**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to follow the facility policy and the resident's care plan by transferring one sampled resident, (Resident #1) without using two staff or using a gait belt, out of five sampled residents. The facility census was 54 residents. The Administrator was notified on 7/8/24 Past Non-Compliance which occurred on 6/23/24. An all nursing staff in-service was completed on resident transfers prior to start of the next shift. The deficiency was corrected 6/25/24. Review of the facility policy for Safe Lifting and Movements of Residents revised July 2017 showed: -The purpose of the policy was to protect the safety and well-being of staff and residents, and to promote quality care, using appropriate techniques and devices to lift and move residents. -The manual lifting of residents was to be eliminated whenever feasible. -The facility nursing staff along with the rehabilitation staff was to assess individual residents' needs for transfer assistance on an ongoing basis, documenting the residents' transferring and/or lifting needs in the residents' care plan. -All facility staff responsible for direct resident care was to have been trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 1. Review of Resident #1's facility admission Record showed he/she was admitted on [DATE] with the following diagnose: -Alzheimer's disease-(a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception) -Muscle weakness. -Abnormal gait and mobility. -Repeated falls. Review of the resident's Nursing Care Plan revised on 3/26/24 showed: -He/she needed assistance from facility staff with Activities of Daily Living (ADLs) such as transferring. -He/she liked to go to bed after dinner. -Due to the resident's Alzheimer's disease and dementia, he/she had increased behaviors, becoming emotional and crying during the evening time. -The facility staff was to talk with the resident and hold his/her hand when he/she was emotional. -The facility staff was to use one to two staff to assist the resident with transfers. -The facility staff was to use a gait belt to transfer the resident. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 5/16/24 showed: -He/she was not cognitively intact and not interviewable. -He/she required partial to moderate assistance from facility staff to transfer from the chair to the bed. Review of the resident's Physician Order Sheet (POS) dated 5/20/24 showed the facility staff was to use a gait belt for transferring the resident. Observation of an un-timed video taken via a camera placed in the resident's room and provided by the resident's family dated 6/23/24 showed: -Certified Nursing Assistant (CNA) A wheeled the resident into the resident's room via wheelchair. -The resident was flailing his/her arms and appeared to be yelling. -The resident picked up what appeared to be a stuffed animal and threw it at CNA A. -CNA A prepared the bed for the resident and locked the wheelchair. -CNA A then took the resident under his/her arms and transferred him/her into the bed without using a gait belt or obtaining assistance from another staff member, causing the resident to fall onto the bed. -CNA A then placed the resident's legs into the bed and covered him/her up with a blanket. -CNA A turned off the lights and the resident calmed down. During an interview on 7/8/24 at 12:14 P.M., CNA A said: -He/she came on the shift and immediately needed to get the resident to his/her room and into bed so he/she could calm down. -He/she asked around for help, but everyone was busy. -He/she knew the resident was a two-person transfer as well as that a gait belt was required for the resident's transfer. -He/she did not have a gait belt and the resident was so upset he/she just wanted to get him/her into bed. -The resident had spit on him/her earlier as well as thrown water in his/her face so knew the resident calmed down once he/she got into bed. -He/she just did what he/she had to do to get the resident calmed down. -The resident was not hurt, and he/she meant no harm. During an interview on 7/8/24 at 12:30 P.M., Licensed Practical Nurse (LPN) A said: -If the resident became agitated, he/she calmed down once he/she was placed into bed. -CNA A should have obtained assistance and used a gait belt to transfer the resident into the bed. -If CNA A was having issues obtaining help for the transfer, he/she should have waited to transfer the resident. -He/she did not recall CNA A asking him/her for assistance. Observation of Resident #1 on 7/8/24 at 12:45 P.M., showed: -The resident was in his/her wheelchair in the dining room. -When asked how he/she was and if he/she was doing okay, he/she just smiled. -When asked if he/she had issues with any staff or had been injured during a transfer, he/she just smiled. During an interview on 7/8/24 at 1:00 P.M., the Director of Nursing (DON) said: -He/she would have expected CNA A to follow the physician's order and the nursing care plan and obtain assistance with the resident's transfer from the wheelchair to the bed. -He/she would have expected CNA A to have used a gait belt to transfer the resident. During an interview on 7/8/24 at 1:10 P.M., the facility Administrator said: -He/she would have expected the CNA to have a gait belt available prior to his/her shift began. -He/she would have expected CNA A to both obtain assistance for the resident's transfer and use the gait belt during the transfer. -He/she would have expected the CNA to not complete the transfer until he/she had assistance and a gait belt. MO00238041

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure three sampled residents (Resident #1, Resident #3, and Resident #4) were treated with dignity and self-determination related to their bathing/showering preferences out of five sampled residents. The facility census was 62 residents. Review of the facility's undated policy titled Bathing Policy showed: -It was the responsibility of the licensed nurse and/or nursing assistants to ensure baths/showers were completed. -Residents would receive a whirlpool bath, shower, or bed bath at least weekly and pro re nata (PRN- as needed). -Nursing would update bathing schedule as needed. 1. Review of Resident #1's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Rheumatoid Arthritis (Arthritis- swelling and tenderness in one or more joints, causing joint pain or stiffness that often gets worse with age) (a chronic inflammatory disorder usually affecting small joints in the hand and feet). -Pressure Ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure to the skin) of Right Hip, Unstageable. -Generalized Muscle Weakness. -Pain in Right Hip. -Mild Cognitive Impairment (a condition in which people have more memory of thinking problems than other people their age). -Contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity in the joints), Left Shoulder. -Contracture, Left Elbow. -Contracture, Left Wrist. -Low Back Pain. Review of the resident's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/7/24 showed: -The resident was cognitively intact. -In the section functional abilities and goals, the resident was marked as not applicable related to shower/bathe self (the ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair), this did not include transferring in/out of tub/shower. -The MDS did not include preferences for customary routine and activities. Review of the resident's Care Plan dated 4/23/24 showed: -The resident had a stage IV pressure ulcer (a wound with full thickness skin loss extending through the fascia with considerable tissue loss) which was acquired on 4/7/23. -The resident had and Activities of Daily Living (ADLs) functional status/rehabilitation potential with the following interventions: --To talk with the resident and explain what he/she could do to assist with ADL/hygiene tasks and allow the resident to do what he/she could do what he/she could do to care himself/herself. --He/She preferred whirlpool baths and for the staff to wash his/her hair while being bathed. --He/She would only receive bed baths when the wound care company put a specific dressing on the resident. NOTE: The care plan does not address staff preferences or times for bathing needs. During an interview on 5/6/24 at 11:15 A.M. the resident said: -He/she pointed to his/her hair and called it greasy. -He/She received a bath once a week. -He/She had a wound which made getting a whirlpool bath difficult. -He/She could not remember when his/her last bath was. During an interview on 5/6/24 at 2:47 P.M. the resident said: -It depended on who was working whether or not he/she received a bath on his/her normal bath day. -Some of the staff don't do his/her bath to his/her liking. -He/She did not always feel clean after getting bathed by staff. -He/She felt uncomfortable when he/she did not feel clean after a bath. -He/She had told management that there were certain staff members that he/she had not wanted to receive baths from. -He/She was teary-eyed near the end of the interview. During an interview on 5/6/24 at approximately 3:15 P.M. Certified Nurses Aide (CNA) C said: -He/She was the assigned aide for the resident that shift. -He/She was unsure of any bathing preferences for the resident. During an interview on 5/6/24 at 3:26 P.M. Licensed Practical Nurse (LPN) C said: -The resident did not like for male staff to do his/her baths. -The resident did not like for his/her baths to be done in the evening. -The resident normally received bed baths due to his/her wound. -A shower would be the most appropriate type of bath for the resident. During an interview on 5/6/24 at 3:32 P.M. the Director of Nursing (DON) said: -The resident received a lot of bed baths but could receive different forms of baths. -The resident had a wound that made it difficult for Resident #1 to get up and around. -The resident refused baths frequently. -The resident was very particular in when he/she received a bath. -When the resident refused a bath, then he/she would normally reproach the resident at a later time. -He/She had not received any complaints from the resident related to staff bathing preferences. 2. Review of Resident #3's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration. Confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and restricted oxygen to the brain). Review of the resident's Quarterly MDS dated [DATE] showed: -The resident was cognitively intact. -The resident needed partial/moderate assistance (helper does less than half the effort) related to showering/bathing self. -The MDS did not include preferences for customary routine and activities. Review of the resident's Care Plan dated 3/15/24 showed: -The resident had ADL functional status/rehabilitation potential with the following interventions: --Encourage the resident to wash his/her upper body parts within reach with a prepared washcloth. --He/She preferred a whirlpool bath and to wash his/her hair when bathing. --Talk with the resident and explain what he/she could do to assist with the ADL task. During an interview on 5/6/24 at 12:49 P.M. the resident said: -He/She received a bath about once a week. -He/She never got bathed more than once a week. -It was his/her preference to be bathed more than once a week. During an interview on 5/6/24 at 2:59 P.M. the resident said it was tough to only get one shower a week because he/she was used to showering every day prior to being a resident at the facility. 3. Review of Resident #4's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Chronic Obstructive Pulmonary Disorder (COPD- a disease process that decreases the ability of the lungs to perform ventilation). -Other Chronic Pain. -Generalized Muscle Weakness. -Problem Related to Life Management Difficulty. -Unspecified Osteoarthritis (OA-a type of arthritis that that occurs when flexible tissue at the ends of bones wears down). Review of the resident's Care Plan dated 3/26/24 showed: -The resident required assistance with ADL/hygiene tasks with the following interventions: --He/She preferred a whirlpool bath and to wash his/her hair when bathing. --Talk with the resident and explain what he/she could do to assist with the ADL tasks. --Allow him/her to do what he/she could do for themselves so he/she could maintain his/her highest level of functioning. Review of the resident's Quarterly MDS dated [DATE] showed: -The resident was cognitively intact. -The resident needed partial/moderate assistance (helper does less than half the effort) related to showering/bathing self. -The MDS did not include preferences for customary routine and activities. During an interview on 5/6/24 at 12:54 P.M. the resident said: -He/She received a bath once a week. -His/Her last bath was on 4/29/24. -He/She preferred to be bathed more than once a week especially in the summertime when he/she sweated more often. During an interview on 5/6/24 at 2:56 P.M. the resident said: -Only receiving one bath a week made him/her feel icky and embarrassed. -He/She thought that there were not enough staff to receive more than one bath a week. 4. During an interview on 5/6/24 at 12:20 P.M. Certified Occupational Therapist Assistant (COTA) A said that he/she had helped with bathing residents in the past as part of his/her therapy services. During an interview on 5/6/24 at 1:28 P.M. CNA A said: -He/She did not normally do resident baths. -The facility had bath aides that would give residents baths. -He/She had received complaints from residents related to missing the dates they were supposed to be bathed/showered on. -The facility policy was for the residents were to be bathed two times a week. -He/She was unsure of any bathing preferences of the residents he/she normally took care of. -The facility had recently hired a new bath aide, but he/she thought they had not started yet. During an interview on 5/6/24 at 1:37 P.M. LPN A said: -The facility had designated aides to do resident baths. -Residents were to receive two baths a week. -He/She thought that most residents received baths two times a week. -He/She had not received any complaints from residents related to bathing or not following preferences. During an interview on 5/6/24 at 1:43 P.M. the Staffing Coordinator said: -When he/she made the schedule he/she put bath aides on the schedule. -He/She had to frequently pull the bath aide to work as a regular aide for the residents. -Not all residents were bathed/showered two times a week. -The facility had recently hired a new bath aide, but they had not started yet. During an interview on 5/6/24 at 2:11 P.M. CNA B said: -He/She normally worked on the memory care (special care) unit. -He/She was not responsible for bathing residents. -If staffing allowed, then he/she would do the baths on the unit. During an interview on 5/6/24 at 3:26 P.M. LPN C said: -The CNAs were responsible for completing resident baths. -There were usually assigned aides to do resident baths. -He/She had not received any complaints from residents related to bathing. During an interview on 5/6/24 at 3:32 P.M. the DON said: -The facility had a bath aide until the end of the previous week. -The Administrator kept track of resident bathing. -The residents were to receive two baths a week, but normally only received one bath a week. -Bathing preferences should be on resident care plans. -The MDS Coordinator was responsible for the care plans, but was not at the facility at that time. -He/She had not received any complaints related to bathing from Resident #1, Resident #3 or Resident #4. -To his/her knowledge the facility was following Resident #1's, Resident #3's, and Resident #4's bathing preferences. During an interview on 5/6/24 at 3:47 P.M. the Administrator said: -Residents received baths once a week, which was facility policy. -There were some residents who asked for PRN baths. -When residents asked for PRN baths or to be bathed more frequently, the facility did their best to accommodate bathing preferences, but could not always guarantee the preference would be followed. -Resident bathing preferences should be care planned. MO00234673

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician orders for applying Sequential Compression Devices (SCD- sleeves with separated areas or pockets of inflation, which works to squeeze on the appendage in milking action) for one sampled resident (Resident #44) out of 12 sampled residents. The facility census was 47 residents. A policy for SCD use was requested and not received at the time of exit. 1. Review of Resident #44's Face Sheet showed he/she was admitted to the facility on [DATE] with following diagnoses: -Lymphedema (swelling in the arms or legs caused by lymphatic system blockage). -Chronic pain. Review of the residents Annual Minimum Data Set (MDS-a federally mandated assessment completed by the facility staff for care planning) dated 8/2/23 showed: -He/she was cognitively intact. -He/she needed total two person assist with transfers. -He/she had frequent pain. Review of the resident's care plan dated 8/7/23 showed staff were to ensure that SCD's are applied as physician ordered for his/her lymphedema. Review of the resident's electronic medical record Order Summary Report dated 9/2023 showed sesquential compression of bilateral (both legs) lower extremities daily nursing to apply one hour between lunch and supper in the afternoon. Order start date 5/15/23. Review of the residents Treatment Administration Record (TAR) dated 9/2023 showed SCD's to be applied daily for one hour at 2:00 P.M., for lymphedema. During an interview on 9/25/23 at 1:01 P.M., the resident said: -SCD's were brought in his/her room a while ago and have sat right there on the floor. He/she had not ever used them. -His/her legs had sometimes wept fluid and hurt. Observation on 9/25/23 at 1:01 P.M., showed: -His/her lower SCD leg sleeves were rolled up on the floor. -His/her SCD machine had electric cord rolled up and not connected to the electric outlet. -His/her lower legs were swollen. No redness or weeping. Observation on 9/26/23 at 2:31 P.M., showed: -SCD's boots on floor, one sleeve caught under the bed leg. -SCD not plugged in and electric cord rolled up. During an interview on 9/26/23 at 2:31 P.M., the resident said staff had not applied SCD's yesterday and that they had never been used. During an interview on 9/27/23 at 7:30 A.M., the resident said staff had not applied SCD's yesterday. Observation on 9/27/23 at 7:30 A.M., showed; -SCD's boots on floor, one sleeve caught under the bed leg. -SCD not plugged in and electric cord rolled up. Observation on 9/28/23 at 9:07 A.M., showed: -SCD's boots on floor, one sleeve caught under the bed leg. -SCD not plugged in and electric cord rolled up. During an interview on 9/28/23 at 9:07 A.M., the resident said the SCD's had not been applied yesterday. They have never been used on him/her. During an interview on 9/28/23 at 8:48 A.M., Certified Nursing Assistant (CNA) C said: -He/she would report increased leg swelling to the charge nurse. -He/she would encourage residents to elevate legs if swollen. -He/she would apply compression hose if it was ordered by the physician. -He/she did not know anything about SCD's as the nurses do that for the resident. During an interview on 9/28/23 at 8:53 A.M., License Practical Nurse (LPN) A said: -He/she would elevate the resident's legs if swollen and notify the physician if swelling is new and ask for compression stockings and labs (blood tests). -He/she was aware of the SCD orders or the resident and applied them shortly after lunch for an hour. The resident tolerated the SCD's and has not refused to have them applied and documented in the resident's Treatment Administration Record (TAR). During an interview on 9/28/23 at 11:23 A.M., Director of Nursing (DON) said: -He/she would expect physician orders to be followed and documented in the resident TAR. -He/she was not aware that the resident was not getting his/her SCD's applied.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's undated policy Change of Condition Protocol showed the resident's physician to be notified of a significant change in the resident's physical, mental, or psychosocial status; a need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Review of Resident #38's Face Sheet he/she was admitted on [DATE] with the a diagnosis of low back pain. Review of the resident's electronic medical record admission orders dated 9/5/23 showed Norco (a narcotic pain medication) 7.5-325 mg one by mouth every 4 hours as needed for pain. Review of the resident's electronic MAR for 9/5/23 thru 9/9/23 showed he/she did not receive Norco 7.5-325 mg as needed every four hours for pain. Record review of the resident's progress notes dated 9/9/23 showed: -Staff notified his/her physician of unavailability of the residents Norco 7.5-325 mg. --NOTE: Staff had not notified the resident's physician of not having the ordered as needed pain medication Norco 7.5-325 mg until five days after his/her admission to the facility. -Norco 7.5-325 mg was discontinued by the physician and an available Norco 5-325 mg in the facility emergency kit was ordered by the physician for one by mouth every 6 hours as needed for pain. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 9/11/23 showed: -He/she was cognitively intact. -He/she had pain present and frequently in pain. -He/she was on a scheduled pain medication. Review of the resident's pain care plan initiated on 9/14/23 showed: -He/she received pain medication. -He/she would state relief of breakthrough pain with use of as needed pain medications or non-pharmaco logical interventions. -Staff would administer his/her as needed pain medication as ordered by physician. -Staff would monitor effectiveness of his/her pain interventions and notify his/her physician if not effective. Review of the resident's electronic medical record on 9/23/23 showed: -The physician had discontinued his/her order for Norco 5-325 mg one every 6 hours as needed for pain. -The physician had ordered Norco 7.5-325 mg one tablet every 6 hours as needed for pain. Review of the resident's Individual Patient Narcotic Record for Norco 7.5-325 received on 9/23/23 showed: -Eight tabs removed from the narcotic card. -On 9/23/23 one dose removed at 8:00 A.M. -On 9/23/23 one dose removed at 8:30 P.M. -On 9/24/23 one dose removed at 10:00 A.M. -On 9/25/23 one dose removed at 3:00 A.M. -On 9/25/23 one dose removed at 5:20 P.M. -On 9/26/23 one dose removed at 7:00 A.M. -On 9/26/23 one dose removed at 10:30 P.M. Review of the resident's electronic MAR dated 9/2023 showed: -Norco 7.5-325mg one tablet every 6 hours as needed for pain. --One dose on 9/23/23 was not accounted for. --One dose on 9/24/23 was not accounted for. --One dose on 9/25/23 was not accounted for. During interview on 9/25/23 at 12:13 P.M., Resident #38 said: -It had taken the facility ten days to get him/her the correct dosage of pain medication that was ordered from the hospital. -He/She had only received Tylenol for the first five days of admission. -He/She had requested the stronger pain medication numerous times and staff had told him it had not arrived from the pharmacy and were waiting on a prescription to be signed. During an interview on 9/28/23 at 8:53 A.M., Licensed Practical Nurse (LPN)A said: -He/she would check the electronic MAR for current as needed pain medications and sign it out in the residents MAR and on the resident's narcotic count sheet. -He/she would notify the resident's physician immediately if an as needed pain medication is not available to get new orders for a pain medication that is available in the facility emergency kit. During an interview on 9/28/23 at 11:23 A.M., Director of Nursing (DON) said: -He/she would expect resident narcotic count sheets match the residents electronic MAR. The nurses should be signing the narcotic count sheet and the electronic MAR when administering a narcotic medication. -He/she is responsible for auditing the narcotic counts. He/she has been auditing the narcotic count sheets but not the electronic MAR. -He/she would expect nursing to contact the pharmacy and physician immediately if a narcotic medication is not available. -He/She would not expect nursing to wait five days to contact the physician for unavailable medication. Based on observation, interview, and record review, the facility failed to ensure accurate documentation and reconciliation of narcotic pain medications for two sampled residents (Resident #35 and #38); and to notify the physician of unavailable pain medication in a timely manner for one sampled resident (Resident #38) out of 12 sampled residents. The facility census was 47 residents. Review of the facility's undated Oral Medication Administration policy showed: -Review the five rights of medication administration including the right drug name, right drug dose, and right time. -Check narcotic record for previous drug count and compare with supply available. -Compare Medication Administration Record (MAR) with prepared drug label/container. -Record administration of oral medication on MAR by placing nurse's initials or signature. Review of the facility's Controlled Substances policy updated 11/14 showed: -Separate records are maintained for controlled drugs. -When a Class Il drug (controlled substance - narcotic) is administered, record of that administration must be recorded on a proof of use form (Controlled Substances Medication Record). -The following information is documented by the individual administering the drug; date, amount, and signature of nurse. -Controlled drugs are destroyed in the presence of two licensed staff members. The following information is documented when a drug is destroyed: date, name of drug, and amount destroyed. 