**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician's orders for four residents (Residents #5, #9, #19, and #68) out of 20 sampled residents. The facility's census was 74. The facility did not provide a policy regarding following physician's orders. 1. Review of Resident #5's medical record showed: - admitted on [DATE]; - Diagnoses of chronic obstructive pulmonary disorder (COPD - a debilitating, progressive lung disease), respiratory failure (insufficient oxygen carried to the blood), pneumonia (infection in the lungs), major depressive disorder (low mood), and heart failure (heart does not pump correctly). Review of the resident's Physician Order Sheet (POS), dated October 2024, showed an order for daily weights, contact the healthcare provider if a gain of 2 to 3 pounds a day or 5 pounds a week for heart failure (CHF), dated 09/28/24. Review of the resident's weights summary, dated September 2024-October 2024, showed no documentation of weights for 09/28/24-10/01/24, 10/03/24-10/07/24, 10/09/24-10/11/24, 10/13/24, 10/14/24, 10/15/24-10/20/24. Review of the resident's Treatment Administration Record (TAR), dated September 2024-October 2024, showed: - For September 2024, one missed out of three opportunities for daily weights; - For October 2024, nine missed out of 23 opportunities for daily weights. 2. Review of Resident #9's medical record showed: - admitted on [DATE]; - Diagnoses of acquired kidney absence, COPD, and vascular disorder of the intestine (blood flow is reduced or blocked to the intestine). Review of the resident's POS, dated October 2024, showed an order for weekly weights one time a day every Friday, dated 08/30/24. Review of the resident's weights summary, dated September 2024-October 2024, showed no documentation of weights for 09/13/24, 09/20/24, 10/04/24, and 10/11/24. Review of the resident's (TAR), dated September 2024-October 2024, showed: - For September 2024, two missed out of four opportunities for weekly weights; - For October 2024, two missed out of three opportunities for weekly weights. 3. Review of Resident #19's record medical showed: - admitted on [DATE]; - Diagnoses of dementia (thinking and social symptoms that interfere with daily function), hypothyroidism (the thyroid doesn't produce enough thyroid hormone), and hyperlipidemia (high level of fat participles in the blood). Review of the resident's POS, dated October 2024, showed an order for weekly weights every day shift every Friday, dated 06/04/24. Review of the resident's weights summary, dated September 2024-October 2024, showed no documentation of weights for 09/13/24, 09/20/24, 09/27/24, 10/04/24, and 10/11/24. Review of the resident's TAR, dated September 2024-October 2024, showed: - For September 2024, three missed out of four opportunities for weekly weights; - For October 2024, two missed out of three opportunities for weekly weights. During an interview on 10/24/24 at 10:15 A.M., Certified Nurse Assistant (CNA) E said the the CNAs weigh the residents and chart it in the computer. They knew who needed to be weighed and how often by the shift report or if the nurse told them. During an interview on 10/24/24 at 12:05 P.M., Registered Nurse (RN) D said the restorative aide was responsible for completing the weights on residents. He/She didn't know if they were being completed. He/She would expect the restorative aide to following the physician orders when completing the weights. During an interview on 10/24/24 at 12:52 P.M., CNA F said he/she was responsible for getting and charting the weekly and monthly weights. The CNA's were responsible for getting the daily weights. He/She learned who needed weights by going to the daily meetings, charts, or if people like the dietitian told him/her about someone needing weighed. 4. Review of Resident #68's medical record showed: - admitted on [DATE]; - Diagnoses of anemia (low number of red blood cells), orthostatic hypotension (a sudden drop in blood pressure when rising from sitting or lying down), diabetes mellitus (a chronic condition that affects the way the body processes glucose), and dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking). Review of the resident's POS, dated October 2024, showed an order for insulin lispro inject per the sliding scale subcutaneously (an injection under the skin) before meals and at bedtime for diabetes with blood sugar checks before meals and at bedtime, dated 06/06/24. Review of the resident's Medication Administration Record (MAR), dated August 2024-October 2024, showed: - For August 2024, 20 missed out of 124 opportunities for insulin administration and blood sugar checks; - For September 2024, 19 missed out of 120 opportunities for insulin administration and blood sugar checks; - For October 2024, nine missed out of 65 opportunities for insulin administration and blood sugar checks. During an interview on 10/25/24 at 8:00 A.M., Resident #68 said staff checked his/her blood sugar three or four times a days every day and they must have forgotten to write it down. During an interview on 10/25/24 at 8:30 A.M., Licensed Practical Nurse (LPN) G said Resident #68 frequently refused blood sugar checks and insulin administration, but his/her refusal should be documented on his/her MAR. During an interview on 10/24/24 at 8:25 A.M., the Director of Nursing (DON) and the Administrator said they would expect staff to follow physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure physician's orders for oxygen with the use of a bilevel positive airway pressure (BIPAP - a noninvasive ventilation device that helps people breathe by delivering pressurized air into the airways) was followed for two residents (Residents #5 and #75) out of two sampled residents. The facility census was 74. Review of the facility's policy titled, Oxygen Administration, revised October 2010, showed: - Verify that there is a physician's order for this procedure; - Review the physician's orders or facility protocol for oxygen administration; - Review the resident's care plan to assess for any special needs of the resident; - Assemble the equipment and supplies as needed. 