resident's Attending Physician, and IDT work to help the resident move toward resident-specific goals that address the resident's medical, nursing, mental and psychosocial needs. -Each resident's comprehensive care plan would describe the following: --Services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. --Any services that would be required but are not provided due to the resident's exercise of rights, which includes the right to refuse treatment. --The resident's goals and desired outcomes. Review of the facility's policy titled Pressure Ulcer Prevention dated October 24, 2022, showed: -The facility will identify residents at risk for pressure ulcers and provide care and services to promote the prevention of pressure ulcer development. -The licensed nurse should complete a Braden Scale Assessment (a standard tool for assessing pressure ulcer risk) upon admission, and quarterly to identify residents at risk for skin breakdown. -The licensed nurse will conduct a skin assessment for a resident upon admission, readmission, weekly, and as needed. -The results of the weekly skin assessment should to be documented in the medical record and may be documented using the Weekly Skin Inspection form. -The licensed nurse should develop a care plan specific to the resident's risk factors such as moisture control, pressure reduction, positioning, mobility, and nutrition in consultation with the following: --Attending physician. --Interdisciplinary Team (IDT)-Skin committee. --Registered Dietician. --Director of Rehabilitation Services. -Nursing staff should monitor interventions for effectiveness and resident tolerance. -The care plan will be revised as indicated. -Certified Nursing Assistants (CNA) should inspect the resident's skin during Activities of Daily living (ADL) care and report unusual findings to the licensed nurse. -CNA's should complete body checks on resident's shower days and report unusual finding to the licensed nurse -The licensed nurse should document effectiveness of pressure ulcer prevention techniques in the resident's medical record on a weekly basis. Review of the facility's Smoking by Residents policy, dated 10/24/22, showed: -Residents who wanted to smoke were assessed for their ability to smoke safely. -A Licensed Practical Nurse (LPN) provided the Safe Smoking Assessment. -A smoking care plan was created for the resident. -If clothing was observed with burn holes the resident must wear a smoking apron (an apron made from flame retardant material which prevented burns in clothing and kept hot ashes from burning the skin). 1. Review of Resident #29's admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with following diagnoses: -Cerebral Infarction (stroke). -Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body) following stroke affecting the left non-dominant side. -Muscle wasting and apathy (is characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 1/2/2024 showed: -Risk for pressure ulcer. -One or more unhealed pressure ulcers. -One unstageable pressure ulcer due to coverage of the wound bed by slough. Review of the resident's care plan dated 3/28/24 showed there was no care plan for wounds or risk for wounds and/or skin breakdown. Review of the resident's Physicians Order Summary (POS) dated April 2024 showed: -Weekly skin assessment every evening shift on Friday. -Refer to an outside wound care company for evaluation and treatment. -Wound care treatment every day shift for wound healing: --Cleanse wound on left heel with hypochlorous acid (helps disinfect and provide treatment for wounds), and pat dry. --Cover wound bed with nickel thick Santyl (an enzyme ointment that helps remove dead skin tissue and aids in wound healing by removing damaged tissue from chronic skin ulcers). --Cover Santyl with Calcium Alginate (CaAlg-a type of dressing that can absorb 20 times its weight in exudate [fluid that leaks out of blood vessels into nearby tissues] and soak up loose debris from a wound bed) cut to the size of wound bed. --Cover with bordered gauze (a type of wound dressing) and change daily and PRN if soiled. During an interview on 4/4/24 at 10:45 A.M., the MDS Coordinator said: -The resident should have a care plan for any type of wound if he/she had one. -Corporate made changes to the care plans when something was found. -They tried to make care plans specific.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of the facility's list of employees hired since the facility's last annual survey showed: -Employee G was hired on 11/11/23. -Employee J was hired on 11/1/23. Review of Employees G's TB tracking sheet showed: -Employee G had the first step TST administered on 10/30/23 and read on 11/2/23. --Employee G had the second step TST administered on 11/13/23 with no date read dated recorded. Review of Employee J's TB tracking sheet showed: -Employee J had the first step TST administered on 11/4/23 and read on 11/7/23. --Employee J had the second step TST administered on 11/18/23 and read on 11/21/23. 7. During an interview on 4/5/24 9:00 A.M., the Business Office Manger (BOM)/Human Resources (HR) Director said: -The Assistant Director of Nursing (ADON) administered and tracked employee TB. -Employee J started working 11/1/23. -Employee J started working before everything cleared. During an interview on 4/5/24 at 9:41 A.M., the ADON said: -New employees were usually hired directly after the interview. -He/She gave the new employees their first TST directly after the interview. -He/She told them to come back in two to three days to have it read then they could start working. -All new employees received their TST. -New employees started working the day the first TST was read with a negative result. -Employees were not allowed to start working until the first TST was read. -He/She documented on a form and tracked it in a binder. -If he/she was unavailable another nurse read the results. -He/She remembered giving and reading Employee G's TST but could not find the documentation of the reading. -He/She was not working when Employee J hired. -Employee J started before the TST was administered. During an interview on 4/5/24 at 12:04 P.M., the DON said: -TST's were completed before employees started working. -Once a TST was read with a negative result, the employee was able to start working. -The ADON was responsible for tracking employee TST. -He/She expected staff to have the first TST completed and read prior to working. Based on observation, interview, and record review, the facility failed to ensure residents were screened for Tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for four sampled residents (Resident #29, #38, #47, and #50) out of 15 sampled residents; and failed to properly screen new employees for TB for two sampled employees, (Employee's G and J) out of ten sampled new employees prior to hire. The facility census was 56 residents. Review of the facility's policy (Tuberculosis - Screening) dated October 24, 2022 showed: -The facility screened residents for TB upon admission, readmission, and as indicated thereafter. -Any resident without documentation receives a baseline (two-step test) upon admission. -When the first TB test is negative, a follow-up TB test is administered one to three weeks after the initial test was read. -The Attending Physician screens new admissions for possible signs and symptoms of TB. -Facility staff were given a screening for TB. -NOTE: the policy did not address any TST procedures or details for employees. Review of 19 Code of State Regulations 20-20.100 TB testing for residents and workers in long-term care facilities, paragraph three, showed: -All new long-term care facility employees who work ten or more hours per week should have the first of two TB skin tests (TST) within one month prior to starting employment in the facility. -The results of TST should be read 48-72 hours from administration. -If the initial TST result is zero to nine millimeters (mm) in duration, the second test should be administered as soon as possible within three weeks after employment begins, unless documentation is provided indicating a two-step TST was completed in the past and at least one subsequent annual test within the past year. 1. Review of Resident #29's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's TB tests showed: -There was no documentation of a TB test being given before 12/17/19. -Step one of the admission two step TB test was administered on 12/17/19. --There was no documentation the test was read. --There was no documentation a second test was given. -Step one of the annual two step TB test was administered on 1/6/20. --There was no documentation the test was read. --There was no documentation a second test was given. -Step one of the annual TB test was administered on 12/21/21. --There was no documentation the test was read. -Step one of the annual TB test was administered on 12/9/22. --There was no documentation the test was read. Review of the resident's Physician's Order Sheet (POS) dated April 2024 showed the following order for a TB test or chest x ray annually. 2. Review of Resident #38's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's TB tests showed: -Step one of the admission two step TB test was administered on 2/14/24 --There was no documentation the test was read. -The second step was administered on 3/26/24 and read on 3/28/24. -The second step was administered more than three weeks after the first TB test was administered. Review of the resident's POS dated April 2024 showed the following order: -TB testing per community protocol. -Initiate TB testing protocol, dated 2/14/24. 3. Review of Resident #47's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's TB tests showed: -Step one of the admission two step TB test was administered on 1/16/24. --There was no documentation the test was read. -The second step was administered on 3/26/24 and read on 3/28/24. -The second step was administered more than three weeks after the first TB test was administered. Review of the resident's POS dated April 2024 showed the following order: -TB testing per community protocol. -Initiate TB testing protocol, dated 1/16/24. 4. Review of Resident #50's face sheet showed he/she was admitted to the facility on [DATE]. Review of the resident's two step TB tests showed: -Step one of the two step TB test was administered on 3/26/24 and read on 3/28/24. --There were no TB test documented prior to the 3/26/24 test. --There was no documentation that a chest x-ray had been completed at the tie of admission. Review of the resident's POS dated April 2024 showed the following order: -TB testing per community protocol. -Initiate TB testing protocol, dated 6/16/23. 5. During an interview on 4/5/25 at 10:00 A.M. the Infection Preventionalist (IP) said: -He/She had just started in the IP position. -Many of the residents did not have two step TB tests done per protocol. -Newly admitted residents should have had their first TB test done within the first day or so of admission. -72 hours after administration of the first TB test, the test should have been read. -The date and results of the TB test should have been documented on the immunization tag. -A second TB test should have then been administered within three weeks of the first TB test. -The date and results of the second TB test should have been documented on the immunization tag. -The person who was in his/her position previously was not keeping track of the residents' TB tests. -Many of the residents' TB tests were not done timely or documented correctly. During an interview on 4/5/24 at 12:00 P.M. the Director of Nursing (DON) said: -Residents should have their first TB test done as soon as they were admitted . -Residents should have a TB test read within 72 hours of administration. -Residents should have had a second TB test administered one to three weeks after the first test was read. -He/She or the IP were responsible for ensuring the TB tests were given to the residents timely. -The TB test and results should have been documented in the immunization log on the computer. -Many of the TB tests were missed in the past.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide 12 hours of training/in-services to include behavior and dementia training, abuse and neglect prevention, and resident rights, for three Certified Nursing Assistants (CNA B, C, & D). The facility census was 56 residents. A policy was requested and not provided by the time of exit. 1. Review of the list of current employees who were CNA's showed three CNA's were chosen for records to be reviewed for the required 12 hour training/in-services. 2. Review of CNA B's training record dated April 2023 to April 2024 showed he/she was hired on 8/27/21 and worked as needed (PRN) and attended the following in-services: -On 4/28/23 nurses meeting (did not say what the topic was). -On 5/19/23 COVID changes, Transmission Based Precautions (TBP), New owner. -On 7/31/23 abuse prevention and prohibition program, interact-stop and watch early warning tool. -He/She did not receive training/in-services for the following: --Abuse and Neglect. --Behavior and dementia training. --Resident rights. --Care of the cognitively impaired resident. -CNA B did not receive the required 12 hours of training/in-services from April 2023 through April 2024. 3. Review of CNA C's training record dated April 2023 to April 2024 showed he/she was hired on 5/4/20 and attended the following in-services: -On 5/19/23 COVID changes, Transmission Based Precautions (TBP), New owner. -On 6/16/23 accessing [NAME] (name brand of an informational system used as a quick reference for nursing staff, resident transfer method. -On 6/17/23 care for a specific resident (the in-service sheet did not list what the cares for the resident were). -On 6/18/23 notification processes of grievances, complaints, and events. -On 7/31/23 abuse prevention and prohibition program, interact-stop and watch early warning tool. -September meeting (did not show a date) agenda showed the following areas that were covered: --Skin and Pressure Ulcers, reporting, care and prevention. --Bedbound- turn every two hours, low air loss mattress, bunny boots, rashes, red areas, skin tears. -On 9/5/23 the in-service sheet showed bed hold policy, hydration, skin pressure ulcers, reporting, care and prevention. -In October 2023 (no day listed) transfer of residents. -On 12/26/23 stop and watch (acronym for observing and reporting changes in a resident's condition). -February 2024 meeting agenda had dates of 1/6/24, 1/7/24, and 1/8/24 on it included: --Toileting residents between meals. --Call lights. --Skin issues- let the wound nurse know immediately. -On 2/2/24 monthly nursing meetings (no specific topics listed). -On 3/20/24 abuse and neglect, infection prevention ad control program, hand hygiene -On 4/1/24 enhanced barrier precautions. -CNA C did not receive training/in-services for the following: --Behavior and dementia training. --Resident rights. --Care of the cognitively impaired resident. 4. Review of CNA D's training record dated April 2023 to April 2024 showed he/she was hired on 10/21/19 and attended the following in-services: -On 4/28/23 -nurses meeting (did not say what the topic was). -On 5/19/23 COVID changes, Transmission Based Precautions (TBP), new owner. -On 6/17/23 care for a specific resident (the in-service sheet did not list what the cares for the resident were). -On 6/18/23 notification processes of grievances, complaints, and events. -September meeting (did not show date) agenda showed the following areas that were covered: --Skin and Pressure Ulcers, reporting, care and prevention. --Bedbound- turn every two hours, low air loss mattress, bunny boots, rashes, red areas, skin tears. -On 9/5/23 bed hold policy, hydration, skin pressure ulcers, reporting, care and prevention. -CNA D did not receive training/in-services for the following: --Abuse and Neglect. --Behavior and dementia training. --Resident rights. --Care of the cognitively impaired resident. -CNA D did not receive the required 12 hours of training/in-services from April 2023 through April 2024 when he/she was terminated. 5. During an interview on 4/5/24 at 12:03 P.M., the Director of Nursing (DON) said: -CNA's should receive 12 hours of in-service/training a year. -In-services are held monthly at a minimum. -He/She had a calendar of what topics were covered for each month. -Topics that should be covered at least once a year were: --Abuse and neglect safety. --Dementia and Alzheimer's safety. --Fire safety. --Resident falls. --Any other resident needs that would come up. --In-services were taught by the DON, the Assistant Director of Nursing (ADON) or other department heads depending on the topic presented. --Staff should sign the in-service attendance sheet. --In-services were about an hour each. --Human Resource staff should be monitoring the in-service hours for the CNA's. --PRN staff should attend each month's in-service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer/formulate advanced directives (documents that allow one to communicate their health care preferences when decision-making capacity is lost) and/or a Durable Power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) for two sampled residents (Resident #50 and #16) out of 16 sampled residents. The facility census was 64 residents. Record review of the facility policy Advanced Directives revised 11/2017 showed: -Prior to or upon admission written information would be given to the resident/family regarding formulating advanced directives and request any current advanced directives. -The advanced directives would be reviewed annually. 1. Record review of Resident #50's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Stroke. -Dysphagia (inability or difficulty swallowing). -Aphagia (loss of ability to produce or comprehend language due to brain injury). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning) dated 5/6/22 showed the resident was severely cognitively impaired. Record review of the resident's Care Plan revised 7/14/22 showed: -The resident had a communication problem related to a stroke. -The resident would be able to make his/her basic needs known. -The staff were to monitor the effectiveness of his/her communication strategies while using a communication board. Record review of the resident's medical record on 8/2/22 showed no information regarding the right to formulate advanced directives or any advanced directives. 2. Record review of Resident #16's admission Record showed he/she was admitted to the facility on [DATE]. Record review of the resident's quarterly MDS dated [DATE] showed the resident was moderately cognitively impaired. Record review of the resident's Care Plan revised 7/14/22 showed: -The resident's advanced directives would be respected. -The staff were to educate and/or designate a representative on advanced directives quarterly and as needed. During an interview on 8/1/22 at 11:47 A.M. the resident said: -He/she thought a family member was his/her DPOA. -He/she was unsure about having any advanced directives. Record review of the resident's medical record on 8/2/22 showed no information regarding the right to formulate advanced directives or any advanced directives. 3. During an interview on 8/4/22 at 1:19 P.M. the admission Coordinator said: -The right to formulate advanced directives was not being completed upon admission. -The form was not being utilized as part of the admission packet but going forward it would be. -He/she was just informed to include it in the packet. -The Social Services Designee (SSD) would be responsible for annual follow up for the right to formulate advanced directives. -The SSD was out on medical leave. During an interview on 8/4/22 at 1:45 P.M. Registered Nurse (RN) B said: -All advanced directives were reviewed during care plan meetings. -The SSD was responsible for completing advanced directives along with the Director of Nursing (DON). During an interview on 8/05/22 10:24 A.M. the Director of Nursing (DON) said: -He/she normally was responsible for advanced directives. -The admission Coordinator was responsible for obtaining the residents' advanced directives upon admission. -The SSD was responsible for reviewing the residents advanced directives or offer the right to formulate advanced directives but was unsure how often this was completed. -He/she reviewed the residents' advanced directives during care plan meetings.

Based on interview and record review, the facility failed to provide a completed Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) at the termination of Medicare Part A benefits for two sampled residents (Resident #47 and #43) out of two sampled residents who remained in the facility upon discharge from Medicare Part A services. The facility census was 64 residents. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09 showed: -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 has 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. 1. Record review of Resident #47's SNF Beneficiary Protection Notice Review showed: -The resident's last covered day for Medicare Part A services was 7/22/22 and was staying at the facility for long term care. -A SNFABN was not provided to the resident by the facility because the resident did not receive any non-covered benefits. 2. Record review of Resident #43's SNF Beneficiary Protection Notice Review showed: -The resident's last covered day for Medicare Part A services was 7/9/22 and was staying at the facility for long term care. -A SNFABN was not provided to the resident by the facility because the resident did not receive any non-covered benefits. 3. During an interview on 8/5/22 at 8:25 A.M. the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) Coordinator said: -He/she was responsible for completing all liability notices to the residents. -The notices were provided to the resident three to four days prior to discharge off of Medicare Part A services. -The residents were not receiving any other benefits that Medicare previously paid for after the Medicare Part A discharge. -He/she was unaware the SNFABN was required to be provided to the resident. During an interview on 8/05/22 10:24 A.M. the Director of Nursing (DON) said: -The MDS Coordinator was responsible for providing the SNFABN notices. -He/she expected the MDS Coordinator to provide the SNFABN forms to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for three sampled residents (Resident #8, #38, and #51) out of 16 sampled residents. The facility census was 64 residents. Record review of Policy titled Care Plans-Comprehensive-F 656, F 657, F 658 dated 9/2012 and revised 11/2017, and last approved on 5/2022 showed: -An individualized comprehensive person centered care plan that included measurable objectives and time frames that met the resident's medical, nursing, mental, and psychological needs was developed for each residents. -Person Centered Care: A focus on the resident as the locus of the community and supported the resident in making their own choices and having control over their daily lives. -The care plan would describe the resident's nursing, medical, physical, mental, and psychosocial prefaces. 1. Record review of Resident #51's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's smoking evaluation completed on 1/04/2022 that showed the resident could smoke safely. Record review of the resident's admission Minimum Data Sheet (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning purposes) dated 1/10/22 showed the resident currently used tobacco. Record review of the resident's care plans 7/14/22 showed no care plan addressing the resident's smoking status. Record review of the resident's smoking evaluation completed on 4/4/22 and 7/4/22 showed the resident could smoke safely. Observations on 8/2/22 at 11:21 A.M. and 1:24 P.M., and on 8/3/22 at 11:30 A.M. showed the resident in the smoking area smoking a cigarette. During an interview on 8/03/22 at 9:32 A.M., Registered Nurse (RN) A said: -Residents who smoke should have a care plan addressing smoking. -He/She said the resident did smoke. During an interview on 8/3/22 at 9:33 A.M., RN B if said: -A resident who smokes should have a care plan for smoking. -He/She said the resident smoked regularly. During an interview on 8/3/22 at 9:35 A.M., MDS Coordinator said: -If a resident smoked, it would be on the care plan. -He/She was responsible for formulation of care plans and the revisions of the care plans. -He/she would verify all the residents that smoked had it care planned. -He/She knew the resident smoked. -The nurses informed him/her about the residents and what needs to be changed in the care plans. 2. Record review of Resident #8's admission Record showed he/she was admitted to the facility on [DATE]. Record review of the resident's quarterly MDS dated [DATE] showed the resident was cognitively intact. Record review of the resident's Care Plan revised 7/17/22 showed no care plan for smoking. Record review of the resident's Smoking Evaluation dated 7/19/22 showed the resident could smoke cigarettes independently while being supervised by staff. Observation on 8/2/22 at 11:10 A.M. showed the resident was smoking a cigarette outside in the resident smoking area while attended by a staff member. 3. Record review of Resident #38's admission Record showed the resident was admitted to the facility on [DATE]. Record review of the resident's Order Summary Report showed a physician's order dated 1/21/22 for Citalopram Hydrobromide tablet 10 milligrams (mg) give 20 mg by mouth daily for depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Record review of the resident's annual MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Had received an antidepressant medication seven out of seven days prior to the assessment. Record review of the resident's Care Plan revised 7/14/22 showed no care plan for depression. 4. During an interview on 8/2/22 at 1:24 P.M., Social Services Director said the smoking evaluations are used to determine what added safety interventions are needed for the resident like a smokers bib. During an interview on 8/3/22 10:09 A.M., Certified Nursing Assistant (CNA) A said residents who smoked would have something on the care plan about smoking. During an interview on 8/4/22 at 1:45 P.M. Registered Nurse (RN) B said MDS Coordinator was responsible for care planning and updating care plans. During an interview on 8/5/22 at 8:22 A.M. the MDS Coordinator said: -He/she was responsible for all MDS's and care planning. -If a resident smoked cigarettes or had depression, these should be on the care plan. -He/she was not aware Resident #8 smoked cigarettes and there was no smoking care plan for the resident. -Resident #38 should have a care plan for depression. During an interview on 8/5/22 at 10:23 A.M., Director of Nursing (DON) said: -The MDS Coordinator was responsible for creating care plans and updating care plans. -If a resident smoked cigarettes or had depression, a care plan should have been created.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate supervision while eating and drinking for one sampled resident (Resident #50) out of 16 sampled residents who had a diagnosis of dysphagia (inability or difficulty swallowing). The facility census was 64 residents. A policy was requested related to supervised eating but it did not contain information on residents with swallowing issues. 1. Record review of Resident #50's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Stroke. -Dysphagia. -Aphagia (loss of ability to produce or comprehend language due to brain injury). Record review of the resident's physician's Order Summary Report (OSR) dated 3/15/22 showed a order for a regular diet with mechanical soft chopped meat and regular thin liquids. Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning) dated 7/14/22 showed the resident: -Was severely cognitively impaired. -Needed the limited assistance of one staff member during meals. -Had loss of liquids and solids from his/her mouth while eating and drinking. -Had coughing or choking during meals or when swallowing medications. Record review of the resident's care plan revised 7/14/22 showed the resident: -Had a diagnosis of dysphagia. -Needed to be monitored by staff for choking, coughing, drooling, holding food in his/her mouth, and several attempts at swallowing while eating and drinking. Observation on 8/1/22 at 10:45 A.M. showed: -The resident was seated on the side of his/her bed with his/her tray table in front of him/her. -He/she had six white hand towels on the floor. -Oatmeal and toast were on the floor and on the tray table. -The resident was excessively drooling from his/her mouth and would wipe the drool off. -The resident took a drink of orange juice from a specialized lidded cup and had a wet cough. -There were no staff present in the room. Observation on 8/1/22 at 12:40 P.M. showed: -The resident was seated on the side of his/her bed with his/her tray table in front of him/her. -The resident had chipped beef with gravy, mashed sweet potatoes, mixed vegetables, a roll and a specialized lidded cup of lemonade. -The resident had peanut butter crackers in a cup. -The resident was eating the peanut butter crackers and drinking. -The resident had a wet cough while eating and drinking. -There were no staff present in the room. Observation on 8/2/22 at 8:12 A.M. showed: -The resident was seated on the side of his/her bed with his/her tray table in front of him/her. -The resident had hash browns, chopped sausage, eggs, cream of wheat, and toast. -The resident was trying to eat a slice of toast and had a large piece of toast hanging out his/her mouth while excessively drooling from the left side of his/her mouth. -The resident had a wet coughing while eating and drinking. -There were no staff present in the room. During an interview on 8/3/22 at 7:56 A.M., Certified Nursing Assistant (CNA) B said: -The resident preferred to eat in his/her room. -He/she was unaware the resident had dysphagia. -The resident excessively drooled. -The resident normally would eat in his/her room and staff members do not sit with the resident while he/she was eating and drinking. During an interview on 8/3/22 at 8:26 A.M., CNA C said: -He/she would pass the meal tray to the resident and he/she would eat alone in his/her room. -The resident could eat independently and no one watched him/her eat. -He/she was not aware the resident had swallowing issues. -He/she has not seen him/her eat because he/she passed the tray then left the resident alone. During an interview on 8/3/22 at 9:57 A.M., CNA A said: -The staff would deliver a meal tray to his/her room and he/she would eat independently. -Staff do not stay in the room with him/her while the resident was eating and drinking. During an interview on 8/3/22 at 10:06 A.M., Registered Nurse (RN) A said: -The resident loved to eat food. -The resident had swallowing issues and was at high risk for aspiration. -The staff do not sit in the room with him/her while eating and drinking to monitor the resident. -The resident choked and coughed when he/she ate and drank and would cough on his/her own saliva. During an interview on 8/3/22 at 12:09 P.M. the MDS Coordinator said: -The resident normally would eat in dining room and staff assisted and monitored. -The staff do hover over him/her when he/she eats in the room. -The staff should have him/her go to the dining room for meals so he/she could be monitored due to his/her dysphagia. During an interview on 8/4/22 at 8:18 A.M. Licensed Practical Nurse (LPN) A said: -The resident refused to do pureed and was his/her own responsible party. -The resident was doing better with swallowing. -He/she can swallow pills without pocketing the pills in his/her mouth. -He/she was going to the dining room for monitoring and was allowed to eat in his/her room per his/her choice. -He/she would listen in when passing medications and was not alarmed by his/her eating and drinking. During a telephone interview on 8/4/22 at 10:16 A.M. the Registered Dietician (RD) said: -He/she came in from the hospital and the referral that showed the resident chose a regular diet even though he/she had severe dysphagia. -The staff should be watching him/her in his/her room while eating. -He/she assumed the staff would monitor the resident while eating. During an interview on 8/05/22 10:24 A.M. the Director of Nursing (DON) said: -If a resident had dysphagia they should eat in the dining room. -If a resident with dysphagia ate meals in his/her room and he/she should be monitored at all times by staff members. -The resident always had fluids and snacks in his/her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address the resident's behaviors, which included verbal aggression and physical aggression for one sampled resident (Resident #50) out of 16 sampled residents. The facility census was 64 residents. Record review of the facility policy Behavioral Health Services revised 11/2017 showed: -The facility should assess the resident for needed behavioral health services upon admission, quarterly and with a change of condition. -Apply a person centered approach to care which included knowledge of each individual's daily routine, lifelong patterns, interests, preferences and choices. -Interact and communicate with the resident in a manner that promoted mental and psychosocial well-being. 1. Record review of Resident #50's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Stroke. -Dysphagia. -Aphagia (loss of ability to produce or comprehend language due to brain injury). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning) dated [DATE] showed the resident: -Was severely cognitively impaired. -Did not have mood or behavior issues. Record review of the resident's Nursing Progress Noted dated [DATE] showed: -The resident was withdrawn and refusing medications. -When staff talk to the resident about these concerns, the resident would spell home on his/her sign board. -The resident was his/her own responsible party. -The resident had a friend come and visit two days ago and stated he/she might want to take the resident to live with them. Record review of the resident's Nursing Progress Note dated [DATE] showed: -The resident was angry and pounding on walls and doors. -The resident's family member's funeral was tomorrow and the resident was not attending. -The resident had been throwing his/her walker (a light, portable framework used for support and assistance in walking by a person with a gait impairment) and swinging it at staff members. Record review of the resident's significant change MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Did not have mood or behavior issues. Record review of the resident's care plan revised [DATE] showed the resident would put himself/herself on the floor and make loud noises. Record review of the resident's Nursing Progress Note dated [DATE] showed: -The resident was seen in the hallway and placed himself/herself on the floor. -Night shift had reported the resident had went for coffee first thing this morning and was angry. -The resident had been throwing his/her walker and pushing on the outer door. -The resident calmed as soon as his/her coffee arrived with no further behaviors. Record review of the resident's Nursing Progress Note dated [DATE] showed: -The staff had attempted to move the resident's clothes back into the resident's closet and explain this was a safety risk and the dresser could tip over. -The resident pushed the dresser over and staff started to clean this up. -The resident became angry and started throwing items at staff members including his/her walker. -The staff were continuing to monitor the resident's behavior. Observation on [DATE] at 8:32 A.M. showed: -The resident was in his/her room on his/her bed. -He/she had a paper letter board. -The resident was asked how he/she was doing today. -The resident spelled out home on his/her paper letter board. During an interview on [DATE] at 7:56 A.M. Certified Nurses Assistant (CNA) B said: -The resident can get angry. -He/she screams and hollers even though he/she cannot talk. -He/she can make verbal noises. -He/she pulled his/her dresser over and hit the bed/mattress. -We try to calm him/her down and he/she sometimes would get worse so we try to leave him/her alone. -Then we go back and check on him/her, he/she fixed his/her own attitude. -He/she had a mood change recently and the resident wants to go home. -The resident was aware of things but cannot communicate. -His/her family would come and he/she thinks they were coming to get him/her. -Family visits increase his/her anger. -This started after his/her family member died, more behaviors and wanting to go home. During an interview on [DATE] at 8:26 A.M. CNA C said: -One time, the resident came out here and threw a walker and hit a staff member with the walker. -The staff try to talk to him/her and calm him/her down, take him/her back to his/her room. -He/she felt he/she could not speak and this was very frustrating to him/her. -He/she could not write so we use word sheets, coffee, pain, and he/she can point at those. -After his/her family member died, he/she was pretty upset because he/she did not go to the funeral because the family did not take him/her. -There was confusion and the family thought he/she did not want to go to the funeral. -The resident wanted to go home and not be here. -The family would say on the phone we were working on that, but felt the family was just saying this without intent to take him/her home. During an interview on [DATE] at 10:06 A.M. Registered Nurse (RN) A said: -The resident has behaviors of throwing things at myself and another nurse, hit walls, pictures, turned over his/her dresser. -His/her behaviors were mainly towards staff and not towards residents. -This all started when family stated months ago that they would take him/her home. -The family stopped answering him/her. -The resident can make noises with mouth but no words and this frustrated the resident. -He/she was not aware of any behavioral health services or psychiatric involvement. -The Director of Nursing (DON) and Social Services were responsible for putting these services in place for the resident. During an interview on [DATE] at 1:45 P.M. RN B said: -The resident had mental health issues and should have mental health services related to behaviors for him/her. -The resident wanted to go home. -He/she had friends that offer to take him/her home or pick him/her up and go somewhere for a while. -The friends did not show up and the resident would get upset and have behaviors. -He/she was not aware of any behavioral health services or psychiatric services for the resident. During an interview on [DATE] 10: 24 A.M. the DON said: -If high behaviors, the Social Services Designee (SSD) and he/she were responsible for assisting with psychiatric services and behavioral health services. -The resident had behaviors and mood issues. -The psychiatric services and behavioral health services should have been put in place for the resident. -The SSD was out on medical leave.