1. Review of Resident #35's Face Sheet showed he/she was admitted to the facility on [DATE] with the a diagnosis of Peripheral Neuropathy (damage to the nerves in the extremities). Review of the resident's July 2023 physician's Order Recap Report showed: -Tramadol (a narcotic pain medication) 50 milligrams (mg) one tablet by mouth every four hours for comfort measures dated 7/24/23 and discontinued on 7/25/23. -Tramadol 50 mg one tablet by mouth every four hours for pain dated 7/25/23 and discontinued on 7/31/23. -Hydrocodone-Acetaminophen (Norco - a narcotic pain medication) 5-325 mg one tablet by mouth every six hours as needed for pain dated 7/31/23 and discontinued on 8/8/23. Review of the facility's Emergency Medication Kit access the resident in July 2023 showed: -Tramadol 50 mg removed five times. -Hydrocodone-Acetaminophen 5-325 mg removed two times. Review of the resident's Medication Administration Record (MAR) dated July 2023 showed: -Tramadol 50 mg one tablet by mouth every four hours for pain dated 7/25/23 and discontinued on 7/31/23 documented as administered three times. --Two doses of Tramadol 50 mg removed from the emergency kit were not accounted for. -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 7/31/23 documented as administered one time. --One dose of Hydrocodone-Acetaminophen 5-325 mg removed from the emergency kit was not accounted for. Review of the resident's August 2023 physician's Order Recap Report showed: -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 7/31/23 and discontinued on 8/8/23. -Hydrocodone-Acetaminophen 5-325 mg two tablets by mouth every six hours as needed for pain dated 8/8/23 and discontinued on 8/8/23. -Hydrocodone-Acetaminophen 10-325 mg one tablet by mouth every six hours as needed for pain dated 8/8/23 and discontinued on 8/9/23. -Hydrocodone-Acetaminophen 10-325 mg 0.5 tablets by mouth every six hours as needed for pain dated 8/9/23. -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 8/17/23. Review of the facility's Emergency Medication Kit access the resident in August 2023 showed Hydrocodone-Acetaminophen 5-325 mg removed three times. Review of the resident's Individual Patient Narcotic Record for Hydrocodone 5/325 mg received on 8/5/23 showed: -41 tablets were removed from the narcotic card. -Two tablets were removed on 8/8/23 at 5:50 P.M. -On 8/12/23 one tablet was removed at 3:30 A.M., one was removed at 7:00 A.M. and one was removed at 11:00 A.M. These were less than every six hours per the physician's orders. --NOTE: This order was discontinued on 8/8/23. -On 8/13/23 one tablet was removed at 1:00 A.M. and one tablet was removed at 6:00 A.M. This was less than every six hours per the physician's orders. --NOTE: This order was discontinued on 8/8/23. -On 8/22/23 one tablet was removed at 5:15 A.M. and one tablet was removed at 8:00 A.M. This was less than every six hours per the physician's orders. --NOTE: This order was discontinued by the resident's physician on 8/8/23 and restarted on 8/17/23. Eight tablets of Hydrocodone 5-325 mg were removed from the narcotic card without a valid physician's order. Review of the resident's Controlled Substances Medication Record for Hydrocodone 10-325 mg received on 8/8/23 showed: -Directions for use: take one tablet every six hours for pain. -An undated hand-written note at the top of the page: New order - only give 0.5 tab. -One tablet was documented as removed four times. --NOTE: The order for one tablet was discontinued on 8/9/23. Three doses were documented as one tablet removed without a valid physician's order. -Eight tablets were documented as removed, cut by staff with a second staff person signing as witnessing the waste of 0.5 tablets. Review of the resident's August 2023 MAR showed: -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 7/31/23 and discontinued on 8/8/23 administered seven times. -Hydrocodone-Acetaminophen 5-325 mg two tablets by mouth every six hours as needed for pain dated 8/8/23 and discontinued on 8/8/23. No documentation any doses were administered. -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 8/17/23 administered 11 times. --NOTE: 18 tablets out of the 41 tablets removed from the narcotic card were documented as administered to the resident with 23 tablets unaccounted for. -Hydrocodone-Acetaminophen 10-325 mg one tablet by mouth every six hours as needed for pain dated 8/8/23 and discontinued on 8/9/23 documented as administered to the resident two times. -Hydrocodone-Acetaminophen 10-325 mg 0.5 tablets by mouth every six hours as needed for pain dated 8/9/23 documented as administered to the resident 12 times. --NOTE: Eight 0.5 tablets and four whole tablets were documented as removed from the Narcotic Card. Review of the resident's September 2023 physician's Order Recap Report showed: -Hydrocodone-Acetaminophen 10-325 mg 0.5 tablets by mouth every six hours as needed for pain dated 8/9/23. -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 8/17/23 and discontinued on 9/26/23. -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 9/26/23 with orders to discontinue when Oxycodone is received from the pharmacy. Review of the resident's Individual Patient Narcotic Record for Hydrocodone 5/325 mg received on 8/5/23 showed: -19 tablets were removed from the narcotic card with the last dose removed on 9/15/23. Review of the resident's Individual Patient Narcotic Record for Hydrocodone 5/325 mg received on 8/17/23 showed 18 tablets were removed from the narcotic card in September 2023. Review of the resident's Controlled Substances Medication Record for Hydrocodone 10-325 mg received on 8/8/23 showed: -Directions for use: take one tablet every six hours for pain. -An undated hand-written note at the top of the page: New order - only give 0.5 tab. -One tablet was documented as removed five times. --NOTE: The order for one tablet was discontinued on 8/9/23. Five doses were documented as one tablet removed without a valid physician's order. Review of the resident's September 2023 MAR showed: -Hydrocodone-Acetaminophen 5-325 mg one tablet by mouth every six hours as needed for pain dated 8/17/23 administered 30 times. --NOTE: A total of 35 tablets were removed from the resident's narcotic cards. Five tablets are unaccounted for. -Hydrocodone-Acetaminophen 10-325 mg 0.5 tablets by mouth every six hours as needed for pain dated 8/9/23 administered six times. --NOTE: Five whole tablets were documented as removed from the Narcotic Card. Observation and interview on 9/28/23 at 8:27 A.M. with Licensed Practical Nurse (LPN) B showed: -The resident had narcotic cards for Hydrocodone-Acetaminophen 5-325 mg and for Hydrocodone-Acetaminophen 10-325 mg. -The cards of Hydrocodone-Acetaminophen 10-325 mg included whole tablets. -The resident had Controlled Substances Medication Records for each narcotic card. -The Controlled Substance Medication Record for Hydrocodone-Acetaminophen 10-325 mg include a handwritten note to only give 0.5 tabs. -LPN B said: -Staff cut the Hydrocodone-Acetaminophen 10-325 mg in half to administer to the resident. -The resident's Hydrocodone-Acetaminophen 10-325 mg order was originally for one tablet then the physician changed the order. -Staff did not return or destroy the whole Hydrocodone-Acetaminophen 10-325 mg medication cards and instead would just cut each tab in half and destroy the other half tab with a second staff person. -Staff should document medication administration correctly on the resident's MAR. -If staff remove a Hydrocodone-Acetaminophen 10-325 mg half tablet, it should be documented on the Hydrocodone-Acetaminophen 10-325 mg half tablet entry on the resident's MAR. -He/She wasted half a tablet of the Hydrocodone-Acetaminophen 10-325 mg when he/she removed it, but acknowledged the narcotic card did not show the tablet was wasted. -When staff do not show the additional half tab was wasted, it would appear a whole tab was administered. -The resident's MAR and narcotic count log should match. During an interview on 9/28/23 at 8:45 A.M., Registered Nurse (RN) A said: -Staff can cut the Hydrocodone-Acetaminophen 10-325 mg tablet in half to administer to the resident. -If staff cut the Hydrocodone-Acetaminophen 10-325 mg in half and waste half the tablet, two staff should sign the wasted amount. -The MAR and narcotic count sheets should match. -If a dose was removed from the narcotic log, it should be documented on the correct dose on the MAR. During an interview on 9/28/23 at 11:26 A.M., the Director of Nursing (DON) and Assistant Administrator said: -Staff should not cut medications in half to obtain the correct dose, it should come from pharmacy already cut. -The narcotic log and MAR should match. -If a narcotic is removed from the narcotic count sheet, it should be documented under the correct dose on the MAR. -At this time no one was auditing the narcotic count sheets to ensure they matched the resident's MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow infection control protocol for cross-contamination with the placement of the resident's urinary catheter drainage bag (a bag that collects urine that is attached to a tube that is inside the bladder) for one sampled resident (Resident #38) out of 12 sampled residents. The facility census was 47 residents. Review of the facility's undated Infection Control and Safe Practice Policy showed the facility will apply standard precautions practices at all times, to as far as possible to prevent the transmission of infection. 1. Review of Resident #38's Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Obstructive and Reflux Uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). -Malignant Neoplasm of the Prostate (a disease in which cancer cells form in the tissues of the prostate). -Chronic Kidney Disease (a condition characterized by a gradual loss of kidney function over time. Review of the resident's electronic medical record Order Summary Report dated 9/23 showed: -Catheter care every shift; to dependent drain; check placement of leg strap (a device that secures catheter tubing to prevent pulling or tugging) every shift; ensure bag is stored in dignity bag off the floor. Review of the resident's Care Plan dated 9/8/23 showed: -He/she had an indwelling catheter. -He/she would not have urinary discomfort. -To ensure his/her urinary catheter drainage bag was secured in a privacy bag. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff for care planning) dated 9/11/23 showed: -He/she was cognitively intact. -He/she needed extensive assist with activities of daily living. -He/she had an indwelling urinary catheter (a hollow tube inserted and left in the bladder to drain urine from the bladder into a bag outside his/her body). Observation on 9/26/23 at 9:40 A.M., 10:31 A.M., and 12:02 P.M. showed his/her urinary catheter bag was hanging off his/her walker touching the floor not covered with a dignity bag or barrier between the floor and the urinary catheter bag. During an interview on 9/28/23 at 8:48 A.M., Certified Nursing Assistant (CNA) C said: -He/she would place urinary catheter bag in a dignity bag and keep bag off of the floor. -He/she had catheter care education on Monday 9/11/23. During an interview on 9/28/23 at 8:53 A.M., Licensed Practical Nurse (LPN) A said he/she would make sure catheter bag is in a dignity bag and not on the floor. During interview on 9/28/23 at 11:23 A.M., Director of Nursing (DON) said: -He/she would expect urinary catheter bags be covered with a dignity bag and would not expect them to be on the floor. -He/she would be responsible to monitor facility infection control practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a process in place to ensure Cardiopulmonary Resuscitation (CPR- an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who was in cardiac arrest) certified staff were available on all shifts. The facility census was 47 residents. Review of facility's undated policy Cardiopulmonary Resuscitation (CPR) showed: -It was the policy of this facility to provide Basic Life Support (BLS), including CPR, when a resident required such emergency care, prior to arrival of emergency medical services, subject to the physician order and residents choices indicated in the residents advance directive (documents that allow one to communicate their health care preferences when decision-making capacity is lost). -Nurses and other care staff are educated to initiate CPR, as recommended by the American Heart Association (AHA). -CPR certified staff would be available at all times. -CPR certified staff members would maintain current CPR certification for healthcare providers including hands-on skill practice and in person assessments and demonstration of skills. -Prompt imitation of CPR was essential as brain death would begin in four to six minutes following cardiac arrest if CPR was not initiated within that time. -Only current BLS/ACLS (Advanced Cardiac Life Support) certified personnel would provide basic life support, including CPR, to a resident who required such emergency care prior to arrival of emergency medical personnel. -CPR certified staff would be available at all times. 1. Review of the facility's list of CPR certified staff showed there were 20 CPR certified employed in the facility. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. During an interview on [DATE] at 8:25 A.M., Certified Nursing Assistant (CNA) A said: -All CNA's and nurses were supposed to be CPR certified. -He/she was CPR certified. -The schedule did not designate who was CPR certified. During an interview on [DATE] at 8:28 A.M., Licensed Practical Nurse (LPN) A said: -He/she was CPR certified. -He/she thought all staff were CPR certified. -The staffing sheets did not designate who was CPR certified. During an interview [DATE] at 8:30 A.M., Registered Nurse (RN) A said: -He/she was CPR certified. -Not all staff were CPR certified at the facility. -All licensed nurses were supposed to be CPR certified. -There was nothing on the staffing schedule that listed who was CPR certified. -He/she thought it was policy is that all licensed personnel were supposed to be CPR certified so no official list was used. -When he/she used to do the scheduling he/she went by the facility policy. During an interview on [DATE] at 8:36 A.M., Laundry Assistant (LA) A said: -If a resident was found non-responsive he/she would check on the resident and if the resident was not breathing he/she would contact the nurse, or find a phone and use the intercom to call for help. -He/she had no idea of who is CPR certified in the building. -He/she assumed all nurses were CPR certified. -There was nothing on the staffing schedule that denoted who was CPR certified. -He/she did not look at the staffing schedule. During an interview on [DATE] at 8:48 A.M., CNA B said: -When a resident was found unresponsive he/she would yell out of for help. -He/She was CPR certified but would call for the nurse and start CPR. -All nurses should be CPR certified. -There was nothing on the schedule that denoted who was CPR certified. During an interview on [DATE] at 8:50 A.M., CNA C said: -When a resident was found unresponsive he/she would check the residents pulse and see if resident is breathing and if not he/she would start CPR. -He/she was CPR certified. -There was nothing on the schedule that denoted who was CPR certified. -He/she assumed all nurses were CPR certified. -He/she was an agency employee and had to CPR certified to work. During an interview on [DATE] at 11:32 A.M., Director of Nursing (DON) said: -He/she started doing the staffing as of this week. -It was his/her expectation that all nurses and CNA's were CPR certified. -There was nothing on the schedule that designated who was CPR certified. -There was currently no list of staff that were CPR certified and when the certification expires.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a Stage II Pressure Ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) to the left heel was kept clean and covered with a dressing per the physician's order for one sampled resident (Resident #48) out of 15 sampled residents. The facility census was 58 residents. Record review of the facility's undated policy titled Wound Care Protocol showed: -Certified Nursing Assistant (CNA), Bath Aide, and other staff were to report skin issues to the charge nurse. -Treatments were to be completed per the physician's order. -The wound nurse was to document on wounds weekly on the back of the resident's treatment sheet. 1. Record review of Resident #48's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of pressure ulcer of his/her left heel, unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed). Record review of the resident's Physician's Order Report dated 3/2/22 showed his/her left heel was to be cleansed with wound cleanser of choice, apply skin prep to the intact tissue surrounding the wound, apply medihoney to wounds, cover with dry dressing and wrap with kerlex. Dressing to be changed on bath days (2 times a week) and as needed. Record review of the resident's care plan dated 11/16/21 showed staff were to complete treatment to left heel Stage II wound as ordered per Treatment Administration Record (TAR), and to monitor and document healing progress weekly. Record review of the resident's TAR dated April 2022 showed 4/4/22 to 4/11/22 was blank with no indication that wound care for left heel was completed. Weekly skin assessments were requested from facility but not received. Observation on 4/11/22 at 9:06 A.M. showed the resident: -Was in his/her room with his/her bare feet on the floor. -Did not have a dressing in place to his/her left heel. Observation on 4/11/22 at 9:11 A.M. showed: -CNA D entered the resident's room and put the resident's shoes on. -CNA D did not notify the charge nurse that the resident did not having a dressing on his/her left heel. Observation on 4/11/22 at 12:34 P.M. showed the resident: -Was in bed with bare feet showing from under the blanket. -An open area approximately 3 centimeters (cm) by 3 cm with some depth present, minimal eschar (dry, dead tissue within a wound) and slough (necrotic/avascular tissue in the process of separating from the viable portions of the body & is usually light colored, soft, moist, & stringy) was present around the edges of the wound, the wound bed was visible with beefy, red tissue present. -There was no dressing in place. During an interview on 4/11/22 at 1:31 P.M., Nurse Aide (NA) A said: -He/she reviewed the care plan book daily. -He/she would report a missing dressing to the charge nurse immediately. -He/she was aware of what wounds required dressings because he/she reviewed the care plan book daily. Observation on 4/11/22 at 1:53 P.M. showed the resident's wound remained uncovered as he/she laid in bed with his/her bare feet showing. During an interview on 4/12/22 at 7:21 A.M., Licensed Practical Nurse (LPN) C said CNAs were expected to notify a nurse if a wound was found uncovered. Observation on 4/12/22 at 8:29 A.M. showed the resident: -Was sitting in his/her wheelchair with only shoes covering his/her feet. -Was able to remove his/her shoes and show uncovered wound. -There was no dressing in place. During an interview on 4/12/22 from 9:20 A.M. to 10:44 A.M., LPN B said: -He/she was unaware the resident's wound was uncovered. -The nurses notify CNA's and bath aides of which residents need dressings on their wounds. -CNA's should notify a nurse if a wound dressing was missing/soiled/or loose. During an interview on 4/13/22 at 8:29 A.M., Registered Nurse (RN) A said aides were to report any skin abnormality or missing/loose/dirty wound dressings to the nurse. During an interview on 4/13/22 at 10:39 A.M., the Director of Nursing (DON) said: -Staff were expected to know each resident's care plan as the care plan book was available on the treatment floor. -CNA's were to notify the nurse any time he/she sees a wound uncovered. -Nurses give report to the CNA's at the beginning of the shift and should know what wounds need dressings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a significant medication error did not occur during the administration of insulin by not providing food or beverage with carbohydrates within 10 minutes of insulin administration for one sampled resident (Resident #24) out of 15 sampled residents. The facility census was 58 residents. Record review for the product insert for Novolog dated October 2021 showed Novolog is a fast-acting insulin. Eat a meal within five to ten minutes after taking it. A facility policy for insulin administration was requested and not provided. 1. Record review of Resident #24's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus (a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Record review of the resident's Physician Order Report dated 3/23/22 showed he/she had the following physician order: -Novolog sliding scale to be given subcutaneously before meals and at bedtime: blood sugar of 0-149=0 units, blood sugar of 150-199=administer 2 units, blood sugar of 200-249=administer 4 units, blood sugar of 250-299=administer 6 units, blood sugar of 300-349=administer 8 units, blood sugar of 350-400=administer 10 units, blood sugar greater than 400=call physician. Observation on 4/12/22 at 6:24 A.M. showed Licensed Practical Nurse (LPN) C reviewed the blood sugar results from 6:00 A.M. which was recorded as 189. Observation on 4/12/22 at 6:38 A.M. showed: -LPN C administered 2 units of Novolog to the resident. -The resident did not have a meal, snack, or beverage with carbohydrates at his/her bedside at time of administration. Observation on 4/12/22 at 7:09 A.M. showed staff gave the resident a glass of orange juice which he/she drank. Observation on 4/12/22 at 7:18 A.M. showed: -Staff gave the resident a full breakfast which he/she ate. -NOTE: This was 40 minutes after receiving insulin. During an interview on 4/12/22 at 8:18 A.M., LPN C said: -Residents need food within one hour when receiving fast acting insulin. -He/she knew when insulin could be given because breakfast was usually at 7:00 A.M. and the resident would eat soon. During an interview on 4/12/22 at 10:44 A.M., LPN B said: -Residents should eat within one hour of Novolog administration. -Breakfast was usually at 7:00 A.M. so he/she waited until then to give Novolog to ensure the resident ate within the one hour time frame. During an interview on 4/13/22 at 8:29 A.M., Registered Nurse (RN) A said: -Residents should eat within 30 minutes of Novolog administration. -Staff should give residents a supplement (a drink that contains a balance of protein, carbohydrates, and fat) or snack if no meal available within 30 minutes of administration. During an interview on 4/13/22 at 10:39 A.M., the Director of Nursing (DON) said: -Residents should eat 15 to 30 minutes after Novolog was given. -Staff should bring the resident some type of carbohydrate snack if breakfast was not served right away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the narcotic count sheet log was completed each shift; and to ensure staff properly discarded narcotics (substances with a high probability for physical and/or psychological dependence) for one sampled resident (Resident #50) out of 15 sampled residents. The facility census was 58 residents. Record review of the facility's undated policy titled Disposition of Drugs from the Floor showed controlled drugs were to be destroyed using the Drug Buster (a solution in a jug that dissolves medications on contact) in the presence of two licensed nurses and recorded appropriately on the Narcotic Count Sheet. A policy for the Daily Narcotic Count Sheet was requested and not received. 1. Record review of the facility's Daily Narcotic Count Sheet showed: -January 2022 logs missing 45 signatures out of 434 opportunities. -February 2022 logs missing 92 signatures out of 630 opportunities. -March 2022 logs missing 73 signatures out of 594 opportunities. -April 2022 logs missing 32 signatures out of 270 opportunities. 2. Record review of Resident 50's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Wedge compression fracture of second lumbar vertebra (this fracture usually occurs in the front of the vertebra, collapsing the bone in the front of the spine and leaving the back of the same bone unchanged, which results in the vertebra taking on a wedge shape). Record review of the resident's Physician Order Report showed a physician order for Buprenorphine 10 micrograms (mcg)/hour patch (a patch used to control moderate to severe pain over one week)applied weekly to the skin. Observation on 4/12/22 at 9:59 A.M. showed Licensed Practical Nurse (LPN) C: -Removed a Buprenorphine patch from the resident. -Placed the used patch in the biohazard trash can attached to the medication cart. NOTE: No other staff were in the area during disposal of the patch. During an interview on 4/12/22 at 10:44 A.M., LPN B said: -Staff should dispose of narcotics with another staff member present as a witness. -Staff should dispose of narcotics by using the Drug Buster. -He/she was unsure if narcotic patches could be placed in Drug Buster. During an interview on 4/13/22 at 8:29 A.M., Registered Nurse (RN) A said: -On-coming staff counted the narcotics with the off-going staff and both staff were to sign the Daily Narcotic Count Sheet when the count was completed. -Staff should dispose of used narcotic patches in the Drug Buster. -Staff frequently cut up the patches and put them in the sharps container instead. During an interview on 4/13/22 at 10:39 A.M., the Director of Nursing (DON) said: -Staff were to count each resident's narcotics together and both were to sign the Daily Narcotic Count Sheet to verify agreement. -Staff were to dispose of narcotic patches in the Drug Buster. -Staff should have a second staff member present when disposing of narcotics in the Drug Buster. -He/she did not want staff disposing of narcotic patches in the biohazard as someone could remove the narcotic from the biohazard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure dental care was offered once yearly for one sampled resident (Resident #4) out of 15 sampled residents. The facility census was 58 residents. A dental policy was requested and not received. 1. Record review of Resident #4's face sheet showed he/she was admitted on [DATE]. Record review of the resident's care plan dated 1/6/22 showed: -He/she had his/her natural teeth with some missing. -The facility should ensure he/she received dental consults as needed. Record review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 1/5/22 showed no dental concerns. Record review of the resident's Social Services Progress Notes showed: -On 6/9/20, there were no oral concerns. -On 9/8/20, there were no oral concerns. -On 12/8/20, there were no oral concerns. -On 1/18/21, there were no oral concerns. -On 3/30/22, the resident was interested in dentures but wanted to discuss with his/her family and get back with social services. Record review of the resident's Physician Order Sheet (POS) dated March 2022 showed the resident had an order that he/she may see the dentist dated 1/12/21. All documentation of dental appointments and dental care offered/declined were requested. The only documentation provided was the social services note dated 3/30/22 showing that the resident was interested in dentures. Observation on 4/8/22 at 2:18 P.M. showed the resident had three full teeth with all other teeth either missing or broken. During an interview on 4/8/22 at 2:18 P.M., the resident said: -He/she injured his/her neck and that was when his/her teeth started breaking off. -He/she had three teeth and the rest had either fallen out or had broken off. -No one had offered to make him/her a dentist appointment since he/she had been at the facility. During an interview on 4/13/22 at 8:51 A.M., Agency Certified Nursing Assistant (CNA) C said: -He/she had noticed the resident's teeth missing. -He/she was an agency CNA and was only at the facility for a couple of days a month. -He/she didn't know how the facility handled dental consults or dental issues. During an interview on 4/13/22 at 8:57 A.M., Licensed Practical Nurse (LPN) A said: -He/she was the charge nurse on the resident's hall. -He/she thought the residents go outside the facility to the dentist. -He/she thought maybe before COVID-19, a dentist may have come into the facility. -Residents could go to the dentist of his/her choice. -There wasn't someone specifically who set up dentist appointments. -Dentist appointments were set up per resident's request. -He/she did not know of anyone asking to go to the dentist. During an interview on 4/13/22 at 9:30 A.M., Registered Nurse (RN) A said: -He/she supervised East Hall. -He/she was aware of the resident and his/her dental issues. -Providing dental care to the residents was the resident's family's decision. -The facility did have a dentist who would come in and look at residents if they needed him/her to. -The dentist semi-retired but would still come into the facility. -Families wanted residents to go to a dentist they had already been seeing a lot of times. -He/she thought back in the beginning of the resident's stay, they talked with his/her family about a dental consult. -It was in the middle of the COVID-19 pandemic and his/her family wasn't interested in dental at that time. -If the conversation was documented, it would be in the nurse's notes but he/she would have no idea of the date. -He/she was not sure if Social Services went over dental with residents and/or family or if it was only provided as needed. During an interview on 4/13/22 at 10:20 A.M., Social Services Worker said: -When a new admission arrived, there should have been a paper asking about dental. -Nursing could set up a dentist's appointment. -During the MDS process, they asked about oral issues. -If the resident had said he/she had oral issues, they would assist in making an appointment. -When social work progress notes noted no oral concerns, it could mean the resident declined needing any oral care. -He/she thought the resident wanted to check with his/her family about money before scheduling a dentist appointment. During an interview on 4/13/22 at 10:25 A.M., the MDS Coordinator said Social Services does the dental portion of the MDS. During an interview on 4/13/22 at 10:38 A.M., the Director of Nursing (DON) said: -He/She guessed he/she just expected that all residents would be offered dental. -Nursing and social services were in charge of scheduling dental consults.