1. Review of Resident #5's medical record showed: - admission date of 02/25/05; - Diagnoses of acute and chronic respiratory failure, pneumonia (infection in lungs which can make it harder to breathe), heart failure (heart not pumping as it should), chronic obstructive pulmonary disease (COPD - a debilitating, progressive lung disease), and morbid obesity (excessive weight). Review of the resident's Physician Order Sheet (POS), dated October 2024, showed: - An order for a bipap with settings of 20/8 with 2 liters per minute (LPM) of oxygen bled (to add oxygen directly into a ventilator circuit) into the bipap at bedtime for COPD, dated 09/27/24; - An order for oxygen at 2 liters per minute by nasal cannula (NC) continuous, dated 06/04/24. Observation on 10/24/24 at 9:23 A.M., and 10/25/24 at 8:15 A.M., showed no connector piece to bleed in oxygen and no oxygen attached to Resident #5's bipap. During an interview on 10/25/24 at 8:15 A.M., Resident #5 said staff removed his/her oxygen and the nasal cannula when they applied the bipap mask every night. He/She didn't know if oxygen was hooked up to the bipap but relied on the staff to do everything related to the bipap. 2. Review of Resident #75's medical record showed: - admitted on [DATE]; - Diagnoses of dyspnea (difficulty breathing), hypoxemia (low oxygen levels in the blood), respiratory failure, lymphedema (chronic condition that occurs when lymph fluid builds up causing swelling, and pneumonia (lung infection that makes it difficult to breathe). Review of the resident's detailed physician order, dated 08/13/24, showed: - Oxygen 2 LPM via NC with activity; - Oxygen 2 LPM via bled in with bipap at bedtime. Review of the resident's plan of care, last revised 10/22/24, showed: - Required bipap at night and during naps during the day; - Ensure bipap is on the correct setting; - Ensure that bipap is worn correctly. Observation of the resident showed: - On 10/22/24 at 11:10 A.M., and 10/23/24 at 2:53 P.M., the resident sat on the side of the bed with oxygen at 2 LPM via NC. The bipap sat at the bedside without an adapter piece to allow for oxygen to be bled in and no oxygen attached. During an interview on 10/23/24 at 2:54 P.M., the resident said he/she believed the bipap was not operating correctly and didn't feel like he/she was receiving enough air with it on. He/She wore the nasal cannula with the bipap but was told by staff not to wear the nasal cannula with the bipap because the mask wouldn't seal correctly. He/She did attempt to wear the nasal cannula with the bipap mask for about 20 minutes one night and became very short of breath. During an interview on 10/23/24 at 3:15 P.M., the Assistant Director of Nursing (ADON) said the company who supplied the resident with the bipap supplies was here last week and checked it. During an interview on 10/24/24 at 3:28 P.M., the ADON said she was not aware of an order to bleed in oxygen with the bipap for Residents #5 and #75 and had cared for the residents during the night shifts. During an interview on 10/24/24 at 8:25 A.M., the Director of Nursing (DON) and the Administrator said they expect staff to follow physician orders. If the nurses apply a bipap at night, they should check the mask to make sure it was airtight, no kinks in the tubing, the settings were correct, monitor for complaints of air hunger, and check the resident's oxygen saturation level (the level of oxygen in a person's blood).

Based on observation, interview, and record review, the facility failed to maintain an error rate of less than five percent (%) when medications were administered. There were 28 opportunities with three errors made, for an error rate of 11% which affected one resident (Resident #8) outside the sample of four residents. The facility census was 74. Review of the facility's policy titled, Insulin Administration, dated 2001, showed: - Only appropriately licensed or certified personnel shall draw and administer insulin; - The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order; - The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. Review of the insulin glargine manufacture guidelines for administration, revised 11/2018, showed: - To prime an insulin pen, follow these steps: turn the dosage selector to select a dose of two units; hold the pen with the needle pointing upwards; tap the insulin reservoir so that any air bubbles rise up towards the needle; press the injection button all the way in; check if insulin comes out of the needle tip; if no insulin comes out, repeat the safety test up to two more times, if still no insulin comes out, the needle may be blocked. Change the needle and try again; check for insulin flow, ensure that insulin is coming out of the needle tip to confirm that the pen is primed and ready for use; - By following these steps, you ensure that the pen and needle are working properly and that any air bubbles are removed, which helps in delivering an accurate dose of insulin. Review of the Humalog manufacture guidelines for administration, revised 07/2023, showed: - Prime the pen before each injection; - Priming Directions of Insulin Pen: turn the dose knob to select two units; hold the pen with the needle pointing up; tap the cartridge holder gently to collect air bubbles at the top; push the dose knob in and continue holding the pen with the needle pointing up; push the dose knob in until it stops, and zero is seen in the dose window. Hold the dose knob in and count to five slowly; check for insulin at the tip of the needle; if insulin wasn't present, repeat the priming steps one to three, no more than four times; if insulin still not present, change the needle, and repeat the priming steps; - Priming the pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly; - If the pen isn't primed before each injection, the patient may get too much or too little insulin. 