Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity. One resident (Resident #3) required staff assistance with mobility and personal care needs. Staff left the resident alone in the bathroom while seated on the toilet and again while the resident hovered over the toilet. Staff made comments about their dislike of the job and/or level of care the resident required. In addition, during a transfer from the wheelchair to the bed, the resident was not properly assisted into bed and was left with legs hanging off the bed. The sample was five. The census was 82. The administrator was notified on 2/21/25, of the past non-compliance. The facility has in-serviced staff and are monitoring staff and resident interactions. The deficiency was corrected on 2/20/25. Review of the facility's undated Resident Rights policy, showed: -Each resident is encouraged and assisted in making grievances and recommendations, and the resident is ensured against any form of reprisal or intimidation. The Administrator, Director of Nursing (DON), and Social Services will receive these grievances at anytime; -Each resident shall be treated with consideration, respect, and full recognition of his/her dignity and individuality including privacy in treatment and care for personal needs; -Each resident shall participate in the decision-making process, including individual preferences in such things as menus, clothing, religious activities, friendships, activity and entertainment. This includes planning his/her total care and medical treatment; -Residents shall not have their personal lives regulated or controlled beyond reasonable meal schedules and other policies that may be necessary for the orderly management of facility. Review of the resident's admission Minimum Data Set (MDS, a federally mandated instrument completed by facility staff), dated 2/24/25, showed: -Severe cognitive impairment; -Diagnoses included high blood pressure, orthostatic hypotension (when the blood pressure drops suddenly when changing position and can result in falls), acid reflux, dementia, Parkinson's disease, and depression; -Impairment to both sides of the lower extremities; -Used a wheelchair; -Required supervision or touching assistance with toileting hygiene; -Required supervision or touching assistance with sit to stand; -Required partial/moderate assistance with chair/bed to chair transfer; -Required partial/moderate assistance with toilet transfer. Review of the resident's care plan, in use at the time of the investigation, showed: -Cognitive loss/dementia: Impaired cognition related to dementia, Parkinson's, depression, and anxiety. The resident's specific information: He/She has poor short-term memory, difficulties with word finding at times and becomes anxious if he/she does not recall where he/she is or what to expect. He/She benefits from frequent cueing and reassurances; -He/She will main or improve level of cognitive functions as evidenced by answering simple yes/no questions x 90 days; -Identify baseline cognition as follows: Oriented to x 2 (person and place only); -Use a calm, slow approach; -Explain all procedures before beginning and repeat during procedure as necessary; -Bring out to area of activity to enhance mental stimulation; -Encourage use of familiar objects; -Activities of Daily Living (ADL) functional rehab: Resident is alert and oriented to 1-2 with confusion. He/She is able to make his/her basic needs known but confused to his/her ability. He/She need extensive to total assist with care and able to set up meals and cues. He/She has diagnosis of dementia, Parkinson's, tremor, and diagnosis of seizures. He/She can be anxious at times which may increase his/her tremors. Resident receives Hospice for care with diagnosis of dementia; -Will maintain ADL function in the next 90 days; -Assist with ADLs as necessary with staff assist x 1; -Provide sufficient time to complete tasks. Avoid rushing, but keep on task and assist to complete as needed; -Walking in room: not ambulate; -Walking in hallway: not ambulate; -Toileting: extensive to total assist x 1 with check and change every two hours while awake; -Personal hygiene: extensive to total assist x 1; -Bed Mobility: extensive assist x 1. Observation and interview on 2/21/25 at 11:19 A.M., showed the resident lay in his/her bed. Family Member A was in the room with the resident. The resident was asked if he/she wanted to talk to the surveyor. He/she said, not really. Family Member A said the resident was about to take a nap, so he/she was tired. During an interview on 2/21/25 at 11:19 A.M., Family Member A said the resident has Parkinson's and dementia and believed that gets lost with facility staff. They have a camera in the room and were able to see staff interacting with the resident. There are videos of staff rudeness and harsh movements. The aide was seen dancing around in the room. After he/she watched the events that occurred on 2/14/25, he/she called the facility and requested the Certified Nurse Aide (CNA) to be re-assigned. He/She receive a confirmation from nursing that the aide was re-assigned and Family Member A confirmed it on the camera. Family Member A sent the video footage to facility management. The resident would not recall the events that happened due to the dementia. If someone asked him/her about something right when it happens, he/she would be able to tell you, but at this point, the resident would not recall what happened. At 2:20 P.M., Family Member A said the facility needed to work on educating their staff in having more compassion towards the residents. Review of the camera footage, dated 2/14/25 at 9:07 P.M., showed the camera positioned to show the resident's room, hallway outside the resident's room, and bathroom. The video begins with the resident seated on the toilet in the bathroom. The walker was in front of the resident. He/she was alone in the bathroom. At 15 seconds, CNA B walked into the resident's room. CNA B walked into the bathroom and said, you finished. The resident spoke to CNA B, but the resident's words were indistinct/inaudible. CNA B responded to the resident, all night, all night and I don't have to, I am waiting for you to get up. CNA B and the resident have another exchange, but the words were inaudible. The resident leaned down on the top of the walker with his/her hands covering his/her face. CNA B stood in the doorway and watched the resident. CNA B leaned back on the frame of the bathroom door. CNA B looked over at the resident and said sit up for me so you don't fall. The resident started to lean down while seated on the toilet. CNA B walked closer to the resident and said, sit up honey so you won't fall. The resident sat back up straight and continued to be seated on the toilet. The aide said thank you. The aide then said, do not lean back on the toilet, you have to sit up. The resident responded to the aide, sit up, but the rest of what was said was inaudible. The aide responded to the resident, I didn't say stand up. The resident said, I didn't mean stand up, but I don't have anything to hold on to. CNA B responded, hold on to the rail. The video ends. Review of the camera footage, dated 2/14/25 at 9:12 P.M., showed the camera footage started with the resident seated on the toilet in the bathroom. He/She was seen doing his/her own personal care. CNA B stood in the doorway of the bathroom. CNA B continued to stand in the doorway as he/she observed the resident doing personal care on him/herself. CNA B started to clap his/her hands few times, snap fingers, and move side to side while standing in the doorway. CNA B continued to move around in the doorway, looking over at the resident. He/she stood in the doorway, leaning against the door frame. The resident continued to clean him/herself up without staff assistance. CNA B started snapping fingers again and begun to sway from side to side in the doorway of the bathroom. CNA B pulled out his/her phone from his/her jacket pocket, looked at it, and placed it back into his/her pocket. CNA B stood in the doorway until the last eight seconds of the video when CNA B entered the bathroom. No words were exchanged during the two-minute video. Review of the camera footage, dated 2/15/25 at 9:14 P.M., showed the resident seated on the toilet in the bathroom. The resident had his/her walker in front of him/her. CNA B was in the bathroom with the resident, grabbing supplies and placing it on the counter. CNA B said stand up, but did not assist the resident with standing. CNA B placed gloves on his/her hands, standing approximately two to three feet away from the resident, in front of the sink. CNA B asked the resident to stand up. The resident began to lean forward but did not stand up. The resident was told again stand up, stand up for me. CNA B walked toward the resident as the resident lifted his/herself off the toilet seat, holding on to the walker in front of him/her. CNA B lifted the back of the resident's gown and started to clean the resident's backside. CNA B then attempted to put a brief on the resident. The resident's backside continued to hover over the toilet. CNA B said stand up and you're not standing. The resident's started to lower him/herself down until he/she sat back on the toilet seat. CNA B said, stand up, 1-2-3 and assisted the resident to stand up. The resident stood up slightly, leaned forward, and started to slouch down, but was not seated on the toilet seat. CNA B dropped the brief on the bathroom counter, walked out the bathroom, and said I can't, I can't as he/she walked out of the resident's room. The resident was left in the standing/slouch position off the toilet. The resident sat back on the toilet a few seconds later. The resident said, you shouldn't be doing this job if you can't, honey. CNA B, who was out of the resident's room and seen in the hallway, was heard calling out to staff help me with him/her please, please me get him/her off this toilet, he/she was not trying to stand, he/she was trying to fall, and who wants to fall. CNA B walked back into the resident's room with CNA C. CNA B said, it does not take, but the rest was inaudible. The video stops. Review of the camera footage, dated 2/15/25 at 9:16 P.M., showed the camera footage continued after CNA B and CNA C entered the resident's bathroom. CNA C took the resident's wheelchair and moved it into the bathroom with the resident and CNA B. CNA C began to fix up sheets and blankets on the resident's bed. CNA B, in the bathroom with the resident, placed towels on the seat of the resident's wheelchair. A third staff entered the room. CNA B and CNA C said, we got it. The third employee said, you got it and thank you as exits the resident's room. CNA B asked the resident to stand up, 1-2-3. The resident begun to stand; however, CNA C walked into bathroom and obstructed the view as the resident was transferred to his/her wheelchair from the toilet. CNA C re-positioned the resident back in the wheelchair. The resident was seen wearing a gait belt around the upper body. The resident was transferred in the wheelchair from the bathroom to his/her bed. The resident was seated in the wheelchair as staff lowered the resident's bed. The resident was told to sit up, the resident leaned forward while CNA C reached around the resident to grab the gait belt and quickly pulled the resident out of the wheelchair onto the bed. The resident was heard saying oooh twice as he/she was positioned on his/her left side in the bed. The resident's legs were hanging off the bed as the resident's right arm reached out. CNA C exited the room. CNA B placed a brief under the resident as he/she was positioned on his/her left side with legs off the bed. CNA B placed the brief under the resident and told the resident to turn on the other side as he/she lifted the resident's legs up and turned the resident. CNA B told the resident to go that way as he/she was turned on his/her right side. CNA B was seen with the brief in his/her hand and the video ends. Review of the camera footage, dated 2/14/25 at 9:18 P.M., showed CNA B placed a brief under the resident and repositioned the resident on his/her back. CNA B secured the resident's brief, covered him/her with a blanket and lowered the bed. CNA B moved the wheelchair back into the resident's bathroom. The resident lay in bed and asked the aide a question that was inaudible. CNA B moved the resident's bedside tray closer to him/her and handed the resident a pack of hand wipes. CNA B turned the light off and exited the room. The resident was seen pulling a wipe out of the pack and cleaning his/her hands until the video ends. During an interview on 2/21/25 at 3:00 P.M., the DON said the nursing supervisor emailed her and informed her that the family did not want to the two aides working with the resident. The family said staff needed more compassion. The DON received the video footage from the resident's room and watched it. The resident will try to move, get up or stand. The aides were moving too fast as well. The DON spoke to CNA C. He/She watched the video and admitted he/she was going too fast and needed education. He/She was educated by the DON. CNA B was contacted, but it sounds as if he/she was in a place with a lot of people, and he/she gave a one word answers after he/she was told the family had concerns. CNA B resigned the next day. It was not appropriate for the resident to be left alone on the toilet. The DON would have expected staff to ask resident if he/she could help him/her. CNA B behavior when he/she said, I can't and yelling down the hall was not appropriate. It was not appropriate for CNA C to transfer the resident the way he/she did and would have expected him/her to continue to assist the resident in bed, so the lower half was not hanging out of bed. The DON would have also expected CNA B to assist the resident instead of standing in the doorway. During an interview on 2/21/25 at 10:45 A.M., the Administrator said that he reviewed the videos sent by the family. The behavior of the aides was not appropriate and that is not how staff are expected to treat residents. They have addressed the issue and will continue to monitor care. MO00249621

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from accident hazards after one resident (Resident #2) reported an injury to the left ankle during a Hoyer lift (full body mechanical lift) transfer. The investigation found staff reported several improper transfers had occurred in the days preceding the injury, to include the resident being transferred with a sit to stand lift (mechanical lift that requires residents to be able to stand with assistance) several days before and one Certified Nursing Assistant (CNA) reported he/she operated the Hoyer lift alone one day instead of using two staff as required. In addition, observation showed the facility failed to ensure one resident was connected properly into the Hoyer lift resulting in the wheelchair that they sat in being lifted approximately one foot into the air with the resident seated (Resident #7). The sample was 8. The census was 85. Review of the facility's Mechanical Lift policy, dated August 2019, showed: -To ensure safe and appropriate behavior transfer techniques for residents per regulatory guidelines and professional standards of practice; -Purpose: To transfer a resident using mechanical means; -To help prevent resident and staff injury; -Supplies: -Mechanical lift; -Sling; -Two staff members; -Sit to stand lift: To be transferred with a sit to stand lift, the resident must have no medical contraindications for using the lift. The resident should have the following characteristics: -Alert; -Predictable and cooperative behavior; -Able to follow simple commands; -Can at least partially bear weight and hold on to the hand grips; -Able to lean back into the sling; -Full mechanical total lift: To be transferred with the full mechanical total lift, the resident must have no medical contraindications for using the lift. The resident should have the following characteristics: -Unable to sit erect; -Frequent unpredictable behavior/cooperative during transfers; -Located on a low bed close to the floor level; -Resident in the floor (in lying or seated position); -Total dependence and/or bedfast. 1. Review of Resident #2's physical therapy progress and Discharge summary, dated [DATE], showed: -Diagnoses included: Contracture (rigidity or loss of range of motion of a joint) right knee, contracture left knee, contracture left ankle, contracture right ankle, muscle weakness, unsteadiness on feet, and reduced mobility; -Functional deficits: Transfers, bed/chair: -Maximum assist x 2 people; -Transfers, sit/stand: maximum assist x2 people; -Device use, mechanical lift: Yes; -Analysis of functional outcome/clinical impression: Patient has ceased progress and is appropriate for discharge. Patient improved with sitting balance; however, did not progress with [NAME] flex lift (sit to stand lift), standing, or gait (walking); -Transfers: Patient unable to stand safely with [NAME] flex lift and Hoyer still recommended. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 10/4/24, showed: -Severe cognitive impairment; -Diagnoses included coronary artery disease (CAD, heart disease), high blood pressure, dementia, Parkinson's disease, anxiety, and depression; -Impairment on one side of the lower extremity; -Uses wheelchair; -Sit to stand: Not attempted due to medical conditions or safety concerns; -Chair/bed to chair transfer: Dependent, helper does all of the effort. Resident does none of the effort to complete the activity; -Tub/shower transfer: Dependent, helper does all of the effort. Resident does none of the effort to complete the activity. Review of the resident's care plan, in use during survey, showed: -Activities of Daily Living (ADL) rehab: Resident is alert and oriented to 1-2 with confusion. He/She is able to make his/her basic needs known but confused to his/her ability. He/She needs extensive to total assist with care and able to set up with meals and cues. He/She has dx of dementia, Parkinson's, tremor, and diagnosis of seizures. He/She can be anxious at times which may increasing his/her tremors. Resident receives hospice for care with diagnosis of dementia; -Transfer: Hoyer lift x 2. Review of the resident's hospice clinical summary, showed: -Mobility: Transfer using mechanical lift; -Narrative note: Unable to ambulate due to weakness and drop right foot. Review of the resident's progress notes, showed: -On 1/7/25 at 4:13 P.M., Hospice nurse here this A.M. and resident, writer informed that resident complained to pain to left foot and ankle and order was received per hospice doctor for x-ray of left ankle and foot. No further complaints voiced thru out the shift. X-ray tech here at this time to obtain x-ray; -On 1/8/25 at 4:43 P.M., Resident complained of right foot pain this morning, assessed, no bruising noted, non-pitting edema noted and foot internally rotated. Resident denied any pain to left foot, able to wiggle toes and move extremity without discomfort. Call placed to x-ray company at noon for x-ray results of left foot, at 12:45 P.M., received results: Minimally displaced sub-acute (fracture that occurred between 5-13 days prior) chip fracture along anterior (front) surface of talus (ankle bone). Nurse Practitioner (NP) here in facility and made aware of x-ray results, Director of Nursing (DON) made aware of results also. Resident seen by NP and stated that family was made aware of x-ray results; -On 1/8/25 at 6:38 P.M., New orders received from NP for Ibuprofen 400 milligram (mg), twice a day (BID) as needed (PRN) for breakthrough pain not relieved by Tylenol and non-weight bearing (NWB) to both lower extremities due to ankle contractures and left ankle fracture. Review of the facility's investigation, showed: -Allegation type: Injury of unknown origin; -Date/time staff became aware of incident: 1/8/24 at 1:40 P.M.; -Allegation details: Resident receives hospice services, the morning of 1/7/25, attending hospice nurse reported to facility charge nurse Licensed Practical Nurse (LPN) D that the resident was complaining of left foot and ankle pain. An x-ray was ordered and taken on 1/7/25. Results of the x-ray reported on 1-8-25. Minimally displaced chip fracture along anterior surfaces of talus seen. Reduced bone density seen. Resident interviewed by Social Services reports not remembering anything that could have caused it, only that it hurts. Resident reports no adverse treatment from staff. Resident's family was informed of fracture by hospice. Attending physician was notified and we are waiting on call back and any new orders. Review of the resident's x-ray report, dated 1/7/25, showed: -X-ray: left ankle; -Reason for exam: pain; -Findings: Minimally displaced chip fracture along anterior surface of talus seen; -Avulsion (forceful tearing away) injury seen along medial malleolus (bump on the inner side of ankle) with adjacent soft tissue edema (swelling); -Reduced bone density seen; -Impression: Minimally displaced sub-acute chip fracture along anterior surface of talus seen. Avulsion injury seen along medial malleolus with adjacent soft tissue edema. Reduced bone density seen. Review of the DON's written statement, showed: -On 1/8/25 around 12:45 P.M., charge nurse reported that the resident's x-ray results to left ankle came back positive for fracture. Nurse had made me aware yesterday that hospice nurse ordered x-ray due to resident complaining of pain; -Spoke with CNA A who cared for resident Saturday through Monday who stated resident never complain of any discomfort. Spoke with bath aide from hospice who stated he/she visited the resident on Tuesday 1/7/25. Resident complained of pain and told him/her that on Monday 1/6/25, his/her foot got caught in the Hoyer. Aide reported this to hospice nurse who was also here for a visit. Hospice nurse and aide both visited on Friday 1/3/25 and resident complained of no pain or discomfort. After hospice aide reported pain on Tuesday 1/7/25, x-ray to left foot/ankle was ordered. Order for x-ray to right foot/ankle due to resident complaint; -Spoke with CNA E, who was assigned to resident on dayshift on 1/7/25, who also stated resident did not complain of any pain or discomfort that day; -Spoke with CNA C who states resident's private duty staff also told him/her resident's foot was broke because CNA got it caught on the Hoyer. CNA C stated he/she saw hospice aide transfer resident with sit to stand. CNA C could not describe hospice aide or remember what day it was. He/She states the private duty was present. Confirmed with hospice nurse that the resident only has one hospice aide that has been visiting; -Nurse Practitioner here and notified of results and spoke with family. Family had declined orthopedic (bone specialist) consult; -New Order received for prevalon boots (protective boot) and request for routine pain meds; -Evening shift nurse to complete head to toe skin assessment when resident lays down tonight. Review of the Social Worker's written statement, dated 1/8/25, showed social worker met with resident in his/her room to follow up on recently found left ankle fracture of unknown origin. He/She was awake, alert, lying in bed watching TV. He/She readily welcomed a visit and gave good eye contact throughout the visit. He/She showed no outward signs of discomfort or distress. Social worker asked the resident how he/she was feeling today and he/she reported fine. Social worker stated, I heard you hurt your ankle, and he/she said yes he/she did. Social worker asked if he/she was in pain right now and she stated no, not at all right now, but that it had hurt earlier. Social worker asked which ankle he/she hurt, and he/she was uncertain. Social worker asked if he/she recalled how he/she hurt his/her ankle. He/She responded that he/she did not remember and said it just started hurting one day. Social worker asked if anyone had hurt him/her, and he/she stated no. Social worker asked if he/she recalled hitting or bumping it on something and he/she stated he/she did not remember hitting it on anything. Social worker asked the resident how the staff has been doing in caring for him/her and he/she replied just fine. Social worker inquired if he/she had any concerns, worries or fears and he/she denied having any. Observation and interview on 1/13/25 at 9:45 A.M., showed the resident in his/her the tilted wheelchair, with lower extremities elevated including a pillow underneath the feet. The resident was with his/her private caregiver, washing his/her face. The resident was asked if he/she was in pain and he/she said there was pain in the right leg/foot. The resident said he/she did not remember the injury and he/she was told it was the left foot that was fractured. The resident thought it was weird because he/she did not have any pain in the left foot. He/she did not remember injuring it on the Hoyer lift and did not remember standing up. The resident said sometimes he/she has trouble remembering which leg was injured. During observation and interview on 1/13/25 at 9:55 A.M., the resident's private caregiver said he/she comes on Monday through Friday. On Tuesday, 1/7/25, the resident was getting ready for hospice to give him/her a bed bath and the resident said he/she hit his/her foot on the Hoyer lift on Monday. He/she said it was jammed or something to that effect. It was hurting him/her. The caregiver was not at the facility on Monday, 1/6/25. He/she did see the resident's ankle at the time, and it was bruised. He/she took a picture and showed it to the surveyor. The resident's ankle in the pictures appeared reddened around the inner ankle and foot. There was dark bruising around the big toe; however, the picture cut off at that point. The private duty caregiver said he/she let the hospice nurse know and he/she said they would get an x-ray of it. The resident is transferred with a Hoyer lift, but he/she had witnessed staff use other devices. On 1/1/25, staff used a sit to stand. It was two CNAs that he/she saw before. The caregiver told staff the resident does not stand, and staff said it was ok, it will work out. They also used it on 1/3/25, but it was in the shower. The resident did verbalize he/she wanted to stand at that time to hospice. He/she asked are you sure you want to stand and are you sure you want to get in the shower and the resident said yes. He/She did not have complaints of pain at that time. The caregiver said he/she told CNA C that the resident was transferred in the sit to stand and then he/she stood again on 1/3/25 with hospice in the shower. The caregiver was not comfortable with the resident standing because he/she had not stood in a year. Review of CNA A's written statement, dated 1/8/25, showed CNA A worked with the resident on the weekend and Monday day shift. Resident did not complain about foot pain, but Saturday, his/her left foot was touching his/her foot peddle and CNA A put his/her foot on two pillows. During an interview on 1/15/25 at 9:13 A.M., CNA A confirmed he/she worked on Monday 1/6/25, during the day shift. He/She is familiar with the resident and the resident transfers with use of a Hoyer lift. He/She transferred the resident his/herself. There was no one else around and he/she did not see anyone, so he/she did it. The transfer went well. He/She transferred the resident to the side of the chair. He/She had difficulty describing it. The resident's chair was next to the Hoyer lift and the resident was transferred into the chair from the side and not the front of the chair. The resident did not have any complaints of pain during the transfer or after. There was no indication of an injury before or after the transfer. He/She was not aware of the resident transferred by use of another device, or it was not reported he/she stood up; however, somebody reported that someone used a stand-up lift. He/She learned the resident's ankle was fractured. He/she did not report to nursing that he/she operated the Hoyer lift alone. The resident is also a good transfer. The resident's private caregiver was there, but did not say anything. If he/she wanted to know how a resident is to be transferred, he/she would go to the nurse and ask what the resident's transfer status was. He/She was familiar with the care card on the resident of the resident's door. He/She did not know how often it was updated. Review of CNA C's written statement, dated 1/8/25, showed the resident's sitter came and said the resident's foot was broke because a CNA got it caught on the Hoyer and I need to tell my nurse because he/she does not listen anyway. Resident's sitter also said, they better watch out tomorrow because family will be here, watch. I saw hospice give the resident a shower using a sit to stand, but he/she was not sure of date. During an interview on 1/15/25 at 10:23 A.M., CNA C said he/she worked with the resident on Friday, 1/3/25. He/She is familiar with the resident and was aware the resident transferred with use of the Hoyer lift. The resident's private caregiver told him/her that someone used a sit to stand. He/She was not good at remembering dates, but the caregiver described them and said they were doing the resident's shower. CNA C also confirmed his/her written statement. He/she believed hospice used a sit to stand in the shower. CNA C did not witness the resident on it, but the Hoyer lift was never in the bathroom. He/She could not say he/she saw the resident on the sit to stand, but he/she put two and two together. Someone said they used a sit to stand on the resident and it was Friday, 1/3/25. It was discussed after the caregiver told CNA C. CNA C went to LPN D and said the caregiver said something about the resident. LPN D told CNA C to not be a go between for the caregiver. CNA C went back to the private caregiver and said LPN D needs to be informed by the caregiver and CNA C cannot be a go between. CNA C cannot say if LPN D followed up with the private caregiver and CNA C did not report it to management. If the private caregiver reports something regarding the resident, they go to the nurse depending on what happened. The caregiver can report to other staff. If he/she wanted to know how a resident transferred, he/she would go to charting or find the care card on the back of the door. It is updated quite often. Review of LPN D's written statement, dated 1/8/25, showed LPN D was the charge nurse for the resident on Saturday, 1/4/25 and resident did not complaint of any pain or discomfort and no one reported any issues. During an interview on 1/15/25 at 10:50 P.M., LPN D confirmed he/she worked on Friday, 1/3/25. He/She worked with the resident before and was aware he/she transferred with a Hoyer lift. It was not reported to him/her that the resident stood up prior to learning about the fracture. He/She did not receive any reports from the private caregiver. LPN D did instruct CNA C to not be a go between but that was on Tuesday, 1/6/25. CNA C did approach him/her and said, don't shoot the messenger, but and LPN D stopped CNA C mid-sentence and said if something needed to be reported, the caregiver needs to tell me. It was on Tuesday. The resident had already received the x-ray and hospice saw him/her. Whatever happened had already happened and he/she wanted the resident's caregiver to go to him/her, otherwise it is second hand information. During an interview on 1/15/25 at 2:40 P.M., the Administrator and DON said they would expect residents to be transferred appropriately per orders, policy, and care plan. If a resident required to be transferred with a Hoyer lift, it is not appropriate to use other devices. They would expect there to be two people. If staff cannot find a second person, they are expected to wait until someone is available. They were not aware the resident was transferred in the Hoyer lift with one staff on Monday, 1/6/25. There is no rule with whom the private caregiver has to report to; however, they would expect him/her to go to the nurse. The CNA could forget. They would have expected the CNA to report to the administrator or DON if he/she could not report information to the nurse from the caregiver. If it was reported that the resident stood on 1/1/25 and 1/3/25, they would expect staff to report it so the resident could have been assessed. It was not reported to them prior to 1/7/25 that staff believed hospice used a sit to stand to transfer the resident on 1/3/25. Staff are in-serviced/educated on mechanical lifts year or if there is an investigation. 2. Review of Resident #7's significant change MDS, dated [DATE], showed: -Moderate cognitive impairment; -Diagnoses included heart failure, depression, asthma, and respiratory failure; -Impairment to both sides of the upper and lower extremity; -Uses wheelchair; -Sit to stand: Not attempted due to medical condition or safety concerns; -Chair/bed to chair transfer: Dependent, helper does all the effort. Resident does none of the effort to complete the activity. Review of the resident's care plan, in use during survey, showed: -Activity of Daily Living (ADL) function rehab: Resident has a self-care deficit for ADL and mobility performance. He/She requires supervision and assist to complete cares. Related to decline in cognition as evidenced by St. Louis University Mental Status exam (SLUMS, 30 point test that assess cognitive function) of 21/30 (mild neurocognitive disorder), chronic back pain related to spinal stenosis (when spaces inside the bones of the spine get too small) in lumbar (lower back) region, unsteadiness on his/her feet, abnormalities of gait, history of falling, and generalized weakness; -Assist with ADLs as necessary with staff assist of limited-no weight bearing, set up at sink side have necessary items in place. Offer supervision and verbal cues. Segment tasks as needed to allow resident to complete tasks in efficient time, safe and quality manner; -Transfers: Extensive assist x1 using gait belt and wheeled walker (ww), may use EZ stand (a transfer assist device that helps people stand up) as needed x 2. Observation on 1/13/25 at 12:53 P.M., showed the resident sat in his/her wheelchair preparing to be transferred by CNA F and CNA G. Staff connected the Hoyer pad, that was located underneath the resident, and hooked it onto the Hoyer lift. Staff reminded the resident to give him/herself a bear hug. Resident crossed his/her arms. CNA F operated the Hoyer lift and lifted the resident. The resident's chair begun to rise with the resident seated, approximately one foot into the air before staff lowered the chair and re-assess. The resident did not show any signs of being scared, nervous, or anxious. The resident's shoe fell off. Staff re-assessed and checked the chair. CNA F operated the lift a second time and the resident was lift. The resident continued to keep arms crossed. CNA A guided the resident approximately six feet from the chair to the bed. The resident was lowered slowly onto his/her bed. The resident did not have any complaints. Observation of the resident's care card on the back of the door, showed extensive assistance x 2 using a gait belt. During an interview on 1/15/25 at 2:25 P.M., the administrator and DON said they were not aware of Resident #7's Hoyer transfer. They would expect staff to ensure the Hoyer pad is not hooked to the chair and ensure resident safety prior to lifting. Staff are able to find information on how a resident transfers on the back of their door and they can go to the DON. It is updated every three months or when there is a change in condition. Nursing or social worker is responsible for updating it. The DON would expect it to be updated timely. MO00247718

