1. Please refer to event ID YO6F12, exit date 03/26/25, for details. Based on record review and interview, the facility failed to protect each resident's right to be free from misappropriation of proper when narcotic pain medications for one resident (Resident #3) went missing while in the possession of the facility staff. The facility census was 71. Review of the facility's policy titled Administering Pain Medications, dated October 2022, showed the following: -Document in the resident's medical record results of the pain assessment, medication, dose, route of administration, and results of the medication; -Report other information in accordance with facility policy and professional standards of practice. Review of the facility's policy titled Medication Orders, dated February 2023, showed the following: -Medications included in the Drug Enforcement Administration (DEA) classification of controlled substances (drug or chemical whose manufacture, possession, and use are regulated by a government), and mediation classified as controlled substance by state law, are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations; -Before a controlled drug can be dispensed, the pharmacy must be in receipt of a prescription from a person lawfully authorized to prescribe; -The Director of Nursing (DON) and the contracted consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications; -Only authorized, licensed nursing and pharmacy personnel have access to controlled medications; -Controlled substance medications are dispensed by the provider pharmacy in readily accountable quantities and containers designed for easy counting of contents; -The pharmacy will include an individual resident controlled drug record (count sheet) for each controlled substance medication container dispensed to a resident if the facility so desires; -Alternatively, the facility may utilize a bound book in place of count sheets; -The following information is completed up dispensing or upon receipt of the controlled substance: resident's name, prescription number, drug name, strength, and dosage for of medication, date received, quantity received, and the name of person receiving the medication supply; -If the facility uses a bound book in lieu of the pharmacy count sheets, all of this information will be completed by a licensed nurse at the facility; -At each change of custody (shift change or exchange of keys) all on-hand controlled medication quantities shall be counted by two nurses and reconciled with the count sheets; -This shall be documented by completing a Controlled Drug Count Form indicating the date and time the physical count was completed; -Any discrepancies shall be reported to the charge nurse and the DON immediately; -With the nurse supervisor present, the discovering nurse should place a signed entry on the resident controlled drug record where the discrepancy was detected; -If it is something other than a mathematical error, the DON should provide assistance with the investigation and resolving the discrepancy; -Controlled substance medications are stored at the facility under double lock on the medication cart or medication room separate from all other medications. 1. Review of Resident #3's face sheet (brief information sheet about the resident) showed the following: -admission date of 10/04/24; -Diagnoses included rhabdomyolysis (medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream), multiple fractures of ribs, pain, muscle weakness, and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). Review of the resident's care plan, dated 10/18/24, showed the following: -Resident received as needed pain medication therapy related to rhabdoymyolysis, rib fractures, and occasional generalized pain; -Staff should administered analgesic (pain) medications as ordered by physician; -Staff should monitor and document side effects and effectiveness every shift; -Staff should notify physician if medication does not control pain to tolerable level. Review of the resident's Physician Order Sheet (POS), current as of 03/26/25, showed an order, dated 10/04/24, for morphine sulfate ER (drug used to treat moderate to severe pain), oral tablet extended release 30 milligrams (mg), give one tablet by mouth two times per day for multiple fracture of ribs. Review of the resident's March 2024 Medication Administration Record (MAR), showed staff documented administration of morphine sulfate ER 30 mg every day in the morning and at bedtime from 03/01/25 to 03/26/25. Review of the pharmacy consolidated delivery sheets, dated 03/10/25, showed morphine sulfate ER 30 mg tablets, quantity of 60 tablets, received for the resident. Review of the controlled medication logbook on the medication cart showed the following: -On 03/10/25, staff documented there was 9 tablets of morphine sulfate and the pharmacy delivered 60 tabs. The total at the end of shift was 69 tablets; -On 03/16/25, the resident had 57 tablets of morphine sulfate. When the evening shift completed the change of shift count there were only 27 tablets of morphine sulfate in the cart; -On 03/24/25, the pharmacy delivered 30 tablets of morphine sulfate; -On 03/26/25, at 1:55 P.M., there were 38 tablets of morphine sulfate in the cart when reviewed with nurse. Review of the facility's Investigation Report, dated 03/18/25, showed the following information: -On 03/16/25, at 10:10 P.M., the Administrator received a call from Licensed Practical Nurse (LPN) B that the narcotic count for the resident showed there was 30 tablets of morphine sulfate missing; -Staff searched the medication cart and medication room. The medication was not located; -Police department notified on 03/17/25; -Notified pharmacy to report and request they send replacement for the missing medication and to bill the facility; -LPN F's statement, dated 03/16/25, showed the LPN worked 4 ½ hour shift, from 5:30 P.M. to 10 P.M. The nurse was rushing during the count at the beginning of shift and was unsure if the count was actually correct at that time; -LPN A's statement, dated 03/17/25, showed he/she counted medications on beginning of shift on 03/15/25 evening and end of shift on 03/16/25 morning. The count was correct at those time. When he/she worked the day shift on 03/17/25, he/she was informed by the night shift nurse that the count was off by 30 tablets. During an interview on 03/26/25, at 10:45 A.M., LPN A said the narcotic count was completed at the beginning and end of every shift. If the count was incorrect staff should notify the DON and administrator immediately. During an interview on 03/26/25, at 11:35 A.M., LPN B said the process for narcotics included the off-going nurse taking the narcotic book and the on-coming nurse taking the narcotic drawer to complete the shift count. Staff start by going through all of the tablets and then they count the liquids. If the narcotic count was not correct staff were to immediately contact the supervisor and staff do not leave the facility until the supervisor approved. During an interview on 03/26/25, at 1:55 P.M., LPN D said that if the log and tablets do not match during shift change, staff are to call management and have to stay at the facility until approved to leave. During an interview on 03/26/25, at 2:15 P.M., the Assistant Director of Nursing (ADON) said staff should complete a narcotic count during each shift change. If an error was found, staff were to contact management immediately. During an interview on 03/26/25, at 2:20 P.M., the DON said she expected the staff to follow facility policy. During an interview on 03/26/25, at 2:40 P.M., the Administrator said when she was notified of narcotic count discrepancy on 03/16/25 around 10:00 P.M. by LPN B. The medication cart and medication room were searched, and the narcotic was not located. The nursing staff did not have any knowledge of where the narcotics could be. The Administrator expected staff to complete narcotic counts accurately with every shift change. If the count was not accurate the staff were to notify the DON and Administrator immediately for further instructions. MO00251335

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Please refer to event ID YO6F12, exit date 03/26/25, for details. Based on observation, record review, and interview, the facility failed to promote and facilitate each residents right to self-determination when staff failed to honor four residents' (Resident #1, #2, #3, and #4) shower preferences. The facility census was 71. Review of the facility's policy titled Bath, Shower/Tub, dated February 2018, showed the following information: -The purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Document the date and time the shower/tub bath was performed; -Document the name and title of the individual who assisted the resident; -Document all assessment data obtained during the shower/tub bath; -Document if the resident refused the shower/tub bath and the reason; -Notify the supervisor if the resident refused the shower/tub bath. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following: -admission date of 07/22/20; -Diagnoses included multiple sclerosis (chronic, autoimmune disease that affects the central nervous system (brain and spinal cord)), spastic hemiplegia (paralysis or severe weakness) affecting left dominant side on the left side of the body, chronic pain syndrome, and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 03/03/25, showed the following: -Cognitively intact; -Resident was totally dependent on staff for showering, toileting hygiene, and lower body dressing; -Resident required substantial to maximal assistance of staff for upper body dressing and personal hygiene. Review of the resident's nursing progress notes dated 03/03/25, at 5:26 P.M., showed the resident was totally dependent on staff for toileting and bathing, and substantial assistance to dependent on staff for dressing and grooming. Due to his/her impairment the resident required total assistance for mobility in bed and transfers. He/she was unable to ambulate. Review of the resident's care plan, last updated 03/17/25, showed staff did not care plan regarding the resident's need for shower assistance and his/her shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive Certified Nurse Aide (CNA) Shower Review, showed the following: -On 03/05/25, staff documented resident received a shower, fingernail care, and shaved. Staff stripped off the resident's linen, wiped down bedding, and made bed with clean linen. Staff noted no new skin concerns. A CNA and licensed practical nurse (LPN) signed the form. -On 03/18/25 (13 days after prior shower), staff documented resident received a shower and shaved. Fingernail care was not needed. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 10:20 A.M., showed the resident was in his/her bed. He/she said Tuesday and Friday were his/her scheduled shower days. His/her last shower was over one week ago. Before last week it had been over two weeks since his/her last shower. He/she felt terrible, dirty, and worried about smell without a shower twice per week. 2. Review of Resident #2's face sheet, showed the following: -admission date 05/08/23; -Diagnoses included atrial fibrillation (condition where the upper chambers of the heart (atria) beat irregularly and rapidly), glaucoma (condition of increased pressure within the eyeball, causing gradual loss of sight), need for assistance with personal care, and muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Resident required partial to moderate assistance of staff for showering, toileting hygiene, lower body dressing, upper body dressing and personal hygiene. Review of the resident's care plan, updated 12/20/24, showed staff did not care plan related the resident's need for assistance with showers or shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/02/25, staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/05/25, staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/12/25 (seven days after prior shower), staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 11:25 A.M., showed the resident was seated in his/her recliner. He/she said his/her last shower was over two weeks ago. He/she was offered a shower before his/her leg was broken, but it was going to be done by a man, and he/she did not want a man to complete the shower. He/she wrote dates down when he/she a shower, but was unable to find the last date. He/she felt dirty without being shower routinely. 3. Review of Resident #3's face sheet, showed the following: -admission date 10/04/24; -Diagnoses included rhabdomylosis (medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream), multiple fractures of ribs, muscle weakness, pain, and need for assistance with personal care. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Resident was totally dependent on staff for toileting hygiene; -Resident required staff assistance for set up or clean up of personal hygiene; -Resident required partial to moderate assistance for upper body dressing; -Resident required substantial to maximal assistance for showering and lower body dressing. Review of the resident's care plan, updated 01/21/25, showed the following: -Resident required assistance with activities of daily living (ADL's) related to limited mobility and pain; -Resident required dependent to max assistant with shower transfers and full body showering; -Resident required max to dependent assist of two staff for transfer to/from toilet, dependent for toilet hygiene and clothing management, and incontinent care of bowels. Resident had Foley catheter (a tube that is inserted into the bladder, allowing urine to drain freely) and dependent for catheter care. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/03/25, staff documented resident received a shower and fingernail care. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/06/25, staff documented resident received a shower and fingernail care was refused. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/13/25 (7 days after prior shower), staff documented resident received a shower and toenail care was not provided. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 10:52 A.M., showed the resident was in his/her wheelchair near the nursing station. The resident said he/she usually received a shower twice per week, but was unsure when he/she last received a shower. He/she really liked when he/she did receive a shower twice per week. 4. Review of Resident #4's face sheet, showed the following: -admission date 09/07/18; -Diagnoses included cerebral infarction (stroke), hemiplegia (complete paralysis on one side of the body) and hemiparesis (milder form of weakness on one side) affecting unspecified side, anxiety disorder, and chronic pain syndrome. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Resident was totally dependent on staff for toileting hygiene; -Resident required substantial to maximal assistance for showers and lower body dressing; -Resident required set up or clean up assistance from staff for upper body dressing; -Resident required supervision or touching assistance from staff for personal hygiene. Review of the resident's care plan, updated 01/21/25, staff did not care plan regarding shower assistance or the resident's shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/03/25, staff documented resident received a shower and fingernail and toenail care provided. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/06/25, staff documented resident received a shower and fingernail care. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/10/25, staff documented resident received a shower and fingernail care not needed. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/17/25 (seven days after prior shower), staff documented resident received a shower and fingernail care not provided with toenail care provided by podiatrist. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/24/25 (seven days after prior shower), staff documented resident received a shower and fingernail care not provided with toenail care provided by podiatrist. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 11:00 A.M., showed the resident in his/her room in a wheelchair. The resident said he/she was only getting one shower per week, but preferred two per week. He/she a shower this Monday, 03/24/25, but felt it was only because he/she had a doctor's appointment. He/she was embarrassed when he/she had not received a shower and especially embarrassed to go to the doctor without a shower. The shower aide was frequently being pulled to work the floor. 5. During an interview on 03/26/25, at 10:00 A.M., CNA E said that there was only one shower aide that was not working this day. He/she said very few residents were receiving two showers per week. During an interview on 03/26/25, at 1:40 P.M., CNA C said that he/she was not told that any residents needed a shower. There was one shower aide and that he/she was not working this day. The shower aide had the shower schedule. During an interview on 03/26/25, at 11:20 A.M., LPN A said residents were not receiving showers twice per week. One shower aide recently quit and there was only one shower aide for the entire facility. During an interview on 03/26/25, at 11:35 A.M., LPN B said there was currently only one shower aide in the facility, but there was no one working as a shower aide this day. The residents were not receiving two showers per week. During an interview on 03/26/25, at 1:55 P.M., LPN D said he/she knew that residents were not receiving showers twice per week. There was only one shower aide for the facility and the aide was not working this day. During an interview on 03/26/25, at 2:15 P.M., the Assistant Director of Nursing (ADON) said there was a recent turn over and only one full time shower aide was working. He/she called in on this day. Until another shower aide could be hired or assigned, the home planned to start having the floor aides provide showers as well. During an interview on 03/26/25, at 2:20 P.M., the Director of Nursing (DON) said the expectation was for residents to receive two showers per week and if a resident refused a shower they would have to sign the shower sheet. MO00251410, MO00251648

Based on record review and interview, the facility failed to protect each resident's right to be free from misappropriation of proper when narcotic pain medications for one resident (Resident #3) went missing while in the possession of the facility staff. The facility census was 71. Review of the facility's policy titled Administering Pain Medications, dated October 2022, showed the following: -Document in the resident's medical record results of the pain assessment, medication, dose, route of administration, and results of the medication; -Report other information in accordance with facility policy and professional standards of practice. Review of the facility's policy titled Medication Orders, dated February 2023, showed the following: -Medications included in the Drug Enforcement Administration (DEA) classification of controlled substances (drug or chemical whose manufacture, possession, and use are regulated by a government), and mediation classified as controlled substance by state law, are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations; -Before a controlled drug can be dispensed, the pharmacy must be in receipt of a prescription from a person lawfully authorized to prescribe; -The Director of Nursing (DON) and the contracted consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications; -Only authorized, licensed nursing and pharmacy personnel have access to controlled medications; -Controlled substance medications are dispensed by the provider pharmacy in readily accountable quantities and containers designed for easy counting of contents; -The pharmacy will include an individual resident controlled drug record (count sheet) for each controlled substance medication container dispensed to a resident if the facility so desires; -Alternatively, the facility may utilize a bound book in place of count sheets; -The following information is completed up dispensing or upon receipt of the controlled substance: resident's name, prescription number, drug name, strength, and dosage for of medication, date received, quantity received, and the name of person receiving the medication supply; -If the facility uses a bound book in lieu of the pharmacy count sheets, all of this information will be completed by a licensed nurse at the facility; -At each change of custody (shift change or exchange of keys) all on-hand controlled medication quantities shall be counted by two nurses and reconciled with the count sheets; -This shall be documented by completing a Controlled Drug Count Form indicating the date and time the physical count was completed; -Any discrepancies shall be reported to the charge nurse and the DON immediately; -With the nurse supervisor present, the discovering nurse should place a signed entry on the resident controlled drug record where the discrepancy was detected; -If it is something other than a mathematical error, the DON should provide assistance with the investigation and resolving the discrepancy; -Controlled substance medications are stored at the facility under double lock on the medication cart or medication room separate from all other medications. 1. Review of Resident #3's face sheet (brief information sheet about the resident) showed the following: -admission date of 10/04/24; -Diagnoses included rhabdomyolysis (medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream), multiple fractures of ribs, pain, muscle weakness, and osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down). Review of the resident's care plan, dated 10/18/24, showed the following: -Resident received as needed pain medication therapy related to rhabdoymyolysis, rib fractures, and occasional generalized pain; -Staff should administered analgesic (pain) medications as ordered by physician; -Staff should monitor and document side effects and effectiveness every shift; -Staff should notify physician if medication does not control pain to tolerable level. Review of the resident's Physician Order Sheet (POS), current as of 03/26/25, showed an order, dated 10/04/24, for morphine sulfate ER (drug used to treat moderate to severe pain), oral tablet extended release 30 milligrams (mg), give one tablet by mouth two times per day for multiple fracture of ribs. Review of the resident's March 2024 Medication Administration Record (MAR), showed staff documented administration of morphine sulfate ER 30 mg every day in the morning and at bedtime from 03/01/25 to 03/26/25. Review of the pharmacy consolidated delivery sheets, dated 03/10/25, showed morphine sulfate ER 30 mg tablets, quantity of 60 tablets, received for the resident. Review of the controlled medication logbook on the medication cart showed the following: -On 03/10/25, staff documented there was 9 tablets of morphine sulfate and the pharmacy delivered 60 tabs. The total at the end of shift was 69 tablets; -On 03/16/25, the resident had 57 tablets of morphine sulfate. When the evening shift completed the change of shift count there were only 27 tablets of morphine sulfate in the cart; -On 03/24/25, the pharmacy delivered 30 tablets of morphine sulfate; -On 03/26/25, at 1:55 P.M., there were 38 tablets of morphine sulfate in the cart when reviewed with nurse. Review of the facility's Investigation Report, dated 03/18/25, showed the following information: -On 03/16/25, at 10:10 P.M., the Administrator received a call from Licensed Practical Nurse (LPN) B that the narcotic count for the resident showed there was 30 tablets of morphine sulfate missing; -Staff searched the medication cart and medication room. The medication was not located; -Police department notified on 03/17/25; -Notified pharmacy to report and request they send replacement for the missing medication and to bill the facility; -LPN F's statement, dated 03/16/25, showed the LPN worked 4 ½ hour shift, from 5:30 P.M. to 10 P.M. The nurse was rushing during the count at the beginning of shift and was unsure if the count was actually correct at that time; -LPN A's statement, dated 03/17/25, showed he/she counted medications on beginning of shift on 03/15/25 evening and end of shift on 03/16/25 morning. The count was correct at those time. When he/she worked the day shift on 03/17/25, he/she was informed by the night shift nurse that the count was off by 30 tablets. During an interview on 03/26/25, at 10:45 A.M., LPN A said the narcotic count was completed at the beginning and end of every shift. If the count was incorrect staff should notify the DON and administrator immediately. During an interview on 03/26/25, at 11:35 A.M., LPN B said the process for narcotics included the off-going nurse taking the narcotic book and the on-coming nurse taking the narcotic drawer to complete the shift count. Staff start by going through all of the tablets and then they count the liquids. If the narcotic count was not correct staff were to immediately contact the supervisor and staff do not leave the facility until the supervisor approved. During an interview on 03/26/25, at 1:55 P.M., LPN D said that if the log and tablets do not match during shift change, staff are to call management and have to stay at the facility until approved to leave. During an interview on 03/26/25, at 2:15 P.M., the Assistant Director of Nursing (ADON) said staff should complete a narcotic count during each shift change. If an error was found, staff were to contact management immediately. During an interview on 03/26/25, at 2:20 P.M., the DON said she expected the staff to follow facility policy. During an interview on 03/26/25, at 2:40 P.M., the Administrator said when she was notified of narcotic count discrepancy on 03/16/25 around 10:00 P.M. by LPN B. The medication cart and medication room were searched, and the narcotic was not located. The nursing staff did not have any knowledge of where the narcotics could be. The Administrator expected staff to complete narcotic counts accurately with every shift change. If the count was not accurate the staff were to notify the DON and Administrator immediately for further instructions. MO00251335