Based on interview and record review, the facility failed to implement policies and procedures to ensure all staff either completed the COVID-19 (a new disease caused by a novel (new) coronavirus) vaccination series or had documentation of a granted exemption from the vaccination on file for three out of eight sampled staff. Facility records showed 95.9% of facility staff were either fully vaccinated or had an approved exemption or delay. The facility had zero COVID-19 positive residents in the previous 4 weeks. The facility census was 58 residents. Record review of the facility undated Vaccine Mandate Policy showed: -As of 1/4/22, all staff and contracted staff will have completed their primary vaccination series. -This does not include staff that has been granted an exception from the COVID-19 vaccination. -The facility will follow the Centers for Medicare and Medicaid Services (CMS) rule that preempts any state law that is contrary to the CMS rule, and the CMS rules take priority over other federal vaccination rules and standards for facilities that participate in and are certified under the Medicare and Medicaid programs and are regulated by CMS health and safety standards known as the Conditions of Participation. -Workers must receive their first dose of a two-dose series or the single shot of the one-dose series by 12/5/21. -Workers must receive their second dose by 1/4/22 unless they received a religious or medical exemption. -Applies to workers who do and do not have patient-facing roles. -Applies to students, trainees, and volunteers working or volunteering in covered facilities regardless of whether they have patient contact. -Also applies to those who perform services at covered facilities under a contract, such as food service or janitorial workers. -Phases of implementation included all covered employees will have received their second dose or have received an approved exemption within 60 days of the Interim Final Rule (IFR) published on 11/5/21. -Proof of vaccination must be provided. -The facility will track and securely document the vaccination status of each staff member, including those for whom there is a temporary delay in vaccination, as defined by Center for Disease Control and Prevention (CDC). -Exemptions and delayed vaccination included: --Religious and medical exemption requests under federal law will be considered. --Those seeking religious exemptions will complete the religious accommodations request form available from Department Head or front office. --In granting exemptions, the facility will ensure minimized risk of transmission of COVID-19 to protect the health and safety of residents. Unvaccinated (staff) will continue to be tested based on County Transmission Rate as directed by CMS/Department of Health and Senior Services (DHSS) regulations. All staff will continue to wear Personal Protective Equipment (PPE) as directed by CMS/DHSS regulations. All staff will be tested if showing signs/symptoms of COVID-19. Facility wide testing will occur for all staff and residents if there is a COVID outbreak per CMS/DHSS regulations. --The presence of antibodies from a prior COVID-19 infection does not exempt any covered employee from the IFR's vaccination mandate. -New Hires included: --Requirements for new hires are the same as for existing staff. --All new hires will be vaccinated or receive an approved exemption by 1/4/22. --If a new staff member is hired after the compliance deadline and is not vaccinated, the staff member must become vaccinated or approved for an exemption prior to providing any care, treatment, or other services for the facility and/or its residents. 1. Record review of the facility undated Vaccination Matrix for Staff showed 95.9% of facility staff were fully vaccinated or had an approved exemption: -A total of 147 staff and volunteers listed for the facility. -Six unvaccinated staff were marked as having no exemption or delay. -One unvaccinated staff was marked as having a temporary delay per CDC/New Hire. -No staff were listed as having a medical exemption. Record review of the facility's COVID-19 positive resident cases from 3/11/22 - 4/8/22, showed no new COVID-19 resident infections in the prior 4 weeks. Record review of Employee #21's employee file showed: -He/She was hired on 1/20/22 as a Dietary Student Waiter/Waitress. -He/She did not have documentation of having received a COVID-19 vaccine. -He/She did not have documentation of having an approved medical or non-medical exemption. --NOTE: The facility employee matrix listed this staff as no exemption or delay. Record review of Employee #22's employee file showed: -He/She was hired on 4/7/22 as a Licensed Practical Nurse (LPN). -He/She had a copy of his/her COVID-19 vaccination record on file. -His/Her vaccine was administered on 10/1/21, prior to his/her employment at the facility. --NOTE: The facility employee matrix listed this staff as no exemption or delay, rather than completely vaccinated. Record review of Employee #23's employee file showed: -He/She was hired on 4/5/22 as a Dietary Student Waiter/Waitress. -He/She did not have documentation of having received a COVID-19 vaccine. -He/She did not have documentation of having an approved medical or non-medical exemption. --NOTE: The facility employee matrix listed this staff as no exemption or delay. Record review of Employee #24's employee file showed: -He/She was hired on 4/8/22 as a Dietary Waitress/Waiter. -He/She did not have documentation of having received a COVID-19 vaccine. -He/She did not have documentation of having an approved medical or non-medical exemption. --NOTE: The facility employee matrix listed this staff as temporary delay per CDC/New Hire. During an interview on 4/12/22 at 10:35 A.M., the Assistant Director of Nursing (ADON) said: -He/She used the staff vaccination matrix to keep track of who received their vaccines and who had an exception to ensure everyone was accounted for. -Employees #21, #22, #23, and #24 were newly hired staff. He/She thought he/she may have their vaccine cards or exemptions in his/her office and just had not updated the matrix yet. During an interview on 4/12/22 at 11:30 A.M., the ADON said: -Employee #22 was one of the nursing staff that just recently started working at the facility. His/Her hire date was 4/7/22. He/She had a copy of the employee's vaccination record and had not updated the matrix when survey started. -Employees #21, #23, and #24 were all dietary staff. It was up to the department head of each department to verify and follow-up on their employee's vaccination and/or exemption status. Employees #23 and #24 just started within the last week. Employee #21 was hired in January 2022 and should have had something one way or the other on file by now. -He/She acknowledged five out of the six staff that did not have documentation of a vaccine or an exemption were dietary staff. -The Department Head for that department was responsible to ensure all his/her staff were compliant with the regulation. During an interview on 4/12/22 at 11:45 A.M., the Dietary Manager said: -Employee #21 has worked at the facility since January 2022. He/She was a minor and worked in the kitchen part time. He/She had spoken with the employee and the employee's parents several times regarding his/her vaccination status. At one point it seemed as though they were going to allow the employee to get the vaccine, but then decided they wanted a religious exemption for him/her instead. He/She provided the employee and his/her parents with the non-medical exemption form, but they had not returned it at this point. The employee had been suspended on two separate occasions for missing the deadline for turning in his/her form and for being late in his/her daily testing. The employee was required to test every day and wear an N95 mask while he/she was at work. He/She worked in the dishwashing area only and was not around residents. -Employee #23 had recently started working at the facility, his/her hire date was 4/5/22. He/She was a minor and worked part time in the kitchen washing dishes. He/She was currently not vaccinated and was working on obtaining a non-medical exemption. He/She had to test every day when he/she came in to work and wear an N95 mask while at work. He/She worked in the dishwashing area only and was not around other residents. He/She has been given a deadline of 4/15/22 to submit his/her exemption. -Employee #24 was hired on 4/8/22. He/She had indicated he/she would submit a non-medical exemption, but had not done so yet. The employee would not be allowed to work until his/her documentation was received. He/She was given a deadline of 4/15/22 to submit his/her exemption. -He/She acknowledged five out of the six staff that did not have documentation of a vaccine or an exemption were dietary staff. During an interview on 4/13/22 at 10:38 A.M., the Director of Nursing (DON) said: -He/She had assisted the ADON with getting staff vaccination or exemption documentation. -All Staff should have the vaccination or exemption documentation on file. -The Administrator was in charge of tracking each department for compliance. -Each Department Head was in charge of tracking their own department to ensure compliance. -He/She acknowledged five out of the six staff that did not have documentation of a vaccine or an exemption were dietary staff.

Based on interview and record review, the facility failed to ensure that the criminal background checks (CBC) requested for four employees (Employees B, D, E and F) out of 10 sampled employees, pulled information from the Missouri (MO) Highway Patrol as outlined in state statute 43.540. This deficient practice had the potential to affect all facility residents. The facility's census was 58 residents. Record review of facility policy titled Resident Abuse/Neglect/Exploitation Policy and Procedure dated 12/30/16 showed: -Screening Policy: --All potential employees shall receive a criminal background check. --Attempts shall be made to obtain information from current and previous employers as listed on the employment application. -Procedure: --Individuals who had a disciplinary action due to abuse, neglect, mistreatment of residents, or misappropriation of their property taken against their professional license by a state licensure body cannot be hired by facilities. 1. Record review of Employee B's employee file dated 1/27/22 showed the CBC was conducted through a private online company which did not include the Missouri State Highway Patrol. 2. Record review of Employee D's employee file dated 1/27/22 showed the CBC was conducted through a private online company which did not include the Missouri State Highway Patrol. 3. Record review of Employee E's employee file dated 1/27/22 showed the CBC was conducted through a private online company which did not include the Missouri State Highway Patrol. 4. Record review of Employee F's employee file dated 1/27/22 showed the CBC was conducted through a private online company which did not include the Missouri State Highway Patrol. 5. During an interview on 4/8/22 at 2:15 P.M., the Assistant Administrator said he/she was not sure of the process for doing the the criminal background checks because the payroll secretary was the person who performed that task. During an interview on 4/8/22 at 2:15 P.M., the payroll secretary said: -He/she was not sure if the private online company that was used to check CBC's utilized the Missouri State Highway Patrol. -The facility runs a background check prior to hiring an employee. -Once hired the facility did not go back to do a family registry check. During an interview on 4/13/22 at 11:19 A.M., the Assistant Administrator said the facility did not have a policy for criminal background and employee disqualification list checks for new hires.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Record review of Resident #14's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Major depressive disorder. -Anxiety disorder, unspecified. Record review of the Consultant Pharmacist's Medication Regimen Review: Listing of Residents reviewed with no recommendations from July 2021 through March 2022 showed: -The resident's name was listed on all months, except for October 2021. -The October 2021 listing was missing. Record review of the resident's POS dated April 2022 showed: -On 12/15/21, the resident was prescribed Risperidone (used off-label in the treatment of anxiety. Risperdal is typically prescribed to treat schizophrenia, bipolar mania, and autism) 0.25 mg once daily for increased depression. -On 12/15/21, the resident was on the Lexapro (used to treat depression) 10 mg once daily for Major Depressive Disorder. -On 2/18/22, the physician increased the Risperidone to 0.5 mg once daily for Major Depressive Disorder. 8. During an interview on 4/11/22 at 2:04 P.M., the MDS Coordinator said he/she could not find a consultant pharmacist's DRR listing of residents reviewed with no recommendations for October 2021. During an interview on 4/13/22 at 10:38 A.M. the DON said: -The pharmacist came into the building monthly. -The pharmacist notified him/her that he/she was coming by email prior to his/her visit and notified him/her when he arrived at the facility. -When the pharmacist completed all of the DRR's, he/she sent the DRR in an email to him/her and their Infection Preventionist. -The Infection Preventionist printed the DRR recommendations and gave them to the nurses. -The nurses notified the physician of the DRR recommendation(s) and they documented the physician's response on the form. -The nurses put the forms in the charts. -Some of the nurses sent him/her a copy of the form but some did not. -The pharmacist sent him/her the list of residents he/she reviewed who had no recommendations. -No one checked to make sure all resident's DRR were completed by the pharmacist. -No one checked to make sure the follow up on the DRR's were completed. -They discussed the DRR's in their behavior meetings and if there was anything pertinent, they talked about the DRR's at their QAPI meeting also. 5. Record review of Resident #2 face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Acute kidney failure (when your kidneys suddenly become unable to filter waste products from your blood). -Major depressive disorder. Record review of Consultant Pharmacist's Medication Regimen Review: Listing of residents reviewed with no recommendations dated 7/2021 to 3/2022 showed: -Reports for 7/2021 to 9/202. -Reports for 11/2021 to 3/2022. -The resident was listed as reviewed by the consulting Pharmacist on 7/2021, 8/2021, and 11/2021 through 3/2022. -Recommendations were made for the resident by the consulting Pharmacist on 9/2021. Record review of the resident's Care Plan dated 10/14/21 showed: -The resident received psychotropic medication. -The resident will not receive injury from the side effects of psychotropic medications, -Staff were to administer Zoloft (used to treat depression) 25 mg, give 1/2 tablet by mouth once a day as ordered, -Observe for signs and symptoms of adverse reactions to Zoloft. -Monitor for signs and symptoms of increased depression. -Assure pharmacy consultants review medications and make recommendations to the doctor as appropriate. -The resident had a reduction of Zoloft on 10/1/19. Record review of the residents POS dated 4/1/22 to 4/30/22 showed he/she had the following orders: -Zoloft 25 mg, 1/2 tablet by mouth once a day. -Norco (combination medication is used to relieve moderate to severe pain. It contains an opioid pain reliever (hydrocodone) and a non-opioid pain reliever (acetaminophen Tylenol) 5/325 mg one tablet twice daily and every four hours as needed. 6. Record review of Resident #21 Face Sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Unspecified intellectual disabilities (a condition characterized by significant limitations in both intellectual functioning and adaptive behavior). -General anxiety disorder. Record review of the resident's Care Plan dated 5/13/21 showed: -The resident was receiving Ativan (a medication is used to treat anxiety) 0.5 mg one tablet by mouth twice daily and hydroxyzine (used in the treatment of allergy, nausea, and anxiety) 25 mg one tablet by mouth twice daily. -The resident would not receive injury from the side effects of psychotropic medications. -Staff were to administer Ativan as ordered. -Staff were to observe for signs and symptoms of adverse reactions to Ativan and report to the nurse/doctor. -Staff were to observe for signs and symptoms of increased depression. -Assure pharmacy consultants review medications and make recommendations to the doctor appropriate. -Administer hydroxyzine as ordered and monitor for signs and symptoms of adverse reactions. Record review of Consultant Pharmacist's Medication Regimen Review: Listing of residents reviewed with no recommendations dated 7/2021 to 3/2022 showed: -Reports for 7/2021 to 9/2021. -Reports for 11/2021 to 3/2022. -The resident was listed as reviewed by the consulting Pharmacist on 8/2021, 9/2021, and 12/2021 through 3/2022. -Recommendations were made for the resident on 7/2021 and 11/2021. Record review of the resident's POS dated 4/1/22 to 4/30/22 showed he/she had the following orders: -Ativan 0.5 mg one tablet by mouth twice daily. -Hydroxyzine 25 mg one tablet by mouth twice daily. 3. Record review of Resident #10's face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Dementia. -Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Major depressive disorder. Record review of the resident's Consultant Pharmacist's DRR, dated 7/1/21 through 8/30/21 showed the resident had DRR no recommendations. Record review of the resident's DRR dated 9/1/21 through 9/17/21 showed: -The DRR was completed with recommendations. -No documentation available showing pharmacist recommendations or the physician response. Record review of the resident's MRR showed no pharmacy review was completed for October 2021. Record review of the resident's care plan, dated 10/14/21 showed: -The resident received psychotropic medications. --Assure pharmacy consultants review medications and make recommendations to my Primary Care Physician (PCP) as appropriate. Record review of the resident's MRR, dated 11/1/21 through 11/21/21 showed the resident had no recommendations. Record review of the resident's MDS dated [DATE], showed: -The resident scored a 1 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions). --This showed that the resident was severely cognitively impaired. Record review of the resident's DRR, dated 1/1/22 through 2/17/22, showed the resident had no recommendations. Record review of the resident's POS, dated 4/1/22 to 4/30/22, showed: -On 8/13/20 the physician ordered Klonopin (a medicine used to treat the symptoms of seizures and panic disorder) tablet 0.5 milligram (mg) for dementia with lewy bodies (a disease associated with abnormal deposits of a protein in the brain). -On 8/13/20 the physician ordered Remeron (an antidepressant) tablet, 15mg for major depressive disorder re-current severe with psychotic symptoms, give at bed time between 6:00 P.M.-10:00P.M. -On 12/31/21 the physician ordered Seroquel (an antipsychotic or tranquilizing psychiatric medication), tablet 50 mg for dementia and other diseases classified elsewhere with behavioral disturbances. -On 3/22/22 the Seroquel was decreased to 25 mg at bedtime. During an interview on 4/12/22 at 10:03 AM, the MDS Coordinator said: -He/she was unable to locate the September 2021 DRR with recommendations for the resident. -He/she was unaware if the physician viewed it or received a copy. -There was no DRR for October 2021. 4. Record review of Resident #5's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Dementia. -Anxiety disorder. -Muscle weakness. Record review of the resident's facilities Consultant Pharmacist's DRR dated 7/1/21 through 9/17/21, showed the resident had no recommendations. Record review of the resident's DRR showed no pharmacy review was completed for October 2021. Record review of the resident's care plan, dated 10/8/21, showed: -The resident received psychotropic medications. --Assure pharmacy consultant reviewed medications and made recommendations to physician as appropriate. Record review of the resident's DRR, dated 11/1/21 through 1/31/22, showed the resident had no recommendations. Record review of the resident's MDS dated [DATE] showed: -The resident scored a 00 on the BIMS. --This showed that the resident was severely cognitively impaired. During an interview on 4/12/22 at 10:03 AM, the MDS Coordinator said: -He/she was unable to locate the September 2021 DRR with recommendations for the resident. -He/she was unaware if the physician viewed it or received a copy. -There was no DRR for October 2021. Based on interview and record review, the facility failed to ensure the drug regimen review (DRR) of each resident was completed at least once a month by a licensed pharmacist and/or to maintain the list of residents with no irregularities and to ensure DRR were completed or failed to maintain the DRR recommendations and responses for seven sampled residents (Residents #35, #50 #10, #5, #2, #21, and #14) out of 15 sampled residents. The facility census was 58 residents. Record review of the facility's DRR policy dated November 2017 showed: The DRR was to be completed by a pharmacist on all residents monthly. -Following the completion of the DRR, the pharmacist shall: --Complete the consultant pharmacist DRR form that is kept in each chart. --Complete a note to the attending physician/prescriber form for residents requiring recommendations and give the forms to the Director of Nursing (DON) and inform the DON of any irregularities that require urgent action. -Within one week of the completion of the DRR, the DON shall: --Provide the Registered Nurse (RN) supervisor or a charge nurse a copy of the note to the attending physician/prescriber forms that were completed. --Follow-up monthly by audit to assure the note to the attending physician/prescriber forms are returned after being addressed by the physician. --If not already done, return completed note to attending physician/prescriber to each nurses' station for filling in the chart. --Provide facility medical director with the DRR information at the monthly Quality Assurance and Performance Improvement (QAPI) meeting. -Following the completion of the DRR, the RN supervisor or charge nurse shall: --Fax the notes to the attending physician/prescriber forms to appropriate persons and assure response is received. --Re-fax physician if no response received within one week. --Upon receipt of response from the physician, return the notes to the attending physician/prescriber to the DON upon completion by the attending physician. -The DON or designee shall complete monthly chart audits for the following: --Consultant Pharmacist DRR form in each chart is initialed by the physician. --Notes to the attending physician/prescriber forms have been addressed by physician/prescriber for each recommendation and filed in the chart. --Recommendations rejected by attending physician/prescriber have documentation from physician/prescriber as to why the recommendation was rejected. 1. Record review of Resident #35's face sheet showed he/she was admitted to the facility on [DATE] and some of his/her admitting diagnoses included heart failure, diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes) and major depressive disorder (depressed mood most of the day and a loss of interest in normal activities and relationships). Record review of the pharmacist's monthly list of residents with no DRR recommendations and the resident's DRRs for July 2021 through March 2022 showed: -No DRR or response for July 2021 and the resident was not on the list of residents with no DRR recommendations. -No DRR or response for August 2021 and the resident was not on the list of residents with no DRR recommendations. -No list of residents with no recommendations and no DRR or response for October 2021. Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 2/16/22 showed the resident received insulin, an anticoagulant (blood thinner reduces the formation of blood clots) and an antidepressant and some of his/her diagnoses included heart disease, diabetes, dementia and depression. Record review of the resident's care plan dated 2/17/22 showed he/she received antidepressants, insulin and an anticoagulant. Record review of the resident's April 2022 Physician's Order Sheet (POS) showed he/she had physician's orders for multiple medications for heart disease with heart failure, a medication for dementia, two antidepressants for major depressive disorder, an anticoagulant (medication used to thin the blood) and multiple medications for diabetes including insulin. During an interview on 4/11/22 at 2:04 P.M., the MDS Coordinator said: -He/she could not find a consultant pharmacist's DRR listing of residents reviewed with no recommendations for October 2021. -He/she could not find the DRR's or responses for July 2021 and August 2021 for the resident. 