Based on interview and record review, the facility failed to ensure services provided met professional standards of practice when the facility failed to complete neuro checks (neurological assessments) following unwitnessed falls for two residents, including one fall in which the resident reported he/she hit his/her head (Residents #41 and #27). The sample was 18. The census was 84. Review of the facility's Fall policy, dated August 2019, showed: -Policy: It is the policy of this facility to evaluate each resident immediately after a fall; -Procedure included: -If the fall was unwitnessed or involved a potential head injury, initiate neurological assessment per facility policy; -Document relevant post-fall clinical findings, such as neurological checks, in the resident's record. Review of the facility's Neurological Checks policy, revised January 2022, showed: -Policy: It is the policy of the facility to ensure proper neuro checks at the time a resident falls and hits their head or has an unwitnessed fall. Each resident will have neuro checks completed so the facility can provide immediate care; -Purpose: -To determine the degree of injury so that proper care can be rendered in a timely manner; -To evaluate condition; -Procedure included: -Complete neurological assessment form; -Vital Signs and Neuro Assessment Status Post Fall: -Every 15 minutes's x one hour, then; -Every 30 minutes x one hour, then; -Every hour x four hours, then; -Every four hours x 24 hours; -The nurse will place the completed assessment in the medical records box at the nurse's station; -Medical records staff will then scan assessment into resident's chart. 1. Review of Resident #41's medical record, showed: -Diagnoses included Parkinson's disease (brain disorder causing unintended or uncontrolled movements), repeated falls, unsteadiness on feet, other abnormalities of gait and mobility, dementia with mood disturbance, Alzheimer's disease with late onset, and visual hallucinations; -An order, dated 8/4/24, for Eliquis (blood thinner) 5 milligrams (mg) by mouth twice daily. Review of the resident's care plan, in use at the time of survey, showed: -Problem: At risk for falls related to poor safety awareness, vision loss, and dementia; -Approaches included documentation of falls on 8/4/24 and 8/30/24. Review of the resident's progress note, dated 8/4/24, showed nurse summoned to room via Certified Nurse Aide (CNA). As the nurse entered the room, the resident noted on the floor in sitting position in front of a chair. Resident noted to be agitated, demanding for staff to get him/her up off the floor. The nurse along with CNA explained that the nurse needed to assess before transferring and resident became upset, yelling at staff. When the nurse asked if the resident hit his/her head, the resident yelled, Yes. The nurse asked the resident to point to the spot that was hit on the head. No complaints of pain with range of motion, so the nurse and CNA used a gait belt and attempted to transfer the resident from the floor to a standing position, and resident screamed out for help and demanded the nurse and CNA to stop. Nurse attempted to unbuckle the gait belt to look at the resident's skin, and the resident yelled at the nurse and CNA to leave him/her alone while snatching the gait belt. Resident in chair post fall. Review of the resident's post fall summary, dated 8/4/24, showed: -Vital signs: Refused; -Fall was witnessed: No. Review of the resident's medical record, showed no neuro checks documented following the fall on 8/4/24. Review of the resident's progress note, dated 8/30/24, showed at 5:00 P.M., CNA found resident sitting on the floor in the bathroom and notified the nurse. The resident was sitting on his/her buttocks with legs outstretched. Full range of motion to all extremities, no signs/symptoms of injury, denies pain. Assist of two with a gait belt to help him/her stand. Review of the resident's post fall summary, dated 8/30/24, showed: -Vital signs: Blank; -Fall was witnessed: No. Review of the resident's medical record, showed no neuro checks documented following the fall on 8/30/24. During an interview on 9/9/24 at 11:47 A.M., the resident said he/she was doing fine and had no concerns. The resident was unable to answer questions specific to his/her medical history. 2. Review of Resident #27's medical record, showed: -Diagnoses included stroke, hemiplegia (paralysis to one side of the body) following stroke affecting right dominant side, aphasia (language impairment), and dementia with other behavioral disturbance; -An order, dated 6/15/24, for aspirin 81 mg., one tab by mouth once daily; -A progress note, dated 5/27/24 at 8:30 P.M., showed the resident found sitting on the floor next to his/her bed smiling and talking, Pretty, pretty, pretty. Assessed, no signs/symptoms of injury found. Assist of two with gait belt to get him/her back in bed. Review of the resident's post fall summary, dated 5/24/24, showed: -Vital signs: Blank; -Fall was witnessed: No; -Level of consciousness/mental status: Intermittent confusion. Review of the resident's medical record, showed no neuro checks documented following the fall on 5/24/24. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Impaired cognition related to inability to express wants/needs. Resident has history of stroke with impaired communication and impacted mobility. Diagnosis of vascular dementia; -Problem: Resident had a stroke in 2017, which resulted in aphasia. He/She is only able to shake head for yes or no. The only word he/she uses with clarity is Pretty; -Problem: At risk for falls related to history of stroke, weakness, psychotropic medication use, history of falls; -Approaches included documentation of fall on 5/24/24. During an attempted interview on 9/9/24 at 11:38 A.M., the resident was unable to respond to questions and repeatedly said, Pretty. 3. During an interview on 9/12/24 at 9:28 A.M., Licensed Practical Nurse (LPN) E said after an unwitnessed fall, the nurse is to immediately complete a neurological assessment. After the initial assessment, the nurse fills out a neuro check flow sheet on paper, where they complete the specified assessments, such as pupil checks, blood pressure, and level of consciousness. The assessments on the neuro check form are completed every 15 minutes four times, then every 30 minutes for two times, then every hour for four hours, and then every four hours for 24 hours. The purpose of a neurological assessment is to assess for any type head injury or change in condition. It is especially important when the residents are on blood thinners or aspirin to complete the neuro assessments because the medications could worsen a brain injury. 4. During an interview on 9/12/24 at 10:47 A.M., LPN A said after an unwitnessed fall, the nurse completes a head to toe assessment on the resident, including assessing their vital signs, pain, and range of motion. The nurse starts the resident on neuro checks and completes a post-fall assessment in the electronic medical record (EMR). Neuro checks are done on paper and the nurse notifies the oncoming shift of the need to continue the neuro checks until 72 hours after the fall. Neuro checks are to be completed at the intervals indicated on the neuro check flow sheet. Once the neuro check sheet is completed after the 72 hours following the fall, the flow sheet goes to medical records. Neuro checks are done to rule out a head injury. Neuro checks are particularly important for residents on blood thinners and residents who are unable to tell staff what happened with the fall. 5. During an interview on 9/11/24 at 1:51 P.M., the Director of Nurses (DON) said she was unable to locate documentation to show completion of neuro checks following the unwitnessed falls for Residents #41 and #27. Resident #41 is alert and oriented times two to three with confusion. He/She has hallucinations and is visually impaired. Resident #27 is alert and oriented times one to two. Neither resident would be able to tell staff what happened following a fall. Neuro checks should be completed for the 72 hours following all unwitnessed falls for all residents, and any witnessed fall in which the resident hits their head. Neuro checks are performed to make sure there is no head injury. Neuro checks are documented on a paper flow sheet, then given to medical records to be filed in the resident's medical record. 6. During an interview on 9/12/24 at 11:31 A.M., the Administrator said documentation of neuro checks completed following the unwitnessed falls for Residents #41 and #27 could not be located. He expected neuro checks to be completed following unwitnessed falls to ensure there is no unseeable injury. Neuro checks should be retained in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene in accordance with their needs and preferences (Residents #24 and #11). The sample was 18. The census was 84. Review of the facility's AM (morning) Care policy, dated August 2019, showed: -Policy: It is the policy of this facility to provide the necessary morning care and services based upon the comprehensive assessment of a resident and consistent with the resident's needs and choices, or order to maintain or improve a resident's ability to carry out the activities of daily living; -Purpose included: -To prepare the resident for their day; -To maintain oral health and bodily hygiene; -To provide for physical comfort; -To maintain the resident's desired physical appearance; -Procedure included: -Review resident specific plan of care interventions, assistance, devices, supplies and instructions; -Follow resident preferences as stated in the care plan; -Assist the resident with grooming according to their preferences (make up application, shaving and hair removal, hair care and styling, etc.); -Transport resident to their desired location (e.g. dining room) or ensure that call bell is in place if the resident is remaining in their room. If the resident is bed bound, position in a safe position for breakfast. 1. Review Resident #24's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/19/24, showed: -Cognitively intact; -Rejection of care behavior not exhibited; -Lower extremity impairment on both sides; -Substantial/maximal assistance for upper body dressing; -Dependent for showering/bathing -Dependent for personal hygiene; -Dependent for sitting to lying, lying to sitting, chair/bed to chair transfers; -Diagnoses included multiple sclerosis (MS, disease of the central nervous system), dementia, and depression. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Resident is at risk for alteration in psychosocial well-being and mood state related to memory loss, history of depression and anxiety, diagnosis of MS and overall decline in mobility; -Problem: Self-care deficit for ADL performance as result of end state MS. Resident is able to feed him/herself but is total assist with other ADLs; -Goal: Resident's needs will be anticipated and met in next 90 days; -Approaches included: -Assist resident to transfer into Broda (reclining chair) chair and assist to position for comfort while up and for transport distances; -Bed mobility assistance of one to two staff; -Transfer via Hoyer lift (mechanical lift) assistance of two staff; -Walking in room and locomotion on neighborhood dependent to be pushed in Broda chair; -Dressing assist of one staff; -Bath/shower assistance of one to two staff, twice a week; -No documentation of the resident refusing care or to get out of bed. Review of the resident's medical record, showed no documentation of refusals of hygiene care or refusals to get out of bed during the past 90 days. Observation on 9/9/24 at 11:48 A.M., showed the resident in bed wearing a hospital gown with yellow stains on the front, below the collar of the gown. The fingernails on the resident's right hand were long and jagged with sharp edges. During an interview, the resident said staff sometimes give him/her bed baths. Staff do not trim or file his/her nails. He/She would like staff to look at his/her nails because they need to be taken care of. He/She cannot walk and staff have to get him/her out of bed. Staff said they cannot get him/her out of bed today. Observation on 9/9/24 at 12:33 P.M., 1:04 P.M., and 6:18 P.M., showed the resident in bed with the same hospital gown on. Observation on 9/10/24 at 8:03 A.M., showed the resident in bed, wearing the same hospital gown as the day before, with yellow stains on the front of the gown. The nails on his/her right hand were long and jagged with sharp edges and a light brown substance underneath the nails. Observation on 9/10/24 at 10:47 A.M., showed the resident in bed, wearing the same stained hospital gown. During an interview, the resident said staff last changed his/her hospital gown a couple days ago. He/She wants to get out of bed today, but staff have not offered to get him/her up. His/Her fingernails are the same, and he/she would really like them to be addressed. His/Her fingernails really are a mess and it is really important to him/her that they get done. Observation on 9/10/24 at 1:23 P.M., showed the resident in bed, wearing the same stained hospital gown. The fingernails on his/her right hand were long and jagged with a light brown substance underneath. During an interview, the resident said staff did not get him/her out of bed today and he/she hopes they do tomorrow. Observation on 9/11/24 at 7:55 A.M., showed the door to the resident's room closed. Certified Nurse Aide (CNA) C and CNA D walked down the hall, and CNA C asked CNA D who else needed to get up for the day. CNA D said one resident up the hall needs get his/her treatment before he/she gets up, and another resident will get up later. CNA D said he/she will handle Resident #24. Observation on 9/11/24 at 9:41 A.M., showed the resident in bed, wearing the same stained hospital gown he/she had been wearing since 9/9/24. The fingernails on his/her right hand remained untrimmed with a light brown substance underneath the nails. During an interview, the resident said staff have not offered to get him/her up today. His/Her hospital gown has not been changed in days and his/her fingernails have not been trimmed, and he/she would like to be changed and have his/her nails trimmed. Observation on 9/11/24 at 12:14 P.M., showed the resident in bed in his/her room. During an interview on 9/11/24 at 12:17 P.M., Licensed Practical Nurse (LPN) B said the resident's legs are contracted and he/she requires a Hoyer lift for transfers. The resident is total care and does well with hygiene care. He/She does not refuse hygiene care. LPN B expects residents' nails to be cleaned and trimmed daily during morning care. He/She expects staff to change residents' hospital gowns daily and when soiled. Staff should offer to get bedbound residents out of bed daily. During an interview on 9/11/24 at 1:11 P.M., CNA D said he/she personally asked the resident if he/she wanted out of bed earlier, and the resident said he/she did not want to get up. Staff should provide nail care while providing daily care to residents. Hospital gowns should be changed daily. Observation on 9/11/24 at 1:13 P.M., showed the resident in bed in his/her room, wearing the same stained hospital gown. LPN B wet a washcloth in the resident's bathroom sink. During an interview, LPN B said he/she was getting ready to wash the resident's hands. He/She acknowledged the fingernails on the resident's right hand need to be trimmed. During an interview on 9/11/24 at 12:42 P.M., CNA C said resident nails should be trimmed and cleaned by the CNAs during morning daily care. Hospital gowns should be changed daily and as needed. During an interview on 9/11/24 at 11:55 A.M., LPN A said he/she expects nursing staff to clean and trim resident nails as part of the resident's daily care. Hospital gowns should be changed daily and when soiled. He/She expects staff to offer to assist residents out of bed daily and to honor their preferences for assistance. 2. Review of Resident #11's admission MDS, dated [DATE], showed: -Cognitively intact; -No rejection in care; -Both upper extremities have impairment; -Requires some touching assistance from staff for showering and bathing, toilet hygiene, and upper and lower body dressing; -Requires set up or clean up assistance from staff for personal hygiene. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's ADL needs. Review of the resident's face sheet dated 9/10/24, showed diagnoses included heart failure, end stage renal (kidney) disease, diabetes, chronic (long-term) wound, muscle weakness, rectal cancer, unsteadiness on feet, and reduced mobility. Review of the resident's shower schedule dated 9/2 through 9/8/24, showed the resident received one shower on 9/5/24. During observation and interview on 9/9/24 at 11:30 A.M., the resident sat in his/her room in his/her wheelchair. The resident's hair appeared oily. The resident said he/she has only been receiving showers about once a week and that the last shower he/she received was 9/5/24. The resident would like a shower at least twice a week or more often. He/She requires assistance covering her Quinton Catheter (a tube surgically inserted tube into large blood vessel in the chest used for dialysis, a treatment to clean the body's blood supply of impurities). He/She will sometimes have swelling in his/her hands that makes his/her fingers difficult to move. He/she would also like some supervision from staff getting in and out of the shower to make sure he/she doesn't fall. During observation and interview on 9/10/23 at 7:50 A.M., the resident's hair appeared oily. The resident said that his/hair was oily, and he/she just he/she tries to keep it combed since he/she cannot wash it him/herself. During observation and interview on 9/11/24 at 9:35 A.M., the resident was in his/her bathroom standing at the sink getting his/her coccyx (tailbone) dressing changed by LPN K. The resident's hair appeared oily and in string-like segments. When the resident's wound treatment was completed, the resident sat in his/her wheelchair and combed his/her oily hair. The resident was getting ready to go to the facility chapel to say the Rosary. During an interview on 9/12/24 at 9:28 A.M., LPN E said the resident requires one person assistance with showering and would expect staff to cover his/her Quinton catheter so that his/her hair could be washed. Residents have scheduled shower days and should have showers twice a week. During an interview on 9/12/24 at 9:40 A.M., CNA L said the resident requires minimal assistance with his/her showers. He/She would need assistance with covering his/her Quinton catheter, making sure it doesn't get wet when his/her hair gets washed. The resident also requires assistance getting in and out of the shower. Resident showers are to be completed twice a week. 3. During an interview on 9/11/24 at 1:51 P.M., the Director of Nurses (DON) said Resident #24 is total care. Staff should offer to get him/her up daily. The resident does not refuse care, or assistance with hygiene. Nail care should be provided to residents as part of their daily care. CNAs can trim and file nails. Hospital gowns and clothing should be changed daily and when soiled. If a resident has ongoing refusals of care or getting of bed, it should be documented on their care plan. All residents in the building require assistance bathing and showering. Resident #11 is more independent than many residents on the Grand Hall, but she would expect the staff to offer and provide assistance to the resident for all his/her needs. 4. During an interview on 9/12/24 at 11:31 A.M., the Administrator said he expects nail care to be provided to residents as part of their daily care. Certified Medication Technicians (CMTs) have been asked to check this when they see the residents for medication administration. He expects staff to change hospital gowns or clothing daily and as needed. He expects staff to offer to get bedbound residents out of bed daily. If a resident refuses to get out of bed, or refuses hygiene assistance, staff should document this in the resident's medical record. He expects staff to provide and assist residents with their showers twice a week.

Based on observation, interview and record review, the facility failed to provide a pre-assessment and post assessment communication form to the dialysis center for one resident (Resident #11) receiving hemodialysis (a treatment to clean the body's blood supply of impurities). The sample was 18. The census was 84. Review of the facility's Hemodialysis Access Policy revised, 1/10/18, showed: -Documentation (for Dialysis Communication forms): -Location of the hemodialysis access point; -Condition of the dressing and any interventions required at the time of assessment; -Prior date or shift of dialysis completed; -Report received from dialysis clinic registered nurse (RN); -Resident observation post-dialysis from nurse assessment of resident and access site; -Physician notifications of unusual observations. Review of Resident #11's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/26/24, showed: -admission date: 8/19/24; -Cognitively intact; -Receives hemodialysis. Review of the resident's care plan, in use at the time of survey, showed it did not address the resident's hemodialysis treatments. Review of the resident's face sheet dated 9/10/24, showed diagnoses that included heart failure, end stage renal (kidney) disease, and diabetes. Review of the resident's physician order sheets (POS) dated September, 2024, showed; -An order, with a start date 8/20/24, hemodialysis on Tuesdays, Thursdays, and Saturdays. During observation and interview on 9/9/24 at 11:30 A.M., the resident said he/she goes to dialysis on Tuesday, Thursday and Saturday around 11:00 A.M., and the facility provides transportation. No paperwork was ever sent with him/her to or from dialysis. The resident had a dressing covering his/her right chest dialysis catheter. During an interview on 9/10/24 at 1:10 P.M., Licensed Practical Nurse (LPN) K, said no paperwork or any forms were sent with the dialysis residents. The only paperwork that was sent was the POS on the first day of treatment. During an interview on 9/11/24 at 7:35 A.M., Registered Nurse RN S said there is a communication form that the facility uses for dialysis residents to take with them. It usually includes vital signs, weights, and any new orders or changes with the resident. During an interview on 9/11/24 at 10:00 A.M., the Director of Nurses (DON) said there were no completed dialysis communication forms in the resident's medical record. She would expect staff to utilize the dialysis communication forms that include pre and post treatment assessments.