1. Review of Resident #8's Physician Order Sheet (POS), dated October 2024, showed: - An order for insulin glargine 20 unit subcutaneously (an injection under the skin) two times a day for diabetes (a disease that occurs when the blood sugar is too high), dated 09/30/24; - An order for Humalog (a type of insulin) 18 unit subcutaneously before meals for diabetes, dated 09/30/24; - An order for Humalog per sliding scale for blood sugar of 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 and above = 8 units subcutaneously before meals for diabetes, dated 09/30/24. Observations of the resident's insulin administration on 10/24/24, showed: - At 8:30 A.M., Registered Nurse (RN) D administered Humalog and insulin glargine to the resident as ordered. RN D failed to prime the Humalog and glargine insulin pens prior to the administration of the insulins; - At 11:55 A.M., RN administered Humalog insulin to the resident as ordered. RN D failed to prime the Humalog insulin pen prior to the administration of the insulin. During an interview on 10/24/24 at 2:21 P.M., the Assistant Director of Nursing (ADON) said he/she didn't prime insulin pens prior to administering insulin and hadn't educated the nursing staff to prime insulin pens prior to insulin administration. During an interview on 10/24/24 02:25 P.M., RN D said he/she didn't prime insulin pens prior to administering insulin for any resident. During an interview on 10/24/24 at 2:40 P.M., the Director of Nursing (DON) said he/she would expect nursing staff to prime insulin pens prior to administering medications if indicated.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted practices. The facility also failed to ensure one resident (Resident #22) outside of the 20 sampled residents had a physician's order to keep medications at the bedside. This had the potential to affect all residents. The facility census was 74. The facility did not provide a policy regarding residents keeping at the bedside/self-administering medications. Review of the facility policy titled Medication Labeling and Storage, revised February 2023, showed: - Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 1. Review of Resident #20's Physician Order Sheet (POS), dated October 2024, showed: - An order for Muro (used to reduce swelling of the cornea) 128 ophthalmic solution instill one drop in both eyes three times a day for dry eyes, dated 06/05/24; - An order for Pataday (treats itchy and red eye caused by allergies) ophthalmic solution instill one drop in both eyes one time a day for allergies, dated 06/05/24; - No documentation of an order for the resident to self-administer and keep the Muro and Pataday ophthalmic solutions at the bedside. Review of the resident's medical record showed no assessments the resident's ability to self-administer and keep the Muro and Pataday ophthalmic solutions at the bedside. Review of resident's care plan, dated 09/22/23, showed it did not address the resident's ability to self-administer and keep the Muro and Pataday ophthalmic solutions at the bedside During an interview on 10/24/24 at 11:11 A.M., Resident #20 said he/she did administer his/her own eye drops when he/she feels like it and nursing administered them if he/she requested. He/She kept both the Muro and the Pataday at his/her bedside daily. During an interview on 10/24/24 at 11:25 A.M., the Assistant Director of Nursing (ADON) said he/she would not expect any resident to have medications of any kind at bedside unless there was a physician order in place. During an interview on 10/24/24 at 12:50 P.M., the Director of Nursing (DON) said he/she would not expect resident's to have medications at bedside without a physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a code status was accurately and consistently documented throughout the medical record for one resident (Resident #66) out of 18 sampled residents. The facility census was 76. Review of the facility policy titled, Do Not Resuscitate Order, revised [DATE], showed: - The facility will not use cardiopulmonary resuscitation (CPR) (an emergency procedure consisting of chest compressions if the heart stops beating or the person stops breathing) and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate (DNR) (does not want cardiopulmonary resuscitation) Order in effect; - A DNR order form must be completed and signed by the attending physician and the resident or the resident's legal surrogate and placed in the front of the resident's medical record; - The interdisciplinary team (IDT) (a group of health care professionals from diverse fields who work in a coordinated effort toward a common goal for a resident) care planning team will review advance directives with resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. 1. Review of Resident #66's medical record showed: - An admission date of [DATE]; - Baseline care plan indicated a CPR code status, dated [DATE]; - No comprehensive care plan documentation; - A DNR code status indicated on the Outside The Hospital Do Not Resuscitate (OHDNR) form signed by the resident representative and the physician, dated [DATE]; - The Physician Order Sheet (POS), dated [DATE] through [DATE], with a full code status (wants CPR if the heart stops beating or the person stops breathing) order, dated [DATE]; - A red star indicated a DNR code status on the spine of the hard chart. During an interview on [DATE] at 2:03 P.M., Registered Nurse (RN) A said he/she would look at the color-coded star on the side of the resident's chart. The code status should also be checked on the physician's order sheet for verification. He/she would expect a resident's code status be documented accurately and consistently throughout the medical record. During an interview on [DATE] at 2:09 P.M., RN B said if a resident coded, CPR was started until the resident's code status was verified. He/she would expect the code status to be documented accurately and consistently throughout the medical record. During an interview on [DATE] at 3:04 P.M., the Assistant Director of Nursing (ADON) said he/she would expect a resident's code status to be documented accurately and consistently throughout the medical record. During an interview on [DATE] at 3:06 P.M., the Director of Nursing (DON) said she would expect a resident's code status to be documented accurately and consistently throughout the medical record and updated as needed. During an interview on [DATE] at 9:48 A.M., the Administrator said she would expect a resident's code status to be documented accurately and consistently throughout the medical record.