2. Record review of Resident #50's face sheet showed he/she was admitted to the facility on [DATE] and some of his/her admitting diagnoses included heart failure, major depressive disorder and memory deficit following a stroke. Record review of the pharmacist's monthly list of residents with no DRR recommendations and the resident's DRRs for July 2021 through March 2022 showed: -No list of residents with no recommendations and no DRR or response for October 2021. -No DRR or response for February 2022 and the resident was not on the list of residents with no DRR recommendations. Record review of the resident's annual MDS dated [DATE] showed the resident received: -An antipsychotic (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) commonly but not exclusively used to treat psychosis). -An antidepressant (medication used to treat depression). -A diuretic (any drug that elevates the rate of urination). Record review of the resident's care plan dated 3/11/22 showed some of the resident's diagnoses included memory impairment and dementia and the resident received an antipsychotic medication, an antidepressant and a diuretic. Record review of the resident's April 2022 POS showed: -The resident had physician's orders for an antipsychotic medication and a diuretic. -Some of the physician's orders included medications to treat heart failure, hypothyroidism (below normal function of the thyroid gland which regulates metabolism), major depressive disorder, high cholesterol, high blood pressure and dementia. During an interview on 4/11/22 at 2:04 P.M., the MDS Coordinator said: -He/she could not find a consultant pharmacist's DRR listing of residents reviewed with no recommendations for October 2021. -He/she could not find the DRR or response for the resident for February 2022 for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the CDC's website for C. diff guidelines for healthcare professionals, dated 7/20/21, showed: -Healthcare workers should wear gloves and a gown when treating patients suspected of having C. diff, even during short visits. -Hand sanitizer does not kill C. diff. Record review of the facility's Infection Prevention and Control Manual, dated 2019, showed staff were instructed to: -Disinfect reusable equipment between resident uses with hospital grade disinfectant. -Disinfect equipment before removal from a room of a resident on Contact Precautions (precautions taken to prevent the spread of infectious agents which are spread by direct or non-direct contact with the resident or their environment). Record review of the facility's Infection Prevention and Control Manual Transmission-Based Precautions with the subset Procedure for Contact Precautions, dated 2019, showed staff were instructed to: -Don (put on) gloves upon entry to resident's room. -Don gown upon entry to resident's room. -Remove gown and gloves and perform hand hygiene before leaving the resident's care environment. -Clean and disinfect equipment used for multiple residents after use. Record review of Resident #48's Face Sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Covid pneumonia (inflammation of one or both lungs with consolidation after Covid-19 [a new disease caused by a novel {new} coronavirus] infection). Review of the resident's MDS, dated [DATE], showed the resident's was frequently incontinent of bowel. Record review of the resident's care plan, updated 4/7/22, showed potential for injury related to signs and symptoms of C. diff. Record review of the resident's laboratory requisition sheet showed a stool sample was collected for suspected C. diff testing 4/7/22 at 08:30 A.M. Observation of the resident's room on 4/7/22 at 10:21 A.M., showed: -No precautions noted on the resident's door. -No personal protective equipment (PPE- equipment worn to minimize exposure to a variety of hazards. Examples of PPE include such items as gloves, face masks or face shields, respirators, foot, and eye protection) near door or in his/her room. Observation on 4/8/22 at 9:03 A.M., showed: -The resident's door now had a stop sign attached to it which instructed anyone entering the room to check with the nurse first. -There was no PPE near the door or in his/her room. During an interview on 4/8/22 at 9:03 A.M., Registered Nurse (RN) A said: -The resident was now on contact precautions due to suspected C. diff. -He/she suspected C. diff due to the resident's recent use of antibiotics and three or more loose stools in a 24 hour period. Observation on 4/11/22 at 9:08 A.M., showed: -Stop sign indicating precautions remained on the resident's door. -No PPE was available nearby. During an interview on 4/11/22 at 9:08 A.M., LPN B said the resident's labs to determine if he/she had C. diff results were not back yet. Observation on 4/11/22 at 9:11 A.M. showed: -Certified Medication Technician (CMT) A and Certified Nurses Aide (CNA) D entered the resident's room with the sit to stand lift. -CMT A and CNA D put on gloves. Staff did not apply gowns. -CNA D lowered the resident's pants while he/she was standing. -CMT A removed the resident's pants once he/she was safely moved to his/her bed and verbalized the resident had been incontinent of stool. -CNA D cleaned stool from the resident's front side while CMT A assisted. -CMT A removed gloves, did not perform hand hygiene, and moved things in the resident's closet to find a new brief. -CMT A put on new gloves without performing hand hygiene. -CMT A held biohazard bag for CNA D to put fecal covered wipes in. -CMT A then placed new brief under resident with the same gloves. -CMT A removed his/her gloves, performed hand hygiene, then picked up biohazard bag and tied it closed. -CNA D removed the sit to stand lift from the resident's room and put it in the storage area. -At 9:32 A.M., when asked if they would have done anything differently both staff responded no. During an interview on 4/11/22 at 1:31 P.M., Nurse Aide (NA) A said: -Night shift was responsible for cleaning equipment. -C. diff precautions included wearing a gown, but the resident had been started on antibiotics so they were no longer required. During an interview on 4/11/22 at 1:50 P.M., LPN B said he/she had received the resident's lab results and the resident did not have C. diff. During an interview on 4/12/22 at 7:21 A.M., LPN C said: -Staff should clean equipment with bleach wipes between resident uses. -He/She would expect a dedicated stethoscope, gown, gloves, and goggles or a face shield for residents with transmission-based precautions. -He/She would not use gowns or goggles/face shield for a resident with C. diff as it was not needed. During an interview on 4/12/22 at 10:44 A.M., LPN B said: -Staff should clean the sit to stand lift with bleach wipes after every use. -Staff only needed gloves and good hand hygiene when working with suspected C. diff residents. During an interview on 4/13/22 at 8:29 A.M., RN A said: -Staff should clean the sit to stand lift with bleach wipes between resident uses. -C. diff precautions included wearing gloves and thorough hand washing, gowns and face shields were not required. During an interview on 4/13/22 at 10:39 A.M., the DON said: -Staff should clean the sit to stand lift immediately if soiled, otherwise weekly. -Staff should clean the lift with bleach wipes before it is removed from the room of a resident on contact precautions. 2. Record review of the facility policy Suprapubic Catheter Care, dated 11/21, showed: -Procedure steps included the following: --Check physician orders for catheter care. --Wash hands and change gloves. --May apply dressing as needed for drainage. Review of facility Use of Foley Catheter Policy, dated 11/21, showed: -All residents with foley catheters should be checked frequently for the following: --Drainage tubing should not be kinked, bent or touching the floor. --Urinary drainage bag should be securely fastened to the bed, off the floor. Record review of Resident #21's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord or nerve problems). -Retention of urine (a condition in which you cannot empty all the urine from your bladder). Record review of the resident's Care Plan, dated 5/13/21, showed: -He/she had a supra pubic catheter (drains urine from your bladder. It is inserted into your bladder through a small hole in your belly). -Staff were to provide catheter care every shift and as needed per facility policy, dated 8/9/21. -Staff were to ensure the drainage bag was placed in a dignity bag when in bed, dated 8/9/21. Record review of the resident's Physician Order Report, dated 4/1/22 to 4/30/22, showed he/she had an order dated 10/17/21 for a supra pubic catheter care. Observation on 4/11/22 at 9:35 A.M., showed the resident: -Had a supra pubic catheter. -The catheter drainage bag was in a dignity bag under his/her wheelchair. Further observation showed the dignity bag was in contact with the floor. Observation on 4/11/22 at 1:44 P.M., showed the resident: -Was lying in bed. -The supra pubic catheter drainage bag was hanging from bed and was on the floor. During an interview on 4/12/22 at 5:28 A.M., Licensed Practical Nurse (LPN) D said: -Catheter care should be done every shift. -Drainage bags should be put in a dignity bag appropriately. -Drainage bags should be hung on the wheelchair or on the bed below the bladder. Observation on 4/12/22 at 12:29 P.M., of LPN A completing the resident's catheter care showed he/she: -Obtained supplies from treatment cart with bare hands. -Used scissors to cut the 4x4 gauze. -Gathered supplies from top of treatment cart with un-sanitized hands. -Obtained a towel in route to resident's room. -Placed the towel on the bedside table as a barrier. -An almost full package of gauze, wound cleanser, and partially used roll of tape were placed on the cloth barrier. -Obtained gloves, sanitized his/her hands, and applied clean gloves. -Removed the resident's dressing and discarded it into trash can. -Changed his/her gloves without washing or sanitizing his/her hands. -Obtained gauze from package and sprayed the gauze with wound cleanser. -LPN A wiped the insertion site and discarded used gauze in trash can. -With the same gloved hands, he/she obtained more gauze from the package, sprayed it with wound cleanser and wiped the insertion site and discarded gauze in trash. -Removed gloves, sanitized hands, and applied clean gloves. -LPN A obtained a marker from his/her pocket and marked the tape. -Cut gauze placed over insertion site, -Applied tape to the top portion of gauze. -Obtained second piece of tape from the roll and applied to the bottom side of gauze. -LPN A removed his/her gloves and discarded them in trash and did not wash his/her hands. -LPN A covered resident and raised the head of the bed. -Picked up supplies with un-sanitized hands. -Tucked supplies against body and sanitized his/her hands. -Placed all unused supplies back in treatment cart without being sanitized. During an interview on 4/12/22 at 12:30 P.M., LPN A said he/she would not have done anything differently. Observation on 4/13/22 at 8:30 A.M., of the resident showed: -He/she was sitting in his/her wheelchair in his/her room. -His/her drainage bag was hanging under his/her wheelchair. -His/her catheter tubing and drainage bag was on the floor. During an interview on 4/13/22 at 10:38 A.M., the Director of Nursing (DON) said: -He/She expected supra pubic catheter care to be done like any other catheter care. -He/she would expect them to introduce himself/herself to the resident, wash their hands prior to starting cares, put on clean gloves, complete the catheter care, remove gloves, and wash hands when finished. -Multi-use items should be wiped down to disinfect prior to returning to the treatment cart. Based on observation, interview, and record review, the facility failed to meet the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease) including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility. The facility staff also failed to wash or sanitize hands between glove changes during suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) care and ensure dignity bag (covering used to hold urine catheter bag out of sight) did not make contact with the floor for one resident (Resident #21) and use appropriate infection control procedures to prevent the possible spread of clostridium difficile (C. diff - an infection which typically occurs after use of antibiotic medications that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon and is shed in feces) for one sampled resident with suspected C.Diff (Resident #48) out of 15 sampled residents. The facility census was 58 residents. 1. Record review of the facility's EP plan in a binder entitled Facility Disaster Manual, provided by the ESS from the main conference room and last reviewed on 2/16/22 showed a 4-page document entitled Water Management Program to Reduce the Risk of Legionella, under the tab Water Outage, that did not include the following CMS requirements for a waterborne pathogen program: -A facility-specific risk assessment that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard. -A completed Centers for Disease Control (CDC) toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -A schematic or diagram of the facility's water system with a written explanation of the water flow throughout the facility. -A facility-specific infection prevention program or plan to deal with outbreaks of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever.) and/or other waterborne pathogens. -A program and/or flowchart that identified and indicated specific potential risk areas of growth within the building with assessments of each individual area's potential risk level. -Testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility. -Facility-specific interventions or action plans for when control limits are not met. -Documentation of any site log book being maintained with any dated cleanings, sanitizings, descalings, and inspections mentioned. Record review on 4/7/22 at 11:17 A.M., of the facility's Emergency Preparedness (EP) plan in a binder entitled OSHA Plan - MSDS Plan - Disaster Preparedness obtained from the East Nurse Station and last reviewed on 2/16/22 showed an absence of a water-borne pathogen prevention program. Observations during the facility Life Safety Code (LSC) inspection with the Environmental Services Supervisor (ESS) on 4/8/22 between 10:04 A.M. and 2:21 P.M. showed the following: -There was a boiler room in the basement. -There was a plumbing backflow access. -There were two resident shower/bathtub rooms. -Each resident room had a private or shared bathroom. -There was an ice machine and a dehumidifier. During an interview on 4/8/22 at 11:09 A.M., the ESS said the following: -He/she knew the facility's water-borne pathogen prevention program was in their disaster manual under the Water Outage tab because he/she wrote it. -If there was not a copy in the disaster manual at the East Nurse Station now, there used to be. During an interview on 4/12/22 at 12:08 P.M., the Assistant Administrator said the ESS and the previous Maintenance Director put the facility's water-borne pathogen prevention program together and he/she believed they tried to go by government guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents and/or family were notified when a staff or resident in the facility tested positive for COVID (a new disease caused by a novel (new) coronavirus) for five sampled residents (Residents #3, #16, #39, #47, and #50) out of 15 sampled residents. The facility census was 58 residents. A policy for notification of residents and family for positive COVID staff and/or residents was requested but not received at the time of exit. 1. Record review of Resident #3's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 3/30/22 showed: -He/She was admitted to the facility on [DATE]. -He/She had a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating he/she was cognitively intact. Record review of the resident's medical record from 1/15/22 - 4/13/22 showed no documentation the resident or the resident's family was notified of positive COVID staff or residents. 2. Record review of Resident #16's quarterly MDS dated [DATE] showed: -He/She was admitted to the facility on [DATE]. -He/She had a BIMS of two out of 15 indicating he/she was severely cognitively impaired. Record review of the resident's medical record from 1/15/22 - 4/13/22 showed no documentation the resident or the resident's family was notified of positive COVID staff or residents. 3. Record review of Resident #39's annual MDS dated [DATE] showed: -He/She was readmitted to the facility on [DATE]. -He/She had a BIMS of eight out of 15 indicating he/she was moderately cognitively impaired. Record review of the resident's medical record from 1/15/22 - 4/13/22 showed no documentation the resident or the resident's family was notified of positive COVID staff or residents. 4. Record review of Resident #47's quarterly MDS dated [DATE] showed: -He/She was admitted to the facility on [DATE]. -He/She had a BIMS of 10 out of 15 indicating he/she was moderately cognitively impaired. Record review of the resident's medical record from 1/15/22 - 4/13/22 showed no documentation the resident or the resident's family was notified of positive COVID staff or residents. 5. Record review of Resident #50's annual MDS dated [DATE] showed: -He/She was admitted to the facility on [DATE]. -He/She had a BIMS of eight out of 15 indicating he/she was moderately cognitively impaired. Record review of the resident's medical record from 1/15/22 - 4/13/22 showed no documentation the resident or the resident's family was notified of positive COVID staff or residents. 6. Record review of the facility social media account showed the last post notifying residents and family of a COVID positive resident and a COVID positive staff was on 1/13/22. Record review of the facility undated Vaccination Matrix for Staff showed: -Two contracted staff tested positive for COVID-19 from 1/20/22 to 1/31/22. -17 staff tested positive for COVID-19 from 1/20/22 to 1/31/22. -Two contracted staff tested positive for COVID-19 from 2/1/22 to 2/28/22. -Ten staff tested positive for COVID-19 from 2/1/22 to 2/28/22. -Two staff tested positive for COVID-19 from 3/1/22 to 4/8/22. Record review of the facility's COVID-19 positive resident cases from 1/20/22 to 4/8/22 showed: -Five residents tested positive for COVID-19 from 1/20/22 to 1/31/22. -Three residents tested positive for COVID-19 from 2/1/22 to 4/5/22. --The last resident positive COVID-19 was documented on 2/10/22. The resident was discharged to the hospital related on 2/13/22 and returned to the facility on 3/1/22. 7. During an interview on 4/13/22 at 10:05 A.M., Licensed Practical Nurse (LPN) B said: -Notification of family for positive COVID residents or staff would be documented in the resident's nurse's notes in his/her medical record. -He/she could not locate the notes for notification of positive residents or staff since 1/13/22 in the sampled resident's nurse's notes. During an interview on 4/13/22 at 10:38 A.M., the Director of Nursing (DON) said: -The facility notified residents and their families through their social media account and through a mass text/voicemail system when there was a COVID positive staff or resident. -He/She thought it was Social Services who sent out the notifications. -He/She did not think it was also noted in the resident's chart when a notification was sent out regarding positive COVID cases in the building. During an interview on 4/13/22 at 11:03 A.M., Social Services and the Assistant Administrator said: -The facility notified residents and family of positive COVID cases through their social media account and through a mass text message/voicemail service. -He/She could not find any notification of positive COVID cases through their social media account since 1/13/22. -He/She did not know if the mass text/voicemail service had a call log to verify notification was sent. -He/She was not able to provide evidence the facility notified residents and/or family of positive COVID cases in the building since 1/13/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #26's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses of polyostarthritis (joint pain and stiffness), dorsalgia (back pain, backache or spine pain) and cerebrovascular disease affecting left non-dominant side (stroke which cause weakness on the left side). Record review of the resident's side rail assessment completed on 5/6/17 showed: -The side rails will be consider for mobility; -Nothing was marked for identify all that contribute to the resident need to use side rails related to physical, cognitive or security; -Will the side rail assist the resident in bed mobility, and transfer was all marked yes and -Recommend 1/2 siderails for the top right and left of the resident's bed. Record review of the resident's Activity of Daily Living (ADL's) Care plan dated 7/9/18 showed: -The resident has side rails up when in his/her bed; -Goal the resident will not receive injury related to the side rail over the next review period target date was 10/9/18; -Approach was for staff to assure the resident's side rails were up on the top right half to assist with bed mobility as per physician's order and the side rail does not restrict the resident's movement; --Reposition the resident on routine round with prompts if needed to assure no danger from the side rails and -The staff did not document that they reviewed or updated the resident's the siderail care plan since 7/9/18. Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Usually understood and usually can understand others and can make his/her needs known; -Had impaired vision and minimal hearing and -No indication of the use of side rails. Record review of the resident's April 2019 Monthly Nursing Summary dated 5/1/19 showed: -The resident was able to turn himself/herself in bed; -Does not have any positioning devices; -The resident required stand by assistance from staff for transfers and -Did not document anything regarding the use of 1/2 side rails and did not document anything regarding any ongoing safety monitoring of the 1/2 side rails. Record review of the resident's May 2019 Monthly Nursing Summary dated 6/5/19 showed: -The resident was able to turn himself/herself in bed; -Does not have positioning devices; -He/she required stand by assistance from staff for transfers and -Did not document anything regarding the use of 1/2 side rails or anything regarding the ongoing safety monitoring of the 1/2 side rails. Record review of the resident's POS dated 6/1/19 to 6/31/19 showed a physician's order with a start date of 11/16/17 for the resident to have an upper 1/2 side rail the right side of the resident's bed for mobility. Record review of the resident's May and June 2019 Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed area for the staff to document if they did any safety monitoring of the resident's side rails. Observation 6/11/19 at 12: 38 P.M. of the resident room showed he/she had a quarter side rail on the upper right side of his/her bed. During an interview on 6/14/19 at 12:20 P.M. Licensed Practical Nurse (LPN) D said: -The therapy would assess the resident's quarterly; -The facility had gotten rid of all the siderails for any new resident; -If a resident had side rails on their bed prior to the new policy there would only be the original physician's orders and the original assessment in the resident's medical record and -The resident has been using the siderail for positioning himself/herself in bed. During an interview on 6/14/19 at 1:10 P.M., DON said: -He/she would expect the resident to be reevaluated quarterly and annually for the use of side rails and -The LPN's/Registered Nurses (RN) are able to complete the residents' side rail use assessments. Based on observation, interview and record review, the facility failed to ensure the physician's order stated the medical symptom for a seatbelt and to ensure the seat belt was assessed at least quarterly for continued use as the least restrictive means for one sampled resident (Resident #35) and to provide ongoing assessment and monitoring for the use of a side rail for one sampled resident (Resident #26), out of 19 sampled residents . The facility census was 79 residents. Record review of the facility's Usage of Restraint/Enabler policy and procedure dated 11/2008, showed physical restraints is defined as any manual method or or physical or mechanical device, material, or equipment attached or adjacent to a resident's body that the individual cannot remove easily [NAME] restricts freedom of movement or normal access to one's body. A device is considered an enabler if the resident would have to stay in bed or be in a reclining chair if the device was not in place. The purpose was to ensure that dignity and self esteem will be maintained for the resident while protecting him/her from injury to self and others. The most appropriate and least restrictive device will be used for an individual when some type of restraint is needed. The procedure showed: -Nursing will assess the resident's medical, psychological and physical condition; -According to occupational and Physical therapy recommendations, a physician's order will be obtained for the least restrictive restraint; -The resident, family member or significant other will be notified with explanation for the request, expected outcome and potential negative outcomes with the use of the restraint and consent for will be signed by the resident, family or significant other; -Nursing staff will monitor all restraints every 30 minutes to ensure resident safety; -The restraint committee meets monthly and will review; -Side Rail Assessments will be completed on admission, quarterly and deemed as necessary and -Physical Restraint Assessment will be utilized to assess the initial application and reduction assessment will be done quarterly. Record review of the Facility Bed Rail Policy dated 9/13/17 showed: -In attempt to discontinue and reduce current physician order for side/bed rails use of bed side rails must be assessed for appropriateness monthly as part of updating the resident's care plan, or more often as necessary.; -Nursing staff are to do a monthly audit and check beds physically to ensure bedrails that are on bed match current orders and -Safety device meeting will be held monthly with review of current rails and ways to reduce them. 1. Record review of Resident #35's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including cerebral palsy (a condition marked by impaired muscle coordination (spastic paralysis) and/or other disabilities, typically caused by damage to the brain before or at birth), bipolar disorder, depression with psychotic symptoms, seizures, scoliosis (curvature of the spine) and high blood pressure. Record review of the resident's Restraint Consent form dated 2009, showed: -The resident had a seatbelt for his/her wheelchair and it was considered the least restrictive device; -The resident was able to release the seat belt upon command; -The resident was on an anti anxiety medication and -Risks of using a restraint was documented and attached to the form, and the consent form was signed by the resident. Record review of the resident's Device Decision Guide dated 9/13/12, showed the facility determined whether the device was a restraint using the decision guide. The facility showed: -They determined the device was not a restraint because the resident had cognitive and functional ability to remove the device; -They determined the device had enabling qualities because it allowed the resident to participate in activities the resident would otherwise be incapable of, allowed the resident to do something that improved his/her quality of life and/or improved his/her physical or emotional status; -They determined the resident was not vulnerable to safety risks; -The guide provided instructions for care planing and monitoring which included identifying reasons for selecting the device, managing fall risks, using the device correctly, identifying the goals for use, monitoring for the impact of using the device and potential risks, explaining why continued use was needed, maintaining ongoing monitoring for safety hazards while using the device, periodically (at least quarterly) re-assessing the resident for continued need and documenting and -The guide showed using a seat belt for positioning is inadequate. Include cause of the positioning problem. Record review of the resident's Physician's Order Sheet (POS) dated 6/2019, showed a physician's order stating: -Self releasing seat belt when up in wheelchair for wheelchair positioning-ensure it is released every 2 hours for at least 10 minutes and at meals-can self release on command. This order was dated 5/24/13 and -The physician's order did not show the medical symptom for the resident's seatbelt use. Record review of the resident's Nursing Notes showed: -On 4/17/19, the facility had the resident's Care Plan meeting and the nurse documented the resident was alert and oriented with some confusion at times. The resident's mood was happy and cooperative with cares but can be combative at times. The resident liked to sleep until mid morning. Staff checked on the resident every two hours for incontinence. The nurse documented the resident wore a seatbelt in his/her wheelchair that he/she could release upon request and -There were no further notes showing the nursing staff assessed the resident for continued use of the seat belt device and if it was still appropriate for the resident. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 4/23/19, showed he/she: -Was alert and oriented with some confusion; -Needed supervision with transfers and did not ambulate; -Used a wheelchair for mobility; -Had a fall history (one non-injury fall) since admission or within the prior assessment period; -Used routine anti-psychotic medications and -Did not have a restraint. Record review of the resident's Care plan updated 4/24/19, showed the resident wore a seat belt when he/she is in his/her wheelchair for seizure precautions and uncoordinated movements, related to cerebral palsy. Staff was to ensure the resident's seat belt was released every two hours for 10 minutes. The care plan showed the resident was able to release his/her seat belt upon command. Record review of the resident's Monthly Nursing Summaries dated April 2019 and May 2019, showed an area on the form titled positioning devices that showed the resident had a seat belt and the resident removed the device on command. Record review of the resident's Medical Record showed there was no documentation showing the facility completed a restraint re-assessment quarterly, which showed the resident's current ability (physical and cognitive) remained conducive to maintaining the seat belt device as the least restrictive device for enabling the resident and that it was being monitored and was still considered appropriate for the resident. Observation on 6/13/19 at 12:30 P.M., showed the resident was sitting up in his/her wheelchair in the dining room waiting for lunch to be served. The resident was not wearing a seat belt at this time. He/She was pleasant and was interacting with peers. During an interview on 6/14/19 at 10:13 A.M., the MDS Coordinator said: -They review all restraints in their monthly restorative care meetings to ensure the restraint devices are currently still appropriate for the residents that have them, but they do not put that information in each individuals medical record (the information is kept in the facility's monthly minutes) and -The nurses were supposed to check the resident's restraint when they complete the resident's monthly summary to determine that it was still adequate for the resident and that the resident could still demonstrate he/she could release the seat belt. Observation on 6/14/19 at 10:53 A.M., showed the resident was sitting in the doorway of his/her room in his/her wheelchair. He/she was dressed for the weather and was not wearing his/her seatbelt. The resident said that he/she was able to release his/her seat belt himself/herself and then he/she connected the seat belt, then released it. During an interview on 6/14/19 at 1:38 P.M., the Director of Nursing (DON) said: -The physician's order for the resident's seat belt should show the medical symptom for having a seat belt; -Positioning is not a medical symptom and it should have shown the resident's diagnosis of cerebral palsy (uncontrolled muscle movement) and/or seizures as the symptoms and -The assessment process for continuing the seat belt device is to check to ensure they document that the they observed the resident release the seatbelt (circling the monthly assessment sheet was not sufficient).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to verify and obtain physician's orders for follow up care for suture removal and follow-up appointments for one sampled resident (Resident #124) out of 19 sampled residents. The facility census was 79 residents. 1. Record review of Resident #124's Hospital Physician Progress Note dated 5/24/19 showed: -On 5/1/19 the resident underwent a right leg above the knee amputation (AKA); -Had a wound vac (it is vacuum sealed dressing that pulls fluid from the wound over time. This can reduce the swelling help clean the wound and remove bacteria and it helps pull the edges together and may stimulate growth of new tissue that helps the wound to close) after surgery for six days and was on an antibiotic for one day; -In 2012 the resident had a left below the knee amputation (BKA) and was wearing leg prosthesis; -On 5/8/19 the resident was admitted to hospital inpatient rehabilitation for Physical Therapy (PT) for trunk weakness, difficulty with transfers and bed mobility; -The resident's was having right AKA post surgical pain and had a dressing on the right stump that was clean, dry and intact; -He/she was to follow up with the vascular surgeon on 5/28/19 and it was okay for the surgical staples to remain until then per conversation with the vascular surgeon and -The resident was having pain issues and consider giving pain medication to the resident prior leaving for dialysis for pain management. Record Review of the resident's admission Face Sheet showed he/she was admitted to the facility on [DATE] with diagnosis of Right AKA. Record review of the resident's admission assessment dated [DATE] showed he/she: - Had surgical dressing to the right and left lower leg stumps and -Had bruising to his/her left forearm from an Intravenous therapy (IV) that measured 4.2 centimeters (cm) in length and 2.3 cm in width. Record review of the resident's admission Initial Care Plan dated 6/6/19 showed: -The resident had a surgical wound to his/her right lower leg stump; -The nursing staff had surgical wound treatment orders and -The staff did not document anything regarding the removal of the sutures or any follow up appointments. Record review of the resident's Physician Order Sheet (POS) 6/6/19 showed: -Had physician's order to cleanse the surgical wound to his/her right lower extremities with normal saline or wound cleanser and then cover with a dry dressing and the nursing staff were to change the dressing daily and as needed; -Had a physician order to monitor his/her left lower leg stump every shift for signs and symptoms (s/sx) of infection, may cover the area with a dry dressing as needed and -The resident was to follow up with the vascular clinic but the staff did not document the date or the time of the follow-up appointment. Record review of the resident's hospital physician discharge order report that was faxed on 6/7/19 showed: -On 5/1/19 the resident had a Right AKA; -Admit to Skilled nursing; -Continue PT and Occupational Therapy (OT); -The resident may shower and -Call vascular surgery clinic for follow up appointment. Observation and interview on 6/13/19 at 10:55 A.M., showed the resident: -Had sutures to his/her RLE amputee stump that were intact and there were no redness or drainage noted; -The left leg stump had a dime size pinkish-reddened area; -The resident said that his/her leg prostheses had rubbed an area on the left stump area and -Licensed Practical Nurse (LPN) F had treated the areas. During an interview 06/13/19 at 1:19 P.M., LPN F said he/she was unsure when the resident's sutures are to be removed from the resident right stump and he/she would have to find out. During interview on 6/14/19 at 12:30 P.M., Registered Nurse (RN) A said: -He/she expected the nursing staff to call the hospital to clarify the Physician orders related to suture removal and for the treatment to the surgical wounds to the resident's right and left leg stumps; -He/she had contacted the hospital to clarify the resident's discharge orders and also had contacted the surgeon office to setup a follow-up appointment and -RN A did not document in the resident's medical record or write a physician's order of these findings. During an interview on 6/14/19 at 1:10 P.M., Director of Nursing (DON) said: -He/she expect nursing staff to clarify hospital discharge instruction orders; -Should have had physician's order for any follow-up care appointments with the vascular surgeon and the resident's primary care physician; -Would expect to have physician's order for when and by whom the resident sutures was to be removed; -Expect nursing staff to document in the resident's medical record when they had contacted the hospital, when the resident's appointments were setup and any other orders that were given when called and -The resident's stitches/staples are to stay in place until seen by the surgeon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify the resident's physician in a timely manner so treatment of the pressure sore could be initiated for three days for one sampled resident (Resident #41) out of 19 sampled residents. The facility census was 79 residents. 1. Record review of Resident #41's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease (is a progressive nervous system disorder that affects movement and thought process), restless leg syndrome (causes unpleasant or uncomfortable sensations in the legs and an irresistible urge to move them) and Anemia (low blood count, tired and weak). Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/24/19 showed he/she: -Was severely cognitively impaired and had short term and long term memory problems; -Was usually able to understand others and make his/her needs known; -Required assist of one staff member for supervision for transfer; -Was able to provide most of his/her own cares; -Was at risk for pressure ulcers and had a pressure reducing device for his/her chair and bed and -Did not have any pressure ulcers or other skin treatments indicated at the time of the assessment. Record review of the resident's nursing note dated 5/25/19 at 2:00 P.M. showed: -The resident had a new open area to his/her left buttocks that measured 0.8 centimeters (cm) in length (L), 1.40 cm in width (W) and 0.1 cm in depth (D); -The wound bed had 75% -100% granulation tissue (good viable tissue); -Registered Nurse (RN) had seen the wound and staged the wound at a Stage 2 pressure Ulcer (is a defined as an area of partial thickness, loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough); -A dry dressing was applied to prevent drainage on clothes and protect from germs; -The on-call physician was to be notified; -The information was passed on to the next shift to follow-up and -The staff did not document that they had notified the on-call physician and there was no documentation that the next shift of resident's new pressure wound. Record review of the resident's nursing notes from 5/26/19 to 5/31/19 showed on 5/27/19 the evening shift did not document anything related to the resident's new pressure ulcer or that the resident's physician had been notified. Record review of the resident's wound assessment notes showed: -On 5/25/19, the resident was found to have a new open area to his/her inner left buttock with 100% pink granulation tissue; --Plans were to protect area with dry dressing and daily dressing changes; --Had only superficial tissue damage at this time and the wound was staged at a Stage II pressure wound and -The staff did not document that they notified the resident's physician of the resident's new Stage II pressure ulcer found on 5/25/19. Record review of the resident's Wound Assessment Flow Sheet dated 5/25/19 showed: -The resident wound measurements were 0.8 cm in length, 1.40 cm in width and 0.1 cm in depth; -Was staged at a Stage II pressure ulcer and -Had scant amount of serosanguineous (blood tinge) drainage. Record review of the resident's wound assessment notes dated 5/28/19 showed: -On 5/28/19, a physician's order was obtained and gave wound care treatment orders for the staff to clean the wound with normal saline and to cover with Calcium alginate (is a dressing designed for use on wounds with moderate to heavy drainage) dressing and then cover with a gentle boarder foam dressing; -No other wound assessment notes were found after this date related to the resident wound and -The resident's physician was notified three days after the resident's Stage II pressure ulcer was found. Record review of the resident's Treatment Administration Record (TAR) for May 2019 showed: -There were no physician orders for treatments for the resident's Stage II pressure wound from 5/25/19 to 5/27/19 and -On 5/28/19, new physician's order was written for staff to clean the wound to the resident's left buttocks with normal saline; then apply skin prep around peri-wound area (skin around the wound) and cover the wound with Calcium alginate; then cover with a gentle boarder foam dressing and dressing was to be changed daily and as needed. Record review of the resident's Physician Order Sheet (POS) dated 5/1/19 to 5/31/19 showed the resident: -Had a new physician's order dated 5/28/19 for the staff to clean wound on the resident's left buttocks with normal saline; --Then apply skin prep around peri-wound area and cover the wound with Calcium Alginate; --Then cover with gentle boarder foam dressing; --The dressing was to be changed daily and as needed and -The staff did not receive a physician order for the resident's new Stage 2 pressure ulcer until 3 days after the Stage II pressure ulcer was found. Record review of the resident's Skin Wound Care Plan dated 5/28/19 showed: -The goal was for the resident's Stage 2 pressure injury to the resident's left buttock will be free of sign and symptoms of infection and show healing progress over the next review period; -The approach was to complete the treatment to the resident's left buttock as ordered per the POS and the TAR; --Monitor the resident's wound for sign and symptoms of infection (redness, warmth, foul odor) and report to nurse and the resident physician if these symptom occur; --Monitor and document the resident's healing progress weekly and as needed; and --If no healing progress had been noted in 14 days then re-evaluate treatment. Record review of the resident's Wound Assessment Flow Sheet dated 6/3/19 showed: -The resident wound measurements were: 0.3 cm in length by 0.7 cm in width by 0.1 cm in depth; -Had no drainage documented and -There were not further wound assessments completed after 6/3/19. Record review of the resident's POS dated 6/1/19 to 6/31/19 showed the resident: -Had a physician's order dated 5/28/19 to clean the wound to his/her left buttocks with normal saline; --Then apply skin prep around peri-wound area and cover the wound with Calcium Alginate; --Then cover with a gentle boarder foam dressing; --The dressing was to be changed daily and as needed and -Had a physician's order for Calazime skin protection (skin protectant) to fragile /irritated skin areas Review of the resident's TAR dated 6/1/19 to 6/31/19 showed wound care treatment had been done and documented by a nurse signature in all the boxes verifying the wound care had been completed to the resident's left buttock. Observation 6/11/19 at 9:00 A.M., of the resident's wound care showed: -The resident had a wound on his/her left buttocks; -The wound was the oval shape and size of a dime, with center of the wound was a pinkish red; -No drainage noted to the site and the wound was healing; -Licensed Practical Nurse (LPN) F provide wound care per physician's orders; -LPN F cleaned the resident's left buttock wound with normal saline, then applied skin prep around peri-wound and covered the wound with Calcium Alginate then covered it with a gentle boarder foam dressing change and -The resident remained standing holding onto his/her walker with the gait belt around the waist of the resident during the treatment. During an interview on 6/14/19 at 11:30 A.M., Registered Nurse (RN) A said: -He/she did not feel need the need to call the resident's Primary Care Physician upon finding of the wound since he/she had the nursing staff start preventative treatment for the resident's Stage II pressure ulcer and -The RN then called the resident's physician on 5/28/19. During an interview on 6/14/19 at 12:49 P.M., Director of Nursing (DON) said: -Nursing staff are to notify the RN's of any new wounds and the RN will assess the new or changing wounds and can stage the wounds; -Would expect to to see documentation in the resident's nurses notes or wound notes of any follow-up care provided and the staff should document when they had contacted or to follow-up with the resident's physician; -He/she expected the nursing staff to notify the resident's physician immediately when the resident has a new wound or a change in the resident's medical condition and -The staff should have contacted the resident's physician the same day the wound was found and not to wait three days to call to receive physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base on observation, interview and record review, the facility failed to ensure a comprehensive detail assessment was completed for the resident colostomy site to include location and description of the stoma, the skin around the site and the stool in the colostomy pouch for one sampled resident (Resident #26), out of 19 sampled residents. The facility Census was 79 residents. 1. Record review of Resident #26's admission Record showed he/she was admitted to the facility on [DATE] and had a diagnosis of colostomy (is an opening (stoma) in the large intestine (colon) and cerebrovascular disease affecting left non-dominant side(stroke which cause weakness on the left side). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 4/3/19 showed he/she: -Was cognitively intact and -Require extensive assistant of one staff member with toileting; -Has a ostomy and was continent of urine. Record review of the resident's progress notes showed: -On 4/19/19 a nursing note that the resident needs assistance with colostomy care; --No other documentation related to monitoring of the colostomy site; -On 4/27/19 at 8:00 A.M. the staff had changed the resident's colostomy bag; --Was noted that the resident's skin surrounding the colostomy was red and irritated; --Had no complaints during the changing of the colostomy; -Did not indicated if the resident's physician had been notified regarding the red irritated skin surrounding the colostomy and if there were any treatment orders given; -On 4/29/19, the nursing staff provided colostomy care to the resident and --The staff did not document anything else related to the monitoring of the stoma site. Record review of the resident's medical record and skin assessment showed no details or documentation on the appearance of the resident's stoma or the location of the resident's stoma or the color and the texture of the resident's bowel movements. Record review of the resident's Physician's Order Sheet (POS) 6/1/19 to 6/31/19 showed the resident: -Had a diagnosis of Diverticulitis (an inflammation or infection in one or more pouches in the digestive tract) of the large intestine and colostomy; -Had a physician's order to change his/her colostomy pouch system weekly and as needed on Saturday (type is HTP 14604 wafer); -Had a physician's order to apply Ventlex (antibacterial ointment) to the irritation around the colostomy site and to change the colostomy wafer and bag as needed and -The nursing staff are to rinse out the resident's colostomy bag every shift and as needed. Record review of the resident's monthly nursing summary dated May 2019 showed he/she: -Was continent of his/her bowel and bladder; -Was not on a toileting program and -Did not have any documentation found related to monitoring of the resident's ostomy site or that the resident had a colostomy. Review of the resident's Urinary Incontinence assessment dated [DATE] showed: -The resident was occasionally incontinent of his/her bladder and to continue to have the staff provide colostomy care and -No other comprehensive detail assessment was found related to his/her colostomy. During an interview on 6/13/19 at 10:31 A.M., the resident said he/she: -Does have a colostomy that was located on the left middle/upper quadrant area of the abdomen; -The resident ostomy bag had brownish green stool and -The Certified Nursing Assistants (CNA)s and the nurses change his/her colostomy bag and provide the care for it. Observation on 6/14/19 at 12:10 P.M., of the resident ostomy care by CNA F showed: -CNA F had washed his/her hand prior placing his/her gloves on his/her hands; -The ostomy was located on the resident left side middle to lower abdomen; -The resident had very loose brown stool in the colostomy bag and air. The bag was about half full; -CNA F said the resident's colostomy bag has to be frequently emptied due it fills up fast; -CNA F had placed a plastic bag over the resident soiled ostomy bag prior to removal; -The resident ostomy stoma was the size of a golf ball and the color was a deep red tint; -CNA F cleaned around the wafer (part that hold the bag in place) prior to applying a new bag; -CNA F had removed his/her gloves and had washed his/her hand prior placing gloves on his/her hands; -CNA F then place a new colostomy bag and ensured that it was sealed; -The resident was able to transfer himself/herself with stand by assist and -CNA F said the resident does all the rest of his/her cares. During an interview on 6/14/19 at 1:10 P.M., Director of Nursing (DON) said he/she expected: -The nursing staff to complete a comprehensive assessment for the resident to include placement and type of ostomy the resident had and -To include a detail of what the resident ostomy stoma looks like and to ensure to document if had any abnormal findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to monitor one sampled resident's weight loss adequately, to notify the resident's physician and Registered Dietician (RD) timely so that interventions could be implemented before the resident's weight loss became significant for one sampled resident (Resident #57) out of 19 sampled residents. The facility census was 79 residents. Record review of the facility's Weight Loss undated policy and procedure showed nursing assistants, monitored by the charge nurse, will weigh residents upon admission and weekly thereafter to establish weight patterns and monitor changes. The procedure showed: -Each resident will be weighed according to the facility's weighing schedules; -Residents capable of standing will be weighed on a standing scale; -Residents incapable of standing will be weighed on a wheelchair scale; -Residents with significant weight changes or questionable weights will be re-weighed for verification; -Staff will record the weight in the medical record; -Weight gain or loss of 5% in one month should be verified and if confirmed, reported to the physician and -Weight loss/gain consult with the Registered Dietician for recommendations of appropriate interventions. 1. Record review of Resident #57's Face Sheet showed he/she was admitted on [DATE], with diagnoses including dementia with behavioral disturbance, insomnia (sleep disturbance), cognitive communication deficit, heart disease, high blood pressure, arthritis, muscle weakness and high cholesterol. Record review of the resident's Physician's Order Sheet (POS) dated 6/2019, showed a physician's order for a regular diet (the order was dated 11/12/18). There were no physician's orders for any nutritional supplements for treatment of weight loss. Record review of the resident's Dietary History and initial Screening dated 11/27/18 showed the resident: -The resident's weight was 167 lbs (pounds). His/her ideal body weight was 149 lbs (pounds) to 153 lbs; -Was prescribed a regular diet; -Had some missing teeth, but there was no documentation that the resident wore dentures; -The resident's food preferences were not documented and -The resident had no potential risk factors at the time of the screening. Record review of the resident's RD assessment dated [DATE], showed the resident: -Had a diagnosis of dementia, was incontinent and had a history of urinary tract infections which were potential nutritional risk factors; -Was prescribed diuretics and also was administered vitamin and mineral supplements; -There were no lab results to review; -He/she performed estimated nutritional needs and the resident was within a normal range for energy, protein and fluids and -He/she made a recommendation to continue the resident's current plan of care. Record review of the resident's Care plan dated 11/20/18, showed the resident had a communication deficit, memory deficit and visual loss and needed staff assistance with all activities of daily living. It showed the resident had his/her natural teeth with some missing and received a therapeutic diet. The goal showed the resident would maintain his/her current weight within five pounds over the next review period. Interventions showed staff would: -Ensure the resident received his/her regular diet as ordered; -Assist the resident with setting up his/her food; -Assist the resident with eating if he/she was unable to feed himself/herself; -Assist the resident with food choices at meals as needed; -Encourage him/her to drink fluids during and between meals; -Weigh the resident weekly and as needed; -Monitor the resident's weight for fluctuations and notify the resident's physician as needed and -Administer medications as ordered. Record review of the resident's Physician's Telephone Orders showed there were no physician's orders for diuretic medications (medications designed to increase the amount of water and salt expelled from the body as urine) or for appetite stimulants. Record review of the resident's Weight Record showed the resident's monthly weights were: -December 2018=185 lbs; -January 2019=181 lbs; -February 2019=174.5 lbs (weight loss was gradual but not significant over three months or 30 days) and -The weight record showed the resident was on weekly weights from 11/14/18 to 1/27/19 (the weight on 2/27/19 was 168 lbs.). Record review of the resident's Nutritional Monthly Summary/Progress Notes showed: -On 2/14/19, the Dietary Manager documented he/she completed the resident's nutritional section of the resident's Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) and there were no concerns. Record review of the resident's quarterly MDS dated [DATE], showed he/she: -Was alert but not oriented and had delusions; -Needed supervision with eating; -Did not have any chewing or swallowing problems; -Was prescribed a regular diet that was not mechanically altered and -Did not have any significant weight loss or weight gain within the look back period. Record review of the resident's Nursing Notes showed: -From 2/1/19 to 2/28/19 the resident had falls and was treated for urinary tract infection (UTI). There were no notes showing the resident's physician or RD were notified of the resident's gradual weight loss. There was no documentation showing any supplements or nutritional interventions were implemented to prevent further weight loss. There was no documentation