Based on observation, interview and record review the facility failed to ensure a medication administration error rate of less than 5%. Out of 25 opportunities for error, three errors occurred, resulting in a medication error rate of 12% which affected two residents (Residents #34 and #9). The sample was 18. The facility census was 84. Review of the facility's Medication Administration policy, revised 8/2019, showed: -All personnel administering medications will ensure that the medication given is the correct medication, the correct dose, the correct person, the correct administration time, and the correct route of administration. 1. Review of Resident #34's physician order sheet (POS), showed an active physician order for Refresh Tears eye drops to be given once daily. Observation and interview on 9/10/24 at 6:45 A.M. showed Certified Medication Technician (CMT) I administered morning medications to Resident #34. CMT I sanitized his/her hands and noted that the resident's daily Refresh Tears eye drops (for dry eyes) were not available on the cart. CMT I asked the floor nurse to check the emergency kit (e-kit) in the facility medication room for the medication, but it was not available. CMT I re-ordered the medication from the pharmacy and completed Resident #34's medication administration without administering the medication. CMT I said the pharmacy makes two runs to the facility per day, once in the afternoon and once around 4 A.M., and medications can sometimes be delivered same day if ordered early enough. CMTs and nurses are expected to re-order medications from the pharmacy when they begin to run low on current supply, not when the medication runs out. Review of the resident's medication administration record on 9/11/24 at 9:35 A.M., showed the ordered Refresh Tears eye drops had not been administered on 9/10/24. 2. Review of Resident #9's POS, showed an active physician order for PreserVision Eye drops and Thera-M multivitamin to be given once daily. Observation and interview on 9/10/24 at 6:58 A.M. showed CMT I administering morning medications to Resident #9. CMT I sanitized his/her hands and noted the resident's PreserVision Ocular Vitamins (eye drops containing vitamins key to eye health) and daily Thera-M multivitamin (multivitamin containing vitamins and iron) were missing from the cart. The floor nurse checked the e-kit and stock medications for CMT I and was unable to find the medications. CMT I again re-ordered the medications from the pharmacy and completed the resident's medication administration without administering the missing medications. Review of the resident's medication administration record on 9/11/24 at 9:37 A.M., showed the ordered Thera-M multivitamin and PreserVision eye drops were not administered on 9/10/24. 3. During interview on 9/11/24 at 1:55 P.M. the facility Director of Nursing (DON) said all medications should be administered to residents per physician orders, and staff who cannot find a medication on the cart should check the e-kit and the facility's stock medications. If the medication cannot be found in either of those places, staff are instructed to contact the pharmacy to try and resolve the issue. Staff should document the medication as not given if it could not be located, and it should be administered at the soonest appropriate administration time.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were labeled and stored per acceptable standards of practice. Problems were noted in one of two identified facility medication rooms and in two of four medication administration carts. The facility census was 84. Review of the facility's Medication Storage in the Facility policy, no noted revision date, showed: -Medications and biologicals are stored safely, securely, and properly following the manufacturer or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications; -Outdated, contaminated, or deteriorated drugs and biologicals in containers which are cracked, soiled, or without closure will be immediately withdrawn from stock. They will be disposed of according to drug disposal procedures and reordered from the pharmacy if a current order exists; -The nurse will check the expiration date of each medication before administering it. 1. Observation on 9/10/24 at 10:41 A.M. of the facility's first floor medication room, showed: -One 12 ounce (oz) bottle of Milk of Magnesia (a medication used to treat upset stomach, constipation, and heartburn) ordered for Resident #22 expired as of July 2024; -One box of Albuterol Sulfate inhalation aerosol solution packets (a medication used to treat coughing, wheezing, chest tightness, and difficulty breathing) expired as of October 2023; -One box of Covidien Xeroform Occlusive gauze strips with 3% Bismuth (a petroleum-based fine mesh gauze impregnated with an antimicrobial medication to aid in wound healing) expired as of July 31, 2022; -One box containing 12 KerraFoam gentle border foam dressings (foam wound dressings used to aid in wound healing) expired as of May 2023; -One half-full gallon container of white distilled vinegar expired as of April 8, 2024; -Three total punch cards of Divalproex (a medication used to treat seizure disorders and some forms of migraine headaches) 500 milligram tablets ordered for Resident #30. One punch card expired as of May 9, 2024 with one tablet left, one punch card expired June 7, 2024 with 23 tablets left, and one punch card expired as of July 2, 2024 with 30 tablets left. Observation on 9/10/24 at 10:58 A.M. of a first floor nurse treatment cart, showed a Glucagen Hypokit 1 milligram glucagon (a medication used to quickly counteract critically low blood sugar levels) expired as of August 31, 2024. Observation on 9/10/24 at 11:06 A.M. of a first floor Certified Medication Technician (CMT) cart, showed a 30-tablet punch card for Senokot (stool softener) ordered for Resident #50, expired as of June 14, 2024 with 27 tablets left in the card. During interview on 9/10/24 at 12:18 P.M. CMT I said CMTs and treatment nurses are responsible for auditing carts on the hall for expired or discontinued medications, and are expected to waste them per facility policy if found. CMT I was not aware of any routine or formal process for this auditing at the facility. During interview on 9/11/24 at 12:22 P.M. Licensed Practical Nurse (LPN) B said night shift staff are typically responsible for auditing the medication rooms and ensuring expired medications are removed, but all staff are expected to participate in removing expired medications and biologicals as an ongoing process. LPN B said facility administration asked nurses and CMTs randomly to go perform high-sensitivity medication audits to ensure insulin and other time-sensitive medications were not expired, but was unaware of a routine audit process for medication rooms or treatment carts. LPN B said facility administration would expect staff to remove an expired medication and waste it per facility policy if found on a cart or in a facility medication room. 2. Observation on 9/9/24 at 1:05 P.M., showed a medication cart on the Grand Unit located near the dining area, unlocked, and unattended by staff. CMT J was assisting the residents with meals. At 1:07 P.M., CMT J returned to the unlocked medication cart. Observation on 9/10/24 at 7:50 A.M., showed CMT J standing at the medication cart on the Grand Unit near the dining room. Resident #11 was self-propelling him/herself in his/her wheelchair out of the dining room and returning to his/her room. CMT J walked away from the unlocked medication cart to take Resident #11's blood pressure in the Grand Unit hallway around the corner from where the medication cart was positioned. The medication cart was left unlocked and unattended. At 7:53 A.M., CMT J returned to the medication cart. Observation and interview on 9/10/24 at 8:25 A.M., showed a medication cart located on the Grand Unit near the dining area, unlocked, and unattended by staff. CMT J assisted residents in the dining room. Resident #26 sat in his/her wheelchair directly next to the unlocked medication cart. The resident said he/she was waiting on his/her medication. At 8:28 A.M., CMT J returned to the medication cart and administered Resident #26's medications. At 8:33 A.M., CMT J walked away from the unlocked medication cart to assist in the dining room. At 8:35 A.M., CMT J returned to the medication cart. During an interview on 9/11/24 at 12:10 P.M., LPN K said the medication carts are to be locked every time the medication cart is left unattended. During an interview on 9/11/24 at 12:07 P.M., CMT G said the medication carts are to be locked every time a staff member walks away from it. No matter how long it is going to be, an unattended medication cart is to be always locked. The reason why the medication cart should be locked is for resident safety. On the Grand Unit there are dementia residents, and they may try to get inside the cart and take medications out. 3. During an interview on 9/11/24 at 1:51 P.M., the facility Director of Nursing (DON) said Nurses, CMTs, and nursing administration are responsible for auditing the medication rooms and carts for expired medications and biologicals, and would expect medications found in these places outside of expiration date to be wasted per facility policy. The DON said she expects staff to lock the medication carts every time the cart is left unattended to ensure resident safety. 4. During interview on 9/12/24 at 11:31 A.M. the facility Administrator said he would expect medication carts to be kept locked when not in use by staff, and medications should be stored in accordance with acceptable standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with central lines to include dialysis access sites and wounds requiring treatments (Residents #70 and #11). In addition, the facility failed to ensure staff wore N-95 respirator masks in rooms of residents positive for COVID, who were on airborne (precautions that reduce the risk of an airborne transmission of infections airborne droplets) and droplet precautions (precautions that reduce the risk of large-particle droplet transmission or infectious agents), and the facility failed to ensure staff wore surgical masks properly as a means of source control on the facility's first floor, where the facility identified a COVID outbreak, in accordance with the facility's policy and the Director of Nurse's (DON) expectations (Residents #30, #21, and #132). The sample was 18. The census was 84. Review of the facility's Enhanced Barrier Precautions policy, developed 4/2/24, showed: -Purpose: Prevention of transmission of resistant organisms in all settings to employees, residents and visitors is a major concern; -Enhanced barrier precautions reinforces the proper procedure for hand hygiene to promote clean hands by everyone before entering and leaving the room of any resident, regardless of diagnosis; It also includes directions for all providers and staff to also wear gloves and a gown for the following high contact resident care activities: -Dressing; -Bathing or showering; -Transferring; -Changing linens; -Providing hygiene; -Change briefs or assisting with toileting; -Device care or use: Central line, urinary catheter (a tube that drains the bladder), a feeding tube (a surgically inserted tube into the abdomen that provides liquid nutrition and medications), tracheostomy (a surgically developed opening in the windpipe that assists with breathing); -Wound care: Any skin opening requiring a dressing; -EBP signage shall be placed outside of the resident room for all entering the room to see. Review of the facility's Updated COVID-19 with Ending of Public Health Emergency policy, updated 5/11/23, showed: -Purpose: Provide safe care and protect the safety of all residents, families, staff, volunteers and contractors from exposure to COVID-19; -Caring for a resident with suspected COVID-19; --The resident should immediately be placed in transmission-based precautions (airborne, contact, droplet, and standard precautions) with any staff entering the room wearing gown, gloves, N95 respirator, and face shield or goggles; --Source control (masks), the use of surgical masks by all persons entering the building shall be based on community metrics and cases of COVID in the building; --Source control shall be required for all who enter the building based upon cases in the building. 1. Review of Resident #70's medical record, showed; -Diagnoses included Stage III (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.) pressure ulcer to right heel, Alzheimer's disease with late onset, and dementia. -A physician order, dated 8/19/24, for right heel cleanse with normal saline (NS), apply Hydrofera Blue (moist wound dressing), cover with foam dressing, three times a week for wound. Review of the resident's care plan, in use at the time of survey, showed: -Problem: Fragile skin. Triggered area: Pressure ulcers; -Approaches included Enhanced Barrier Precautions, start date 8/9/24 and goal date 11/7/24. Observation and interview on 9/9/24 at 11:09 A.M., showed no signage regarding EBP outside of the resident's room. During an interview, the resident said he/she has a wound on his/her right heel. He/She wore a dressing on his/her heel. Observations on 9/10/24 at 10:52 A.M. and 9/11/24 at 6:46 A.M., showed no signage regarding EBP outside of the resident's room. Observation and interview on 9/11/24 at 9:47 A.M., showed no signage regarding EBP outside of the resident's room. Certified Nurse Aide (CNA) N entered the room and donned gloves. He/She did not wear a gown. With gloved hands, CNA N removed the sock on the resident's right foot. There was a dressing on the resident's right heel. As CNA N held the resident's right calf, his/her left forearm rubbed the outer portion of the resident's right foot. During an interview, CNA N said the resident has had a wound on his/her right heel for a couple of months now. The resident is not on EBP. EBP is for residents with open areas, like pressure ulcers. The resident used to have an EBP sign, but it is gone now. The EBP signs are posted by the Infection Preventionist. The EBP signs tell staff what Personal Protective Equipment (PPE) to wear, which just means gloves for residents on EBP. EBP just means staff have to wear gloves when they provide direct care that requires touching the resident, like dressing, changing, or transferring them. 2. Review of Resident #11's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 8/26/24, showed: -Cognitively intact; -Receives hemodialysis (filtering the blood). Review of the resident's face sheet, dated 9/10/24, showed diagnoses that included: Heart failure, end stage renal (kidney) disease, diabetes, and chronic (long term) ulcer to the back with the fat layer exposed. Review of the resident's physician order sheets (POS) dated September, 2024, showed; -An order, with a start date 8/20/24, hemodialysis on Tuesday, Thursday, and Saturday; -An order, with a start date 8/21/24, cleanse coccyx (tailbone) wound with wound normal saline, apply Manuka Honey coated dressing (a specialized wound dressing), cover with a dry dressing or a foam dressing; daily and as needed (PRN). During observation and interview on 9/9/24 at 11:30 A.M., the resident said he/she goes to dialysis on Tuesday, Thursday, and Saturday around 11:00 A.M. and the facility provides transportation. The resident had a dressing covering his/her right chest dialysis catheter (a tube surgically inserted for hemodialysis). The resident also said that he/she has a wound to his/her backside that requires a daily dressing change. The resident has never seen the staff wear an isolation gown when they provide his/her care. Observation and interview on 9/11/24 at 9:40 A.M., showed outside the resident's room was signage that read Stop, EBP, providers and staff must also wear gloves for high contact resident care activities :Dressing; Bathing or showering; Transferring; Changing linens; Providing hygiene; Change briefs or assisting with toileting; Device care or use: Central line, urinary catheter, a feeding tube, tracheostomy; Wound care: any skin opening requiring a dressing. In the resident's bathroom, Licensed Practical Nurse (LPN) K provided wound care to the resident's coccyx area with gloves on. LPN K did not have an isolation gown on. LPN K said that EBP was something new, and it is just extra precautions that staff have to take. According to the sign, he/she said he/she should have worn an isolation gown while providing the residents wound care. 3. During an interview on 9/11/24 at 8:08 A.M., Certified Medication Technician (CMT) O said the EBP signs outside of resident rooms mean to make extra sure to wear gloves During an interview on 9/11/24 at 12:42 P.M., CNA C said the orange signs outside of some resident rooms mean that resident is on EBP. He/She was not sure what EBP means. He/She thought it meant to just make sure he/she wore gloves and a mask when in the resident's room, and to wash his/her hands constantly in those rooms. During an interview on 9/11/24 at 11:55 A.M., LPN A said residents who have wounds, catheters, and ports are placed on EBP. The admitting nurse was responsible for hanging signage outside of the resident's room regarding EBP. The Infection Preventionist (IP) also follows up with this. The EBP signs indicates which PPE to use. Staff will not know to wear certain PPE for EBP if the EBP sign is not posted. For residents on EBP, it is expected that staff wear gowns and gloves while providing any direct care to the resident. During an interview on 9/11/24 at 12:17 P.M., LPN B said residents who receive dialysis, or who have catheters or wounds are placed on EBP. Upon admission or when there is a change, such as a new wound, nurses are responsible for hanging EBP signs outside of resident rooms when the resident is on EBP. The EBP sign tells staff what PPE to wear and staff will not know they should wear certain PPE unless the sign is posted. 4. During an interview on 9/11/24 at 1:51 P.M., the Director of Nurses (DON) said residents with wounds, catheters, and dialysis ports should be on EBP. Resident #70 should be on EBP because he/she has a wound on his/her heel. EBP means gowns and gloves are worn by staff when providing any kind of direct care. Gowns are typically found in the resident bathrooms and should be restocked by night shift staff. Gowns can also be located in the clean utility room. All nurses and the IP are responsible for posting EBP signs outside of resident rooms. 5. During an interview on 9/12/24 at 8:29 A.M., the IP said the facility has completed multiple in-services regarding EBP. EBP is used for residents with wounds, indwelling devices, or an MDRO. Anyone from the clinical team can put the EBP sign up on the resident's door. The use of EBP for residents with wounds is a little bit more vague. The process of normal healing does not have to be on EBP. Just because someone has a pressure ulcer, it doesn't mean they should be on EBP. For residents with pressure ulcers, a collaborative discussion is held about the resident. The wound company and risk assessment committee give input as to whether or not a resident is placed on EBP. Some residents have wounds that progress or regress, and this determines whether they are on or off EBP. Resident #70 was on EBP before and was recently removed. He/She was seen by the wound company on Monday (9/9/24) and was determined to have some regression in his/her wound. Staff brought the wound regression to the IP's attention on Wednesday. If a coworker identifies a wound regression, a discussion of placement on EBP should be held that day. If the wound company identifies a wound regression, the IP doesn't really get those reports right away. The expectation is for staff to follow the guidance and to wear the PPE as indicated while in direct contact with residents on EBP. During an interview on 9/12/24 at 10:14 A.M., the IP said the CDC guidance for EBP in regard to wounds is vague. It is a grey area and no one is comfortable taking on that thought process. A resident with dry eschar (dead tissue) would not require EBP, but they would if they had weeping eschar. In a perfect world, people would have the free flow of thought if a wound goes back and forth between weeping and dry. If she were to send out an edict about this, staff would question her judgment. 6. During an interview on 9/12/24 at 11:31 A.M., the Administrator said he expected residents on EBP to have placards outside of their rooms to indicate they are on EBP. Nursing and the IP make the determination of when a resident is on EBP. EBP is used for residents with catheters, MDROs, and wounds. He expected staff to wear the appropriate PPE during the activities specified on the EBP signs. 7. Review of the facility's Airborne Precautions sign, undated, showed everyone must put on a fit-tested N-95 or higher level respirator before room entry. Remove respirator after exiting the room and closing the door. Review of the facility's Droplet Precautions sign, undated, showed everyone must make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. Observation and interview on 9/11/24 at 12:50 P.M., showed rooms [ROOM NUMBERS] with the doors closed and several signs posted outside of each door. Signs posted included residents on isolation, Airborne Precautions, Droplet Precautions, donning PPE guidance, and doffing PPE guidance. CNA D exited room [ROOM NUMBER] and stood in the hallway with no mask on. During an interview, CNA D said the signs outside of the resident rooms tell staff what PPE to wear. He/She had to wear full PPE in room [ROOM NUMBER] because the resident in that room has COVID. CNA D donned a surgical mask, a gown, and gloves, then entered room [ROOM NUMBER]. CNA D did not wear an N95 mask when entering the resident's room. At 1:11 P.M., CNA D exited room [ROOM NUMBER] with no mask on. He/She walked down the hall and entered room [ROOM NUMBER] with no mask on. Signs outside of room [ROOM NUMBER] showed the resident was not on isolation. 8. During an interview on 9/9/24 at 10:07 A.M., the DON said five residents on the first floor have tested positive for COVID. Surgical masks are required on the first floor, and additional PPE is required in the rooms of COVID positive residents. 9. Observations on 9/9/24 at 10:59 A.M. and all days of the survey from 9/9/24 through 9/12/24, showed signs posted outside of the first floor unit as follows: -A sign showed, COVID outbreak. All first floor staff must wear face mask; -A sign showed, masks help protect everyone. We ask that all patients, visitors, staff and others working here wear a mask that covers their mouth and nose while in our facility. Observation on 9/10/24 at 8:53 A.M., showed Activity Assistant (AA) H entered the first floor unit from the main hall. He/She wore a surgical mask over his/her mouth, leaving his/her nose uncovered. He/She pulled the surgical mask over his/her nose and it fell back down, leaving his/her nose uncovered again. He/She approached Resident #30, who was not wearing a mask while seated in the common area. AA H knelt down to speak face to face with the resident, approximately two feet away, while wearing his/her surgical mask over his/her mouth and not his/her nose. Observation on 9/10/24 at 10:58 A.M., showed CMT I entered the first floor unit from the main hall with no surgical mask on. He/She walked through the common area and approached Resident #21, who was not wearing a mask while seated in the common area. CMT I spoke to the resident, approximately two feet away, while not wearing a mask. CMT I continued walking through the common area to the [NAME] hall, while not wearing a mask. Observation of the first floor resident hall on 9/10/24 at 6:40 A.M. showed Lab Technician T entered the unit with no mask on. Lab Technician T walked onto the unit halfway down the facility's Main hall past room [ROOM NUMBER] before putting on a surgical mask. Observation of the first floor resident hall on 9/10/24 at 6:47 A.M. showed Housekeeper U emptying the soiled linen closets on the hall. Housekeeper U wore one glove on the right hand and was not wearing a glove on the left hand. Housekeeper U touched handrails and door handles on the hall without sanitizing the ungloved hand or donning a second glove, and emptied all soiled linen closets on the hall in this fashion. Housekeeper U was also wearing a surgical mask under the chin and not covering his/her mouth or nose. Observation on 9/10/24 at 11:00 A.M., showed Dietary Aide (DA) M exited the kitchen through the door leading to the first floor dining room, with no mask on. He/She crossed through the dining room, passing by Residents #21 and #132, who were seated in the common area without masks on. DA M entered the restroom by the dining room and exited a minute later, without a mask on, again passing by Residents #21 and #132, as he/she exited the first floor unit. Observation on 9/11/24 at 9:45 A.M., showed the Admissions Specialist at the first floor Main hall nurse's station with a surgical mask on his/her chin, leaving his/her nose and mouth uncovered, while talking to three staff at the nurse's station. Observation on 9/11/24 at 7:22 A.M., showed Housekeeper F exited the housekeeping closet on the [NAME] hall, by room [ROOM NUMBER], wearing a surgical mask on his/her chin, leaving his/her nose and mouth uncovered. Housekeeper F walked down the [NAME] hall toward the dining room, passing by one resident in the hallway and one resident in the dining room, who were not wearing masks. 10. During an interview on 9/11/24 at 12:42 P.M., CNA C said the first floor is positive for COVID, so staff need to wear surgical masks at all times while on the floor. Masks need to cover the nose and mouth to prevent the spread of COVID. During an interview on 9/11/24 at 11:55 A.M., LPN A said seven residents on the first floor have tested positive for COVID. Staff have to wear surgical masks at all times in all areas on the first floor. Surgical masks must be worn so they cover the nose and the mouth. In the rooms of residents who are positive for COVID, staff must wear a N-95 mask, gown, gloves, and eyewear. The signs outside of the resident's door indicate which precautions to take and which PPE to use. During an interview on 9/11/24 at 12:17 P.M., LPN B said seven residents on the first floor tested positive for COVID, and one of the residents is currently in the hospital. All staff were expected to wear surgical masks at all times while working on the first floor. Surgical masks should cover the nose and the mouth to prevent the spread of germs. 11. During an interview on 9/11/24 at 1:51 P.M., the DON said the facility has COVID positive residents on the first floor. It was expected that staff, from all departments, wear surgical masks while on the first-floor unit. Masks should be worn over the nose and mouth to help prevent transmission. It was expected that visiting health professionals wear surgical masks as well. It is expected that staff wear the appropriate PPE as indicated on the signs posted outside of resident rooms. In the rooms of residents who are positive for COVID, staff should wear an N-95 mask, gown, gloves, and eyewear. 12. During an interview on 9/12/24 at 8:29 A.M., the IP said there is an outbreak of COVID on the first floor of the facility. Once the facility identified an outbreak, it became expected that staff wear a surgical mask while in the workspace on the first floor. Surgical masks should be worn to cover the nose and mouth completely and correctly. Under outbreak circumstances, it would be inappropriate for staff to remove their mask and enter another resident's room without putting on a new mask. PPE should be removed in the doorway of the resident's room. After removing their PPE, staff should sanitize their hands and replace their mask. Staff from all departments are expected to wear their masks properly while in outbreak mode. It is expected that visiting professionals wear masks as well. 13. During an interview on 9/12/24 at 11:31 A.M., the Administrator said he expected staff from all departments to wear surgical masks at all times while on the first floor. Surgical masks are being used to protect the staff and the residents. He expected staff to doff PPE before leaving a resident's room and to put on new PPE.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNA) received a minimum of 12 hours of ongoing education annually for four out of five sampled CNAs (CNA Q, CNA N, Certified Medicine Technician (CMT) R and CNA P). The census was 84. A policy related to CNA 12-hour training was not provided by the facility. 1. Review of CNA Q's employee file showed: -Hire date: 5/18/23; -CNA hours of training completed: 0. 2. Review of CNA N's employee filed showed: -Hire date: 3/23/23; -CNA hours of training completed: 3. 3. Review of CMT R's employee file showed: -Hire Date: 3/16/09; -CNA hours of training completed: 10.6. 4. Review of CNA P's employee file showed: -Hire Date: 10/2/14; -CNA hours of training completed: 11.7. 5. During an interview on 9/11/24 at 1:55 P.M., the Director of Nursing (DON) said the CNAs were expected to complete their 12 hour annual training by their anniversary date. They are expected to complete them independently without being reminded. 6. During an interview on 9/12/24 at 11:35 A.M., the Administrator said he would expect CNA staff to complete their 12 hour annual education by their anniversary date.