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This deficient practice had the potential to affect all residents. The facility census was 76. Review of the facility policy titled, Pest Control, revised 2008, showed: - The facility shall maintain an effective pest control program; - The facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents; - Pest control services are provided by a contract company; - Maintenance services assist, when appropriate and necessary, in providing pest control services. 1. Observation on 06/05/23 at 11:08 A.M., of the secure unit showed: - Licensed Practical Nurse (LPN) F swatted at flies with a fly swatter in the hallway and in the dining room; - Several flies buzzed throughout the dining room and crawled on the dining room tables, walls and windows. Observations on 06/05/23 at 12:26 P.M., of the secure unit lunch meal showed: - Several flies buzzed throughout the dining room and crawled on the dining room tables, walls and windows while staff served the residents; - Two flies crawled on Resident #61's plate of food; - A fly crawled on Resident #61's right ear; - Resident #61 swatted at the flies several times; - A fly crawled on Resident #60's ice cream cup; - Resident #60 swatted at the fly several times; - A fly crawled on Resident #56's ice cream cup and another fly crawled on the resident's forehead; - Resident #56 swatted at the flies several times; - Resident #4 sat in a chair in front of a beside table with a fly on his/her plate of food; - Resident #73 sat in a chair at a dining room table with a fly on his/her drink cup; - Three flies crawled on a brown recliner with visible crumbs on the seat located near the television; - No fly control devices in the secure unit. Observation on 06/06/23 at 8:08 A.M., of the secure unit breakfast meal showed: - Several flies buzzed throughout the dining room and crawled on the dining room tables, walls and windows while staff served the residents; - No fly control devices in the secure unit. Observation on 06/07/23 at 8:11 A.M., of the secure unit shower room showed: - Two flies on the toilet; - Two flies on the air and heating unit; - Three flies on the door and doorframe; - No fly control devices on the secure unit. Observation on 06/07/23 at 8:13 A.M., of the secure unit breakfast meal showed: - Several flies buzzed throughout the dining room and crawled on the dining room tables, walls and windows while staff served the residents; - Four flies on an opened food cart with food trays inside while staff served the residents; - Several flies buzzed and flew out of the opened food cart; - No fly control devices in the secure unit. Observation on 06/07/23 at 11:18 A.M., of the secure unit dining area showed: - Resident #56 sat in a chair in the dining area and watched TV while a fly crawled on the shirt of his/her left shoulder; - Resident #4 sat in a chair in the dining area and watched TV while two flies crawled on the bedside table directly in front of him/her; - Resident #60 sat in a chair at the dining room table while a fly crawled on his/her right forearm; - No fly control devices in the secure unit. Observation on 06/08/2023 at 8:24 A.M., of the secure unit breakfast meal showed: - A fly crawled on Resident #23's plate of food; - A fly crawled on Resident #61's plate of food; - No fly control devices in the secure unit. Review of the maintenance request log, dated 05/08/23 through 06/02/23, showed no current requests for areas of concern documented. Review of the Pest Elimination Division inspections showed no documentation of pest control services for the months February 2023 through April 2023. During an interview on 06/05/23 at 11:17 A.M., LPN F said he/she tried hard to keep the flies under control and some times were worse than others. The unit used a fly swatter to get rid of the flies. The concern had been reported and the facility was aware. During an interview on 06/07/23 at 8:23 A.M., the Assistant Director of Nursing (ADON) said staff should fill out a form located on the maintenance door for any concerns related to the environment such as pest control and other issues that need addressed. During an interview on 06/07/23 at 8:26 A.M., Nurse Assistant (NA) C said he/she verbally told maintenance of issues with pest control or any other concerns with the environment. He/she had not reported any concerns to maintenance regarding pest control. During an interview on 06/07/23 at 8:29 A.M., Certified Nurse Assistant (CNA) D said he/she verbally told maintenance of any concerns with the environment. He/she had reported concerns with flies and gnats on the secured unit and the facility was aware. During an interview on 06/07/23 at 8:34 A.M., Registered Nurse (RN) B said a maintenance form should be filled out with the location and problem identifying any environmental concern such as pest control. He/she had not reported any concerns to maintenance recently. During an interview on 06/07/23 at 10:37 A.M., the Maintenance Supervisor (MS) said he/she would prefer the staff to write down any concerns related to the environment such as pest control and other issues rather than be verbally informed. A contract company provided pest control services and inspections for the facility on a monthly basis. There had been no concerns of flies and gnats reported anywhere in the facility from staff. He/She had been in the maintenance role for approximately two months and the Administrator kept the pest control inspections. During an interview on 06/07/23 at 10:43 A.M., Housekeeper E said he/she verbally notified maintenance of any environmental issues or concerns such as insects. He/She had not reported any environmental concerns to maintenance. During an interview on 06/07/23 at 10:46 A.M., CNA G said that he/she had worked the secure unit in the past and reported the issue with flies and gnats. The facility had been aware of the fly problem for a while. He/she had not reported any concerns other than the flies and gnats on the secure unit. During an interview on 06/08/2023 at 8:34 A.M., Certified Medication Technician (CMT) H said the facility staff was aware of the flies on the secure unit. He/she thought the flies come in the unit through the exit door when it was opened during the resident smoke breaks. During an interview on 06/08/23 at 9:32 A.M., the Administrator said pest control services and inspections were completed on a monthly basis and/or as needed. She would expect staff to write down areas of concerns such as pest control or other environmental issues on the maintenance request log and not verbally tell maintenance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 76. Review of the facility policy titled, Maintenance Service, revised 2009, showed: - Maintenance service shall be provided to all areas of the building, grounds, and equipment; - The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times; - The Maintenance Director is responsible for maintaining inspections of the buildings and work order requests; - Records shall be maintained in the Maintenance Director's office. Review of the facility policy titled, Resident Rights, undated, showed: - Resident has the right to a safe, clean, comfortable and homelike environment; - Facility must provide housekeeping and maintenance services to maintain a sanitary, orderly and comfortable interior; - The facility must provide clean bed and bath linens that are in good condition. 