Based on interview and record review, the facility failed to ensure the Employee Disqualification List (EDL), Criminal Background Checks (CBCs), and/or the Nurse Aide (NA) Registry were completed prior to hire, re-hire, and/or periodically, and to ensure potential employees did not have a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prior to hire for ten out of ten sampled employees. The facility census was 64 residents. Record review of the facility's Employee Background Checks (Screening) F606 policy last revised 11/2017 showed: -Background checks are completed per state guidelines on each employee. -The facility would not knowingly employee individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties and/or, have findings entered into the State nurse registry or licensing authorities any knowledge of actions by court of law during background checks or ongoing employment. -All employees would have CBCs, State and Federal required background checks. 1. Record review of Employee A's employee file showed: -The employee was hired on 5/15/17 as laundry personnel. -The Family Care Safety Registry (FCSR - an organization that is accepted by the Department of Health and Senior Services (DHSS) for completing, both, the CBC and EDL pre-employment checks)) check was completed on 12/4/13 with the prospective employee not being found in the DHSS Database, indicating that the prospective employee was not registered with the FCSR. -The EDL check was completed on 12/4/13 with no other EDL checks recorded prior to the current EDL check on 8/1/22. -The FI check was not completed. 2. Record review of Employee B's employee file showed: -The employee was hired on 6/1/22 as a Licensed Practical Nurse (LPN). -The FI check was not completed. 3. Record review of Employee C's employee file showed: -The employee was hired on 2/11/22 as a LPN. -The EDL check was completed on 2/9/22 with no other EDL checks recorded after that date. -The FI check was not completed. 4. Record review of Employee D's employee file showed: -The employee was hired on 7/13/22 as housekeeping personnel. -The FI check was not completed. 5. Record review of Employee E's employee file showed: -The employee was re-hired on 6/9/21 as housekeeping personnel. -The FCSR check was completed on 11/30/15 with the prospective employee not being found in the DHSS Database, indicating that the prospective employee was not registered with the FCSR. -The CBC check was completed on 12/1/15. -The EDL check was completed on 7/8/22 with no other EDL checks recorded prior to that date. -The FI check was not completed. -No documentation that the facility completed a new FCSR, CBC, EDL, or FI prior to the employee's re-hire date. 6. Record review of Employee F's employee file showed: -The employee was re-hired on 10/19/21 as a Certified Nursing Assistant (CNA). --NOTE: the employee never started when they originally completed the checks. Employee changed his/her mind and waited later to start work. -FCSR check was completed on 7/10/20 with the prospective employee being listed with the agency. -The EDL check was completed on 7/10/20 with no other EDL checks recorded after that date. -The FI check was not completed. -No documentation that the facility completed a new FCSR, CBC, EDL, or FI prior to the employee's re-hire date. 7. Record review of Employee G's employee file showed: -The employee was re-hired on 6/10/22 as dietary personnel. --NOTE: the employee never started when they originally completed the checks. Employee changed his/her mind and waited later to start work. -FCSR check was completed on 10/14/21 with the prospective employee being listed. -The FI check was not completed. -No documentation the facility completed a new FCSR, CBC, EDL, or FI prior to the employee's re-hire date. 8. Record review of Employee H's employee file showed: -The employee was hired on 5/10/22 as a CNA. -The FI check was not completed. 9. Record review of Employee I's employee file showed: -The employee was hired on 4/25/22 as a Registered Nurse (RN). -The EDL check was completed on 4/20/22 with no other EDL checks recorded after that date. -The FI check was not completed. 10. Record review of Employee J's employee file showed: -The employee was re-hired on 5/25/22 as a CNA. --NOTE: the employee never started when they originally completed the checks. Employee changed his/her mind and waited later to start work -The EDL check was completed on 5/13/21 with no other EDL checks recorded prior to or after that date. -The FI check was not completed. -No documentation the facility completed a new FCSR, CBC, EDL, or FI prior to the employee's re-hire date. 11. During an interview on 8/3/22 at 10:11 A.M. the Business Office Manager said: -He/she was responsible for doing the background screenings for all employees. -He/she did not document the date he/she did the FI checks. -He/she did not always do background screenings prior to hiring employees, sometimes they were completed by the Director of Nurse (DON). -He/she was unaware that the quartler EDLs would have to be completed on every staff member. -He/she did not complete quarterly EDL checks on the facility employees and did not know whether or not the DON completed them. During an interview on 8/3/22 at 11:56 A.M. the DON said: -Background screenings were completed by their Business Office Manager. -All staff should have FI checks before working at the facility, not just the nurse aides. -Employment should only be offered pending the criminal and other background screening results. -She believed that all staff should have FI checks before working at the facility, not just the nurse aides. -He/she was unaware that the quarterly EDLs would have to be completed on every staff member and did not complete them. -He/she did not know whether or not the BOM completed quarterly EDL checks on the facility employees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to the extent practicable, to include residents and their representatives in the care planning process and to conduct care plan conferences to include resident/resident representative participation for four sampled residents (Residents #38, #16, #20, and #22) out of 16 sampled residents. The facility census was 64 residents. Record review of the facility policy Comprehensive Care Plans revised 11/2017 showed: -The facility's care planning/Interdisciplinary team, in coordination with the resident, his/her family member or representative, developed and maintained a comprehensive care plan for each resident that identified the highest level of function the resident may be expected to obtain. -Assessments of residents were ongoing and care plans revised as information about the resident's conditions changes. 1. Record review of Resident #38's admission Record showed he/she was admitted to the facility on [DATE]: -Had the following diagnoses: --Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). --Anxiety disorder (a psychiatric disorder causing feelings of persistent anxiety). -Had a family member as his/her Durable power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known). Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 3/10/22 showed the resident was severely cognitively impaired. Record review of the resident's Care Plan dated 3/26/22 showed the resident had a DPOA as his/her responsible party. During a telephone interview on 8/1/22 at 12:24 P.M. the resident's DPOA said: -He/she had not been invited to care plan meetings. -He/she would like to have care plan meetings to be informed of the resident's care and medications. 2. Record review of Resident #16's admission Record showed he/she was admitted to the facility on [DATE]: -Had the following diagnoses: --Heart disease and heart failure. --Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Had a DPOA as his/her responsible party. Record review of the resident's annual MDS dated [DATE] showed the resident was severely cognitively impaired. Record review of the resident's Care Plan revised 7/14/22 showed the resident's advanced directives would be respected. During an interview on 8/1/22 at 11:47 A.M. the resident said: -He/she was not sure if care plan meetings were held. -He/she had not been to a care plan meeting. 3. Record review of Resident #20's admission Record showed: -He/she was admitted to the facility on [DATE]. -He/she had diagnoses of bipolar disorder (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). -His/her sibling was his/her a legal guardian (court appointed substitute decision maker). Record review of the resident's quarterly MDS dated [DATE] showed: -He/she was cognitively intact. -He/she had no hallucinations (perceptual experiences in the absence of external stimuli) and no delusions (misconceptions or beliefs that are firmly held, contrary to reality). Record review of the resident's care plan revised on 5/11/21 showed he/she had a substitute decision maker. During an interview on 8/11/22 at 11:44 A.M. the resident's legal guardian said: -He/she received a letter from the facility regarding an upcoming care plan meeting for the resident that was mailed on 6/14/22. -The notice said the resident's care plan meeting would be held on 7/14/22 and to call if he/she wanted to attend the care plan meeting. -He/she called the facility repeatedly and was not able to get anyone on the phone; when there was an answer it was an answering machine; he/she left several messages to call him/her back and no one returned his/her call. -He/she would like to have attended the resident's care plan conferences; giving input into the resident's care plan was very important to him/her. 4. Record review of Resident #22's admission Record showed: -He/she was admitted to the facility on [DATE]. -He/she had a diagnoses of schizophrenia (a serious mental illness that interferes with a person's ability to think clearly, understand what is real, manage emotions, make decisions and relate to others), dated 3/3/22. Record review of the resident's Orders Summary Sheet showed: -Mirtazapine (antidepressant medication) 7.5 milligrams (mg), give one tablet at bedtime for depression). -Invega Sustenna (antipsychotic medication) suspension prefilled syringe, 158 mg/milliliter (mL), inject 1.5 mL intramuscularly (IM-into a muscle) one time every month for psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), start date 4/1/22. Record review of the resident's significant change in status MDS dated [DATE] showed: -He/she was severely cognitively impaired. -He/she was sometimes understood and usually understood others. -He/she received antipsychotic and antidepressant medications daily. Record review of the resident's care plan, revised on 5/20/22 showed: -His/her antipsychotic medications were not addressed in his/her care plan. -His/her antidepressant medications were not addressed in his/her care plan. During an interview on 8/4/22 at 11:41 A.M. the resident said: -He/she did not know what a care plan meeting was. -He/she did not know if anyone had invited him/her to his/her care plan meeting. 5. During an interview on 8/4/22 at 1:45 P.M. Registered Nurse (RN) B said: -Care plan meetings were held quarterly and the MDS Coordinator was responsible for these. -Department heads should be involved including Activities, the Social Services Designee, (SSD), the Director of Nursing (DON) and some charge nurses. During an interview on 8/5/22 at 8:22 A.M. the MDS Coordinator said: -He/she was not involved with care plan meetings. -Care plan meetings were held by Activities, the SSD, and the DON but he/she did not go to care plan meetings. -The Activity Director sent out letters for care plan meetings for family and talked to the residents directly to invite them to care plan meetings. -Care plan meetings were monitored by the Activity Director and he/she was responsible for ensuring these were done. -There was confusion on who was supposed to attend and write notes for care plan meetings. During an interview on 8/5/22 at 8:42 A.M. the Activity Director said: -He/she was responsible for inviting residents and family members to care plan meetings every three months. -He/she sent letters to the family to invite them to the care plan meetings. -He/she would go to the residents' room to invite the resident to the care plan meeting and ask if they want to attend. -He/she would send a text message to the DON, Administrator, Dietary Manager, and Social Services Director (SSD) to let them know the date and time. -The DON was responsible for writing all notes in the resident's medical record the content of the care plan meeting. -Care plan meetings discussed all quality of care and quality of life including nursing care, food, activities and concerns. During an interview on 8/05/22 10:24 A.M. the DON said: -Care plan meeting included the SSD, the DON, Activity Director, Dietary Manager, and MDS Coordinator. -If a resident was on therapy, the therapist would attend. -The family and resident were notified of the care plan meetings by the Activity Director and then he/she would notify the department heads so they could attend. -He/she had started doing notes of care notes in the care plan notes. -He/she was responsible for competing the care plan meeting notes. -He/she expected care plans to be held quarterly for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure recommendations from the pharmacist for Gradual Dose Reduction (GDR) of psychotropic medications (drugs which affect psychic function, behavior, or experience) were acted upon or acted upon timely by the resident's physician for four sampled residents (Resident's, #33, #20 #50, and #38) out of 16 sampled residents. The facility census was 64 residents. Record review of Policy titled Tapering Medications and Gradual Dose Reduction-F 758 dated 9/2012 and revised 11/2017, and last approved on 5/2022 showed: -Tapering of medications and gradual dose reductions would be completed in consultation with the Attending Physician and Consultant Pharmacist and would be conducted per CMS guidelines. -The Consultant Pharmacist would consider tapering of medications or a gradual dose reductions as one approach to find an optimal dose or determine whether continued use of a medication benefited the resident. -Tapering would be per current CMS guidelines. -Resident who used antipsychotic (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis) drugs would receive gradual dose reductions, unless clinically contraindicated, per established state and federal guidelines. -Pertinent state and federal guidelines were as follows: Within the first year after a resident was admitted on antipsychotic medication, or after a resident had been started on an antipsychotic medication, the staff and practitioner would attempt a GDR in two separate quarters, unless clinically contraindicated. -After the first year, the facility would attempt a GDR at least annually, unless otherwise clinically contraindicated. 1. Record review of Resident #33's Face Sheet showed he/she was initially admitted to the facility on [DATE]. Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning purposes) dated 5/30/21 showed the resident: -Had received antianxiety medication (A drug used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness that may occur as a reaction to stress. Most antianxiety agents block the action of certain chemicals in the nervous system. Also called anxiolytic and anxiolytic agent) for seven day look back period prior to the assessment being documented. -Had received antidepressant medication (Antidepressants are prescription medicines to treat depression) for seven day Look back period prior to the assessment being documented. -Had a documented diagnosis of Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety) and Depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). Record review of the resident's Monthly Medication Review (MMR) dated 9/14/21 showed: -Resident was receiving Paroxetine (Selective Serotonin Reuptake Inhibitor (SSRI) It can treat depression, anxiety disorders, obsessive-compulsive disorder (OCD), and premenstrual dysphoric disorder (PMDD)) 20 milligram (mg) daily and the pharmacist recommended decreasing dose to 10 mg day for the GDR. -Resident was receiving Buspirone (used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety) 5 mg twice a day and the pharmacist recommended decreasing dose to 2.5 mg twice a day for the GDR. -Neither recommendation was accepted or declined by the resident's physician. Record review of the resident's September 2021 Medication Administration Report (MAR) showed: -The resident received Paroxetine 20 mg daily from 9/15/21 thru 9/30/21 15 out of 15 opportunities. -The resident received Buspirone 5 mg twice a day from 9/15/21 thru 9/30/21 30 out 30 opportunities. Record review of the resident's MMR dated 10/15/21 showed: -Resident was receiving Paroxetine 20 mg daily and the pharmacist recommended decreasing dose to 10 mg day for the GDR. -Resident was receiving Buspirone 5 mg twice a day and the pharmacist recommended decreasing dose to 2.5 mg twice a day for the GDR. -The resident's physician agreed to the recommendations on 10/28/21. Record review of the resident's October 2021 MAR showed: -The resident received Paroxetine 20 mg daily from 10/1/21 thru 10/26/21 26 out of 26 opportunities. -The resident received Buspirone 5 mg twice a day from 10/1/21 thru 10/26/21 52 out 52 opportunities. 3. Record review of Resident #50's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Stroke. -Dysphagia (difficulty swallowing foods or liquids). -Aphagia (loss of ability to produce or comprehend language due to brain injury). Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Did not have mood or behavior issues. -Received and antipsychotic medication seven days out of the last seven days prior to the assessment. Record review of the resident's Consultant Pharmacist's Medication Regimen Review dated 5/11/22 showed: -The resident had a physician's order for Seroquel 50 mg give three tablets by mouth at bedtime for-. -Please clarify the order to include indication for use. -There was no response from the physician. Record review of the resident's Consultant Pharmacist's Medication Regimen Review dated 6/9/22 showed: -The resident had a physician's order for Seroquel 50 mg give three tablets by mouth at bedtime for-. -Please clarify the order to include indication for use. -The physician discontinued the medication on 6/9/22. 4. Record review of Resident #38's admission Record showed he/she was admitted to the facility on [DATE] and had the following diagnoses: -Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). -Anxiety disorder . Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was severely cognitively impaired. -Received anti-depressant medication seven days out of seven days prior to the assessment. Record review of the Note to the Attending Physician/Prescriber dated 9/14/21 showed: -The resident was currently receiving Citalopram 20 mg daily (for depression). This medication has been in place since 8/25/20. -Please consider a Citalopram GDR to 10 mg daily. -On 11/2/21, the physician reduced the medication to Citalopram 10 mg daily. -The physician responded to the GDR request on 11/2/21 which was 49 days after the initial request. 5. During an interview on 8/3/22 at 11:07 A.M., Registered Nurse (RN) C said: -He/she was unsure who received the MMR. -He/she would have expected for the physician to act on pharmacy reviews in a timely manner which would be within a week. During an interview on 8/3/22 at 11:12 A.M., RN A said: -The DON got the MRR from the pharmacist and then gave it to the physician. -He/she would have expected recommendations to be followed up in a timely manner by the physician. -A timely manner would be within a week. During an interview on 8/05/22 10:24 A.M., the DON said: -Medications are to be reviewed every 30 days. -The physician would have addressed to the pharmacy recommendations within a week. -If the MMR was not filled out, he/she would ask the physician where it was and follow up on it. -The pharmacy reviews came from pharmacy to the DON and he/she gave them to the physician. -After the physician signs off on the recommendations, he/she the inputs the recommendations into the system. -He/she was responsible for GDR and MMR emails from the pharmacy. - The process was pharmacy emailed them to him/her. -He/she then prints them off and take the MMRs to the physician. -When the MMRs are returned from the physician, he/she would input the response in the electronic heath record of the resident. -The expected turn around time for MMR and GDR was seven days. 2. Record review of Resident #20's admission Record showed: -He/she was admitted to the facility on [DATE]. -He/she had diagnoses of bipolar disorder (a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). Record review of the resident's Order Summary Report showed an order for quetiapine (Seroquel - an antipsychotic medication) 400 mg, give one tablet one time daily for behavioral disturbance, dated 10/28/21. Record review of the resident's quarterly MDS dated [DATE] showed: -He/she was cognitively intact. -He/she had no hallucinations (perceptual experiences in the absence of external stimuli) and no delusions (misconceptions or beliefs that are firmly held, contrary to reality). -He/she received antipsychotic medications daily. Record review of the resident's Note to Attending Physician/Prescriber, dated 3/14/22 showed: -The resident received quetiapine 400 mg daily for behavioral disturbance. -During the first year in which the resident is admitted on a psychopharmacological medication (a medication that treats a mental illness/condition) or after the facility has initiated such a medication, the facility should attempt to taper (slowly lessen the dosage strength) the medication during at least two quarters (with at least one month between attempts), unless clinically contraindicated. -Please consider a dosage reduction to 300 mg daily OR document clinical rationale below (including risk/benefit) for continuing current dose. -The document provided a section for the Physician/Prescribe Response including boxes for Agree, Disagree, Other, blank area for comments, and a signature line and a date line for the physician's response, which were completely blank. Record review of the resident's quarterly MDS dated [DATE] showed: -He/she was cognitively intact. -He/she had no hallucinations and no delusions. -He/she received antipsychotic medications daily. Record review of the resident's Order Summary Report showed: -Seroquel 200 mg, give one tablet one time daily for bipolar disorder, dated 6/23/22. -Seroquel 50 mg, give one tablet one time daily for bipolar disorder, dated 6/23/22. Record review of the resident's Order Summary Report showed Seroquel tablet 300 mg, give one tablet in the evening for bipolar disorder, dated 7/31/22. During an interview on 8/5/22 at 10:03 A.M. the Director of Nursing (DON) said: -He/she knew in March, 2022 that the pharmacist had recommended a GDR for the resident's Seroquel. -He/she sent the recommendation to the resident's physician and did not get a response from the physician. -He/she had not followed up with the resident's physician to obtain his/her response to the pharmacist's recommendation for a GDR of the resident's Seroquel. -He/she should have followed up with the physician within about week to obtain the physician's response to the pharmacist's recommendation for a GDR of the resident's Seroquel. -The resident's GDR recommendation follow up did not get done because he/she had been working on staffing and resident care issues.

Based on interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases when the facility failed to properly screen new employees for tuberculosis ((TB) a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for five out of ten sampled new and continuing employees (Employees C, E, F, I and J) prior to and after their hire date per the facility policy. The facility census was 64 residents. Record review of the facility's, Tuberculosis, (TB) Employee Screening for F880, policy dated September 2021 showed the Employee Health Coordinator (or designee) would accept documented verification of two-step TST (TB skin test), BAMT (a TB test checks to see if you have been infected with Mycobacterium tuberculosis complex, which is the bacteria that causes tuberculosis (TB)), or chest x-ray results from the applicant within the preceding 12 months and/or arrange for all TB vaccinations initially and, if applicable, post-offer screenings, prior to the applicant having contact with residents and beginning work in their duty assignment position. A BCG (Bacille Calmette-Guerin, a vaccine for TB) from an applicant would be accepted by the Employee Health Coordinator but would still have an initial screening test. Record review of TB Screening, Testing and Treatment of U.S. Health Care Personnel on the Centers for Disease Control and Prevention's website showed instructions to repeat a TST (TB skin test) within one to three weeks after an initial negative TST. 1. Record review of Employee C's employment file showed: -He/she was hired on 2/11/22 which was his/her first day working on the floor. -Facility's records showed a one-step TB skin test was administered on 2/10/22 and read on 2/13/22. -There was no documentation provided of a two-step TB skin test being administered after his/her date of hire of 2/11/22. 2. Record review of Employee E's employment file showed: -He/she was hired on 6/9/21 which was his/her first day working on the floor. -Facility's records showed documentation of a one-step TB skin test administered after his/her date of hire of 6/9/21, on 6/16/21 and read on 6/18/21. -There was no documentation of a two-step TB skin test being administered prior to or after his/her date of hire of 6/9/21. 3. Record review of Employee F's employment file showed: -He/she was hired on 10/19/21 which was his/her first day working on the floor. -The employee had a first step TB skin test administered on his/her date of hire, 10/19/21 and read on 10/21/21. -Facility's records showed no documentation of a two-step TB skin test being administered prior to or after his/her date of hire of 10/19/21. 4. Record review of Employee I's employment file showed: -He/she was hired on 4/25/22 which was his/her first day working on the floor. -Facility's records showed documentation of a first-step TB skin test being administered after his/her date of hire of 4/25/22, on 5/2/22 and read on 5/5/22 with a follow-up two-step TB skin test administered on 5/17/22 and read on 5/19/22. 5. Record review of Employee J's employment file showed: -He/she was hired on 5/25/22 which was his/her first day working on the floor. -Facility's records documentation of a one-step TB skin test being administered of 5/23/22 and read on 5/25/22. -There was no documentation of a two-step TB skin test being administered prior to or after his/her date of hire of 5/25/22. 6. During an interview on 8/3/22 at 10:27 A.M., the Business Office Manager (BOM) said: -He/she was the person responsible for keeping the records of the staffs' TB records and thought the employees could complete their first TST while still in orientation. -The second TST should be completed one to three weeks after the first TST was read. -He/she oversaw the new employees and informed the employees when they needed to do their TSTs. -The nurse on duty was responsible and instructed to give the TB skin test. -Any nurse can read (check for swelling) the results 48 to 72 hours later. -Employee second TB skin test should be administered two to three weeks from the date when the first TB skin test was read. -There were other employee records maintained and kept by the employee's department supervisor. -Many times the new employee orientation took place with the department supervisors and he/she would not receive back a copy of their new employee TB screenings to place in their files. During an interview on 8/3/22 11:56 A.M., the Director of Nursing (DON) said: -The BOM oversaw the new employees and informed the employees when they needed to do their TSTs. -He/she would expect the first TST to be administered and read prior to hire. -He/she would expect the second TST to be administered within one to three weeks after the first TST. -Any nurse could administer and read the results of the TSTs. -Sometimes the TB records were not completed in a timely manner, but would verify that the system change of tracking new employee's TSTs with the BOM was in practice. -The change in the TST tracking system change partly involved keeping a calendar to keep track of the dates to administer the TST skin test to prospective employees and the dates to read them. During interview on 8/4/22 at 1:50 P.M., the Administrator said: -He/she would expect the first-step TB test to be given prior to the hire date with a followed-up, two-step administered in a timely manner if there was no documentation of a two-step being offered by the employee prior to his/her hire date. -He/she was aware of a new system of tracking the TSTs given to the prospective and new employees, but thought that it was working efficiently.