Based on interview and record review, the facility failed to prevent further misappropriation/diversion (the unauthorized removal) of controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) by not following the facility's policy for suspension during an investigation. Licensed Practical Nurse (LPN) C reported alleged violations of misappropriation/diversion by LPN A on the morning of 4/23/24 at 7:02 A.M. The facility allowed LPN A to work the evening shift on 4/23/24 while the facility investigated the allegation. LPN B continued the misappropriation/diversion with three residents (Residents #1, #3 and #4) when LPN B was not suspended. In addition, the facility failed to conduct a thorough investigation, by not following the facility's policy of interviewing additional staff and residents regarding the misappropriation/diversion. This had the potential to affect all residents with controlled substance orders. The census was 82. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, dated 10/2022, showed: -Preface: -It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The term abuse (abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation) will be used throughout this policy unless specifically indicated; -An owner, licensee, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator; -All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator; -All owners, operators, employees, managers, agents, or contractors must report to the State Agency and one or more law enforcement entities any reasonable suspicion of a crime against an individual who is a resident of or is receiving care from the facility; -An immediate report, not later than two hours after forming a suspicion that the events resulted in serious bodily injury; -Not later than 24-hours if the events did not result in serious bodily injury; -The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal requirements; -Definitions of Abuse and Neglect: -Abuse and neglect exist in various forms and degrees. The following are the approved CMS definitions of abuse and neglect from Advanced Copy of the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities: -b. Alleged violation: is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.; -Crime: is defined by law of the applicable political subdivision where the facility is located. A political subdivision would be a city, county, township or village, or any local unit of government created by or pursuant to State law.; -Immediately: means as soon as possible but ought not to exceed 24 hours after discovery of the incident, in the absence of a shorter State time frame requirement. *Immediately for the purposes of reporting a crime resulting in serious bodily injury means covered individual shall report immediately, but not more than 2 hours after forming the suspicion; -u. Misappropriation of resident property: as defined at §483.5, means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.; -Abuse Policy: It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties; -Objective of Abuse policy: The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. The abuse policy will be reviewed on an annual basis or more frequently and will be integrated into the facility Quality Assurance and Performance Improvement (QAPI) program; -Overview of eight components: -Screening; -Training; -Prevention; -Identification; -Investigation; -Protection; -Reporting and Response; -Coordination with QAPI; -8. Training components: Abuse policy requirements: It is the policy of this facility that all new and existing employees on all forms abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, injuries of unknown source, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms. Training shall include prohibiting and prevention, identification, recognition, reporting and understanding behavioral symptoms that may increase risk of abuse and neglect in order to properly respond; -Procedure: All employees and volunteers will receive education about all forms of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms. upon first employment and annually after that, incorporating the following elements: -Orientation and ongoing programs; -Training on the abuse policies and procedures; -Prohibiting and preventing all forms of abuse; -Identification of what constitutes abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms; -Recognition of signs of abuse, neglect, exploitation of residents, misappropriation; of resident property, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms; -Reporting of abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms; -How to report abuse without fear of reprisal; -The definitions of what constitutes abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms; -How to identify residents at risk for neglect or abuse; -Resident [NAME] of Rights; -Annual notification of covered individuals of their obligation to comply with reporting of a crime requirements; -C. Prevention: Abuse policy requirements: It is the policy of this facility to prevent abuse by establishing a safe environment, identifying, correcting and intervening in situations in which abuse, is more likely to occur, put systems in place for provision of care and services for all residents, assessing and implementing appropriate interventions for residents with needs and/or behaviors that could lead to conflict or neglect, ensure the health and safety of all residents in regards to visitors and provide residents and their representatives information on how and to whom to report concerns or grievances without fear of reprisal; -Procedure: -7. Supervision of staff: Staff will be supervised to identify inappropriate behaviors while caring for or in attendance with residents; -D. Identification: Abuse policy requirements: It is the policy of this facility that all staff monitor residents and trained on how to identify potential signs and symptoms of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms. Occurrences, patterns and trends that may constitute abuse will be investigated; -Procedure: All staff will receive education about how to identify signs and symptoms of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms. Residents will be monitored for possible signs of abuse. Symptoms that will be monitored; -E. Investigation: Abuse policy requirements: It is the policy of this facility that reports of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms, are promptly and thoroughly investigated; -Procedure: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration; -a. Investigation of abuse: When an incident or suspected incident of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms, is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. During the investigation, caution will be exercised when handling evidence that could potentially be used in a criminal investigation. The investigation will include statements from all individuals involved to include: - i. Statement from individual reporting alleged abuse; -ii. Residents' statements; -For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview the resident first. If unable, observe resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings; -v. All involved staff who have or may have witnessed the abuse; -ix. Observation of resident and staff behaviors during the investigation; -xi. A complete and thorough documentation of the entire investigation. All staff must cooperate during the investigation to assure the resident is fully protected; -b. Investigation regarding misappropriation: Examples of reportable allegations of Misappropriation of resident property that will be investigated include, but are not limited to: -Theft of property and valuables; -Staff coerced or unauthorized use of resident personal property; -Missing medications or diversion; -For missing items, the administrator or designee will direct completion of an active search for missing item(s) including documentation of investigation; -1. The investigation will consist of at least the following: -A review of the completed complaint report; -An interview with the person or persons reporting the incident; -Interviews with any witnesses to the incident; -A review of the resident medical record if indicated; -An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident; -Interviews with the resident's roommate, family members, and visitors; -A root-cause analysis of all circumstances surrounding the incident; -Additional Investigation Protocols: -While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to the resident. Visits may only be made in designated areas, supervised by staff after approval by the Administrator; -The Administrator will keep the resident or his/her resident representative informed of the progress of the investigation; -The results of the investigation will be documented and attached to the report; -The Administrator or human resources designee will complete a copy of the investigation materials; -The Administrator or designee will inform the resident and/or his/her representative of the findings of the investigation and corrective action taken; -Inquiries made concerning abuse reporting and investigation must be referred to the Administrator or Designee; -If the investigation shows abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion or a crime did take place, the employee will be disciplined, up to and including termination; -i. If licensed staff member, if found at fault - must be reported to the applicable licensing board; -ii. Complaints about a nursing assistant must be reported to the State Specific Agency for Nursing Assistants. An investigation must be completed before a finding can be substantiated and entered onto the Registry; -iii. If the Department of Health determines an aide mistreated a resident or misused a resident's property, the Department will notify the aide of their intention to put this information on the registry; -If the investigation shows abuse or a crime was unsubstantiated, the employee's individual situation will be reviewed to determine, reinstatement, and further training education needs in coordination with the Administrator, Director of Nursing (DON) and Human Resources; -The resident and /or family will be notified of the completion of the investigation and whether the incident was substantiated. Information will be provided according to confidentiality guidelines; -F. Protection: Abuse policy requirements: It is the policy of this facility that the resident(s) will be protected from the alleged offender(s); -Procedure: Immediately upon receiving a report of alleged abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms, the Administrator, and or designee will immediately protect the resident, and coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable individual are of utmost priority. Safety, security and support of the resident, their roommate, if applicable and other residents with the potential to be affected will be provided. This should include as appropriate: -Procedures must be in place to provide the resident with a safe, protected environment during the investigation: -ii. The alleged perpetrator will immediately be removed and the resident protected. Employees accused of alleged abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion be immediately removed from the facility and will remain removed pending the results of a thorough investigation. (Decision of the extent of immediate disciplinary action will be made by the Administrator or designee); -v. Examine, assess and interview the resident and other residents potentially affected immediately to determine any injury, complete a psychosocial assessment if needed, and identify any immediate clinical interventions necessary. Notify resident physician; -vi. Social Services or designee should keep in frequent contact with the resident and/or resident representative; -Notification of law enforcement and/or State Agency, Crisis Response, Poison Control, etc. as indicated; -G. Reporting and response: Abuse policy requirements: It is the policy of this facility that abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion allegations are reported per Federal and State Law. The facility will ensure that: -All alleged violations involving abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion are reported immediately to the administrator; -All alleged violations of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion must also be reported by the facility to officials in accordance with State law, including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities; -a. Immediately, but not later than two hours if the alleged violation involves abuse or results in serious bodily injury; -b. Not later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment or misappropriation of resident property and does not result in serious bodily injury; -c. Results of all investigations of alleged violations must be reported within five working days of the incident; -If there is any reasonable suspicion of a crime against a resident or any other individual that receives care from the facility a covered individual must report to the State Survey Agency and one or more law enforcement entities: -a. For serious bodily injury, immediately but not later than 2 hours after forming the suspicion; -b. If no serious bodily injury- not later than 24 hours; -Covered individuals will be provided education upon hire and on an annual basis on reporting requirements to include how is a covered individual, each individual's independent obligation to report the suspicion of a crime directly to local law enforcement and State Survey Agency, timeframe, penalties associated for failure to report and documentation; -Temporary/agency/contracted staff will be provided with education on reporting requirements and the abuse policy and procedure; -Internal reporting: -a. Employees must always report any abuse, neglect, exploitation, misappropriation of resident property, injuries of unknown origin, involuntary seclusion or corporal punishment or suspicion of abuse immediately to the Administrator. Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law; -b. The Administrator will involve key leadership personnel as necessary to assist with reporting, investigation and follow-up; -External reporting: Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from, the facility, and each covered individual shall report immediately, but no more than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Examples of situations that would likely be considered crimes include, but are not limited to: -Theft/Robbery; -Drug diversion for personal use or gain; -Facility initial reporting of allegations: For all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator or designee will notify officials in accordance with State law, to include the State Survey Agency and adult protect services where state law provides for jurisdiction in long-term care facilities immediately but not later than two hours if the alleged violation involves abuse or results in serious bodily injury or not later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; and does not result in serious bodily injury. A follow up report of the results of the investigation will be submitted to the State Agency within five working days. When making a report, the following information should be reported: -Facility name, CMS Certification Number, Address, Phone Number and Email Address; -Type of abuse reported (physical, sexual, misappropriation of property, exploitation, neglect, verbal or mental abuse, injury of unknown source, suspected crime, etc.; -Date, time, location and circumstances of the alleged incident; -Date and time Administrator was notified of incident and by whom; -Name, position if staff, relationship to victim and contact information to witness(es) and person reporting abuse; -Name of resident victim, date of birth and current location of resident; -Notification to law enforcement, agency, contact person, date and time and name of individual reporting; -Notification to other agencies (i.e., Adult Protective Services, Ombudsman, etc.); -Report/Notification to resident's attending physician; -Steps the facility has taken to protect the resident; -Name(s), position and social security number(s) of staff (alleged perpetrator) involved and contact information if known. If not a staff member, relationship to alleged victim; -Name, title, date and contact information (phone and email) of person submitting report; -Report the results of the investigation to officials in accordance with State law, and to the State Agency, within five working days of the incident; -Brief description of additional information and updates; -Additional description of outcomes to the resident; -Include date and time allegation was reported to resident representative; -Include, if applicable, the date, time and outcome for reports made to additional agencies (i.e., nurse aide registry, professional licensing boards, etc.); -Detailed summary of all steps taken to investigate the allegation; -Summary of interviews with resident; -Identification of resident psychosocial distress and harm; -Summary of witness statements; -Summary of interview with alleged perpetrator; -Summary of additional interviews (i.e., other residents, supervisors, etc.); -Additional resident information from the resident record; -Hospital or medical progress notes, law enforcement reports, death reports, etc., as applicable; -Conclusion- indicate if verified, not verified or inconclusive; -All reports submitted will be accurate to the best of its knowledge at the time of submission; -The Administrator or designee will inform the resident or resident's representative of the report of an incident and that an investigation is being conducted; -The resident and /or resident representative will be notified of the completion of the investigation and whether the incident was substantiated. Information will be provided according to confidentiality guidelines; -Covered individuals are obligated to comply with reporting requirements. If uncertain whether or not to report an incident, call the State Agency for further direction: -Employees will be trained on an annual basis on requirements to report abuse and reasonable suspicion of a crime; -Employee rights will be posted (identify the conspicuous location); -The facility will protect reporting individuals from potential retaliation; -The Administrator or designee will report to the Medical Director; -For the protection of all individuals involved, copies of any internal reports, interviews and witness statements during the course of the investigation sh

Based on interview and record review, the facility failed to prevent staff misappropriation/diversion (the unauthorized removal) of controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) for four residents (Residents #1. #2, #3 and #4). This had the potential to affect all residents with controlled substance orders. The census was 82. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, dated 10/2022, showed: -Preface: -It is the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. The term abuse (abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation) will be used throughout this policy unless specifically indicated; -An owner, licensee, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the Nursing Home Administrator; -All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Administrator; -All owners, operators, employees, managers, agents, or contractors must report to the State Agency and one or more law enforcement entities any reasonable suspicion of a crime against an individual who is a resident of or is receiving care from the facility; -Crime: is defined by law of the applicable political subdivision where the facility is located. A political subdivision would be a city, county, township or village, or any local unit of government created by or pursuant to State law.; -Immediately: means as soon as possible but ought not to exceed 24 hours after discovery of the incident, in the absence of a shorter State time frame requirement. *Immediately for the purposes of reporting a crime resulting in serious bodily injury means covered individual shall report immediately, but not more than 2 hours after forming the suspicion; -u. Misappropriation of resident property: as defined at §483.5, means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.; -Abuse Policy: It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for Protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties; -Investigation regarding misappropriation: Examples of reportable allegations of Misappropriation of resident property that will be investigated include, but are not limited to: -Theft of property and valuables; -Staff coerced or unauthorized use of resident personal property; -Missing medications or diversion; -Additional Investigation Protocols: -While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to the resident. Visits may only be made in designated areas, supervised by staff after approval by the Administrator; -External reporting: Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from, the facility, and each covered individual shall report immediately, but no more than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Examples of situations that would likely be considered crimes include, but are not limited to: -Theft/Robbery; -Drug diversion for personal use or gain. Review of email sent by Licensed Practical Nurse (LPN) C on 4/23/24 at 7:02 A.M., showed: -From: LPN C; -Sent: 4/23/24 at 7:02 A.M.; -To: DON, Assistant Director of Nursing (ADON), LPN C; -Subject: LPN A excessive Norco (Hydrocodone-Acetaminophen, opioid, used for moderate-to-severe pain control) sign out; -LPN A is signing out Norco to residents as much as is allowed like three times yesterday and at 11:00 P.M. Resident #1 requested Tylenol (Acetaminophen) for pain and LPN C administered the Tylenol as needed (PRN) at 11:00 P.M. as the resident requested. Then later LPN C saw that LPN A had signed out Norco for Resident #1 at 11:00 P.M. and two other times to the resident yesterday evening (4/22/24). This is not a one-time occurrence. It is for every resident on main that has a PRN order for Norco for the last 3 months or longer. LPN A does not seem to have any residents that have pain if they are not on Norco, example on 4/1/2024, Registered Nurse (RN) E was the nurse on main on evening shift and LPN A worked as the Certified Medication Technician (CMT), and no one at all received any pain meds not even Norco. LPN A is the only nurse that signs out so much Norco. Hardly any Norco is given when LPN A is not here. LPN B even questioned this for Resident #3 as LPN A signed out a lot of Norco every shift, when he/she works. On my shift Resident #3 will only ask for PRN Tylenol. LPN A will sign out the number of pills on a lot of residents and then at the end of the shift LPN A will write in the time given and it is always the same time. LPN A charts that residents are not having pain but signs out as much as he/she is able to sign out for all residents on the Individual Patient Narcotic Record (IPNR) sheets only and all residents have the same time that he/she gave them Norco this can be verified on the monitor camera at the end of LPN A's shift. LPN A does not sign in Electronic Treatment Record (eTAR) that Norco was given. This all can be verified in resident electronic chart. I can give more dates if needed referring to how much is signed out by LPN A. LPN A only gives Norco to residents that would not remember or would not be questioned. Check Resident #2's chart when he/she was given Norco four times in one day, day and evening shift that LPN A had worked, and that night Resident #2 asked for Tylenol and did not want Norco. Resident #2 stated that he/she only takes it at bedtime and after I mention this to LPN B, LPN A went back to once daily at bedtime. LPN A will not sign out Norco to alert residents unless they ask for it, this can be verified with the sign outs on the IPNR sheet. Why does LPN A only give PRN Norco pain medication. The residents do not get pain PRN, Tylenol, or tramadol. Does the Doctor and Nurse Practitioner know that the residents are receiving so much pain med on evening shift only. I hope that you all trust and believe me. Review of the Facility Investigation Report, dated 4/24/24, showed: -Investigation: -The DON, received an email from LPN C night shift, on 4/23/24. In the email LPN C voiced some concerns over the amount and documentation of pain pills given out by the evening shift nurse, LPN A. He/She was concerned about the amount of Norco residents were documented as received and the fact that hardly any pain medication was given to these same residents on other shifts. (The copy of the email follows); -On 4/23/24 the DON interviewed two of the alert residents, Resident #1 and Resident #2, who confirmed they hadn't received pain pills at the recent times it was documented. (DON's interview summaries follow). Narcotic count sheets were reviewed and it appeared Norco was given out regularly by LPN C to these residents routinely despite it being PRN prescription; -On 4/23/24 the DON requested video footage from the camera near the Main nurses station. She reviewed the footage and found nothing to confirm the medications were given or proof that they weren't; -On 4/24/24, the DON re-interviewed Resident #1 and the resident confirmed he/she hadn't received pain medication at the times LPN A had signed them out for giving; -The DON interviewed Resident #4 on 4/24/24. He/She stated he/she only receives medications from CMT F. It was documented that Resident #4 had received pain medications from LPN A; - Resident #3 was not interviewed but was suspected to be a victim. He/She is a poor historian; -Review of residents' narcotic record documentation revealed that LPN A had documented the giving of Norco on many occasions over the past month that alert residents were unable to confirm they received; -The Administrator contacted the police department on 4/24/24. Police Officer (PO) H took down the report details. He/She interviewed Resident #1 and Resident #2. PO H concluded that there is a probable misappropriation of property and theft of narcotics. The facility has cooperated with the police with additional information for the prosecutor to determine what charges if any will be brought against LPN A; -On Thursday 4/25/24, LPN A returned for work after a day off and was interviewed by the DON and Administrator. After voicing the suspicions of LPN A's misappropriating residents' medications, we asked LPN A for an explanation. LPN A immediately confessed he/she had been taking the medications and he/she had a problem with addiction that he/she hasn't faced. The DON and Administrator encouraged him/her to seek help and he/she was dismissed from employment at the facility; -Conclusion and Remedy: -The allegation of misappropriation of resident property is substantiated. LPN A has been terminated from employment at the facility; -The facility is preparing to file a complaint with the Missouri Board of Nursing on LPN A related to this incident; -A request will be sent to the pharmacy to credit the dollar amount of the last order of Norco for the residents believed to have been affected; -The facility has a follow up meeting with the police department Wednesday 5/1/24 with PO H; -The misappropriation of resident's property policy will be reviewed with nursing staff and signed off on. Review of the DON's interview summaries, dated 4/24/24, showed: -On 4/23/24, no time documented, spoke with Resident #1 regarding pain medication, Norco. The DON asked the resident how his/her pain was. The resident stated he/she often has more pain than no pain. The DON asked the resident if he/she felt his/her pain medication was effective. The resident said yes. The DON asked how often he/she thought he/she needed to take pain meds. The resident stated often but more during the day. The DON asked if he/she took it often in the evening. Resident stated he/she did maybe once, but he/she would not take any close to bedtime because it makes him/her hallucinate. Due to IPNR sign out sheet showing Norco was given on 4/22/24 at 11:00 P.M. by LPN A the DON asked the resident if he/she received a pain pill the night before at bedtime. The resident stated, if he/she did it would have been Tylenol because he/she does not take Norco at bedtime because he/she hallucinates; -On 4/23/24, no time documented, the DON spoke with Resident #2 who was sitting with his/her family member. The DON asked the resident how his/her pain was and the resident stated fine. The DON asked the resident if he/she had been needing to take Norco for pain. The resident stated he/she has not taken pain pills in the last month. I asked the resident if he/she recalled recently requesting Norco as it had been signed out on IPNR sheet on 4/19/24. Resident once again stated he/she hasn't used this in a while; -On 4/24/24, no time documented, the DON spoke with Resident #1 again as Norco was signed out on 4/23/24 at 12:00 P.M., 3:00 P.M., 5:00 P.M., and at 10:00 P.M. The resident stated yes, he/she received all doses except for the 10:00 P.M. dose. The resident stated he/she does not take Norco at bedtime; -On 4/24/24, no time documented, the DON spoke with Resident #4 regarding pain and if pain medications are effective. The resident stated when he/she has pain he/she asks for Tylenol and CMT F brings it in. The DON asked if a nurse had to bring him/her a stronger pain medication like Norco the day before on 4/23/24. The resident said that he/she received all her medications from CMT F. Review of Police Department Investigative Report, dated 4/24/24, showed: -Date/Time received: 4/24/24 at 3:53 P.M.; -Date/Time dispatch: 4/24/24 at 3:53 P.M.; -Date/Time arrival: 4/24/24 at 3:56 P.M.; -Offense: Stealing and possession; -Nature: Larceny; -Premise: Nursing Home; -Victim Business #1 information: -Will prosecute: checked; -Victim Business #2: Resident #15; -Victim #3 information: -Additional party information: ED; -Subject information: LPN A; -Property information: -Property roles: stolen, taken without owner's consent, fraud transaction/good/service; -Property classification: drug/narcotics; -Quantity: one; -Article: medication; -Property value: $1.00; -Property value: $1.00; -Narrative: -On 04/24/2024, PO H received a message from dispatch asking him/her to contact the Administrator with the facility about an employee stealing. Due to the nature of the call, I decided to respond in person the facility. Upon my arrival, I was met by reporting party the Administrator. He explained that he had reason to believe that an LPN had been stealing controlled medications from residents at the facility. The Administrator identified LPN A, who had been employed by the facility since 09/28/2023. The Administrator stated that the trouble began when another nurse, LPN C, came to him with concerns that residents were not receiving medication that LPN A was signing out of the medication book. The Administrator asked the residents in question if they had received their controlled medications, to which they denied. However, when the nursing documentation was reviewed, it showed that they had received the medication and LPN A had administered it. I asked the Administrator if it would be OK to interview the residents who denied receiving their controlled medication, and the Administrator advised that it would be OK; -At 1625 hours on the above date, I spoke with Resident #2, who stated that he/she was prescribed Norco. I asked Resident #2 when he/she last took the medication, to which he/she replied she was unsure but knew that she had not taken any nurse medication in the last month. When Resident #2 was asked to clarify what she meant by nurse medication, Resident #2 said it was medication he/she had to ask the nurse to bring him/her. It should be noted that Resident #2 was very concerned that she might be getting LPN A in trouble and that he/she did not believe that LPN A was the kind of person on drugs. According to records, LPN A had signed out to Resident #2 on several occasions; -At 1635, I spoke with Resident #1, who stated that he/she was prescribed Norco. It is important to mention that Resident #1 is a former nurse himself/herself, and he/she noted that he/she understood why we were asking questions about LPN A. Resident #1 noted that he/she did take the Norco but never took it after 2:00 P.M. because it gave her night terrors. According to records, LPN A had signed out Norco to Resident #1 at night on several occasions. On the above date, at 11:00 P.M., PO H returned to the facility to meet with reporting LPN C. LPN C stated that he/she had often observed LPN A making what he/she believed to be false entries into the controlled medication log. He/She believed that LPN A was signing out medications to residents and then keeping them for himself/herself because some of the residents had not required pain meds and Resident #1 never took those pills at night. LPN C reported his/her suspicions to his/her supervisors; -On 04/26/2024, I received an email from the Administrator that stated the following: -Hi PO H, I wanted to give you an update on our investigation that you responded to on Wednesday 4/24/24 evening. The Administrator and DON met with LPN A when he/she arrived at work on Thursday 4/25/24 at about 2:30 P.M. We verbally presented our findings to LPN A. I then asked him/her if he/she had any explanation for our conclusion that he/she was misappropriating medications. LPN A broke down crying and he/she admitted to having a problem with narcotics and hasn't been able to quit. LPN A was visibly trembling and apologetic for his/her actions. LPN A stated he/she knows she/he needs help. We talked for some time and offered some resources for LPN A to seek help, which he/she assured us he/she would. We parted ways with him/her understanding that the Department of Health and Senior Services (DHSS), the police, and the nursing board would probably get involved. I encouraged him/her to cooperate fully. I then visited with the same two residents you interviewed, Resident #2 and Resident #1. I told them that LPN A had confessed to taking medications. Neither wants to press charges for their medications, which were presumably taken. I will contact two other resident representatives to see if they are interested in pressing charges. The Administrator stated he has copies of documents that support the accusations if the PO H would like to see/have them; -On 05/01/2024 at 3:30 P.M. hours, PO H met with the Administrator and received a copy of the findings that include the following: Summary of resident interviews. Copy of email from Witness LPN C. Face sheet medicine list and narcotic records for Resident #2 (5 pages). Face sheet medicine list and narcotic records for Resident #4 (3 pages). Face sheet medicine list and narcotic records for Resident #3 (5 pages). Face sheet medicine list and narcotic records for Resident #4 (3 pages). All documentation from the Administrator is attached to this report; -On 05/01/2024, PO H called LPN A and asked him/her to come to the station to make a statement. LPN A stated that he/she would have to rearrange his/her schedule to make time to meet. I explained to LPN A that I would give him/her until 05/02/2024 to arrange to meet. -On 05/02/2024 PO H again attempted to contact LPN A and left voicemail and text messages for him/her to contact PO H. PO H was met with negative results; -On 05/03/2024 I received a call from Attorney G. Attorney G left a voice mail stating that he/she would be representing LPN A, and he/she would not be making any statements. I attempted to return the call to Attorney G to inform him/her that LPN A would need to come in to be fingerprinted and booked. At this time, PO H has not received a call back from LPN A or his/her attorney. Investigation to continue; -Investigation information: -Date/Time: Monday, 5/13/24 at 9:00 P.M.; -Supplement purpose: Warrant screen; -Nature: Larceny; -Warrant Application Information: -LPN A; -Warrant Information: -Application date: 5/13/24; -Prosecuted by: State Prosecutor; -Final Approval: Wednesday, 5/15/24 at 7:57 A.M. Review of the Employee Corrective Action Notice, dated 4/25/24, showed: -Discharge, marked with an X; -Today's date: 4/25/24; -Employee name: LPN A; -Employee's department and position: Nursing LPN; -Date of last corrective action: not applicable (N/A); -Level of corrective action: N/A; -Corrective action Subject (list proof of knowledge such as policies, job description, training, etc.): Nursing personnel are to document accurately and truthfully. Staff was fully aware of the misappropriation of resident property policy; -Date of occurrence: Various times; -Description of occurrence (list only facts): Employee was falsifying narcotic records as given to residents and was taking medications for self; -Expectation: Staff is expected to follow misappropriation of resident property and document the delivery of medication to residents accurately; -Employee Statement: LPN A when presented with evidence admitted he/she had taken the medications and suffers from addiction. During an interview on 5/17/24 at 9:09 A.M., LPN C said he/she sometime in January 2024 he/she noticed LPN A was signing out Norco frequently because LPN A was off work for a few days and LPN C noticed the Norco was not being signed out for residents when LPN A was off work. When LPN A returned to work, he/she began signing out the maximum amount of PRN Norco for residents that had a PRN order on his/her shift. LPN C said he/she mentioned to the ADON, when she came in to work because of an ice storm, that something did not look right when doing the count for Resident #3 and mentioned that Resident #3 only takes Tylenol on his/her shift. LPN C did not have any other conversations with management after that until he/she sent an email the morning of 4/23/24. LPN C said LPN A would frequently not have the IPNR sheets filled out completely when he/she would arrive for his/her shift. LPN C said that LPN A had numbers written in the far-left column of the IPNR sheets that show the total amount of pills remaining on the card and would put like 16, 15 and would not have the other information filled out on the IPNR like time date or his/her signature. So, when LPN C and LPN A would count the actual numbers it would be correct. LPN A would then finish filling out the rest of the information after LPN C and LPN A counted. LPN C said LPN A had often written the same times down for multiple residents when he/she filled in the information after counting. LPN C said that he/she came in to work the night shift on 4/22/24 around 10:25 P.M. and Resident #1 requested Tylenol at 11:00 P.M. LPN C said he/she administered the Tylenol per the resident request. Later that night LPN C noticed that LPN A had signed out Norco to Resident #1 at 11:00 P.M. on 4/22/24. LPN C said he/she did not talk to Resident #1 about it because he/she was unsure how to talk to the resident about it. LPN C sent an email to the DON and ADON regarding his/her concerns that following morning on 4/23/24. LPN C said that nobody in management reached out to ask any questions after the email was sent. During an interview on 5/22/24 at 2:36 P.M., the ADON said she was grateful that LPN C brought the concern to her attention by sending the email the morning of 4/23/24. The ADON said this was the first time she recalled any concerns being brought to her attention related to LPN A misappropriating medications. The ADON and the Unit Manager (UM) looked at the IPNR on Main Hall where LPN A worked and said, When we looked at the sheets we were like, Oh, something is wrong, it just screamed at you when you looked at it. The ADON said it was obvious that LPN A was signing out the narcotics to residents like LPN C described in the email. ADON said no other nurses were signing out narcotics like LPN A. The ADON said her, and the UM discussed wanting to start looking at the IPNR sheets weekly on Fridays because before they were not looking at the IPNR sheets. The ADON said if her and the UM had been monitoring the IPNR sheets they would have caught it earlier. The ADON said her and the UM have not started looking at the IPNR sheets on Friday yet but they plan to start this week. The ADON said she has worked with Resident #2 on day shift and evening shift and the ADON has never heard Resident #2 complain of pain and never requested pain medication from the ADON. The ADON said Resident #2 is vocal and would let the ADON know if he/she was in pain and needed pain medication. The ADON said Resident #1 has requested pain medication from the ADON in the evening usually before or after dinner but not late in the evening. The ADON said she never gave Resident #3 PRN pain medication. The ADON said she never remembered Resident #3 complaining of pain. The ADON said it would be weird if a nurse would only document the number of pills remaining and did not have all the other information filled in when counting, that would be a cause for concern. The ADON said if a resident had available medication on the nurse's cart there would be no reason to pull that same medication from the cubex. During an interview on 5/30/24 at 9:43 A.M., the Administrator said LPN A admitted to stealing narcotics from the residents on 4/25/24 during the interview he and the DON had with LPN A. LPN A was terminated on 4/25/24. MO00235186