1. Observation on 06/06/23 at 8:15 A.M., 06/07/23 at 7:57 A.M., and 06/08/23 at 8:32 A.M., of the secure unit's shower room showed: - A ceiling tile with two large visible holes near a vent located above the sink; - A vent with a buildup of dust located above the sink; - A round ceiling light fixture with brown dried stains and a buildup of debris inside the light fixture located above the toilet; - A buildup of debris and hair located on the shower drain; - A metal floor strip with exposed rigid edges leaned against the wall located in a corner by the window; - A 12 inch (in.) x 12 in. cracked floor tile missing a large piece of the ceramic located at the entrance of doorway; - Two 12 in. x 12 in. floor tiles with two circular areas of worn down ceramic located near the toilet. 2. Observation on 06/06/23 at 08:17 A.M., of shower room [ROOM NUMBER] on the 200 Hall showed: - One 1 in. x 1 in. missing floor tile; - Multiple ceiling tiles above the shower stall with peeled away edges; - One ceiling tile above the toilet with a peeled away edge; - Three metal vents in the ceiling with a brown substance and a heavy grime build up; - Shower wall tile grout with black colored grime build up; - Shower floor tile grout with black colored grime build up; - One 3 in. x 2 in. shower wall tile cracked with black colored grime build up. 3. Observation on 06/06/23 at 12:44 P.M., of the shower room [ROOM NUMBER] on the 200 Hall showed: - Six 1 in. x 1 in. floor tiles missing and with black colored grime build up; - A 7 in. x 4 in. section with multiple chipped/cracked 1 in. x 1 in. floor tiles with black colored grime build up and discoloration; - A 12 in. x 6 in. section buckled area of floor tiles noted with cracks and discoloration near the right side of the shower stall; - Multiple ceiling tiles peeled at the edges; - Metal vent in the shower stall area with a brown substance and grime build up; - Metal vent in ceiling near door with a brown substance and grime build up; - Metal vent over the toilet area with a brown substance and grime build up; - One 3.5 ft. x 4 in. area of cove base missed in the shower stall and with a discoloration to the wall; - A brown substance covered the pipe under the sink, with a brown colored drip line on the wall, and one half-dollar size brown colored water spot on the floor under the sink. 4. Observation on 06/07/23 at 09:15 A.M., of the bathroom between room [ROOM NUMBER] and 257 showed: - A brown substance on the metal vent and grates in the ceiling; - A brown substance on the ceiling strips. During an interview on 06/07/23 at 8:23 A.M., the Assistant Director of Nursing (ADON) said staff should fill out a form located on the maintenance door for any concerns related to the environment such ceiling tiles, floor tiles and other issues that need addressed. During an interview on 06/07/23 at 8:26 A.M., Nurse Assistant (NA) C said he/she verbally told maintenance of issues with the ceiling tiles, floor tiles or any other concerns with the environment. He/she had not reported any concerns to maintenance in regards to the physical environment. During an interview on 06/07/23 at 8:29 A.M., Certified Nurse Assistant (CNA) D said he/she verbally told maintenance of any concerns with the environment. During an interview on 06/07/23 at 8:34 A.M., Registered Nurse (RN) B said a maintenance form should be filled out with the location and problem identifying issues with an environmental concern such as ceiling tiles and floor tiles. He/she had not reported any concerns to maintenance recently. Review of the maintenance request log, dated 05/08/23 through 06/02/23, showed no current requests for areas of concern documented. During an interview on 06/07/23 at 10:37 A.M., the Maintenance Supervisor said he/she preferred the staff to write down any concerns related to the environment such as ceiling tiles, floor tiles, base boards, cove base and other issues rather than be verbally informed. He/She had been in the maintenance supervisor role for approximately two months. During an interview on 06/07/23 at 10:43 A.M., Housekeeper E said he/she verbally notified maintenance of any environmental issues such as ceiling tiles, floor tiles or other concerns. He/she had not reported any environmental concerns to maintenance. During an interview on 06/09/23 at 9:50 A.M., the Administrator said she would expect staff to write down areas of concerns on the maintenance request log such as ceiling tiles, floor tiles, or other environmental issues and not verbally tell maintenance. 