that the resident had any medical issues (excess fluid in the tissues) that impacted the resident's weight. Record review of the resident's Care Plan updated 2/20/19, showed: -There were added interventions to the resident's nutritional care plan that showed staff should offer assistance to the resident if he/she was not eating (2/20/19); -Use spill proof drinking cups at meals (2/27/19) and -There was no update showing the resident had weight loss and there were no additional nutritional interventions to prevent further weight loss. Record review of the resident's Medical Record showed: -There was no documentation showing the resident's meal intake percentages, which would show the resident's daily consumption at each meal and any snacks consumed between meals; -There was no documentation showing the resident's responsible party was notified of the resident's weight loss and there was no documentation showing the resident's weight loss was planned; -There was no documentation showing the resident was referred to Speech Therapy for evaluation to determine if the resident had developed a chewing or swallowing issue and -There was no documentation showing the interdisciplinary team was monitoring the resident's weights, weight loss and nutritional status so that they could determine why the resident continued to lose weight, whether they needed to plan a weight loss regimen for the resident or to implement interventions to prevent further weight loss. Record review of the resident's Nursing Notes showed documentation from 3/1/19 to 3/31/19, showed there were no notes related to the resident's nutritional status or weight loss. There were no notes showing the resident's weights were reviewed or that any interventions were implemented to maintain the resident's weight or prevent further weight loss. Record review of the resident's Physician's Telephone Orders showed there were no physician's orders for any nutritional supplements or interventions for weight loss. There was no documentation showing the resident had medications that impacted his/her weight (diuretics). Record review of the resident's Physician's Notes showed on 3/29/19, the physician visited the resident, completed a physical exam and reviewed the resident's labs, medications, health diagnoses and medical record. The physician changed the resident's medications to better manage the resident's agitation, but there were no notes regarding an evaluation of the resident's nutritional status, recent weight loss or possible causes. Record review of the resident's Monthly Weight Record showed: -The facility continued the resident on weekly weights during March 2019 and April 2019; -Documentation showed the resident's weight fluctuated between 165 lbs. and 170 lbs; -The resident's monthly weight for March 2019 was 169 lbs and -The resident's monthly weight for April 2019 was 168.5 lbs. (showing weight loss was gradual, but there was no no significant weight loss in 30 days, 3 months or 6 months). Record review of the resident's Nursing Notes showed from 4/1/19 to 4/30/19, the nursing staff documented was treated for a UTI and had falls. The resident was sent to the hospital after a fall on 4/20/19 for evaluation and treatment (the resident returned to the facility the same day). There was no documentation that addressed the resident's continued weight loss, there was no documentation showing nursing staff notified the resident's responsible party, physician or RD of the resident's continued weight loss and there was no documentation showing nutritional interventions were implemented to prevent further weight loss. Record review of the resident's Physician's Notes showed on 4/8/19, the physician visited the resident, completed a physical exam and reviewed the resident's labs, medications, health diagnoses and medical record. The physician documented the resident showed some somnolence (sleeping for long periods of time) and decreased the dosage of the resident's anti-anxiety medication. The physician did not document anything regarding the resident's gradual weight loss or whether the resident's medication may have had any impact on the resident's appetite. The physician did not make any recommendations or orders for any nutritional interventions to manage the resident's nutritional status or address his/her continued weight loss. Record review of the resident's Monthly Weight Record showed: -The facility continued the resident on weekly weights during May 2019 and up to June 5, 2019. The resident's weights fluctuated between 165 lbs. and and 167 lbs; -The resident's monthly weight for May 2019=167 lbs and -The resident's monthly weight dated June 5, 2019=165.5 lbs. (the resident did not have significant weight loss in 30 days or 3 months, however the resident's weight loss within 6 months was 10.81% which was a significant weight loss). Record review of the resident's Physician's Notes showed on 5/6/19, the physician visited the resident, completed a physical exam and reviewed the resident's labs, medications, health diagnoses and medical record. The physician documented an update to the resident's recent fall (on 4/20/19) and showed the resident fell out of bed and sustained a scalp laceration, was sent to hospital and received staples which were removed and the area was healing properly. The physician did not address the resident's continued weight loss or nutritional status and there were no recommendations for any nutritional interventions. Record review of the resident's Nursing Notes from 5/1/19 to 5/30/19, showed there was no documentation showing the resident's gradual weight loss nor interventions implemented to prevent continued weight loss. There was no documentation showing nursing staff notified the resident's responsible party, physician or RD of the resident's continued weight loss. Record review of the resident's quarterly MDS dated [DATE], showed he/she: -Had memory loss; -Needed extensive assistance with transfers, mobility, bathing, dressing, toileting and eating; -Was not on a specialized diet and had no swallowing disorder and -Did not have any significant weight loss or gain during the look back period. Record review of the resident's Nutritional Summary/Progress Notes showed: -There were no dietary notes documented since the last quarterly note dated 2/14/19 and -On 5/14/19 the Dietary Manager documented he/she completed the nutritional section of the resident's MDS . There was no documentation showing the resident's current nutritional status, intake, weight loss or interventions to try to prevent further weight loss. There was no review of the resident's prior quarter nutritional status or plan of care goals documented. Record review of the resident's annual Nutritional assessment dated [DATE], showed; -The resident was currently 146 lbs. (this value was incorrect according to the resident's weekly and monthly weight record); -The resident received a regular diet and ate 100% at breakfast, 100% at lunch and 75% at dinner; -The resident had some missing teeth; -The resident's body mass index (BMI-a measure of body fat based on height and weight) was 20.95 (there was no documentation showing the significance of this information in relationship to the resident's nutritional status and weight loss) and -The resident's food preferences were not documented and there was no documentation showing the resident's weight record (weekly or monthly) which showed the resident's continued gradual weight loss over the past 6 months. There was no documentation showing the resident's weights and nutritional status were reviewed and there were no recommendations for follow up to the resident's physician, RD or Speech Therapist for further evaluation of the resident's medical status, medications, physical capacity for chewing/swallowing or nutritional status to determine why the resident was continuing to lose weight. There was no immediate plan of action documented to address the resident's weight loss. Record review of the resident's RD Assessment (on the back of the Dietary History Screening) showed the assessment was blank. There were no RD notes or assessment since 11/12/18. Record review of the resident's Care Plan showed an update to the resident's nutritional care plan dated 5/20/19 to provide a clothing protector at meals at the resident's preference. There was no documentation that addressed the resident's weight loss over the past 6 months or any nutritional interventions implemented to prevent further weight loss or to show that the resident's weight loss was planned. Observation on 6/10/19 at 11:30 A.M., showed the resident was sitting in his wheelchair on the locked unit in the dining room. He/she was served a regular diet of a fried chicken, mixed vegetables and au gratin potatoes with cake and ice cream. He was also served water and tea. The charge nurse on the unit fed the resident. The resident did not try to eat or drink independently. He/she ate his/her meal with his/her eyes closed. The resident did not seem to have any chewing or swallowing problems. He/she ate well as long as the nurse continued to feed him/her. Observation on 6/12/19 at 11:03 A.M., showed the resident was sitting in the dining room in his/her wheelchair at the dining table awaiting lunch. The resident was served a glass of water and tea and a regular diet of a pork fritter on bun with lettuce, whole kernel corn and a small bowl of pear cubes. The resident did not try to grab or reach for his/her food or drink. He/she kept his/her eyes shut during the meal as the nursing staff fed the resident his/her food. The resident was eating and drinking without difficulty. It was noted that the resident ate very slowly. At 11:30 A.M. resident had eaten 1/2 of his sandwich and 1/4 of his corn. He drank 1/4 of his water. Most of the residents were finished eating. The resident continued to be fed by nursing staff. Observation and interview on 6/13/19 at 9:20 A.M., the resident's spouse came to get the resident to take him/her out of the facility. The resident's spouse said: -For the longest time, the resident weighed 200 lbs. and he/she thought the resident weighed too much (was overweight), but that was a normal weight for the resident; -A few years ago, the resident began losing some of the weight and by the time he/she came into the facility he/she was around 190-180 lbs., which he/she thought was still to much weight for the resident; -The resident ate fairly well, though the staff have to feed him/her because he/she will not feed himself/herself; -When he/she is here visiting, he/she will feed the resident and he/she ate very well; -He/she did not know how much the resident currently weighed but if the resident has lost weight, he/she was happy because he/she did not think the resident should be carrying a lot of weight; -The nursing staff had not mentioned anything about the resident's weight loss to him/her, but he/she was content with the resident's current weight since he/she was still eating and -He/She would be concerned if the resident stopped eating but he/she eats fairly well now. During an interview on 6/13/19 at 2:31 P.M., Certified Nursing Assistant (CNA) D said: -When the resident came to this unit, he/she was eating more independently, but they still needed to assist him/her; -For the last 2-3 months on the 2:00 P.M. to 10:00 P.M. shift, they have been feeding the resident because they noticed that he/she had stopped feeding himself/herself; -The resident would pick up the food on his/her fork/spoon, but would not put it in his/her mouth. -The resident rarely will try to feed himself/herself; -Usually either a charge nurse or Certified Medication Technician (CMT) is in the dining room at all meals to observe him/her; -He/She was not aware of any changes to the resident's diet or any nutritional interventions, such as health shakes or fortified foods, to try to increase his/her weight; -They do not document meal intake records on any of the residents, they just report to the nurse if they notice someone is not eating and -CNA B said the resident was not on the skilled care unit until March 2019. During an interview on 6/14/19 at 9:37 A.M., Licensed Practical Nurse (LPN) C said: -The resident used to eat independently with cueing and some assistance, but now they have to feed the resident or he/she will not eat; -They do not complete meal intake records because they complete weekly weights on the resident; -They complete weekly weights and monthly weights on the resident and all of the residents for weight monitoring; -Nursing staff are supposed to monitor the resident's weights for indications of weight loss; -They have weight meetings either monthly or quarterly (he/she did not attend the weight loss meetings) and the meetings consist of the Director of Nursing (DON), Assistant Director of (ADON), RD and Dietary manager and the physician; -During the meetings, they discuss the resident weights and determine interventions for the residents who are at risk for weight loss or who have lost weight; -Once interventions are recommended or ordered, the RD will inform the nurses of the recommendations for weight loss interventions and any orders and the nurses them implement the orders and nutritional interventions; -The resident has not had any nutritional interventions for weight loss; -If they continue to notice weight loss and there have been no interventions, the nurses can implement additional snacks between meals for the resident without physician's orders; -The nurse can/should also call the physician and notify him/her of concerns with the resident's weight loss/nutritional status so they can obtain orders for weight loss supplements (they do not need a RD recommendation); -He/She did not know whether the resident's weights had been reviewed or when his/her weights were last reviewed by the weight committee; -The resident recently had a care plan meeting and he/she did not hear anyone discuss the resident having significant weight loss. He/she said during the meeting the resident's spouse was in attendance and he/she did not express any concerns about the resident's weight or nutritional status at the time; -The resident did not have a planned weight loss; -The nursing staff have offered the resident snacks between meals and provided snacks to him/her; -The resident is eating well at meals and they continue to feed him/her and -They have not notified the residents physician or RD for nutritional supplements or other nutritional interventions for the resident. During an interview on 6/14/19 at 1:20 P.M., [NAME] B said: -The Dietary Manager was not working today, but he/she usually attended the weight meetings; -When they have residents who are at risk for weight loss or who have weight loss, they usually have a physician's order for nutritional interventions that they will document on the resident's meal ticket so that they know to follow the order; -Residents at risk or with weight loss usually have orders for fortified foods and health shakes. The fortified foods include extra butter on foods, super cereal, ice cream, shakes and foods that provide extra calories; -Usually the nutritional orders come from the recommendation of the RD; -The RD was here yesterday and periodically comes in to check the residents nutritional records and the menus and dietary concerns; -He/she did not know if the Dietary Manager made quarterly notes on the status of the resident's nutritional status and -If the nursing staff are aware that a resident has weight loss, they will notify the Dietary Manager and RD so nutritional interventions can be ordered and implemented. During an interview on 6/14/19 at 1:38 P.M., the DON said: -They complete weight meeting once monthly and in the meeting they review resident's at risk for weight loss and those who have current weight loss; -They discuss resident weight losses and gains, dietician recommendations, interventions that they want or need to implement or change; -The nursing staff should be looking at the weights weekly and monthly; monitoring to see if a resident is gradually losing weight so that they can catch it before it becomes significant; -If nursing staff see that a resident is losing weight or not eating, they should first notify the physician and the RD and him/her about the resident's weight loss; -They should begin taking some action once the resident looses five pounds in a months time or three pounds within a week; -They could start interventions (such as high calorie foods and health shakes) before the resident s weight loss became significant; -He/She did not see any documentation that the RD had seen the resident and -The resident's weight loss should have triggered and thought that the resident's weight loss got overlooked/missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to monitor the effectiveness of the pain medication after administration for two sampled resident's (Resident's # 62 and # 70) out of 19 sampled residents The facility census was 79 residents. Record review of the facility Pain Management Policy dated 8/27/10 showed nursing was to document the outcome of the nursing intervention regarding pain medication as shown on the pain flow sheet. Record review of the facility's Pain Procedure dated 11/20/13 showed the nursing staff is to monitor and document the effectiveness of the pain medication or non-pharmalogical interventions on a pain flow sheet and if it is found ineffective to notify the resident's physician. Record review of the facility's Administering Medication Policy dated 4/08 showed the nursing staff is to document all medication administration. 1. Record review of Resident # 62's face sheet showed he/she was admitted to the facility on [DATE] with diagnoses: -Muscle weakness; -History of falls; -Displaced intertrochanteric fracture of left femur (hip fracture); -Orthostatic hypotension (sudden low blood pressure when standing up quickly) and -Acute pain due to trauma. Record Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated showed the resident was alert and oriented with no behavioral problems. Record review of the resident's Physician Order Sheet (POS) dated 6/1/19, showed physician orders for: -Norco (Hydrocodone-acetaminophen) Schedule II tablets 5/356 milligrams (mg) one tablet orally every 4 hours PRN (as needed) for pain and -Not to exceed 3000 mg in a 24 hour period. Record review of resident's Medication Administration Record (MAR) dated 5/1/19 - 5/31/19, showed: -The resident was not on a scheduled pain medication; -Norco 5/325 mg one tablet every 4 hours PRN for pain. -PRN Norco was administered on: -6/13/19 at 3:30 A.M., with no documentation on resident's pain flow sheet; -6/13/19 at 8:00 A.M., with no documentation on the Controlled Substances Medication Record of Norco being removed. The pain flow sheet was missing documentation of the effectiveness of the medication after administration with a pain rating; -6/12/19 at 3:00 A.M., The resident's pain flow sheet was missing the effectiveness of the medication after administration with a pain rating; -6/12/19 at 3:00 P.M., The staff did not document on the pain flows sheet; -6/12/19 at 9:00 P.M., the staff did not document on the pain flow sheet; the third dose administered was not documented on the resident's MAR; -6/11/19 at 3:00 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/11/19 at 9:00 P.M., the pain flow sheet was missing documentation of the effectiveness of the medication with the pain rating; -6/10/19 at 8:00 A.M., the staff did not document on the pain flow sheet; -6/10/19 at 3:00 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/10/19 at 9:15 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/9/19 at 9:00 P.M., the staff did not document on the resident's MAR of second dose being given; -6/8/19 at 2:00 P.M; the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/7/19 at 6:30 A.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/6/19 at 3:30 A.M., the Controlled Substance Medication Record showed one Norco was removed. The staff did not document this on the Pain Flow sheet; -6/6/19 at 8:05 A.M., the staff did not document on the resident's MAR for the second dose and this was not documented on the pain flow sheet; -6/5/19 at 3:45 A.M., the staff did not document on the pain flow sheet; -6/5/19 at 2:00 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/4/19 at 3:00 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/4/19 at 9:00 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/319 at 2:00 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/3/19 at 8:00 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating and -6/2/19 at 8:30 P.M., the staff did not document on the resident's MAR for the fourth 4th dose and the staff did not document this on the pain flow sheet. 2. Record review of Resident # 70's face sheet showed he/she was admitted on [DATE] with diagnoses: -Muscle weakness; -Cerebral infarction; -Outdistanced intertrochanteric fracture of the left femur and -Other acute post procedural pain. Record Review of the resident's quarterly MDS showed the resident was alert and oriented with no behavioral problems. Record review of the resident's MAR dated 6/1/19, showed: -Norco (Hydrocodone-acetaminophen) Schedule II tablets 5/325 mg one tablet orally every 4 hours PRN (as needed) for pain and -Not to exceed 3000 mg of the in a 24 hour period. -6/1/19 at 8:30 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/3/19 at 8:00 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating and the nursing staff did not document the dose on the resident's MAR; -6/4/19 at 9:00 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/5/19 at 9:00 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/8/19 at 1:45 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/10/19 at 8:00 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating; -6/11/19 at 8:00 P.M., the pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating and -6/13/19 at 8:00 P.M., the Controlled Substance Medication Record showed no Norco medication was removed. The pain flow sheet was missing the documentation of the effectiveness of the medication with a pain rating and the staff did not document on the resident's MAR that they administered the Norco to the resident. Record review of the resident's Care Plan dated 5/24/19 showed to monitor the effectiveness of the pain interventions. During an interview on 6/14/19 at 10:30 A.M., Licensed Practical Nurse (LPN) E said: -The pain flow sheet is where documentation is to be placed when a pain medication is administered and -He/she would expect to find date and time, pain level, medication that was administered, non-pharmaceutical that was used, what reason it was given, behaviors, location of the resident's pain and the documentation of resident's pain relief. During an interview on 6/14/19 at 2:46 P.M., the Director of Nursing (DON) said: -The Controlled Substances Medication Record is kept in the DON's office; -The DON is new to the facility and is still learning the processes of the facility; -DON is unfamiliar with a process or knows if a process to check the Controlled Substances Medication Records is being completed; -The DON expects the Certified Medication Technician (CMT) and the nurses to know and adhere to the process for administering and documentation of controlled substances; -DON's expectation of all medications to have a date and time of the administration documented and -The DON was not aware that medications on the MAR were not written with actual time of administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess and document upon admission the resident dialysis port site; to ensure to verify physician orders for the residents dialysis port site and to initiate a care plan for one sampled resident (Resident #124) receiving dialysis out of 19 sample residents. The facility census 79 residents. Review of the Facility Contract with Dialysis Clinic showed was signed 6/11/19 and 6/10/19: -The facility is responsible for providing an assessment of the resident's physical condition and determine whether the patient is stable enough to be dialyzed on outpatient basis; -This communication and assessment will occur prior to each and every transfer of a resident to dialysis clinic for hemodialysis on an outpatient basis regardless of the number of times any particular patient may be transferred and dialyzed; -Dialysis clinic is responsible for providing Long Term Care Facility information which may be utilized in the development and maintenance of Care plan; -Information should include emergency and non-emergency situations --information about follow-up care or observation by Long Term Care Staff and --About the proper care and treatment of a dialysis patients vascular access (used in the dialysis treatment) and about the care and treatment and monitoring of a patient with chronic renal failure 1. Record review of Resident #124's Hospital's Physician Progress Note dated 5/24/19 showed: -The resident had history of End Stage Renal Disease (ESRD) and hemodialysis (a medical procedure to remove fluid and waste products from the blood and to correct electrolyte imbalances by using a machine and a dialyzer) on Monday, Wednesday and Friday; -The resident has two inoperable arteriovenous fistula (AV fistula is an abnormal connection between an artery and a vein, and to create an access point for the dialysis machine); -He/she has not been interested in any further access attempt per nephrology; -The resident having pain issue, consider giving pain medication prior leaving for dialysis for pain management; -Access of a Right internal jugular (RIJ) vein catheters in place and -The resident had a RIJ tunneled dialysis catheter (A tunneled catheter is a thin tube that is placed under the skin in a vein, allowing long-term access to the vein and can be placed in subclavian area, the internal jugular (neck) or groin area), and the catheter dressing was clean, dry and intact. Record review of the resident's admission Face Sheet undated showed he/she was admitted to the facility on [DATE] with a diagnosis of dependence on renal dialysis and Diabetes. Record review of the resident's admission assessment dated [DATE] showed; -The resident had bruising to his/her left forearm due to Intravenous therapy (IV) that measured 4.2 centimeters (cm) in length by 2/3 cm in width and - The staff did not document or complete a comprehensive assessment related to the resident's dialysis site on the right side the resident's upper chest. Record review of the resident's admission Physician order Sheet (POS) dated 6/6/19 showed: -The resident was on a Fluid restriction of 1200 mililiters (ml) every 24 hour; -Had physician orders for the nursing staff to check the resident's dialysis site on his/her left upper arm after dialysis for bleeding and thrill as needed and -There was no current physician's order for the resident's RIJ tunneled dialysis catheter. Record review of the resident's initial admission Care Plan dated 6/6/19 showed