Based on interview and record review, the facility failed to document on the individual patient narcotic record and the electronic Treatment Administration Record (eTAR) after administering a controlled substance medication to four out of four sampled residents (Residents #1, #2, #3 and #4). The facility also failed to document the effectiveness of pain medication after it was administered to four out of four sampled residents (Residents #1, #2, #3 and #4). In addition, the facility failed to document on the Individual Patient Narcotic Record (IPNR) the signature of the nurse receiving the controlled medication and the date it was received. The facility also failed to update the order on the IPNR when the order changed. This had the potential to affect all residents with pain medication orders and controlled substance orders. The census was 82. Review of the facility's Schedule II-V Controlled Substances (schedule two controlled substance (CII, medication with higher potential of dependency and abuse), Schedule three controlled medication (CIII, medication with low to moderate potential of dependency and abuse), Schedule four controlled substance (CIV, medication with low potential of dependency and abuse), Schedule five controlled substance (CV, lowest potential of dependency and abuse)) Policy, dated 8/2019, showed: -Policy: It is the policy of the facility to ensure compliance with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances; -Purpose: It is the purpose of the facility to unsure all residents receive prescribed medication, including Controlled substances for quality of resident care: -Pain management; -Anxiety; -Other related diagnosis; -Procedure: -1. Read/Review pharmacy policy and procedure regarding this policy; -2. Only authorized licensed nurses that are permanent employees of the facility or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. No agency nurse is allowed to carry narcotic keys or administer narcotics to and resident; -3. Controlled substances must be counted upon delivery. The nurse receiving the order must count the controlled substance together with the Shift Supervisor. Both individuals must sign the designated narcotic record; -4. If the count is correct, a control sheet must be made for each substance. Do not enter more that one prescription per page. This record must contain: -Name of the resident; -Name and strength of the medication; -Quantity received; -Number on hand; -Name of physician; -Time of administration; -Method of administration; -Signature of person receiving the medication; -Signature of nurse administering medication; -8. Unless otherwise instructed by the Director of Nursing (DON), when a resident refuses a non-unit dose medication or it is not given, or receives partial tablets or single dose ampules, or it is not given, the medication shall be destroyed, and may not be returned to the container or bubble pack. (see Discarding and Destroying Medications policy within the Medications policy and procedure); -9. Nursing staff must count controlled dugs at the end of each shift, for each eight-hour or 12-hour shift. The nurse coming on duty and the nurse going off duty must complete the count together. They must document and report and discrepancies to the shift supervisor and DON immediately; -10. The DON shall investigate all discrepancies in controlled substance reconciliation to determine the cause and identify any responsible parties and shall give the Administrator a written report of such findings; -11. The DON shall consult with the provider pharmacy and the Administrator to determine whether any further legal action is indicated; -12. When a resident or patient is transferred or discharged from the facility, it is allowable to send schedule II drugs with the resident or responsible party. Documentation of education should be completed in the medical record. -13. Schedule II-V Controlled Substances may not be returned to the pharmacy but must be destroyed by two licensed nurses. (Describe how to destroy and documentation here). Review of the facility's Controlled Drugs Policy, not dated, showed: -Policy: Medications included in the Drug Enforcement Agency (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations; -Procedure: -A. Only authorized nursing personnel and pharmacy personnel have access to controlled drugs. The DON is responsible for the control of these medications; -B. Schedule II, III, IV and V drugs will be provided by the pharmacy in containers designed for easy counting of contents; -C. When possible, orders for injectable controlled drugs will be provided in single dose containers; -D. Schedule II drugs and any other drugs that the facility deems necessary will be kept in a double locked area separate from other drugs. The access key to this area is separate from the key giving access to the rest of the medication cart; -E. The pharmacy can only dispense a 72-hour supply for a scheduled II drug, until a signed prescription is received from the physician. The prescribing physician may send the follow-up written prescription to the pharmacy by facsimile (fax); -F. A controlled medication delivery manifest will accompany all scheduled II, III, or V medication deliveries. The flowing information will be present: -Name of resident; -Room number of resident; -Prescription number; -Name, strength (if designated) and dosage form of medication; -Date and delivery sent from pharmacy; -Quantity dispensed; -Name of person receiving medication supply and date received signed at the time of delivery; -A copy is retained in the pharmacy prior to delivery. The delivery personnel will retain a copy of this record, and a copy will be left at the facility to document the receipt of the medication; -G. Schedule II drugs and any other specific medications as deemed necessary by the facility will be dispensed by the pharmacy along with an Individual charting record. This record will be maintained by the nursing staff at the time of each administration of the medication as follows: -1. Place charting record in narcotic box or in charting record binder; -2. Record each done at the time of administration; -3. Confirm the amount of controlled drug remaining is correct prior to assembling required dose for administration; -Date; -Time; -Dosage; -Signature of nurse who administered dose; -Number of doses remaining; -4. When the prescription has been exhausted, the individual charting record becomes a permanent part of the medical record; -5. When the prescription is no longer an active order and there are remaining doses of medication, the individual charting record and the remaining medications are retained in the facility in a securely locked area with restricted access. The remaining quantity will remain in this area until destroyed by two licensed personnel; -6. A controlled medication may never be returned to the pharmacy for destruction. It must be destroyed in the presence of two licensed personnel in the facility; -H. When a dose of controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose. The disposal of unused partial tablets and unused single dose portions of single dose ampules must be destroyed and recorded in the presence of two licensed personnel; -I. At each shift change. A physical inventory of specific mediations, those selected by the facility, is conducted by two licensed nurses and is documented on an audit record; -J. Current controlled medication accountability records and audit records are kept in the medication administration record (MAR) or other specific binder. When completed, audit and accountability records are submitted to the DON and kept on file according to facility policy for health records retention; -K. Any discrepancy in controlled substance medication counts is reported to the DON immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. Irreconcilable discrepancies are documented by the DON and reported to the consultant pharmacist and Administrator. The Administrator, Pharmacist, and the DON will make a determination concerning of any actions that may need to be taken. Review of the facility's Pain Management Policy, dated 8/2019, showed: -Purpose: It is the policy of this facility that all residents will be assessed for presence, absence or history of pain on admission, quarterly, with a significant change in status and with the new onset of pain or discomfort, in order to plan a pain management program for an acceptable level of resident comfort whenever possible; -Purpose: To identify, treat and manage pain and discomfort. To determine what pain relief level of function in activities of daily living, eating, sleeping, mobility, socialization and all other aspects of the residents daily routine; -Procedure: -1. Upon admission, annually and with a change in resident pain, a pain assessment will be completed to identify: -a. Presence of pain; -b. location; -c. Intensity; -d. Diagnosis and prognosis; -e. Description of pain; -f. Activities that make pain worse; -g. Does pain impair resident function; -h. Frequency of pain; -i. Pain medications; -j. Non-pharmacological interventions attempted and results; -k. History of mediation side effects (drowsiness, constipation, etc.); -l. Observations/pain indicators for non-verbal or cognitively impaired residents; -m. Type of pain; -5. Attempt to identify the cause of the pain in order to discuss treatment or prevention plan; -6. Update resident care plan to include: -a. Type of pain; -b. Location; -c. Resident preferences for level of comfort and interventions; -d. Measurable goals; -e. Monitoring; -f. Physician orders; -g. Non-pharmacological interventions; -h. Pharmacological interventions; -7. If residents pain is not managed with current pain regimen, notify physician; -8. If a as needed (PRN) pain medication is used routinely, for three or more consecutive days and/or greater than six times in a month, discuss with physician a routine pain management plan; -9. If the resident displays behaviors which could possibly indicate pain or discomfort, consult with physician about an adjustment in the pain management plan; -10. Care plan instances in which pain can be anticipated in order to provide a pain management plan (i.e. prior to therapy or dressing change); -11. Implement non-pharmacological interventions as indicated in the care plan. Examples may include: -Cold or heat application; -Distraction; -Breathing exercises; -Relaxation; -Repositioning; -Transcutaneous electrical nerve stimulation (TENS, uses low-voltage electrical currents to relieve pain) unit; -Acupuncture; -Meditation; -Exercise; -Biofeedback (mind-body technique used to control some of the body's functions, such as heart rate, breathing patterns and muscle responses); -Music therapy; -Essential oils; -Art therapy; -Etc.; -Document effectiveness; -12. Administer pain medication as ordered. For PRN medications, document: -a. Location; -b. Intensity using the pain scale; -c. Implementation of any non-pharmacological interventions (ice, heat, massage, etc.); -d. Effectiveness of pain medication; -e. Modifying approaches as necessary; -13. For the resident with pending discharge, address pain control needs in the discharge planning to include: -a. Physician orders for medication after discharge; -b. Education to resident and/or resident representative; -c. Non-pharmacological interventions; -d. Return demonstration. 1. Review of Resident #1's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff, dated 4/10/24, showed: -Admission, 4/3/24; -Cognitively intact; -High-Risk drug classes use and indication, opioid: -Not checked as taking; -Not checked as indicated; -Pain management: -Been on scheduled pain medication regimen, yes; -Received PRN pain medications, yes; -Received non-medication intervention for pain, no; -Pain presence, yes; -Pain frequency, frequently; -Pain effect on sleep, rarely or not at all; -Pain interference with therapy activities, occasionally; -Pain interference with day-to-day activities, occasionally; -Pain intensity, rating scale 0-10 (pain level 1 through 10; 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 10 = severe pain), 6; -Diagnoses included high blood pressure, subacute (recent onset) osteomyelitis (inflammation of bone and bone marrow), paraplegia (paralysis of lower portions of the body and of both legs), unspecified injury at seventh thoracic vertebra (T7) through tenth thoracic vertebra (T10) (nerves that affect the muscles of the trunk (abdominal and back muscles)) level of thoracic spinal cord, neuralgia (severe, sharp, often shock-like pain that follows the path of a nerve) and neuritis (inflammation of the nerves). Review of the resident's Physician Order Sheet (POS), showed: -Oxycodone (Roxicodone, opioid, used to treat moderate to severe pain) immediate-release (IR) 10 milligram (mg) one tablet every six hours as needed (PRN) for pain, with a start date of 4/3/24 and end date of 4/8/24; -Oxycodone IR 10 mg 1 tablet every six hours, PRN for pain, with a start date of 4/8/24 and end date of 4/12/24; -Oxycodone IR 5 mg 1 tablet every six hours, PRN for pain. May have one tablet of 5 mg or 10 mg every 6 hours PRN for pain, with a start date of 4/8/24 and end date of 4/12/24; -Hydrocodone-Acetaminophen (Norco, opioid, used for moderate-to-severe pain control) 5-325 mg one tablet every four hours PRN for pain, maximum daily amount six tablets, with a start date of 4/12/24 and end date of 4/15/24; -Norco 10-325 mg one tablet every four hours PRN for pain, with a start date of 4/15/24 and end date of 4/23/24; -Norco 10-325 mg two tablets every four hours PRN for pain, with a start date of 4/23/24; -Norco 10-325 mg one tablet every four hours PRN for pain, with a start date of 4/30/24; -Acetaminophen (Tylenol) 500 mg two tablets every six hours as needed for pain, with a start date of 4/3/24. Review of the resident's IPNR for Oxycodone IR 10 mg every six hours PRN for pain, dispensed 4/4/24, with a start date of 4/3/24, and end date of 4/8/24, showed; -One tablet signed out on 4/4/24 at 11:15 A.M.; -One tablet signed out on 4/4/24 at 5:15 P.M.; -One tablet signed out on 4/4/24 11:15 P.M.; -One tablet signed out on 4/5/24 at 10:00 A.M.; -One tablet signed out on 4/5/24 at 4:00 P.M.; -One tablet signed out on 4/5/24 at 10:00 P.M.; -One tablet signed out on 4/6/24 at 10:00 A.M.; -One tablet signed out on 4/7/24 at 1:20 P.M.; -One tablet signed out on 4/7/24 at 8:21 P.M.; -One tablet signed out on 4/8/24 at 9:13 A.M. Review of the resident's second IPNR for Oxycodone IR 10 mg every six hours PRN for pain, dispensed 4/5/24, with a start date of 4/3/24, and end date of 4/8/24, showed; -One tablet signed out on 4/8/24 at 4:30 P.M.; -One tablet signed out on 4/9/24 at 2:30 A.M.; -One tablet signed out on 4/9/24 at 10:50 A.M.; -One tablet signed out on 4/9/24 at 7:30 P.M.; -One tablet signed out on 4/10/24 at 10:00 A.M.; -One tablet signed out on 4/10/24 at 4:00 P.M.; -One tablet signed out on 4/11/24 at 5:30 P.M.; -One tablet signed out on 4/12/24 at 12:00 A.M. Review of the resident's IPNR for Norco 5-325 mg one tablet every four hours PRN for pain, dispensed 4/13/24, with a start date of 4/12/24 and end date of 4/15/24, showed; -One tablet signed out on 4/13/24 at 10:30 A.M.; -One tablet signed out on 4/14/24 at 10:33 A.M.; -One tablet signed out on 4/14/24 at 3:00 P.M.; -One tablet signed out on 4/14/24 at 7:00 P.M.; -One tablet signed out on 4/14/24 at 11:00 P.M. Review of the resident's IPNR for Norco 10-325 mg one tablet every four hours PRN for pain, with a start date of 4/15/24 and end date of 4/23/24, restart date of 4/30/24, Norco 10-325 mg two tablets every four hours PRN for pain, with a start date of 4/23/24, dispensed 4/16/24 at 4:30 A.M., showed; -One tablet signed out on 4/16/24 at 12:30 P.M.; -One tablet signed out on 4/17/24 at 2:30 P.M.; -One tablet signed out on 4/17/24 at 7:00 P.M.; -One tablet signed out on 4/18/24 at 3:00 P.M.; -One tablet signed out on 4/18/24 at 8:00 P.M.; -One tablet signed out on 4/19/24 at 2:30 P.M.; -One tablet signed out on 4/19/24 at 7:30 P.M.; -One tablet signed out on 4/20/24 at 1:45 P.M.; -One tablet signed out on 4/22/24 at 9:10 A.M.; -One tablet signed out on 4/22/24 at 3:00 P.M.; -One tablet signed out on 4/22/24 at 7:00 P.M.; -One tablet signed out on 4/22/24 at 11:00 P.M.; -One tablet signed out on 4/23/24 at 12:00 P.M.; -One tablet signed out on 4/23/24 at 3:00 P.M.; -Two tablets signed out on 4/23/24 at 5:00 P.M.; -Two tablets signed out on 4/23/24 at 10:00 P.M.; -Two tablets signed out on 4/24/24 at 10:00 A.M.; -Two tablets signed out on 4/24/24 at 2:15 P.M.; -Two tablets signed out on 4/25/24 at 10:00 A.M.; -Two tablets signed out on 4/25/24 at 3:50 P.M.; -Two tablets signed out on 4/26/24 at 10:00 A.M.; -Order not updated on IPNR when changed on 4/23/24 from one tablet every four hours to two tablets every four hours. Review of the resident's IPNR for Norco 10-325 mg one tablet every four hours PRN for pain, with a start date of 4/15/24 and end date of 4/23/24, restart date of 4/30/24, Norco 10-325 mg two tablets every four hours PRN for pain, with a start date of 4/23/24, dispensed 4/16/24 at 4:30 A.M., with a start date of 4/23/24, showed; -Order on IPNR reads: take one (number one has single line marked through it and the number two written above number one) tablet by mouth every four hours PRN; -Two tablets signed out on 4/26/24 at 2:15 P.M.; -Two tablets signed out on 4/27/24 at 11:30 A.M.; -Two tablets signed out on 4/27/24 at 3:30 P.M.; -Two tablets signed out on 4/28/24 at 11:00 A.M.; -Two tablets signed out on 4/28/24 at 4:38 P.M.; -Two tablets signed out on 4/29/24 at 10:30 A.M.; -One tablet signed out, on 4/30/24 at 4:36 A.M., on signature line documented: Resident requested one tablet only, followed by two nurses signatures; -Two tablets signed out on 4/30/24 at 3:00 P.M.; -Two tablets signed out on 5/1/24 at 1:00 P.M.; -One tablet signed out on 5/1/24 at 8:56 P.M.; -Two tablets signed out on 5/2/24 at 7:30 A.M.; -One tablet signed out on 5/2/24 at 5:36 P.M.; -Two tablets signed out on 5/3/24 at 1:00 P.M.; -Two tablets signed out on 5/4/24 at 1:00 P.M.; -Two tablets signed out on 5/5/24 at 4:35 A.M.; -One tablet signed out on 5/5/24 at 12:30 P.M.; -Order not updated on IPNR when changed on 4/30/24 from two tablets every four hours to one or two tablets every four hours. Review of the resident's second IPNR for Norco 10-325 mg one tablet every four hours PRN for pain, with a start date of 4/15/24 and end date of 4/23/24, restart date of 4/30/24, Norco 10-325 mg two tablets every four hours PRN for pain, with a start date of 4/23/24, dispensed 4/16/24 at 4:30 A.M., with a start date of 4/23/24, showed; -Order on IPNR reads: take one tablet by mouth every four hours PRN; -Order not updated on IPNR when changed on 4/30/24 from two tablets every four hours to one or two tablets every four hours; -One tablet signed out on 5/5/24 at 12:30 P.M.; -One tablet signed out on 5/5/24 at 7:35 P.M.; -One tablet signed out on 5/6/24 at 4:28 A.M.; -Two tablets signed out on 5/6/24 at 3:00 P.M.; -One tablet signed out on 5/6/24 at 9:45 P.M.; -One tablet signed out on 5/7/24 at 6:20 A.M.; -Two tablets signed out on 5/8/24 at 11:54 A.M.; -Two tablets signed out on 5/8/24 at 8:30 P.M.; -Two tablets signed out on 5/9/24 at 10:00 A.M.; -One tablet signed out on 5/9/24 at 7:10 P.M.; -One tablet signed out on 5/11/24 at 2:00 P.M.; -One tablet signed out on 5/11/24 at 10:00 P.M.; -One tablet signed out on 5/12/24 at 11:00 A.M.; -One tablet signed out on 5/12/24 at 8:00 P.M.; -Two tablets signed out on 5/13/24 at 9:00 A.M.; -Two tablets signed out on 5/13/24 at 6:30 P.M.; -Two tablets signed out on 5/14/24 at 10:00 A.M.; -One tablet signed out on 5/14/24 at 9:30 P.M.; -One tablet signed out on 5/15/24 at 7:08 A.M.; -One tablet signed out on 5/16/24 at 8:00 A.M.; -One tablet signed out on 5/16/24 at 1:21 P.M. Review of the resident's eTAR record for Oxycodone IR 10 mg every six hours PRN for pain, with a start date of 4/3/24, and end date of 4/12/24, Oxycodone IR 5 mg one tablet every six hours, PRN for pain: May have one tablet of 5 mg or 10 mg every 6 hours PRN for pain, with a start date of 4/8/24 and end date of 4/12/24, cubex (electronic emergency medication kit), eMAR record for Tylenol 500 mg two tablets every six hours as needed for pain, with a start date of 4/3/24, and Interdisciplinary Notes (IDN) dated 4/3/24 through 4/12/24, showed; -Tylenol 500 mg two tablets on 4/4/24 at 10:29 A.M. documented as administered, treatment effectiveness not documented, pain level (pain level 1 through 10; 0 = no pain, 1 through 3 = mild pain, 4 thro