5. Observations of room [ROOM NUMBER] showed: - On 06/05/23 at 10:46 A.M., a strong urine odor with a blanket and bed pad on the floor in the corner at the end of Resident #51's bed next to the window, and a full trash can at the bedside; - On 6/05/23 at 11:42 A.M., a strong urine odor and urine saturated bed linens on the bed next to the door where Resident #55 lay on his/her bed; - On 6/05/23 at 03:15 P.M., a strong urine odor and the same saturated bed linens remained on Resident #55's bed with both residents out of the room; - On 06/05/23 at 03:55 P.M., the same urine saturated linens remained on Resident #55's bed. Staff entered the room and changed the bed linens on Resident #51's bed but left the same urine saturated linens on Resident #55's bed with both residents out of the room; - On 06/05/23 at 04:50 P.M., the same urine saturated linens remained on the Resident #55's bed with both residents out of the room; - On 06/06/23 at 10:50 A.M., Resident #55 lay on the bed with his/her eyes closed and a strong urine odor in the room; - On 06/06/23 at 11:45 A.M., Resident #55 stood in the middle of the room with his/her bed linens on his/her bed saturated with urine and a strong urine odor in the room; - On 06/07/23 at 02:30 P.M., Resident #55's urine saturated linens and clothes lay on his/her bed, the window opened, and both residents out of the room; - On 06/07/23 at 04:00 P.M., the same urine saturated linens and clothes lay on Resident #55's bed, the window opened, and both residents out of the room. During an interview on 06/05/23 at 3:30 P.M., Resident #51 said Resident #55, his/her roommate, always lay in a wet bed all day a lot of the time. The staff try to get Resident #55 up and he/she refused. During an interview on 06/06/23 at 10:30 AM, Resident #51 said Resident #55 frequently urinated in his/her bed and refused to let staff clean him/her, so the room smelled very strong of urine. He/She could not stand to smell that strong urine odor all the time. He/She wished the facility would do something about that. During an interview on 06/08/23 at 09:51 A.M., NA J, said if he/she saw a wet bed, or a resident that had wet clothes, he/she would change them. During an interview on 06/08/23 at 09:56 A.M., CNA I, said if he/she saw a resident was wet or soiled in bed, he/she would change them and provide peri-care. If the resident did not want to get up, he/she would continue to try and get them to let him/her change them and change their sheets. If he/she couldn't get them up, he/she would tell the nurse. If he/she saw a bed was wet and the resident wasn't in it, he/she would get rid of the dirty linens, wipe the bed down and put new linens on the bed. During an interview on 06/08/23 at 10:19 A.M., the ADON said she was not aware of the strong odor in room [ROOM NUMBER], but she was in and out of so many of the rooms. She said she would expect the residents to be happy with their environment. During an interview on 06/08/23 at 11:24 A.M., the Administrator said she would expect nursing staff to keep an incontinent resident clean and dry and the bed linens should be changed as often as possible.

Based on interview and record review, the facility failed to complete a significant change assessment for one resident (Resident #49) out of 17 sampled residents. The facility's census was 66. 1. Record review of Resident #49's admission Minimum Data Set (MDS, a federally mandated assessment completed by the facility), dated 11/26/20, showed the resident not on hospice care. Record review of the resident's medical record showed: - admitted to hospice care on 12/10/20; - The facility failed to complete a significant change MDS within 14 days after election of hospice benefit. During an interview on 1/14/21 at 12:12 P.M., the Administrator and Director of Nursing said they would expect a significant change MDS to be completed when a resident experiences a significant change in condition such as being admitted to hospice services. Record review of the facility's policy titled, Resident Assessments, dated November 2019, showed: - A significant change in status assessment is required when a resident enrolls in a hospice program, and experiences a consistent pattern of changes with two or more areas of decline from baseline including decision-making ability has changed and emergence of unplanned weight loss problem of five percent change in 30 days or 10 percent in 180 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident and/or the representative received a written summary of the baseline care plan (an initial plan for delivery of care and services) for one resident (Resident #49) out of 17 sampled residents. The facility's census was 66. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, showed: - A comprehensive, person-centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Record review of Resident #49's Physician's Order Sheet (POS), dated 12/16/20 through 1/15/21, showed admitted on [DATE] with diagnosis of left hip fracture (broken left hip). Record review of the medical record showed a baseline care plan completed on 11/19/20. During an interview on 1/12/21 at 11:43 A.M., the resident's responsible party said he/she was with the resident when he/she was admitted . A plan of care was not discussed with him/her and he/she did not receive a copy of a care plan. During an interview on 1/14/21 at 12:12 P.M., the Director of Nurses said she would expect the baseline care plan to be discussed with the representative and a copy provided. The facility did not provide a policy for baseline care plans.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan with specific interventions to meet individual needs of two residents (Resident #34 and #43) out of 17 sampled residents. The facility's census was 66. 1. Record review of Resident #34's Physician's Order Sheet (POS), dated 12/16/20 to 1/15/21, showed: - Diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs); - An order, dated 11/19/20, for oxygen up to six liters per nasal cannula (NC) for oxygen saturation less than 92% or shortness of breath as needed. Observation on 1/11/21 at 11:26 A.M., showed the resident with oxygen per NC at 2 liters in place. Record review of the resident's nurse's notes, dated 1/11/21, showed no documentation of oxygen in place. Record review of the resident's comprehensive care plan, last updated 11/23/20, showed no care plan for oxygen. 2. Record review of Resident #43's baseline care plan, dated 11/17/20, showed resident to be an elopement risk. Record review of the resident's annual Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility), dated 11/24/20, showed in section E the resident had wandering behaviors 4 to 6 days, but less than daily. Record review of the resident's comprehensive care plan, last updated 12/4/20, showed no care plan for elopement. Observation on 1/11/21 at 10:55 A.M. showed the resident walking in the hallway asking if he/she could smoke. During an interview on 1/11/21 at 11:00 A.M., NA B and NA C said the resident wanders the hallways and he/she likes to sit outside because he/she is a smoker. During an interview on 1/14/21 at 12:12 P.M., the Director of Nurses said she would expect there to be a care plan in place for elopement risk if the resident is at risk for elopement and for oxygen use if the resident has an order for oxygen. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, showed: - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; - The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS), a federally mandated assessment completed by the facility. Reference Complaint # MO00179919