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide care that met professional standards quality for one resident (Resident #2) from a sample of 13 residents. Facility staff failed to accurately transcribe the resident's physician orders on admission. The facility census was 74. Review of the facility policy titled Administering Medications, dated April 2019, showed the following: -The Director of Nursing (DON) services supervises and directs all personnel who administer medications and/or have related functions; -If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's attending physician, or the facility's medical director to discuss the concerns; -Each nurses' station has a current Physician's Desk Reference (PDR - comprehensive reference book that compiles information about prescription drugs available, including details like dosage, side effects, and indications) and/or other medication reference; -Manufacturer's instructions or user's manuals related to any medication administration devices are kept with the devices or at the nurses' station. Review of the facility's checklist titled admission Checklist, undated, showed the following: -admission medications verified by physician and pharmacy notified; -Orders entered correctly; -Admitting nurse and date; -Items requiring follow-up; -Nurse completing form and date. Review of Resident #2's face sheet (a brief information sheet about the resident), showed the following: -admission date of 01/24/25; -Diagnoses included aftercare following joint replacement surgery (post-operative care and monitoring that a patient receives after undergoing a joint replacement procedure), osteoarthritis (type of arthritis (painful inflammation and stiffness of the joints that occurs when flexible tissue at the ends of bones wears down) of left knee, and osteoporosis (condition in which bones have lost minerals-especially calcium-making them weaker, more brittle, and susceptible to fractures (broken bones)). Review of the resident's baseline care plan, dated 01/24/25, showed staff noted see physician orders for medications. Review of the resident's hospital Discharge summary, dated [DATE], showed an order for alendronate (used to prevent and treat osteoporosis), 70 milligrams (mg) by mouth, one tablet every seven days. Review of the resident's Physician Order Sheet (POS), dated 01/31/25, showed an order, dated 01/24/25, for alendronate sodium oral tablet 70 mg, give one tablet by mouth in the morning for osteoporosis related to unilateral primary osteoarthritis, left knee. Review of the resident's medical record showed the following: -On 01/24/25, at 2:26 P.M., a system note showed alendronate sodium oral tablet 70 mg, give one tablet by mouth in the morning for osteoporosis related to primary osteoarthritis of left knee was outside of the recommended dose or frequency. The dosing regimen of 1 tablet daily exceeded the usual dosing regimen of 0.5 tablet every 7 days to 0.67 tablet daily. Review of the resident's medical record showed staff did not document addressing the system notice related to the medication dosage. Review of the resident's medical record showed an administration note date 01/25/25, at 9:45 A.M., showed alendronate 70 mg, give one tablet in the morning for osteoporosis related to primary osteoarthritis of left knee was not available and nurse notified. Review of the resident's January 2025 Medication Administration Record (MAR) showed the following: -On 01/25/25, staff documented alendronate was not administered due to medication not available; -On 01/26/25, staff documented alendronate was not administered due medication not available; Review of the resident's Physician Order Sheet (POS), dated 01/31/25, showed the prior order for alendronate was discontinued. A new order, dated 01/27/25, with start date of 02/02/25, for alendronate sodium oral tablet 70 mg, give one tablet in the morning every one week on Sunday. Review of the resident's January 2025 Medication Administration Record (MAR) showed the following: -On 01/27/25, staff documented the alendronate was administered. During an interview on 02/06/25, at 11:00 A.M., Certified Medication Tech (CMT) A said if he/she had any concerns related to a medication order, he/she would talk to the charge nurse and the DON. If there was a medication error, it was to be reported to the charge nurse and DON. The nurse would contact the physician and the family. When preparing and administering medications for residents he/she followed the orders in the MAR for medication administration. During an interview on 02/06/25, at 11:40 A.M., Licensed Practical Nurse (LPN) C said the charge nurse entered physician orders from the hospital discharge summary and notified the physician for approval before residents received medications. Chart audits were done by management, but he/she did not know when that was completed. The pharmacy completed a medication review at least once per month. The pharmacy would send recommendations by fax and the nursing staff notified the physician to review the recommendations and make changes according to the physician's order. If there was a medication error, staff was to complete the medication error sheet, notify the DON and the physician, and follow any physician orders. During an interview on 02/10/25, at 2:50 P.M., LPN E said that he/she usually was on the medication cart and the charge nurse was the one to enter orders for new admissions. There was a new admission checklist. Once the hospital sent the discharge summary, the charge nurse would send it to the physician to review and approve orders. The nurse would enter and he/she would help review the orders entered when available. He/she said when entering orders a screen will pop up if there was a drug to drug interaction alert or other warning about the drug. The nurse had to sign off on that page when it popped up. During an interview on 02/06/25, at 11:25 A.M., Registered Nurse (RN) B said when a new resident was admitted , the charge nurse on shift should enter the hospital discharge medication orders in the computer system and notify the physician for review. He/she would send the list to the pharmacy to fill the medications. Once the admission was completed the DON or Assistant Director of Nursing completed chart audits. If notified of a medication error, he/she would notify the physician for orders, and notify the DON and Administrator. During an interview on 02/11/25, at 3:35 P.M., LPN H said when he/she received a new admission, he/she would look for the hospital discharge final orders and go through the orders with the resident being admitted if the resident was alert, and verify that they seemed familiar to the resident. He/she would then verify the orders with the physician. Once the orders were entered into the computer, he/she would put the admission packet in the medical records box and was told that a copy was given to the administration staff to verify. If he/she was aware of a medication error, he/she would notify the physician and the family. He/she would monitor the resident for 72 hours and notify the physician of any issues. He/she would complete a risk management form, like an incident report. When he/she worked, if a CMT told him/her that something looked inaccurate on the MAR, he/she would thoroughly check into and investigate. He/she said it was not uncommon for him/her to find and fix errors. During an interview on 02/10/25, at 4:30 P.M., LPN C and RN B both said the nurse getting the order from the physician would enter it into the electronic system onto the POS. If the system detected a problem with the dosing amount/time, an allergy, or a conflict with another current medication, a warning message will pop up on the screen stating the information. The nurse should see the message before continuing. A warning symbol would then appear next to the medication on the POS. When administering medications, the warning does not pop up on the MAR, but the nurse or medication technician could check the warning box for the medication on the POS. During an interview on 02/06/25, at 11:50 A.M., the Interim DON said typically the charge nurse would put new physician orders into the computer and there would be a chart audit. The facility had gotten behind on chart audits. The nurse will now have the next shift nurse review the order entries because there had been some orders entered wrong. She was not aware of any outcome or medication errors due to the incorrect order entry. During an interview on 02/06/25, at 2:15 P.M., the Corporate Nurse said the best practice for new resident admissions would be for the charge nurse to enter the orders from the hospital discharge summary and then to reconcile once entered into the computer. Staff should ask someone else to check their data entry of the orders. The interim DON should be doing chart audits. During an interview on 02/06/25, at 1:55 P.M., the Administrator said when a charge nurse received a new resident admission he/she should review and enter the orders from hospital discharge summary. The physician visited with the new resident as soon as possible. She was not aware if staff were completing chart audits after new admission. There had been three DONs in the past four months. MO00249050

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to promote and facilitate each residents right to self-determination when staff failed to honor four residents' (Resident #1, #2, #3, and #4) shower preferences. The facility census was 71. Review of the facility's policy titled Bath, Shower/Tub, dated February 2018, showed the following information: -The purpose of the procedure was to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Document the date and time the shower/tub bath was performed; -Document the name and title of the individual who assisted the resident; -Document all assessment data obtained during the shower/tub bath; -Document if the resident refused the shower/tub bath and the reason; -Notify the supervisor if the resident refused the shower/tub bath. 1. Review of Resident #1's face sheet (brief information sheet about the resident) showed the following: -admission date of 07/22/20; -Diagnoses included multiple sclerosis (chronic, autoimmune disease that affects the central nervous system (brain and spinal cord)), spastic hemiplegia (paralysis or severe weakness) affecting left dominant side on the left side of the body, chronic pain syndrome, and anxiety disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 03/03/25, showed the following: -Cognitively intact; -Resident was totally dependent on staff for showering, toileting hygiene, and lower body dressing; -Resident required substantial to maximal assistance of staff for upper body dressing and personal hygiene. Review of the resident's nursing progress notes dated 03/03/25, at 5:26 P.M., showed the resident was totally dependent on staff for toileting and bathing, and substantial assistance to dependent on staff for dressing and grooming. Due to his/her impairment the resident required total assistance for mobility in bed and transfers. He/she was unable to ambulate. Review of the resident's care plan, last updated 03/17/25, showed staff did not care plan regarding the resident's need for shower assistance and his/her shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive Certified Nurse Aide (CNA) Shower Review, showed the following: -On 03/05/25, staff documented resident received a shower, fingernail care, and shaved. Staff stripped off the resident's linen, wiped down bedding, and made bed with clean linen. Staff noted no new skin concerns. A CNA and licensed practical nurse (LPN) signed the form. -On 03/18/25 (13 days after prior shower), staff documented resident received a shower and shaved. Fingernail care was not needed. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 10:20 A.M., showed the resident was in his/her bed. He/she said Tuesday and Friday were his/her scheduled shower days. His/her last shower was over one week ago. Before last week it had been over two weeks since his/her last shower. He/she felt terrible, dirty, and worried about smell without a shower twice per week. 2. Review of Resident #2's face sheet, showed the following: -admission date 05/08/23; -Diagnoses included atrial fibrillation (condition where the upper chambers of the heart (atria) beat irregularly and rapidly), glaucoma (condition of increased pressure within the eyeball, causing gradual loss of sight), need for assistance with personal care, and muscle weakness. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Resident required partial to moderate assistance of staff for showering, toileting hygiene, lower body dressing, upper body dressing and personal hygiene. Review of the resident's care plan, updated 12/20/24, showed staff did not care plan related the resident's need for assistance with showers or shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/02/25, staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/05/25, staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/12/25 (seven days after prior shower), staff documented resident received a shower and fingernail care was not provided. Staff stripped off bed linen, wiped down bed, and made bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 11:25 A.M., showed the resident was seated in his/her recliner. He/she said his/her last shower was over two weeks ago. He/she was offered a shower before his/her leg was broken, but it was going to be done by a man, and he/she did not want a man to complete the shower. He/she wrote dates down when he/she a shower, but was unable to find the last date. He/she felt dirty without being shower routinely. 3. Review of Resident #3's face sheet, showed the following: -admission date 10/04/24; -Diagnoses included rhabdomylosis (medical condition characterized by the breakdown of muscle tissue, leading to the release of harmful substances into the bloodstream), multiple fractures of ribs, muscle weakness, pain, and need for assistance with personal care. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Resident was totally dependent on staff for toileting hygiene; -Resident required staff assistance for set up or clean up of personal hygiene; -Resident required partial to moderate assistance for upper body dressing; -Resident required substantial to maximal assistance for showering and lower body dressing. Review of the resident's care plan, updated 01/21/25, showed the following: -Resident required assistance with activities of daily living (ADL's) related to limited mobility and pain; -Resident required dependent to max assistant with shower transfers and full body showering; -Resident required max to dependent assist of two staff for transfer to/from toilet, dependent for toilet hygiene and clothing management, and incontinent care of bowels. Resident had Foley catheter (a tube that is inserted into the bladder, allowing urine to drain freely) and dependent for catheter care. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/03/25, staff documented resident received a shower and fingernail care. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/06/25, staff documented resident received a shower and fingernail care was refused. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/13/25 (7 days after prior shower), staff documented resident received a shower and toenail care was not provided. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 10:52 A.M., showed the resident was in his/her wheelchair near the nursing station. The resident said he/she usually received a shower twice per week, but was unsure when he/she last received a shower. He/she really liked when he/she did receive a shower twice per week. 4. Review of Resident #4's face sheet, showed the following: -admission date 09/07/18; -Diagnoses included cerebral infarction (stroke), hemiplegia (complete paralysis on one side of the body) and hemiparesis (milder form of weakness on one side) affecting unspecified side, anxiety disorder, and chronic pain syndrome. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Resident was totally dependent on staff for toileting hygiene; -Resident required substantial to maximal assistance for showers and lower body dressing; -Resident required set up or clean up assistance from staff for upper body dressing; -Resident required supervision or touching assistance from staff for personal hygiene. Review of the resident's care plan, updated 01/21/25, staff did not care plan regarding shower assistance or the resident's shower preferences. Review of the facility's shower sheets titled Skin Monitoring: Comprehensive CNA Shower Review, showed the following: -On 03/03/25, staff documented resident received a shower and fingernail and toenail care provided. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/06/25, staff documented resident received a shower and fingernail care. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/10/25, staff documented resident received a shower and fingernail care not needed. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/17/25 (seven days after prior shower), staff documented resident received a shower and fingernail care not provided with toenail care provided by podiatrist. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form; -On 03/24/25 (seven days after prior shower), staff documented resident received a shower and fingernail care not provided with toenail care provided by podiatrist. Staff stripped the bed linen, bed wiped down the bed, and made the bed with clean linen. Staff noted no new skin concerns. A CNA and LPN signed the form. Review of the resident's record, on 03/26/25, showed no additional showers and no shower refusals. Observation and interview on 03/26/25, at 11:00 A.M., showed the resident in his/her room in a wheelchair. The resident said he/she was only getting one shower per week, but preferred two per week. He/she a shower this Monday, 03/24/25, but felt it was only because he/she had a doctor's appointment. He/she was embarrassed when he/she had not received a shower and especially embarrassed to go to the doctor without a shower. The shower aide was frequently being pulled to work the floor. 5. During an interview on 03/26/25, at 10:00 A.M., CNA E said that there was only one shower aide that was not working this day. He/she said very few residents were receiving two showers per week. During an interview on 03/26/25, at 1:40 P.M., CNA C said that he/she was not told that any residents needed a shower. There was one shower aide and that he/she was not working this day. The shower aide had the shower schedule. During an interview on 03/26/25, at 11:20 A.M., LPN A said residents were not receiving showers twice per week. One shower aide recently quit and there was only one shower aide for the entire facility. During an interview on 03/26/25, at 11:35 A.M., LPN B said there was currently only one shower aide in the facility, but there was no one working as a shower aide this day. The residents were not receiving two showers per week. During an interview on 03/26/25, at 1:55 P.M., LPN D said he/she knew that residents were not receiving showers twice per week. There was only one shower aide for the facility and the aide was not working this day. During an interview on 03/26/25, at 2:15 P.M., the Assistant Director of Nursing (ADON) said there was a recent turn over and only one full time shower aide was working. He/she called in on this day. Until another shower aide could be hired or assigned, the home planned to start having the floor aides provide showers as well. During an interview on 03/26/25, at 2:20 P.M., the Director of Nursing (DON) said the expectation was for residents to receive two showers per week and if a resident refused a shower they would have to sign the shower sheet. MO00251410, MO00251648

Based on record review and interview, the facility failed to ensure a written transfer agreement with a hospital was in effect to ensure residents timely admission to the hospital when medically appropriate and that information would be exchanged between providers. This has the potential to effect all the residents. The facility census was 74. Review showed the facility did not provide a policy pertaining to written transfer agreements with a hospital or a written transfer agreement with a community hospital. During interviews on 02/10/25, at 1:30 P.M. and 2:10 P.M., the Regional Director of Operations said he/she was not aware of the federal requirement for the facility to have a written transfer agreement with a hospital. Staff could not locate a written transfer agreement with a hospital. During an interview on 02/10/25, at 2:00 P.M., the Regional Nurse Consultant (RNC) said he/she was unaware of the federal requirement for a written transfer agreement with one or more hospitals. The RNC said the facility made a determination on which hospital to send a resident to based on the specific medical condition and the hospitals had always accepted their residents. During an interview on 02/10/25, at 5:00 P.M., the Administrator said he/she had not been able to locate a written transfer agreement.

Based on interview and record review, the facility failed to maintain an effective infection control program including screening all staff for tuberculosis (TB - a contagious infection that usually attacks the lungs) as required when the facility failed to ensure the first and second step of the two-step tuberculin skin test (TST) was completed prior resident contact for three staff members (Registered Nurse (RN) A, Certified Medication Tech (CMT) B, and Licensed Practical Nurse (LPN) C), failed to ensure the TB test was read within 48 to 72 hours from placement for one staff (CMT B), and failed to complete a second step TB test for one staff (RN A), of 10 sampled staff members. The facility census was 67. Review of the facility policy Employee Screening for Tuberculosis, dated March 2021, showed the following: -All employees are screened for latent tuberculosis infection (LTBI - infected with TB but not active TB) and active tuberculosis disease, using tuberculin skin test or interferon gamma release assay (IGRA - blood test to determine if exposed to TB) and symptom screening prior to beginning employment; -Each newly hired employee is screened for LTBI and active TB disease after an employment offer has been made but prior to the employee's duty assignment; -Screening includes a baseline test for LTBI using either a TST or IGRA, individual risk assessment, and symptom evaluation; -If the baseline test is negative and the individual risk assessment indicates no risk factors for acquiring TB, then no additional screening is indicated; -If the baseline test is positive, but the individual risk assessment is negative and the individual is asymptomatic, a second test is conducted; -The employee health coordinator will accept documented verification of TST or IGRA results within the preceding 12 months. Review of the Center for Disease Control (CDC) Guidelines, dated 04/10/24, title Tuberculosis Skin Test, showed the following: -The tuberculin skin test is one method of determining whether a person is infected with mycobacterium tuberculosis (the specific bacteria that causes tuberculosis); -It is performed by injecting 0.1 milliliter (ml) of tuberculin purified protein derivative (PPD) into the inner surface of the forearm; -The skin test reaction should be read between 48 and 72 hours after administration by a health care worker trained to read TST results; -A patient who does not return within 72 hours will need to be rescheduled for another skin test. Review of 19 CSR 20-20.100 showed the following: -Long-term care employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD two)-step tuberculin test within one month prior to starting employment in the facility. -If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. -It is the responsibility of each facility to maintain a documentation of each employee ' s and volunteer ' s tuberculin status. 1. Review of RN A's personnel record showed the following: -Date of hire of 08/01/23; -The first step TB test was administered on 08/02/23 and read on 08/04/23 (three days after the RN's hire/start date). -Staff did not document a second step administered or a prior history of prior test in the prior two years. 2. Review of CMT B's personnel record showed the following: -Date of hire of 05/31/23; -The first step TB test was administered on 05/31/23 and read on 06/01/23 (24 hours later and after the CMT's hire/start date). -The second step TB test was administered on on 06/14/23 and read on 06/16/23. 3. Review of LPN C's personnel record showed the following: -Date of hire of 12/19/23; -The first step TB test was administered on 02/06/24 and read on 02/09/24 (a month and a half after the LPN's hire/start date). -The second step TB test was administered on 02/16/24 and read on 02/19/24. -Staff did not document other TB testing documented in the preceding two years. 4. During an interview on 09/17/24, at 12:45 P.M., LPN D said that newly hired staff have TB testing placed and read by the nursing staff. The TB test should be read 48 to 72 hours after placement for accurate results. 5. During an interview on 09/17/24, at 2:00 P.M., LPN E said that newly hired staff have TB placed and read by the one of the nurses. The TB test is read 48 to 72 hours after placement and a second step is then repeated 10 days after the reading of the first step. 6. During an interview on 09/17/24, at 2:15 P.M., the Director of Nursing (DON) and Regional Nurse Consultant (RNC), the RNC said that new hire TB testing should be started before staff can work on the floor with residents. The TB test is generally read 24 to 48 hours after placement and a second test is completed one to two weeks after the first step. 7. During an interview on 09/17/24, at 2:35 P.M., with the Administrator and Interim Administrator, the Interim Administrator said staff should have TB testing on hire, with the first step completed before working with residents. The TB test should be read 48 to 72 hours after placement and the second step should be done within 21 days. The facility did not have additional test results documented for the reviewed staff.