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to establish a system for records of disposition of all controlled substances (medication that is regulated by the United States Drug Enforcement Administration (DEA) due to the potential of causing dependency and abuse) in sufficient detail to enable an accurate reconciliation for three out of three controlled substance shift change count sheets reviewed. In addition, the facility failed to have a system in place to document the destruction in sufficient detail of controlled substances when controlled medications were removed from stock for four out of four sampled residents (Residents #1, #2, #3 and #4). This had the potential to affect all residents with controlled substance orders. The census was 82. Review of the facility's Schedule II-V Controlled Substances (schedule two controlled substance (CII, medication with higher potential of dependency and abuse), Schedule three controlled medication (CIII, medication with low to moderate potential of dependency and abuse), Schedule four controlled substance (CIV, medication with low potential of dependency and abuse), Schedule five controlled substance (CV, lowest potential of dependency and abuse)) Policy, dated 8/2019, showed: -Policy: It is the policy of the facility to ensure compliance with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances; -Purpose: It is the purpose of the facility to unsure all residents receive prescribed medication, including Controlled substances for quality of resident care: -Pain management; -Anxiety; -Other related diagnosis; -Procedure: -1. Read/Review pharmacy policy and procedure regarding this policy; -2. Only authorized licensed nurses that are permanent employees of the facility or pharmacy personnel shall have access to Schedule II controlled drugs maintained on premises. No agency nurse is allowed to carry narcotic keys or administer narcotics to and resident; -3. Controlled substances must be counted upon delivery. The nurse receiving the order must count the controlled substance together with the Shift Supervisor. Both individuals must sign the designated narcotic record; -4. If the count is correct, a control sheet must be made for each substance. Do not enter more that one prescription per page. This record must contain: -Name of the resident; -Name and strength of the medication; -Quantity received; -Number on hand; -Name of physician; -Time of administration; -Method of administration; -Signature of person receiving the medication; -Signature of nurse administering medication; -8. Unless otherwise instructed by the Director of Nursing (DON), when a resident refuses a non-unit dose medication or it is not given, or receives partial tablets or single dose ampules, or it is not given, the medication shall be destroyed, and may not be returned to the container or bubble pack. (see Discarding and Destroying Medications policy within the Medications policy and procedure); -9. Nursing staff must count controlled dugs at the end of each shift, for each eight-hour or 12-hour shift. The nurse coming on duty and the nurse going off duty must complete the count together. They must document and report and discrepancies to the shift supervisor and DON immediately; -10. The DON shall investigate all discrepancies in controlled substance reconciliation to determine the cause and identify any responsible parties and shall give the Administrator a written report of such findings; -11. The DON shall consult with the provider pharmacy and the Administrator to determine whether any further legal action is indicated; -12. When a resident or patient is transferred or discharged from the facility, it is allowable to send schedule II drugs with the resident or responsible party. Documentation of education should be completed in the medical record. -13. Schedule II-V Controlled Substances may not be returned to the pharmacy but must be destroyed by two licensed nurses. (Describe how to destroy and documentation here). Review of the facility's Controlled Drugs Policy, not dated, showed: -Policy: Medications included in the DEA classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations; -Procedure: -A. Only authorized nursing personnel and pharmacy personnel have access to controlled drugs. The DON is responsible for the control of these medications; -B. Schedule II, III, IV and V drugs will be provided by the pharmacy in containers designed for easy counting of contents; -C. When possible, orders for injectable controlled drugs will be provided in single dose containers; -D. Schedule II drugs and any other drugs that the facility deems necessary will be kept in a double locked area separate from other drugs. The access key to this area is separate from the key giving access to the rest of the medication cart; -E. The pharmacy can only dispense a 72-hour supply for a scheduled II drug, until a signed prescription is received from the physician. The prescribing physician may send the follow-up written prescription to the pharmacy by facsimile (fax); -F. A controlled medication delivery manifest will accompany all scheduled II, III, or V medication deliveries. The flowing information will be present: -Name of resident; -Room number of resident; -Prescription number; -Name, strength (if designated) and dosage form of medication; -Date and delivery sent from pharmacy; -Quantity dispensed; -Name of person receiving medication supply and date received signed at the time of delivery; -A copy is retained in the pharmacy prior to delivery. The delivery personnel will retain a copy of this record, and a copy will be left at the facility to document the receipt of the medication; -G. Schedule II drugs and any other specific medications as deemed necessary by the facility will be dispensed by the pharmacy along with an Individual charting record. This record will be maintained by the nursing staff at the time of each administration of the medication as follows: -1. Place charting record in narcotic box or in charting record binder; -2. Record each done at the time of administration; -3. Confirm the amount of controlled drug remaining is correct prior to assembling required dose for administration; -Date; -Time; -Dosage; -Signature of nurse who administered dose; -Number of doses remaining; -4. When the prescription has been exhausted, the individual charting record becomes a permanent part of the medical record; -5. When the prescription is no longer an active order and there are remaining doses of medication, the individual charting record and the remaining medications are retained in the facility in a securely locked area with restricted access. The remaining quantity will remain in this area until destroyed by two licensed personnel; -6. A controlled medication may never be returned to the pharmacy for destruction. It must be destroyed in the presence of two licensed personnel in the facility; -H. When a dose of controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose. The disposal of unused partial tablets and unused single dose portions of single dose ampules must be destroyed and recorded in the presence of two licensed personnel; -I. At each shift change. A physical inventory of specific mediations, those selected by the facility, is conducted by two licensed nurses and is documented on an audit record; -J. Current controlled medication accountability records and audit records are kept in the medication administration record (MAR) or other specific binder. When completed, audit and accountability records are submitted to the DON and kept on file according to facility policy for health records retention; -K. Any discrepancy in controlled substance medication counts is reported to the DON immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. Irreconcilable discrepancies are documented by the DON and reported to the consultant pharmacist and Administrator. The Administrator, Pharmacist, and the DON will make a determination concerning of any actions that may need to be taken. Review of the facility's Controlled Drug Disposal policy, not dated, showed: -Policy: It is the policy of this facility to comply with federal and state requirements for controlled substances. The following procedures will be adhered to at all times for disposal of Schedule II through V medications; -Procedure: -A. Controlled substances that are no longer needed in the facility must be disposed of in the facility. They cannot be returned to the pharmacy; -B. When a dose Schedule II substance is discontinued or when a resident receiving Schedule II substances expires, a licensed nurse will record the number of doses that remain and the date of the resident's Controlled Substance Record (count sheet). If the facility uses a count sheet for Schedule III through V substances, the same procedure will be followed; -C. The medications and accompanying count sheets will be kept in the medication cart until they are surrendered to the DON or his/her designee for destruction. Shift-to-shift counts will be done, and endorsed on the appropriate record, for all controlled substances awaiting destruction for which there are count sheets; -D. The DON or designee will then record the name of the drug, dosage form, quantity and resident's name or the inventory of control drugs from all Schedule II controlled substances. Schedule III through V controlled substances do not require documentation of the residents name on the Inventory of Control Drugs Form. They can be listed as multiple; -E. The DON will keep the medication and numbered count sheets in a secure, double locked area. The DON, or designee, and one additional licensed person will destroy medication utilizing the appropriate form for recording the destruction according to the accepted standards of practice for disposal and in accordance will sign the disposal record, including their title. The date of destruction should also be documented; -F. After destruction, the count sheets will be forwarded to the medial records for filling with each residents clinical record; -G, The DON will retain a copy of the disposal record for filing locally. 1. Review of the March 2024, Main station, Controlled Substance Shift Change Count, showed: -Signing signifies all doses are recorded on the MAR, count sheets match inventory on hand, and package log matches actual package count; -Irregularities must be reported to the DON immediately; -Only one staff initial 8 out of 93 opportunities. Review of the April 2024, Main station, Controlled Substance Shift Change Count, showed: -Signing signifies all doses are recorded on the MAR, count sheets match inventory on hand, and package log matches actual package count; -Irregularities must be reported to the DON immediately; -Only one staff initial 7 out of 90 opportunities. Review of the May 2024, Main station, Controlled Substance Shift Change Count, reviewed 5/17/24 at 2:46 P.M., showed: -Signing signifies all doses are recorded on the MAR, count sheets match inventory on hand, and package log matches actual package count; -Irregularities must be reported to the DON immediately; -Only one staff initial 4 out of 49 opportunities. During an interview on 5/21/24 at 1:13 P.M., the DON said she expected nursing staff on-coming and off-going with controlled medications on the cart to count the controlled medications and sign that the count was completed. The process ensures accurate count for controlled medication. No staff should leave the building before the count is complete. If a discrepancy occurs, staff should immediately contact the DON, Assistant Director of Nursing (ADON) or Unit Manager (UM). During an interview on 5/22/24 at 2:36 P.M., the ADON said she expected nursing staff who have controlled medications to count with the on-coming and off-going staff to ensure the count is accurate, and both staff should initial that the count is accurate. Nursing staff should not accept a cart if the count has not been completed. If a discrepancy occurs, the nursing staff should immediately contact the DON, ADON or UM. The ADON said nursing staff had been written up in the past for not completing count but there has not been any formal education to all the nursing staff to ensure count is completed at the beginning and end of each shift and to initial that it was completed. During an interview on 5/30/24 at 9:43 A.M., the Administrator said he expected nursing staff who had controlled medications to complete the shift-to-shift count at the beginning and end of each shift and document it on the controlled substance shift change count check sheet. If nursing management noticed that nursing staff were not documenting the count was completed on every shift, the Administrator expected the DON and/or nursing management to complete in-servicing with the nursing staff on the ensuring shift to shift count was completed at the beginning and end of each shift. 2. Review of Resident #1's admission Minimum Data Set (MDS) a federally mandated assessment completed by facility staff, dated 4/10/24, showed: -Admission, 4/3/24; -Cognitively intact; -High-Risk drug classes use and indication, opioid: -Not checked as taking; -Not checked as indicated; -Pain management: -Been on scheduled pain medication regimen, yes; -Received PRN pain medications, yes; -Received non-medication intervention for pain, no; -Pain presence, yes; -Pain frequency, frequently; -Pain effect on sleep, rarely or not at all; -Pain interference with therapy activities, occasionally; -Pain interference with day-to-day activities, occasionally; -Pain intensity, rating scale 0-10 (pain level 1 through 10; 0 = no pain, 1 through 3 = mild pain, 4 through 6 = moderate pain, 7 through 10 = severe pain), 6; -Diagnoses included high blood pressure, subacute (recent onset) osteomyelitis (inflammation of bone and bone marrow), paraplegia (paralysis of lower portions of the body and of both legs), unspecified injury at seventh thoracic vertebra (T7) through tenth thoracic vertebra (T10) (nerves that affect the muscles of the trunk (abdominal and back muscles)) level of thoracic spinal cord, neuralgia (severe, sharp, often shock-like pain that follows the path of a nerve) and neuritis (inflammation of the nerves). Review of the resident's Physician Order Sheet (POS), showed: -Oxycodone (Roxicodone, opioid, used to treat moderate to severe pain) immediate-release (IR) 10 milligram (mg) one tablet every six hours as needed (PRN) for pain, with a start date of 4/3/24, and end date of 4/8/24; -Oxycodone IR 10 mg 1 tablet every six hours, PRN for pain, with a start date of 4/8/24 and end date of 4/12/24; -Oxycodone IR 5 mg 1 tablet every six hours, PRN for pain. May have one tablet of 5 mg or 10 mg every 6 hours PRN for pain, with a start date of 4/8/24 and end date of 4/12/24; -Hydrocodone-Acetaminophen (Norco, opioid, used for moderate-to-severe pain control) 5-325 mg one tablet every four hours PRN for pain, with a start date of 4/12/24 and end date of 4/15/24; -Norco 10-325 mg one tablet every four hours PRN for pain, with a start date of 4/15/24 and end date of 4/23/24; -Norco 10-325 mg two tablets every four hours PRN for pain, with a start date of 4/23/24; -Norco 10-325 mg one tablet every four hours PRN for pain, with a start date of 4/30/24. Review of the resident's individual patient narcotic record for Oxycodone 10 mg every six hours PRN for pain, dispensed 4/5/24, showed: -4/5/24, total of 30 tablets dispensed; -4/12/24, total of 22 tablets remaining; -Discontinued (D/C'd) written at the bottom of the page with DON and Licensed Practical Nurse (LPN) B signature underneath, dated 4/12/24, no time listed; -No documentation on what was done with the remaining 22 tablets. Review of the resident's second individual patient narcotic record for Oxycodone 10 mg every six hours PRN for pain, dispensed 4/5/24, showed: -4/5/24, total of 10 tablets dispensed; -4/12/24, total of 10 tablets remaining; -D/C'd written at the bottom of the page with DON and LPN B signature underneath, dated 4/12/24, no time listed; -No documentation on what was done with the remaining 10 tablets. Review of the resident's individual patient narcotic record for Norco 5-325 mg every four hours PRN for pain, dispensed 4/13/24, showed: -4/13/24, total of 30 tablets dispensed; -4/14/24, total of 25 tablets remaining; -D/C'd written at the bottom of the page with DON and LPN B signature underneath, no date or time listed; -No documentation on what was done with the remaining 25 tablets. Review of Main controlled substance log, dated 3/17/24 through 5/3/24, showed: -Dated 4/24/24; -Time: 7:00 A.M. - 3:00 P.M.; -Resident #1; -Drug: Oxycodone IR 10 mg; -Nurse signature: DON, LPN B; -Adding card to count or subtracting card from count: subtracting two; -New card total: 12; -If subtracted, document why: blank; -No documentation on what was done with the remaining 32 tablets. Review of Main controlled substance log, dated 3/17/24 through 5/3/24, showed: -Dated 4/24/24; -Time: 7:00 A.M. - 3:00 P.M.; -Resident #1; -Drug: Norco 5-235 mg; -Nurse signature: DON, LPN B; -Adding card to count or subtracting card from count: subtracting one; -New card total: 11; -If subtracted, document why: blank; -No documentation on what was done with the remaining 25 tablets. Review of the resident's interdisciplinary notes, dated 4/12/24 and 4/24/24, showed: -No note on removal of two cards of Oxycodone IR 10 mg or one card of Norco 5-325 mg from cart; -No note on destruction of two cards of Oxycodone IR 10 mg with a total of 32 tablets or one card of Norco 5-325 mg with 25 tablets. 3. Review of Resident #2's annual MDS, dated [DATE], showed: -Admission, 10/17/22; -Cognitively intact; -High-Risk drug classes use and indication, opioid: -Not checked as taking; -Not checked as indicated; -Pain management: -Been on scheduled pain medication regimen, no; -Received PRN pain medications, yes; -Received non-medication intervention for pain, no; -Pain presence, yes; -Pain frequency, occasionally; -Pain effect on sleep, rarely or not at all; -Pain interference with day-to-day activities, rarely or not at all; -Pain intensity, rating scale 0-10, 5; -Diagnoses included high blood pressure, stroke, hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body), following stroke affecting right nondominant side. Review of the resident's POS, showed: -Norco 5-325 mg one tablet every six hours PRN for pain, with a start date of 11/18/23 and end date of 5/7/24. Review of the resident's individual patient narcotic record for Norco 5-325 mg every six hours PRN for pain, dispensed 3/14/24, showed: -3/14/24, total of 40 tablets dispensed; -4/19/24, total of 18 tablets remaining; -D/C'd written at the bottom of the page with LPN B and ADON signature underneath, dated 5/14/24 at 10:20 A.M.; -No documentation on what was done with the remaining 18 Norco tablets. Review of Main controlled substance log, dated 5/5/24 through 5/20/24, showed: -Dated 5/14/24; -Time: 10:00 A.M.; -Resident #2; -Drug: Norco 5-325 mg; -Nurse signature: LPN B, ADON; -Adding card to count or subtracting card from count: subtracting one; -New card total: 9; -If subtracted, document why: Discontinued; -No documentation on what was done with the remaining 18 tablets. Review of the resident's interdisciplinary notes, dated 5/14/24, showed: -No note on removal of Norco 5-325 mg from cart; -No note on destruction of Norco 5-325 mg. During an interview on 5/23/24 at 1:46 P.M., the DON said she believed the order was discontinued because the resident stated that he/she had not used the medication in over 30 days. The DON said the 18 tablets of Norco went into the drug buster (disposal system to instantly break down medications into a solution). The DON said the facility had never documented that medication is destroyed in the drug buster because that is the only thing the facility uses to destroy medication. The DON said two nurses sign the individual narcotic record and the controlled substance log to show the controlled medication was destroyed. The DON said there is not a spot on the controlled substance log to mark the medication was destroyed, and said they never write in the column that the medication was destroyed. The DON said if a resident had the controlled medication sent home with them, it would have a nurse's signature and a family member or the resident signature at the bottom of the page. The DON said she would not know if the controlled medication was destroyed unless she went and asked both nurses who signed. The DON said the facility does not have a system in place to track and monitor when controlled medications are destroyed. 4. Review of Resident #3's admission MDS, dated [DATE], showed: -Admission, 2/9/24; -Severe cognitive impairment; -High-Risk drug classes use and indication, opioid: -Checked as taking; -Checked as indicated; -Pain management: -Been on scheduled pain medication regimen, yes; -Received PRN pain medications, yes; -Received non-medication intervention for pain, no; -Pain presence, yes; -Pain frequency, occasionally; -Pain effect on sleep, Not rated; -Pain interreference with therapy activities, rarely or not at all; -Pain interference with day-to-day activities, occasionally; -Pain intensity, rating scale 0-10, 6; -Diagnoses included fracture of right lower leg, pain in left hip, arthritis, dementia and hemiplegia flowing stroke affecting unspecified side. Review of the resident's POS, showed: -Norco 5-325 mg half tablet by mouth every four hours PRN for pain, with a start date of 2/14/23 and end date of 4/26/24. Review of the resident's individual patient narcotic record for Norco 5-325 mg half tablet every four hours PRN for pain, dispensed 2/21/24, showed: -2/21/24, total of 30 half tablets dispensed; -4/19/24, total of 11 half tablets remaining; -Destroyed, and D/C'd, written at the bottom of the page with LPN B and RN D signature underneath, no date or time listed; -No documentation on how 11 half tablets of Norco were destroyed. Review of Main controlled substance log, dated 3/17/24 through 5/3/24, showed: -Dated 5/3/24; -Time: 7:00 A.M. - 3:00 P.M.; -Resident #3; -Drug: Norco 5-325 mg; -Nurse signature: LPN B, RN D; -Adding card to count or subtracting card from count: subtracting one; -New card total: 11; -If subtracted, document why: Discontinued; -No documentation on what was done with the remaining 11 half tablets. Review of the resident's interdisciplinary notes, dated 4/26/24 and 5/3/24, showed: -No note on removal of Norco 5-325 mg card from cart; -No note on destruction of 11 half tablets of Norco 5-325 mg. 5. Review of Resident #4's admission MDS, dated [DATE], showed: Norco -Admission, 3/29/24; -Discharge, 5/8/24; -Cognitively intact; -High-Risk drug classes use and indication, opioid: -Not checked as taking; -Not checked as indicated; -Pain management: -Been on scheduled pain medication regimen, no; -Received PRN pain medications, yes; -Received non-medication intervention for pain, yes; -Pain presence, yes; -Pain frequency, frequently; -Pain effect on sleep, occasionally; -Pain interreference with therapy activities, rarely or not at all; -Pain interference with day-to-day activities, occasionally; -Pain intensity, rating scale 0-10, 6; -Diagnoses included displaced intertrochanteric (relating to the bones of the thigh) fracture of left femur (thigh bone), subsequent encounter for closed fracture with routine healing, lumbar radiculopathy (inflammation of a nerve root in the lower back), hereditary (passed on genetically from parent to child) and idiopathic (no obvious underlying etiology is found) neuropathy (disease or dysfunction of one or more peripheral (located near the surface part if the body) nerves, typically causing numbness or weakness). Review of the resident's POS, showed: -Norco 5-325 mg one tablet every four hours PRN for pain, with a start date of 3/29/24 and end date of 5/7/24. Review of the res

Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the Department of Health and Senior Services (DHSS) within the required timeline after a resident (Resident #1) reported a staff member injured his/her arm while providing care. The sample size was three. The census was 79. The Administrator was notified on 10/19/23, of the past non-compliance. The facility has in-serviced all staff on the Abuse Policy: Reporting and Response. The deficiency was corrected on 10/18/23. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy dated 8/19, showed: -It is the policy of the facility to encourage and support all residents, staff and families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property and exploitation; -Physical Abuse includes, but is not limited to hitting, slapping, punching, biting and kicking; -Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and if, verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect or abuse including injuries of unknown source, and misappropriation of resident property; -Covered Individual is anyone who is an owner, operator, employee, manager, agent or contractor of the facility; -Reporting and Response: -It is the policy of this facility that abuse allegations are reported, including injuries of unknown origin source and misappropriation of resident property, per Federal and State law. The facility will ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in a facility; -Procedure: -Internal Reporting: a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator. **Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law; b. The Administrator will involve key leadership personnel as necessary to assist with reporting, investigation and follow up; c. The Administrator will report to the Medical Director; -External Reporting: *Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual who is a resident of or is receiving care from, the facility, and each covered individual shall report immediately, but not more than two hours after forming the suspicion, if the events that cause the suspicion do not result in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury; *Initial reporting of allegations: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency within five working days; *Covered individuals are obligated to comply with reporting requirements. If uncertain whether to report an incident, call the State Agency for further direction. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/23/23, showed: -Adequate hearing/vision; -Ability to express ideas and wants: Difficulty communicating; -Ability to understand others: Understands others; -Moderate assistance required for bed mobility, transfers, dressing and toilet use; -Mobility device: Wheelchair; -Diagnoses of peripheral polyneuropathy (this condition often causes weakness, numbness and pain, usually in the hands and feet.), urinary retention and heart block. -No behaviors or refusal of care listed. Review of the resident's progress notes, showed: -On 10/5/23 at 6:09 P.M., the resident yelled at staff, demanding; -On 10/13/23 at 4:31 P.M., the resident was in his/her room most of day; visitor in afternoon. The resident refused therapy this afternoon, informed therapist he/she was talking business and did not want to be disturbed; -No progress notes documented about the resident being upset or the police investigating an incident during the evening shift of 10/12/23. Review of the facility's investigation sent to DHSS on 10/17/23, showed, the following: -On 10/13/23 at 9:22 A.M., the Administrator received a text from Social Worker A to let him know the Assisted Director of Nursing (ADON) received a call from Resident #1's responsible party who had a concern about an incident that happened the night before when the resident called the police over a disagreement with an aide about care procedures. The resident noticed a bruise on his/her right arm between his/her wrist and elbow and made a non-emergency call to the police in order to have a report completed; -The Administrator directed the Social Worker and ADON to suspend the aide pending an investigation and make a self-report to DHSS, which they did by 10:34 A.M.; -The Administrator interviewed the resident, who said he/she had wet him/herself and called out for assistance. Certified Nurse's Aide (CNA) C entered the room and asked what he/she needed. The resident said his/her pants needed changing. CNA C said he/she would return after caring for another resident. When he/she returned, the resident said he/she wanted his/her pants changed in the restroom, so his/her bed would not be soiled. The resident alleged CNA C grabbed his/her arm and tugged him/her in the direction of the bed. The resident pulled away from him/her, which increased the chance of injury to his/her arm. Another aide came into the room and both of them tried to talk him/her into getting into the bed. They were insinuating in their conversation that he/she was crazy. The nurse then entered the room and the two CNAs left. The nurse took the resident to the restroom to change his/her pants without incident. The resident later noticed his/her arm swelled and becoming discolored and called the police; -On 10/16/23, the Administrator interviewed CNA C who assisted the resident. He/She said he/she was assisting a resident next door when he/she heard Resident #1 yelling for help. He/She entered because he/she felt the resident could have fallen. He/She saw the resident seated in his/her wheelchair in the room. His/Her pants were wet and the resident wanted them changed. CNA C told the resident he/she would return as soon as he/she finished with the resident next door. CNA C heard the resident yelling out again. He/She returned to find the resident seated parallel to his/her bed. CNA C assumed the resident wanted to get changed from the bed, since he/she was positioned next to it, and CNA C asked if the resident if he/she wanted to get in the bed. The resident said he/she wanted to go to the restroom, and CNA C positioned him/herself behind the wheelchair to push him/her to the bathroom. The resident reached back and scratched his/her arm from the wheelchair. The resident grabbed the enable bar on the bed with his/her right hand and refused to let go, and the aide tried to steer the wheelchair towards the restroom. The resident threatened to call the police. CNA C gave up trying to take the resident to the restroom, when another CNA walked in the room, and then the nurse shortly thereafter; -On 10/16/23, the Administrator interviewed Nurse E, who said he/she entered the resident's room because he/she could hear him/her yelling from the nurse's station. When he/she entered the room, the aides were standing on either side of the resident's wheelchair. The resident was yelling and saying the aides did not know what they were doing. Nurse E dismissed the aides and took the resident to the restroom and changed his/her pants. Nurse E observed the resident's arm but did not notice anything unusual or any signs of damage. The resident mentioned he/she tried to move his/her arm in a manner to hit the CNA who was in earlier. Nurse E was surprised when the police came in later that evening to investigate. They questioned the resident and aide without incident. The officer asked what Nurse E was going to do, and he/she said he/she would let his/her supervisor know about the incident. He/She later called the On-call Nurse Manager and reported the resident being upset about the CNA's care in changing his/her pants, and that the police had been there, but no action was taken. The Administrator asked why Nurse E did not contact him or the Director of Nursing to report the alleged abuse. Nurse E said he/she did contact the On-call Nurse Manager and report the police being summoned and the resident's concerns about his/her pants being changed. The resident had mentioned being scratched, but Nurse E had not observed signs of new scratches. He/She felt the police had dismissed it as a contradiction of procedural preferences between the resident and the CNAs; -The resident did have a significant bruise to his/her right arm. During an interview on 10/19/23 at 8:40 A.M., Social Worker A said he/she received a call from the ADON on 10/13/23 around 9:10 A.M., saying he/she had just spoken to the resident's responsible party about an incident that occurred the night before and asked if he/she would go talk to the resident with him/her. They notified the Administrator about the phone call and then went to talk to the resident. The resident said he/she wet him/herself and put on his/her call light for help. No one came so he/she started yelling for help. The CNA opened the door and told him/her he/she was helping someone else and would be right back. The resident sat, waiting for what felt like an hour, and then started to yell for help again. The CNA came back in and wanted to put him/her in the bed to change. The resident wanted to be changed in the bathroom so the bed did not get soiled. The CNA was not listening to him/her and the resident got angry. He/She did not want to be put into bed and the CNA was trying to put him/her into the bed. The CNA tried to move the wheelchair, and the resident grabbed the bedrail to prevent prevent the CNA from moving his/her wheelchair. The resident wanted the CNA to leave his/her room at this point. The resident claimed the CNA was pulling his/her arm away from the bed and this caused the bruising. Another CNA came into the room and also tried to talk the resident into getting into the bed to get changed. The nurse came in soon after that and the aides left the room. The nurse was able to calm the resident down and get him/her changed. The resident decided to call the police after he/she noticed the swelling on his/her arm later in the evening. The resident had a reddish discoloration on his/her right arm when the Social Worker saw it that morning. During an interview on 10/19/23 at 10:00 A.M., CNA C said on 10/13/23 he/she was in the room next door when he/she heard the resident yelling. CNA C went in the room and saw the resident seated in his/her wheelchair. The resident said he/she needed to be changed, and the CNA asked if he/she could wait a few minutes while he/she finished with the resident next door. The resident started yelling almost immediately after CNA C went back to help the other resident. CNA C finished helping the other resident and returned to Resident #1's room. The resident was in his/her wheelchair adjacent to the bed. CNA C thought the resident wanted to be changed in his/her bed since that is where he/she was located and started to help him/her get into the bed. The resident immediately started screaming he/she wanted to go to the restroom to be changed. CNA C went to grab the wheelchair handles to move him/her towards the restroom, and the resident grabbed the bed rails. The resident kept yelling he/she did not want to be changed in the bed. CNA C tried to explain he/she was trying to take him/her to the restroom, but the resident was so angry at that point and yelled for him/her to get out of the room. He/She walked to the back of the wheelchair to try and take the resident to the bathroom again, and he/she continued to scream, so CNA C was going to leave the room when the other CNA walked in. The resident started screaming at both of them to get out of the room when the nurse walked into the room. The nurse told them they could both leave the room, and they left, and then the nurse helped the resident change his/her pants. CNA C had not worked with the resident that day prior to this interaction. CNA C heard the resident regularly threw staff out of his/her room and threatened to call the police on them, so no one wanted to work with him/her. The CNA heard the resident get on the phone and call someone to say the staff were rough with him/her, and he/she was going to call the police when he/she was at the nurse's station after the incident. CNA C did not report it because the nurse heard it too and said he/she would be notifying the On-call Nurse Manager. During an interview on 10/19/23 at 1:10 P.M., Nurse E said on 10/12/23 between 7:45 P.M., and 8:00 P.M., he/she was assisting a resident and heard screaming coming from Resident #1's room. It was so loud, he/she thought someone was in a bad condition, but he/she saw the two CNAs go in the room, so he/she finished up caring for the other resident. When he/she entered Resident #1's room, he/she saw the two CNAs standing on both sides of the resident's wheelchair. Nurse E asked the resident what was wrong, and he/she said he/she was wet and wanted to be changed. The resident said the CNAs were doing it wrong, and he/she wanted them out of the room. Nurse E felt it best to have the CNAs leave the room at this point and assisted the resident with changing his/her pants. Nurse E knew the resident well and knew to follow step by step directions to avoid making him/her more upset. Nurse E asked the resident what happened, and he/she said the CNAs tried to make him/her get in the bed. They tried to grab his/her arm and he/she pushed back. Either the CNAs held his/her arm or he/she pushed against them. He/she might have struck out at the aide. The resident's statements were very inconsistent. Nurse E assessed the resident's arm and did not see any new bruises or scratches. There was an old bruise on his/her right wrist but nothing that looked new. The resident did not say his/her arm was hurting. He/She seemed calm and happy when Nurse E left the room. Nurse E did not know there was a problem until the police showed up and said the resident called them to report the CNAs tried to change him/her in a way he/she did not like. The resident told the police the aide grabbed his/her hand. The police interviewed the resident and the CNA. Nurse E had the CNA write a statement. Nurse E called the On-call Nurse Manager and reported the resident called the police because staff tried to put him/her to bed by force and grabbed his/her arm. It was very busy that night, and he/she should have called the Administrator and Director of Nursing to report the incident. During an interview on 10/19/23 at 1:00 P.M., On-call Nurse Manager B said he/she received a call from Nurse E around 9:00 P.M., on 10/12/23. Nurse E said the resident was upset with the CNA because he/she was busy next door and he/she wanted to be changed. The resident was hard to calm down and called the police to report the incident. Nurse E reported the resident had calmed down and the police did not think anything happened. Nurse E did not say the resident reported being injured, or the On-call Nurse Manager would have immediately reported the incident to the Administrator or Director of Nursing (DON). During an interview on 10/19/23 at 2:00 P.M., the Administrator said Nurse E and the On-call Nurse Manager should have notified him and/or the DON when the resident made the allegation of his/her arm being injured during the interaction with the CNAs. If the resident called the police to make an allegation, then the staff should have notified him or the DON about the incident, and they would have called or directed the staff to report it. MO00225823

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, it was determined the facility failed to conduct neurological checks following unwitnessed falls for 1 (Resident #75) of 4 residents who were reviewed for falls. Findings included: Review of the facility policy titled, Falls Management Program, dated August 2019, indicated, It is the policy of this facility to evaluate each resident immediately after a fall. Further review of the policy indicated, If the fall was unwitnessed or involved a potential head injury, initiate neurological assessment per the facility policy and/or refer to policy and procedure for suspected head injury. This was the only policy the facility provided related to neurological assessment following a fall. A review of Resident #75's Profile Face Sheet indicated the facility originally admitted the resident on 04/03/2020 and readmitted the resident on 07/30/2021 with diagnoses that included Parkinson's disease, type 2 diabetes mellitus with diabetic polyneuropathy, retention of urine, and orthostatic hypotension. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/2021, revealed the resident had a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required limited assistance of one staff member for transfers, walking in their room and corridor, and toilet use. The MDS indicated the resident was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, moving on and off a toilet, and during surface-to-surface transfers. A review of Resident #75's Care Plan, with a start date of 07/30/2021, revealed the resident was at risk for falls. Interventions directed staff to: - Consult with therapy regarding the resident's current functional status. - Obtain vital signs PRN (as needed) for dizziness or lightheadedness. - Answer call lights quickly. - Monitor out of bed activity and visually check every one to two hours. - Keep call bell and fluids within reach. - Provide continuous as needed safety reminders. - Assist the resident with ambulation, monitor signs and symptoms of Parkinson's disease and increasing tremors. - Keep the resident's room well-lit and clutter free. - Follow up with neurology. Further review of the resident's Care Plan revealed the resident had an unwitnessed fall on 07/25/2021 at 9:15 PM. The Care Plan indicated the resident was found on the floor in a supine position. The resident informed the staff that he/she had not hit their head. The Care Plan indicated that neurological checks would be initiated. The Care Plan revealed the resident also had unwitnessed falls on 07/25/2021 at 11:00 PM and on 07/26/2021 at 12:01 AM. The Care Plan entries did not indicate that neurological checks would be conducted for the two additional falls. Review of a discharge summary from a local hospital, dated 07/30/2021, revealed Resident #75 had been admitted to the hospital on [DATE]. During the imaging studies conducted at the hospital, it was determined the resident had a left subdural hematoma secondary to a fall. The discharge summary revealed the subdural hematoma did not require treatment. A review of Resident #75's medical record revealed no indication the facility had conducted neurological checks for the unwitnessed falls that occurred on 07/25/2021 and 07/26/2021. During an interview on 07/21/2023 at 12:55 PM, the Acting Administrator stated the facility did not have documented neurological checks that were completed after any of Resident #75's unwitnessed falls. The Director of Nursing was on leave and was unavailable for an interview. MO00212277