. Based on observation, interview, and record review, the facility failed to revise and update comprehensive care plans for four residents (Resident #15, #60, #61, and #63) out of 17 sampled residents. The facility's census was 66. 1. Record review of Resident #15's Nurse's Notes, showed: - On 9/10/20, Resident found laying on the floor between his/her wheelchair and bed. No apparent injuries noted. Resident encouraged to lock wheelchair and call for assistance; - On 12/13/20, Resident found laying on right side with a skin tear to right elbow. Record review of the resident's Care Plan, updated 7/23/20 and 10/20/20, did not reflect falls on 9/10/20 and 12/13/20 or new interventions. 2. Record review of Resident #60's Nurse's Notes, dated 12/20/20, showed resident found laying face down in another resident's room with upper lip bleeding and swelling, and discoloration and swelling of left cheek. Record review of the resident's Care Plan, updated 9/17/20, did not reflect fall on 12/20/20 or new interventions. 3. Record review of Resident #61's Nurse's Notes, dated 11/13/20, showed resident found lying on floor in memory unit dining room on his/her right side with a knot on the right side of his/her head. Record review of the resident's Care Plan, updated 12/17/20, did not reflect fall on 11/13/20 or new interventions. 4. Observation on 1/11/21 at 12:07 P.M., showed Resident 63's left forearm wrapped and dressing soaked with red fluid. Observation on 1/12/21 at 3:15 P.M., showed the resident's left forearm wrapped and dressing clean. During an interview on 1/11/21 at 12:07 P.M., the resident said he/she has blood sores pop up on his/her skin and they break open and bleed. Record review of the resident's Physician's Order Sheet (POS), dated 12/16/20 to 1/15/21, showed: - Diagnoses of A-Fib (atrial fibrillation, an irregular, often rapid heart rate that commonly causes poor blood flow) and HTN (hypertension, elevated blood pressure); - Plavix (blood thinner to treat A-Fib) 75 mg 1 tablet by mouth daily; - Xarelto (blood thinner to treat A-Fib) 20 mg 1 tablet by mouth twice a day; - Cleanse open area to left forearm with stock cleanser. Apply TAO (triple antibiotic ointment) and dressing, change daily and as needed. Record review of the resident's care plan, updated 11/24/20, did not show update of skin condition to open area on left forearm. During an interview on 1/14/21 at 12:12 P.M., the Administrator and Director of Nursing said they would expect care plans to be updated with new interventions after every fall and updated for skin conditions. They would expect updates on the care plan to be dated. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, showed: - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; - The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS), a federally mandated assessment completed by the facility.

Based on observation, interview, and record review, the facility failed to provide care and services for activities of daily living for one resident (Resident #65) out of 17 sampled residents. The facility's census was 66. 1. Observation of Resident #65 showed: - On 1/11/21 at 3:15 P.M., hair greasy and unkempt and odor of urine; - On 1/12/21 at 3:06 P.M., strong odor of urine; - On 1/13/21 at 10:21 A.M., odor of urine and teeth had old food particles on them. During an interview on 1/11/21 at 3:15 P.M., Resident #65 said it's been two weeks since he/she had a shower. During an interview on 1/11/21 at 4:30 P.M., Resident #65's roommate said their room smells of urine and Resident #65 needs to take showers but sometimes refuses. During an interview on 1/13/21 at 12:58 P.M., Certified Nurse Assistant (CNA) A said Resident #65 needs assistance with showers and the resident received a shower yesterday. During an interview on 1/13/21 at 1:02 P.M., Resident #65 said he/she needs help with showers. During an interview on 1/13/21 at 1/36 P.M., the Director of Nursing (DON) said they are aware Resident #65 refuses showers and are educating him/her on better hygiene. Record review of Resident #65's shower sheets showed: - Resident received 6 showers in October and refused 2 times; - Resident received 5 showers in November; - Resident received 4 showers in December; - Resident received 1 shower in January and refused 3 times. Record review of the resident's Physician's Order Sheet (POS), dated 12/16/20 to 1/15/21, showed: - No medication or non pharmacological treatment for pain. Record review of the resident's care plan for Activities of Daily Living (ADL), dated 12/17/20, showed: - I need help with ADLs, rejects showers and poor personal hygiene at times; - Setup with personal hygiene-extensive assist of one staff for rest of ADLs; - Occasionally incontinent of bowel and bladder (B&B); - Need help with toileting and incontinent care-wear pulls ups. Record review of the resident's care plan for Behaviors, dated 12/17/20, showed: - I reject care at times such as hygiene tasks, showers, teeth brushing, washing hair; - If I refuse care then reapproach me at a later time and try again. If I still refuse tell my nurse; - Encourage me to have good hygiene and take showers/bathe. Record review of the facility's policy titled, Activities of Daily Living (ADLs), Supporting, revised March 2018, showed: - Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; - Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with - Hygiene (bathing, dressing, grooming, and oral care); - Mobility (transfer and ambulation, including walking); - Elimination (toileting); - Dining (meals and snacks); - Communication (speech, language, and any functional communication systems); - The resident's response to interventions will be monitored, evaluated and revised as appropriate.