Based on interview and record review, the facility failed to develop a comprehensive and complete Emergency Operational Preparedness (EOP) program that included plans and procedures relating to the electrical power system where the critical safe devices, appliances and facility fixtures and systems were not listed as being supported by the essential electrical systems (EES) or generator. The lack of emergency operational ability and functionality of the facility would have a direct effect on the residents and staff in the event of a normal electrical supply being interrupted during an emergency or evacuation. This deficient practice potentially affects all residents, family, visitors, and staff who reside, use, visit, volunteer, or work in the facility's six facility smoke compartments. The facility census was 64 residents with a capacity for 98 residents. 1. Record review of the facility's Emergency Operations Plan (EOP) updated on 1/7/22 showed, in the event of an interruption of normal electrical power, no documentation of what would supply electricity to the following devices, fixtures and systems: -Lighting all entrances and exits. -Equipment to maintain the fire detection and alarm systems. -Extinguishing systems. -Life support systems. During an interview on 8/2/22 at 2:05 P.M., the Plant Operations Director (POD) said: -The Disaster Manual had been worked on and updated but it wasn't completely documented or finished. -There were two variations of the EOP manual - a thick one and a thinned out one. -The manuals have not been combined into one, but the Administrator and himself/herself were working on it. -Many pieces of the EOP needed to be updated. -Almost everything in the facility would operate and be functional when the generator is engaged, however, there was no documentation of the facility appliances or items that would have power supplied by the EES, but the Administrator and himself/herself were still working on incorporating it into the EOP. During an interview on 8/2/22 at 2:25 P.M., the Administrator said: -The EOP had been worked on and updated but it wasn't completely documented or finished. -There were two variations of the EOP manual - a thick one and a thinned out one. -The manuals have not been combined into one, but the Plant Operations Director (POD) and herself were working on it. -Many pieces of the EOP needed to be merged and converted into one manual. -The POD said almost everything in the facility would operate and be functional when the generator is engaged, however, he/she said there was no documentation or listing of the appliances or items that had power supplied by the EES, but was working on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident dignity by not providing a dignity bag to cover a resident's Foley catheter (a tube with retaining balloon passed through the urethra into the bladder to drain urine) while the resident was in his/her room for two sampled residents (Resident #40 and #197) and to ensure the resident's privacy curtain and window blinds were pulled closed during incontinent and wound care for one sampled resident (Resident #40) out of 16 sampled residents. The facility census was 55 residents. Record review of the facility Indwelling Urinary Catheter Policy revised date of November 2017 showed: -Cover the urine bag to provide privacy. -Drainage bag and tubing are to be kept off the floor. 1. Record review of Resident #40's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Anxiety disorder. -Pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral region (tailbone), unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough [necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy] and/or eschar (tan, brown or black) in the wound bed). -Bipolar disorder (mood disorders characterized usually by alternating episodes of depression and mania). -Major Depressive Disorder. Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/20/19 showed the resident: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. -Required extensive staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. -Had a urinary catheter and colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen). -Had no pressure ulcers or skin issues. Observation on 11/19/19 at 8:19 A.M., 11/20/19 at 8:40 A.M. and 9:01 A.M., showed: -The resident was in his/her room in bed. -His/her Foley catheter bag was hanging from the side of the bed without a dignity bag. -The resident's uncovered Foley catheter bag was visible from the hallway. Observation on 11/20/19 at 10:46 A.M. showed: -The resident's Foley catheter bag was hanging from the side of the bed, uncovered and visible from the hallway. -Certified Nursing Assistant (CNA) C and Licensed Practical Nurse (LPN) D performed catheter care for the resident. -CNA C and LPN D closed the resident's door, and without pulling the privacy curtain closed or closing the open window blind, uncovered the resident so his/her genitalia were visible, and assisted the resident with opening his/her legs to access the area between his/her legs. -CNA C and LPN D assisted the resident to turn to his/her side, exposing his/her buttocks so LPN D could perform wound care with the resident's privacy curtain not pulled closed and the window blinds open. -CNA C and LPN D assisted the resident to turn to lay on his/her back, and with the resident's bed linens pulled to the end of the bed and the resident's genitalia exposed, LPN D opened the door to exit the room, the resident was fully visible from the hallway. During an interview on 11/20/19 at 11:10 A.M., LPN D said: -The resident's blinds should have been closed before starting personal cares, exposing the resident, who could have been seen by anyone who was outside at the smokers patio. -He/She had not noticed the resident did not have a privacy curtain since the resident's bed was by the door and the door was closed. -The room had a privacy curtain that could be pulled to separate the resident from the resident who lived by the window. -He/She did not think the resident's catheter bag needed to be covered when he/she was in his/her room. -The resident's catheter was covered in a dignity bag when he/she was in his/her wheelchair out in the facility. During an interview on 11/20/19 at 11:23 A.M., CNA C said: -The resident's blinds should have been closed to prevent anyone at the smokers patio from seeing the resident exposed during cares. -He/She could have pulled the privacy curtain that separated the resident from the resident that lives on the side by the window, but he/she could not reach the chain that needed to be pulled to switch the tract the privacy curtain was on. -The resident should have been covered up before the door was opened since there was not a privacy curtain to prevent the resident from being exposed to anyone in the hallway. -He/She did not think the resident's catheter bag needed to be covered when he/she was in his/her room. -The resident's catheter was covered in a dignity bag when he/she was in his/her wheelchair out in the facility. Observation on 11/21/19 at 9:53 A.M. and 12:45 P.M. showed: -The resident was in his/her room in bed. -His/Her Foley catheter bag was hanging from the side of the bed without a dignity bag. -The resident's uncovered Foley catheter bag was visible from the hallway. 2. Record review of Resident #197's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system). -Pressure ulcer, unspecified stage. -Right below the knee amputation. -Left below the knee amputation. -Colostomy. -Major Depressive disorder. -Anxiety. -Paraplegia (loss of movement of both legs and generally the lower trunk). Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS of 15 out of 15. -Required total staff dependence for bed mobility, transfers, dressing, toileting, and personal hygiene. -Had a urinary catheter and colostomy. -Had Stage III pressure ulcer (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) and Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). Observation on 11/19/19 at 8:33 A.M., 11/20/19 at 1:26 P.M., 11/21/19 at 9:52 A.M. showed: -The resident was in his/her room in bed. -His/her Foley catheter bag was hanging from the side of the bed without a dignity bag. -The resident's uncovered Foley catheter bag was visible from the hallway. 3. During an interview on 11/21/19 at 2:55 P.M., the Director of Nursing (DON) and Administrator said: -A resident's Foley catheter bag should be in a dignity bag, even if the resident is in his/her room. -He/she expected staff to pull the privacy curtain closed and closed the window blinds before exposing the resident during personal cares and wound care. -He/she expected the residents who resided on the side of the room by the door to have a privacy curtain, and that privacy curtain should have been pulled closed to ensure the resident was not accidentally exposed if someone entered the resident's room. -He/she was not aware staff had to pull a cord to change the tract for the privacy curtain or that staff could not reach the cord in order to pull he curtain closed for resident's residing by the door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an authorization to manage Resident #35's funds from his/her legal guardian after that resident became a ward (a person who by reason of incapacity is under the protection of a court either directly or through a guardian appointed by the court-called also ward of court) of the public administrator and to obtain written authorization for Resident #3's hair styling. This practice potentially affected two out of four residents selected for the resident fund review process. The facility census was 55 residents. 1. Record review of the authorization forms (a form signed by the resident or the resident's responsible party to authorize the facility to manage the resident's money), for four selected residents, showed the absence of an authorization for Resident #35. During an interview on 11/20/19 at 9:10 A.M., the Social Service Designee (SSD) said: - There was not an authorization form for Resident #35. - The resident was admitted on [DATE], and - The resident signed up for funds shortly after that. 2. Record review of Resident #3's records, showed the resident spent $10 on each of the following dates, 8/29/19, 9/8/19, and 9/12/19 for a total of $30.00, and the absence of any signatures by the resident or the resident's designee for hair styling. During an interview on 11/20/19 at 937 A.M, the Business Office Manager (BOM) and the SSD agreed there were not signatures to authorize those expenses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and send a Third Party Liability (TPL) form (a form which is sent to MO Healthnet which gives an accounting of the remaining balance of that resident's funds in the resident trust account), which is required to be sent 30 days after the death of one deceased resident (Resident #1002) who died on [DATE]. This practice affected one resident (Resident #1002) of two deceased residents whose resident fund records were reviewed for the purpose of conducting the resident fund investigation for the completion of the TPL forms. The facility census was 55 residents. 1. Record review of Resident #1002's records showed: - The resident expired on [DATE]; and - The Resident had $10.00 in the system at the time of the review. During interviews on [DATE] at 11:18 A.M., the Social Service Designee (SSD) said: - The resident received Medicaid; and - He/she did not know what the TPL form was at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's current code status (whether the resident wanted life saving measures taken in the event of his/her heart stopped beating or he/she stopped breathing) was accurate and clear on the resident's Physician's Order Sheet (POS) for two sampled residents (Resident #13 and #198) out of 16 sampled residents. The facility census was 55 residents. 1. Record review of Resident #13's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Major Depressive disorder. -Anxiety. -Hepatitis C (a viral infection that attacks the liver). -Chronic kidney disease (CKD - gradual loss of kidney function over time). -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -The resident had a Do Not Resuscitate (DNR - do not perform chest compressions or artificial breathing in the case of an emergency; allow natural death). -The resident had a guardian. Record review of the resident's care plan dated [DATE] showed: -The resident was a full code status (all life saving measures are to be taken in the case of an emergency [Cardiopulmonary Resuscitation - CPR - an emergency life saving measure when the heart stops beating and breathing has stopped]). -A paper was placed on the resident's chart to reflect the resident's wish for a full code status. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated [DATE] showed the resident: -Was cognitively intact with a BIMS of 13 out of 15. -Was independent with bed mobility. -Required staff supervision for dressing, eating, toileting, and personal hygiene, -Required limited staff assistance for transfers. Record review of the resident's paper chart showed: -A sheet of paper that had Full Code in all capital, bold letters. -If he/she should stop breathing for any reason, it was his/her wish that the facility begin CPR and transport him/her to the hospital. -The form was dated [DATE]. -An Outside the Hospital Do Not Resuscitate Order (a standardized order form explaining the meaning of a DNR order signed by the resident and/or the resident's representative and the resident's physician) was not located on the resident's chart as of [DATE]. Record review of the resident's hospital discharge orders dated [DATE] showed the resident had a DNR/Do not intubate (DNI - no artificial breathing) status. Record review of the resident's Telephone Order Sheet (TOS) dated [DATE] showed: -The resident was readmitted to the facility. -The resident had a DNR/DNI status. -The order was signed by one nurse. -The order was not signed by the resident's physician as of [DATE]. Record review of the resident's [DATE] Physician's Order Sheet (POS) showed: -The resident had a Full Code status. -The resident's TOS dated [DATE] did not have the resident's desire for DNR/DNI transcribed to the POS. Record review of the resident's electronic medical record on [DATE] showed the resident had a DNR code status on the resident's profile screen. During an interview on [DATE] at 10:56 A.M., the resident said he/she wanted to be a full code status. During an interview on [DATE] at 11:05 A.M. Certified Nursing Assistant (CNA) D said: -According to the resident's electronic medical record, he/she had a DNR status. -According to the resident's paper medical record, he/she had a Full Code paper on his/her chart, meaning the resident was Full Code status. -He/She thought the resident may have had a recent change in code status, but with the conflicting papers, he/she was not sure what the resident's code status was. During an interview on [DATE] at 11:07 A.M., the Assistant Director of Nursing (ADON) said: -The resident had a TOS with an order for DNR dated [DATE]. -The order was not signed by the resident's physician, so it was not a valid order. -If the resident had a DNR order, it should have been signed before 14 days had passed. During an interview on [DATE] at 11:11 A.M., the Administrator and Social Service Designee said: -Per the resident's guardian, the resident was a DNR status due to being non-compliant at the hospital. -The resident's paper chart showed he/she had a Full Code status, but had a DNR order on his/her TOS dated [DATE] when he/she was readmitted to the facility. -They will search to see if a signed DNR form was received by the facility in the signed order forms from the physician received by the facility that day. 2. Record review of Resident #198's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses of peripheral neuropathy (damage to the nerves resulting in sensory loss in the extremities). Record review of the resident's Care Plan dated [DATE] showed no care plan for the resident's desired code status. Record review of the resident's [DATE] POS showed no documentation related to the resident's desired code status. Record review of the resident's electronic medical record showed he/she had a DNR status. Record review of the resident's paper medical records chart showed: -An Outside the Hospital Do Not Resuscitate Order signed by the resident on [DATE]. -The order was not signed by the resident's physician as of [DATE]. During an interview on [DATE] at 11:00 A.M. the resident said he wanted to have a DNR status. During an interview on [DATE] at 11:02 A.M., CNA D said: -The resident had a DNR order on his/her electronic medical record. -He/she also had an Outside the Hospital DNR order on his/her paper chart. -The resident's Outside the Hospital DNR was not signed by his/her physician. During an interview on [DATE] at 11:08 A.M., the Social Service Designee said: -A resident's code status is in both the electronic medical record and the paper medical record. -The resident had a DNR order. -The resident's DNR order was not signed by his/her physician, so the order was not valid at that time. -The resident had signed his/her DNR order form on [DATE]. 3. During an interview on [DATE] at 11:02 A.M., CNA D said: -In the case of an emergency, he/she would look either in the resident's electronic medical record on the resident's profile section, or in the resident's paper medical record to find the resident's desired code status. -The resident's electronic medical record and his/her paper medical record should show the same thing related to the resident's code status. During an interview on [DATE] at 11:11 A.M., the Administrator and Social Service Designee said: -A resident's current and accurate code status should be on the resident's POS. -A resident's TOS orders should be accurately transcribed to the resident's POS. -A resident's DNR order should be signed by his/her physician within 24 hours. During an interview on [DATE] at 11:15 A.M., the MDS Coordinator said: -The resident's care plan should accurately reflect the resident's code status. -In the past, it was the medical records person's responsibility to ensure TOS orders were signed by the physician and returned to the facility timely. During an interview on [DATE] tat 3:17 P.M., the Administrator and Director of Nursing (DON) said: -A resident's DNR order should be signed by his/her physician within 24 hours. -If the resident's physician was not able to sign the order within 24 hours, two nurses could take a telephone order for the DNR order, or the order could be faxed to the resident's physician for an immediate signature until he/she was able to come in to sign the form. -Staff could also take the DNR order to the physician to have the physician sign the order. -The resident's electronic medical record, TOS, POS, and paper medical record should all accurately reflect the resident's DNR status and should match.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre admission Screen and Resident Review (PASARR) Level II screening was obtained for one sampled resident (Resident #28), after the Level I screening identified the resident as having a mental condition requiring additional screening out of 16 sampled residents. The facility census was 55 residents. 1. Record review of Resident #28's Face Sheet showed he/she was admitted on [DATE] with diagnoses including schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), anxiety and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). Record review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/19/19, showed the resident: -Had severe cognitive incapacity and had no behaviors or mood disturbance. -Needed supervision with transfers, but was independent with walking, bathing, dressing, grooming eating and toileting. -Received anti-psychotic and anti-depressant medication. Record review of the resident's PASARR Level I screening dated 9/25/19, showed the resident had: -A major mental health disorder (diagnoses of schizoaffective disorder, psychotic disorder and anxiety disorder). -Has had serious problems with level of functioning in the last six months. -A level II screening was recommended to be completed. Record review of the resident's Physician's Telephone Orders showed the following physician's orders: -7/31/19 Risperdal (used to treat schizophrenia and bipolar disorder) 1 milligram (mg) twice daily for bipolar disorder (a mental health diagnoses for behavior that is characterized by periods of elevated or irritable mood (mania), alternating with periods of depression). -8/7/19 increase Lexapro (used to treat depression) to 10 mg daily for schizophrenia (a severe mental disorder that can result in hallucinations, delusions, and extremely disordered thinking and behavior). -8/13/19 discontinue Lexapro-start Cymbalta 30 mg daily for depression per psychiatric review Record review of the resident's Care Plan dated 9/2019, showed the resident exhibits behavior symptoms such as socially inappropriate/verbally aggressive/abusive and physically aggressive/abusive behaviors related to Schizoaffective Disorder. Interventions showed staff would: - On 6/20/2019 when placing a roommate, match with the same likes and dislikes to avoid conflict. -Administer psychotropic meds as ordered. -Determine cause of behavior and remove resident. -Distract resident with activities of interest. -Document all behaviors. Attempt to identify pattern to target interventions. -Evaluate side effects of medications. -Initiate psychiatric evaluation as needed. -The resident prefers to stay in his room in bed with the blanket over his/her head. -Modify the environment to reduce episodes of negative behavior and risk for fall or injury. -Notify the physician of inappropriate behavior. -Notify the physician of negative behavior or activity. -Provide the resident an opportunity to express him/herself. -Redirect negative behavior as needed. -When aggressive behaviors start, place immediately on one to one, attempt to redirect, give medication as needed and allow time to work, when the resident is no longer aggressive you can discontinue one to one (monitoring). If unable to redirect send the resident to the hospital for evaluation and treatment. -When the resident becomes agitated, remove him/her from the situation and offer one on one activities of choice. During interview on 11/20/19 at 9:55 A.M., the MDS Coordinator said: -The resident had been homeless and after he/her received the Public Administrator as Guardian, he/she was placed at the facility. -The former Social Service Director was employed at the facility when the resident was admitted and was in charge of ensuring the PASARRs were obtained. -The resident had the PASARR Level I screening completed but he/she was unable to locate a Level II screening and did not know if one had ever been completed on the resident. -He/she did not know if the facility had contacted the Missouri Central Office Medical Review Unit (COMRU) to see if the resident had ever had a Level II screening completed or to have a Level II screening completed on the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #197's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system). -Pressure ulcer, unspecified stage. -Right below the knee amputation. -Left below the knee amputation. -Colostomy. -Major Depressive disorder. -Anxiety. -Paraplegia (loss of movement of both legs and generally the lower trunk). Record review of the resident's Nursing Notes dated 8/25/19 showed: -Staff attempted to access the resident's Port-a-cath with a 1 1/2 inch Huber needed (a special needle used to access port-a-cath) but was unsuccessful. -The resident was sent to the hospital to access his/her port-a-cath. -The resident returned to the facility, reporting the hospital used a smaller needed to access his/her port-a-cath. Record review of the resident's Telephone Order Sheet (TOS) dated 9/27/19 showed an order for the resident to go the hospital to access his/her port-a-cath. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS of 15 out of 15. -Required total staff dependence for bed mobility, transfers, dressing, toileting, and personal hygiene. -Had a urinary catheter and colostomy. -Had Stage III pressure ulcer (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) and Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). Record review of the resident's October 2019 and November 2019 POS showed: -Huber needle 20 gauge (g - the diameter size of the needle), 1 1/2 inches in length, use as directed. --The 1 1/2 inches in length was crossed out and 1 inch in length was handwritten on the POS. --No physician's order on the resident's TOS or POS to reflect the change from a 1 1/2 inch needle to a 1 inch needle. -No documentation of a physician's order directing staff to change the dressing on the resident's accessed port-a-cath site or how often to change the dressing. Record review of the resident's October 2019 and November 2019 Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed: -No orders to change the dressing on the resident's accessed Port-a-cath. -No documentation by the facility staff the resident's accessed Port-a-cath dressing was changed. Record review of the resident's Nursing Notes from 10/1/19-11/21/19 showed: -No documentation by the facility staff the resident's accessed Port-a-cath site was assessed for signs and symptoms of infection. -No documentation by the facility staff the resident's accessed Port-a-cath dressing was changed. Observation on 11/20/19 at 1:28 P.M. showed the resident's transparent dressing covering his/her Port-a-cath was loose and dated 11/12/19. During an interview on 11/20/19 at 1:30 P.M., LPN D said: -The resident's Port-a-cath dressing was loose with the edges coming off and no longer adhering to the resident's skin. -He/she had reported the resident's dressing not adhering to the resident's skin to the Registered Nurse (RN) so it could be changed since it was outside his/her scope of practice. -The resident's Port-a-cath dressing had not been changed or reinforced yet. -He/she thought it was supposed to be changed every three days and documented by the nurse on the resident's TAR. -The resident's Port-a-cath dressing was dated 11/12/19. During an observation of the resident and interview on 11/21/19 at 11:45 A.M., the Administrator said: -He/she expected the ADON to monitor and document the Port-a-cath dressing change at least weekly. -The resident should have orders for his/her Port-a-cath dressing change. -He/she would expect the order to be on the resident's POS and transcribed to the resident's MAR/TAR. -He/she would expect the Port-a-cath dressing change to be documented as completed on the resident's MAR/TAR. -The resident's Port-a-cath dressing was dated 11/12/19. -The resident's Port-a-cath dressing was peeling away from the resident and no longer adhering to the resident's skin. Based on observation, interview and record review, the facility failed to ensure a physician's order for self-administration of medication kept at the bedside was obtained for one sampled resident who was a new admission (Resident #48); and to ensure a resident with a Port-a-cath (a device surgically implanted under the skin attached to a catheter [a thin, narrow tube] that is threaded into a large vein above the heart. It is used to deliver intravenous medications) had orders directing staff to change the transparent dressing to prevent infection for one sampled resident (Resident #197) out of 16 sampled residents. The facility census was 55 residents. Record review of the facility's Self-Administration of Drugs policy and procedure dated November 2016, showed residents in the facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so and clinically appropriate. It showed: -As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications and if such is clinically appropriate. -In addition to general evaluation of decision making capacity, the staff and practitioner will perform a more specific skill assessment, including the resident's ability to read and understand medication labels; comprehension of the purpose and proper dosage and administration time for his/her medications; ability to remove medications from a container and to ingest and swallow them and the ability to recognize risks and major adverse consequences of his/her medications. 