no documentation related to his/her dialysis and an assessment and care of his/her dialysis port site. Record review of the resident's Hospital physician discharge order report faxed on 6/7/19 showed: -The resident had diagnosis include Stage 5 kidney disease, high blood pressure, chronic kidney disease, requiring chronic dialysis, diabetes with kidney complications, history of seizure, moderate malnutrition, and high potassium levels; -Has a catheter for dialysis and -Did not have instructions for the monitoring or the care for the resident Right IJ tunneled dialysis catheter. Record review of the resident's medical record found no documentation to clarify the discharge order from the hospital on 6/7/19 related to the resident dialysis site care, correct type of dialysis catheter and the location of the dialysis catheter. Record review of the resident dialysis communication form dated 6/10/19 showed: -No changes in orders and -No documentation related to the dialysis access site or care instructions for before or after dialysis. Observation 6/13/19 at 2:30 P.M., of the resident's dialysis port showed: -The resident port was located on the right upper side of his/her chest area; -Dressing was dry and intact and had tubing access from the port and -He/she said that both his/her left and right arm shunts no longer work. Record review of the resident's medical record from 6/10/19 to 6/14/19 showed; -No current Physician's order for the resident's RIJ tunneled dialysis catheter and -Do not find any admission assessment or current assessment related to the placement for the resident's dialysis site upon admission or a recent; During interview on 6/14/19 at 10:00 A.M., the MDS coordinator said he/she did not include dialysis care or treatment plan in the resident's initial care plan. During interview on 6/14/19 at 12:30 P.M., Registered Nurse (RN) A said: -He/she expect the nursing staff to call the hospital to clarify Physician orders related to dialysis site and care; -He/she did not document in the resident medical record or write a physician order of the findings; -He/she would expect nursing staff to had a detail assessment and documentation related to the resident's dialysis access site placement and the type of dialysis access, to be included in part of the resident's admission assessment; -RN A had also completed the resident admission assessment and forgot to document information related to his/her dialysis port and -He/she should had obtain correct physician orders and instruction on how to care for the dialysis site. During an interview on 6/14/19 at 1:10 P.M., Director of Nursing (DON) said; -The MDS Coordinator is responsible for updating the residents care plans; -He/she expect nursing staff had details when nursing staff are completing resident's assessment to include placement, type of dialysis site and -Expect nursing staff to document in the resident's medical record when had contact hospital for clarification of discharge orders and any other outcome from the calls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document behaviors that justified increasing the Seroquel (antipsychotic) for one sampled resident (Resident #35) with a diagnosis of Bipolar disorder (a psychiatric disease characterized by extreme mood swings of depression and mania), and a history of delusional and combative behaviors out of 19 sampled residents. The facility census was 79 residents. Record review of the facility's Behavior Monitoring and Evaluation of Psychiatric Drug Use policy and procedure dated [DATE], showed residents receiving psychoactive medication will not exhibit involuntary movement, or any other adverse reaction or side effects. Use of medications will be the least amount of drug therapy necessary for the resident reducing the risks for side effects to occur. The procedure showed: -Any resident receiving anti-psychotic, anti-depressant or anti-anxiety medication shall be evaluated monthly by the interdisciplinary team. This evaluation will be documented in a note that will be reviewed monthly at the monthly behavior meeting. Nursing staff will chart daily on behaviors on a behavior monitoring tool. The Abnormal Involuntary Movement (AIM) scale will be used as a tool for evaluating every six months. A tracking tool may also be used to monitor trends with behaviors and reduction attempts on psychoactive medication and behaviors which will be monitored by the quality assurance committee; -Nurses will make supervisors aware any time there is a new behavior noted or a psychiatric medication started. Nurses will chart on acute episodes in nursing notes every shift and as needed. Medication changes will charted in nursing notes weekly and as needed for six weeks to monitor the effectiveness of the medication change along with any adverse reactions; -Supervisors will review nurses notes on resident, the behavior monitor tool on residents with a psychiatric diagnosis, if they consult with the Psychologist, or id they receive anti-psychotic, anti-depressant or anti-anxiety medication. Supervisors will also review pharmacist recommendations for reduction attempts; -The resident's family, physician, Director of Nursing (DON) and Social Services Designee will be informed of increased or severe behaviors. Referrals will be made as necessary and -The prescriber should specify the behavior to be treated in the order or progress notes, and will sign and review pharmacy recommendations monthly in an attempt for medication reduction of psychotropic medications. 1. Record review of Resident #35's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including cerebral palsy (a condition marked by impaired muscle coordination (spastic paralysis) and/or other disabilities, typically caused by damage to the brain before or at birth), bipolar disorder, depression with psychotic symptoms, seizures, scoliosis (curvature of the spine) and high blood pressure. Record review of the resident's Physician's Notes showed on [DATE], the resident's physician completed a physical exam of the resident and reviewed his/her medications and laboratory results. There were no new complaints and no new findings. The resident's activities of daily living (bathing, dressing, toileting, mobility, eating) remained unchanged and the physician recommended continuing the rsident's plan of care. There were no further monthly Physician's Notes documented in the resident's medical record until [DATE]. Record review of the resident's Nursing Notes showed: -On [DATE], the resident was noted to have increased confusion and kept asking about where his/her mother was (mother has passes away). Staff attempted to redirect the resident and the resident became upset. Staff notified Social Service Director, who spoke with the resident. The resident was unable to remember that his/her mother passed away and hit the Social Service Director and the Activity Director. Nursing staff notified the physician who ordered a urinalysis if indicated; -On [DATE], the resident put on his/her call light to be assisted to the bathroom and was upset-he/she had a delusion stating people from St. Louis had not called him/her 6 months ago when his/her mother died; -On [DATE], the results from urinalysis testing came back showing no infection; -On [DATE], the resident was noted to be combative when staff got the resident up for lunch (no additional information was documented) and -There were no further notes documented for [DATE]. There was no documentation that nursing staff had increased concern about the resident's behavioral symptoms and had notified the resident's Psychologist for therapeutic treatment. Record review of the resident's Medication Administration Record (MAR) dated 3/2019, showed a physician's order for Seroquel 25 milligrams (mg) once daily. The MAR showed the physician's order was followed as ordered and there was no documentation showing the resident refused to take his/her medication when it was administered. Record review of the resident's Behavior Monitor and intervention tool showed in [DATE], his/her behaviors of kicking that occurred on [DATE] and [DATE]. Interventions were one to one monitoring, assisting with tasks, cueing, re-orientation, and reducing demands (these interventions were implemented on both incidences). The outcome for both incidents showed the resident's behavior improved. Record review of the resident's quarterly Comprehensive Psychoactive Medication and Behavior interdisciplinary team review completed [DATE] (for [DATE], February 2019,and [DATE]) showed the resident: -Received psychotropic medications (Risperdal and Seroquel); -Had a gait or balance impairment; -Did not have significant weight loss, dizziness or increased sedation; -Did not have stroke, heart attack, increased blood sugars or use diabetic medications and -The document showed a gradual dose reduction was successful for Risperdal (last attempted on 7/2018), but a gradual dose reduction was unsuccessful for Seroquel (last attempted on 11/2017). -The document did not show the resident was having an increase in delusional behaviors or combativeness. Record review of the resident's monthly Psychology Progress Notes showed: -On [DATE], the Psychologist visited with the resident and documented the resident was quite unusually delusional today, sticking to well formed delusion of wanting to return his/her car to the airport. It showed the resident's affect was depressed (stable) anxious (worsened) and had poor focus with thought processes, and had delusions. The recommendation was to please evaluate for urinary tract infection or other infection-likely due to physical cause and -The documentation did not show the nursing staff had spoken to the Psychologist about the resident's daily behaviors or had indicated an increase in behavioral symptoms. There was no documentation showing whether the Psychologist had addressed the resident's behaviors that focused on his/her mother (if the behavior was a delusion or dementia). Record review of the resident's Nursing Notes showed: -On [DATE], the nursing staff began urinary tract infection (UTI) protocol and, per physician's order, obtain a urinalysis for the resident (to test for infection); -On [DATE] and [DATE] the resident remained on monitoring for signs and symptoms of a urinary tract infection and the nursing staff documented the resident's vital signs and monitored his/her fluid intake (encouraging fluids); -On [DATE], the resident wanted to make a long distance call to his/her mother. Staff attempted to redirect the resident, but the resident attempted to make the call anyway. The resident was able to orient to person and place. Nursing staff reminded the resident that his/her mother was no longer living and the resident then stated he/she remembered someone told him/her that his/her mother passed a while ago. The resident had no further behaviors. The nursing staff completed charting for signs and symptoms of urinary tract infection on [DATE]; -On [DATE], the facility had the resident's Care Plan meeting and the nurse documented the resident was alert and oriented with some confusion at times. The resident's mood was happy and cooperative with cares but can be combative at times. The resident liked to sleep until mid morning. Staff checked on the resident every two hours for incontinence and -Nursing notes during the rest of [DATE] showed the resident had no further behaviors documented. Record review of the resident's Urinalysis report dated [DATE], showed there were no organisms found and the urine Culture and Sensitivity test dated [DATE], showed there were few bacteria and all other values were within normal limits. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated [DATE], showed he/she: -Was alert and oriented with some confusion; -Had no delirium or acute onset mental status change within the lookback period; Had no mood concerns, psychosis, hallucinations, delusions or behaviors (physical, verbal or otherwise) during the lookback period. The resident's current behavioral status was the same as the prior assessment; -Needed supervision with transfers and did not ambulate and used a wheelchair for mobility; -Needed extensive assistance with bathing, dressing, and was incontinent of urine; -Used routine anti-psychotic medications and -A gradual dose reduction of the resident's anti-psychotic medications was attempted most recently on [DATE]. The gradual dose reduction was contraindicated by the resident's physician on [DATE]. Record review of the resident's Social Service Notes dated [DATE] showed: -The resident was cognitively intact without delirium; -The resident had delusions thinking that his/her mother was still living at times; -The resident had no behaviors and -The resident was taking Seroquel for depression and Risperdal for Schizoaffective disorder. Record review of the resident's Care Plan updated on [DATE], showed: -The resident had a history of paranoia, suspiciousness and delusions and took Risperdal and Seroquel for behavior symptom management; -The resident had a history of physical aggression and resistance to care and medication; -When the resident had behaviors, he/she was easily redirected; -The resident had trial reductions of Risperdal and Seroquel and the trial reduction of Seroquel was unsuccessful; -There was a handwritten note showing the resident Seroquel had been increased and -There was no documentation showing the resident had an acute issue with behaviors or that the resident's behaviors had worsened and were such that an increase in Seroquel was necessary. Record review of the resident's Monthly Nursing Summary dated [DATE], showed the resident was friendly, easily upset at times, hostile at times cooperative and wandered. Record review of the resident's Behavior Monitor and intervention tool showed in [DATE] there were no behaviors or interventions documented during the month-the form was blank. Record review of the resident's MAR dated 4/2019, showed a physician's order for Seroquel 25 mg once daily. The MAR showed the physician's order was followed as ordered and there was no documentation showing the resident refused to take his/her medication when it was administered. Record review of the resident's Physician's Notes showed: -On [DATE], the resident's physician completed a physical exam of the resident and reviewed his/her medications and laboratory results. There were no new complaints and no new findings. The resident's activities of daily living (bathing, dressing, toileting, mobility, eating) remained unchanged and the physician recommended continuing the rsident's plan of care and -There was no documentation showing that the resident had an increase of behavioral symptoms (delusions, hallucinations, psychotic episodes) that supported an review of the resident's medications or that showed an increase of anti-psychotic, anti-depressant medication was needed because the current medications were not effectively managing his/her behavioral symptoms. Record review of the resident's Nursing Notes showed: -On [DATE] the resident asked to make a call to his/her mother. Staff attempted to redirect the resident and the resident stated that he/she needed to make the call because his/her mother would be angry if he/she did not call on Mother's day. Staff reminded the resident that the holiday has past. The resident said okayand would ask to call later and -The nursing notes showed no documentation that the resident had increased psychosis, aggressive behaviors or indications that the resident was behaviorally unmanageable. There were no notes showing nursing staff had notified the resident's physician or psychologist that the resident was showing increased delusions, psychosis or aggressive/combative behaviors that were becoming unmanageable and the resident's medication needed to be reassessed or increased. Record review of the resident's Behavior Monitor and intervention tool showed in [DATE], there were no behaviors documented during the month and no interventions documented. The form was blank. Record review of the resident's monthly Psychology Progress Notes showed on [DATE], the Psychologist visited with the resident and documented the resident said he/she was all out of money and needed to make a car payment and buy gas. He/she documented the resident continues with delusions and recommended the resident's primary care physician may wish to review Seroquel and Risperdal and adjust (the dosage) or request a psychiatric consult for the resident. Record review of the rsident's Physician's Telephone Order dated [DATE], showed a physician's order to increase Seroquel to 25 mg, twice daily for major depressive disorder with psychotic symptoms. Record review of the resident's MAR dated 5/2019, showed a physician's order for Seroquel 25 mg twice daily (dated [DATE]). The MAR showed nursing staff administered Seroquel 25 mg once daily from [DATE]-[DATE] and from [DATE] to [DATE] the nursing staff administered Seroquel 25 mg twice daily. Record review of the resident's Monthly Nursing assessment dated [DATE], showed the resident was friendly, quiet and cooperative and also became easily upset and hostile at times. There was no additional reports showing increase of behavioral episodes or delusional incidences prior to increasing Seroquel or a decrease in behavioral episodes after the increase was implemented. Record review of the resident's Medical Record showed there was no documentation showing the facility had scheduled or obtained a psychiatric evaluation to assess the resident's behavioral and emotional status to determine the resident's baseline and to assist with justifying the need to increase/adjust his/her anti-psychotic and/or anti-depressant medications. There was no documentation in the resident's medical record that showed the resident had received a psychiatric assessment over the past 6 months. There was no documentation showing nursing staff notified the resident's physician of increased psychotic behaviors that warranted an increase in Seroquel. There was no documentation in the resident's medical record showing that nursing staff notified the resident's responsible party or the Director of Nursing (DON) that the resident's behaviors had increased or that he/she had an increase in psychosis and an increase in Seroquel was recommended prior to the increase being ordered. Record review of the resident's Physician's Order Sheet (POS) dated 6/2019, showed a physician's order for: -Risperdal 1 mg twice daily for bipolar disorder, Schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). The order showed the last gradual dose reduction was attempted on [DATE]. This physician's order was dated [DATE] and -Seroquel 25 mg twice daily for major depressive disorder with psychotic symptoms. The order showed special instructions: failed attempt at gradual dose reduction-do not retry. The order showed the last attempted gradual dose reduction was on [DATE]. This order was dated [DATE]. Record review of the resident's Behavior Monitor and intervention tool showed ON [DATE], there were no behaviors documented and no interventions documented from [DATE] to [DATE] Observation on [DATE] at 5:47 A.M., showed the resident was in his/her bed with his/her eyes closed, resting comfortably. There were partial rails up with sheepskin on the bed rails. His/her bed was in a normal position with his/her call light within reach. Observation at 7:10 A.M. showed the resident was still in bed and was not in the dining room for breakfast. During an interview on [DATE] at 7:15 A.M., Licensed Practical Nurse (LPN) E said: -The resident stays up late in the evening and then liked to sleep during the day; -The resident does not get up for breakfast, he/she usually gets up from bed between 9:30 A.M. and 11:00 A.M and -They will usually bring the resident a meal tray once he/she gets up. Observation on [DATE] at 9:47 A.M., showed the resident was still in his/her bed with eyes closed resting comfortably, with his/her call light within reach. The resident had a beverage at her bedside table that was within reach. Observation on [DATE] at 3:15 P.M., showed the resident was in his/her bed with his/her eyes closed resting comfortably. His/her call light was within reach and he/she also had a beverage on his/her tray table that was within reach. The resident showed no signs or symptoms of distress or discomfort. During an interview on [DATE] at 3:20 P.M., Certified Nursing Assistant (CNA) A said: -He/she worked the 2:00 P.M. to 10:00 P.M. shift and worked directly with the resident; -He/she had known the resident for a long time and was familiar with the resident's pattern of behaviors; -The resident usually gets up between 10:00 A.M. and 11:00 A.M. daily, he/she will eat lunch and then he/she will ask to lay down around 2:15 P.M; -They get the resident up again around 4:00 P.M. and the resident stays up until between 11:00 P.M. and 1:00 A.M. He/she said this was the resident's normal routine; -He/she had not noticed the resident having any increase in behaviors or increase in delusional behaviors over the last three months, the resident has been his/her normal self; -The resident's behaviors are that the resident can become combative with staff at times, hitting and kicking; -Sometimes the resident's behaviors are determined by the staff who are assisting him/her; -He/she had not witnessed the resident having those behaviors over the past few months; -The resident has some confusion and that was not out of the ordinary for him/her and -They usually document the resident's behaviors on the behavior monitoring sheets-they are kept in a behavior monitoring book at the nursing station. During an interview on [DATE] at 3:28 P.M., Certified Medication Technician (CMT) A said: -He/she has known the resident for a long time and the resident has always had delusional behaviors and confusion; -He/she had a history of randomly hitting staff without provocation; -He/she noticed that the resident's delusional behaviors had been increasing over the last year but also over the last 2-3 months; -He/she was aware that the resident's Seroquel had been increased but he/she had not noticed any changes in the resident resident's behaviors since the increase occurred. The resident's behaviors have not continued to escalate; -The resident seemed more confused at times; -When the resident has behaviors, they notify the charge nurse and document the behaviors in the resident's behavior charting log at the nursing station and -He has passed the resident's medications and has not noted the resident is resistive to taking his/her medications. During an interview on [DATE] at 3:30 P.M., Registered Nurse (RN) A said: -The resident has always had delusions and hitting/kicking behaviors at times; -The resident over time has been more confused at times , but his/her behaviors are at baseline and he/she really has not had any recent increase in psychosis; -The nursing staff were supposed to document the resident's behaviors in the behavior log when the resident exhibits behaviors; -They kept the behavior log book at the nursing station for the current month but when the month is over they file the behavior logs in the resident's medical record; - After looking at the resident's current behavior log dated [DATE]-it showed the form was blank indicating the resident has had not behaviors to date this month and -The resident's physician probably increased the resident's Seroquel due to an increase in the resident's confusion. Observation and interview on [DATE] at 10:53 A.M., showed the resident was sitting in the doorway of his/her room in his/her wheelchair fully dressed for the weather. The resident showed no signs or symptoms of tardive dyskinesia (a sometimes permanent side effect of antipsychotic medications that involves involuntary muscle movements) or adverse side effects from medications. The resident said: -He/she liked to sleep in during the morning and he/she usually stayed up until 10:30 PM., sometimes later. He/she also naps during the day sometimes; -He/she denied having combative behaviors; -He/she was not drowsy and slept more because of this and -The resident was lucid and did not make any delusional statements during the interview and he/she did not behave in a way that would suggest he/she was over medicated. During an interview on [DATE] at 10:58 A.M., Licensed Practical Nurse (LPN) B said: -He/she only worked over the weekends and on Fridays and he/she had been gone for about eight months before recently returning to work; -He/she was familiar with the resident and had worked with the resident before and since his/her absence; -The resident used to have a lot of behaviors such as kicking and hitting staff at times and those were his/her primary behaviors before he/she started taking medication to manage those behaviors; -He/she noticed that upon his/her return to the facility, the resident was not having those behaviors as much-they were very rare; -The resident was receiving Seroquel at 25 mg twice daily when he/she came back to work and he/she noticed today that the resident's Seroquel dosage was lowered yesterday to 12.5 mg twice daily and -He/she did not know why the changes in the resident's Seroquel were made. During an interview on [DATE] at 12:48 P.M., LPN A said: -The resident's physician came in yesterday and changed the resident's Seroquel order to 12.5 mg twice daily; -There was no documentation in the resident's medical record, that he/she saw, for why the physician decreased Seroquel after increasing it on [DATE], but it was decreased; -There was no documentation in the resident's notes in April and [DATE] showing that the resident was having an increase of delusional behavior and the nursing staff had not documented on the behavior record that the resident was having any behaviors that would show that an increase in Seroquel was warranted and -If the resident's Seroquel was to be increased, it should have had supporting documentation justifying why they were increasing it besides the psychologist stating that the resident was having delusions and recommending an increase in his/her medication. During an interview on [DATE] at 1:38 P.M., the Director of Nursing (DON) said: -If the resident's antipsychotic medication was increased he/she would expect to see supportive prior to the increase showing the resident had increased delusions or psychosis that would warrant an increase in the resident's medication; -The Psychologist comes in once monthly and spends about 20 minutes with the resident, so it (the increase in the resident's Seroquel) may have been based on his/her conversation with the resident; -The nursing staff had not informed him/her that the resident had been having an increase in behaviors, delusions or psychotic episodes over the past few months and -The physician and nursing staff should have reviewed whether the resident's behaviors had increased to the point that an increase was needed and if not, they should not have increased the resident's Seroquel.