Based on observation, interview, and record review, the facility failed to store drugs in accordance with accepted professional standards of practice. This deficient practice had the potential to affect all residents residing in the facility. The facility's census was 66. 1. Record review of the facility's policy titled, Storage of Medications, revised April 2019, showed: - Drugs and biological's used in the facility are stored in locked compartments under proper temperature, light and humidity controls; - Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurse's station or other secured location. Medications are stored separately from food and are labeled accordingly. Record review of the 100 Hall refrigerator temperature log showed: - The temperature on 1/1/21 was 32 degrees Fahrenheit (F); - The temperature on 1/2/21 was 31 degrees F; - The temperature on 1/3/21 was 30 degrees F; - The temperature on 1/4/21 was 31 degrees F; - The temperature on 1/5/21 was 32 degrees F; - The temperature on 1/6/21 was 32 degrees F; - The temperature on 1/7/21 was 32 degrees F; - The temperature on 1/8/21 was 32 degrees F. 2. Observation on 1/12/21 at 3:30 P.M. showed the 100 Hall refrigerator temperature at 32 degrees F and the refrigerator contents showed: - Emergency kit contained, Lorazepam (to treat anxiety) 1 milliliter (ml) vial recommended storage to be 36-46 degrees F, Humalog (insulin to treat diabetes) 3 ml vial recommended storage 35.6 to 46.6 degrees F, do not freeze, Humalog R 3 ml vial, Humalog 70/30 3 ml vial, phenergan (to treat nausea and vomiting) suppository recommended storage at room temperature, keep from freezing.; - Humalog Kwik 100 units/ml - 3 new syringes; - Lantus Solostar (insulin to treat diabetes) 100 units/ml - 1 new syringe, recommended storage to be 36 to 46 degrees F; - Victoza (non-insulin to treat type 2 diabetes) 3 ml - 2 new syringes, recommended storage to be 36 to 46 degrees F; - Basaglar (insulin to treat diabetes) 3 ml - 4 new syringes, recommended storage to be 36 to 46 degrees F; - Lorazepam 2 gm/ml 30 ml bottle - 1 bottle unopened; - Lorazepam 2 gm/ml 30 ml bottle with 29 ml left; - Tuberculin (used in a skin test to help diagnose tuberculosis infection, infectious bacterial disease that mainly affects the lung) 3 ml vial - 3 vials unopened, recommended storage to be 35-46 degrees F; - Acetaminophen (to treat minor aches and pains, and reduces fever) 650 mg suppository - 39 unopened, recommended storage 68-77 degrees F. During an interview on 1/14/21 at 12:12 P.M., the Administrator, Director of Nursing, and the Quality Assurance Nurse said they would expect the medication refrigerator to be within recommended temperature for medications.

Based on interview and record review, the facility failed to obtain laboratory services to meet the needs for one resident (Resident #21) out of 17 sampled residents. The facility's census was 66. Record review of Resident #21's medical record showed a diagnosis of Huntington's Disease (a heredity disease causing degeneration of the brain cells and causing progressive dementia). Record review of the resident's Physician's Order Sheets (POS), dated 10/16/2020 through 11/15/2020, and 12/16/20 through 1/15/21 showed an order for annual labs to be drawn every November including: - Complete Blood Count (CBC), (a blood test that is used to evaluate overall health and detect a variety of diseases and conditions); - Comprehensive Metabolic Panel (CMP) (a blood test that provides information about the current status of the body's metabolism). Record review of the resident's medical record showed no laboratory results for the CBC or CMP. During an interview on 1/14/21 at 10:30 AM, the Director of Nursing (DON) said the lab they had used had been shut down and she was unable to find a record of the labs being drawn. The facility had been using a different lab but was having issues with it as well and they would be changing labs immediately. During an interview on 1/14/21 at 12:12 PM, the DON said she would expect labs ordered yearly, to be completed every 12 months. Record review of the facility's policy titled, Availability of Services, Diagnostic, last revised December 2009, showed: - Facility does not provide on-premises diagnostic services except routine urinalysis, stool exam for occult blood, and others as necessary or appropriate; - Diagnostic and radiological services provided by AHA Labs and Biotech; - The following diagnostic services are available twenty four hours a day and seven days a week including holidays: -Biochemical; -Hematology; - Agglutination; - Serology; - Bacteriology; - Pathology; - Radiology; - Electrocardiography; - Others as may become necessary. - Our diagnostic testing facilities are in compliance with currant Clinical Laboratory Improvement Amendment (CLIA) regulations; - Blood and blood products are not maintained within our facility; - Residents requiring blood transfusions are transferred to the hospital.