1. Record review of Resident #48's Face Sheet showed he/she was admitted on [DATE], with diagnoses including breast, bone and lung cancer, diabetes, indigestion, high cholesterol, atrial fibrillation (irregular heartbeat), asthma and high blood pressure. Record review of the resident's Medical Record showed the resident did not have an admission Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) completed yet. Record review of the resident's Physician's Order Sheet (POS) dated 11/1/19 to 11/30/19 showed there were no physician's orders for the resident to self-administer any prescribed medications and there were no physician's orders showing the resident could keep any medications at bedside. Observation and interview on 11/19/19 at 6:55 A.M., showed the resident was sitting up in his/her recliner, dressed for the weather and without odors. The nurse was in his/her room administering the resident's medication. The resident complained of pain to his/her right heel. Licensed Practical Nurse (LPN) C assessed the resident's pain and gave him/her pain medication. Observation and interview on 11/19/19 at 7:15 A.M., showed the Assistant Director of Nursing (ADON) was in the resident's room to provide wound assessment and care to the resident. The resident was sitting in his/her recliner and instructed the ADON to look in his/her dresser drawer for an ointment to place on his/her wound. The ADON was unable to find the ointment, but he/she found a small prescription box labeled Triamcinolone 0.1% with orders to spray in each nostril as needed, in the resident's drawer. The resident said it was a nasal spray he/she used for his/her allergies. He/she said he/she brought the medication in from home. The ADON said that he/she as unaware that the resident had this medication in his/her dresser drawer and had been self-administering it as needed. He/she said he/she would have to take the medication and give it to the nurse to put away and notify the physician to obtain an order for the resident to keep it at bedside. During an interview on 11/21/19 at 12:48 P.M., the ADON said: -He/she went back into the resident's room to look for the ointment he/she said he/she had to put on his/her wound and found the resident had Pluragel in his/her room, which is used for moisture and for debridement (removal of dead tissue to promote wound healing) of wounds, in addition to Triamcinolone that was in his/her dresser drawer. -The resident and his/her family were putting that on his/her wound when the resident was at home. -When a resident is admitted , if they have medications with them, they are to leave the medications with the nurse and then the Charge Nurse has to get an order from the physician for self-administration of medications. -If the medication is not on their POS when they are admitted , the charge nurse has to notify the physician for clarification orders for the resident to have the medication. -The nurse will complete a general assessment to see if the resident is able to self-administer medications. -The resident did not have a physician's order for Pluragel or Triamcinolone, and did not have an order to self-administer them, so that was why he/she removed them from the resident's room. -They did not know the resident had the medications in his/her room and will assess the resident's ability to self-administer medications. -He/She informed the resident that the resident could not have medications in his/her room. During an interview on 11/21/19 at 2:23 P.M., the Administrator and Director of Nursing (DON) said: - If a resident comes into the facility with medications from home. they only accept medications from home that they (the facility) have orders for. -When they complete the resident's inventory, they go through the resident's belongings with the resident and if they discover medications at that time, that they don't have order for, they will call the family and have them pick the medications up. -If they have orders for the medications, they will take the medications and put them in the medication cart after verifying the medications with the physician. -The resident should not have had medications in his/her room that the nursing staff was unaware that he/she had. -Nursing staff should have assessed the resident to self-administer medications. -The resident should have orders to self-administer medications and it should be on his/her POS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #31's admission Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis: -Necrotizing Fascitis (an infection that results in the death of parts of the body's soft tissue). -Non-pressure chronic ulcer right foot with necrosis of muscle (sore with blacking/ death of tissue and muscle). -Sepsis (infection) following a procedure. -Gangrene of extremities (a type of tissue death caused by a lack of blood supply). -Left leg above knee amputation (surgical removal of a limb). Record review of the resident's 5 day MDS assessment dated [DATE] showed he/she: -Was cognitively intact. -Was able to understand others and was able make his/her needs known. -Required assistance of two staff for transfer. -Was at risk for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin, they most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips and tailbone) or skin issues. -Had an infected open area on his/her foot. -Was receiving dressing changes. Record review of the resident's Physician Telephone Order (PTO) dated 10/4/19 showed to cleanse the wound between the 4th and 5th toes (did not indicate which foot) with wound cleanser, then apply xeroform and lightly wrap with gauze. Record review of the resident's POS dated 10/1/19 to 10/31/19 showed no physician order for wound care. Record review of the resident's POS dated 11/1/19 to 11/30/19 showed no new or old physician's order for wound care to the resident's right foot. Record review of the resident's Medication Administration Record (MAR) dated November 2019 showed he/she: -Had order for Augmentin (is a prescription medication that's used to treat infections caused by bacteria) 500-125 milligram (mg) by mouth for seven days for infections. - Had the last dose on 11/13/19 for a diagnosis of Gangrene. Record review of the resident's November 2019 TAR showed to cleanse between the resident's little toe and 4th toe with wound cleanser on his/her right foot, then place a folded 4 x 4 gauze pad between the toes was transcribed on to the TAR on 11/13/19. Record review of the resident's progress note dated 11/6/19 at 10:09 P.M. showed: -He/she had arrived back to the facility at 5:00 P.M. -Had a order for an antibiotic for the wound on the right little toe. -Had a small wound noted between the little toe and forth toe that had a small amount of purulent (containing pus) drainage. -No dressing was in place and the facility had no orders for treatment from the hospital. -The resident said it was to be left open to air. -No documentation that staff had verified the physician orders with the hospital or the resident's physician upon readmission. Record review of the resident's progress notes from 11/6/19 to 11/12/19 showed: -No documentation related to verifying with the resident's physician or the hospital physician the discharge plan of care related to the monitoring and treatment of the infected wound on the resident's right little toe and forth toe. -The wound had been left open to air as documented in nursing progress notes. Record review of the resident's progress note dated 11/13/19 at 8:56 P.M. showed: -New treatment order received for his/her little toe on right foot. -Did not have detailed instructions on how the physician prescribed the wound care treatment. During an interview on 11/17/19 at 5:40 P.M., in main dining room the resident said: -He/she came to the facility with gangrene in his/her left leg. -He/she had to have his/her left leg amputated due to the gangrene. Observation on 11/17/19 to 11/19/19 of the resident wound care showed multiple attempts were made to observe the wound care and dressing change but resident was not available or the wound care and dressing change had been completed. Record review of the resident's Daily Pressure Injury Documentation dated 11/19/2019 at 5:02 P.M., showed: -The resident had a wound on his/her right toes and a dressing was present. -Gangrene was listed as the description of the wound. -The dressing was changed and the area was dry and intact. -No other comments or detailed description of the wound was documented. During an interview on 11/20/19 at 3:30 P.M., LPN A said: -His/her normal duties was the desk nurse which included the assessment of residents on Medicare skilled services and other medical assessment as needed. -The Charge Nurses were assigned the resident's Weekly Skin Assessment and the facility's wound nurse did the resident's Weekly Skin Conditions Wound Assessment. -He/she would expect to have a physician's order for treatment of the resident's wounds. -Should had a written physician order if had a received a telephone order or if on site physician order obtained. -When receive a physician's order should had been transcribed to the resident's POS and to his/her TAR or MAR. Observation on 11/20/19 and 11/21/19 of the resident wound care showed multiple attempts were made to observe the wound care and dressing change but the resident was not available or the wound care and dressing change had been completed. During an interview on 11/21/19 at 12:25 P.M., the resident said: -He/she had a wound on his/her right foot and nursing staff had been changing the dressing daily. -Staff clean the area first, then place the dressing between the toes. -The wound on his/her toes was getting better. -He/she had not had the dressing change done today. -He/she was not in his/her room much as he/she participated in most facility activities, and smoked outside. -He/she was getting ready to go out side to smoke. During interview and record review on 11/21/19 10:10 A.M., LPN D said: -The resident should have an order for wound treatment. -Staff should document the wound care on the resident's TAR. -Staff should not provide care without a physician's order and if not transcribed onto the resident's MAR or TAR. -Staff should call to verify orders or obtain physician's orders for wound care/treatment and then transcribe the order to the resident's POS, TAR and MAR. -During end of the month change over, the DON and the ADON would review the resident's POS, TAR and MAR to ensure physician's orders had been transcribed. -He/she should have verified the resident's physician orders and not provided wound care or treatment to the resident's wound without a physician order. During an interview on 11/21/19 at 2:17 P.M. the DON and Administrator said: -When they receive a physician's telephone order, nurses write the order on the POS, the MAR and the TAR. -On the following morning the DON and other administrative staff check the orders during the morning meeting to ensure the orders were correct and the medications and treatment supplies were obtained. -The DON and other administrative staff go over the POS, MAR and TAR when there are new orders that come in, to ensure all orders are being accurately transcribed on all three documents and they compare to ensure they are accurate and transcribed correctly. -The reconciliation of the POS's are done at the end of the month by the DON, ADON and MDS Coordinator. -He/she would expect to have a physician's order prior to providing wound care or treatment. -Physician's orders for wound care should have been obtained and should be transcribed onto the resident's POS and TAR. -He/she expected staff to follow those physician's orders for treatment and care. -Documentation should be on the TAR showing the treatments were completed as ordered. -If nursing staff see a wound during the skin or wound assessment, he/she expected nursing staff to call the physician and obtain an order for treatment. -The nursing staff should document the new and changing skin or wound issue and should be descriptive in documentation to show what it looked like and to include measurements of the wound. -Documentation should be in the weekly skin assessment document and in nursing progress notes. -The nurses were responsible for completing the weekly skin assessments and they should be comprehensive in documenting skin issues if the resident had a skin concern. -The Wound Nurse was responsible for completing the Weekly Skin Conditions Wound Assessment for residents with wounds and the staff should be comprehensive in documenting detailed descriptions of the wound and include measurements. -He/she expected the wound nurse to be responsible for monitoring and tracking the resident's status with skin issues or wounds to include current physicians order and documentation. 3. Record review of Resident #36's admission face sheet showed he/she was admitted on [DATE] with the following diagnoses Arthritis (joint pain) and depression. Record review of the resident's Plan of Care dated 7/22/19 showed: The resident had a potential nutritional problem related to Hypokalemia ( blood's potassium levels are too low). -Monitor weight monthly and maintain five percent gain or loss through the next review. Record review of the resident's telephone order dated 7/25/19 showed an order for support stockings. Record review of the resident's admission POS dated 7/25/19 showed the following orders: -Lasix (used to treat edema (swelling) 40 mg, give 1 tablet by mouth at 8:00 A.M. and 12:00 P.M. for edema. -Daily weights and support stockings. Record review of the resident's Care Plan dated July 2019 showed no documentation to include monitoring for edema or use of support stockings. Record review of the resident's POS dated 8/1/19 to 8/31/19 showed: -Lasix 40 mg give 1 tablet by mouth 2 times a day for edema with an order date of 7/25/19. -No orders transcribed for support stockings or documentation showing they had been discounted. Record review of the resident's TAR dated September, October and November 2019 showed the TAR was blank. Record review of the resident's POS for September and October 2019 showed no orders transcribed for support stockings or documentation showing they had been discounted. Record review of the resident's POS dated 11/1/19 to 11/31/19 showed: -Lasix 40 mg give 1 tablet by mouth two times a day for edema. -His/her diet order was a Regular Texture, 2 Gram Low Sodium diet. -No physician's order for support stockings or [NAME] hose. During an interview on 11/17/19 at 9:05 A.M., the resident said: -He/she had concerns with the edema in his/her legs. -He/she had support knee high stockings in place. Observation on 11/19/19 at 10:19 A.M. showed the resident had support stocking in place for edema. During interview and record review on 11/21/19 at 10:10 A.M., LPN D said: -The resident should have a physician's order and document care on the resident TAR for support hose. -He/she had monitored the resident for edema in the past, but he/she did not always document the care provided in the resident's medical chart. -He/she may not know where to document the information of the care or treatment provided due to not transcribed onto the resident's TAR or MAR. During an interview on 11/21/19 10:20 A.M., Certified Nursing Assistant (CNA) A said: -He/she reviewed the resident's care plan to check for the type of care to provide for the resident. -The CNA's document in the electronic record and have some paper records. -He/she weighs the residents. -He/she did not think the resident's weight had increased more than two to five pounds depending on fluid due to his/her edema. -The resident was able to make his/her needs known and was able to put own support stockings on. -The resident's legs have been swollen for a while and nursing was aware. Observation on 11/21/19 at 10:25 A.M. showed: -The resident did not have support stockings on. -He/she did not have any weeping or open areas on his/her legs. During an interview on 11/21/19 at 10:25 A.M., the resident said: -He/she was not able to find the support stockings in his/her room. -He/she was not sure where he/she put them. -The staff monitor his/her weight as needed. -The CNA's assist him/her put on the stockings when he/she request assistance. -He/she put the support stockings on as he/she needed them or wanted them on. -The nursing staff and CNA's sometime look at at the swelling of his/her legs during showers. -He/she had no weeping or open area on his/her legs. During an interview on 11/21/19 at 2:17 P.M., the DON and Administrator said he/she would expect: -Staff to have a physician's order for preventative measures and treatment of edema. -Staff to have a physician's orders for monitoring edema and placement of support stocking. -Documentation to be on the TAR showing the treatments were completed as ordered. -A resident to have a care plan that addresses monitoring for and treatment of edema. Based on observation, interview and record review, the facility failed to ensure physician's wound treatment orders were followed and documented as administered; to ensure the resident's wound care interventions were on the resident's comprehensive care plan for one sampled resident who was admitted with a surgical wound (Resident #45); to ensure physician's wound treatment orders were transcribed to the resident's current Physician's Order Sheet (POS) for two sampled resident's (Residents #45 and #31); to ensure physician's orders for monitoring edema and treatment of support hose were transcribed to the POS and Treatment Administration Record (TAR) and documented as administered, and to ensure the resident's edema care interventions were on the resident's comprehensive care plan for one sampled resident (Resident #36) out of 16 sampled residents. The facility census was 55 residents. Record review of the facility's Wound Care Guidelines policy and procedure dated May 2013, showed the purpose was to provide guidelines for the care of wounds. The preparation for caring for wounds showed staff should: -Verify that there is a physician's order for treatment. -Review the resident's care plan to assess any special needs of the resident. -Assemble equipment and supplies as needed -The procedure detailed steps in providing wound care, but did not address assessment or documentation protocols. 1. Record review of Resident #45's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including left hip fracture (with an artificial left and right hip joint), high blood pressure, anemia (low iron) dementia, cardiomyopathy (a disease of the heart muscle that makes it harder for your heart to pump blood to the rest of your body) and muscle weakness. Record review of the resident's Nursing admission assessment dated [DATE] showed the resident's general overall skin condition was pale, warm with normal skin turgor. It showed the resident had a surgical wound to his/her left hip. There was no additional documentation showing any treatment orders. Record review of the resident's POS dated 10/17/19, showed physician's orders to cleanse the resident's hip incision with wound cleanser, pat it dry, and apply border gauze (an absorptive dressing that consists of three layers to ensure wound healing) daily until healed. Record review of the resident's initial Care Plan dated 10/18/19, showed: -The resident was at risk for skin issues. -Staff was responsible for inspection and documentation of skin. -Incontinence care and skin treatments were to be completed as ordered. -The Care Plan did not show the resident was in the facility for rehabilitation after hip surgery and it did not show the resident had an incision that required treatment daily. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 10/30/19, showed he/she: -Had severe cognitive impairment. -Needed extensive assistance for bed mobility, transfers, dressing, bathing, and toileting. -Was at risk for developing wounds. -Had a surgical wound and received surgical wound care to include the application of surgical dressings and application of ointments. -Also received preventive interventions such as a pressure relieving device for his/her bed and chair, turning and repositioning program and nutrition/hydration interventions to manage skin problems. Record review of the resident's Daily Pressure Injury Documentation dated 10/18/19, 10/19/19, 10/20/19, 10/21/19, and 10/22/19, showed: -A dry intact odorless dressing was present. -There were no additional comments documented. -There was no documentation showing the dressing had been changed or that the treatment had been completed on those dates. There was no description showing what the progression of the incision was, what the incision looked like or if the incision was healing/healed. Record review of the resident's TAR dated 10/17/19 to 10/31/19, showed: -A physician's order instructing nursing staff to cleanse the resident's hip incision with wound cleanser, pat it dry and apply border gauze daily, until healed. -Treatments were not administered from 10/17/19 to 10/25/19 (there were no initials on each date showing treatments were administered). -Nursing staff documented they administered the treatment every day from 10/26/19 to 10/31/19 except on 10/28/19. -Did not show why wound treatment was not administered to the resident on the dates that were not initialed. Record review of the resident's Nursing Notes from 10/17/19 to 10/31/19 showed there were no nursing notes that the resident received any wound care treatment from 10/17/19 to 10/25/19. There were no notes showing any wound care treatments or description of the resident's incision or healing process. Record review of the resident's Weekly Skin Evaluation dated 10/24/19 and 10/31/19, showed the resident's skin was dry and intact and the resident had no open areas. There was no documentation identifying the resident's incision on his/her left hip or that he/she was receiving treatments for it. Record review of the resident's POS dated 11/1/2019 to 11/30/19, showed there were no treatment orders for the resident's surgical hip wound documented and there were no physician's orders showing the resident's wound care treatment had been discontinued. Record review of the resident's Comprehensive Care Plan dated 11/7/19, showed the resident had fall/gait and balance problems and showed interventions to help with preventing falls. It did not show the resident had a surgical wound due to hip surgery. It did not show when the resident's incision was healed and did not show any after care to the site. Observation and interview on 11/19/19 at 6:47 A.M., showed the resident was up and dressed for the weather sitting in his/her wheelchair, groomed without odor. The resident was pleasantly confused and said he/she was here for rehabilitation and was waiting for his/her spouse because he/she was leaving today to go home (the resident was not discharging to go home). At 6:52 A.M., nursing staff came to give the resident his/her medication. The resident was able to self-propel in and around the facility without assistance. At this time observation of his/her incision site was not completed. Nursing staff said the resident no longer had a wound at his/her left hip. During an interview on 11/20/19 at 4:00 P.M., Licensed Practical Nurse (LPN) D said: -When a resident is admitted , the nurse who is completing the admit is supposed to complete a comprehensive evaluation of the resident to include the physical and skin evaluation within four hours of the residents admission. -During the assessment, they should see if a resident has a wound and if so, the nurse should measure it and document what they saw, cover it and notify the wound care nurse. -If the resident came in with orders for treatment the can use those orders until the wound nurse sees the resident If the resident did not have orders,the nurse should notify the physician to obtain orders for treatment of the wound within the four hour admission period. -The resident's care plan should show that the resident has a wound and treatment orders until the comprehensive care plan is developed and the comprehensive care plan should show that the resident had a wound and received treatment for it. It should show interventions for care and treatment. During an interview on 11/21/19 at 12:48 P.M., the Assistant Director of Nursing (ADON) said: -He/she was also the Wound Care Nurse in the facility. -When they have a new admission, the charge nurse completes the initial assessment of the resident and they should complete a full body assessment. -If they see any skin issues, they are to document it on the initial assessment in the skin section and notify him/her. -He/she will then complete a wound assessment and and if there are no orders for wound care, he/she will notify the physician for orders and then he/she will start weekly wound assessments. -If the resident had physician's orders upon admission, he/she will verify those orders with the physician. -There should be documentation showing the resident had a wound, and treatment should be initiated within 24 hours. -A resident with a physician's order for wound care should receive their ordered treatment within 24 hours. -He/she should be notified of all wounds ore pressure sores. -If wound treatment is not given, there should be documentation showing why it was not given. -It should be documented that treatment was offered and why it was was not administered on the TAR. -He/she was unaware that Resident #45's treatment record showed no treatments were administered until 11/25/19. -Documentation showing what the wound looked like, measurements and overall assessment should have also been in the resident's nursing notes. During an interview on 11/21/19 at 2:23 P.M., with the Administrator and Director of Nursing (DON): -The DON said there should be a full body assessment completed upon admission and it should show any wounds on the resident or any skin concerns. -If nursing staff see a wound during the assessment, nursing staff should call the physician and obtain an order for treatment. -The documentation of the wound should be descriptive to show what it looked like and include measurements. Documentation should be in the initial admission assessment, and on the weekly skin assessment document. -The nurse is responsible for completing the weekly skin assessments and they should be comprehensive and show/describe the skin issue if the resident has a skin concern. -Physician's orders for wound care should be obtained, should be documented on the resident's POS and TAR and he/she expects staff to follow those orders. -She said documentation should be on the TAR showing the treatments were completed as prescribed and if they are unable to complete the treatment, nursing staff should document the reason on the back of the TAR. -The Administrator said it seems a full body assessment is not being done on admission or with re-admissions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #41's admission Face Sheet showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Benign Prostatic hyperplasia with lower urinary track symptoms (BPH enlarged prostate with difficulty in urination). -Neuromuscular Dysfunction of Bladder (neurogenic bladder when a person lacks bladder control due to a brain, spinal cord, or nerve condition). -Has a supra pubic catheter and a colostomy. Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was severely cognitively impaired and had short term and long term memory problems. -He/she was able to understand others and make his/her needs known. -Required total assistance for staff for all cares and transfers. -Had a diagnosis of neurogenic bladder. -Had an indwelling catheter and colostomy. Record review of the resident's TAR and MAR dated 10/1/19 to 10/31/19 showed no detailed physician's order for supra pubic catheter site care, monitoring and changing urinary drainage bag. Record review of the resident's nursing progress notes dated 10/1/19 to 11/19/19 showed no documentation related to the monitoring and care of the resident's supra pubic catheter. Record review of the resident's personalized Care Plan as of 11/19/19 showed no plan of care for the supra pubic catheter site cleaning, monitoring and changing, care or emptying of the urinary drainage bag. Record review of the resident's POS dated 11/1/19 to 11/30/19 showed no detailed physician's order for supra pubic catheter site care, monitoring and changing urinary drainage bag. Record review of the resident's TAR and MAR dated 11/1/19 to 11/30/19 showed no detailed physician's order for supra pubic catheter site care, monitoring and changing urinary drainage bag: Observation on 11/17/19 at 3:41 P.M., showed: -The resident was laying in bed with his/her eyes open, but did not respond when asked a question. -The urinary drainage bag and tubing were lying on the floor not in a dignity bag. -The urinary drainage bag had 350 cubic centimeter (cc) of urine inside the bag that was the color of apple juice. -There was an open container of personal care wipes at the foot of his/her bed. -There was an uncovered graduate measuring container on the back of the toilet. Observation on 11/18/19 at 1:10 P.M., showed the resident had a supra pubic catheter. Record review of the resident's Weekly Skin Condition Report (Pressure and Non Pressure Combined) dated 11/19/2019 10:33 showed no documentation related to the resident's supra pubic site. Observation on 11/20/19 at 3:25 P.M., showed: -The resident was reclined in his/her broda chair (a specialized wheelchair) by the nurse's station most of the day. -He/she had a catheter bag in a dignity bag. During an interview on 11/21/19 at 10:20 A.M., Certified Nurses Aide (CNA) A said the resident's catheter bag should be placed in privacy bag and not touching the floor. During an interview and record review on 11/21/19 at 10:10 A.M., Licensed Practical Nurse (LPN) D said: -The resident should have a physician's order for catheter care and should document care on the resident's TAR. -He/she had cleaned the resident's supra pubic site with wound cleanser and then applied a gauze pad. -He/she had not been documenting care on the resident's TAR. -The resident's current POS did not have a physician's order for the supra pubic catheter. -Staff should not provide care without a physician's order and if not transcribed on the MAR or TAR. -If a resident does not have orders, staff should obtain orders for supra pubic catheter care and then transcribe the orders to the resident's TAR. During an interview on 11/21/19 at 2:17 P.M. the DON and Administrator said: -When staff receive a physician's telephone order, nurses write the order on the POS, the MAR and TAR. -On the following morning the DON and other administrative staff check the orders during the morning meeting to ensure the orders are correct and the medications and treatment supplies were obtained. -They go over the POS, MAR and TAR when there are new orders to ensure all orders are being accurately transcribed on all three documents and they compare to ensure they are accurate and transcribed correctly. -The reconciliation of the POS's are done at the end of the month by the DON, ADON and MDS Coordinator. -He/she would expect to have physician order prior to providing catheter care or treatment. -Physician's Orders for catheter care should have been obtained and should have been transcribed onto the resident's POS and TAR. -He/she expects staff to follow physician's orders for treatment and care. -Documentation should be on the TAR showing the treatments were completed as ordered. -The urinary drainage bag should be stored in a dignity bag. -The urinary drainage bag and catheter tubing should not be touching the floor. Based on observation, interview and record review, the facility failed to obtain a physician's order for a suprapubic catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) to include the reason for a suprapubic catheter, to obtain a physician's order for the care of the resident's suprapubic catheter for three sampled residents (Resident #40, #197, and #41), and to ensure proper placement of the resident's catheter bag for two sampled resident's (Resident #197 and #41), out of 16 sampled residents. The facility census was 55 residents. Record review of the facility Indwelling Urinary Catheter Policy revised on November 2017 showed: -Cover the urine bag to provide privacy. -Drainage bag and tubing are to kept of the floor. 1. Record review of Resident #40's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Anxiety disorder. -Pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral region (tailbone), unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough [necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy] and/or eschar (tan, brown or black) in the wound bed). -Bipolar disorder (mood disorders characterized usually by alternating episodes of depression and mania). -Major Depressive Disorder. -Neuromuscular dysfunction of the bladder. Record review of the resident's August 2019, September 2019, and October 2019 Physician's Order Sheet (POS), Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed: -No order for a suprapubic catheter, including a reason for the suprapubic catheter. -No order for suprapubic catheter care. -No documentation by the facility staff of providing suprapubic catheter care. Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/20/19 showed he/she: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. -Required extensive staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. -Had a urinary catheter and colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen). -Had no pressure ulcers or skin issues. Record review of the resident's November 2019 POS, MAR, and TAR showed: -No order for a suprapubic catheter, including a reason for the suprapubic catheter. -No order for suprapubic catheter care. -No documentation by the facility staff of providing suprapubic catheter care. Observation on 11/20/19 at 10:46 A.M., showed the resident had a suprapubic catheter. 2. Record review of Resident #197's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system). -Pressure ulcer, unspecified stage. -Right below the knee amputation. -Left below the knee amputation. -Colostomy (surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall). -Major Depressive disorder. -Anxiety. -Paraplegia (loss of movement of both legs and generally the lower trunk). Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS of 15 out of 15. -Required total staff dependence for bed mobility, transfers, dressing, toileting, and personal hygiene. -Had a urinary catheter and colostomy. -Had Stage III pressure ulcer (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) and Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). Observation on 11/19/19 at 8:33 A.M., 10:15 A.M., and 2:30 P.M. showed: -The resident was in his/her room in bed. -His/her Foley catheter bag was hanging from the side of the bed without a dignity bag. -The resident's uncovered Foley catheter bag was touching the floor. 3. During an interview on 11/21/19 at 3:12 P.M., the Administrator and Director of Nursing (DON) said: -A resident should have an order for catheter care. -A resident should have an order for a suprapubic catheter, including the reason for the suprapubic catheter. -The catheter bag and/or tubing should never touch the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a comprehensive pain assessment once one sampled resident (Resident #29) began having chronic pain and to ensure documentation was completed upon administration of as needed (PRN) pain medication, to include the date, time, reason for administering pain medication, pain intensity assessment before and after administration and non-pharmacological interventions for two sampled residents (Resident #28 and #29) out of 16 residents. The facility census was 55 residents. Record review of the facility's Pain Assessment and Management policy and procedure dated October 2010, showed the purpose was to help staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The procedure instructed staff to: -Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition and when there is an onset of new pain or worsening of pain. -Assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. -During the comprehensive pain assessment, gather the following information as indicated from the resident or responsible party: a history of pain and treatment, including pharmacological and non-pharmacological interventions; characteristics of pain (intensity, description of pain, pain pattern, location and radiation of pain, frequency, timing and duration); impact on quality of life;factors that precipitate or exacerbate pain; strategies that reduce pain and symptoms that accompany pain. -Documentation: Document the resident's level of pain with adequate detail as necessary and in accordance with the pain management program. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record. -Pain Management interventions shall be consistent with the resident's goals for treatment. They shall reflect sources, type and severity of pain. They shall address the underlying causes of the resident's pain. -Non-pharmacological interventions may be appropriate alone or in conjunction with medications. 