Based on interview and record review, the facility failed to ensure all residents, or resident representatives, received written notice of transfer when staff failed to provide a written notice of discharge to one resident (Resident #56), of one sampled resident, or his/her representative, for a facility initiated emergent hospital transfers. Review of the facility's Discharge Policy, dated 2021, showed the policy did not address written transfers notice. 1. Review of Resident #56's face sheet, located in the electronic medical record (EMR) under the Resident tab, showed the following: -admission date of 06/27/24; -Diagnoses included chronic respiratory failure with hypoxia (low oxygen levels). Review of the resident's Progress Note, located in the EMR under the Progress Note tab, showed the following: -The resident was sent to the emergency room for increased anxiety, complaints of extreme back pain, and difficulty with breathing. -The resident was admitted to the Intensive Care Unit (ICU) for chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems). -Staff did document regarding, or have a copy of, a written transfer provided to the resident and/or representative. During an interview on 09/04/24, at 6:53 A.M., Licensed Practical Nurse (LPN) 5 said he/she did not complete a transfer/discharge summary to provide to the resident and/or representative when a resident discharges to the hospital. During an interview on 09/05/24, at 4:30 P.M., the Administrator agreed a transfer/discharge summary should be provided to all residents upon discharge. She confirmed the resident and/or the representative did not receive a transfer/discharge summary when she was sent to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a new Preadmission Screening and Resident Review (PASARR) Level l assessment was submitted after a new mental illness diagnosis for two (Resident #20 and #42) out of five residents reviewed for PASARR. 1. Review of Resident #20's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 10/09/18; -readmission date of 04/19/24; -Diagnoses included unspecified mood affective disorder (mental disorder characterized by dramatic changes or extremes of mood) and major depressive disorder. Review of the resident's PASARR Level l, located under the Diagnosis tab in the EMR and dated 05/14/20, showed no mental illness diagnosis. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an assessment reference date (ARD) of 05/01/24 and located under the MDS tab of the EMR, showed the resident had no cognitive impairment and an active diagnosis of psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions.) and depression. Review of of the resident's Care Plan, located under the Care Plan tab of the EMR and dated 01/23/23, showed staff care planned regarding the resident being verbally aggressive to staff members. Review of the resident's Diagnosis List, located under the Diagnosis tab in the EMR, showed unspecified mood affective disorder was diagnosed on [DATE] and major depressive disorder was diagnosed on [DATE]. Review of of the resident's Initial Psychiatric Evaluation, located under the Diagnosis tab in the EMR and dated 06/01/23, showed the resident's physician requested an evaluation due to resident's increased paranoia. A new diagnosis of mood disorder was added. Review of the resident's Physician Orders, located under the Orders tab in the EMR dated 08/01/24, showed an order for olanzapine (an antipsychotic medication) 0.5 milligrams (mg) tab once daily for psychotic disorder. Staff did not have a copy of, or document completion of, a new Level l PASSAR was with the mental health diagnoses. 2. Review of Resident #42's Face Sheet, located in the Profile tab of the EMR, showed the following: -admission date of 07/31/20; -readmission date of 03/29/24; -Diagnoses included major depressive disorder, generalized anxiety disorder, panic disorder, bipolar II disorder (defined by a pattern of depressive episodes and hypomanic episodes), alcohol abuse, and opioid dependence. Review of the resident's PASARR Level l, located under the Diagnosis tab in the EMR dated 08/30/20, showed no mental illness diagnosis. Review of the resident's Psychiatric Follow-up, located under the Diagnosis tab in the EMR dated 05/04/23, showed the resident reported a suicide attempt and had a new diagnosis of bipolar disorder. Review of the resident's annual MDS, with an ARD of 09/18/23 and located under the MDS tab of the EMR, showed no cognitive impairment and active diagnoses of anxiety, bipolar disease, and depression. Review of the resident's Care Plan, located under the Care Plan tab of the EMR and dated 03/29/24, showed staff care planned related to self-destructive behaviors due to alcohol abuse. Review of the resident's Diagnosis List, located under the Diagnosis tab in the EMR, showed the following: -Bipolar was diagnosed on [DATE]; -Major depressive disorder, generalized anxiety disorder, and panic disorder were diagnoses on 07/14/23. Review of the resident's Physician Orders, located under the Orders tab in the EMR dated 08/01/24, showed an order for fluoxetine, an antidepressant medication, 40 mg tab once daily. Staff did not have a copy of, or document completion of, a new Level l PASSAR was with the mental health diagnoses. 3. During an interview on 09/05/24, at 10:14 A.M., Licensed Practical Nurse (LPN) 2 said the following: -His/her understanding was that a new PASARR level I only needed to be completed when a resident discharged , or there was a major change in the resident like a new psychiatric diagnosis, or a major decline. -Whenever staff got the new diagnosis for the resident they would have communicated that to him/her, but there was not a process in place to monitor for new mental illness diagnosis. -He/she has never completed a new PASARR level I for any resident. -He/she never received training in PASARR, and that he/she had just winged it. 4. During an interview on 09/05/24, at 12:46 P.M., the Director of Nursing (DON) said she knew that a PASARR level I was completed on admission or with any significant change in status. She did not know another one needed to be done after a new diagnosis.

Based on interview and record review, the facility failed to ensure a baseline complete care plan was developed and provided for one resident (Resident #123), of 27 sampled residents, when the facility failed to care plan for the resident's diagnosis of schizophrenia (a mental health condition that affects how people think, feel and behave). Review of the facility's policy titled, Care Plans - Baseline, revised 03/2022, showed the following: -A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission; -The baseline care plan included instructions needed to provide effective, person -centered care of the resident and must include the minimum healthcare information necessary to properly care for the resident including physician orders. 1. Review of Resident #123's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, showed the following: -admission date of 08/29/24; -Diagnoses of included schizophrenia. Review of the resident's medical record showed staff did not document, or have copy of, a base line care plan or a comprehensive care plan completed within 48 hours of admission related to the resident's diagnosis of schizophrenia. During an interview on 09/04/24, at 3:15 PM, the Director of Nursing (DON) said that all diagnoses a resident had upon admission should be included in the baseline care plan and the resident's diagnosis of schizophrenia was not included. During an interview on 09/05/24, at 4:30 PM, the Administrator said that the baseline care plan should have included the resident's admitting diagnosis of schizophrenia.

Based on observation, interview, and record review, the facility failed to ensure all residents received respiratory care by standards of practice when staff failed to change one resident's (Resident # 4), out of 27 sampled residents, nebulizer tubing as ordered. 1. Review of the Resident #4's admission Record, found in the electronic medical record (EMR) under the Profile tab, showed the following: -admission date of 09/07/19; -Diagnoses included COPD (chronic obstructive pulmonary disease - a common lung disease causing restricted airflow and breathing problems), asthma, and allergic rhinitis. Review of the resident's Respiratory Care Plan, in the EMR under the Care Plan tab, dated 03/14/24, showed the following interventions: -Administer respiratory medication as ordered. -The resident did not like to keep nebulizer mask in plastic bag and will often take it out and sit it on top of the machine. Review of the resident's Physician's Order, dated 07/27/24, and in the EMR under the Orders tab, showed the following: -An order, dated 08/23/24, for nebulizer tubing to be changed weekly, every night shift, every Sunday night and place tubing in bag when not in use. Review of the resident's Treatment Administration Record (TAR), dated for September 2024, in the EMR under the Orders tab, showed the following: -An order, dated 08/23/24, for nebulizer tubing changed weekly, every night shift, every Sunday night, place tubing in bag when not in use; -Staff had not signed off as completing the order on the night of 09/01/24 (Sunday). During an observation on 09/02/24, at 3:39 P.M., and again on 09/03/24, at 10:29 A.M., the resident's nebulizer machine was on the shelf in her room. The tubing was undated tubing. During an observation and interview on 09/03/24, at 10:30 A.M., Registered Nurse (RN) #1 the nebulizer tubing should have had a date on it to indicate when it was changed. She said that oxygen and nebulizer tubing are supposed to be changed every Sunday night.

Based on interview and record review, the facility failed to ensure dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services were provided per standards of practice and resident's care plan when staff failed to have ongoing pre and post dialysis communication for one resident (Resident #38) who received dialysis. 1. Review of Resident #38's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following : -admission date of 12/05/19; -readmission date of 07/16/24; -Diagnoses included end stage renal disease (ESRD). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an assessment reference date (ARD) of 07/23/24, located under the MDS tab of the EMR, showed the following: -The resident had severe cognitive impairment. -The resident received hemodialysis treatment (a machine filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work adequately). Review of the resident's Physician Orders, located under the Orders tab in the EMR, dated 07/16/24, showed an order for dialysis Monday, Wednesday, and Friday. Review of the resident's Care Plan, located under the Care Plan tab of the EMR, dated 07/19/24, showed the resident required dialysis three times weekly. Intervention in place included to ensure staff coordinate with dialysis team to provide best care for resident. Review of the resident's Dialysis Communication Record, located under the Misc tab in the EMR for the months of July, August and September of 2024 , showed the forms were only completed for the dates of 07/22/24, 07/26/24, and 08/19/24. During an interview on 09/05/24, at 9:06 A.M., Registered Nurse (RN) 1 said after they switched the resident's dialysis time to 5:00 A.M., staff have not been completing the pre and post dialysis communication form. The night shift was supposed to send it with the resident to dialysis and day shift was supposed to make sure it came back with the resident after he/she returned from dialysis. He/she knew it had not been done in the last few weeks. He/she was the nurse in the hall yesterday and the resident did not come back from dialysis with one. He/she had not reported that to anyone. He/she assumed if there was an issue the dialysis center would call the facility to make them aware. During an interview on 09/05/24, at 9:46 A.M., Licensed Practical Nurse (LPN)1 said the dialysis communication should be completed before and after dialysis. If the form was not being completed by the dialysis center staff should call the dialysis center to get the information and document that in a progress notes and let the Administrator know. During an interview on 9/05/24, at 12:46 P.M., the Director of Nursing (DON) said nurses had the dialysis communication form and it should have been filled out and sent with the resident to dialysis and the dialysis center should have completed their portion and it sent it back with the resident. If staff knew the dialysis center was not filling out their portion they need to let her or the Administrator know and make the dialysis center aware. She expected it to be completed each and every time and if dialysis wasn't completing their portion they need to be calling the dialysis center and getting that information.

Based on interview and record review, the facility failed to implement an effective grievance process when staff failed to ensure all grievances included documentation of a full investigation, of a final decision, and of follow-up regarding findings with the resident who filed the grievance. Review of the facility policy Grievances/Complaints, Recording and Investigating, dated 2021, showed the following: -The administrator has assigned the responsibility of investigating grievances and complaints to the grievance officer. -The investigation and report will include the circumstances surrounding the alleged incident, the names of any witnesses and their accounts of the alleged incident, the resident's account of the alleged incident, and recommendations for corrective action. 1. Review of the Grievance/Complaint Report, dated 04/29/24, showed the following: -Resident stated the night shift Certified Nurse Aide (CNA) 4 was rough when doing cares and transfers. -Staff spoke to CNA 4 about his/her behavior and educated him/her on customer service. CNA 4 with issues at home. Explained that home problems must be left at the door. CNA 4 verbally agreed that he/she understood the education given. Staff will continue to monitor CNA 4 behavior with residents. (Staff did not document a full investigation, the final decision, or the follow-up with the resident who filed the grievance.) 2. Review of the Grievance/Complaint Report, dated 05/03/24, showed the following: -Resident stated that staff member, CNA 4, was rude and hateful on night shift. -Staff spoke to CNA 4 and reminded him/her that resident can often recognize and feel when they are rushed and have personal frustrations. (Staff did not document a full investigation, the final decision, or the follow-up with the resident who filed the grievance.) 3. Review of the Grievance/Complaint Report, dated 07/11/24, showed the following: -Resident stated that night shift CNA 4 was rude and rough and he/she did not want him/her in his/her room or providing cares for him/her. (Staff did not document a full investigation, the final decision, or the follow-up with the resident who filed the grievance.) 4. Review of the Grievance/Complaint Report, dated 08/09/24, showed the following: -Resident stated staff member CNA 4 was very rough when doing cares. -Director of Nursing (DON) educated staff on proper customer service and transferring technique when doing cares. (Staff did not document a full investigation, the final decision, or the follow-up with the resident who filed the grievance.) 5. Review of the Grievance/Complaint Report, dated 08/09/24, showed the following: -Resident stated staff (CNA 4) was very rough. Resident said he/she just jerks me around. Resident also stated that employee was rude and hateful. -Staff educated employee to announce to resident before he/she starts any cares and to practice good customer service skills. (Staff did not document a full investigation, the final decision, or the follow-up with the resident who filed the grievance.) 6. During an interview on 09/03/24, at 3:15 PM, the Regional Operations Director (ROD), Regional Nurse Consultant (RNC) 2 and the Administrator reviewed the grievance forms related to CNA 4. The Administrator said when education was completed it was completed verbally and nothing was documented. The RNC agreed the current documentation was not enough to ensure the grievance was resolved.

Based on observation, interview, and record review, interview, the facility failed to develop and implement complete and accurate care plans for all residents when staff failed to ensure five residents' (Resident #36, #42, #3, #1, and #4), of 27 residents reviewed, care plans addressed all appropriate care areas. Review of the facility's policy Care Plans, Comprehensive Person-Centered, dated 03/2022, showed the following: -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. -The comprehensive person-centered care plan included measurable objectives and timeframes, resident's stated goals upon admission, and desired outcome. 1. Review of Resident #36's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 03/01/24; -Diagnoses included anxiety disorder and major depressive disorder. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an assessment reference date (ARD) of 07/04/24 and located under the MDS tab of the EMR, showed the following: -The resident had no cognitive impairment; -The resident received antidepressant and antipsychotics on a routine basis. Review of the resident's current Physician Orders, located under the Orders tab in the EMR and dated 08/12/24, showed the following: -An active order for buspirone (an antidepressant medication) 15 milligrams (mg) tab, three times daily for anxiety disorder; -An active order for quetiapine (an antipsychotic medication) 50 mg, once daily for major depressive disorder. Review of the resident's Care Plan, located under the Care Plan tab of the EMR dated 03/14/24, showed staff did not care plan related to the resident's psychotropic medication use. During an interview on 09/05/24, at 12:35 P.M., the MDS Coordinator (MDSC)/Director of Nursing (DON) said the resident's medications should have been care planned. She said any type of psychotropic medication should have their own care plan with interventions. 2. Review of Resident #42's Face Sheet, located in the Profile tab of the EMR, showed the following: -admission date of 07/31/20; -readmission date of 03/29/24; -Diagnoses included major depressive disorder, generalized anxiety disorder, panic disorder, bipolar II disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), alcohol abuse, and opioid dependence. Review of the resident's annual MDS, with an ARD of 09/18/23 and located under the MDS tab of the EMR, showed the following: -Resident had no cognitive impairment; -Resident received antidepressant and antianxiety medication on a routine basis. Review of the resident's current Physician Orders, located under the Orders tab in the EMR, showed an active order for fluoxetine (an antidepressant medication) 40 mg tab, once daily. Review of the resident's Care Plan, located under the Care Plan tab of the EMR and dated 03/14/24, showed staff did not care plan related to the resident's psychotropic medication use. During an interview on 09/05/24, at 12:35 P.M., the MDSC/DON said the resident's medications should have been care planned. She said any type of psychotropic medication should have their own care plan with interventions. 4. Review of Resident #1's admission Record, in the EMR under the Profile tab, showed the following: -admission date of 08/30/19; -Diagnoses included of chronic allergic conjunctivitis (inflammation of the conjunctiva from infection or allergies). Review of the resident's Progress Note, dated 04/16/24 found in the EMR under the Progress Note tab, showed the resident had left side effect from previous CVA (cerebral vascular accident or stroke) that limited his/her range of motion (ROM) to his/her upper extremity. Review of the resident's quarterly MDS, with an ARD of 06/05/24, showed the resident had limited ROM to the upper and lower extremities on one side. Review of the resident's Physician's Orders, in the EMR under the Orders tab, showed the following: -An order, dated 07/29/24, for Pataday Ophthalmic Solution 0.1 % (olopatadine HCl), instill one drop in both eyes one time a day for chronic allergic conjunctivitis. Observation and interview on 09/02/24, at 4:14 P.M., showed the resident had a contracture of the left wrist. The resident said it was the result of a stroke. Review of the the resident's current Care Plan, in the EMR under the Care Plan tab showed staff did not care plan related to the resident's chronic allergic conjunctivitis or his left wrist contracture. During an interview on 09/04/24, at 4:37 P.M., the DON/MDSC said confirmed staff did not care plan the above concerns for the resident. 5. Review Resident #4's admission Record, in the EMR under the Profile tab, showed the following: -admission date of 09/07/18; -Diagnoses included of glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called the optic nerve) and dry eye syndrome. Review of the resident's annual MDS, with an ARD of 05/30/24 found in the EMR under the MDS tab, showed the following: -The resident had moderate difficulty with her hearing and was moderately impaired for her vision. -The resident received anti-anxiety and anti-depressant medications. During an interview on 09/02/24, at 4:08 P.M., the resident said he/she had a detached retina in the right eye making him/her blind in that eye and he/she was hard of hearing in the left ear. Review of the resident's Care Plan, in the EMR under the Care Plan tab, showed staff did not care plan related to the resident's hearing, vision, or for the use of anti-anxiety and anti-depressant medications. During an interview on 09/04/24, at 4:37 P.M., the DON/MDSC said confirmed staff did not care plan the above concerns for the resident. 6. During an interview on 09/05/24, at 12:35 P.M., the MDSC/DON said staff would let her know after a new care area was identified or if they noticed that something was not on the care plan. 7. During an interview on 09/05/24, at 3:57 P.M., the Administrator said that all regulations should be followed. She said the care plan should be specific to the needs of the residents and updated timely. 3. Review of Resident #3's admission Record, located in the EMR under the Profile tab, showed the following: -admission date of 03/11/20; -Diagnoses included major depressive disorder, anxiety disorder, and Alzheimer's Disease. Review of the resident's MDS, with an ARD of 06/24/24, located in the EMR under the MDS tab, showed the following: -The resident was severely cognitively impaired; -The resident received antidepressant and antipsychotic medication for seven of seven days during the look back review period. Review of the resident's Medication Administration Record (MAR), dated 09/2024, located in the EMR under the Orders tab, showed the following: -The resident received citalopram (an antidepressant) 10 mg, daily for major depressive disorder; -The resident received olanzapine (an antipsychotic) 2.5 mg, daily for an anxiety disorder. Review of the resident's comprehensive Care Plan, updated 08/17/24, showed the following: -Staff did not care plan related to the resident's diagnoses of major depressive disorder, anxiety, or Alzheimer's Disease; -Staff did not care plan related to the resident's use of an antidepressant. During an interview on 09/04/24, at 12:42 PM, the DON/MDSC said there should be a care plan for each psychotropic medication and each diagnosis the resident had. The DON agreed that the resident did not have a care plan for the use of an antidepressant, a major depression diagnosis, a diagnosis of Alzheimer's Disease, or a diagnosis of anxiety.