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, it was determined the facility failed to conduct a root cause analysis into resident falls to identify a potential accident hazard for 1 (Resident #75) of 4 residents reviewed for falls. Findings included: Review of the facility policy titled, Falls Management Program, dated August 2019, indicated, The intent of this requirement (F689) is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This includes: - Identify hazard(s) and risk(s); - Evaluate and analyze hazard(s) and risk(s); - Implement interventions to reduce hazard(s) and risk(s); - Monitor for effectiveness and modify interventions as indicated. A review of Resident #75's Profile Face Sheet indicated the facility originally admitted the resident on 04/03/2020 and readmitted the resident on 07/30/2021 with diagnoses that included Parkinson's disease, type 2 diabetes mellitus with diabetic polyneuropathy, retention of urine, and orthostatic hypotension. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/29/2021, revealed the resident had a Brief Interview for Mental Status score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident required limited assistance of one staff member for transfers, walking in their room and corridor, and toilet use. According to the MDS, the resident was not steady and was only able to stabilize with staff assistance when moving from a seated to standing position, walking, turning around, moving on and off a toilet, and during surface-to-surface transfers. A review of Resident #75's Care Plan, with a start date of 07/30/2021, revealed the resident was at risk for falls. Interventions directed staff to: - Consult with therapy regarding the resident's current functional status. - Obtain vital signs PRN (as needed) for dizziness or lightheadedness. - Answer call lights quickly. - Monitor out of bed activity and visually check every one to two hours. - Keep call bell and fluids within reach. - Provide continuous as needed safety reminders. - Assist the resident with ambulation, monitor signs and symptoms of Parkinson's disease and increasing tremors. - Keep the resident's room well-lit and clutter free. - Follow up with neurology. Further review of the resident's Care Plan, with a start date of 07/30/2021, revealed the resident was at risk for pressure ulcers and had pressure ulcers on the bilateral heels. An intervention indicated the resident was to wear pressure reducing boots when in bed. The Care Plan included entries indicating the resident had fourteen falls between 05/30/2021 and 06/07/2022. Five of the fall entries contained information indicating the resident was wearing pressure reducing boots when the resident fell as described below: - On 05/30/2021 at 7:00 PM, the resident was found on the floor on their back near the bathroom. The care plan entry indicated the resident was walking in [the resident's] boots. - On 06/07/2021 at 4:45 PM, the resident was found on the floor between their wheelchair and a recliner chair. The care plan entry indicated heel protectors were on. - On 07/25/2021 at 9:15 PM, the resident was found on the floor in a supine position. The resident asked the staff to take these boots off so they could use the bathroom. - On 10/21/2021 at 3:00 AM, the resident was found sitting on the floor with their back against the bed; the resident's pressure reducing boots were on. - On 11/23/2021 at 2:18 PM, the resident was found on the floor near their bed. The entry indicated Bilateral boots on. The care plan entries did not indicate if the resident was or was not wearing the pressure reducing boots when falls occurred on 07/01/2021, 07/25/2021 (11:00 PM), 07/26/2021, 11/24/2021, 12/10/2021, 01/12/2022, 01/29/2022, and 06/07/2022. Review of a discharge summary from a local hospital, dated 07/30/2021, revealed Resident #75 had been admitted to the hospital on [DATE]. During the imaging studies conducted at the hospital, it was determined the resident had a left subdural hematoma secondary to a fall. The discharge summary revealed the subdural hematoma did not require treatment. During an interview on 07/19/2023 at 2:13 PM, Licensed Practical Nurse (LPN) #22 stated the resident attempted to self-transfer. LPN #22 said the resident wore soft (pressure reducing) heel boots, which made transfers difficult. During an interview on 07/21/2023 at 12:55 PM, the Acting Administrator was asked if the interdisciplinary team had discussed the possibility that the pressure reducing boots were a causative factor for the resident's falls. She stated she thought the facility staff just looked at the pressure ulcers and falls as separate issues. She replied that staff did not make the connection that the interventions to prevent and treat pressure ulcers might be causing a fall risk. She added that it was not discussed. The Director of Nursing was on leave and was unavailable for an interview. MO00212277

Based on interview and record review, the facility failed to ensure newly hired employees were screened to rule out the presence of a Federal Indicator, with the Certified Nurse Aide (CNA) Registry, for four of 10 sampled employees hired since the last survey. The facility hired at least 300 new employees since the last survey. The census was 79. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property Policy, dated 8/2019, showed the following: -Policy: It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties; The objective of the abuse policy is to comply with the seven step approach to abuse and neglect detection and prevention; -Overview of seven components: -Screening; -Training; -Prevention; -Identification; -Investigation; -Protection; -Reporting and Response. -Screening Components: -Abuse Policy Requirements: It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check. 1. Review of Utility Aide A's employee file, showed the following: -Hire date: 9/1/22; -No CNA registry check performed. 2. Review of [NAME] B's employee file, showed the following: -Hire date: 11/3/22; -No CNA registry check performed. 3. Review of Server C's employee file, showed the following: -Hire date: 1/12/23; -No CNA registry check performed. 4. Review of Server D's employee file, showed the following: -Hire date: 4/27/23; -No CNA registry check performed. 5. During an interview on 7/26/23 at 12:54 P.M., the Administrator said the Human Resources Department should be checking the CNA registry. The Administrator said he nor they knew non-nursing staff needed to be checked on the CNA registry.

Based on interview and record review, the facility failed to ensure allegations of abuse were reported to the Department of Health and Senior Services (DHSS) after an allegation was made by one resident's (Resident #1) family member to facility management. The sample size was nine. The census was 86. Review of the facility's abuse prevention policy dated 10/2022, showed: -It is the policy of the facility to encourage and support all residents, staff and families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property and exploitation. All alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately to the Administrator. All owners, operators, employees, managers, agents or contractors must report to the state agency and one or more law enforcement entities any reasonable suspicion of a crime against an individual who is a resident of or is receiving care from a facility; *An immediate report, not later than two hours after forming a suspicion that the events resulted in serious bodily injury; *Not later than 24 hours if the event did not result in serious bodily injury; The nursing home administrator or designee will report abuse to the state agency per State and Federal requirements; -Physical abuse included but is not limited to hitting, slapping, punching, biting and kicking; -Alleged violation: Is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not been investigated and if verified could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property; -Immediately means as soon as possible but ought not to exceed 24 hours after discovery of the incident, in the absence of a short State time frame requirement; -198.070: Abuse or neglect of residents - reports, when, by whom-contents of report-failure to report, penalty-investigation, referral of complaint, removal of resident, investigations, when; 1. When any home care facility administrator or employee, nurse, social worker or other person with the care of a person sixty years of age or older has reason to believe that a resident of a facility has been abused or neglected, he or she shall immediately report or cause a report to be made to the department; 2. The report shall contain the name and address to the facility, the name of the resident, information regarding the nature of the abuse or neglect, the name of the complainant and any other information which might be helpful in an investigation; 3. Any person required to report or cause a report to be made to the department who knowingly fails to make a report within a reasonable time after the act of abuse or neglect as required in this subsection is guilty of a class A misdemeanor; -Reporting and Response: It is the policy of the facility that abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion allegations are reported per Federal and State Law. The facility will ensure that: *All alleged violations involving abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment and involuntary seclusion are reported immediately to the administrator; *All alleged violations of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment and involuntary seclusion must also be reported by the facility to officials in accordance with State Law, including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities: a. Immediately, but not later than two hours if the alleged violation involves abuse or results in serious bodily injury; b. Not later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property and does not result in serious bodily injury; c. Results of all investigations of alleged violations must be reported within five workings days of the incident; -If there is any reasonable suspicion of a crime against a resident or any other individual that receives care from the facility a covered individual must report to the State Survey Agency and one or more law enforcement entities; a. For serious bodily injury-immediately but not later than two hours after forming the suspicion; b. If no serious bodily injury, not later than 24 hours; -External Reporting: Facility initial reporting of allegation: For all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, the Administrator or designee will notify officials in accordance with State law, to include the State Survey Agency and adult protect services where state law provides for jurisdiction in long-term care facilities immediately but not later than two hours if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property and does not result in bodily injury. A follow up report of the results of the investigation will be submitted to the State Agency within five working days; -Covered individuals are obligated to comply with reporting requirements. If uncertain whether or not to report an incident, call the State Agency for further direction. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/23/22, showed: -Adequate hearing/vision; -Ability to express ideas and wants: Difficulty communicating; -Ability to understand others: Difficulty understanding; -Rejection of care: Exhibits rejection of care; -Extensive assistance of two person assist required for bed mobility, transfers, dressing and toilet use; -Mobility device: Wheelchair; -Diagnoses of Alzheimer's Disease, dementia, chronic obstructive pulmonary disease (lung disorder) and neurocognitive disorder with Lewy bodies (marked by dementia that occurs before or concurrently with Parkinsonism or within one year of onset of motor symptoms). Review of the resident's progress notes dated 11/12/22 at 9:50 P.M., showed the nurse was not able to to complete a skin check that was requested by the family due to the resident's refusal. The family had a video camera in the room. The family member called concerned because in the video, he/she heard a sound he/she thought could have been a slap. Then he/she heard the staff member say sorry. The family member also heard the resident say ouch. The family sent two videos to the nurse. The first video showed staff entered the resident's room and then a slapping sound could be heard when no staff were near the resident. Staff stated the resident said ouch when they were removing his/her pajamas and they apologized at that time. The family was updated of the findings. During an interview on 2/3/23 at 11:15 A.M., the resident's family member said he/she became aware of the alleged incident the afternoon of 11/12/22 after viewing the camera. He/She immediately emailed his/her concern along with the videos of the incident to the Director of Nursing (DON) and Social Worker C. He/she told the DON he/she believed the resident might have been slapped. The DON asked him/her why he/she immediately assumed the sound was a slap. The family member wanted the incident investigated. The DON explained about hearing the same sound in the first video, but the resident could actually be heard crying out in the second video after the loud slapping noise. The facility never provided him/her any information about the results of the investigation. The family member also spoke to Social Worker C the following week about his/her concerns and the social worker told him/her, he/she forwarded his/her concerns to administration and there was nothing more he/she could do. During an interview on 2/6/23 at 11:30 A.M., the DON said she immediately called the family member back after she received the email and voicemail messages on 11/12/22. She viewed the videos and could hear a noise on the first video that sounded like the same noise on the second video. Since the staff were not in the room on the first video, then the noise on the second video could have been the same noise and not caused by the staff. She interviewed two of the staff members who were in the bathroom with the resident in the videos and they said nothing happened. She did not write up a statement because she documented the information in the resident's nursing notes. She immediately notified the Administrator. She did not call the state because she did not think any abuse occurred. During an interview on 2/7/22 at 9:00 A.M., Social Worker C said he/she received two videos from the resident's family member on 11/12/22. The family member had a concern about an incident that happened that morning in the bathroom with the resident and several staff. The social worker got the videos on Saturday evening when he/she was off work and by the time he/she listened to them on Monday, he/she was told the DON had already investigated the incident and made the necessary contacts. During an interview on 2/9/23 at 10:00 A.M., the Administrator said the DON immediately looked into the family member's concern once it was brought to her attention and once investigated, they did not believe anything happened and did not think it needed to be reported to the State. MO00213458

Based on observation, interview and record review, the facility failed to follow their abuse and neglect policy and procedures when not all staff involved in the incident were interviewed, staff interviews were not included in the investigation, a skin assessment was not performed on the resident and alleged perpetrators were allowed to continue working with the residents during the investigation (Resident #1). These failures to conduct a thorough investigation and provide a safe environment during the investigation could impact all residents who make future abuse/neglect allegations. The sample size was nine. The census was 86. Review of the facility's Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident policy, dated 10/22, showed: -Definitions of Abuse and Neglect: -Physical abuse includes, but is not limited to, hitting, slapping, punching, biting and kicking; -Alleged violation: Is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and if, verified, could be noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property; -Abuse Policy: It is the policy of the facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, physical, misappropriation of property, exploitation, corporal punishment or involuntary seclusion. Additionally, residents will be protected from abuse, neglect and harm while they are residing at the facility. No abuse or harm will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in technique to protect all parties; -It is the policy of the facility that reports of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment and involuntary seclusion are promptly and thoroughly investigated; -Procedure: The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. The information gathered is given to administration; a. Investigation of abuse: When an incident or suspected incident of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment and involuntary seclusion is reported, the Administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include statements from all individuals to include: *Statement from individual reporting alleged abuse; *Residents statements - for nonverbal residents, cognitively impaired residents who refuse to be interviewed, attempt to interview the resident first. If unable, observe the resident, complete an evaluation of resident behavior, affect and response to evaluation and document findings; *All involved staff who have or may have witnessed the abuse; *A description of the resident's behavior and environment at the time of the incident; *Observation of resident and staff behaviors during the investigation *A complete and thorough documentation of the entire investigation; -While the investigation is being conducted, accused individuals not employed by the facility will be denied unsupervised access to the resident; -The Administrator will keep the resident or his/her resident representative informed of the investigation; -The results of the investigation will be documented and attached to the report; -The Administrator or human resources designee will complete a copy of the investigation materials; -The Administrator or designee will inform the resident and/or his/her representative of the findings of the investigation and corrective action taken; -Protection: It is the policy of the facility that the resident(s) will be protected from the alleged offenders; -Immediately upon receiving a report of alleged abuse, neglect, exploitation or residents, misappropriation of property, injuries of unknown origin or corporal punishment, the Administrator or designee will immediately protect the resident and coordinate delivery of appropriate medical and/or psychological care and attention; -Procedures must be in place to provide the resident with a safe, protected environment during the investigation; -The alleged perpetrator will immediately be removed and the resident protected. Employees accused of alleged abuse, neglect, exploitation or residents, misappropriation of property, injuries of unknown origin or corporal punishment shall be immediately removed from the facility and remain removed pending the results of a thorough investigation; -Examine, assess and interview the resident and other residents potentially affected immediately to determine any injury, complete a psychosocial assessment if needed and identify any immediate clinical interventions necessary. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/23/22, showed: -admission date of 8/18/22; -Adequate hearing/vision; -Ability to express ideas and wants: Difficulty communicating; -Ability to understand others: Difficulty understanding; -Rejection of care: Exhibits rejection of care; -Extensive assistance of two person assist required for bed mobility, transfers, dressing and toilet use; -Mobility device: Wheelchair; -Diagnoses of Alzheimer's Disease, dementia, chronic obstructive pulmonary disease (lung disorder) and neurocognitive disorder with Lewy bodies (dementia that occurs before or concurrently with Parkinsonism or within one year of onset of motor symptoms.) Review of the resident's care plan dated 2/3/22, located in the electronic medical record, showed: -Category: Cognitive loss/dementia: Problem: Resident has short term memory loss as a result of dementia. Has history of confusing other residents for family member and can be difficult to redirect. Ability to communicate needs has declined and needs increased time to respond to requests/instructions. Often talks nonsensensical; -Approach: Cue for daily routine as needed. Medications as ordered. Provide simple one to two step instructions; -Category: Communication: -Problem: Impaired cognition with Alzheimer's disease. Able to make basic needs known with a lot of cuing. Staff to anticipate needs and direct activities of daily living; -Approach: Speak clearly and slowly. Use props to emphasis activity. Enable resident to observe the activity involvement of others. May direct needs as indicated; -Category: Psychosocial: -Problem: Resident has behaviors that others may find disruptive/socially inappropriate. Behavior exhibited: Screaming, pushing staff away. May result in harm to resident. Other residents yell at resident to be quiet; -Approach: Intervene as needed as soon as behavior is noted, to ensure safety of residents and others. Gain attention of resident by using name and talk to him/her in a calm manner; -Category: Behavior: -Problem: Resident has a history of displaying inappropriate behavior and/or resisting care/services. Specific behaviors exhibited: History of lashing out by hitting, grabbing, scratching, yelling and cursing. Other risk factors: Easily startles and reacts to loud or sudden movements. Resident does best with a calm, soft approach and talking to him/her before initiating task; -Approach: Introduce self upon contact, make eye contact, approach from front, explain all procedures prior to beginning. During periods of inappropriate behavior, use a consistent, calm, firm approach. If resident is engaging in verbally abuse behavior of screaming, yelling at staff, remove to quiet calm area to speak in calm, comforting manner. If resistance continues during care, walk away and give resident time to calm down and reproach at a later time. Review of the resident's progress notes dated 11/12/22 at 9:50 P.M., showed the nurse was not able to complete a skin check requested by the family due to the resident's refusal. The family had a video camera in the room. The family member called concerned because in the video he/she heard a sound he/she thought could have been a slap. Then he/she heard the staff member say sorry. The family member also heard the resident say ouch. The family sent two videos to the nurse. The first video showed staff enter the resident's room and then a slapping sound could be heard when no staff were near the resident. Staff stated the resident said ouch when they were removing his/her pajamas and they apologized at that time. The nurse updated the family of the findings. During an observation and interview on 2/3/22 at 11:15 A.M., the resident's family member said he/she had installed video surveillance system in the resident's room to monitor his/her care. The family member requested to show the surveyor the video surveillance of the incident that occurred on the morning of 11/12/22. The family member said this was the same video provided to the Director of Nursing (DON) and Social Worker C on the day of the incident. The family member said the incident happened on the morning of 11/12/22 but he/she did not see it until later that afternoon. He/She immediately sent an email and voicemail to the DON and Social Worker C with the video footage. Review of the video dated 11/12/22, showed the following: -At 6:41 A.M., Certified Nursing Assistant (CNA) E, CNA F and CNA J can be seen walking outside Resident #1's bathroom. CNA F goes into the bathroom. CNA E goes to the dresser to get some clothing and CNA J stands by the bed looking at something on the wall. CNA E then enters the bathroom. A few seconds later CNA J enters the bathroom; -At 6:42 A.M., a loud slapping noise can be heard and the resident yelled out, Ow. Twenty seconds later a staff member can be heard saying, I'm sorry. Review of an e-mail from the family member sent to the DON, dated 11/12/22, no time noted, showed he/she discovered a worrisome event from that morning. He/She could only send brief videos but could show her the video in entirety. The first video was of all the staff who were in the bathroom with the resident. The second video was what sounded like a very loud slap and the resident crying out in pain. It appeared the loud sound or slap was applied to the resident. Review of the facility's typed, undated investigation provided by the facility on 2/3/23, showed the following: -The allegation was investigated by the DON when she became aware. The investigation was discussed by the DON with the family members; -The family member sent an email to Social Worker C and the DON at 6:42 P.M. on 11/12/22. It contained two clips. It also had a note that said among other things, I discovered a worrisome event from this morning. The family member commented he/she had spoken to the charge nurse but had not mentioned anything about the incident to him/her; -The film clip footage: The first clip was time stamped 11/12/22 at 6:41:36 A.M. and showed three aides walking into the resident's room/bathroom (CNA F, CNA E and CNA J). The clip lasted around three seconds. The second clip was time stamped 11/12/22 at 6:42:09 A.M. with no figures or motion in the bedroom. Thirty-three seconds of the film were missing between the first clip and the second; -The resident's family member contended there was a slapping noise in the second clip followed by the resident crying out. The DON watched and listened to both clips and noticed the same or very similar noise heard at the beginning of both clips. No one was near the resident in the first clip so it could not have been another slap; -The DON interviewed CNA E and CNA F. Both reported they did not hear a noise upon entering the resident's room or bathroom. CNA F said the resident did cry out when the CNA took the resident's shirt off, and he/she told the resident he/she was sorry. CNA F's voice can barely be made out after the resident cries out. CNA E also concurred that is what happened. CNA J was not available for interview; -The DON talked to the family member that evening and the family member agreed he/she could hear a similar sound in the first clip. The DON emailed Social Worker C and let him/her know he/she had talked to the family and the issue was resolved; -The administrator's name at the bottom of the form; -No documentation of written statements from CNA E, CNA F or CNA J; -No documentation of a skin assessment completed on the resident; -The investigation did not include an interview with CNA J who was in the bathroom during the alleged incident on 11/12/22. During an interview on 2/3/23 at 3:30 P.M., CNA F said CNA E asked for assistance on the morning of 11/12/22 because the resident was being combative and CNA F had a good rapport with the resident. When he/she arrived to the bathroom, the resident was seated on the toilet. The resident did not want to take his/her pajama top off, so he/she and CNA E each grabbed a side and pulled the shirt top off the resident. The resident was already yelling before they pulled the shirt off. This might have been when he/she yelled Ow. The resident tried to swing at CNA E. This was his/her regular behavior. This is why they needed two staff to work with him/her. After they took the resident's pajama top off, he/she calmed down and let them get him/her dressed. They immediately reported the incident to the nurse. CNA F had never been told there was an allegation about possible abuse about the incident. During an interview on 2/3/23 at 5:20 P.M., CNA E said he/she assisted the resident up that morning and put him/her on the toilet, but he/she started to become combative. This was normal behavior for the resident. He/She could hit, kick and slap at the staff. CNA E went to get CNA F because the resident liked him/her. The noise on the video was the sit to stand lift strap hitting the toilet. It made a slapping sound. When CNA F arrived to the room they assisted the resident off the toilet with no problem. CNA E was never told there was an allegation of potential abuse about the incident. During an interview on 2/6/23 at 11/15/23 A.M., the DON said he/she immediately called the family member back after he/she received the email and voicemail messages on 11/12/22. She viewed the videos and could hear a noise on the first video that sounded like the same noise on the second video. Since the staff were not in the room on the first video then the noise on the second video could have been the same noise, and not caused by the staff. She interviewed two of the staff members who were in the bathroom with the resident as seen in the videos, and they both said there were no problems with the resident. She did not interview the third CNA because both the other CNAs said nothing happened. She tried to perform a skin assessment on the resident, but he/she would not let her. She did not have the staff write up statements or write the statements herself because she documented the information in the resident's nursing notes. She did not send the staff home because he/she did not think any abuse occurred. She immediately notified the Administrator. She called the resident's family and notified them of the results of the investigation. During interviews with the resident's family member on 2/7/23 at 9:00 A.M. and on 2/8/22 at 10:30 A.M., he/she said he/she did not agree with the DON that the sound in the two video clips were the same. The resident could actually be heard crying out after the second sound. The family member was concerned because he/she saw CNA F working with the resident on the evening of 11/12/22, after the allegation had been made. He/she asked for a skin assessment to be done on the resident but never heard about the results if one was done. He/She did not think the situation was resolved and brought it to the attention of Social Worker C again the next week and was told it had been looked into and there was nothing they could do. During a telephone interview on 2/7/23 at 9:15 A.M., Social Worker C said the family member sent him/her an email and videos on Saturday, 11/12/22. He/she did not check his/her emails until Monday. The DON told him/her, she had investigated the incident and made all notifications. She thought it was handled. During a telephone interview on 2/9/23 at 10:05 A.M., the Administrator said the DON immediately began an investigation once the family emailed their concerns. They did not send the staff home because that would have affected other residents by not having enough staff for resident care. They did not interview the other staff member because he/she was in orientation and was not available when the DON was investigating the allegation. After the DON looked at the videos and talked to the staff, it was determined that nothing occurred. He thought the family was fine with the results of the investigation. MO00213458