1. Record review of Resident #28's Face Sheet showed he/she was admitted on [DATE] with diagnoses including schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), anxiety and psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality). Record review of the resident's Pain assessment dated [DATE], showed the resident had no current complaints of pain. Record review of the resident's Care Plan dated 9/19/19, showed the resident had an alteration in his/her cardiovascular function related to complaints of chest wall pain. Interventions showed nursing staff would: -Administer medications as prescribed. -Assess for signs and symptoms of cardiac decompensation and report to the physician. -Minimize agitation or situations which cause anxiety. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/19/19, showed the resident: -Had severe cognitive incapacity and had no behaviors or mood disturbance. -Needed supervision with transfers, but was independent with walking, bathing, dressing, grooming eating and toileting. -Did not have pain and did not receive any scheduled or prn pain medication during the review period. Record review of the resident's Physician's Order Sheet (POS) dated 11/1/19 to 11/30/19, showed physician's orders for: -Tramadol (an opioid pain medication used to treat moderate to severe pain) HCL 50 milligrams (mg) every six hours as needed for pain (The original order was dated 8/26/19). Record review of the resident's Medication Administration Record (MAR) showed: -September 2019 the resident was administered Tramadol on 22 days (out of 30 days). --Documentation on the MAR showed the nurse documented the resident's pain intensity level prior to administering Tramadol, where the resident's pain was located, any non-pharmacological interventions initiated, and the resident's pain intensity level after Tramadol was administered only 14 times Tramadol was administered to the resident. -October 2019 the resident was administered PRN Tramadol on 21 days (out of 31 days). --The documentation on the MAR did not show the resident's pain intensity level prior to administering Tramadol, where the resident's pain was located, any non-pharmacological interventions initiated, or the resident's pain intensity level after Tramadol was administered to the resident. -November 2019 the resident was administered PRN Tramadol on 15 days (out of 30 days). --The documentation on the MAR did not show the resident's pain intensity level prior to administering Tramadol, where the resident's pain was located, any non-pharmacological interventions initiated, or the resident's pain intensity level after Tramadol was administered to the resident. Record review of the resident's nursing notes from 9/1/19 to 11/18/19, showed there was no documentation showing the frequency the resident requested pain medications, the assessment of the resident's pain each time he/she requested pain medications or the nursing assessment of the resident's pain when he/she requested pain medications. Observation on 11/18/19 at 11:18 A.M., showed the resident was standing in the hallway dressed for the weather. He/She was groomed and was not odorous. He/she was ambulatory without an assistive device and said he/she was doing fine (his/her speech was difficult to understand, but nursing staff was able to communicate with him/her and he/she was able to make his/her needs known). He/she showed no signs or symptoms of pain. 2. Record review of Resident #29's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including high blood pressure, indigestion, stroke, high cholesterol, lung cancer and pain. Record review of the resident's Pain assessment dated [DATE], showed the resident had no complaints of pain during the assessment period. The document showed the rest of the form was not completed. Record review of the resident's Medical Record showed there were no additional pain assessments in the resident's medical record after the resident began having pain and taking pain medication. Record review of the resident's quarterly MDS dated [DATE], showed the resident: -Was cognitively intact and had no memory problems. -Was independent with dressing, toileting, eating, grooming; needed supervision with bathing and used a wheelchair for mobility. -Did not have pain and did not receive any pain medication during the assessment period. Record review of the resident's POS dated 11/1/19 to 11/30/19, showed the following physician's orders: -Fentanyl patch (an opioid pain medication applied to the skin in a patch) 50 mg change every 72 hours (discontinued on 11/5/19). -Hydrocodone (Norco) 10/325 mg give two tablets every 6 hours as needed for pain (initially ordered on 10/25/19). -Roxanol (morphine a pain medication) 0.25 milliliter (ml) to 1 ml every hour for pain (ordered on 11/10/19). -Oxycontin (a time release morphine like pain medication) 10 mg every 12 hours for pain (10/22/19). Record review of the resident's Nursing Notes showed: -10/19/19-the nurse documented the resident had complained of pain constantly at 8/10 (on the pain scale,10 represents intense pain) despite pain medication. He/she called hospice and received a physician's order to increase the Roxanol to Roxanol 20mg/ml-give 0.25-1 ml every two hours PRN for pain. He/she documented the resident tolerated Roxanol 0.5ml and reported his/her pain intensity at 5/10 and his/her pain was much more tolerable. -11/5/2019 the nurse documented the resident complained of severe pain that was not relieved by his/her current pain regimen. Hospice was notified and the nurse received new physician's orders to increase Roxanol to every hour as needed. and to increase Hydrocodone to one to two tablets every four hours as needed. The note showed pain medication was administered as ordered and the resident was resting quietly in bed at this time. -There were no additional notes showing the resident's pain intensity level before and after each PRN pain medication administration. Record review of the resident's MAR dated 10/1/19 to 10/31/19 showed physician's orders for Oxycontin 20 mg twice daily for pain (start date 10/10/19 to discontinue date 10/25/19 and reordered from 10/25/19 to 10/31/19); Norco 7.5/325 mg give two tablets every four hours as needed for pain; Roxanol 20 mg/ml give 0.25 ml sublingually (under the tongue) every four hours as needed for pain and Roxanol 20 mg/ml give 0.25 ml sublingually every two hours as needed for pain. The MAR showed: -Scheduled Oxycontin was administered as ordered. -PRN Norco was administered on 20 days from 10/10/19 to 10/31/19. -PRN Roxanol was administered 14 days from 10/12/19 to 10/31/19. -The MAR showed the nurse only documented the resident's pain intensity level prior to administering pain medication, where the resident's pain was located, any non-pharmacological interventions initiated, or the resident's pain intensity level after pain medication was administered to the resident on three dates that he/she administered pain medication to the resident. Record review of the resident's MAR dated 11/1/19 to 11/30/19, showed physician's orders for Hydrocodone 10/325 mg give one to two tablets every six hours as needed for pain (ordered on 10/25/19-the order was changed on 11/5/19 to show Hydrocodone 10/325 mg every four hours as needed for pain); and Roxanol 0.25 ml to 1 ml every hour as needed for pain. The MAR showed: -PRN Hydrocodone was administered to the resident on 14 days from 11/1/19 to 11/18/19. -PRN Roxanol was administered to the resident on 16 days from 11/1/19 to 11/18/19. -The documentation on the MAR did not show the resident's pain intensity level prior to administering pain medication, where the resident's pain was located, any non-pharmacological interventions initiated, or the resident's pain intensity level after pain medication was administered to the resident. Observation on 11/18/19 at 12:06 P.M., showed the resident was laying down in his/her bed with his/her call light within reach. His/her bed was in a low position. The resident's eyes were closed and he/she was resting comfortably without signs or symptoms of pain or distress. Observation on 11/19/19 at 6:30 A.M., showed the resident was sitting up in his/her wheelchair by the nursing station with other residents. He/she was alert but was not interacting with anyone. He/she was dressed for the weather without odor and showed no signs or symptoms of pain or discomfort. When trying to speak with the resident, resident did not respond. 3. During an interview on 11/20/19 at 4:00 P.M., Licensed Practical Nurse (LPN) D said: -When a resident complains of pain, the nurse is supposed to ask about their pain, where their pain is located and what the intensity of their pain is. -They usually have the resident rate their pain from 1-10 (10 represents intense pain) then, if they can give a pain medication, the nurse should check to see what pain medication they have, give the pain medication, then about an hour later they are supposed to check back with the resident to see if the pain medication was effective. -The nurse was supposed to document on the back of the MAR the date they gave the pain medication, what they gave, why they gave it, location of the resident's pain, the resident's pain intensity prior to administration and if it was effective. -They also were supposed to document the resident's pain intensity level after giving the pain medication. -If they have non-pharmacological interventions that they can use to try to keep from giving pain medication, they will also use those and they should be documented. During an interview on 11/21/19 at 12:19 P.M., Certified Medication Technician (CMT) A said: -Whenever the resident requests pain medication, they were supposed to ask the resident where their pain is located and to rate their pain intensity. -Depending on the resident's level of pain, they will determine what type of pain medication to give. -They inform the nurse that the resident has pain and then once they give the pain medication, they are supposed to document the date and time they gave the pain medication and on the back of the MAR they document what they gave, the location of the resident's pain and the pain intensity level before and after giving pain medication. During an interview on 11/21/19 at 12:48 P.M., the Assistant Director of Nursing (ADON) said: -He/she expects the nursing staff to assess the residents pain prior to giving pain medication. -They should ask the location and intensity (if the resident can tell them) of their pain, or look for signs and symptoms of pain and assess their vital signs (temperature, respirations, pulse and blood pressure). -They should assess the resident's pain intensity again 35 to 45 minutes after giving pain medication. -They should be documenting this information on the back of the MAR and with the transition to e-charting, it should be documented in the computer on the MAR. During an interview on 11/21/19 at 2:23 P.M., the Administrator and Director of Nursing (DON) said: -When a resident complains of pain nursing staff should assess the resident's pain intensity level then attempt non-pharmacological interventions first, then if they do not work, administer pain medication. -After giving the resident pain medication, they should follow up and complete another pain assessment. -Documentation showing the resident's pain intensity level before and after administering pain medication, the time they administered pain medication and where the resident's pain was located should be documented on the back of the MAR each time they administer pain medication. -They should initial that they gave the pain medication on the front of the MAR. -Documentation for non-pharmacological interventions implemented should also be documented on the back of the MAR. -The DON and ADON should be monitoring for accuracy and completion. -They should complete a comprehensive pain assessment on any resident who has pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's physician was notified of his/her significant weight gain; to follow the Registered Dietitian's (RD) recommendations of stopping the resident's double portions at meals, and to address the resident's clothing no longer being able to fit the resident comfortably due to his/her significant weight gain for one sampled resident (Resident #13) out of 16 sampled residents. The facility census was 55 residents. Record review of the facility's Weight Assessment and Intervention policy revised September 2012 showed: -The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss or gain for residents. -Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight change is verified, nursing will notify the Registered Dietician (RD) per facility protocol. -The threshold for significant unplanned and undesired weight change will be based on the following criteria [where percentage of body weight loss = (usual weight - actual weight)/(usual weight) x 100]: --One month - 5% weight change is significant; greater than 5% is severe. --Three months - 7.5% weight change is significant; greater than 7.5% is severe. --Six months - 10% weight change is significant; greater than 10% is severe. -If the weight change is desirable, this will be documented and no change in the care plan will be necessary. -Individualized care plans shall address, to the extent possible, the identified causes of weight gain. -Interventions for undesirable weight gain shall be based on careful consideration of the the following: --Resident choice and preferences. --Nutrition and hydration needs of the resident. --Functional factors that may inhibit independent eating. --Environmental factors that may inhibit appetite or desire to participate in meals. 1. Record review of Resident #13's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Major Depressive disorder. -Anxiety. -Hepatitis C (a viral infection that attacks the liver). -Chronic kidney disease (CKD - gradual loss of kidney function over time). -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -The resident had a Do Not Resuscitate (DNR - do not perform chest compressions or artificial breathing in the case of an emergency; allow natural death). -The resident had a guardian. Record review of the resident's care plan dated 2/6/19 showed: -The resident had a potential nutritional problem related to his/her COPD. -The resident will maintain his/her current weight plus or minus five percent (5%) through the next review date. -Monitor the resident's weight monthly. -Provide diet and consistency per the resident's physician's orders. Record review of the resident's weight record showed on 2/9/19 he/she weighed 255 pounds. Record review of the resident's Dietary Nutrition assessment dated [DATE] showed: -The resident had a regular diet order. -He/she weighed 255 pounds. -The resident had a significant weight change. -The resident had weighed 275 pounds at the time of his/her discharge in December 2018. -The resident had a 25 pound weight loss (this was actually 20 pounds of weight loss). -The resident had been living in the community and not eating well after his/her discharge from the facility. -He/she did not refuse food and generally ate 50 - 75% of his/her meals. -The resident's dietary intake had decreased to less than 50% for most meals -His/her goal was to maintain his/her weight. -It was recommended by the RD the resident was offered high calorie snacks between meals and at bedtime and for the staff to complete weekly weights for for weeks. --Weekly weights were not documented as being completed by the staff. Record review of the resident's weight record showed: -On 2/20/19 he/she weighed 256 pounds. -On 3/3/19 he/she weighed 253.6 pounds. -On 4/1/19 he/she weighed 255 pounds. -On 5/5/19 he/she weighed 260 pounds. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility staff for care planning) dated 5/29/19 showed: -The resident was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. -Was independent with bed mobility. -Required staff supervision for dressing, eating, and personal hygiene, -Required limited staff assistance for transfers and toileting. -Weighed 255 pounds. Record review of the resident's weight record showed: -On 6/2/19 he/she weighed 275 pounds. --This was a 15 pound weight gain in one month (5.77% in one month). Record review of the resident's Nursing Notes for June 2019 showed no documentation staff notified the resident's physician of his/her 15 pound weight gain in one month. Record review of the resident's July 2019 Physician's Order Sheet (POS) showed his/her diet order was a regular diet with double portions. Record review of the resident's weight record showed: -On 7/3/19 he/she weighed 312.6 pounds. --This was a 37.6 pound weight gain in one month (13.67% in one month) and 57.6 pound weight gain in three months (22.59% in three months). Record review of the resident's Nursing Notes for July 2019 showed no documentation staff notified the resident's physician of his/her 37.6 pound weight gain in one month and 57.6 pound weight gain in three months. Record review of the resident's weight record showed: -On 8/2/19 he/she weighed 312 pounds. --This was a 57.6 pound weight gain in six months (22.59% in six months). Record review of the resident's Nursing Notes for August 2019 showed no documentation staff notified the resident's physician of his/her 57.6 pound weight gain in six months. Record review of the resident's August 2019 (POS) showed his/her diet order was a regular diet with double portions. Record review of the resident's Dietary Nutritional Quarterly Assessment completed by the dietary manager dated 8/28/19 showed: -The resident was on a regular diet. -His/her weight was 312 pounds on 9/4/19. --This weight was after the date the quarterly assessment was completed. -He/she ate 76% or more of his/her meals. -He/she would refuse food. -The resident eats 75-100% of his/her meals. -He/she had requested to be taken off double portions because he/she had gained too much weight. -Had a 10% weight gain since 4/1/19. --The resident weighed 255 pounds on 4/1/19 and 312 pounds on 9/4/19. This was a 57 pound weight gain (22.35%) since 4/1/19. -The resident will refuse breakfast at times. Record review of the resident's quarterly MDS dated [DATE] showed the resident: -Was cognitively intact with a BIMS of 13 out of 15. -Was independent with bed mobility. -Required staff supervision for dressing, eating, toileting, and personal hygiene, -Required limited staff assistance for transfers. -Weighed 312 pounds. -Had a significant weight gain that was not part of a physician prescribed weight gain regimen. Record review of the resident's September 2019 and October 2019 POS showed his/her diet order was a regular diet with double portions. Record review of the resident's weight record showed: -On 9/4/19 he/she weighed 312 pounds. -On 10/7/19 he/she weighed 304.8 pounds. Record review of the resident's November 2019 POS showed his/her diet order was a regular diet with double portions. Record review of the resident's weight record showed a weight had not been recorded for November 2019 as of 11/21/19. Observation on 11/18/19 at 1:50 P.M. showed the bottom of the resident's shirt in front came down to the middle of his/her abdomen, exposing the resident's abdomen as he/she was in the hall in his/her wheelchair. During an interview on 11/18/19 at 1:56 P.M., the resident said: -He/she had gained between 80 to 100 pounds since July 2018. -His/her shirts no longer fit correctly. -His/her shirts were so small they only covered to the middle of his/her belly. -He/she thought some of his/her breathing problems may have been due to his/her weight gain. Observation of the resident on 11/19/19 at 12:00 P.M., 11/20/19 at 8:20 A.M., and 11/21/19 at 10:50 A.M. showed the bottom of the resident's shirt in front came down to the middle of his/her abdomen, exposing the resident's abdomen as he/she was in the hall in his/her wheelchair. During an interview on 11/21/19 at 10:56 A.M. the resident said: -He/she had some clothes that fit correctly. -He/she needed some shirts in a bigger size because the ones that he/she had only fit to the middle of his/her belly. -He/she did not think he/she had money to get shirts, even from a thrift store, because he/she used his/her money for cigarettes each month. -His/her weight gain and clothing not fitting correctly bothered him/her and made him/her feel badly about his/her appearance, especially when staff would come up to him/her and pull his/her shirt down in front to cover his/her belly. -It made him/her feel like a character in a movie known for being excessively overweight. -He/she was getting double portions of food at one time, and sometimes still does, but he/she had asked to only get a regular portion due to his/her significant weight gain. During an interview on 11/21/19 at 3:28 P.M., the Administrator and Director of Nursing (DON) said: -He/she would expect staff notify the resident's physician of recommendation by the RD and/or Dietary Manager. -He/she would expect staff to notify the resident's physician of his/her significant weight gain. -He/she would expect staff to document in the Nursing Notes of the resident's physician notification and of any orders received. -He/she had noticed the resident's shirts did not fit him/her properly, but he/she did not think it bothered the resident. -The resident did not have any money in his/her resident trust account to purchase new shirts. -He/she would inform the resident's guardian about his/her clothing not fitting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from unnecessary medications for one sampled resident (Resident #4) out of 16 sampled residents. The facility census was 55 residents. Record review of the facility's Medication Regimen Review policy and procedure dated June 2012, showed: -Unnecessary drugs are medications given in excessive dose, in excessive duration, without adequate monitoring, without adequate indications for use, or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. -Regarding Psychotropic medications it showed: --A review of new orders for this class of drugs to include the documentation of a specific condition as diagnosed and documented in the clinical record. --Need for gradual dose reductions. --Need for behavioral interventions unless clinically contraindicated. 1. Record review of Resident #4's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Acute respiratory failure. -Anxiety. -Major Depressive Disorder. -Quadriplegia (paralysis of all four extremities and usually the trunk). Record review of the resident's care plan dated 12/26/17 and revised on 1/22/18 showed: -The resident uses psychotropic medications for depression. -He/She will have minimal side effects or adverse reactions related to the use of psychotropic medications. -Educate the resident family/caregivers about risks, benefits, and the side effects and/or toxic symptoms of psychotropic medications. -Give medications as ordered by his/her physician. -Monitor/document side effects and effectiveness. Record review of the resident's Note to Attending Physician/Prescriber dated 5/23/19 showed: -The pharmacist recommended the following: --Please assess if there is a potential for gradual dose reduction of the resident's Fluoxetine (Prozac - an anti-depressant medication). --He/she is currently prescribed 20 milligrams (mg) daily. --Consider a trial reduction to 10 mg if clinically appropriate. -If no reduction is made please provide a brief rationale as to why in order to help the facility remain in compliance with state regulations. -The resident's physician marked the box to disagree with the pharmacist's recommendation. -The resident's physician did not provide a brief rationale for the disagreement. -The form was signed by the physician on 6/7/19. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 8/7/19 showed he/she: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. -Had a Mood Assessment Score for depression was zero, indicating no signs or symptoms of depression. Record review of the resident's November 2019 POS and MAR showed: -Fluoxetine (Prozac - an anti-depressant medication) 20 mg daily for depression. -Staff documented Fluoxetine 20 mg was administered to the resident daily. During an interview on 11/21/19 at 10:45 A.M., Licensed Practical Nurse (LPN) C said he/She thought the Director of Nursing (DON) was responsible to check for pharmacy recommendations and to notify the resident's physician if there were any recommendations. During an interview on 11/21/19 at 2:44 P.M., the Administrator and DON said: -The DON was responsible to monitor recommendations from the pharmacist regarding drug regime review and gradual dose reduction. -The resident's physician needed to document a reason why he/she declined the pharmacist's recommendations. -If the resident's physician did not document a reason why he/she declined the pharmacist's recommendations, he/she should contact the physician for clarification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the physician re-evaluated one sampled resident (Resident #35) after 14 days for continued use of as needed (PRN) psychotropic medication out of 16 sampled residents. The facility census was 55 residents. Record review of the facility's Medication Regimen Review policy and procedure dated June 2012, showed unnecessary drugs are medications given in excessive dose, in excessive duration, without adequate monitoring, without adequate indications for use, or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Regarding Psychotropic medications it showed: -A review of new orders for this class of drugs to include the documentation of a specific condition as diagnosed and documented in the clinical record. -Need for gradual dose reductions. -Need for behavioral interventions unless clinically contraindicated. -A review of the resident's with as needed (PRN) psychotropic medications for a documented diagnoses specific condition and they are limited to 14 days. If greater than 14 days, the rationale for such listed in the medical record. -A review of residents with PRN anti-psychotic orders is limited to 14 days. Review of documentation for an attending physician or nurse practitioner evaluations to justify the continued need of the medication. -Residents who have not used psychotropic drugs are not given them unless the medication is necessary to treat a specific condition as diagnosed. 1. Record review of Resident #35's Face Sheet showed he/she was admitted on [DATE], with diagnoses including schizoaffective disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression), psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), delusional disorder and hallucinations. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/16/19, showed the resident: -Was cognitively intact with no memory problems. -Was independent with bathing, dressing, grooming, toileting and ambulation. -Received antidepressant medication. Record review of the resident's Physician's Order Sheet (POS) dated 9/1/19 to 9/30/19, showed a physician's order for Haldol Deconate injection 100 milligrams (mg)/milliliters (ml), inject 1 ml intramuscular (IM) for outbursts as needed (the origin of the order dated 8/23/19 with no end date documented) for agitation. Record review of the resident's Physician's Telephone Order dated 9/4/19, showed the following physician's orders: -Discontinue Haldol Deconate. -Zyprexa 5 mg every 6 hours as needed for agitation with no end date documented. -Zyprexa 5 mg IM every 6 hours as needed for agitation with no end date documented. Record review of the resident's Physician's Telephone Orders showed: -There were no orders showing Zyprexa 5 mg every six hours as needed for agitation and Zyprexa 5 mg IM as needed for agitation were discontinued after 14 days (from the start date). -There were no orders showing Zyprexa 5 mg every six hours as needed for agitation and Zyprexa 5 mg IM as needed for agitation were reordered after 14 day duration (from the order start date). Record review of the resident's Physician's Notes showed: -There were no physician's notes since 8/22/19. -There was no physician's note documented from 9/1/19 to 9/30/19. Record review of the resident's Medical Record showed there was no documentation showing the resident's physician re-evaluated the resident in person after 14 days of the physician ordered Zyprexa (on 9/4/19). Record review of the resident's Drug Regimen Review dated 9/23/19, showed the Pharmacist's recommendation stating PRN Zyprexa must be written for a 14 day duration; cannot be indefinite in duration due to new regulations. PRN anti-psychotics must be re-evaluated in person after 14 days before writing a new order. The review showed the Physician responded on 10/25/19 stating the resident was stable with his/her current dose. Record review of the resident's POS dated 10/1/19 to 10/31/19, showed the following orders: -Zyprexa 15 mg daily for agitation. -Zyprexa 5 mg dissolve tablet on tongue every 6 hours as needed for agitation (ordered 9/25/19).There was no end date documented and no re-order date documented. -Zyprexa 10 mg inject 5 mg intramuscular every 6 hours as needed for agitation (ordered 9/25/19). There was no end date documented and no re-order date documented. Record review of the resident's Physician's Notes dated 10/23/19, showed the physician visited the resident during rounds at the facility. The Physician documented the resident had anxiety, and confusion with delusional thought processes. The recommendation was to continue his/her current plan of care, the resident was followed by psychiatry and refuses medications. There were no notes or orders regarding the resident's Zyprexa medications. Record review of the resident's Medical Record showed there was no documentation showing the most recent observation and re-evaluation of the resident's for continuing his/her PRN Zyprexa medications. Observation and interview on 11/18/19 at 11:32 A.M., showed the resident was in his/her room listening to music. He/she said: -He/she has lived at other nursing homes and this one is the best so far because the staff treated him/her with dignity and respect. -He/she had been on Lithium (an anti-psychotic) for schizoaffective disorder and grandiose ideas but he/she experienced several bad side effects. -He/she was hospitalized for seven days at the psychiatric hospital and discussed the side effects he/she was having. -The physician's in the hospital discontinued Lithium and started him/her on Zyprexa and Zyprexa seems to make him/her feel more balanced. During an interview on 11/21/19 at 2:23 P.M., the Administrator and Director of Nursing (DON) said: -Whenever a resident is prescribed PRN antipsychotic medications, the physician should complete a re-evaluation of the resident after 14 days in order to continue the medications. -If on the Drug Regimen Review the Pharmacist documents that the resident should be re-evaluated after 14 days of having a PRN anti-psychotic, the expectation is for the physician to re-evaluate the resident and then re-order the anti-psychotic if he/she wanted the PRN to continue. -The Administrator said all PRN anti-psychotic medications should be ordered for a 14 day duration. -The DON is expected to review the Drug Regimen Review and upon observing the recommendation, they would call the physician to let him/her know he/she needs to complete a face to face evaluation of the resident if he/she wants the PRN to continue.

Based on observation, interview and record review, the facility staff failed to puree (make food into a paste or thick liquid suspension usually made from cooked food that was ground finely) the ranch potatoes to be smooth and without chewable bits and pieces and to have recipes for pureed foods available for the Dietary [NAME] (DC) to use. This practice potentially affected three residents with pureed diets. The facility census was 55 residents. 1. Observation on 11/18/19, showed: - At 5:21 P.M., the Dietary [NAME] (DC) made pureed ranch potatoes. - At no time, was there a recipe book open. - At 5:21 P.M. and 40 seconds, the DC added milk to the food processor and still, no recipe book was opened, and - At 5:22 P.M., the DC did not taste the product when he/she placed the pureed ranch potato mixture into a metal pan, the mixture still had visible pieces of the ingredients such as the bacon and the herbs. Observation with the Dietary Manager (DM) on 11/18/19 at 5:46 P.M., during a taste test of the pureed ranch potatoes, the DM said he/she noticed the pureed ranch potatoes were gritty to the taste. Record review of the recipe book with the DM on 11/18/19 at 5:52 P.M., showed the absence of recipes and instructions for pureed foods. During an interview on 11/18/19 at 5:53 P.M., the DM said: - There were not any pureed recipes to be used because they did not print off with the regular recipes and - The recipes for pureed items are on the computerized system but he/she did not know why they did not print. During an interview on 11/18/19 at 6:05 P.M., the DC said: - He/she cannot eat a lot of the prepared foods items, because of onions, and - He/she did not ask anyone to taste the pureed foods that day.