Based on record review and interview, the facility failed to provide effective pain management for all residents when the facility failed to ensure four of four residents (Resident #57, #32, #18 and #7) had pain medication available to be administered as ordered at all times. Review of the facility policy titled, Pharmacy and Medication Administration, undated, showed the following: -The emergency medication kit is refilled by the pharmacy; -The facility will have a clear practice about reordering of medication. lf the medication nurse or CMT (Certified Medication Tech) does not pull the labels to reorder the medications during their med pass, they may not be available when needed. Review of the facility policy titled, Emergency Kit System/With Controlled Substances (E-Kit), dated March 2015, showed the following: -The E-kit will be replaced after it has been opened and the pharmacy notified. -Replacement of the entire E-Kit will be done on the next scheduled delivery. -Remove the item/s needed. Remove enough of the medication to last until the order is filled and can be delivered. -lf for some reason the E-Kit is not exchanged at the next delivery, again call the pharmacy during regular business hours. -The facility is responsible to notify the pharmacy if the E-Kit is not delivered as expected. 1. Review of Resident #57's admission Record, located in the electronic medical record (EMR) under the Profile tab, showed the following: -admission date of 05/05/23; -Diagnoses included pain and fibromyalgia (musculoskeletal pain). Review of the resident's Minimum Data Set (MDS - a federally mandated assessment completed by facility staff ), with an Assessment Reference Date (ARD) of 05/15/24, located in the EMR under the MDS tab, showed the following: -The resident had no cognitive impairment. -The resident received scheduled and PRN (as needed) pain medications during the five day look back period, -The resident had occasional pain frequency and pain occasionally affected her sleep. -The resident rated the pain as a seven out of 10 (with one being no pain and 10 being the worse pain). Review of the resident's pain Care Plan, updated 11/11/23, showed the following: -Resident was experiencing the presence of occasional pain; -Interventions included teaching distraction techniques, resting after receiving pain medication, monitoring worsening of pain symptoms, notifying physician of changes, and assessing pain daily using the 1 to 10 scale. Review of the resident's August 2024 Medication Administration Record (MAR), located in the EMR under the Orders tab, showed the following: -A current order for tramadol (an opioid pain medication) 50 mg (milligrams), three times a day for pain; -A current order for acetaminophen 325 mg, two tablets every four hours as needed for general discomfort; -A current order to assessed for pain every shift. -The resident did not receive his/her tramadol or acetaminophen on 08/31/24 during the evening medication administration. The resident rated his/hr pain as a seven. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, dated 08/27/24,showed Licensed Practical Nurse (LPN) 1 notified the physician by voice mail that the resident was out of tramadol. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, dated 08/28/24, showed LPN 1 contacted the pharmacy to follow-up on the resident's tramadol. The LPN was informed the pharmacy was waiting for the order from the physician. Review of the resident's September 2024 MAR, located in the EMR under the Orders tab, showed the following: -The resident did not receive his/her tramadol on 09/01/24 during the evening medication administration. The resident rated his/her pain as a seven at 6:00 PM. -The resident did not receive all three doses of tramadol on 09/02/24. The resident rated his/her pain as an eight. -The resident did not received all three doses of tramadol on 09/03/24. The resident rated his/her pain as a seven. Review of the facility E-kit forms showed four tramadol 50 mg were removed for the resident on 08/27/24. Two tramadol were removed for the resident 08/28/24 and 08/30/24. The pharmacy was noted to have been sent a fax on 08/31/24. During an interview on 09/02/24, at 2:58 P.M., the resident the resident said he/she had not received his/her tramadol over the weekend because the facility ran out. The facility had called the doctor, but they had not received it yet. He/she had been taking Tylenol (acetaminophen) and gabapentin (can be used to treat neuropathic pain) which was somewhat effective. The resident said he/she noticed the difference between tramadol and Tylenol and he/she was hurting more without the tramadol. During an interview on 09/04/24, at 3:14 PM, LPN 5 said he/she would order medication when the medication card indicated the resident had seven days of medication left. At this time the physician should be notified. If he/she didn't get any results the day after calling the physician, he/she would call the next day. LPN 5 said medication was delivered at night, so nurses knew they needed to call by 4:00 P.M. to have it delivered that day. On 09/01/24, there was no tramadol on the medication cart or in the E-kit. There was also no one to call to receive more medication. He/she thought there was a backup pharmacy for the facility, but he/she was not sure who it was. He/she confirmed he/she had not called the physician to see if she could give the resident something else for pain. 2. Review of Resident #32's admission Record, located in the EMR under the Profile tab, showed the following: -admission date of 01/15/20; -Diagnosis included chronic pain. Review of the resident's quarterly MDS, with ARD of 06/24/24, located in the EMR under the MDS tab, showed the following: -The resident was severely cognitively impaired. -The resident received scheduled and PRN pain medications during the five day look back period. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed the resident had an active order for tramadol 50 mg, two tablets two times a day for chronic pain syndrome. Review of the facility's E-kit forms provided showed four tramadol 50 mg were removed for the resident on 08/27/24. Four tramadol 50 mg were removed for the resident on 08/31/24. The pharmacy was noted to have been sent a fax on 08/31/24. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed the following: -The resident had an active order for tramadol 50 mg, two tablets two times a day for chronic pain syndrome; -The resident missed his/her medication twice on 09/01/24, once on 09/02/24, and twice on 09/03/24; -Staff did not document notification of the resident's physician about the resident being out of tramadol, or of any non-pharmacological interventions were attempted. 3. Review of Resident #18's admission Record, located in the EMR under the Profile tab, showed the following: -admission date of 11/21/19; -Diagnoses included of chronic pain syndrome. Review of the resident's quarterly MDS, with ARD of 06/19/24, located in the EMR under the MDS tab, showed the following : -The resident was moderately cognitively impaired. -The resident received scheduled pain medications during the five day look back period. -A pain assessment interview should be conducted and the resident had pain constantly. The resident rated his/her pain as a eight out of 10. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed the following: -The resident had an order for ordered Norco (narcotic pain medication) 5-325 mg, one tablet six times per day for pain; -The resident missed his/her medication twice on 08/31/24, six times on 09/03/24, and twice on 09/02/24; -Staff did not document notification of the physician that the resident was out of medication or that any non-pharmacological interventions were attempted. 4. Review of Resident #7's admission Record, located in the EMR under the Profile tab, showed the following: -admission date of 12/29/22; -Diagnoses included pain. Review of the resident's quarterly MDS, with ARD of 07/03/24, located in the EMR under the MDS tab, showed the following: -The resident was moderately cognitively impaired. -The resident received scheduled and PRN pain medications during the five day look back period. -The resident reported his/her pain was frequent and affected his/her sleep occasionally. The resident's pain intensity was seven out of 10. Review of the resident's Progress Notes, located in the EMR under the Progress Notes tab, showed the following: -The resident has an order for hydrocodone-acetaminophen (narcotic pain medication) tablet 5-325 mg, one tablet three times a day for pain. -The resident missed his/her medication once on 09/01/24, once on 09/02/24, and all three times on 09/03/24. -Staff did not document notification of the physician that the resident was out of medication or that non-pharmacological interventions were attempted. 5. During an interview on 09/04/24, at 2:38 P.M., Licensed Practical Nurse (LPN) 1 said if the medication was out on the medication cart then medication should be pulled from the E-kit. There was no tramadol in the E-kit on 09/02/24 and 09/03/24. He/she knew that Resident #57 and Resident #32 had run out of medication. He/she confirmed he/she had contacted the physician on 08/27/24 to order more medication and the pharmacy was contacted on 08/28/24 and they said they were waiting for the orders from the physician. This was the only time the physician and the pharmacy were contacted. He/she was not sure if the facility had a backup pharmacy, but it was difficult to obtain medication from the pharmacy or orders from the physician during a holiday weekend. 6. During an interview on 09/04/24, at 3:04 P.M., the Regional Nurse Consultant (RNC) 1 said the EMR System interfaced through the pharmacy and medication should automatically be reordered and delivered in timely manner. If the medication was not available, nurses should use the medication in the E-kit. The physician should be called daily. The pharmacy manager should be called to find out why the E-kit was not stocked. Since the facility ran out of pain medication, nurses should have asked the physician if there was another medication that was available that could be administered and non-pharmacological approaches for pain should have been attempted. Additionally, the backup pharmacy should have been called. 7. During an interview on 09/05/24, at 9:24 A.M., Registered Nurse (RN) 1 said if the medication card indicated the resident had seven days worth of medication, it would be time to notify the physician to reorder the medication. They should call sooner if a resident was running out of a narcotic for pain. They could also get medication from the E-kit and if the E-kit was out of medication they would call the pharmacy to determine when the medication would be delivered. RN 1 said there were risks if a resident did not receive their medication which included the potential for withdrawal. The physician should be notified every time a resident missed their medication. A nurse should also ask the physician if they could give the resident something else for pain and try non-pharmacological interventions. Occasionally a physician will not respond to the request then the Administrator, Director of Nursing (DON), and the Medical Director should be notified to get assistance to obtain the unavailable medication. He/she knew that Resident #57 had run out of tramadol and there was no tramadol in the E-kit. He/she also knew Resident #18 had run out of Norco. It was important that nurses always think ahead to ensure a residents' medication was ordered to ensure they did not run out. 8. During an interview on 09/05/24, at 9:39 A.M., the Regional Operations Director (ROD) 1 and Regional Nurse Consultant (RNC) 2 agreed that more should have been done to obtain the medication for the residents RNC 2 said that the physician should have been notified daily about the missing medication for each resident and should have been asked if there was another medication that could be provided in place of the missing medication. Residents should have also been offered and provided non-pharmacological interventions to assist with managing their pain. 9. During an interview on 09/05/24, at 9:54 AM, the Administrator said the physician should have been called to see if something else could have been given to the resident.

Based on record review and interview, the facility failed to ensure a system was in place to account for all controlled drugs and that allowed for accurate reconciliation when staff failed to routinely complete a documented narcotic count for each change of shift. 1. Review of the 200 Hall Narcotic Record Books, reviewed with Licensed Practical Nurse (LPN) 5 and Medical Records, showed there were missing signatures for the following: -On 08/17/24 for 6:00 P.M. outgoing; -On 08/21/24 for 6:00 P.M. outgoing; -On 08/26/24 for 6:00 P.M. outgoing; -On 08/27/24 for 6:00 P.M. outgoing; -On 09/01/24 for 6:00 A.M. incoming; -On 09/01/24 for 6:00 P.M. outgoing. Review of the medication tech 100 Hall Narcotic Record Books, reviewed with LPN 5 and Medical Records, showed there were missing signatures for the following: -On 08/17/24 for 6:00 P.M. outgoing; -On 08/20/24 for 6:00 A.M. incoming; -On 08/22/24 for 6:00 A.M. incoming; -On 08/22/24 for 6:00 P.M. outgoing; -On 08/26/24 for 10:00 A.M. incoming; -On 08/26/24 for 10:00 P.M. outgoing; -On 08/27/24 for 6:00 A.M. incoming; -On 08/27/24 for 6:00 P.M. outgoing; -On 08/30/24 for 6:15 A.M. incoming; -On 08/30/24 for 6:00 P.M. outgoing; -On 09/01/24 for 11:00 P.M. outgoing; -On 09/02/24 for 6:00 P.M. outgoing. Review of the nurse 100 Hall Narcotic Record Books, reviewed with LPN 5 and Medical Records, showed there were missing signatures for the following: -On 08/17/24 for 6:00 A.M. incoming; -On 08/17/24 for 6:00 P.M. outgoing; -On 08/19/24 for 10:00 P.M. incoming; -On 08/20/24 for 6:00 P.M. outgoing; -On 08/21/24 for 6:00 A.M. incoming and outgoing; -On 08/21/24 for 7:00 P.M. outgoing; -On 08/22/24 for 6:00 A.M. incoming; -On 08/22/24 for 6:00 P.M. outgoing; -On 08/26/24 for 10:00 P.M. outgoing; -On 08/27/24 for 6:00 A.M. incoming; -On 08/27/24 for 6:00 P.M. outgoing; -On 08/30/24 for 6:15 A.M. incoming; -On 08/30/24 for 6:00 P.M. outgoing; -On 08/31/24 for 6:00 A.M. incoming; -On 08/31/24 for 6:00 P.M. outgoing; -On 09/01/24 for 6:00 A.M. outgoing; -On 09/04/24 for 6:00 A.M. incoming. Review of the medication tech 200 Hall Narcotic Record Books, reviewed with Registered Nurse (RN) 1, was missing signatures for: -On 08/20/24 for 6:00 A.M. incoming; -On 08/20/24 for 6:00 P.M. outgoing; -On 09/03/24 for 6:00 A.M. incoming; -On 09/03/24 for 6:00 P.M. outgoing; -On 09/05/24 for 6:00 A.M. incoming. During an interview on 09/05/24, at 8:49 A.M., RN 1 reviewed the results of the review of the four Narcotic Record Books and confirmed the missing signatures. The RN said the Narcotic Record Books were supposed to be signed by the oncoming and outgoing staff, at the change of every shift, after the narcotics are counted by those two staff, acknowledging that the narcotic count was done and correct. During an interview on 09/05/24 at 11:19 A.M., the Administrator said the Narcotic Record Books contained empty signature areas indicating staff was not signing consistently at every change of shift, after the narcotic count was done.

Based on interview and record review, the facility failed to have a system in place to monitor for side effects and targeted behaviors for five of five sampled residents (Resident #48, #36, #42, #4, and #3) reviewed for unnecessary medications who received psychotropic medications. Review of the facility's Psychotropic Medication Use policy, dated 7/2022, showed the following: -Psychotropic medication management included .adequate monitoring for efficacy and adverse consequences and preventing, identifying, and responding to adverse consequences. 1. Review of Resident #48's Face Sheet, located in the Profile tab of the electronic medical record (EMR), showed the following: -admission date of 11/28/23; -Diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), anxiety disorder, schizoaffective disorder (a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania), and major depressive disorder. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an assessment reference date (ARD) of 09/18/23 and located under the MDS tab of the EMR, showed the following: -The resident had severe cognitive impairment. -The resident received antipsychotics on a routine basis. Review of the resident's current Physician Orders, located under the Orders tab in the EMR, showed the following: -A current order for fluphenazine (an antipsychotic medication) 5 milligram (mg) tablet, twice daily for schizoaffective disorder; -A current order for risperidone (an antipsychotic medication) 1 mg, twice daily for schizoaffective disorder. Review of the resident's Medication Administration Record (MAR), dated 08/01/24 through 09/05/24, found in the EMR under the Orders tab, showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. Review of the resident's Progress Notes, dated 08/01/24 through 09/05/24, showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. During an interview on 09/05/24, at 9:06 A.M., Registered Nurse (RN) 1 reviewed the resident's Treatment Administration Records (TAR) and MARs and verified there was nothing that indicated behavior monitoring completed by staff. During an interview on 09/05/24, at 12:13 P.M., the Regional Nurse Consultant (RNC) verified there was no behavior monitoring for the resident. 2. Review of Resident #36's Face Sheet, located in the Profile tab of the EMR, showed the following: -admission date of 03/01/24; -Diagnoses included anxiety disorder and major depressive disorder. Review of the resident's significant change MDS, with an ARD of 07/04/24 and located under the MDS tab of the EMR, showed the following : -The resident had no cognitive impairment; -The resident received antidepressant and antipsychotics on a routine basis. Review of of the resident's current Physician Orders, located under the Orders tab in the EMR, showed the following: -A current order for buspirone (an antidepressant medication) 15 mg tab, three times daily for anxiety disorder; -A current order for quetiapine (an antipsychotic medication) 50 mg, once daily for major depressive disorder. Review of the resident's MAR, dated 08/01/24 through 09/05/24 and found in the EMR under the Orders tab, showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. Review of the resident's Progress Notes, dated 08/01/24 through 09/05/24, showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. During an interview on 09/05/24, at 9:06 A.M., RN 1 reviewed the resident's TARs and MARs and verified there was nothing that indicated behavior monitoring completed by staff. During an interview on 09/05/24, at 12:13 P.M., the RNC verified there was no behavior monitoring for the resident. 3. Review of Resident #42's Face Sheet, located in the Profile tab of the EMR, showed the following: -admission date of 07/31/20; -readmission date of 03/29/24; -Diagnoses included major depressive disorder, generalized anxiety disorder, panic disorder, bipolar II disorder, alcohol abuse, and opioid dependence. Review of the resident's annual MDS, with an ARD of 09/18/23 and located under the MDS tab of the EMR, showed the following: -The resident had no cognitive impairment; -The resident received antidepressant and antianxiety medication on a routine basis. Review of the resident's Physician Orders, located under the Orders tab in the EMR, showed a current order for fluoxetine (an antidepressant medication) 40 mg tablet, once daily. Review of the resident's MAR, dated 08/01/24 through 09/05/24, found in the EMR under the Orders tab, showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. Review of the resident's Progress Notes, dated 08/01/24 through 09/05/24, showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. During an interview on 09/05/24, at 9:06 A.M., RN 1 reviewed the resident's TARs and MARs and verified there was nothing that indicated behavior monitoring completed by staff. During an interview on 09/05/24, at 12:13 P.M., the RNC verified there was no behavior monitoring for the resident. 4. Review of Resident #4's admission Record, found the EMR under the Profile tab, showed the following; ' -admission date of 09/07/18; -Diagnoses included anxiety disorder and depression. Review of the resident's annual MDS, with an ARD of 05/30/24 and found in the EMR under the MDS tab, showed the resident was on anti-anxiety and anti-depressant medication. Review of the resident's Physician Orders, found in the EMR under the Orders tab, showed the following: -A current order for lorazepam (anti-anxiety medication) oral tablet one mg, give one tablet by mouth at bedtime for anxiety; -A current order for paroxetine HCL (antidepressant medication) 20 mg, give one tablet by mouth in the afternoon for depression. Review of the resident's medical record showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. During an interview on 09/05/24, at 10:12 AM, RN 1 said behavior monitoring or side effect monitoring for these medications should be listed on a resident's Medication Administration Record (MAR) or the Treatment Administration Record (TAR). RN 1 confirmed this was not being completed for the resident. During an interview on 09/04/24, at 4:35 P.M., the Director of Nursing (DON) confirmed there was no behavior or side effect monitoring being completed for the resident's use of the anti-anxiety or anti-depressant medications. 5. Review of Resident #3's admission Record, located in the electronic medical record (EMR) under the Profile tab, showed the following; -admission date of 03/11/20; -Diagnoses included major depressive disorder, Alzheimer's Disease, and anxiety disorder. Review of the resident's MDS, with an ARD of 06/24/24, located in the EMR under the MDS tab, showed the following: -The resident had severe cognitive impairment; -The resident received antidepressant and antipsychotic medication for seven of seven days during the look back review period. Review of the resident's comprehensive Care Plan, updated 08/17/24, showed the following: -The resident was at risk for side effects of antipsychotic drug use; -Intervention included monitoring patterns of target behaviors. Review of the resident's MAR, dated 09/2024, located in the EMR under the Orders tab, showed the following: -A current order for citalopram (an antidepressant) 10 mg, daily for major depressive disorder; -A current order for olanzapine (an antipsychotic) 2.5 mg, daily for an anxiety disorder. Review of the resident's medical record showed staff did not document monitoring of side effects of the resident's psychotropic medication or specific behaviors associated with the administration of the resident's psychotropic medications. 6. During an interview on 09/05/24, at 9:06 A.M., Registered Nurse (RN) 1 said most of the residents on antipsychotic medications had a question on the Treatment Administration Record (TAR) that asked about behaviors. 7. During an interview on 09/05/24, at 12:13 P.M., the RNC verified said they were unaware there needed to be behavior monitoring for psychotropic medications because they have never monitored for anything other than anti-psychotic medications. 8. During an interview on 09/05/24, at 12:46 P.M. and 1:15 P.M., the DON said as a nurse she knew to look for and monitor for any change in a resident's condition that was on psychotropic medications. She agreed that if behavior monitoring was not on the MAR/TAR that not all staff would know what to look for or ensure they were monitoring for specific behaviors and there would not be any consistency in monitoring. Specific targeted behavior and potential side effects should be monitored for all psychotropic medications. 9. During an interview on 09/05/24, at 3:57 P.M., the Administrator said that all regulations should be followed, including behavior monitoring and monitoring side effects for anti-depressants and anti-psychotics.