Based on observation, interview and record review, the facility failed to ensure services met professional standards by failing to follow physician orders to have a resident wear a brace on his/her hand after lunch and at night. The staff also failed to ensure the resident was supervised and was provided a divided plate during meals (Resident #3). The sample size was nine. The census was 86. Review of the facility's Assisting Residents in Room with Meals policy dated 8/2019, showed: -The purpose of this procedure is to provide appropriate support for residents who need assistance with eating in their rooms; -Preparation: *Review the resident's care plan and provide for any special needs of the resident; *Check the tray before serving it to the resident to be sure it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow; *Ensure that the necessary non-food items (i.e., silverware, napkin, special devices, straw, etc) are on the tray. Report or replace missing items -Equipment/supplies: The following equipment and supplies will be necessary when performing this procedure: *Food service tray; *Silverware; *Special feeding devices (as indicated); *Wash cloth and towel. Review of Resident #3's change of condition Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/23/22, showed: -Moderately impaired vision; -Some difficulty hearing; -Usually understands; -Usually understood; -Extensive assistance of at least one person needed for bed mobility, transfers, dressing, toilet use and personal hygiene. -Diagnoses included history of stroke, heart failure, unspecified severe protein-calorie malnutrition and hereditary and idiopathic neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body for unknown reasons). Review of the resident's care plan, dated 1/22/23, showed: -Problem: Activities of Daily Living (ADL) Function Rehab: Resident needs supervision to limited assistance with ADLs due to impaired cognition and risk for falls, some confusion and delusion noted; -Approach: Eating set up; -Problem: Nutrition: Inadequate oral intake related to cognitive impairment, diminished appetite; -Approach: Provide diet per physician order; -Provide nutrition supplement per physician's orders; -Provide adaptive equipment to aid in self-feeding. Provide food in divided plate and beverages in cups with lids and straws; -Provide set up assistance with encouragement with meals. Provide resident with a clothing protector; -Problem: Resident had a episode of choking on 3/25/22, history of dysphagia (swallowing difficulties); -Approach: Set up and supervision with meals; -No documentation about a boxer's brace (hand splint) in care plan. Review of the resident's electronic physician order sheet (ePOS), showed: -An order for 11/16/22 for Diet Consistency: Mechanical soft - Open containers and cut up food; -An order dated 1/23/23, for a boxer's brace; apply to right hand for two hours after lunch then remove; -An order, dated 1/23/23, for a boxer's brace at bedtime; apply to right hand; off in morning. Review of the resident's electronic Treatment Administration Orders, showed: -On 1/24/23 at 4:23 P.M., the resident refused to wear the boxer's brace after lunch; -On 1/25/23 at 4:10 P.M., the treatment was not administered; -On 1/27/23 at 5:30 P.M., the treatment was refused. The resident stated he/she wanted to give his/her hand a rest; On 1/30/23 at 5:20 P.M., the resident refused the treatment. He/she stated it was not time to wear it; -On 1/31/23 at 5:11 P.M., the resident refused the treatment. He/she said it was not time to wear it; -On 2/1/23 at 4:49 P.M., the resident refused to wear the boxer's brace after lunch; -On 2/2/23 at 9:51 P.M., the resident refused to wear the boxer's brace after lunch. Observation on 2/6/23 between 6:00 A.M. and 8:50 A.M., showed the resident asleep in his/her bed. His/Her hand brace sat on the table at the foot of his/her bed. During an interview on 2/6/22 at 6:00 A.M., Nurse L said the resident did not always like to wear his/her brace and would take it off him/herself. Observation on 2/3/22 at 2:30 P.M., of a sign posted on the resident's wall, showed: -Aspiration precautions; -Supervise while eating and/or drinking; -Assist with cutting up food; -Alert: Resident is at high risk for aspiration/choking. Review of the resident's meal ticket on 2/6/22 at breakfast, showed: -Regular-Mechanical soft; -Adaptive Equipment: Cups with lids and straws and divided plate; -Clothing protector; -Fortified hot chocolate. Observation and interview on 2/6/23 at 9:00 A.M., showed a staff member brought a tray of food into the resident's room and sat it on his/her bedside table. The resident was in the restroom at the time. The tray contained a regular (not divided) plate with an omelet, a hashbrown and a piece of cake. There was a cup of cocoa without a lid and a cup of water with a lid and an unopened straw. The staff member sat the tray on the table and left the room. The staff member did not remove the plastic from the plate, cut up the food or open the straw and put it in the water. The resident removed the plastic from the plate. He/She was unable to use the fork and knife to cut up the food and ate all of the food with his/her hands. He/She spilled cocoa on his/her shirt because his/her hands shook when he/she took a drink. There was no clothing protector. The resident ate most of the cake, a few bites of the hashbrown and a few bites of the omelet. He/She drank some of the cocoa but did not drink any of the water. The resident said he/she usually ate meals in his/her room. He/She used to like to go to the dining room, but not so much any more. He/She found it harder to eat some of the food. During an interview on 2/6/22 at 11:25 A.M., the Director of Nursing (DON) said the resident did not always like to wear the brace. He/She would take it off him/herself or refuse to let staff put it on him/her. The DON had not notified the resident's physician this was occurring. The resident used to eat in the dining room but did not like to eat in there because he/she did not like his/her table mates. If he/she needed supervision, staff should have placed him/her at another table or provided supervision in his/her room. The resident should have been provided a divided plate. Staff should have helped cut up his/her food and opened his/her straws. Set up assistance usually depended on what the resident needed. Staff should provide a clothing protector if the resident needed or wanted one. During an interview on 2/6/22 at 11:45 A.M., the resident's family member said the resident used to like to eat in the dining room but was embarrassed because he/she spilled a lot of food on him/herself. He/She took pride in his/her appearance and was embarrassed at having to wear a clothing protector and not being able to eat food without dropping it on him/herself. He/She had trouble with his/her right hand and had to wear a brace. This was making it harder to cut up his/her food. He/She ate with his/her fingers because it was hard to use the silverware. Observation on 2/6/22 at 12:50 P.M., showed a staff member brought a tray to the resident's room and sat it on his/her bedside table. The meal was served on an undivided plate. During an interview on 2/9/23 at 10:25 A.M., the Administrator said the resident should have been wearing his/her brace as ordered unless he/she refused it. If the resident was taking the brace off or refusing to wear it, staff should document this and report it to the resident's physician. The resident should have had been supervised with his/her meals if it was in his/her care plan. If he/she did not like sitting in the dining room, a staff member should have stayed in his/her room while he/she ate. He/She should have had a divided plate with each meal. MO00213418

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement fall prevention interventions to ensure a bed alarm was on a bed and wheelchair as ordered, failed to notify the physician when the resident refused the alarms, failed to provide consistent directions in the care plan about the use of alarms, and failed to provide supervision in the bathroom for one resident who was at high risk for falls (Resident #3). The facility also failed to ensure staff followed the mechanical lift policy and transferred one resident (Resident #1) unsafely with one staff member on three separate occasions. The sample size was nine. The census was 86. 1. Review of the facility's Fall Prevention policy, dated 8/2019, showed: -Strategies for managing falls: -From bed-Unable to transfer: *Bed alarm to alert staff of position changes; *Check and change or offer toileting assist frequently; -Falls related to confusion: *Visual checks every one to two hours; *Consider use of bed alarm and/or chair alarms. Review of Resident #3's change of condition Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/23/22, showed: -Moderately impaired vision; -Some difficulty hearing; -Usually understands; -Usually understood; -Extensive assistance of at least one person needed for bed mobility, transfers, dressing, toilet use and personal hygiene; -Diagnoses included history of stroke, heart failure and hereditary and idiopathic neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body for unknown reasons). Review of the resident's Falls Risk assessment dated [DATE], showed the resident scored a 13. A score of 10 or greater equaled a high fall risk. Review of the resident's care plan dated 1/22/23, showed: -Category: Delirium: -Problem: Resident experienced delusion/hallucinations, has been agitated and anxious off and on; -Approach: Orient to room and surroundings as needed. Use simple direct communication. Minimize directions; -Category: Cognitive Loss/Dementia: -Problem: Impaired cognition related to possible medication, recent changes in environment. As evidenced by delusions, hallucinations, agitation, wandering and anxiety; -Approach: Give resident adequate time to respond. Reassure and redirect. Give simple and clear responses; -Category: Activities of daily living (ADL) Function Rehab: -Problem: Resident hospitalized due to multiple falls at home. Will need supervision to limited assistance with ADLs due to impaired cognition and risk for falls; -Approach: Bed mobility - one-person assistance; transfers - one-person assistance; toileting - Extensive one-person assistance, do not allow to sit on the toilet longer than five minutes at a time; -Category: Falls: -Problem: Resident displaying inattention and disorganized thinking, risk for fall due to recent falls; -Approach: Answer calls quickly; -Keep call bell, fluids, and personal items within reach; -Provide continuous as needed safety reminders; -On 3/17/22 at 11:10 A.M., staff found resident on floor in bathroom. Reeducated on call light for all needs; -On 3/23/22 at 6:35 P.M., staff found resident on floor next to bed. Interventions to continue with chair alarm due to resident unable to remember to use the call light. 7/12/22-alarm discontinued per family request; -On 4/19/22 at 8:13 P.M., staff observed resident seated on floor next to his/her bed. Interventions to continue assist, perimeter mattress, therapy and monitor medication changes and sleep patterns; -On 10/16/22 at 7:50 A.M., staff found the resident on his/her bathroom floor, on his/her left side. The resident stated, I slid on the floor. Intervention: Refer to physical and occupational therapy; -On 1/11/23 at 3:30 A.M., staff found the resident on the floor in the bathroom. The resident stated he/she slid to the floor. Intervention: Staff to stay with resident while on toilet. Physical and occupational therapy to evaluate and treat; -1/12/23 at 2:15 P.M., staff found the resident on the floor. He/she slid from the chair to the floor while trying to transfer him/herself to bed. Staff educated that resident should not be left in bathroom alone; -1/22/23 at 1:35 P.M., the resident fell when he/she attempted to transfer him/herself from the bed to the wheelchair. He/She stated his/her feet slid out from under him/her while he/she was trying to get into the chair. The resident has poor safety awareness. Staff should check the bed and chair alarm to make sure it is in place and functioning. Review of the resident's electronic Physician's Order Sheet dated 2/6/23, showed an order dated 1/23/23, to check the bed/chair alarm placement and function every shift at 7:00 A.M., 3:00 P.M. and 12:00 A.M. Review of the resident's progress notes, showed: -On 12/5/22 at 8:15 A.M., the resident was very weak. Staff almost could not get him/her up to transfer to the wheelchair and the toilet. The resident was trying hard to get up. The resident's lower left extremity gave out while staff were holding him/her with a gait belt and the staff member lowered him/her to the bed; -On 12/7/22 at 8:02 A.M., the resident was awake most of the night shift. He/She was up and down to the bathroom and wanting to get dressed. At times, the resident says his/her legs are giving out and he/she has to sit down; -On 12/12/22 at 2:39 A.M., the resident appeared very weak. He/She required heavy assistance of one with gait belt with transfers to and from the bed and on and off toilet; -On 12/15/22 at 12:49 A.M., the resident was on his/her call light at 11:30 P.M., to go to the bathroom. The resident remains weak and requires one to two person assistance for transfers; -On 12/27/22 at 3:32 A.M., staff found the resident on the floor while doing rounds. The resident was lying on the floor next to his/her bed. The resident said he/she slid out of the bed while trying to go to the bathroom. Staff performed an assessment on the resident and gave him/her an ice pack. He/She had a 2.5 centimeter by 0.5 cm bruise on the left side of his/her head. He/She denied pain, headache, dizziness or blurred vision. Staff assisted him/her off the floor and back to bed. Staff instructed him/her on the use of the call light and verbalized the importance of calling for assistance before getting out of bed to prevent falls after leaving the bathroom and slid to the floor. Staff assessed the resident and he/she had an abrasion to his/her left buttock; -On 1/8/23 at 10:00 P.M., the resident's family member called to report the resident was taking him/herself to the bathroom without assistance and not using the call light, so at times no one is aware he/she is in the bathroom; -On 1/11/23 at 4:22 A.M., staff heard the resident shouting for help and found him/her lying on the floor in the bathroom. The resident said he/she slid to the floor while transferring self to the bathroom. Resident did not use his/her call light. Staff reminded resident to use call light with help with activities of daily living. At 10:01 P.M., the resident was unable to transfer off the toilet with help of only one staff member. CNA requested help from another staff member; -On 1/12/23 at 5:40 P.M., staff heard the resident yelling and found the resident on the floor next to his/her bed with his/her pants around his/her knees. The resident stated he/she had been putting him/herself to bed; -On 1/23/23 at 1:19 P.M., the resident was up in his/her wheelchair. He/She was assist of one person for transfers. The wheelchair and bed alarm were unplugged. At 4:11 P.M., staff heard the resident yelling and found him/her between the bed and the wheelchair. The resident said he/she was trying to get into the chair to go to the bathroom. Staff assessed him/her for injuries and noted bruises and abrasions to his/her lower left leg. He/She was assisted from the floor by the staff. At 10:34 P.M., the resident remained on fall observation. He/She has a bed alarm that goes off even when he/she is not moving in bed. He/She asked the staff to disconnect it, which they did. Observation and interview on 2/3/23 at 11:50 A.M., showed the resident in the bathroom with his/her wheelchair and with no staff present. There was no alarm on his/her wheelchair or on his/her bed. At 12:00 P.M., he/she came out of the bathroom unassisted. The resident said he/she did not call for help because he/she did not want to bother the staff. He/She can do things on his/her own. During an interview on 2/3/23 at 12:09 P.M., Certified Nursing Assistant (CNA) M said he/she did not know where the resident's bed alarm was. The CNA knew the resident was supposed to have an alarm on his/her bed but did not know if he/she was supposed to have one on his/her wheelchair. During an interview on 2/3/23 at 12:20 P.M., the Director of Nursing (DON) said the resident did not like the wheelchair alarm and so the staff had disconnected it. Observation on 2/3/23 at 1:50 P.M., showed the resident in the bathroom on the toilet with no staff present. At 2:00 P.M., a staff member came in the room and asked if he/she was okay and left the room when he/she replied he/she was okay. At 2:10 P.M., the resident continued to be in the bathroom on the toilet, unassisted with no staff present. At 2:15 P.M., the resident came out of the bathroom unassisted. During an interview on 2/3/23 at 2:15 P.M., the resident said he/she did not ask for assistance to the bathroom because he/she did not want to bother staff. He/She did not ask for assistance at night because there was not a lot of staff at night and it could take a while for staff to get him/her up at night. He/She denied falling out of bed and said he/she slid out of bed because the mattress was so smooth. He/She/she did not like the alarm because it made a lot of noise and the staff did not always respond to it right away. He/She did not know where the bed and chair alarm were located. Further review of the resident's progress notes, showed on 2/5/23 at 5:42 P.M., staff found the resident on the floor with his/her back against the bed and his/her wheelchair next to him/her. Observations on 2/6/23 between 6:20 A.M. and 8:45 A.M., showed the resident in bed asleep with no bed alarm on the bed. During an interview on 2/6/23 at 6:25 A.M., Nurse L said he/she did not see the bed alarm on the bed. It had not gone off all night so it was not in the bed like it was supposed to be. The resident kept taking it off, so they needed to remove it from his/her care plan. The nurse did not know where the bed alarm was at. During an interview on 2/6/23 at 11:20 A.M., the DON said she thought the family had previously asked for the alarm to be discontinued when the resident was not falling. The resident recently started having falls again. The resident did not like using the alarms. No one had called the physician to let him know the resident did not like the alarms and did not always use them. She thought they had put the alarms back on the bed but not on the wheelchair. She knew the staff were supposed to provide supervision for the resident but did not always know when the resident was going to the restroom because he/she would not let them know. The DON had not discussed this with the resident's physician. They had tried to tell the resident to call for help if he/she needed it, but he/she kept getting up by him/herself to go to the bathroom. Observation and interview on 2/6/23 at 11:30 A.M., showed the DON checked the resident's bed and the alarm was not on the bed. The DON could not locate the bed or wheelchair alarm. During an interview on 2/6/23 at 11:50 A.M., the resident's family member said they had concerns about his/her falls. They had requested the bed and wheelchair alarms and had not asked that they be removed. The resident was becoming more confused and would forget to ask for help and would fall when he/she transferred out of or into his/her bed. The family member was concerned the resident did not like the alarm because staff did not respond to it quickly enough, and the noise bothered him/her. During an interview on 2/9/23 at 10:05 A.M., the Administrator said if the resident had an order for the bed and wheelchair alarms, staff should have been using them unless the resident was refusing them. If the resident refused to use them, then staff should have notified the family and the resident's physician and documented this. If the resident had an intervention in her care plan for supervision while in the bathroom, staff should have stayed close by to provide assistance. 2. Review of the facility's Mechanical lift policy, dated 8/19, showed: -Policy: To ensure safe and appropriate transfer techniques for residents per regulatory guidelines and professional standards of practice; -Purpose: To transfer a resident using mechanical means. To help prevent resident and staff injury; -Supplies: Mechanical lift, sling, two staff members; -Procedure: Sit to stand lift: To be transferred with sit to stand lift, the resident must have no medical contradictions for using the lift. The resident should have the following characteristics: *Alert; *Predictable and cooperative behavior; *Able to follow simple commands; *Can at least partially bear weight and hold on to the hand grips; *Able to lean back into the sling. Review of Resident #1's quarterly MDS, dated [DATE], showed: -Adequate hearing/vision; -Ability to express ideas and wants: Difficulty communicating; -Ability to understand others: Difficulty understanding; -Rejection of care: Exhibits rejection of care; -Extensive assistance of two persons required for bed mobility, transfers, dressing and toilet use; -Mobility device: Wheelchair; -Diagnoses of Alzheimer's disease, dementia, chronic obstructive pulmonary disease (lung disorder) and neurocognitive disorder with Lewy bodies (dementia that occurs before or concurrently with Parkinsonism or within one year of onset of motor symptoms). Review of the resident's care plan dated 2/3/22, located in the electronic medical record, showed: -Category: Cognitive loss/dementia: Problem: Resident has short term memory loss as a result of dementia. Has history of confusing other residents for family member and can be difficult to redirect. Ability to communicate needs has declined and needs increased time to respond to requests/instructions. Often talks nonsensensical; -Approach: Cue for daily routine as needed. Medications as ordered. Provide simple one to two step instructions; -Category: Communication: -Problem: Impaired cognition with Alzheimer's disease. Able to make basic needs known with a lot of cuing. Staff to anticipate needs and direct activities of daily living; -Approach: Speak clearly and slowly. Use props to emphasis activity. Enable resident to observe the activity involvement of others. May direct needs as indicated; -Category: Psychosocial: -Problem: Resident has behaviors that others may find disruptive/socially inappropriate. Behavior exhibited: Screaming, pushing staff away. May result in harm to resident. Other residents yell at resident to be quiet; -Approach: Intervene as needed as soon as behavior is noted to ensure safety of residents and others. Gain attention of resident by using name and talk to him/her in a calm manner; -Category: Behavior: -Problem: Resident has a history of displaying inappropriate behavior and/or resisting care/services. Specific behaviors exhibited: History of lashing out by hitting, grabbing, scratching, yelling and cursing. Other risk factors: Easily startles and reacts to loud or sudden movements. Resident does best with a calm, soft approach and talking to him/her before initiating task; -Approach: Introduce self upon contact, make eye contact, approach from front, explain all procedures prior to beginning. During periods of inappropriate behavior, use a consistent, calm, firm approach. If resident is engaging in verbally abuse behavior of screaming, yelling at staff, remove to quiet calm area to speak in calm, comforting manner. If resistance continues during care, walk away and give resident time to calm down and reapproach at a later time During an observation and interview on 2/3/22 at 11:15 A.M., the resident's family member said he/she had installed video surveillance in the resident's room to monitor his/her care. The resident's family member requested to show the surveyor the video surveillance of sit to stand lift transfers completed by various staff. Review of the videos showed the following: -On 12/6/22 at 7:21 P.M., the resident's bathroom door opened and CNA I pushed the resident out of the door on a sit to stand lift. The CNA pushed the resident over to his/her bed, lowered him/her onto the bed and removed the belt from around his/her waist. There were no other staff observed in the room during this transfer; -On 1/23/23 at 6:58 A.M., the resident was seated on his/her bed with the sit to stand lift in front of him/her. CNA K lifted the resident up off the bed with the lift and transferred him/her in the lift over to his/her wheelchair. There were no other staff in the room during this transfer; -On 2/5/23 at 5:57 A.M., the resident was seated on his/her bed with the sit to stand lift in front of him/her. CNA E put the belt around the resident's waist and attached it to the lift. The resident put his/her right hand on the lift but not his/her left hand. The CNA lifted the resident up to a standing position. He/she attempted to get the resident to put his/her left hand on the handle by placing the resident's hand on it, but the resident would not cooperate and removed his/her hand. The CNA pushed the resident into the bathroom. There were no other staff in the room during this transfer. Review of an email by the resident's family on 2/9/23 at 8:10 A.M., showed he/she had been worried about the resident's safety during the transfers, and he/she had previously recorded staff conducting transfers alone. The family member had provided this video footage to the DON because of the unsafe practices of not buckling the resident into the lift and the resident not holding onto the lift with both hands. The DON told him/her they had work to do and it would not be done overnight. During an interview on 2/6/23 at 2:00 P.M., the DON viewed the videos of staff using the sit to stand lift alone. The DON identified CNA I, CNA K and CNA E as the staff in the videos. She said these were inappropriate lifts. Per policy, all mechanical lifts should be completed with two staff present. The use of one staff person could put the resident at risk for injury or a fall. During an interview on 2/9/23 at 10:20 A.M., the Administrator said all mechanical lifts should be performed with two staff members present. MO00213418 MO00213458

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to keep the water temperatures between 105 to 120 degrees Fahrenheit (°F). This affected eight resident rooms where 14 residents resided. The facility census was 84. 1. Review of the hot water temperature logs showed: - On 9/12/19 the water temperatures ranged from 87 to 114 °F; - On 9/19/19 the water temperatures ranged from 106 to 110 °F; - On 9/25/19 the water temperatures ranged from 106 to 110 °F; - On 10/3/19 the water temperatures ranged from 108 to 112 °F; - None of the hot water temperatures were taken out of a resident's room. Observation and interview on 10/9/19, at 2:00 P.M., showed six hot water heaters in the utility room all set to 140 °F. Two circulation pumps were in line with the hot water. The Maintenance Supervisor said the six hot water heaters were daisy chained together and work together to keep the hot water temperatures where they needed to be. They kept the hot water temperatures at 140 °F and the hot water temperature test always came back right where they need to be. Observation on 10/10/19, starting at 12:38 P.M., showed: -At 12:38 P.M., the hot water temperature from the sink in room [ROOM NUMBER] was 121.2 °F.; -At 12:42 P.M., the hot water temperature from the sink in room [ROOM NUMBER] was 136.6 °F.; -At 12:53 P.M., the hot water temperature from the sink in room [ROOM NUMBER] was 124.1°F.; - At 12:58 P.M., the hot water temperature from the sink in room [ROOM NUMBER] was 102.0 °F.; -At 1:06 P.M., the hot water temperature from the sink in room [ROOM NUMBER] was 134.9 °F.; -At 1:09 P.M., the hot water temperature from the sink in room [ROOM NUMBER] was 130.4 °F.; -At 1:12 P.M., the hot water temperature from the sink in room [ROOM NUMBER] was 138.8 °F.; -At 1:16 P.M., the hot water temperature from the sink in room [ROOM NUMBER] was 137.1 °F. During an interview on 10/10/19, at 4:07 P.M., Maintenance Worker (MW) A said he/she checked the water with an infrared thermometer and not a metal stemmed thermometer. During an interview on 10/11/19, at 09:32 A.M. and 1:30 P.M., the Maintenance Supervisor said: - They found out one of the two circulation pumps (used to keep the hot water evenly circulated around the facility) had failed. - They also were in the process of fixing their mixing valve (used to regulate water temperatures). - MW A checked the water temperatures weekly. He did not know MW A used an infrared gun to check the water temperatures. For hot water temperatures, metal stemmed thermometers are more accurate. - The hot water heaters were set at 140 °F, but since they fixed the mixing valve, they have been able to drop the temperatures of the hot water tanks down to 125 °F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility staff failed to establish a policy that provided guidance about labeling, dating, and disposing of food brought to residents from outside sources. Facility staff failed to store food under sanitary conditions when they failed to dispose of expired milk, failed to label the contents of food stored in one-time use containers and place a disposal date on any food item brought into the facility. This deficient practice had the potential to affect 31 residents who receive food from the nutrition center that serves residents of [NAME] Avenue and Main Street. The facility census was 84. Review of the Food Safety Requirements-Use and Storage of Food and Beverage Brought in for Residents, Food Procurement policy dated 08/19 showed: - It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food including those brought to residents by family and other visitors. - All residents have the right to accept food brought to them by family or visitor(s). Further review of the policy showed no guidance provided about labeling, dating, and disposing of food brought to residents. Observation on 10/10/19 at 7:13 A.M., showed the following inside the refrigerator located in the Nutrition Center that serves residents of [NAME] Avenue and Main Street: - Milk labeled by the manufacturer with the expiration date of 10/7/19; - A white soup-like liquid in a restaurant container labeled with Resident #47's name and dated 9/25/19. The label did not identify the contents of the container; - A single-use water bottle contained an unknown pink pudding thick substance labeled with the name of Resident #80. The label did not contain a date or identify the contents. Observation on 10/11/19 at 7:33 A.M., showed the following inside the refrigerator located in the Nutrition Center that serves [NAME] Avenue and Main Street. - A white soup-like liquid in a restaurant container labeled with Resident #47's name and dated 9/25/19. The label did not identify the contents of the container; - A single-use water bottle contained an unknown pink pudding thick substance labeled with the name of Resident #80. The label did not contain a date or identify the contents. During an interview on 10/11/19 at 1:12 P.M., the Dietary Manager said nursing staff are responsible for ordering, labeling and maintaining the food in the nutrition centers. During an interview on 10/11/19 at 1:39 P.M., Licensed Practical Nurse (LPN) C said each day a certified medication technician (CMT) is assigned to ensure items are not out of date in the refrigerator. During an interview on 10/11/19 at 1:42 P.M., CMT A said the CMT who puts the stock away in the nutrition centers, checks for expired items and ensures new items are dated. If an item is expired it is thrown away. He/she does not know how long an item should be kept after it has been opened. During an interview on 10/11/19 at 1:53 P.M., CMT B said the evening shift is responsible to clean out the refrigerator. The daily schedule shows which CMT is responsible for disposing of expired food items. Food is labeled with the date opened and disposed of after 24 hours. Milk is disposed of after 3-4 days. During an interview on 10/11/19 at 2:05 P.M., CMT B said he/she spoke to his/her supervisor and his/her supervisor said the assigned evening CMT cleaned out the nutrition center refrigerator each night. During an interview on 10/11/19 at 3:22 P.M., the Director of Nursing said she expected the evening CMT to dispose of expired food. If food is brought in for a resident, the food should be disposed of within 48 hours. She expects staff to label the container with the resident's name and the date and time the food is brought into the facility. The food should be stored in the original container or a reclosable plastic bag. If the food is in a one-time use container, the label should indicate the contents of the container. Items labeled with a manufacturer's expiration date should be disposed of by the date labeled. During an interview on 10/11/19 at 3:33 P.M., the Administrator said the evening shift is responsible for disposing of old items. He expects food brought in from an outside source to be labeled with the date when it is brought into the facility. The food needed to be in a sealed airtight container labeled with the resident's name and the contents. The food should be disposed of within two days of the date an outside source brought it into the facility. The container should be microwave safe, disposable, and not a reused container. Food items labeled by the manufacturer with an expiration date should be disposed of by the date on the label.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility staff failed to ensure all hoses that extended below the flood plain had a backflow preventer (an anti-siphon device used to keep potentially toxic water from backing up into the potable water supply). This affected three of four shower hoses. The facility census was 84. Observation on 10/9/19, starting at 3:52 P.M., showed shower hoses extended below the flood plain (the hose length extended all the way to the floor): -No backflow preventer on the shower hose in the shower room next to room [ROOM NUMBER] (Main Street). -No backflow preventer on the shower hose in the shower room next to room [ROOM NUMBER] ([NAME] Avenue). -No backflow preventer on the shower hose in the shower room next to room [ROOM NUMBER] (Grand Avenue). During an interview on 10/11/19, at 1:30 P.M., the Maintenance Supervisor said he did not realize hoses that extended below the flood plain were required to have a backflow preventer.