Based on interview and record review, the facility failed to maintain records of reconciled bank statements (a form where outstanding checks that were not cashed were subtracted from the ending bank balance) for the months of 11/18 and 12/18; to account for the occurrence of $30 that was still in the account for one sampled resident (Resident #1000) that was discharged ; to have documentation that the Supplemental Security Income (SSI) agency was notified; and to have an accounting of what Resident #1001 had in his/her account after the resident was discharged to another facility, and to prepare and send quarterly statements for 28 residents who allowed the facility to hold and manage funds. This practice potentially affected 28 residents who resided at the facility and two discharged residents. The facility census was 55 residents. 1. Record review of the reconciled bank statements from 11/18 through 10/19 showed the absence of the reconciled statements for 11/18 and 12/18. During an interview on 11/20/19 at 8:13 A.M., the Business Office Manager (BOM) said there were no reconciled bank statements for 11/18 and 12/18, because some records were lost in the computerized files after the changeover form one management entity to another management entity. 2. Record review of Resident #1000's records showed the following: - The resident was discharged on 9/26/19. - An e-mail dated 11/20/19 from a corporate person which showed the Resident's account was closed, and - A balance of $30.00 in the Resident's account. During an interview on 11/20/19 at 10:41 A.M., the BOM said: - The $30 came into the Resident's account on 11/1/19. - There was not documentation to show the facility notified the SSI agency to not send that resident's money to this facility. - No documentation to show why that $30 was still in the resident's account even though the resident was discharged 55 days prior to this resident fund review, and - They (facility personnel) have taken $30 to the resident at another facility in the past. 3. Record review of Resident #1001's records showed the following: - The Resident was discharged on 10/17/19 to another facility. - The absence of the amount of funds the resident had in his/her account on 10/17/19. - The absence of records to show where that resident's funds went, and - A balance of negative $50 as of 11/20/19. During an interview on 11/20/19 at 10:46 A.M., the BOM said he/she could not get into the resident fund account back in 9/19 and 10/19. 4. Record review of the resident fund documentation showed the absence of quarterly statements for all 28 residents who resided at the facility and allowed the facility to manage funds for them. During an interview on 11/20/19 at 11:24 A.M., the Business Office Manager (BOM) said he/she did not know about the quarterly statements being sent to the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #26's admission face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Dementia (is a general term for loss of memory and other mental abilities severe enough to interfere with daily life). -Palliative Care (is need for additional care services for chronic health condition provide by Hospice care agency). Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was severely cognitively impaired and had short term and long term memory problems. -He/she was rarely able to understand others and rarely able make his/her needs known. -Required total assistance from staff for all cares and transfers. -Was at risk for pressure ulcers or skin issues. Record review of the resident's POS dated 11/1/19 to 11/30/19 showed: -The resident's was on Hospice services. -The resident did not have a physician's order for wound care treatment or skin monitoring. -The nursing staff had been providing wound care without a physician's orders on the resident's POS. Record review of Facility Wound Care Log dated 11/4/2019, showed the resident: -Had a skin tear on his/her left hip that measured 0.4 cm in length (l) by 0.4 cm in width (w). -Had a small amount of drainage, the area around the site was red without warmth, and was 100% pink granulation tissue (healing tissue that is lighter than surrounding tissue). -The treatment order was to cleanse the area with wound cleanser, allow to dry, then apply hydrogel (used to help heal open wounds) and secure with border gauze. -No other wounds were documented. Record review of the resident's bath sheet dated 11/13/19 showed he/she: -Had a red area documented on his/her bottom. -The Certified Nursing Assistant (CNA) had signed off by his/her signature. -The bath-sheet had been reviewed by the charge nurses on duty and reviewed by the DON on 11/14/19. -Did not have any documentation related to plan of treatment or if the resident's physician was notified of the red area. Record review of resident's Weekly Skin Condition Report (Pressure and Non Pressure Combined) dated 11/14/2019 at 3:40 P.M. showed the resident: -Had a skin tear on his/her left hip and the measurement was 0.4 cm (l) by 0.4 cm (w). -Had treatment orders to cleanse the area with wound cleanser, allow to dry, apply hydrogel and secure with border gauze. -Had a new wound that was first observed on 11/14/19 of a Stage II pressure ulcers to his/her coccyx (tail bone) that measured 0/4 cm (l) by 0.3 cm (w) by 0.1 cm depth (d) and was pale pink in color. -The treatment was was documented as, cleanse with the area with wound cleanser, allow to dry, apply skin barrier cream and cover with bordered gauze. -No documentation was found on the POS for the treatment orders. -No documentation was found in the resident's progress notes that Hospice was notified of the Stage II pressure ulcer to the coccyx. -No documentation was found in the resident's progress notes that the resident's physician or family had been notified of the Stage II pressure ulcer to the coccyx. Record review of the resident's Weekly Skin assessment dated [DATE] showed the resident's skin was intact and had no other documentation noted. Record review on 11/19/19 of the Facility Initial Entrance Matrix showed the resident: -Had no documentation of skin issue/wounds. -Had been on hospice services. Record review of the resident's TAR dated 11/1/19 to 11/30/19 showed: -Cleanse left hip wound with wound cleanser, pat dry, apply foam adhesive dressing, change daily until healed. -Cleanse right hip wound with wound cleanser, pat dry, apply foam adhesive dressing, change daily until healed (dated 11/4/19). -Cleanse right shoulder with wound cleanser, pat dry, apply skin prep daily until healed. -From 11/1/19 to 11/18/19 the 7:00 A.M. to 3:00 P.M. shift had initialed the treatments were completed. -On 11/19/19 Hospice was documented for all three wound treatments (left hip, right hip and right shoulder). Record review of the resident's medical record dated 11/1/19 to 11/20/19 showed: -No nursing progress notes related to obtaining a physician's order for a treatment for the new coccyx wound. -No documentation on reporting the resident's new Stage II Coccyx wound to his/her physician, Hospice, or family. Observation on 11/20/19 at 1:50 P.M., of the resident's wound care by LPN A and the ADON showed: -Staff had washed their hands upon entry of the resident's room and applied gloves. -LPN A removed the old dressing that was dated 11/18/19 from the resident's left hip. -The ADON measured the red wound area on the left hip at 1 cm (l) by 1.3 cm (w) and said the wound was partial thickness (loss of the first two layers of skin). -The resident also had a new area possibly from the dressing that measured 2.1 cm in (l) by 0.5 cm in (w) to the left hip and had partial thickness tissue loss. -With new gloves on his/her hands, LPN A cleaned area with wound cleanser, pat the area dry, and applied a foam adhesive dressing. -LPN A removed gloves and washed his/her hands. -LPN A removed the old dressing that was dated 11/18/19 from the resident's right hip and then removed his/her gloves and washed his/her hands. -The ADON measured the red wound area on the right hip at 5.0 cm (l) by 4.6 cm (w) with a darker area in the middle that measured 0.5 cm (w). -With new gloves on his/her hands, LPN A cleaned area with wound cleanser, pat the area dry, and applied a foam adhesive dressing. -LPN A removed gloves and washed his/her hands. -The ADON measured the resident's right shoulder at 5.0 cm (l) by 4.5 cm (w) and also measured an area that was not red in color at 2.5 cm (l). -LPN A cleaned the area with wound cleanser and then applied skin prep. --The surveyor requested to see the resident's coccyx and heels. -LPN A and the ADON were not aware of any areas on the resident's bottom or heels. -Per the ADON and LPN A the resident's coccyx area had a redden area and a new open area. -The ADON measured the redden area on the resident's coccyx at 5.0 cm in (l) by 7.7 cm (w) and at the top of the coccyx had a small slit area that had opened and measured 0.8 cm (l) by 1.0 cm (w) by 0.2 (d), was macerated (in contact with moisture too long and skin is lighter in color and wrinkled) and had 50-75% slough (dying or dead tissue). -The ADON said he/she was not aware of the coccyx wound and had to call the resident's physician to obtain physician's orders. -Observation of the resident's heels showed no open areas but they were mushy and soft. Record review of the resident's Registered Nurse (RN) Hospice Visit Note dated 11/20/19 showed: -The resident's had a Stage II Coccyx Pressure ulcer that measured 0.5 cm (l) by 0.5 cm (w) by 0.1 cm (d). -Treatment was to cleanse the area with wound cleanser, apply hydrogel, then cover with bordered gauze. The resident physician orders was for daily dressing changes. During an interview on 11/20/19 at 2:15 P.M., CNA A said: -He/she had provided personal care for the resident and was not aware of any open areas at that time. -The resident's bottom had been red. -He/she said the Hospice Health Aide and the facility CNA both do showers and personal cares for the resident. -If he/she found a new open or red skin area, he/she would notify the charge nurse. During an interview on 11/20/19 at 2:31 P.M., the ADON said: -He/she did the resident's Weekly Wound Assessment and the nurses do the Resident's Weekly Skin Assessment. -CNA's complete the bath-sheets. During an interview on 11/20/19 at 3:30 P.M., LPN B said: - Resident #26 did not have an order for wound care or any skin treatment orders on his/her November 2019 POS. -He/she would expect to have physician's order for treatment of the resident wounds. During an interview on 11/20/19 at 3:30 P.M., LPN A said: -His/her normal duties was the desk nurse, which included the assessment of residents on Medicare skilled services and other medical assessment as needed. -The Charge Nurses were assigned the resident's Weekly Skin Assessment and the facility's wound nurse did the resident's Weekly Skin Conditions Wound Assessment. -In review of Resident #26's medical record, he/she was not able to find a physician's order for the resident's wound care treatments or any other skin treatment or monitoring orders. -He/she would expect to have a physician's order for treatment of the resident's wounds. -When staff receive a physician's order, it should be transcribed to the resident's POS and to his/her TAR or Medication Administration Record (MAR). During interview on 11/20/19 3:33 P.M., the ADON said: -He/she had just talked with the resident's Hospice nurse on 11/20/19 and he/she had reported to the facility the resident had three wound areas. -The ADON said he/she was not aware of the new area until it was found today during observation of wound care. -The ADON was not able to explain how the coccyx wound had been documented on 11/14/19 on the resident's Weekly Skin Condition Report as a Stage II coccyx pressure ulcer. During an interview and record review on 11/21/19 10:10 A.M., LPN D said: -Staff should have physician's orders and should document care on the resident's TAR for wound treatments. -Staff should not provide care without a physician's order and if not transcribed onto the MAR or TAR. -Staff should call to verify orders or obtain a physician's orders for care and treatment and then transcribe the order to the resident's POS, TAR and MAR. -The DON and the ADON review the resident's POS, TAR and MAR to ensure physician's orders had been transcribed during the end of month change over. During an interview on 11/21/19 at 2:17 P.M. the DON and Administrator said: -When they receive a physician's telephone order, nurses write the order on the POS, the MAR and TAR. -On the following morning the DON and other administrative staff check the orders during the morning meeting to ensure the orders are correct and verify the medications and treatment supplies were obtained. -They go over the POS, MAR and TAR when there are new orders, to ensure all orders are being accurately transcribed on all three documents and they compare to ensure they are accurate and transcribed correctly. -The reconciliation of the POS's are done at the end of the month by the DON, ADON and MDS Coordinator. -He/she would expect to have a physician's order prior to providing wound care or treatments. -Physician's orders for wound care should have been obtained, and transcribed onto the resident's POS and TAR. -He/she expects staff to follow those physician's orders for treatment and care. -Documentation should be on the TAR showing the treatments were completed as ordered. -If nursing staff see a wound during the skin or wound assessment, he/she expect nursing staff to call the physician and obtain an order for treatment. -The nursing staff should document the new or changing skin or wound issues and should be descriptive to show what it looked like and to include measurements of the wound. -Documentation should be in the weekly skin assessment document and in progress notes. -The nurses were responsible for completing the weekly skin assessments and they should be comprehensive in documenting skin issues if the resident has a skin concern. -The Wound Nurse was responsible for completing the Weekly Skin Conditions Wound Assessment for residents with wounds and he/she should be comprehensive in documenting detailed descriptions of the wound and include measurements. -He/she expected the wound nurse to be responsible in monitoring and tracking the resident's status with skin issues or wounds to include current physician's orders and documentation.5. Record review of Resident #40's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral region (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity), untraceable (Full thickness tissue loss in which the base of the ulcer is covered by slough [necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, & stringy] and/or eschar (tan, brown or black) in the wound bed). Record review of the resident's outside wound care provider documentation dated 5/7/19 showed the resident: -Had a Stage III pressure ulcer (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) to his/her coccyx (tailbone) that was not healed. -The pressure ulcer measured 3 cm in length by 2.3 cm in width by 2 cm in depth with moderate amount of serosanguineous (containing blood and watery drainage) drainage. -The wound bed had 76-100% pink granulation (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention), no slough, no eschar, and no epithelialization present. -The wound was deteriorating. Record review of the resident's outside wound care provider documentation dated 6/18/19 showed the resident: -Had a wound to his/her coccyx. --The documentation did not identify the wound as pressure or non-pressure and did not include measurements. --The wound to the resident's coccyx was documented by the resident's wound care provider as a Stage III pressure ulcer on 5/7/19. Record review of the resident's Initial Wound assessment dated [DATE] showed: -The resident had a surgical wound to his/her coccyx measuring 11.5 cm in length by 1 cm in width with no documented depth. --The wound to the resident's coccyx was documented by the resident's wound care provider as a Stage III pressure ulcer on 5/7/19. Record review of the resident's Weekly Wound assessment dated [DATE] showed: -The resident had a surgical wound to his/her coccyx measuring 11.5 cm in length by 1 cm in width with no document depth. -Had a small amount of serosanguineous drainage with a no amount of odor. -The wound was closed or was a suspected deep tissue injury (may be characterized by a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Presentation may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue). --The wound to the resident's coccyx was documented by the resident's wound care provider as a Stage III pressure ulcer on 5/7/19. Record review of the resident's Weekly Wound assessment dated [DATE] showed: -The resident had a surgical wound to his/her coccyx measuring 5 cm in length by 0.6 cm in width with no document depth. -Had a small amount of purulent (a thick, milky discharge often indicating an infection) drainage with a moderate amount of odor. --The wound to the resident's coccyx was documented by the resident's wound care provider as a Stage III pressure ulcer on 5/7/19. Record review of the resident's Weekly Skin Condition Report dated 9/30/19 showed the resident: -Had an unspecified wound to his/her coccyx with no measurements. -There was no documentation of the description about the wound. -There was no documentation of the type of wound the resident had. Record review of the resident's outside wound care provider documentation dated 10/1/19 showed: -The resident had a pressure ulcer of his/her sacral region, unspecified stage. -The pressure ulcer onset date was 10/20/18. -The pressure ulcer had several measurements from top to bottom as follows: --1.1 cm in length by 0.3 cm in width by 0.1 cm in depth. --0.3 cm in length by 0.3 cm in width by 0.1 cm in depth. --0.3 cm in length by 0.3 cm in width by 0.1 cm in depth. --2.5 cm in length by 1 cm in width by 3.5 cm in depth. --0.3 cm in length by 0.3 cm in width by 0.2 cm in depth. --0.3 cm in length by 0.2 cm in width by 0.1 cm in depth. -Wound care orders were to apply with silvercell wick (a wound treatment) to largest wound in the center and Aquacel AG strip (a wound treatment) applied over all wounds, cover with tegaderm sacral foam. Skin barrier wipe was applied before and after foam to improve dressing adherence. Additional 4X4 optifoam AG gentle silicone faced and bordered applied at the top portion of the dressing to fully cover the area. Record review of the resident's outside wound care provider documentation dated 10/9/19 showed: -The resident had an unspecified stage pressure ulcer to his/her sacral region. -The wound measured 2.2 cm in length by 1.3 cm in width by 3 cm in depth. -The wound bed was pink with copious amounts of serosanguineous drainage. -The wound had undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure is larger at its base than at the skin surface. Undermining often develops from shearing forces and is differentiated from tunneling by the larger extent of the wound edge involved in undermining and the absence of a channel or tract extending from the pressure ulcer under the adjacent intact skin) present: at noon: 1.5 cm; at 3 o'clock 2 cm; at 6 o'clock 1.7 cm; at 9 o'clock 2 cm. Record review of the resident's Weekly Skin Condition Report dated 10/14/19 showed the resident: -Had a surgical incision to his/her sacral region measuring 2.9 cm in length by 1 cm in width by 3.6 cm in depth with large amount of serosanguineous drainage. -NOTE: The resident's outside wound care provider documented the resident's wound as a pressure ulcer. Record review of the resident's Daily Skilled Nursing Note dated 10/19/19 showed: -The resident had a wound to his/her sacral area described as other skin issues. -The documentation did not identify the type of wound the resident had, whether it was pressure ulcer or non-pressure ulcer, did not describe the appearance of the wound, if the wound had any drainage or odor, or any wound measurements. Record review of the resident's annual MDS dated [DATE] showed the resident: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. -Required extensive staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. -Had a urinary catheter and colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen). -Had no pressure ulcers or skin issues. Record review of the resident's Weekly Skin Condition Report dated 10/21/19 showed the resident: -Had a surgical incision to his/her sacral region measuring 1.7 cm in length by 0.8 cm in width by 3.3 cm in depth with large amount of serosanguineous drainage. -The wound condition had improved. -NOTE: The resident's outside wound care provider documented the resident's wound as an untraceable pressure ulcer. Record review of the resident's Weekly Skin Condition Report dated 10/28/19 showed the resident: -Had a surgical incision to his/her sacral region measuring 1.2 cm in length by 0.7 cm in width by 3 cm in depth with moderate serosanguineous drainage. -The wound condition had improved. -The pressure ulcer had undermining starting at 1 o'clock around to the 12 o'clock position with a maximum distance of 0.5 cm. -NOTE: The resident's outside wound care provider documented the resident's wound as a pressure ulcer. Record review of the resident's outside wound care provider documentation dated 10/30/19 showed: -The resident had a stage IV pressure ulcer of his/her sacral region. -Had a pressure ulcer in the middle of the sacral region. -The documentation did not include measurements. -Staff were directed to clean the wound by flushing the wound with 30 milliliters (ml) normal saline, then absorb excess normal saline with 4X4s before repacking the wound and to change the dressing every third day or more often if needed if outer dressing is saturated. Record review of the resident's November 2019 POS showed: -Wound care treatment: With the resident on his/her left side, remove the old dressing. -Cleanse the wound with sterile saline and 4x4, apply skin barrier to intact skin surrounding the wound -Xerofoam to wound bed, cover with two Allvyn (a wound dressing) foams. -Skin barrier to dressing edges to improve adherence. -Change dressing every two days and as needed if soiled. --NOTE: The new wound care orders by the resident's wound care physician dated 10/30/19 were not transcribed to the resident's current POS. Record review of the resident's November 2019 MAR and TAR showed: -Clean wound with normal saline and pat dry. -Apply Aquacel AG rope (a wound treatment used to pack a wound for healing). -Use skin prep to assist with dressing adhesion. -Change every three days. Record review of the facility's Weekly Skin Condition Report dated 11/4/19 showed: -The resident had a surgical wound in the sacral region measuring 1.5 cm in length by 1 cm in width by 2.7 cm in depth. -The wound bed was dark pink/red and had slough. -There was no change in the wound from the previous assessment. -The pressure ulcer had undermining starting at 1 o'clock around to the 12 o'clock position with a maximum distance of 0.5 cm. -The wound had deteriorated since the previous assessment. --NOTE: the resident's wound care provider documented the resident's wound was a stage IV pressure ulcer, not a surgical wound. Record review of the resident's outside wound care provider documentation dated 11/12/19 showed: -The resident had a stage IV pressure ulcer to his/her sacral region. -He/she had osteomyelitis (infection of the bone) of the vertebra, sacral and sacrococcygeal region. -Had a pressure ulcer in the middle of the sacral region. -The documentation did not include measurements. -Staff were directed to clean the wound by flushing the wound with 30 ml normal saline, then absorb excess normal saline with 4X4s before repacking the wound and to change the dressing every third day or more often if needed if outer dressing is saturated. Record review of the facility's Weekly Skin Condition Report dated 11/13/19 showed: -The resident had a surgical wound in the sacral region measuring 1.5 cm in length by 1 cm in width by 2.7 cm in depth. -The wound bed was dark pink/red and had slough. -There was no change in the wound from the previous assessment. --NOTE: the resident's wound care provider documented the resident's wound was a stage IV pressure ulcer, not a surgical wound. Observation of the resident on 11/20/19 at 10:59 A.M. showed LPN D: -Placed the resident's wound care supplies on his/her bedside table without a barrier. -Said the resident's wound care orders were for the wound to be cleansed with wound cleanser and pack with Aquacel rope, but he/she did not have any Aquacel rope in his/her treatment cart. -He/She completes the resident's wound care weekly and the resident's wound care provider does it on the other days. -He/She washed his/her hands and put on clean gloves. -CNA C washed his/her hands and put on clean gloves. -LPN D removed the resident's Foley catheter from the side of the bed and handed it to CNA C. -Both LPN D and CNA C touched the resident to assist him/her to turn to his/her left side. -LPN D removed the resident's old undated dressing. -LPN D removed the packing from the resident's wound, removed his/her gloves, washed his/her hands and put on clean gloves. -LPN D sprayed the resident's wound with wound cleanser and wiped it with gauze. -He/She removed his/her gloves, washed his/her hands and put on clean gloves. -He/She applied 6 x 6 bordered gauze dressing to the sacral wound. During an interview on 11/20/19 at 11:15 A.M., LPN D said: -He/She should have placed the resident's wound care supplies on a barrier. -The resident did not have Aquacel rope so he/she was not able to do the resident's wound care as it was ordered by his/her physician. During an interview on 11/21/19 at 10:31 A.M., the ADON said: -He/She was responsible for wound documentation in the facility. -The resident had a pressure ulcer to his/her coccyx/sacral area, but then had surgical repair to the site. -After the physician did a surgical repair to the resident's pressure ulcer, he/she thought the type of wound would change from pressure ulcer to surgical wound. -The resident's wound care orders should match on his/her POS and MAR/TAR. -He/she could not find an order to cleanse the resident's wound and put on a dry dressing if he/she did not have Aquacel rope to pack the resident's wound. -Staff should follow the resident's physician's order for wound care. During an interview on 11/21/19 at 3:11 P.M., the Administrator and DON said: -Staff should follow the resident's physician's orders for wound care. -The resident should have plenty of Aquacel rope and if he/she did not, he/she would expect staff to notify him/her to order more. -He/She expected staff to accurately document the type of wound a resident had, if the wound was pressure or non-pressure, the measurements, and description of the resident's wound. 6. Record review of Resident #197's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system). -Pressure ulcer, unspecified stage. -Right below the knee amputation. -Left below the knee amputation. -Colostomy. -Paraplegia (loss of movement of both legs and generally the lower trunk). Record review of the resident's Weekly Wound assessment dated [DATE] showed: -The resident had a stage IV pressure ulcer to his/her right and left buttocks measuring 15 cm in length by 24 cm in width and 3.3 cm in depth. -The wound had undermining the full circumference of the wound measuring a maximum of 4.5 cm. -The wound had tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) at the 6 o'clock position with measuring a maximum of 7 cm. -The wound had a large amount of purulent foul smelling drainage. -The wound bed had 25% epithelial tissue, 25% granulation, and 50% slough. Record review of the resident's Weekly Wound assessment dated [DATE] showed: -The resident had a stage IV pressure ulcer to his/her sacral area measuring 14 cm in length by 25 cm in width and 0.7 cm in depth. -The wound had undermining at 1 o'clock to 7 o'clock with a maximum of 2.1 cm. -The wound had tunneling at the 12 o'clock position with measuring a maximum of 0.7 cm. -The wound had a large amount of serosanguineous slight smelling drainage. -The wound bed had 50% epithelial tissue, 25% granulation, and 25% slough. --The documentation did not address the resident's right or left buttocks pressure ulcers. Record review of the resident's Weekly Wound assessment dated [DATE] showed: -The resident had a stage IV pressure ulcer to his/her sacral area measuring 9 cm in length by 25 cm in width and 0.7 cm in depth. -The wound had undermining at 12 o'clock to 6 o'clock with a maximum of 0.6 cm. -The wound had no tunneling. -The wound had a large amount of serosanguineous slight smelling drainage. -The wound bed had 50% epithelial tissue, 25% granulation, and 25% slough. Record review of the resident's Weekly Wound assessment dated [DATE] showed: -The resident had a stage IV pressure ulcer to his/her sacral area measuring 15 cm in length by 23 cm in width and 1 cm in depth. -The wound had no undermining or tunneling. -The wound had a large amount of serosanguineous foul smelling drainage. -The wound bed had 25% epithelial tissue, 25% granulation, and 50% slough. Record review of the resident's Weekly Wound assessment dated [DATE] showed: -The resident had a stage IV pressure ulcer to his/her sacral area measuring 12.5 cm in length by 26 cm in width and 2 cm in depth. -The wound had no undermining. -The wound had tunneling at the 12 o'clock position with a maximum of 1.5 cm. -The wound had a large amount of serosanguineous slight smelling drainage. -The wound bed had 100% slough. Record review of the resident's Weekly Wound assessment dated [DATE] showed: -The resident had a stage IV pressure ulcer to his/her left buttock measuring 7 cm in length by 5 cm in width and 0.7 cm in depth. -The wound had no undermining or tunneling. -The wound had a moderate amount of serosanguineous slight smelling drainage. -The wound bed had 50% epithelial and 50% slough. -The resident had a stage III pressure ulcer to his/her right buttock measuring 5 cm in length by 2 cm in width by 1.3 cm in depth. -The wound had no undermining or tunneling. -The wound had a small amount of serosanguineous slight odor drainage, -The wound had 50% granulation and 50% slough. --No documentation the resident's physician was notified of the new pressure ulcers to the resident's right and left buttocks or that the resident's sacral pressure ulcer had healed. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS of 15 out of 15. -Required total staff dependence for bed mobility, transfers, dressing, toileting, and personal hygiene. -Had a urinary catheter and colostomy. -Had Stage III pressure ulcer and Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). Record review of the resident's outside wound care provider dated 10/28/19 showed: -The resident had a stage IV pressure ulcer on his/her left buttock. -The resident had a stage IV pressure ulcer on his/her right buttock. -Staff were to clean the resident's wound with Normal Saline and change dressings every day. -The documentation did not include measurements of the wounds or descriptions of the pressure ulcers. Record review of the resident's Weekly Skin Condition Report dated 10/28/19 showed: -The resident had a stage IV pressure ulcer to his/her left buttock measuring 5.5 cm in length by 2.5 cm in width and 1 cm in depth. -The wound had a moderate amount of serosanguineous drainage. -The wound bed was dark pink/red and had slough. -The wound had improved. -The resident had a stage III pressure ulcer to his/her right buttock measuring 6 cm in length by 1 cm in width by 1 cm in depth. -The wound had a moderate amount of foul smelling drainage, -The wound bed was pale pink and had slough. -The wound had improved. --The resident's outside wound care provider documented the resident's right buttock pressure ulcer as a stage IV pressure ulcer, not a stage III pressure ulcer. Record review of the resident's November 2019 POS showed: -Dakins solution 0.125%, dilute to 1/4 strength and apply to the resident's left buttock wound and right buttock wound twice daily, dated 11/14/19. -Wound treatment to the resident's right and left buttocks: clean with wound cleanser, pat dry, apply calcium alginate to wound bed and cover with bordered gauze and reinforce with mefix tape if needed, change twice daily - undated order. R