Based on interview and record review, the facility failed to provide a Preadmission Screening and Resident Review (PASARR - a federally mandated preliminary assessment to determine whether a resident may have a mental illness (MI) or an intellectual disorder (ID), to determine the level of care needed) for one resident (Resident # 61). The facility census was 61. Record review of the Central Office Medical Review Unit (COMRU) instructional guide, updated October 2021, showed the PASARR is a federally mandated screening process for individuals with serious mental illness and /or intellectual or developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of payment. The screening process assures appropriate placement of person known to suspected of having mental impairment and also that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment. 1. Record review of Resident #61's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 11/2/2022; -Diagnoses included post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event). Record review of the resident's medical record showed staff did not complete the required level one screening when the resident admitted to the facility. During an interview on 1/5/23, at 11:40 A.M., the Minimum Data Set (MDS) Coordinator said she is responsible for completing the PASARR assessments for residents on admission. She did not complete a level one assessment for the resident due to the resident being private pay. She does not complete assessments on residents who are private pay unless their payment status changes. During an interview on 1/6/23, at 11:15 A.M., the Administrator said she would expect all residents to have a level one assessment completed unless they are expected to be admitted less than 30 days.

Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan consistent with the resident's specific conditions, needs, and risks to provide effective person centered care that met professional standards of quality care when staff did not address dialysis (a procedure to remove waist products and excess fluid from the blood when the kidneys stop working) port care and monitoring before and after dialysis for one resident (Resident #219) and did not address use of a bilevel positive airway pressure (BIPAP) machine (a devise to provide air pressure for breathing in and breathing out during sleep) for one resident (Resident #222). The facility had a census of 61. Record review of the facility's policy titled Care Plans-Baseline, dated March 2022, showed the following: -The baseline care plan includes instructions needed to provide effective, person-centered care of the resident; -The base line care plan must include minimum health care information necessary to properly care for the resident; -The base line care plan is used until staff develop an interdisciplinary person-centered comprehensive care plan. 1. Record review of Resident #219's face sheet (a document that shows a residents information at a quick glance) showed the following: -admission date of 12/29/22; -Diagnoses included end stage renal disease (a condition in which a person's kidneys cease functioning on a permanent basis) and failure to thrive. Record review of the resident's physician order sheet (POS), dated 12/29/22, showed the physician directed staff to provide the following: -Dialysis appointments three times per week . Record review of the resident's base line care plan, dated 12/29/22, showed staff did not care plan for staff to provide ongoing assessment and oversight of the resident before and after dialysis treatments at a certified dialysis center. Staff did not care plan direction for care of the dialysis access site. Observation and interview on 1/4/2,3 at 8:30 A.M., showed the resident sat on the edge of the bed. He/she said he/she goes to dialysis three times a week and has been receiving dialysis for 4 years. He/she has a dialysis access in his/her groin area that is no longer being used. They use this one now and pointed to his/her upper right chest. The resident said staff at the facility has not checked on him/her before he/she goes or after he/she returns from dialysis. During an interview on 1/6/23, at 11:15 A.M., Licensed Practical Nurse (LPN) D said the following: -The base line care plan should include guidelines for assessment and monitoring for a resident receiving dialysis. During an interview on 1/6/23, at 11:50 A.M., the Director of Nursing (DON) and the Administrator they would expect for ongoing observation and assessment for a resident receiving dialysis to be addressed on the baseline care plan. 2. Record review of Resident #222's face sheet showed the following: -admission date of 12/27/22; -Diagnoses included chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and makes it difficult to breath, acute respiratory failure, dependence on supplementary oxygen). Record review of the resident's base line care plan, dated 12/27/22, showed staff did not care plan direction for staff to provide use of a BIPAP machine. Observation and interview on 1/4/2,3 at 10:00 A.M., showed a Trilogy 100 BIPAP machine on the resident's bedside table. The mask and tubing were attached to the machine and laid inside the open top drawer of the table. The resident said he/she used the BIPAP machine every night. During an interview on 1/6/23, at 11:15 A.M., LPN D said the following: -The base line care plan should provide instructions for administering BIPAP therapy if it is required for the resident. During an interview on 1/6/23, at 11:50 A.M., the DON and the Administrator said they would expect for BIPAP therapy to be addressed on the base line care plan. 3. During an interview on 1/6/23, at 11:15 A.M., LPN D said the following: -The admitting charge nurse is responsible for completing the base line care plan. 4. During an interview on 1/6/23, at 11:50 A.M., the DON and the Administrator said base line care plans should include include all care needed by the resident.

Based on observation, interview, and record review, the facility failed to obtain a physician's order and provide proper cleaning and maintenance for a Bilevel Positive Airway Pressure machine (BIPAP- a devise to provide air pressure for breathing in and breathing out during sleep) for one resident (Resident #222). The facility census was 61. Record review of the facility's policy titled CPAP/BIPAP Support, dated March 2015, showed the following: -Purpose is to administer positive airway pressure to maintain open an airway; -Use to improve arterial oxygenation in residents with respiratory insufficiency; -Review the physician's order to determine the oxygen concentration and flow and the pressure for the machine; -Follow the manufacture's instructions for machine set up, delivery, and care. Record review of the Trilogy 100-BIPAP clinical manual, dated October 2018, showed the following: -The BIPAP is designed to be used by trained and qualified caregivers under the supervision of a physician; -The prescription and other devise settings should only be changed on the orders of the supervising physician; -The external surface should be cleaned before and after each patient use with mild detergent, hydrogen peroxide, or isopropyl alcohol, or 10% bleach solution; -Clean the reusable circuit two times weekly with mild detergent and rinse with tap water, soak in vinegar solution, rinse, and air dry; -Circuits infected with bacteria may infect the patient's lungs. 1. Record review of Resident #222's face sheet showed the following: -admission date of 12/27/22; -Diagnoses included Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and makes it difficult to breath, acute respiratory failure, dependence on supplementary oxygen). Record review of the resident's December 2022 physician order sheet (POS) showed the following: -No order for the resident to use a BIPAP machine; -No order for maintenance or cleaning of a BIPAP machine. Record review of the resident's base line care plan, dated 12/27/22, showed staff did not care plan direction for staff to provide the resident with BIPAP treatment or directions for cleaning and maintaining the BIPAP machine. Record review of the resident's January 2023 POS showed the following: -No order for the resident to use a BIPAP machine; -No order for maintenance or cleaning of a BIPAP machine. Observation and interview on 1/4/23, at 10:00 A.M., showed a Trilogy 100 BIPAP machine on the resident's bedside table. The mask and tubing were attached to the machine and laid inside the open top drawer of the table. The resident said he/she uses the BIPAP machine every night. Staff have not checked or cleaned the machine. The resident said he/she puts the mask on and turns the machine on independently. During an interview on 1/6/23, at 9:00 A.M., with Certified Nurses Aide (CNA) E and Nurse Aide (NA) F , CNA E said no residents use a BIPAP machine. NA F said he/she has seen a black box in the resident's room, but did not know what it was. During an interview on 1/6/23, at 11:15 A.M., Licensed Practical Nurse (LPN) D said he/she did not know if the physician had written an order for the resident to use a BIPAP, but an order should have been obtained prior to use. The order should include setting and a cleaning schedule. During an interview on 1/6/23, at 11:50 A.M., the Administrator and Director of Nursing (DON) said the following: -The resident should have an order for his/her BIPAP machine; -The physician orders for the use of the BIPAP machine should include cleaning and maintenance instructions; -BIPAP use should be addressed on the resident's plan of care.

Based on observation, interview, and record review, the facility failed to provide thorough assessments and provide monitoring of the resident's dialysis central venous catheter (an intravenous line into a vein in the resident's chest), failed to maintain ongoing communication with the dialysis (the cleaning of the blood with a machine due to the kidneys not working) center, and failed to obtain an agreement with a dialysis provider, for one resident (Resident #219) that received dialysis. The facility census was 61. Record review of the facility's policy titled Hemodialysis Access Care, undated, showed the following: -Central Dialysis catheters must be kept clean and dry at all times; -Dressing changes should be done using sterile technique; -The nurse should document every shift, the location of the catheter, condition of the dressing, if dialysis was done during the shift, any part of report from the dialysis center nurse, and post dialysis observations. Record review of the www.mayoclinic.org website regarding hemodialysis (when a machine filters wastes, salts and fluid from blood when kidneys are no longer healthy enough to do this work adequately) showed i it is extremely important to take care of the access site to reduce the possibility of infection and other complications 1. Record review of Resident # 219's face sheet (a document that shows a residents information at a quick glance) showed the following: -admission date of 12/29/22; -Diagnoses included end stage renal disease (a condition in which a person's kidneys cease functioning on a permanent basis), and failure to thrive. Record review of the resident's current physician order sheets (POS) showed the physician directed staff to provide the following: -An order, dated 12/29/22, for dialysis appointments on Monday, Wednesday, and Friday. (The orders did not contain specifics to monitoring the central venous catheter.) Record review of the resident's base line care plan, dated 12/29/22, showed staff did not care plan direction for staff to provide ongoing assessment and oversight of the resident before and after dialysis treatments at a certified dialysis center, or provide direction for care of the dialysis central venous catheter. Record review of the resident's December 2022 and January 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed staff did not document treatment or monitoring of the resident's central venous catheter. Record review of the resident's nurses' notes, dated 12/29/22 to 1/4/23, showed staff did not document assessment or monitoring of the resident's central venous catheter. Record review of the residents medical record, dated 12/29/22 to 1/4/23, showed no dialysis communication forms for any dialysis treatment or communication with the dialysis center. During an interview on 1/4/23, at 8:15 A.M., the Administrator said the facility does not have a dialysis contract with the dialysis center. Observation and interview on 1/4/23, at 8:30 A.M., showed the resident sitting on the edge of the bed. He/she said he/she goes to dialysis three times a week and has been receiving dialysis for four years. He/she has a dialysis access in his/her groin area that is no longer being used. They use this one now and pointed to his/her upper right chest. The resident said staff at the facility has not checked him/her before he/she goes or after he/she returns from dialysis. During an interview on 1/6/23, at 11:15 A.M., Licensed Practical Nurse (LPN) D said the following: -The resident has a central venous catheter in his /her chest; -The facility nurses do not do anything with the central venous catheter, as the dialysis center cares for the site; -No special care is needed for the resident. Staff would only change the dressing if it was soiled; -The facility does not communicate routinely with the dialysis center, but could call them if needed; -The resident should have any dialysis specifics to his/her needs addressed on his/her baseline care plan. During an interview on 1/6/23, at 11:50 A.M., the Director of Nursing (DON) and the Administrator said the following: -The nurses should monitor the resident's central venous catheter daily and before and after dialysis treatment to monitor for infection; -The nurses should document assessment in the nurses progress notes; -Would expect staff to communicate with the dialysis center routinely.

Based on interview and record review, the facility failed to ensure three nursing assistants (Nurse Aide (NA) A, NA B, and NA C) completed a state approved certified nursing assistant (CNA) training program and competency evaluation program within four months of hire. The facility's census was 61. Review of a facility policy entitled Nurse Aide Qualifications and Training Requirements, revised August 2022, showed the following: -Nurse aides must undergo a state-approved training program; -The facility will not use any individual as a nurse aide who has worked less than four months unless the individual is a full-time employee and participating in a state-approved training and competency evaluation program; or has demonstrated competence through satisfactory participation in a state-approved nurse aide training and competency evaluation program; or has been determined competent as provided in section 483.150(a) and (b) of the requirements of participation; -The facility will not employ any individual as a nurse aide for more than four months full-time, temporary, per diem, otherwise, unless that individual is competent to provide designated nursing care and nursing related services; and that individual has completed a training program and competency evaluation program, or a competency evaluation program approved by the state; or that individual has been deemed competent as provided in section 483.150(a) and (b) of the requirements of participation; -Nurse aides will have a minimum of 16 hours of training in the following areas prior to direct contact with the residents: communication and interpersonal skills, infection control, safety/emergency procedures, promoting residents' independence, respecting residents' rights, basic nursing skills, personal care skills, metal health and social service needs, care of cognitively impaired residents, basic restorative services, and resident rights; -Nursing assistant failing to successfully complete the required training program within the first four months of their date of employment may be terminated from employment or may be reassigned to non-nursing related services 1. Record review of NA A's personnel file showed the following: -Date of hire of 4/5/2022; -Staff did not have documentation NA A had completed the nurse aide training program and passed the required certification testing. Record review, during survey, of the Missouri CNA Registry on-line verification showed the NA did not have an active CNA certification. Observation on 1/6/2023, at 12:13 P.M., showed NA A was assisting residents in the dining room wearing a name tag with his/her name and title of NA. During the observation, he/she told the surveyor that he/she had been employed at the facility since April 2022. He/she had been a certified nurse aide (CNA) for 18 years prior, but was not currently active as a CNA. 2. Record review of NA B's personnel file showed the following: -Date of hire of 4/12/2022; -Staff did not have documentation NA B had completed the nurse aide training program and passed the required certification testing. Record review, during survey, of the Missouri CNA Registry on-line verification showed the NA did not have an active CNA certification. Observation on 1/4/2023, at 9:00 A.M., showed NA B assisting residents while wearing a name tag with his/her name and title of NA. 3. Record review of NA C's personnel file showed the following: -Date of hire of 7/27/2022; -Staff did not have documentation NA C had completed the nurse aide training program and passed the required certification testing. Record review, during the survey, of the Missouri CNA Registry on-line verification showed the NA did not have an active CNA certification. Record review of the facility's daily staffing sheets showed the following: -On 12/23/2022, NA C worked as an NA on the night shift; -On 12/24/2022, NA C worked as an NA on the night shift; -On 12/30/2022, NA C worked as an NA on the night shift; -On 12/31/2022, NA C worked as an NA on the night shift; -On 1/3/2023, NA C worked as an NA on the night shift (6:00 P.M. to 6:00 A.M.); -On 1/9/2023, NA C was scheduled to work as an NA on the night shift. 4. During an interview on 1/6/2023, at 10:10 A.M., the Administrator said she was aware that NA A, NA B, and NA C were past the four-month requirement for becoming CNAs. None of the nurse aides were currently in a training class, because the facility could not locate a class within a thirty-minute radius. The facility had not begun the process to enroll the NAs in an on-line training program. NAs A, B, and C had been working the floor as NAs.

Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two resident (Resident #2 and #37) who remained in the facility after discharge from Medicare Part A services. The facility census was 71. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C -09-20), dated 1/9/09, showed the following: -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them his/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met its obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. 1. Record review of Resident #'2's Skilled Nursing Facility Beneficiary Protection Notification Review showed the following: -Medicare Part A skilled services started on 1/29/19; -Last covered day of Medicare Part A services on 2/26/19; -Date services ended was not listed on the Skilled Nursing Facility Beneficiary Protection Notification Review; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -The facility did not provide the resident or his/her legal representative the SNF ABN form CMS-10055 or alternative denial letter. 2. Record review of Resident #37's Skilled Nursing Facility Beneficiary Protection Notification Review showed the following: -Medicare Part A skilled services episode start date on 4/15/19; -Last covered day of Part A services as 5/14/19; -Date services ended was not listed on the Skilled Nursing Facility Beneficiary Protection Notification Review; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -The facility did not provide the resident or his/her legal representative the SNF ABN form CMS-10055 or alternative denial letter. 3. During an interview on 9/10/19, at 5:42 P.M., the social worker said the ABN form was not given to the residents. 4. During an interview on 9/12/19, at 8:15 P.M., the administrator said the facility did not issue ABN notices to the residents who were discharged from therapy and had remaining days.

Based on observation, interview, and record review, the facility failed to assess the use of a seat belt to determine if it was a restraint and obtain a physician order for use of the seatbelt for one resident (Resident #9) who was not consistently able to remove the seat belt without staff assistance. The facility census was 71. Based on the facility policy titled Physical Restraint Application, dated October 2010, showed the following: -The purpose of this procedure is to provide safety or postural support of a resident to prevent injury to the resident or others when the resident has medical symptoms that warrant the use of restraints; -Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body; -The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint. The resident must be physically or cognitively able to self-release devices such as Velcro lap trays or tables, seat belts with Velcro, or easy snap seat belts. If a resident cannot mentally and physically self-release, then the devices is considered a restraint; -Verify physician's order for the use of restraints; -Review the resident's care plan to assess for any special needs of the resident; -Method of application for seat belt: Position the resident's arms and hands free from restriction by the seat belt; -Straighten the seat belt; no irritating twists or wrinkles should be present; -Position seat belt around resident's waist and secure clasp. Place one hand under edge of seat belt to be sure it is not too tight; -Check to be sure that clasp does not cause pressure to any part of the resident's body; -The following information should be recorded in the resident's medical record; -The date and time the restraint was applied; -The name and title of the individual(s) who applied the restraint; -The type of physical restraint applied; -The length of time the restraint will be used; -Each time the device is released for resident exercise, toileting, and position change; -Each time the resident is monitored, per facility policy. 1. Record review of Resident #9's face sheet (a document that gives a resident's information at a quick glance) showed the following: -Resident was readmitted from the hospital on 8/19/19; -Diagnoses include unspecified dementia without behavioral disturbance; -Fracture of orbital floor, right side (fracture of the bone of the eye); -Maxillary fracture right side (fracture to the facial area); -Zygomatic fracture, right side (fracture to the cheek) . Record review of the resident's nurses' note dated 8/20/19, at 1:00 P.M., showed a nurse documented the responsible party was notified of the resident's fall and continually leaning forward picking at his/her shoes on the floor. Staff informed the responsible party of anti-tippers on the front of the resident's wheelchair. The nurse informed the responsible party that a self release seat belt would help remind the resident to wait for help. The responsible party agreed. Staff received verbal consent for the restraint due to the resident's cognition is altered. Record review of the resident's physician orders sheet (POS), dated 8/20/19, showed no physician's order for the seatbelt. Record review of the resident's nurse's note dated 8/21/19, no time, showed a nurse documented anti-tippers and seatbelt on the resident's wheelchair. Record review of the resident's care plan, revised on 8/20/19 and 8/21/19, showed the following: -Care plan for falls, dated 8/20/19, showed the resident is at risk for falls related to ambulates alone; -Care plan update, dated 8/21/19, for self release seat belt applied to wheelchair to remind resident he/she needs assistance when getting up; -Restraint evaluation will be completed. Family agree with seat belt and signing restraint form related to resident has dementia and memory changes from confusion to being coherent. Record review of the resident's physical restraints record of informed consent, dated 8/20/19, with verbal consent from representative showed the following: -The resident/representative was informed about the use of restraints and the possible negative outcomes of their use and provided a copy of the facility's policies and procedures governing the use of restraints; -Should the use of a restraint be necessary, it will only be considered to treat a medical condition or symptom that endangers the resident's physical safety or the safety of other residents; -The restraint will be used as a last resort measure after a trial period where less restrictive measures have been taken and proven to be unsuccessful; -Only be used upon the written order of the resident's attending physician; -Only be used upon written consent and; -Only be used when the benefits of restraint outweigh the risk of not using the restraint. Record review of the resident's nurses' notes, dated 8/22/19 through 9/11/19, showed no documentation regarding the seatbelt. Record review of the resident's significant change in condition Minimum Data Set (MDS), a federally mandated comprehensive assessment tool completed by facility staff, dated 8/26/19, showed the following: -Cognitive skills severely impaired; -Extensive assistance required with bed mobility, transfers, dressing, and toilet use; -Number of falls since admission marked none; -The MDS did not indicate the resident had any physical restraints. Record review of the resident's medical record showed the facility staff did not document assessments for the resident's seatbelt intervention for falls to determine the residents capability to remove the seatbelt. Record review of the resident's September 2019 Physician's Order Sheet (POS) showed no order for the resident's velcro seatbelt. During an observation on 9/11/19, at 9:48 A.M., the resident sat in his/her wheelchair. The resident had a Velcro seatbelt around his/her waist. During an interview on 9/11/19, at 5:01 P.M., Certified Medication Technician (CMT) A said the resident wears a seatbelt. He/she has not seen the resident take off the seatbelt. He/she said the seatbelt keeps the resident from standing up and forgetting he/she cannot walk on his/her own. During an interview on 9/12/19, at 11:53 A.M. Licensed Practical Nurse (LPN) B said the Director of Nursing (DON) or administrator completes an evaluation for the seatbelt. He/she believes he/she has seen the resident undo the seatbelt. During an interview on 9/12/19, at 2:53 P.M., the DON said the following: -Staff should assess a resident for a seatbelt; -Staff should look at the situation, how to keep the resident from falling, and discuss as a care plan team; -The resident likes to be independent. The resident is unsteady; -Staff should involve therapy. An evaluation is completed and staff increase frequency on the resident's checks; -Staff were educated on the device; -Staff should reevaluate the device quarterly; -Staff complete a fall assessment if a resident has a fall and determine if an intervention is not working; -Staff discussed the device with the resident's responsible party regarding the seat belt; -The resident is alert and then can be incoherent; -The resident's family was educated on the device and signed a restraint consent form; -The physician is informed of the device and gives a reason for the use of the device. During an interview on 9/12/19, at 5:43 P.M., the administrator said an assessment should be completed for appropriateness for a resident's seatbelt. During an interview on 9/13/19, at 9:00 A.M., LPN C said staff should develop a care plan for a resident with a seatbelt. The nurse should call the physician for an order and reason for the seatbelt. Staff should reevaluate a resident quarterly for a seatbelt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to develop a comprehensive care plan for one resident (Resident # 46) out of a sample size of 18 residents. The facility census was 71. Record review of the facility policy titled Care Plans, Comprehensive Person-Centered dated December 2016 showed: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical and functional needs is developed and implemented for each resident; - The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident; - The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment; - The comprehensive, person-centered care plan will include measurable objectives and timeframes; describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; include the resident's stated goals upon admission and desired outcomes; include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire; incorporate identified problem areas; incorporate risk factors associated with identified problems; build on resident's strengths; reflect on resident's expressed wishes regarding care and treatment goals; reflect on treatment goals, timetables, and objectives in measurable outcomes; identify professional services that are responsible for each element of care; aid in preventing or reducing decline in the resident's functional status and/or functional levels; enhance the optimal functioning of the resident by focusing on a rehabilitative program; and reflect currently recognized standards of practice for problem areas and conditions. -The comprehensive, person-centered care plan is developed within seven day of the completion of the required comprehensive assessment Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff). Record review of the facility's policy titled Resident Participation - Assessment/Care Plans, dated December 2016, showed: -The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan; -The care planning process will facilitate the inclusion of the resident/and or representative; include the assessment of the resident's strengths and his or her needs; and incorporate the resident's personal and cultural preferences in establishing goals of care. -Resident assessments are begun on the first day of admission and completed no later than the fourteenth (14th) day after admission; -A Comprehensive Care Plan is developed within seven (7) days of completing the resident assessment. 1. Record review of Resident #46's face sheet (general resident information form) showed the following information: -admission date of 06/12/19 with a readmission date of 7/09/19; -Diagnoses include pneumonia, hypertension (high blood pressure), retention of urine, urethral stricture (narrowing of the small structure that drains urine from the bladder), reduced mobility, urinary tract infection, and sepsis (infection). Record review of the resident's admission Minimum Data Set (MDS), dated [DATE], showed the following information: -Cognitively intact; -Independent with bed mobility, dressing, eating, toilet use, personal hygiene; -Supervision for walking; -Physical help in part of bathing; -Indwelling catheter (a sterile tube inserted into the bladder to drain urine); -Neurogenic bladder (dysfunction of the bladder caused by a lesion of the nervous system). Record review of the resident's medical record showed the following: -A 48-hour care plan dated 6/12/19; -An initial care plan dated 7/9/19; -No comprehensive care plan in the chart. During interview on 9/12/19, at 12:24 P.M., the MDS Coordinator said the following: -Care plans are located in the resident's charts under the care plan tab; -Anyone that provides care to the resident should be looking at it; -The admission nurse will develop an initial care plan, a single sheet that gives quick information about resident, with admission paperwork; -Social services will develop a 48 hour care plan (to be used in conjunction with initial care plan within 48 hours of admission); -He/she will then develop a comprehensive care plan that is more personalized to the resident within 14 days. During interview on 9/12/19, at 7:00 P.M., the Director of Nursing (DON) said the following: -Resident care plans are found in the chart; -Upon admission an interim care plan is done by admitting nurse; -Within 48 hours a care plan that involves the IDT and family; -Nurses and nursing aides should be looking at the care plan; -If resident is discharged from the facility and is readmitted after being gone longer than three midnights a new comprehensive care plan should be done within 21 days of readmission as well as a new initial care plan and a 48 hour care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess one resident (Resident #73) for change in condition and adequately complete neurological checks (level of consciousness is evaluated) following a fall. The facility failed to assess the resident's catheter (a sterile tube inserted into the bladder to drain urine) which had blood following a fall. The facility failed to address the resident's request to be discharged to the hospital. This practice affected one resident out of a sample of 18 residents. The facility census was 71. Record review of the facility's Managing Falls and Fall Risk policy, dated March 2018, showed the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -Resident conditions that may contribute to the risk of falls include: fever, infection, delirium and other cognitive impairment, pain, lower extremity weakness, poor grip strength, functional impairments, and medication side effects. Record review of the facility's Change in a Resident's Condition or Status, revised May 2017, showed the following: -The facility will promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental conation and/or status (examples: changes in levels of care, billing/payments, resident rights); -The nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident; discovery of injuries of an unknown source; adverse reaction to medication; significant change in the resident's physical/emotional/mental condition; or a need to transfer the resident to a hospital/treatment center; -A 'significant change' of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions and impacts more than one area of the resident's health status. 1. Record review of Resident #73's face sheet (general information at a quick glance) showed the following: -admitted to the facility on [DATE]; -Diagnoses included paraplegia, unspecified injury at thoracic T7-T10 (spinal cord injury) level of thoracic spinal cord, and fracture of T9-T10 vertebra. Record review of the resident's hospital Discharge summary, dated [DATE], showed the following: -Diagnoses included acute pain due to trauma, traumatic epidural hematoma (brain bruise), acute kidney injury, motor vehicle collision, T-9 spinal cord injury, T- 9 vertebral fracture, and acute renal failure; -Resident is alert and oriented and in no acute distress; -Resident is cooperative with appropriate mood and affect. Record review of the resident's admission evaluation and interim care plan, dated 2/11/19, showed the following: -Level of consciousness marked alert; -Cognitive/emotional factors marked anxious; -Behavioral factors marked resists care; -Dependent for bed mobility, transfer, walking/locomotion, dressing, toileting, personal hygiene, and bathing; -Pain reported daily. Resident reports level 6 out of pain level of 0-10. Intensity level-worst is 10 and tolerable is 4. Record review of the resident's initial care plan, dated 2/11/19, showed the following: -Resident is able to communicate and is alert; -Behaviors present on admit: cries a lot and on call light a lot; -Resident has Foley catheter (a sterile tube inserted into the bladder to drain urine). Record review of the resident' progress note dated 3/1/19, at 5:50 A.M., showed staff found the resident on the floor at 5:50 A.M. The nurse observed blood coming from the resident's face. The nurse assessed the resident. Staff used the Hoyer lift to raise the resident in his/her bed. The nurse performed range of motion on the resident. The resident had a laceration to his/her left eyebrow measuring approximately two centimeters (cm). The nurse cleansed the laceration. The resident was found on the floor of the opposite side of the bed. The resident's catheter bag was hooked. The nurse unfastened the resident's catheter bag to release the tension. Prior to the fall, the nurse had positioned the resident in his/her bed. The resident was hanging off the bed. Staff said the resident said he/she was practicing rolling him/herself. The nurse educated the resident to inform staff to assist him/her with turning. This was approximately 5:35 A.M. Staff found the resident at approximately 5:40 A.M. hanging off the bed again. Staff reeducated the resident. The nurse obtained two sets of neurological checks on the resident. Record review of the resident's neurological flow sheet showed on 3/1/19, at 6:45 A.M., 7:00 A.M., and 7:30 A.M., staff did not document the resident's pulse, blood pressure, respiration, or temperature. Record review of the resident's progress note dated 3/1/19, at 8:00 A.M., showed the nurse called the physician's office and spoke with a staff person. The nurse explained the resident had blood present in his/her catheter and fell out of bed and landed on his/her face. The nurse informed the office the resident had a laceration above his/her left eye approximately two centimeters (cm) and applied steri-strps. The resident rolled out of bed and his/her catheter was hung on the opposite side of the bed so there was possible trauma to his/her genital area. The nurse documented the physician's office instructed staff to push fluids, obtain complete blood count (CBC) with differential, and PT-INR stat (immediately). The nurse informed the physician's office he/she flushed the resident catheter with 120 cc of NS which the resident tolerated well with no complaints of pain or discomfort. The resident stated he/she did not hurt anywhere but his/her chin. The resident stated he/she was freezing and he/she was shivering. The nurse turned up the resident's heat and put another blanket on him/her. Record review of the resident's neurological flow sheet dated 3/1/19 at 8:00 A.M. showed the resident's temperature 100.3 degrees. Record review of the resident's neurological flow sheet dated 3/1/19, at 9:00 A.M. and 10:00 A.M., showed staff did not document neurological checks. Staff documented the resident's temperatures at 99.8 degrees at 9:00 A.M. and 10:00 A.M. Record review of the resident's progress notes showed the following information: -On 3/1/19, at 10:00 A.M., a nurse documented the resident complained of being cold and running a slight fever which was 99.8 degrees. The nurse asked the medication technician to administer Tylenol as ordered. Staff administered Tylenol at 10:00 A.M. and charted effective at 11:00 A.M.; -On 3/1/19, at 12:00 P.M., a nurse documented another nurse informed him/her from the main dining room that the resident wanted to be sent out to the hospital. The nurse asked the resident why he/she thought he/she needed to be sent to the hospital. The resident stated these shorts are too tight. The resident stated he/she can't eat with these shorts on. The nurse asked the resident again why do you feel you need to go to the hospital. The resident stated I need to lay back in my chair, my back hurts. The nurse asked the resident again Why he/she needed to go to the hospital. The resident stated something about his/her feet. The nurse repeated the question again and told him/her to answer the question before addressing other complaints. The resident said therapy staff said I needed to go to the hospital; -On 3/1/19, at 4:30 P.M., a nurse documented the resident still had blood in his/her catheter. The resident's blood pressure was 86/54 millimeter of mercury (mm/Hg) (normal range is under 120/80) and pulse was 73 (normal range is 60 to 100 beats per minute). The nurse notified the physician's office. The nurse practitioner requested for the resident to be sent to emergency room for evaluation; -On 3/1/19, at 7:45 P.M., a nurse documented the administrator called and reported the resident was sent to another hospital due to sepsis, increased troponin (proteins released when the heart muscle has been damaged) levels, and other issues. Record review of the resident's hospital emergency room note, dated 3/1/19, showed the following: -Impression sepsis/septicemia (severe infection that has spread in the bloodstream); -Chief complaint - blood in urine; -Patients' level of distress - severe; -Generalized symptoms-fever; -Assessment on 3/1/19, at 4:46 P.M., showed the patient had fallen out of bed earlier in the morning. The resident's catheter partially came out. The patient had blood in his/her urine. The facility nursing staff informed emergency medical services staff the resident had rolled out of bed in the morning and his/her catheter partially came out. Facility staff said ever since that happened, the resident had been urinating blood that had only accumulated 150 cubic centimeters (cc). Facility staff said the resident had altered mental status. During an interview on 9/11/19, at 4:35 P.M., Certified Nurse aide (CNA) I said the following: -The resident was demanding with his/her care needs; -The resident had constant pain issues in his/her arm and leg; -The resident frequently yelled and cried. During an interview on 9/11/19, at 5:10 P.M., Licensed Practical Nurse (LPN) G said the following: -The resident had a history of traumatic brain injury and had childish reactions; -On the resident's final day in the facility, he/she rolled out of bed, after stating he/she was practicing turning in bed; -The facility sent the resident to the local emergency room and they sent the resident to a larger hospital in another city due to injuries the resident sustained during the fall; -The fall happened before LPN G came into work, he/she believed she arrived around 6:00 A.M. for his/her shift; -The nurse contacted the resident's physician and family; -The resident's blood pressure started dropping and the nurse wanted to send the resident out and the physician said okay, so he/she sent the resident to the emergency room for evaluation. -After the fall the resident had, a lot of blood in his/her catheter, the nurse flushed the catheter, but the bleeding did not resolve; - The nurse said she believes the resident rolled out of the opposite side of the bed from where the resident's Foley catheter bag was connected to the bed, causing the urinary catheter tubing to pull; -The nurse said he/she did not recall if the resident hit his/her head or not; -If a resident has a fall with a head injury, nurses should complete a neurological sheet in the chart; -The day of the fall, the resident went to the dining room for lunch; -During lunch, the nurse working the other side of the building (who was on dining room duty) called and said the resident was feeling really bad and was requesting to go to the hospital; -The resident said his/her shorts were too tight and his/her back hurt, the resident also said something about his/her feet; -The resident told the nurse that one of the therapists thought he should go to the hospital, but another therapist standing behind the resident shook her head no, indicating that was untrue; -The nurse said he/she returned the resident to his/her room and cut the resident's shorts off.; -The nurse said he/she believed he/she spoke to a receptionist at the physician's office; -At approximately 4:30 P.M., the resident continued to have blood in his/her catheter and had a low blood pressure and the nurse called the resident's nurse practitioner (NP) and the NP gave an order to send the resident out to the hospital; -The administrator called the local hospital later in the evening and they sent the resident to a Kansas City hospital due to sepsis. During an interview on 9/11/19, at 5:50 P.M., LPN J said the following: -Nursing should assess the resident for possible injuries from a fall. Staff should assist the resident into his/her chair or bed. Staff should assess the resident for pain, call the resident's physician and responsible party, notify the facility administrator and Director of Nursing (DON); -Nurses should complete neurological checks and monitor for any bumps or bruises if during a fall the resident hit his/her head. Staff should notify the physician if bruises develop; -The nurse said on the morning of the fall, he/she found the resident face down on the floor with a small pool of blood under the resident's head, the pool of blood was approximately the circumference of an orange, the resident had a gaping laceration above his eye approximately 2.0 cm in length which looked like it needed sutures; -The resident had a urinary catheter, but the catheter bag remained hooked on the opposite side of the bed, from which the resident fell, and the tubing stretched across the bed; -The nurse said he/she did not recall whether or not he/she completed neurological checks on the resident after the fall; -The nurse said neurological checks consisted of checking the resident's vital signs, blood pressure, pulse, temperature, respirations, and pulse oximetry; -The resident complained of his/her head hurting after the fall, but the nurse did not recall whether or not she documented this in the resident's record; -The nurse said the DON told him/her to go work on another issue after the fall; -The DON said he/she believed the DON would complete the notifications and the day shift nurse would complete the resident's neuro checks; -The nurse did not recall checking the resident's catheter bag for blood; -The nurse did not call the resident's physician or responsible party. During an interview on 9/11/19, at 6:38 PM., the MDS Coordinator said he/she remembered the resident's fall. The resident appeared sweaty and pale. The facility sent the resident to the hospital for evaluation. During an interview on 9/12/19, at 3:46 P.M., the DON said the following: -Staff should document neurological checks if a resident hit their head due to a fall; -Neurological checks means staff look in the resident's pupils and ask where they are. Staff should have the resident squeeze their hand for bilateral grips; -If a resident requests to go to the hospital, staff should send the resident to the hospital. During an interview on 9/12/19, at 5:21 P.M. the administrator said the resident had a fall. Staff performed general rounds at lunch time. The resident's vision was blurred. MO00160342