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff documented the shift change narcotic count; to ensure a resident's Fentanyl patch (a narcotic medication) was signed off by two staff members when the patch was removed from a resident for destruction for two sampled residents (Resident #40 and #197), and to ensure a narcotic medication brought into the facility from the resident was verified by the facility pharmacy and accurately accounted for for one supplemental resident (Resident #27). The facility census was 55 residents. Record review of the facility's Discarding and Destroying Medications policy dated 6/12: -Medications that cannot be returned to the dispensing pharmacy shall be destroyed as permitted by state regulations. -All controlled substances shall be retained in a securely locked area with restricted access until authorized individuals destroy them. -Scheduled II, III, and IV controlled drugs must be destroyed by the Director of Nursing (DON) and another licensed nurse or per state law. -The medication disposition record must contain, as a minimum, the following information: --The resident's name; the date the medication was destroyed; the name and strength of the medication; the quantity destroyed; reason for destruction; and signature of witnesses. -Whoever witnesses the destruction/disposal of medications must sign and date the medication disposition record. Record review of the facility's Medications Brought to the Facility by the Resident/Family revised April 2007 showed: -The facility ordinarily shall not permit residents and families to bring medications into the facility. -Residents and families must report to the nursing staff any medications that they want to bring, or have brought, into the facility. -The facility discourages the use of medications brought in from outside, and will inform residents and families of that policy, as well as applicable laws and regulations. -If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the Attending Physician and Consultant Pharmacist, shall check to ensure that the contents of each container have been verified by a licensed pharmacist. -Medications brought into the facility that are not approved for the resident's use shall be returned to the family. If the family does not pick up those medications within thirty (30) days, the facility may destroy them in accordance with established policies. 1. Observation of the narcotic shift count on 11/19/19 at 6:40 A.M. showed: -An unidentified night nurse and Licensed Practical Nurse (LPN) C completed the narcotic count for the 100/200 medication cart and for the 300/400 medication cart. -LPN C did not sign as the nurse oncoming nurse the count was completed for either medication cart. Record review of the 100/200 medication cart Change of Shift Narcotic Count record showed: -Staff were instructed the narcotic count must be completed and signed by two staff members at each change of shift. -The form had a space for three shifts each day, a space for the staff coming on duty to sign, a space for the staff going off duty to sign, the count, and any comments. -A notation on 9/15/19 3-11 shift correct count on three with no further comments. -Between 10/11/19 -11/19/19 two staff did not sign the count sheet 54 times out of 236 opportunities. -The oncoming nurse did not sign he/she performed the narcotic count on 11/19/19. Record review of the 300/400 medication cart Change of Shift Narcotic Count record showed: -Staff were instructed the narcotic count must be completed and signed by two staff members at each change of shift. -The form had a space for three shifts each day, a space for the staff coming on duty to sign, a space for the staff going off duty to sign, the count, and any comments. -Between 8/31/19 -11/19/19 two staff did not sign the count sheet 61 times out of 482 opportunities. -The oncoming nurse did not sign he/she performed the narcotic count on 11/19/19. -After a copy was requested of the Change of Shift Narcotic Count record, LPN D signed in the spot the oncoming staff who counted the narcotics on 11/19/19 should have signed. --LPN D did not perform the count during the change of shift on 11/19/19. During an interview on 11/20/19 at 3:11 P.M., LPN D said: -Staff should complete the Change of Shift Narcotic count at each shift. -He/She did not do the narcotic count at the beginning of the shift on 11/19/19, the other day nurse, LPN C did. -He/She should not have signed the Change of Shift Narcotic count record as the oncoming staff who did the count on 11/19/19 since he/she did not do the count. -The staff person who did the count should have been the person to sign the shift change narcotic count record, During an interview on 11/21/19 at 2:44 P.M., the Administrator and DON said: -He/she expected oncoming staff to count narcotics with the off-going staff each shift. -He/she expected the staff who counted the narcotics sign the Narcotic Count record to show it was performed and that it was correct. -It was not appropriate for staff who did not perform the count to sign the Change of Shift Narcotic Count record. 2. Record review of Resident #40's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Anxiety disorder. -Pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral region (tailbone), unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough [necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy] and/or eschar (tan, brown or black) in the wound bed). -Bipolar disorder (mood disorders characterized usually by alternating episodes of depression and mania). -Major Depressive Disorder. Record review of the resident's Care Plan dated 10/15/18 and revised on 10/17/19 showed no care plan for the resident's pain medication. Record review of the resident's September 2019 Physician's Order Sheet (POS) and Medication Administration Record (MAR) showed: -Fentanyl 12 microgram per hour (mcg/hr) patch - remove old patch and apply new patch every 72 hours with a 25 mcg/hr patch. -Fentanyl 25 mcg/hr patch - remove old patch and apply new patch every 72 hours with a 12 mcg/hr patch. --The MAR showed one staff member signed each time the patches were removed and new patches applied on 9/3/19, 9/6/19, 9/12/19, 9/15/19, 9/18/19, 9/21/19, 9/24/19, 9/27/19, and 9/30/19. Record review of the resident's Fentanyl 25 mcg/hr Controlled Medication Utilization Record showed: -One nurse signed out the 25 mcg/hr Fentanyl patch on 9/3/19, 9/6/19, 9/12/19, 9/15/19, 9/18/19, 9/21/19, 9/24/19, 9/27/19, and 9/30/19. -No documentation by the facility staff that the old patch was destroyed, how it was destroyed, or who witnessed the destruction. Record review of the resident's Fentanyl 12 mcg/hr Controlled Medication Utilization Record showed: -One nurse signed out the 12 mcg/hr Fentanyl patch on 9/3/19, 9/6/19, 9/12/19, 9/15/19, 9/18/19, 9/21/19, 9/24/19, 9/27/19, and 9/30/19. -No documentation by the facility staff that the old patch was destroyed, how it was destroyed, or who witnessed the destruction. Record review of the resident's October 2019 POS and MAR showed: -Fentanyl 12 mcg/hr patch - remove old patch and apply new patch every 72 hours with a 25 mcg/hr patch. -Fentanyl 25 mcg/hr patch - remove old patch and apply new patch every 72 hours with a 12 mcg/hr patch. --The MAR showed one staff member signed each time the patches were removed and new patches applied on 10/3/19, 10/6/19, 10/9/19, 10/12/19, 10/14/19, 10/17/19, 10/20/19, and 10/23/19. --The remainder of the month was crossed out with discontinued handwritten across the MAR. Record review of the resident's Fentanyl 25 mcg/hr Controlled Medication Utilization Record showed: -One nurse signed out the 25 mcg/hr Fentanyl patch on 10/3/19, 10/6/19, 10/14/19, 10/18/19, 10/20/19, 10/23/19, and 10/25/19. --No documentation a 25 mcg/hr Fentanyl patch was signed out between 10/6/19 - 10/14/19. --The patch was ordered to be changed every 72 hours (3 days). The administration between 10/14/19 - 10/18/19 was 4 days, and 10/23/19 - 10/25/19 was 2 days. -No documentation by the facility staff that the old patch was destroyed, how it was destroyed, or who witnessed the destruction. Record review of the resident's Fentanyl 12 mcg/hr Controlled Medication Utilization Record showed: -One nurse signed out the 12 mcg/hr Fentanyl patch on 10/3/19, 10/6/19, 10/9/19, and 10/10/19. --No documentation a 12 mcg/hr Fentanyl patch was signed out after 10/10/19. --The patch was ordered to be changed every 72 hours (3 days). The administration between 10/9/19 and 10/10/19 was 24 hours, or one day. --The resident had orders to receive a 12 mcg/hr patch with a 25 mcg/hr patch. The facility was unable to provide documentation a 12 mcg/hr patch was received, signed out, and available to be placed on the resident per the resident's physician's orders. -No documentation by the facility staff that the old patch was destroyed, how it was destroyed, or who witnessed the destruction. Record review of the resident's Fentanyl 50 mcg/hr Controlled Medication Utilization Record showed: -One nurse signed out the 50 mcg/hr Fentanyl patch on 10/26/19 and 10/29/19. -No documentation by the facility staff that the old patch was destroyed, how it was destroyed, or who witnessed the destruction. Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/20/19 showed the resident: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15. -Required extensive staff assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. -Had a urinary catheter and colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen). -Had no pressure ulcers or skin issues. -Had pain and received scheduled pain medications. -Received an opioid medication seven out of seven days during the look-back period. Record review of the resident's November 2019 POS and MAR showed: -Fentanyl 50 mcg/hr patch apply and remove one patch every 72 hours for right hip pain dated 10/25/19. --The MAR showed one staff member signed each time the patches were removed and new patches applied on 11/2/19, 11/5/19, 11/8/19, 11/11/19, 11/14/19, and 11/17/19. Record review of the resident's Fentanyl 50 mcg/hr Controlled Medication Utilization Record showed: -One nurse signed out the 50 mcg/hr Fentanyl patch on 11/2/19, 11/5/19, 11/8/19, 11/11/19, 11/14/19, and 11/17/19. -No documentation by the facility staff that the old patch was destroyed, how it was destroyed, or who witnessed the destruction. 3. Record review of Resident #197's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system). -Pressure ulcer, unspecified stage. -Right below the knee amputation. -Left below the knee amputation. -Colostomy. -Major Depressive disorder. -Anxiety. -Paraplegia (loss of movement of both legs and generally the lower trunk). Record review of the resident's September 2019 POS and MAR showed: -Fentanyl 25 mcg/hr apply and remove one patch with a 12 mcg/hr patch to equal 37 mcg/hr every 72 hours. -The MAR showed one staff member signed each time an old patch was removed and a new patch was applied on 9/2/19, 9/5/19, 9/8/19, 9/11/19, 9/14/19, 9/17/19, 9/20/19, 9/23/19, 9/26/19, and 9/29/19. -Fentanyl 12 mcg/hr apply and remove one patch with a 25 mcg/hr patch to equal 37 mcg/hr every 72 hours. -The MAR showed one staff member signed each time an old patch was removed and a new patch was applied on 9/2/19, 9/20/19, 9/23/19, 9/26/19, and 9/29/19. The 12 mcg/hr patch was marked as not available on 9/5/19, 9/8/19, 9/11/19, 9/14/19, and 9/17/19. Record review of the resident's Fentanyl 25 mcg/hr Controlled Medication Utilization Record showed: -One nurse signed out the 25 mcg/hr Fentanyl patch on 9/5/19, 9/8/19, 9/11/19, 9/14/19, 9/17/19, 9/20/19, 9/23/19, 9/26/19, and 9/29/19. -No documentation by the facility staff that the old patch was destroyed, how it was destroyed, or who witnessed the destruction. Record review of the resident's Fentanyl 12 mcg/hr Controlled Medication Utilization Record showed: -One nurse signed out the 12 mcg/hr Fentanyl patch on 9/20/19, 9/23/19, 9/26/19, and 9/29/19. -No documentation by the facility staff that 12 mcg/hr Fentanyl patches were received or available for the resident between 9/1/19 - 9/20/19. -No documentation by the facility staff that the old patch was destroyed, how it was destroyed, or who witnessed the destruction. Record review of the resident's October 2019 POS showed: -Fentanyl 25 mcg/hr apply and remove one patch with a 12 mcg/hr patch to equal 37 mcg/hr every 72 hours. -The MAR showed one staff member signed each time an old patch was removed and a new patch was applied on 10/2/19, 10/6/19, 10/9/19, 10/14/19, 10/17/19, 10/20/19, 10/23/19, 10/26/19, and 10/29/19. -Fentanyl 12 mcg/hr apply and remove one patch with a 25 mcg/hr patch to equal 37 mcg/hr every 72 hours. -The MAR showed one staff member signed each time an old patch was removed and a new patch was applied on 10/6/19, 10/10/19, 10/14/19, 10/17/19, 10/20/19, 10/23/19, 10/26/19, and 10/29/19. The 12 mcg/hr patch was not available on 10/2/19. Record review of the resident's Fentanyl 25 mcg/hr Controlled Medication Utilization Record showed: -One nurse signed out the 25 mcg/hr Fentanyl patch on 10/2/19, 10/17/19, 10/20/19, 10/23/19, 10/26/19, 10/29/19. --No documentation by the facility to show the resident had 25 Fentanyl patches received or available between 10/2/19 - 10/17/19. -No documentation by the facility staff that the old patch was destroyed, how it was destroyed, or who witnessed the destruction. Record review of the resident's Fentanyl 12 mcg/hr Controlled Medication Utilization Record showed: -One nurse signed out the 12 mcg/hr Fentanyl patch on 10/2/19, 10/14/19, 10/17/19 10/20/19, 10/23/19, and 10/26/19. -No documentation by the facility staff that the old patch was destroyed, how it was destroyed, or who witnessed the destruction. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS of 15 out of 15. -Required total staff dependence for bed mobility, transfers, dressing, toileting, and personal hygiene. -Had a urinary catheter and colostomy. -Had Stage III pressure ulcer (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) and Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). -Received opioid pain medications seven out of seven days during the look-back period. -Received scheduled pain medication. Record review of the resident's November 2019 POS showed: -Fentanyl 25 mcg/hr apply and remove one patch with a 12 mcg/hr patch to equal 37 mcg/hr every 72 hours. -Fentanyl 12 mcg/hr apply and remove one patch with a 25 mcg/hr patch to equal 37 mcg/hr every 72 hours. Note: Fentanyl 25 mcg/hr and Fentanyl 25 mcg/hr patch Controlled Medication Utilization Records for November 2019 were requested and not received at the time of survey. During an interview on 11/20/19 at 3:03 P.M., LPN A said: -One nurse signs the MAR they have removed the Fentanyl patch. -He/she did not think two nurses had to sign for the removal of a Fentanyl patch. During an interview on 11/20/19 at 3:11 P.M., LPN D said: -One nurse signs the MAR they have removed the Fentanyl patch. -He/She did not think two nurses had to sign for the removal of a Fentanyl patch. During an interview on 11/21/19 at 2:44 P.M., the Administrator and DON said: -He/she expected two staff to document the removal of a Fentanyl patch. -He/she expected staff to document the destruction of the Fentanyl patch on the resident's MAR. 4. Record review of supplemental Resident #27's admission MDS dated [DATE] showed the resident: -Was cognitively intact with a BIMS of 13 out of 15. -Was on hospice services. -Received an anti-anxiety seven out of seven days during the look-back period. Observation on 11/19/19 at 8:07 A.M. of the medication room refrigerator showed: -An opened bottle of a liquid substance in an Ativan Intensol bottle with approximately 25 milliliters (ml) in the bottle, not double locked in the refrigerator. -The bottle had Resident #27's name on the label. During an interview on 11/19/19 at 8:07 A.M., the Assistant Director of Nursing (ADON) said: -He/she could see that the Ativan bottle had been opened with some contents missing. -He/she thought the bottle of Ativan was brought in by the resident, his/her family, or his/her hospice (end of life care) provider when the resident was admitted . -The resident's Narcotic Record showed the Ativan bottle should have a full 30 ml in the bottle. -The bottle was in the medication room refrigerator and not in a double locked system. -The bottle of Ativan should have been double locked in the medication refrigerator. -He/She could not say for certain the bottle contained Ativan since it had not been obtained through the facility pharmacy. Record review of the resident's Individual Patient Narcotic Record showed: -The resident's name handwritten on the form. -Ativan 2 milligrams (mg) per ml handwritten on the form. -Administer 0.25 - 1 ml every four hours as needed handwritten on the form. -The form was dated 9/6/19. -The amount on hand was documented as 30 ml. --A copy of the form was requested and upon receipt, 30 ml was crossed out with a notation correct count 25 ml. The notation was signed by LPN C and the MDS Coordinator. During an interview on 11/19/19 at 8:30 A.M., LPN C said: -He/she thought the bottle of Ativan may have been brought in by the resident's hospice provider when he/she was admitted to the facility, but he/she was not certain of that. -The bottle of Ativan had been opened and the bottle was not full. -He/she did not think the facility pharmacy had verified the contents of the bottle. During an interview on 11/20/19 at 8:55 A.M., the MDS Coordinator said: -He/she signed the corrected total on the Ativan narcotic record without checking with pharmacy to verify the contents of the bottle. -He/she did not know when the bottle of Ativan was opened or if it was received in the facility opened. -He/she did not know who brought in the bottle of Ativan for the resident. -He/she did not know what happened to the unaccounted for 5 ml's of Ativan from the bottle. -He/she thought LPN A admitted the resident and may have received the bottle during the resident's admission process. During an interview on 11/20/19 at 3:03 P.M., LPN A said: -He/she did not accept a bottle of Ativan from the resident, the resident's family, or the resident's hospice provider during the resident's admission process. -He/she would not accept a narcotic medication brought in from an outside source. -The medication should have been verified by the pharmacy. -If the bottle of Ativan had been received during the admission process, staff should have written a note about it, including the name of the medication, the amount of the medication, what the medication was, and that it was going to be verified by pharmacy. -Staff should have noticed during the shift change count that the bottle did not have 30 ml's in it. -Staff sign the shift count sheet acknowledging they witnessed the narcotic count and verify the count is correct.

Based on observation, interview, and record review the facility failed to maintain the temperature of the mechanical soft pork riblet at or above 135 degrees Fahrenheit (ºF) for the duration of the dinner meal service and to implement measures to ensure the whole roasted turkeys were cooled to at least 70 ºF within two hours after being removed from the oven. This practice potentially affected all residents. The facility census was 55 residents. 1. Observation on 11/18/19, during the dinner meal preparation and service, showed: - At 4:57 P.M., the Dietary [NAME] (DC) placed six pieces of pork riblets in the food processor to grind into a mechanical soft texture. - At 5:07 P.M., the DC placed ground meat on steam table and failed to check the temperature after the mechanical soft meat was left in the food processor for about 10 minutes. - At 5:32 P.M., the temperature of the mechanical soft riblet was 129.5 ºF, and - At 5:54 P.M., the temperature of the mechanical soft riblet, was 119.6 ºF with seven residents left to serve. During an interview on 11/18/19 at 6:06 A.M., the DC acknowledged that he/she did not check the temperature of the mechanical soft riblet before he/she placed it on the steam table. 2. Observation on 11/18/19 between 3:30 P.M. through 3:40 P.M., showed the Dietary Manager (DM) took whole roasted turkeys out of the ovens and at that time all temperatures of the roasted turkeys were above 190 ºF. - At 4:00 P.M., the DM placed the roasted turkeys into the walk-in refrigerator and - At 6:22 P.M., over two hours after the roasted turkeys were placed into the walk-in refrigerator, the temperature of one of the whole roasted turkeys was 153.4 ºF, which was 83.4 ºF above the required goal temperature of 70 ºF. Record review of the following chapter of the 2017 Food and Drug Administration (FDA) Food Code, showed: -Chapter 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under paragraphs B and C of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: 1) At 135 ºF or above, except that roasts cooked to a temperature and for a time specified in paragraphs 3-401.11(B) or reheated as specified in paragraph 3-403.11(E) may be held at a temperature of 135 ºF or above. Chapter 3-501.14 Cooling. A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: Within 2 hours from 135ºF to 70°F; and (2) Within a total of 6 hours from 135ºF to 41°F or less. -3-501.15 Cooling Methods. A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under -3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: 1) Placing the FOOD in shallow pans; 2) Separating the FOOD into smaller or thinner portions; 3) Using rapid cooling EQUIPMENT; 4) Stirring the FOOD in a container placed in an ice water bath; 5) Using containers that facilitate heat transfer; 6) Adding ice as an ingredient; or 7) Other effective methods.

Based on observation, interview and record review, the facility failed to do or maintain the following: maintain the pipes of the suppression system above the six burner stove free of dust, maintain the area where the fan vent covers were screwed into the walk-in refrigerator, maintain the light fixtures above the steam table free from a buildup of dust, maintain the floor behind the table with the large mixer on it free from food crumbs and debris, maintain the gasket (a seal which fills the space between two or more mating surfaces, generally to prevent leakage from or into the joined objects while under compression) in the walk-in refrigerator to be tight fitting, maintain the floor of the dry goods storage room free from food crumbs, and maintain two the handles of two utensils in an easily cleanable condition, This practice potentially affected all residents. The facility census was 55 residents. 1. Observation and interview on 11/18/19 from 2:19 P.M. through 6:19 P.M, during the dinner preparation, showed: - At 2:21 P.M., dust on range hood extinguishing pipes above stove top. - At 2:25 P.M., there was a dust buildup on fan vent covers in walk-on fridge. - At 2:28 P.M., there was dust on light fixtures above juice machine table, and the steam table. - At 2:34 P.M., there were food crumbs behind the table with big mixer on it. - At 3:24 P.M., a length of the gasket equivalent to 46 inches from the bottom of the walk-in refrigerator door, was peeling away. - At 3:25 P.M., the Dietary Manager (DM) said the gasket has been coming away from the door for the last month, and - At 3:27 P.M., there were two utensils in the utensil storage bin with handles that had melted areas, which made them not easily cleanable. During and interview on 11/18/19 at 6:11 P.M., the DM said: - He/she told her evening person about mopping that store room on a previous night but he/she must have missed it. - The table with the mixer did not get moved very often. - The dietary staff cleaned the fan vent covers of the walk-in refrigerator once per month but not the lip of where the cover was attached to the walk-in refrigerator itself, meet the base. - He/she did not notice the gasket peeling away until the day of the kitchen observations, and - The dishwasher should check for the damaged utensils with melted handles. Record review of the 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: In Chapter 4-501.11, showed Good Repair and Proper Adjustment. A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. - In Chapter 4-602.13, non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues - In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain commode risers in good condition in resident rooms [ROOM NUMBERS]; to maintain the backing of the 400 Hall shower chair without rips; and to maintain the drawers in resident rooms [ROOM NUMBERS] in good repair. This practice potentially affected at least 20 residents who resided in or used those areas. The facility census was 55 residents. 1. Observation on 11/18/19 11:55 A.M., showed the drawers were off of the slides (the metal pieces that are a part of a drawer unit that allows the actual drawer to move in and out, and facilitated by ball bearings, ensuring that movement is smooth) of the night stand and not closing completely in resident room [ROOM NUMBER]. 2. Observations on 11/19/19 showed the following: - At 8:43 A.M., there was rust on the commode riser in the restroom of 206. - At 8:50 A.M., the drawer in resident room [ROOM NUMBER] was broken. - At 10:06 A.M., there were three 3 inch (in) rips in the backing of the shower chair in the 400 Hall Central Bath. - At 10:14 A.M., the Central Supply Coordinator said no one notified him/her of the damaged shower chair. - At 11:01 A.M., there was a 10 in crack in the handle of the commode riser in the restroom of resident room [ROOM NUMBER]. - At 11:02 A.M., the Maintenance Director said he/she did not know about the damaged handle of the commode riser. - At 11:06 A.M., the night stand in resident room [ROOM NUMBER] was damaged. - At 11:07 A.M., the Maintenance Director said the wheel for one of the drawers in the night stand was absent. - At 11:19 A.M., the Central Supply Coordinator said no one informed him/her of the rusty commode riser. - At 11:21 A.M., Housekeeper A said he/she saw the rusty commode riser in the past but has not informed the Central Supply Coordinator of the rusty commode riser, and - At 11:23 A.M., the Central Supply Coordinator said he/she was not informed of the damaged commode riser in the restroom of resident room [ROOM NUMBER]. During interviews on 11/20/19 at 2:11 P.M., the Housekeeping Supervisor said the following: - He/she has been the Housekeeping Supervisor since April 2018, and - He/she has not done a formal training with her housekeeping staff in the reporting of damaged items.