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to obtain an order for a catheter (a sterile tube inserted into the bladder to drain urine) and catheter care for one resident (Resident #46) and failed to follow orders for catheter care for another resident (Resident #56) out of sample size of 18 residents. The facility census was 71. Record review of the facility's policy titled Suprapubic Catheter (urinary bladder catheter inserted through the skin about 1 inch above the symphysis pubis (pelvis)) Care, dated October 2010, showed the following: -The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract; -Review the resident's care plan to assess for any special needs of the resident; -Wash around the catheter site with soap and water. (Note: If the resident has a drainage sponge around the stoma site, remove the drainage sponge before washing with soap and water.) Wash the outer part of the catheter tube with soap and water; -The following information should be recorded in the resident's medical record the date and time the procedure was performed; the name and title of the individual(s) who performed the procedure; all assessment data obtained during the procedure; how the resident tolerated the procedure; if the resident refused the procedure, the reason(s) why and intervention taken; results of the skin assessment around the stoma site; character of urine; any problems or complaints made by the resident during the procedure; and the signature and title of the person recording the data. 1. Record review of Resident #46's face sheet (general resident information form) showed the following information: -admission date of 06/12/19 with a readmission date of 7/09/19; -Diagnoses include pneumonia, hypertension (high blood pressure), retention of urine, urethral stricture (narrowing of the small structure that drains urine from the bladder), reduced mobility, urinary tract infection, and sepsis (infection). Record review of resident's chart showed the following: -A 48-hour care plan, dated 6/12/19, showed Foley catheter; -Initial care plan, dated 7/9/19, showed resident continent of bowel and bladder. -No comprehensive care plan in the chart Record review of the resident's nurse's note, dated 7/09/19, showed the following: -Resident arrived at facility at approximately 6:30 P.M. via facility transport; -Resident has suprapubic catheter in proper placement; -Nurse changed dressing on suprapubic catheter. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument completed by facility staff, dated 08/06/19, showed the following information: -Cognitively intact; -Independent with bed mobility, dressing, eating, toilet use, personal hygiene; -Supervision for walking; -Physical help in part of bathing; -Indwelling catheter; -Neurogenic bladder (dysfunction of the bladder caused by a lesion of the nervous system). Record review of resident's chart showed no comprehensive care plan in the chart Record review of the resident's September 2019 physician orders showed the following: -An order, dated 8/23/19, to monitor output of catheter every shift; -No order for catheter; -No order for catheter care. During an interview on 9/11/19, at 2:45 P.M., the resident said facility staff does not provide any catheter care or assessment of area outside of emptying catheter bag. During an interview on 9/12/19, at 12:24 P.M., Licensed Practical Nurse (LPN) B said the following: -Resident goes out to see physician to get catheter changed; -Resident does not have a dressing on and only wants to wad up paper towels and do it him/herself; -Resident will remove dressing if staff puts one on; -Resident should have a physician order for his/her catheter; -Staff should assess the catheter site every shift and document it on the treatment administration record (TAR). 2. Record review of Resident #56's face sheet (general resident information form) showed the following information: -admission date of 03/03/09 with readmit date of 08/08/19; -Diagnoses include postpolio syndrome (cluster of potentially disabling signs and symptoms that appear decades after the initial polio illness), lack of coordination, and abnormal posture. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Cognitively intact; -Total dependence of two+ persons for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing; -Extensive assistance of one person for locomotion on/off unit; -Setup help for eating; -Indwelling catheter; -Neurogenic bladder; -Urinary tract infection; -Resident at risk for developing pressure ulcers. Record review of the resident's September 2019 physician orders showed the following: -An order, dated 8/8/19, to flush catheter as needed; -An order, dated 8/8/19, to monitor catheter output every shift; -An order, dated 8/8/19, to change catheter dressing daily. During an interview on 9/10/19, at 10:26 A.M., the resident said staff is supposed to clean his/her catheter every day. Sometimes it will go a few days without being cleaned. During an observation on 9/10/19, at 2:55 P.M., with MDS coordinator during skin assessment rounds the resident was found to not have a dressing in place. The MDS coordinator said staff will often remove dressings to give the resident a shower and he/she will replace it when he/she does skin assessment rounds. During an interview on 9/12/19, at 12:24 P.M., LPN B said the following: -Resident's catheter is cleansed with normal saline, apply a split gauze and tape in place; -Resident will refuse catheter care at times; -Catheter changes are typically done at the doctor's office, but resident has not been to the doctor recently so staff did get an order to change it at the facility. During an interview on 9/12/19, at 12:24 P.M., Certified Nurse Aide (CNA) H said the resident has a cloth that is put around his/her catheter tube During an observation/interview on 9/12/19, at 5:04 P.M., LPN G said the following: -Resident had no dressing around catheter site; -Resident had a bed bath and it was removed then; -Upon review of resident's TAR it was found there was no order for the month of September for catheter care for resident. No catheter cares had been documented for the month; -The order was not carried over onto the nurse's TAR for the month of September and therefore was not documented as being done. He/she believed the cares were still being done and just not getting charted. 3. During an interview on 9/12/19, at 12:24 P.M., CNA H said the following: -He/she is told in report if a resident has a catheter; -He/She is responsible for emptying the catheter and writing down the amount and making sure area around it is clean and not irritated. 4. During an interview on 9/12/17, at 7:00 P.M., the DON said the following: -Residents admitted with a catheter should have that as an order on their physician order sheet; -The order should include the size, how often it is change, charting of appearance, charting of output amount, daily dressing changes, catheter care; -Nurses do catheter care every shift; -Aides do catheter care with pericare; -Care should be documented on the TAR to know that it has been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a physician's admission orders in a timely manner for one resident (Resident #73) when the facility did not confirm a physician for the resident until three days later. The physician orders for the resident were signed by a physician two months later. This practice affected one resident out of a sample of 18. The facility census was 71. 1. Record review of Resident #73's face sheet (general information at a quick glance) showed the following: -admitted to the facility on [DATE]; -Diagnoses included paraplegia, unspecified injury at T7-T10 level of thoracic spinal cord, and fracture of T9-T10 vertebra. Record review of the resident's hospital Discharge summary, dated [DATE], showed the following: -Diagnoses included acute pain due to trauma, traumatic epidural hematoma (brain bruise), acute kidney injury, motor vehicle collision, T 9 spinal cord injury, T 9 vertebral fracture, and acute renal failure; -Resident is alert and oriented and in no acute distress; -Resident is cooperative with appropriate mood and affect. Record review of the resident's nurse's note dated 2/11/19, at 12:45 P.M., showed a nurse documented the resident arrived to the facility via stretcher. The resident is maximum assistance of two or more people with a Hoyer lift. The resident's vital signs are stable at the time of his/her arrival. The resident is alert and oriented times four. Staff assessed the resident's skin. Record review of the resident's physician order sheet (POS), dated 2/11/19, showed the following: -Regular diet; -Do not resuscitate; -Complete blood count -Monitor pain every shift; -Oxycodone (pain medication), five milligrams (mg), as needed (PRN); -Lidocaine patch daily; -Monitor Foley catheter (a sterile tube inserted into the bladder to drain urine) output every shift; -Flush catheter with 30 cubic centimeters (cc), PRN; -Change Foley catheter PRN; -Acetaminophen (pain medication) 325 mg, PRN; -Vitamin C 1000 milligrams (mg), daily; -Asorbic acid (supplement) 325 mg, daily; -Baclofen (muscle spasms) 10 mg, three times per day (TID); -Cholecalciferol (supplement), 1 capsule daily; -Clonazepam (anxiety medication) 0.5 mg, PRN; -Clonidine 0.2 mg, every eight hours; -Senna (constipation medication), two tablets twice per day (BID); -Doxazosin (urinary retention), 4 mg at night; -Gabapentin (neuropathy) 100 mg, three times a day; -Lamotrigine (seizures) 200 mg, twice a day; -Melatonin (insomnia) 10 mg at night; -Effexor (anxiety medicine) 150 mg daily. -The physician orders were signed by the new physician on 4/12/19 (two months after the resident was admitted to the home). Record review of the resident's admission evaluation and interim care plan, dated 2/11/19, showed the following: -Level of consciousness marked alert; -Cognitive/emotional factors marked anxious; -Behavioral factors marked resists care; -Dependent for bed mobility, transfer, walking/locomotion, dressing, toileting, personal hygiene, and bathing; -Pain reported daily. Resident reports level 6 out of pain level of 0-10. Intensity level-worst is 10 and tolerable is 4. Record review of the resident's initial care plan, dated 2/11/19, showed the following: -Resident is able to communicate and is alert; -Behaviors present on admit: cries a lot and on call light a lot; -Resident has Foley catheter. Record review of the resident's nurse's note dated 2/14/19, at 2:30 P.M., showed a nurse documented the physician called the facility and advised he did not accept the resident as a patient (three days after admission of the resident). Staff informed the social worker. At 5:00 P.M., the resident is now a patient of another physician. Staff received an order for Zofran from the new physician. Record review of the resident's March 2019 POS showed the physician orders were signed on 2/26/19 by the new physician (15 days after the resident's admission). During an interview on 9/11/19, at 5:10 P.M., Licensed Practical Nurse (LPN) G said the following: -If a resident is being admitted from the hospital, a nurse should call the physician and okay the admission orders before the resident arrives. During an interview on 9/11/19, at 5:50 P.M., LPN J said the following: -When a resident is admitted from the hospital, the day nurse usually starts the admission paperwork; -If the day nurse does not talk to the resident's physician prior to the resident's arrival, then the LPN would call the physician to obtain the admission orders. During an interview on 9/11/19, at 6:38 PM., the MDS Coordinator said the following: -Prior to admission, a nurse should notify a resident's physician prior to the resident's admission to the facility to okay admission orders; -When a nurse speaks to a resident's physician to obtain orders, a nurse should document this conversation in the resident's nurses' notes and write the orders on a physician order sheet with the time and date of the conversation with the physician. During an interview on 9/12/19, at 3:46 P.M., the Director of Nursing (DON) said the following: -A resident's admission transfer orders come from the discharging facility; -Staff should contact the physician if a resident does not have a physician and determine if they will accept the resident; -The social worker calls the physician office and the nurses fax the original discharge orders to the physician. The physician will send back the orders if they want to change an order; -Nurses should document in the admission orders on the POS. During an interview on 9/13/19, at 9:45 A.M., the resident's Nurse Practitioner (NP) said the following: -A nurse from the facility contacted them a couple of days after the resident's admission and said prior physician did not want to be the resident's physician, the NP said he/she believed this was due to the resident's non-compliance; The NP said she and his/her current physician took over the resident's care a day or two after admission due to the other physician's refusal; -The facility should have contacted the prior physician for the resident's admission orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to address one resident's (Resident #66) dental needs out of a sample of 18 residents in a facility with a census of 71. Record review of the facility's policy titled, Availability of Services, Dental, revised August 2007, showed the following information: -Oral healthcare and dental services will provided to each resident; -Dental services are available to all residents requiring routine and emergency dental care; -All requests for routine and emergency dental services should be directed to Social Services and/or designee to assure that appointments can be made in a timely manner; -Residents with lost or damaged dentures will be promptly referred to a dentist. Record review of the facility's policy titled Routine Dental Care, revised April 2007, showed the following information: -Each resident will receive routine dental care; -The attending physician will be notified of a resident's need for dental treatment and order dental consultations as appropriate; -The attending physician will include, as part of his/her initial medical assessment, an assessment of the resident's dental needs. Findings will be included in their resident's medical record. 1. Record review of Resident #66's Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 8/14/19, showed the following information: -Cognitively intact; -Oral hygiene was blank; -Dental - pain, discomfort, difficulty chewing was unchecked. Record review of the resident's current care plan showed the following: -Resident was admitted on [DATE]; -Staff did not care plan dental needs of the resident. Record review of the resident's social service note, dated 2/19/19, showed the resident goes out for dental care as needed. Record review of the resident's nursing home assessment, dated 5/10/19, showed under Exam by Physician Comments, dental cavities. The Treatment/Plan said appointment with Compass Health. Record review of the resident's social service note, dated 5/22/19, showed the resident goes out for dental care as needed. Record review of the resident's June 2019 physician order sheet (POS) showed a standing facility order for dental consult as needed. Record review of the resident's July 2019 POS showed a standing facility order for dental consult as needed. Record review of the resident's August 2019 POS showed a standing facility order for dental consult as needed. Record review of the resident's social service note, dated 8/13/19, showed the resident does go out for dental care. Record review of the resident's September 2019 POS showed a standing facility order for dental consult as needed. Observation and interview on 9/9/19, at 1:00 P.M., showed the resident in his/her room sitting in a recliner. The resident said he/she has some issues with his/her teeth. Several of his/her teeth are bad and he/she has not seen a dentist since he/she has been at the facility. He/she has told the staff about his/her teeth. During an interview on 9/13/19, at 8:15 A.M., the resident says his teeth hurts sometimes and he/she has not said anything. During an interview on 9/13/19, at 8:28 A.M., the Durable Power of Attorney (DPOA) said he/she knows nothing about dental issues for the resident. The facility has not contacted him/her in regards to dental problems. DPOA said he/she visited the facility in July and the facility did not say anything to him/her about dental issues. During an interview on 09/13/19, at 8:40 A.M., the Social Service Director (SSD) said Certified Nursing Assistant (CNA) F is responsible for scheduling residents' appointments and taking them to the appointments. Nursing tells SSD if there is a resident who is having dental problems. If they do not have insurance, the DPOA or family is responsible for paying for dental care. A nurse will contact the SSD and the SSD will contact the family or DPOA. The resident's DPOA is a family member. SSD said she has tried to contact the DPOA, but the DPOA is hard to get in touch with. The SSD thinks the attempts of contacting the DPOA is the resident's notes. The SSD did not talk to the DPOA when the DPOA was at the facility in July about the resident's teeth because the resident told her that he/she didn't want to go to the dentist. The SSD said she did not know there was a note from doctor suggesting Compass Health for a dental appointment. During an interview on 09/13/19, at 8:47 A.M., the resident said he/she never told the SSD that he/she did not want a dentist appointment. During an interview on 09/13/19, at 9:20 AM, Certified Medication Technician (CMT) D said he/she would report dental issues to a nurse or to CNA F. Signs of dental issues are pain, lack of eating, weight loss, swelling, or moaning. During an interview 09/13/19, at 9:50 AM, Licensed Practical Nurse (LPN) E said signs of issues with teeth/dentures could be the resident won't wear dentures, redness of gums, pushing them out, moving tongue, swollen mouth, complaining of pain, or weight loss. During an interview on 09/13/19, at 10:32 AM, CNA F said he/she was the transportation driver and CNA. Nurses will come to CNA F and let him/her know if an appointment is needed and he/she will set up the appointments. SSD will tell CNA F if someone needs an appointment scheduled. CNA F will look at the resident's face sheet and will talk to social worker if the residents are private pay. A nurse told CNA F to get a dental appointment for the resident. Then a second nurse told CNA F to schedule a dental appointment for the resident. CNA F went to SSD and talked to her about scheduling an appointment for the resident. SSD told CNA F she would take care of it and get back with CNA F. SSD never got back with CNA F. CNA F does not recall he/she talked to the SSD, but knows the doctor had written an order for dental care. During an interview on 09/13/19, at 11:32 AM, the Director of Nursing (DON) said the dental provider is Compass Health because Compass Health can get residents in quicker. Some residents have their own dentist. The process of dental care is the facility will call the doctor and the doctor will put in an order for the resident to see dentist. SSD will see where the resident wants to go, then either herself or the SSD will get the transportation lady and schedule the appointments. The family can take the resident to the dentist. If the resident is private pay, the facility will notify the family or responsible family, and see how they want it to be handle the payment. SSD gets in touch with family then goes from there. The DON said she didn't think that the resident had issues with his/her teeth. The DON thinks that the resident said no when asked about dental services. During an interview on 09/13/19, at 11:32 A.M., the administrator said he hasn't been able to get in touch with the DPOA. DPOA always checks in with the SSD. If there is no documentation showing the SSD spoke with the DPOA, it is an oversight. During an interview on 9/13/19, at 4:38 P.M., the administrator said the resident is private pay and would have to wait for the DPOA to authorize the funding for dental care. He does not know about any dental appointment for the resident. The Social Service Director (SSD) is working on funding and an appointment for the resident. The facility is looking for a dental company. The facility is using Compass Health for dental services. The facility would provide services if a resident did not have funding, it would not prevent them from going if there a emergencies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to fully document administration and effectiveness of administered pain medications for three residents (Resident #32, #36, and #72); failed to address and notify the physician of continued pain for one (Resident #32 and #73); and failed to document administration of pain medication for one resident (Resident #36) in a sample of 18. The facility's census was 71. Record review of the facility's pain assessment and management policy, dated March 2015, showed the following: -The purposes of this procedure is to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain; -Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals; -Pain management is a multidisciplinary care process that includes assessing the potential for pain; effectively recognizing the presence of pain; identifying the characteristics of pain; addressing the underlying causes of the pain; developing and implementing approaches to pain management; identifying and using specific strategies for different levels and sources of pain; monitoring for the effectiveness of interventions; modifying approaches as necessary; and reassess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain; -Document the resident's reported level of pain with adequate detail as necessary and in accordance with the pain management program; -Report the following information to the physician or practitioner: significant changes in the level of the resident's pain and prolonged, unrelieved pain despite care plan interventions. Record review of the facility's administering pain medications policy, dated October 2010, showed the following: -The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication; -Be familiar with the physiologic and behavioral (non-verbal) signs of pain including verbal expressions such as groaning, crying, screaming; facial expressions such as grimacing, frowning, clenching of the jaw; behavior such as resisting care, irritability, depression, decreased participation in usual activities; and insomnia; -Conduct an abbreviated pain assessment if there has been no change of condition since the previous assessment; -Evaluate and document the effectiveness non-pharmacological interventions (repositioning, warm or cold compresses); -Administer pain medications as ordered; -Document the following in the resident's medical record: results of the pain assessment, medication, dose, route of administration, and results of the medication (adverse or desired). Record review of the facility's policy titled Administering Pain Medications, dated October 2010, showed to document the following in the resident's medical record: -Results of the pain assessment; -Medication; -Dose; -Route of administration; -Results of the medication (adverse or desired). 1. Record review of Resident #32's face sheet (general information at a quick glance) showed the following: -admitted to the facility on [DATE] and readmitted on [DATE]; -Diagnoses included diabetes mellitus without complications, peripheral vascular disease (a disease of the large blood vessels of the arms, legs, and feet. PVD may occur when major blood vessels in these areas are blocked and do not receive enough blood), unspecified dementia without behavioral disturbance, and acquired absence of right leg above knee. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/21/19, showed the following: -Severely impaired cognitive skills; -No behaviors; -Extensive assistance required with bed mobility, transfers, dressing and toilet use; -Pain frequently with pain intensity of 7 on a 1 to 10 pain scale. Record review of the resident's current care plan, (no date), showed the following: -The resident has a new above the knee amputation on the right side; -Staff to monitor the incision for signs of infection; -Staff to provide the resident with pain medication; -Staff to teach the resident about phantom pain and how to deal with it; -Resident has history of pain; -Staff to medicate appropriately and monitor for effectiveness. Staff to notify the physician if the medication is non-effective; -The resident will often rub his/her right stump and moan. Staff to administer as needed (PRN) medication to the resident as scheduled per the physician. Record of the resident's August 2019 physician's order sheet (POS) showed the following: -Tylenol (used to treat mild to moderate pain), 325 milligrams (mg), every four hours while awake; -Tylenol, 325 mg, every four hours as needed (PRN); -Tramadol (used to treat moderate to severe pain), 50 mg, every six hours PRN-with Tylenol. Record review of the resident's nurse's note dated 8/12/19, at 11:08 P.M., showed a nurse documented the resident reported pain. Staff administered the resident's as needed medication with effective results. Record review of the resident's August 2019 medication administration record (MAR) showed on 8/12/19 staff did not document administering Tramadol to the resident. Record review of the resident's nurse's note dated 8/13/19, at 10:30 P.M., showed a nurse documented the resident reported pain in his/her legs. Staff administered the resident's as needed medication. Record review of the resident's August 2019 MAR showed on 8/13/19 staff administered Tramadol to the resident. Staff did not document reason given, or results. Record review of the resident's nurse's note dated 8/17/19, at 4:30 P.M., showed a nurse documented the resident denied pain. Record review of the resident's August 2019 MAR showed on 8/17/19 staff administered Tramadol to the resident. Staff did not document the reason given or results. Record review of the resident's nurse's note dated 8/19/19, no time noted, showed a nurse documented the resident denied pain. Record review of the resident's August 2019 MAR showed on 8/19/19, at 5:00 A.M., staff administered Tramadol to the resident. Staff documented the resident rated the level of pain at an 8 out of 10 on the pain scale. Staff did not document the results of the medication. Record review of the resident's August 2019 MAR showed the following: -On 8/22/19, at 1:00 P.M., staff administered Tramadol to the resident for leg pain. Staff did not document the results; -On 8/24/19, at 1:20 P.M., staff administered Tramadol for leg pain. Staff did not document the results; -On 8/28/19, at 5:30 A.M., staff administered Tramadol to the resident for leg pain. Staff documented the resident rated an 8 out of 10 on the pain scale. Staff did not document the results of the medication. Record review of the resident's nurse notes dated 8/28/19, at 4:40 P.M., showed a nurse documented the resident denied pain. Record of the the resident's September 2019 (POS) showed the following: -Tylenol, 325 mg, every four hours while awake; -Tylenol, 325 mg, every four hours PRN; -Tramadol, 50 mg, every six hours PRN-with Tylenol. Record review of the resident's September 2019 MAR showed on 9/2/19, staff administered Tramadol twice to the resident. Staff documented at 7:45 P.M. resident reported complaints of leg pain. Staff did not document the results of the medication. Record review of the resident's September 2019 MAR showed the following: -On 9/6/19, staff administered Tramadol to the resident. Staff documented at 12:00 A.M. staff administered Tramadol to the resident for leg pain. Staff did not document the results; -On 9/7/19 staff did not document Tramadol given. Record review of the resident's nurse's note dated 9/7/19, at 4:00 P.M., showed staff documented the resident said some relieved pain from the Tramadol. Record review of the resident's nurse's note dated 9/10/19, at 8:50 A.M., a nurse documented the resident complained of pain and at the time relieved by PRN medications. Record review of the resident's September 2019 MAR showed on 9/10/19 staff administered Tramadol. Staff documented on 9/10/19, at 4:00 P.M., Tramadol given for general pain. Staff did not document the results of the medication. During an interview on 9/11/19, at 11:18 A.M., Certified Nurse Aide (CNA) K said the resident's pain level is hard to gauge. The resident figits a lot, accompanied with moaning. CNA K said the resident's figiting is almost like a tick or habit. The resident will tell staff if he/she is in pain. The resident will complain of pain every other day. During an interview on 9/12/19, at 11:16 A.M., the Assistant Director of Nursing (ADON) said the resident's physician is aware of his/her constant moaning. The ADON said since the resident's amputation, he/she will rock and rub. The resident will moan with his/her right below the knee amputation. During an on 9/11/19, at 5:02 P.M., Certified Medication Technician (CMT) A said staff administered the resident scheduled Tylenol and Tramadol PRN. The resident complains of his/her leg hurting that has been amputated. The resident had his/her knee amputated the beginning of the year. Staff have discussed the resident with the physician. The physician thinks the resident's pain is psychological and phantom pain. Staff have discussed scheduling the Tramadol. The physician is adamant about not scheduling the Tramadol. The resident seems to be more agitated and bounces his/her right amputated knee. An observation on 9/12/19, at 11:32 A.M., showed the resident wheeled his/her wheelchair to his/her room after lunch. The resident moaned all the way to the room. During an interview on 9/12/19, at 12:02 P.M., Licensed Practical Nurse (LPN) B said the resident receives scheduled Tylenol and Tramadol PRN. The resident moans and rubs his/her leg. The resident will tell staff when he/she needs a pain pill. Staff should ask the resident his/her pain level administer the PRN pain medication. Staff should document the resident's pain level, medication given, and the medication effectiveness within 30-45 minutes on the MAR. Staff should notify the physician if a pain medication if non-effective and ask for something more or alternative methods. The resident came back from amputation of his/her leg on Tylenol and Tramadol was added later. LPN B stated the resident's pain appears to be well managed. During an interview on 9/12/19, at 3:00 P.M. and 3:46 P.M., the Director of Nursing (DON) said the resident can tell you if he/she hurts. The resident moaned before his/her below the knee amputation. The resident is a lot better than he/she used to be. The resident's physician thinks his/her moaning is more of a habit. During an interview on 9/13/19, at 9:00 A.M., the MDS coordinator said staff update residents' care plans regarding pain. He/she talked with the resident's physician the other day about the resident's pain. The discussion was maybe not pain, but a habit that he/she has been doing for so long. The resident sometimes states he/she has pain and sometimes states no pain. 2. Record review of Resident #73's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included paraplegia, unspecified injury at T7-T10 level of thoracic spinal cord, and fracture of T9-T10 vertebra. Record review of the resident's hospital Discharge summary, dated [DATE], showed the following: -Diagnoses included acute pain due to trauma, traumatic epidural hematoma (occurs when blood accumulates between the skull and the dura mater, the thick membrane covering the brain), acute kidney injury, motor vehicle collision, T 9 spinal cord injury, T 9 vertebral fracture, and acute renal failure; -Resident is alert and oriented and in no acute distress; -Resident is cooperative with appropriate mood and affect. Record review of the resident's February 2019 POS, dated 2/11/19, showed the following: -Oxycodone (used to treat moderate to severe pain), 5 mg every six hours PRN; -Lidocaine (inhibits conduction of nerve impulses from sensory nerves), 4 percent topical patch, daily; -Acetaminophen (used to treat mild to moderate pain), 325 mg every six hours PRN; -Baclofen (muscle relaxant), 10 mg, three times a day; -Gabapentin (used to treat neuropathic (relating to nerves) pain), 100 mg, three times a day. Record review of the resident's admission evaluation and interim care plan, dated 2/11/19, showed the following: -Level of consciousness marked alert; -Cognitive/emotional factors marked anxious; -Behavioral factors marked resists care; -Dependent for bed mobility, transfer, walking/locomotion, dressing, toileting, personal hygiene, and bathing; -Pain reported daily. Resident reports level 6 out of pain level of 0-10. Intensity level-worst is 10 and tolerable is 4. Record review of the resident's initial care plan, dated 2/11/19, showed the following: -Resident is able to communicate and is alert; -Behaviors present on admit: cries and uses call light a lot; -Resident has a Foley catheter (a sterile tube inserted into the bladder to drain urine). Record review of the resident's February 2019 MAR showed on 2/11/19, at 8:00 P.M., staff administered oxycodone for pain. Staff did not initial on the front of the MAR. Staff did not document results of the medication. Record review of the resident's progress note on 2/11/19, at 11:15 P.M., showed a nurse documented staff administered oxycodone out of the emergency kit because the resident complained of pain. Resident rated the level of pain at a ten out of ten on the pain scale. Record review of the resident's February 2019 MAR showed the following: -On 2/12/19, at 4:00 A.M., staff administered oxycodone for pain. Staff did not document the results of the medication; -On 2/13/19, at 8:05 P.M., staff administered oxycodone for back pain. The resident rated the level of pain at a 9 out of 10 on the pain scale. Staff documented the results as noneffective. Record review of the resident's February 2019 MAR showed on 2/16/19, at 12:40 A.M. staff administered oxycodone for back pain. The resident rated the level of pain at a 9 out of 10 on the pain scale. Record review of the resident's progress note dated 2/16/19, at 1:00 A.M., showed a nurse documented the resident complained of pain. Staff administered oxycodone one time this shift. The resident rated the level of pain at a 9 out of 10 on the pain scale. The resident cried all shift. The resident is very demanding. The resident had multiple complaints of left ankle pain. Staff readjusted the resident several times with no relief. Staff advised the resident to allow the pain pill to take affect for possible relief. Record review of the resident's February 2019 MAR showed on 2/16/19, at 1:40 A.M., staff documented the oxycodone was effective in treating the resident's pain. Record review of the resident's progress note showed on 2/17/19, at 7:30 A.M., a nurse documented the resident cried and yelled loudly which could be heard at the nurses' station. The resident's door was closed. The nurse asked the resident what he/she was upset about and the resident stated my left leg hurts, and your are going to have to rub my leg. Staff repositioned the resident several times previously. The nurse told the resident a staff person would help reposition as soon as available. The resident continued to yell and cry. The nurse asked the resident to quiet down due to other residents could hear him/her and it was upsetting them. The resident continued to yell. The resident said you don't understand. The nurse repositioned the resident's leg, but the resident continued to yell and cry. The nurse told the resident he/she needed to stop and quiet down. The resident got louder. The nurse closed the resident's door and continued to monitor. Record review of the resident's February 2019 MAR showed the following: -On 2/17/19, staff did not administer oxycodone; -On 2/18/19, at 11:00 P.M., staff administered oxycodone for leg pain. The resident rated the level of pain at a 9 out of 10 on the pain scale. Staff documented at 1:00 A.M. the results were non effective; -On 2/18/19, at 12:05 A.M., staff administered Tylenol for leg and muscle pain. Staff did not document the results; -On 2/19/19, at 5:40 A.M., staff administered oxycodone for back pain. The resident rated the level of pain at a 9 out of 10 on the pain scale. Staff documented at 6:30 A.M. the results were noneffective. Record review of the resident's progress note dated 2/20/19, at 3:45 A.M., a nurse documented the resident was very demanding and yelled throughout the shift. The resident is rude and used foul language with the staff. The resident complained of pain. Staff administered Oxycodone. Record review of the resident's February 2019 MAR showed the following: -On 2/20/19, at 4:40 A.M., staff administered oxycodone for general pain. The resident rated the level of pain at a 9 out of 10 on the pain scale. Staff documented at 6:00 A.M. the results were noneffective; -On 2/21/19, at 3:05 A.M., staff administered oxycodone for leg pain. Staff did not document the results of the medication; -On 2/22/19, at 3:30 A.M., staff administered oxycodone for back and leg pain. The resident rated the level of pain at a 9 out of 10 on the pain scale. Staff documented the results as some relief. Record review of the resident's progress note dated 2/22/19, at 3:40 A.M., showed a nurse documented the resident consistently yelled and cried all throughout the shift. Staff repositioned the resident multiple times. The resident complained of pain in his/her back and legs. Staff administered oxycodone twice. The resident stated those pain pills never work The resident continued to yell and cry. This nurse asked the resident to lower his/her voice because other residents are trying to sleep and he/she is disturbing and making them upset, including his/her roommate. The resident stated Don't tell me that, you don't get to tell me that. I don't care about other people. The resident threatened to throw a cup at this nurse and stated you're fired. This nurse told the resident he/she was being very inconsiderate to his roommate and disrespectful to me. This nurse told the resident when he/she was ready to talk nicely, I would come back. The resident continued to yell and cry. Staff administered medication as ordered. Record review of the resident's February 2019 MAR showed the following: -On 2/22/19, at 11:00 A.M., staff administered oxycodone for right foot pain. The resident rated the level of pain at a 9 out of 10 on the pain scale. Staff did not document the results of the medication; -On 2/22/19, at 8:00 P.M., staff administered oxycodone for back pain. The resident rated the level of pain at a 9 out of 10 on the pain scale. Staff documented at 10:00 P.M. some relief. Record review of the resident's progress note showed the following: -On 2/24/19, at 11:35 P.M a nurse documented the resident cried and yelled. The resident was combative with staff when attempted to assist to bed after breakfast. Staff attempted to talk to the resident who continued to yell. Staff asked the resident why he/she was yelling. The resident stated I cry whether I hurt or not, I can't help it; -On 2/25/19, at 3:20 A.M., a nurse documented the resident cried and yelled throughout the night. The resident is very demanding; -On 2/25/19, at 4:00 A.M., a nurse documented the resident continued to yell and scream out at staff. The resident disturbed surrounding peers. Peers cannot sleep and are upset and yelled out as well. This nurse told the resident to please lower his/her voice and be respectful of others. The resident stated I'm firing you. I'm reporting you. What's your name. The resident threatened the nurse to hit head with a rock. This nurse told the resident that is inappropriate and walked out of the resident's room; -On 2/25/19, at 1:00 P.M., staff administered oxycodone for pain. Resident reported a 10 out of 10 on the pain scale. Staff did not document the results. Record review of resident's February 2019 MAR showed on 2/25/19, at 11:00 P.M., staff administered oxycodone for back and leg pain. Staff did not document the results of the medication. Record review of the resident's 14-day admission MDS, dated [DATE], showed the following: -Moderately impaired cognitive skills; -Inattention, disorganized thinking and altered level of consciousness not marked; -Verbal behaviors directed toward others occurred daily; -Total dependence for bed mobility, transfers, dressing and toilet use; -Pain marked frequently; -Hard to sleep at night due to pain marked yes; -Pain limited day-to-day activity marked yes; -Pain level on scale of 0-10 marked at 8. Record review of the resident's nurse practitioner progress note, dated 2/26/19, showed the following: -The resident seen for new admission history and physical and problems with depression, anxiety, and insomnia; -The resident is a new patient following a motor vehicle accident. The resident has a spinal cord injury and is suppose to rehab to home; -The resident had back fusion and has a great deal of pain; -The resident has problems with sleeping and with anxiety related to being here; -The resident is well developed and in no distress. The resident has no acute behaviors; -The resident is alert and oriented times three, but lethargic from the pain medications. Record review of the resident's progress note dated 2/27/19, at 3:20 A.M., showed a nurse documented the resident complained of pain. Staff administered oxycodone. The resident continued to yell and cry throughout the night. Staff received new order for as needed Klonopin (used to treat anxiety) at night. Staff administered Klonopin. The resident continued to yell and cry all throughout the shift. Staff readjusted the resident multiple times. Record review of the resident's February 2019 MAR showed the following: -On 2/27/19, at 5:45 A.M., staff administered oxycodone for pain 9/10. Staff documented at 6:30 A.M. the results were effective; -On 2/27/19, at 10:45 P.M., staff administered oxycodone for leg pain 9/10. Staff documented at 11:45 P.M. the results were noneffecitve. Record review of the resident's progress notes showed the following: -On 2/27/19, at 11:10 A.M., a nurse documented the resident cried and yelled a lot his morning. Staff redirected the resident several times; -On 2/28/19, at 3:45 A.M., the resident cried and yelled at the beginning of the shift. The resident had complaint of pain and discomfort. Staff administered oxycodone. Resident continued to yell and disturb other residents. Staff redirected the resident several attempts. The resident eventually fell asleep. Record review of the resident's February 2019 MAR showed the following: -On 2/28/19, at 5:45 A.M., staff administered oxycodone for leg pain 9/10. Staff documented at 6:30 A.M. the results helped; -On 2/28/19, at 8:20 P.M., staff administered oxycodone for leg pain 9/10. Staff did not document the results of the medication. Record review of the resident's social services' progress note, dated 3/6/19, showed the resident enjoyed some activities. The resident's pain did limit him/her on what he/she was able to do and enjoy. The resident was demanding in his/her cares and would often cry out. During an interview on 9/11/19, at 4:35 P.M., CNA I said the following: -The resident was demanding with his/her care needs; -The resident had constant pain issues in his/her arm and leg; -The resident frequently yelled and cried. During an interview on 9/11/19, at 5:10 P.M., LPN G said the following: -The resident had a history of traumatic brain injury and had childish reactions; -The resident had obesity and required three to four staff and a Hoyer lift (a mechanical lift with a sling used for transferring residents) for transfers; -The resident always complained of pain in his/her legs and wanted staff to pull on his/her legs; -The resident did not have feeling to his/her legs. During an interview on 9/11/19 at 5:50 P.M.,LPN J, on the night (6 P.M. to 6 AM.) shift said the following: -The resident was very confused, wanted staff with him/her all the time and had difficulty understanding that the facility could not provide one on one care; -The resident screamed and yelled frequently at night and the nurse believed the screaming was due to wanting staff in room and frequently wanted re-positioned in bed; -The nurse said staff could reposition the resident and five seconds later, he would be screaming again; -The resident complained of pain at least one or two times per night; -The resident cried, but more frequently whined about pain; -The resident's complained of generalized pain or of back pain; -The resident said his/her legs hurt, but the nurse did not believe the resident had any feeling in his/her legs; -The nurse said the pain medication usually relieved the resident's pain; -The nurse said he/she did not talk to the resident's physician or nurse practitioner (NP) about the resident's pain, but did sometimes mention the issues to the day shift nurse; -The nurse said she thought the resident had another order for an anxiety medication that sometimes helped with the resident's yelling; -The nurse said he/she would sometimes shut the resident's door to cut down on noise at night, so other residents could sleep; -The nurse said there were times when she probably did not go back to the resident after administration on pain medication to see if the medication was effective; -The nurse said, if she re-evaluated the resident's pain after administration of a PRN pain medication, he/she would document on the back of the MAR. During an interview on 9/13/19, at 9:45 A.M., the resident's Nurse Practitioner (NP) said the following: -The resident came to the facility after a moving vehicle accident (MVA); -The resident was non-compliant with staff at times; -The resident had significant pain with any activity; -The NP saw the resident one time at the facility, at that visit the resident sat in a wheelchair and informed the NP he/she was okay as long as he/she took pain medicine and did not do anything, the NP said she assumed this meant the resident did not want to do any (physical or occupational) therapy; -If the pain medication staff administered to the resident did not effectively control his/her pain, the nurses should have called and notified the resident's physician or NP; -If the resident yelled and screamed during the night, the nurses should have called and notified the resident's physician or NP. 3. Record review of Resident #36's face sheet (general resident information form) showed the following information: -admission date of 6/24/19; -Diagnoses included fracture of left femur (thigh bone). Record review of the resident admission MDS, dated [DATE], showed the following information: -Cognitively intact; -Limited assistance of one for bed mobility, transfer, dressing, toileting, and personal hygiene; -Physical help of one for bathing; -Supervision/set up help with eating; -Use of walker/wheelchair; -Received as needed pain medication. Record review of the resident's September 2019 POS showed the following information: -Monitor pain every shift; -An order, dated 6/24/19, acetaminophen (used to treat mild to moderate pain) 325 milligrams (mg), two tablets every four hours as needed; -An order, dated 6/24/19, hydrocodone (used to treat mild to moderate pain) 5/325 mg, one tablet every four hours as needed. Record review of the resident's care plan, dated 6/24/19, showed the resident at risk for altered comfort due to fracture of left femur with goal to be free from pain or discomfort. The approaches included the following: -Coordinate with physician to manage pain medication for optimum control of pain; -Observe for effectiveness of medication; -Observe for non-verbal signs of pain; -Observe for factors that increase/decrease pain; -Observe for side effects of pain medication; -Observe for intolerable pain; -Measure pain level using pain scale 1 to 10. Record review of the resident's September 2019 POS showed the following information: -An order, dated 7/14/19, for hydrocodone 5/325 mg, one tablet at 8:00 P.M. Record review of the resident's Individual Narcotic Log compared to resident's MAR showed the following doses of PRN hydrocodone 5/325 mg signed out on the narcotic log in the controlled substance book, but not documented in the resident's chart on the MAR: -08/01/19, at 3:35 A.M., with no documentation of effectiveness of the PRN pain medication; -08/02/19, at 12:30 A.M., with no documentation of effectiveness of the PRN pain medication; -08/03/19, at 2:30 A.M., with no documentation of effectiveness of the PRN pain medication; -08/04/19, at 5:15 A.M., with no documentation of effectiveness of the PRN pain medication; -08/05/19, at 3:00 A.M., with no documentation of effectiveness of the PRN pain medication; -08/06/19, at 2:21 A.M., with no documentation of effectiveness of the PRN pain medication; -08/06/19, at 9:55 A.M., documented on resident's MAR with no effectiveness documented; -08/07/19, at 12:39 A.M., with no documentation of effectiveness of the PRN pain medication; -08/10/19, at 4:30 A.M., documented on resident's MAR with no effectiveness documented; -08/12/19, at 8:45 A.M., with no documentation of effectiveness of the PRN pain medication; -08/12/19, at 3:10 A.M., with no documentation of effectiveness of the PRN pain medication; -08/13/19, at 4:15 A.M., with no documentation of effectiveness of the PRN pain medication; -08/15/19, at 10:00 A.M., documented on resident MAR with no effectiveness documented; -08/19/19, at 4:00 A.M., with no documentation of effectiveness of the PRN pain medication; -09/05/19, at 2:00 P.M., with no documentation of effectiveness of the PRN pain medication; -09/06/19, at 12:05 P.M., with no documentation of effectiveness of the PRN pain medication; -09/07/19, at 7:35 A.M., with no documentation of effectiveness of the PRN pain medication. During an observation of medication administration on 9/10/19, at 10:54 A.M., the following was observed: -Staff told Licensed Practical Nurse (LPN) G that resident was requesting pain medication; -LPN G removed one tablet of Hydrocodone 5/325 mg from medication card with residents name listed on the label; -LPN G documented the removal of the medication on the individual narcotic log in the controlled substance book; -LPN G did not document the administration of the medication or the pain level on the residents medication administration record (MAR). Record review and interview on 9/11/19, at 11:10 A.M., showed the following: -The resident's MAR did not reflect the administration of the PRN dose given on previous day; -There was no documentation of effectiveness of PRN pain medication from that dose; -LPN G said he/she sometimes forgets to document PRN pain medication administration in both places. During an interview on 9/12/19, at 3:56 P.M., Certified Medication Technician (CMT) A said the following: -Administration of PRN medication would be documented on the back of the MAR with the date, time, and reason given; -After administration, but not sure how long after, he/she would check back and write the result and initial on the back of the MAR. During an interview on 9/12/19,