Based on observation, interview, and record review, the facility failed to ensure expired medications were removed from the medication delivery system; discontinued medications were returned to the pharmacy in a timely manner; multi-dose vials were marked with the date the vial was opened and accessed; narcotic medications were stored in a double-locked system; and medication refrigerator temperatures were monitored to ensure safe storage of refrigerated medications. This deficient practice had the potential to effect all residents who had medications which required refrigeration. The facility census was 55 residents. Record review of the facility's Refrigerator and Freezer Temperature Log showed: -The refrigerator needs to be at 36 - 46 degrees Fahrenheit (F). -The ideal refrigerator temperature was 40 degrees F. Record review of the facility's Discarding and Destroying Medications policy dated 6/12: -Medications that cannot be returned to the dispensing pharmacy shall be destroyed as permitted by state regulations. -All controlled substances shall be retained in a securely locked area with restricted access until authorized individuals destroy them. -The medication disposition record must contain, as a minimum, the following information: --The resident's name; the date the medication was destroyed; the name and strength of the medication; the quantity destroyed; reason for destruction; and signature of witnesses. -Whoever witnesses the destruction/disposal of medications must sign and date the medication disposition record. Record review of the facility's Storage of Medications policy revised April 2007 showed: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. -The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. -The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. -Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys. 1. Record review of the facility's Refrigerator and Freezer Temperature Log for the medication refrigerator showed: -Medication refrigerator temperatures were to be checked twice daily. -March 2019 showed temperatures were documented 41 out of 62 opportunities. -Medication refrigerator temperature logs could not be located for April 2019, May 2019, June 2019, and July 2019. -August 2019 showed temperatures were documented nine out of 62 opportunities. -Medication refrigerator temperature logs could not be located for September 2019, October 2019, or November 2019. During an interview on 11/19/19 at 8:44 A.M., the Assistant Director of Nursing (ADON) said he/She was not sure who was responsible for ensuring the medication refrigerator temperature logs were maintained. During an interview on 11/19/19 at 9:00 A.M., the Housekeeping Supervisor said: -Housekeeping staff was responsible for checking the medication refrigerator temperatures. -He/She was responsible for auditing to ensure the refrigerator temperatures were completed, but he/she had not been doing that. 2. Observation on 11/19/19 at 7:42 A.M. of the 300/400 hall nurse medication cart showed a bottle of Milk of Magnesia with an expiration date of 10/2019. During an interview and observation of the medication room on 11/19/19 at 7:55 A.M. showed: -One cardboard box overfilled with medications to return to the pharmacy. -One medium sized plastic container overfilled with medications to return to the pharmacy. -Licensed Practical Nurse (LPN) C said he/she thought the medications that need to be returned to the pharmacy have been collected for about a month. The facility was waiting for a pharmacy driver to take them back, but the pharmacy has not had anyone going to the city recently, so they have not been collected for return. -The medication refrigerator temperature logs had not been completed since 8/31/19. The following medications were stored in the medication refrigerator: --One bottle of Haldol (an anti-psychotic medication) that had expired on 3/27/19. --Two opened vials of Tubersol (a medication used for tuberculosis screening) that were not marked with the date the vial was opened. --16 medication bulbs of Meropenem (an antibiotic). --Two Lantus pens (a long acting insulin). --Two bottles of Ativan Intensol (an anti-anxiety medication) which were not in a double locked system. -A locked box narcotics were stored in contained the following medications: --Four bottles of Ativan Intensol. ---Two bottles were opened with no date on the bottle when it was opened. LPN C said one bottle belonged to a resident who had expired a while ago and the bottle should have had the contents destroyed. --11 vials of Ativan 2 milligram/milliliter (mg/ml). -A second locked box for emergency medications contained the following medications: --Three Lantus pens (a long acting insulin). --Three Levemir pens (a long acting insulin). --Two Novolog pens (a short acting insulin). --Two Humalog vials (a short acting insulin). --One Ativan Intensol bottle. During an interview on 11/19/19 at 8:07 A.M., the Assistant Director of Nursing (ADON) said: -Staff should check for expired medications on a monthly basis and remove the expired medications from the delivery system. -Multidose vials should be marked with the date the medication vial was opened. -Medications removed from the delivery system and placed in the box for return should not be stored for a month or more, however sometimes the pharmacy delivery driver will not pick up the medications because they are not going to the city to the pharmacy to return them. -He/she thought medications should be returned to the pharmacy at least on a monthly basis. -The Ativan Intensol for the expired resident should have been destroyed before now. -He/She thought housekeeping was monitoring the refrigerator temperatures. -It was important for the medication refrigerator to be maintained within a certain temperature range due to the medications stored in the refrigerator. 3. During an interview on 11/21/19 at 2:44 P.M., the Administrator and Director of Nursing (DON) said: -He/she expected nursing staff to monitor the medication refrigerator temperatures, not housekeeping staff. -All expired medications should be removed from the medication delivery system immediately and either returned to the pharmacy or destroyed. -He/She expected medications that need to be returned to the pharmacy be sent back timely and not overfill two storage containers. -Multiuse medications should be marked with the date the medication was opened. -Expired narcotics or narcotics for expired residents should be destroyed immediately -Staff should check for expired and undated medications on a daily basis, or at least weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #14's admission Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Type II Diabetes Mellitus (is a disease in which the body does not make enough insulin to control blood sugar levels). Record review of the resident's Medication Administration Record (MAR) dated 11/1/19 to 11/30/19 showed: -Accuchecks (blood sugar checks) before meals and at bedtime. -Novolog Injection flex pen subcutaneous injection (sub-Q) based on a sliding scale. Record review of the resident's Physician Order Sheet (POS) dated 11/1/19 to 11/30/19 showed: -Accuchecks (blood sugar checks) before meals and at bedtime. -Novolog Injection flex pen sub-Q based on a sliding scale (what blood sugar was). 3. Record review of Resident #10's admission Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis of Type I Diabetes Mellitus (insulin-dependent diabetes or juvenile diabetes). Record review of the resident's MAR dated 11/1/19 to 11/30/19 showed: -Accuchecks before meals and at bedtime. -Humalog Kwik 100u/ml sub-Q based on a sliding scale. Record review of the resident's POS dated 11/1/19 to 11/30/19 showed: -Accuchecks before meals and at bedtime. -Humalog Kwik 100u/ml sub-Q based on a sliding scale. 4. Observation on 11/19/19 at 7:16 A.M. of accu check and the glucometer cleaning showed: -With ungloved hands, LPN D cleaned the glucometer machine with micro kill wipes while in the resident's room. -With contaminated ungloved hands, LPN D carried the cleaned glucometer out of the resident's room with no barrier or gloves. -LPN D placed the glucometer on top of the medication cart without a barrier, then sanitized his/her hands. 5. Record review of Resident #20's admission Face sheet showed, he/she was admitted to the facility on [DATE] with a diagnosis of Type II Diabetes Mellitus. Record review of the resident's MAR dated 11/1/19 to 11/30/19 showed: -Accuchecks before meals and at bedtime. -Humalog Kwik 100u/ml sub-Q to give 2 units before meals and at bedtime. Record review of the resident's POS dated 11/1/19 to 11/30/19 showed: -Accuchecks before meals and at bedtime. -Humalog Kwik 100u/ml sub-Q to give 2 units before meals and at bedtime. Observation on 11/19/19 at 7:35 A.M. of accu check and the glucometer cleaning showed: -With ungloved hands, LPN D cleaned the glucometer machine with micro kill wipes while in the resident's room. -With contaminated ungloved hands, LPN D then carried the cleaned glucometer out of the resident room with no barrier or gloves. -LPN D placed the glucometer on top of the medication cart without a barrier, then sanitized his/her hands. Observation on 11/19/19 at 7:40 A.M., of insulin administration showed: -LPN D did not wash or sanitize his/her hands upon entering the resident's room. -LPN D placed the resident's insulin pen on the resident's bedside table without a protective barrier. -LPN D did not wash or sanitize his/her hands before leaving the resident's room. -LPN D exited the resident's room and placed the resident's insulin pen back into the medication cart without sanitizing the insulin pen. 6. During an interview on 11/19/19 at 7:50 A.M., LPN D said: -He/she should have washed or sanitized his/her hands when entering and before leaving the resident's room. -He/she should not have put the insulin pen on the resident's bedside table without a barrier. -He/she should have worn gloves to clean the glucometer and should have had a barrier on the medication cart. During an interview on 11/21/19 at 2:17 P.M., the DON said: -He/she expected staff to wash and/or sanitize their hands before placing gloves on hands. -He/she expected staff to have a clean barrier for clean supplies. -Staff should have a dirty barrier for contaminated supplies when completing blood glucose monitoring and for insulin. -He/she expected staff to remove their gloves, and wash or sanitize their hands after removing their gloves before putting on clean gloves. -It was not appropriate to place contaminated supplies in the medication cart without first sanitizing them. 7. Record review of Resident #32's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Acute respiratory failure. -Major Depressive disorder. -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). Record review of the resident's electronic medical record and paper medical record showed: -No documentation of the resident's two-step TB test upon admission to the facility. -No documentation of the resident's yearly TB test for 2018 or 2019. 8. Record review of Resident #20's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's electronic medical record and paper medical record showed: -No documentation of the resident's two-step TB test upon admission to the facility. -No documentation of the resident's yearly TB test for 2019. 9. Record review of Resident #198's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of peripheral neuropathy (damage to the nerves resulting in sensory loss in the extremities). Record review of the resident's electronic medical record and paper medical record showed no documentation of the resident's two-step TB test upon admission to the facility. 10. Record review of Resident #13's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Hepatitis C (a viral infection that attacks the liver). -Chronic kidney disease (CKD - gradual loss of kidney function over time). -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). Record review of the resident's electronic medical record and paper medical record showed: -No documentation of the resident's two-step TB test upon admission to the facility. -No documentation of the resident's yearly TB test for 2019. 11. Record review of Resident #197's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system). -Pressure ulcer, unspecified stage. -Right below the knee amputation. -Left below the knee amputation. -Colostomy. -Paraplegia (loss of movement of both legs and generally the lower trunk). Record review of the resident's electronic medical record and paper medical record showed: -The resident had a TB skin test administered on 1/2/18 that was documented as zero millimeters (mm) of induration, indicating a negative test result. The test result documentation did not include the date the test was read. -No documentation of the resident's a second step TB test was administered seven to 10 days after the first test was read in 2018. -No documentation of the resident's yearly TB test for 2019. During an interview on 11/21/19 at 2:48 P.M., the Administrator and DON said: -The facility started a facility-wide sweep to determine who had received the TB skin testing after discovering during the survey TB skin tests could not be located on the sampled residents. -The facility was able to locate documentation of a TB skin test for seven residents in 2017, but nothing current for those seven residents. -A one-step TB skin test was located for a resident admitted earlier this year, but not the second step. -One new admission in February had both the first step and second step TB skin test completed within the prescribed time frames. -He/She could not locate TB skin tests for the remaining residents in the facility (46 remaining residents). -One resident who was a new admission in the last four weeks refused to have a TB skin test when asked during the facility-wide sweep. -He/She expected staff to administer the first step TB skin test upon admission and read within 48-72 hours. -He/She expected staff to administer the second step TB skin test seven to 10 days after the first step and read within 48-72 hours. -He/She expected staff to administer a TB skin test to all residents yearly and read within 48-72 hours. -Staff had previously documented the TB skin test on paper, but now the documentation should be on the resident's electronic medical record. 12. Record review of the facility's 12 month Infection Control Tracking and Monitoring program showed: -Only one month tracking, trending, and monitoring could be located, and that was for October 2019. -No tracking, trending, or monitoring of infections or antibiotics could be located for November 2018 - September 2019. During an interview on 11/21/19 at 1:33 P.M., the Infection Preventionist said: -He/she took over as the Infection Control Preventionist on 9/30/19. -He/she could not locate an Infection Control tracking, trending, or monitoring data previous to his/her taking over the program. -He/she was able to locate some antibiotic use sheets for June 2019 and August 2019. -The Infection Control program should have a year's worth of data. During an interview on 11/21/19 at 2:48 P.M., the Administrator and DON said: -He/she expected the facility to have an Infection Control Program which consisted of tracking, trending, and monitoring of infections and antibiotic use monthly. -The Infection Control program should have at least 12 months worth of data to monitor for trends. -Infection Control program data could not be located prior to the new Infection Preventionist starting in September 2019. 13. Record review of Resident #48's Face Sheet showed he/she was admitted on [DATE] with a diagnosis of diabetes. During an observation of the resident's blood sugar monitoring on 11/19/19 at 7:02 A.M. with LPN C showed: -He/she removed and sanitized the glucometer and placed it on a clean barrier in the medication cart drawer. -He/she administered the resident's medications then exited the resident's room. -He/she gathered the blood sugar monitoring supplies, removed the glucometer from the medication cart drawer, and put on clean gloves without washing or sanitizing his/her hands. -He/she entered the resident's room and placed the glucometer, without a barrier, on top of the resident's blanket covering the resident. -He/she obtained the resident's blood sugar sample, removed his/her gloves, and with ungloved hands, carried the contaminated glucometer out of the resident's room and placed it on top of his/her medication cart without a barrier. -He/she then sanitized his/her hands, put on gloves, sanitized the glucometer, and placed the glucometer in the medication cart drawer. -He/She sanitized the top of the medication cart. 14. Record review of Resident #47's Face Sheet showed he/she was admitted to the facility on [DATE]. During an observation of the resident on 11/19/19 at 7:18 A.M. showed LPN C: -Gathered the resident's glucose monitoring supplies and donned gloves without washing or sanitizing his/her hands. -Placed the glucometer on the resident's bedside table without a barrier, then removed the now contaminated glucometer to obtain the resident's blood sample. -He/she placed the contaminated glucometer on the resident's bedside table without a barrier, removed his/her gloves, washed his/her hands, and put on gloves to administer the resident's medications. -He/she removed his/her gloves, did not wash or sanitize his/her hands, and with ungloved hands, picked up the contaminated glucometer and exited the resident's room. -He/she placed the contaminated glucometer on top of his/her medication cart without a barrier, and with ungloved contaminated hands, sanitized the glucometer with a bleach wipe and placed the contaminated glucometer in his/her medication cart drawer on top of a barrier. -He/she sanitized his/her hands, then with ungloved hands, administered the resident's insulin injection. During an interview on 11/19/19 at 7:33 A.M., LPN C said: -He/she should have had gloves on when he/she administered the resident's insulin injection. -He/she should have washed or sanitized his/her hands before and after every glove change. -He/she should have placed the glucometer on a barrier in the resident room and not on a blanket or bedside table. -He/she should have had gloves on when handling the contaminated glucometer. During an interview on 11/21/19 at 2:27 P.M., the Administrator and DON said: -Staff should only place glucometers on a barrier, it was not appropriate to place the glucometer on top of a resident blanket or on top of a resident bedside table. -Staff should wash or sanitize their hands after every glove change. -Staff should not touch a contaminated glucometer with ungloved hands. 15. Record review of Resident #22's Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the resident's quarterly MDS dated [DATE] showed he/she: -Was severely cognitively impaired. -Had an indwelling catheter. -Required limited staff assistance for toileting and personal hygiene. Record review of the resident's November 2019 POS showed the resident had a suprapubic catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis). Record review of the resident's urine culture dated 11/18/19 showed the resident's urine specimen was positive for Methicillin Resistant Staphylococcus Aureus (MRSA - a type of bacteria that is resistant to many antibiotics). Observation on 11/18/19 at 3:29 P.M., 11/19/19 at 7:30 A.M. and 12:05 P.M. showed: -A cart with personal protection equipment (PPE) such as gowns, gloves, and masks was outside his/her room and two red barrels were inside his/her room by the door. -No sign directing staff and visitors to see the nurse. Observation on 11/20/19 at 8:31 A.M., 10:45 A.M., and 11:25 A.M. showed the isolation cart was inside the resident's room in front of his/her window. During an interview on 11/20/19 at 11:26 A.M., Certified Nursing Assistant (CNA) C said: -He/she was not aware of any resident on isolation precautions. -If a resident was on isolation precautions, an isolation cart should be outside the resident's door and not in the resident's room by the window. -He/she was not aware the resident was on isolation precautions. Observation on 11/21/19 at 9:20 A.M. showed the isolation cart was inside the resident's room in front of his/her window During an interview on 11/21/19 at 12:46 P.M., CNA D said: -Staff did not need to do anything special when emptying the resident's Foley catheter. -He/she did not know of any resident's on contact isolation precautions. -He/she was not aware the resident was on contact isolation precautions. -If a resident was on isolation precautions, there would be a sign outside his/her door to see the nurse. -If a resident was on isolation precautions, an isolation cart would be outside the resident's door and not in the resident's room. During an interview on 11/21/19 at 1:33 P.M., the Infection Preventionist said: -If a resident is positive for MRSA, he/she should have an isolation cart outside his/her room with PPE supplies in the cart. -Staff and visitors were expected to put on a gown and gloves prior to entering the resident's room, especially if they may come in contact with the source of the resident's infectious organism. -He/she did not know why the isolation cart would be in the resident's room. During an interview on 11/21/19 at 2:48 P.M., the Administrator and DON said: -If a resident has an infection that required isolation precautions, the resident should have an isolation cart outside his/her room and not in his/her room. -A sign should be posted outside the resident's room for staff and visitors to see the nurse prior to entering the resident's room. -Staff should gown and glove before entering the resident's room to provide catheter care or emptying the resident's catheter.Based on observation, interview, and record review, the facility failed to ensure infection control practices to prevent cross contamination were implemented by failing to ensure proper hand hygiene was completed according to standards of practice during wound care for one sampled resident (Resident #47); to ensure proper hand hygiene and gloving was practiced during a glucometer cleaning and insulin administration for three sampled residents (Residents #14, #10, and #20); to have an Infection Control tracking and trending program for the previous 12 month cycle;to ensure residents were assessed and monitored for signs and symptoms of tuberculosis upon admission and annually for five out of five sampled residents (Resident #13, #20, #32, #197, and #198); to ensure infection control protocols were maintained to prevent cross contamination during blood glucose monitoring for two sampled resident's (Resident #47 and #48), and to ensure infection control protocols were maintained for one supplemental resident on contact isolation precautions (Resident #22) out of 16 sampled residents. The facility also failed to include text flow diagrams of where the pipes from the various hot water heater were directed to and a listing of areas where Legionella sp. (a form of pneumonia, caused by the bacterium Legionella pneumophila found in both potable and nonpotable water systems could grow and spread), in the facility's waterborne illness prevention plan. This practice potentially affected all residents and facility staff. The facility census was 55 residents. Record review of the facility's Personal Protective Equipment - Gloves policy revised August 2009 showed: -All employees must wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin. -The use of disposable gloves is indicated during all cleaning of blood, body fluids, and decontaminating procedures. -Wash your hands after removing gloves. Record review of the facility's Infection Control Program - Antibiotic Stewardship policy dated November 2017 showed: -This community has established an infection prevention and control program that includes protocols to establish a system for the use and monitoring of adverse effects of antibiotics. -Residents who need an antibiotic are prescribed an antibiotic. -Antibiotic Stewardship: a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse effects associated with antibiotic use. -Loeb Criteria: minimum criteria for the initiation of antibiotics. -McGeer Criteria: surveillance criteria. -The basic tenets of an antibiotic stewardship program include: --Appropriate prescribing. --Appropriate administration. --Management practices to reduce inappropriate use to ensure that residents receive the right antibiotic for the right indication, right does, and right duration. -Potential side effects to monitor for with use of antibiotics: --Increased adverse drug events and drug interactions. --Serious diarrheal infections for Clostridium Difficile. --Colonization and/or infection with antibiotic resistant organisms. -Core elements of an antibiotic stewardship program: --Track measures of antibiotic use on the facility, one process, and one outcomes measure. --Regular reporting on antibiotic use and resistance to relevant staff, such as prescribing clinicians and nursing staff. -The program is a portion of the overall Infection Prevention and Control Program. -Monitoring of Antibiotic Use: --Monitoring is initiated with any order written at any time for an antibiotic. --Obtaining Antibiogram from a contracted laboratory as a summary of antibiotic susceptibility over the past 12 - 24 months. --Compile a report on antibiotic utilization (from sources such as the pharmacy and the electronic health record itself) and provide feedback at least quarterly to each practitioner. Record review of the facility's Tuberculosis Screening - Administration and Interpretation of Tuberculin Skin Tests revised December 2009 showed: -The facility will administer and interpret tuberculin skin tests (TST) in accordance with recognized guidelines and pertinent regulations. -Only qualified healthcare practitioners will administer and interpret the TST for employees and/or residents. -Individuals with less than 10 millimeters (mm) of induration, unless otherwise indicated, will receive a booster of 0.1 ml (5 tuberculin units) of purified protein derivative (PPD) one to two weeks after the initial TST. -A qualified nurse or healthcare practitioner will interpret the TST 48 to 72 hours after administration. All test results must be read in mm. -The facility will not accept an interpretation of the TST by an employee or resident, but will accept an interpretation by a private physician within the 48 to 72 hour time frame. Record review of the facility's Handwashing/Hand Hygiene policy revised April 2010 showed: -All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: --Before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice). --Before and after entering isolation precaution settings. --Before and after assisting a resident with personal care (e.g., oral care, bathing). --Before and after changing a dressing. --After handling soiled or used linens, dressings, bedpans, catheters and urinals. --After handling soiled equipment. --After removing gloves. -Hand hygiene is always the final step after removing and disposing of personal protective equipment. Record review of the facility's Infection Control Guidelines for Nursing Procedures revised June 2013 showed: -Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. -Recommended hand-washing techniques include: Washing hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: --Before and after direct contact with residents. --When hands are visibly dirty or soiled with blood or other body fluids. --After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin. --After removing gloves. --After handling items potentially contaminated with blood, body fluids, or secretions. -In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for the following situations: --Before and after direct contact with residents. --Before donning (putting on) sterile gloves. --Before performing any non-surgical invasive procedures. --Before preparing or handling medications. --Before handling clean or soiled dressings, gauze pads, etc. --Before moving from a contaminated body site to a clean body site during resident care. --After contact with a resident's intact skin. --After handling used dressings, contaminated equipment, etc. --After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. --After removing gloves. Record review of the facility's Infection Control Program - Antibiotic Stewardship policy dated November 2017 showed: -This community has established an infection prevention and control program that includes protocols to establish a system for the use and monitoring of adverse effects of antibiotics. -Residents who need an antibiotic are prescribed an antibiotic. -Antibiotic Stewardship: a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse effects associated with antibiotic use. -Loeb Criteria: minimum criteria for the initiation of antibiotics. -McGeer Criteria: surveillance criteria. -The basic tenets of an antibiotic stewardship program include: --Appropriate prescribing. --Appropriate administration. --Management practices to reduce inappropriate use to ensure that residents receive the right antibiotic for the right indication, right does, and right duration. -Potential side effects to monitor for with use of antibiotics: --Increased adverse drug events and drug interactions. --Serious diarrheal infections for Clostridium Difficile. --Colonization and/or infection with antibiotic resistant organisms. -Core elements of an antibiotic stewardship program: --Track measures of antibiotic use on the facility, one process, and one outcomes measure. --Regular reporting on antibiotic use and resistance to relevant staff, such as prescribing clinicians and nursing staff. -The program is a portion of the overall Infection Prevention and Control Program. -Monitoring of Antibiotic Use: --Monitoring is initiated with any order written at any time for an antibiotic. --Obtaining Antibiogram from a contracted laboratory as a summary of antibiotic susceptibility over the past 12 - 24 months. --Compile a report on antibiotic utilization (from sources such as the pharmacy and the electronic health record itself) and provide feedback at least quarterly to each practitioner. Record review of the facility's Isolation-Initiating Transmission-Based Precautions policy revised November 2017 showed: -When Transmission-Based Precautions are implemented, the following is recommended: --Protective equipment (i.e., gloves, gowns, masks, etc.) is maintained near the resident's room so that everyone entering the room can access what they need. --Post the appropriate notice on the room entrance door and on the front of the resident's chart so that all personnel will be aware of precautions, or be aware that they must first see a nurse to obtain additional information about the situation before entering the room. Record review of the facility's Infection Prevention and Control Program revised November 2017 showed: -The infection prevention and control program (IPCP), that follows national standards, will at a minimum include systems for: --Prevention. --Identification. --Reporting. --Investigating. --Controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual assessment. -The objectives of our infection control policies and practices are to: --Prevent, detect, investigate, and control infections in the facility. --Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions. --Maintain records of incidents and corrective actions related to infections. --Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. -[The] Infection Control Program is reviewed at least annually with the Facility Assessment. Record review of the Centers for Medicare and Medicaid Services (CMS) Survey and Certification letter dated 6/2/17, showed the facility should develop and implement a water management program that considers the American Society of Heating Refrigerating and Air Conditioning Engineers (ASHRAE) industry standard and the CDC toolkit. The toolkit should contain the following: text and flow diagrams, identify areas where Legionella could grow and spread, that the team has conducted a water program review at least annually, as stated. The annual review should: 1) be implemented; 2) record findings and updates; 3) record participants; and 4) be submitted to the Executive Director. 1. Record review of Resident #47's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including acute respiratory failure, chronic obstructive pulmonary disease (COPD-progressive lung disease), kidney disease, heart disease, heart failure, peripheral vascular disease (PVD-a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), high blood pressure and obesity. Record review of the resident's Medical Record showed the resident did not have an admission Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning) completed yet. Record review of the resident's Physician's Telephone Order dated 11/15/19, showed a physician's orders: -No Physical Therapy and keep legs elevated for five days, perform daily weights and Levaquin 500 milligrams (mg) daily for seven days for cellulitis (fluid in the tissues). -Cleanse the wound with wound cleanser, pat dry, cover with Xeroform and border gauze (an absorptive dressing that consists of three layers to ensure wound healing) daily until healed. Observation on 11/20/19 at 10:34 A.M., Licensed Practical Nurse (LPN) A brought his/her supplies into the residents room and placed them on a clean paper towel on the resident's dresser. He/she then: -Washed his/her hands, using her hand to dispense the paper towels, dried his/her hands and used the paper towel to turn off the water, then gloved. -The resident was sitting in his/her wheelchair with a sock on his/her right foot that was elevated. LPN A placed a pad on the floor then removed the resident's old dressing. -The resident had very dry, flaky skin on his/her foot and leg and there was a wound that was circular and quarter sized, right over his/her ankle bone. There was a flap of skin covering most of the wound and the open area was the shape of a crescent, along the right edge of the wound. There was minimal drainage on the old dressing and no odor. -Using wound cleanser and a clean cotton swab, LPN A sprayed the resident's skin with wound cleanser and cleaned the wound. -He/she then de-gloved, washed his/her hands and used his/her clean hand to pull the paper towel dispenser. He/she dried his/her hands and used the paper towel to turn off the water. -He/she then gloved, opened two packets of skin prep and wiped the wound area with the skin prep pads. -He/she then cut Xeroform and placed it on the wound, then covered it with a dated dressing and placed the resident's sock back on. He/She placed the resident's soft brace over his/her. -LPN A then picked up all of the used supplies and discarded them, degloved and placed them in the trash, dispensed the paper towels then washed his/her hands, turning off the water with the paper towel. During an interview on 11/20/19 at 10:48 A.M., LPN A said he/she may not have used his/her paper towel to pull down the paper towels during handwashing every time he/she washed his/her hands, but remembered pulling it down with the tip of the paper towel once. During an interview on 11/21/19 at 2:23 P.M., the Administrator and Director of Nursing (DON) said: -Nursing staff were supposed to wash their hands before and after removing gloves. -The nursing staff not use their hand to dispense the paper towels after washing their hands. -They should not turn off the water with their hands once done washing their hands. 16. Record review of the facility's Legionella/Waterborne Illness plan dated 11/17, showed the absence of the following: -Text and flow diagrams of pipes from various hot water heaters in the facility and the destinations of those pipes. -Areas or rooms which cont