Based on interview and record review, the facility failed to educate and review the grievance policy and procedural guidelines on how to file a grievance with the residents during the monthly resident's council meeting for eight residents out of 25 sampled residents. The facility census was 79 residents. Record review of the facility's undated Grievance Policy showed: -A grievance is any complaint or dispute expressing dissatisfaction with any aspect of the operations, activities or behavior of the facility, or its providers, regardless of whether remedial action is requested. -The facility will ensure residents know how to file grievance; -The facility will ensure prompt resolution of grievances; -Grievances will be investigated and responded to, in writing (unless otherwise requested), within a reasonable amount of time, but no later than 30 business days. -All written grievances will be investigated, documented and have appropriate follow-up. Grievances will be kept on file for a least three years; -You will never face any retaliation or be discriminated against for filing a grievance and -Grievance forms are available at all nursing stations and Social Services office. 1. During a group resident's council meeting interview on 6/11/19 at 1:00 P.M., the majority of the residents said: -The Activities Director had not gone over the resident's rights pertaining to how to file a grievance within the facility; - The residents in the group meeting did not know where the resident grievance forms were located within the nursing facility and - The residents expressed they wanted to be fully informed of all the procedural guidelines related to resident's grievance procedures or processes. During an interview on 6/14/19 at 10:00 A.M., Licensed Practical Nurse (LPN) C said: -He/she expected staff to encourage the residents to talk with the nursing staff if they had a problem or concern; -The resident grievance forms were located at the nursing station in a file cabinet with a folder labeled grievance form and -The bulletin board in the facility's hallway indicated a contact person's name and telephone number if the resident wanted to file a grievance at the nursing home with the Social Services Department. During an interview on 6/14/19 at 10:30 A.M., the Assistant Administrator said: -The residents were informed of their resident rights during the facility admission Application process; - Had interviewed residents within the facility if they have a problem or concern; -The Social Services Case Worker had been available to hear resident's problems or concerns and -Who kept the grievance notebook in his/her office. Record review of the facility's (Assistant Administrator) Grievance Notebook dated 2019 showed: -The grievance notebook dated 2019 showed two months of reported grievances for the month of April and May. The April, 2019 grievance form paperwork had indicated two completed grievance records on file and May, 2019 grievance form paperwork had indicated two completed grievance records on file. -The months from January 2019 through March 2019, the grievance book contained no resident's grievance recorded files for the above timeframe; -The grievance forms were kept at the nursing station in a file cabinet in a folder and the nursing staff had been able to provide the resident with a grievance form upon request and -He/she had indicated that facility personnel had gone over the resident's grievance form during the admission Application process and during the Resident's Annual Assessment. During an interview on 6/14/19 at 12:30 P.M., the Assistant Director of Nursing (ADON) he/she said: -The residents had been encouraged to file grievances at the facility; -The residents had encouraged to speak to the Assistant Administrator and Social Services Case Worker if the resident had any issues or concerns about the facility or the staff and -The resident's grievance forms were located at the nursing station in a file cabinet with a folder labeled resident grievance form. During an interview on 6/14/19 at 12:40 P.M., the Director of Nursing (DON) said: -The residents had been highly encouraged to file a grievance at the facility if the resident's issues were not resolved in a timely manner; -The resident's grievance forms were located at the nursing station in a large file cabinet and the folder in file cabinet is labeled resident's grievance form and -The residents had been encouraged to talk to both Administrators in the building, if they had unresolved issues or problems within the nursing facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident # 62's admission face sheet dated 2/21/19, showed he/she had diagnosis: -Muscle weakness; -Displaced intertrochanter fracture of left femur (fractured hip); -History of falling and -Unspecified macular degeneration (an eye disease that cause vision loss). Record review of resident's nurses notes dated 4/4/19 showed: -At 7:30 A.M., the resident was alert and orientated x 2. The resident able to make his/her needs known. The resident required extensive assistance with all Activities of Daily Living (ADLs); -At 9:45 A.M., the resident was found on the floor by another nurse; -The resident was lying on his/her right side and had no injuries; -The resident said, he/she was trying to go to the bathroom; -the staff used a mechanical lift to remove the resident off the floor and the resident was placed in his/her recliner and -Prior to the fall the resident was in his/her room sitting in a wheelchair. Record review of the resident's Comprehensive Incident Report dated 4/4/19 at 8:45 A.M., showed: -The resident was sitting in his/her wheelchair in his/her room after breakfast; -The resident had not been toileted by staff after breakfast; -The resident attempted to get up and go the bathroom by himself/herself and fell; -The nurse walked by and found the resident on the floor lying on his/her right side next to his/her wheelchair with the brakes in a locked position; -No injuries were found; -No documentation regarding medications that resident had taken that could have been a contributing factor to fall and -The staff performed post fall vital signs, neurological checks and range of motion every shift for 72 hours and were all within normal limits. Record Review the resident fall care plan updated on 4/4/19, showed a new intervention to toilet the resident when he/she returns to his/her room after meals. Record review of the resident's nurses notes date 4/24/19, showed: -At 10:20 A.M., the resident was alert and orientated x 3. The staff did not document the resident's location during the assessment or if the resident had a visitor; -At 11:05 A.M., the resident had a fall. See incident report and 72 hour documentation. The resident obtained two lacerations; one to the left side of his/her head, bruises to the resident's left forearm and a bruise to resident's left hand 3rd middle finger; -At 12:50 P.M., the resident was taken to the emergency room via private vehicle with the resident's family to obtain stitches to the laceration on the resident's left side of his/her forehead; -Late entry note at the resident had received one Norco (a narcotic used to treat pain) 5/325 milligrams (mg) one tablet at 6:20 A.M., for right foot pain and -At 7:30 P.M., the resident returned from the emergency room at 5:45 P.M., with his/her family and the resident was alert and orientated x 3. Record review of the resident's Comprehensive Incident Report dated 4/24/19 at 11:05 A.M., showed: -The resident's fall was unwitnessed; -The resident was anxious when the injury occurred; -The resident was last seen visiting with his/her family in his/her room. The staff did not document the time the resident was seen visiting his/her family; -The staff did not document the resident received Norco at 6:20 A.M. for foot pain; -The resident was heard from the hallway yelling Help Me Help me -The resident was found at the foot of his/her recliner with the foot rest in the up and extended position; -The resident was lying on his/her left side; -The resident sustained a minor injury of two lacerations to his/her forehead; --The lacerations measurements were 2.1 centimeters (cm) by .5. cm and the second laceration measurements were 3 cm by 1 cm in length by width; --Had a bruise to his/her left forearm that was dark purple that measured 5 cm by 3.5 cm in length by width; --Had a bruise to his/her left had 3rd finger that measured 2.5 cm by 2.5 cm by length by width; -The body diagram only showed a laceration to left side of the resident's head; -No documentation of how the resident was removed from the floor; -Resident did not know how he/she fell and did not need to use the bathroom at the time of the fall; -Possible cause, family member had just left, may have been looking for the family member; -Interventions that were in place prior to the fall was the resident's call light was on the resident's recliner and not turned on and -The resident's transfer form to the hospital was not complete. All pertinent information on the main page was left blank. Second page was filled out but did not identify the resident. Record review of the resident's care plan updated on 4/24/19 showed a new intervention to check on the resident frequently after his/her family leaves to assure the resident is not anxious /restless. Record review of the resident's nurses notes dated 4/29/19 at 9:00 A.M., showed the CNA reported the resident was attempting to self transfer and the CNA assisted the resident from his/her recliner to his/her wheelchair. Record review of the resident's nurses notes dated 5/27/19 at 9:00 P.M., showed: -The resident's confusion had increased; -The resident was found in his/her wheelchair and the resident transferred himself/herself out of bed; -The resident requested to go to hall, once in hall resident requested to be back in his/her room and the resident was assisted to his/her room; -The nurse sat with resident and the resident stated I just don't know what to do. I'm just getting more confused; -The nurse asked the resident if he/she needed to use the bathroom, if he/she was having any pain/discomfort and resident denied any pain; -The resident refused to go to bed and said I tried that, I just couldn't sleep; -The resident was placed at the nurse's station and -At 9:05 P.M., resident complained of severe foot pain and the resident received his/her Norco for pain. Record review of the resident's nurses notes dated 5/30/19 showed: -At 8:35 A.M., the resident was alert and orientated x 3 and has episodes of confusion; -The resident received Tylenol 325 mg two tablets at 1:10 P.M. for severe of right foot pain and -The staff did not document in the resident's nurses notes that the resident had a fall on 5/30/19 at 3:00 P.M. Record review of the resident's Comprehensive Incident Report dated 5/30/19 at 3:00P.M., showed: -Resident was alone in his/her room sitting in his/her recliner; -The staff did not document what medications that the resident was taken prior the fall that could have contributed to the resident's fall; -The fall was unwitnessed and the resident was found by the staff; -Description of fall describes the resident scooted to the end of the recliner to the foot rest and appeared to slide out of the recliner; -Resident sustained a minor injury bruise to the left outer arm that measured 3.5 cm x 2.1 cm; -Resident was removed from the floor with the use of mechanical lift (an assistive device that allows a person with limited mobility to be transferred between a bed and a chair or other similar resting places using hydraulic power) and was placed in a wheelchair; -The resident said he/she was trying to get up to use the bathroom; -Intervention initiated was for the staff to offer toileting around 2:30 P.M and -The interventions were to toilet the resident before placing him/her in the recliner and after the resident has been in the recliner for one hour and after shift change. Record review of resident's 72 hour neuro check assessment sheet dated from 5/30/19 to 6/2/19 showed the staff did not document the resident's level of consciousness, pain level and pupil response in all the times the neurochecks were supposed to be completed. Record review of the resident's nurses notes dated 6/4/19 showed the staff did not document anything regarding the bruising found on the resident. Record review of the resident's Comprehensive Incident Report dated 6/4/19 at 11:30 A.M., showed: -The resident had bruising of unknown of origin; -Resident was in his/her room sitting in his/her recliner visiting with his/her family member when staff was notified of two bruises one to the resident's left ear and to the left side of the resident's head; -The bruise to the resident's left ear measured 4.5 cm by 2.5 cm and it was dark purple in color and the second bruise to the resident left ear measurement were 4 cm by 1 cm and was purple in color; -The bruise to the resident's top left side of his/her head measurements were 3 cm x 2.5 cm and was purple in color; -Resident was unaware of bruising and did not know what happened; -Possible cause was related to fall on 5/30/19; -Treatment provided post fall was to monitor the bruising every shift for 7 days and -Interventions initiated post fall was to monitor placement of the resident's head during cares and transfers. Record review of resident's fall care plan care plan updated on 5/30/19, showed the new intervention was to assist the resident to the toilet around 2:30 P.M. 4. Record review of Resident #9's admission face sheet dated 1/24/19 showed the resident had diagnoses: -Muscle weakness; -Chronic congestive heart failure (CHF- is a chronic progressive condition that affects the pumping power of your heart muscles and causes fluid to build up around the heart and causes it to pump inefficiently; -Pain in left knee and -Unspecified intellectual disabilities. Record review of the residents quarterly MDS dated [DATE], showed the resident: -Was alert and -Unsteady requires assistance with transition and walking. Record review of the resident's Comprehensive Incident Report dated 7/5/18 showed the resident was transferring out of bed and the resident was trying to assist the roommate. Resident was sitting in his/her recliner and was trying to put the foot rest down and the recliner propelled the resident out onto floor. Record review of there resident's Nursing Notes dated 12/28/18 showed: -Resident had leaned over the bed at the foot of the bed and was attempting to fix the bed when he/she lost his/her balance and was found laying on his/her side over the other side the of bed. The resident required extensive assistant getting the resident back up and -The staff did not complete a Comprehensive Incident Report. Record review of the resident's Comprehensive Incident Report dated 3/29/19 showed the resident lost his/her balance while tying to stand and pull up his/her pants. Record review of the resident's Comprehensive Incident Report dated 6/1/19 showed the resident was changing his/her pants and went down on his/her knees. Record Review of the resident care plan dated 6/14/18 showed: -The Intervention for the fall on 7/5/18 was to assure the resident is wearing proper foot wear while transferring out of bed. Intervention does not apply to the incident and -There was no interventions put in place for the fall that occurred on 2/28/18. -The intervention for the fall on 3/29/19 was to encourage resident to ask for assistance and educate staff to check on the resident frequently. This intervention has already been initiated on the initial care plan. No new interventions were put in place after this fall. -The intervention for the fall on 6/1/19 fall was to encourage resident to wear shoes when up and encourage resident to ask for assistance if feeling weak or unsteady. This intervention was already initiated in the resident's care plan. No new intervention were put in place after this fall. 5. During an interview on 6/14/19 at 1:10 P.M., the DON said: -He/she would expect the nursing staff to document in the resident's nursing notes a detail note about the resident's fall; -The facility nursing staff are responsible for completing the facility Incident Packet which includes: an incident report, witness statements, a 72 hour nursing follow-up documentation sheet and 72 neurological assessments; -The nursing staff does provide the initial interventions for preventing further falls; -After incident packet had been completed in full, the nursing staff will give the completed packet to the MDS coordinator for review and to answer any questions as needed; -The MDS coordinator will enter any new interventions into the resident care plan and update his/her care plan about the fall; -The MDS coordinator will give the completed reviewed packet to the DON to sign off; -Any incident reports are reviewed during the fall and safety meeting on a weekly bases; -He/she would expects a final root cause to be determined after every fall and -The facility does not complete an internal comprehensive fall investigation that includes a root cause at this time. 2. Record review of Resident #41's admission Record showed he/she was admitted to the facility on [DATE] and had a diagnosis of Parkinson's Disease (is a progressive nervous system disorder that affects movement and thought process), restless leg syndrome (causes unpleasant or uncomfortable sensations in the legs and an irresistible urge to move them) and Anemia (low blood count, tired and weak). Record review of the resident's Fall Care Plan dated 1/31/19 showed: -The resident was at risk for injury related to falls; -Goals was the resident would not receive injury from falls over the next review period; -Some of the approaches related to the safety of the resident included: --Encourage the resident to call for assist with transfer; --Nursing staff are to assure the call light is within reach in the resident's room; --Has a personal history of a fall; red tape is on his/her rolling walker, wheel chair, and door frame to indicate this; --Nursing staff are to offer the toilet before and after meals and assure the resident needs are met before leaving the room; --Remind the resident frequently not to transfer without assistance from the staff; --Nursing staff are to assure all of the resident's needs are met prior to leaving the room (was already noted prior and was noted again) and --Nursing staff are to keep the resident's wheelchair next to his/her bed with the wheels locked. Record review of the resident's Facility's Comprehensive Incident Report dated 3/16/19 at 1:00 P.M. showed the resident: -Had an unwitnessed non-injury fall in his/her room; -Was leaning up against the dresser; -Prior to the fall showed the resident was in a recliner resting; -He/she was found sitting on the floor with back against his/her dresser; -The resident wheelchair was facing the doorway with right brake locked and left brake unlocked; -Possible cause was the resident transferred himself/herself without assistance; -The resident said he/she was trying to go to the bathroom; -The resident's range of motion and was within normal limits, --Did not indicate any prior interventions the fall happened; -The new preventative intervention added was to check on the resident frequently and assist the resident to the bathroom every 2 hours; -The nursing staff started the 72 hour documentation that included to initiate interventions to prevent further occurrences; --The staff and the resident was educated on: to include staff and resident education showed; --- To check on the resident frequently and assist the resident to the bathroom every 2 hours; -On 3/16/19 at 1:00 P.M., the staff documented: --The staff had heard the resident yelling out; --The staff observed the resident on the floor on his/her buttocks with back against the dresser.; --The resident said he/she was going to the bathroom; --The resident wheelchair was facing the doorway; --The right brake was locked and the left brake was unlocked; --The resident did not use his/her call light; --The nursing staff assessed the resident and no injury was found and denied any pain; --The resident was assisted with three staff members and the mechanical lift up into his/her wheelchair; -- Neuro checks were implemented and were within normal limits; --The resident physician and family were notified and --Did not have include a root cause of why the resident fell. Record review of the resident's Facility's Comprehensive Incident Reports dated 4/2/19 at 4:30 P.M., showed: -The resident had an unwitnessed non-injury fall in his/her room; -The resident was found in front of the sink in his/her room at the time of the fall: -Resident said he/she was washing his/her hands and stood up; -Possible cause that was check marked was other and documented the resident was standing by himself/herself; -Treatment provided was the fall protocol; --The resident's prior intervention was for the staff to ask the resident if he/she needed anything prior to exiting the resident's room and to educate the resident on the use of his/her call light; --The new intervention that was added, was to frequently remind the resident to use the call light for assistance from the staff and for the resident not to stand without assistance; -The nursing staff started the 72 hour documentation that include initiate interventions to prevent further occurrence and to include staff and resident education showed; --The resident to have proper shoes on even when in bed and educated staff on when they are walking by the resident room to make sure resident has his/her call light within reach; -The staff documented on 3/16/19 at 1:00 P.M.: --The staff had found the resident on the floor; --The resident was transferred off the floor with a mechanical lift; --The nursing staff preformed a head to toe assessment and found no injuries; --The resident did have complaints of upper arm hurting due to holding self-up; --Neuro checks were within normal limits; --The resident's family and physician were notified; --Educated staff on the resident having proper shoes and when walking by making sure the resident has the call light within reach and --Did not have a root cause on why the resident fell and there were no new interventions put in place and the interventions they put in place were the the same interventions that had been documented on his/her fall care plan dated 1/2019. Record review of the resident's Fall Care Plan updated on 3/16/19 and 4/2/19 showed: -On 3/16/19 the resident care plan had hand written update approach added: --Nursing staff are to check on the resident frequently and assist the resident to the bathroom every two hours; (this was not an new intervention it was already an intervention); -On 4/2/19 the resident care plan had hand written update approach added: --Nursing staff are to frequently remind the resident to use call light and not to transfer without assistance from staff; (this was not an new intervention. This interventions was already in place) and -On 4/15/19 the facility added anti-rollback brakes were applied to the resident's wheelchair for preventative measure for falls; Record review of the resident Fall Risk evaluation assessment dated [DATE] showed: -The resident had was high risk for falls and had a score of 14; -He/she had two falls in the past 3 months and -There was no documentation in the resident's medical record related to those falls. Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was severely cognitively impaired and had short term and long term memory problems; -He/she was usually able to understand others and make his/her needs known; -Requires assist of one staff member for supervision for transfer and was able to provides most of his/her own cares and -Had two non-injury falls since last review assessment. Record review of the resident's Comprehensive Incident Reports dated 5/14/19 at 12:10 A.M. showed: -The resident had an injury fall in his/her room; -The resident's physician was notified at 12:20 A.M. and gave an order to send the resident to the hospital for evaluation and treatment; -Prior to the fall the resident was last seen at 11:50 P.M. in his/her bed; -The resident was trying to walk to pick something up and fell. The resident said he/she hit his/her head on his/her wheel chair; -The resident received stitches to the area; -The resident sustained a minor injury from the fall; --The resident statement was: I was going to pick something up and fell and hit my head on the wheelchair! -The resident's fall interventions that was in place prior to fall were: --To have the resident's call light within reach; --Have the resident wheelchair moved away from resident's bed; --The facility noted the cause for the fall was: the resident did not use his/her call light; -The treatment provided to the resident was the nursing staff cleaned the wound with normal saline and applied gauze pad to the resident's head; --The facility staff had to use the Hoyer left to assist the resident back into his/her wheelchair; -Interventions prior to the incident was for the resident's call light to be in reach and ensure the resident's wheelchair was moved away from the resident's bed; --The new interventions initiated to prevent further occurrence were: to ensure the resident had everything he/she needs before leaving the resident room and for staff to frequently remind the resident to use his/her call light for assistance; --The resident was trying to walk to pick something up and fell. The resident said he/she hit his/her head on his/her wheel chair; -The resident had returned to the facility with staples in his/her head; -The nursing staff started the 72 hour documentation that include initiate interventions to prevent further occurrence and to include staff and resident education showed; --Continued education to use call light and for staff to assist the resident; --The body diagram showed the staff wrote a laceration to back of the resident's head; --The CNA heard the trash can move in the resident room when he/she went to check on the resident; Found the resident on the floor in front of the sink in his/her room; --The CNA called out for help and put pillows under the resident head; --This nurse came to assist the aide; --A mechanical lift was used to transfer the resident to his/her wheel chair; --The resident had a laceration to crown of the resident's head; --The area was cleansed with normal saline; --Vital signs were taken and the resident did not lose level of conciseness; --The resident physician was notified and gave an order to send the resident to the hospital at 12:20 A.M; --The nursing staff left a message for resident's family member; --Nursing staff had called 911 at 12:28 A.M. and the nursing staff applied a dressing to the resident's wound; --The ambulance arrived to the facility took the resident to hospital at 1:00 A.M. and --The staff did not include a root cause with a reason why the resident fell and there were no new interventions put in place and the interventions the staff put in place were old interventions that were already in use on the resident's fall care plan dated 1/2019. Record review of the resident Nurse's Notes dated 5/14/19 at 11:30 A.M. showed: -See 72 hour documentation sheet for follow-up fall information and -No other information related to what happen to the resident, if he/she went to the hospital or even had a fall. Record review of the resident's Fall Care Plan updated on 5/14/19 showed: -The resident was at risk for injury related to falls; -Goal changed on 5/14/19 was for the resident not to have a major injury from falls over the next review period and --On 5/14/19 the facility staff are to assure the resident has everything he/she needs before leaving his/her room and they are to remind the resident to use the call light for assistance from staff; -These interventions were not new interventions as these interventions were already in place. Record review of the resident's facility fall documentation provided on 6/3/19 showed: -The resident had a fall on 6/3/19 at 2:20 P.M.; -The nursing staff had completed a 72 hour documentation that included interventions initiated to prevent further occurrence, nursing notes, a combination flow sheet of Neurological assessment and 72 Hour Flow sheet which included the resident's alertness, pupil response, level of consciousness, motor function, pain level, vital signs and other observations. -The new interventions initiated to prevent further occurrence were: -To educate the resident on the use of the call light, if and when the resident was needing assistance to get up from his/her bed, wheelchair or recliner, and also for the facility staff to ask the resident if he/she needs to use the phone prior to leaving the room; -The nursing staff documented on 6/3/19 at 2:20 P.M. : --The resident slid out of his/her recliner trying to get up to the phone to call his/her family member; --The resident did not have any injury; --The nursing staff provided a head to toe assessment; --The resident had no complaint of discomfort at that time; --The resident was on his/her bottom against the recliner when found; --Neuro checks were within normal limits the resident's range of motion was within normal limits; --The nursing staff educated the resident on the use of the call light when needing assistance and also educated the staff to ask resident if needs anything before leaving room. Recommended moving the resident's phone closer to his/her recliner. The resident's family and were notified and -The facility did not provide a copy of the Comprehensive Incident Reports for the fall on 6/3/19 and --There was no root cause on this document to find out the reason why the resident fell and there were no new interventions put in place. The interventions that were put in place were already put in place on the resident's fall care plan dated 1/2019. Record review of the resident's Fall Care Plan updated on 6/3/19 showed: -The resident was at risk for injury related to falls; -The goal for the resident was the resident will not have a major injury from falls over the next review period and -On 6/3/19 the facility staff are to assure the resident telephone is within reach while he/she is sitting in his/her recliner. And they are to continue to encourage the resident to call for assistance with transfers. Observation on 6/11/19 at 8:48 A.M., showed LPN E: -LPN E had placed the gait belt around the resident waist; and the resident used his/her rolling walker to help support himself/herself to a standing position; -The staff notice the resident had stool from the brief and up his/her back, the resident was escorted to the toilet with stand by assist of two staff members; -The resident gait was unsteady and slow, his/her knees are bent inward and seems to twist his/her feet up easily while walking; -Staff had to remind the resident to move his/her feet forward; -LPN E said normally the resident does not provide own cares; -The resident remained standing while the nurse provide wound care and -The resident became weak in his/her knees while standing while the nurse was changing his/her dressing and the resident asked the staff how much longer and -The CNA E had to get a tighter grip onto the resident's gait belt. During an interview on 06/14/19 11:26 A.M., LPN E said: -Nursing staff are to complete the fall incident report packet; -The nursing documentation would include how the resident had fallen and where, if witness or unwitnessed, injury or non-injury; -There is a place for physical therapy or the nurse to fill out on current interventions and then try to place new intervention; -The fall committee would decide how the interventions were working and to put in new interventions if needed; -The nursing staff have a list of interventions and things to do to help prevent falls to choose from and -He/she was not aware of the term of root cause. During interview on 6/14/19 at 12:20 P.M., LPN D and Registered Nurse (RN) A said: -The facility staff only have the incident report packets that was provided by the administration; -Falls incidents are reviewed during the fall meeting weekly and during the meeting they discuss if need to add any further interventions; -Nursing staff are responsible for completing the incident reports and the 72 hour follow-up documentation; -The resident's initial fall intervention would be determine by the LPN or the RN on how could best prevent further falls for the resident and -The Physical Therapy and Occupational Therapy would also provide evaluation and new for safety and preventative plans of care. During an interview on 6/14/19 at 1:10 P.M., the DON said: -He/she would expect the nursing staff to document in the resident's nursing notes a detail note about the resident's fall; -The facility nursing staff are responsible for completing the facility Incident Packet which includes: an incident report, witness statements, a 72 hour nursing follow-up documentation sheet and 72 neurological assessments; -The nursing staff does provide the initial interventions for preventing further falls; -After incident packet had been completed in full, the nursing staff will give the completed packet to the MDS coordinator for review and to answer any questions as needed; -The MDS coordinator will enter any new interventions into the resident care plan and update his/her care plan about the fall; -The MDS coordinator will give the completed reviewed packet to the DON to sign off; -Any incident reports are reviewed during the fall and safety meeting on a weekly bases; -He/she would expects a final root cause to be determined after every fall and -The facility does not complete an internal comprehensive fall investigation that includes a root cause at this time. Based on observation, interview and record review, the facility failed to ensure one sampled resident was transferred safely using a gait belt (Resident #10); to ensure the fall investigations were comprehensive and included a detailed summary of the resident's fall, and the causative factors for falls and to have new interventions in place to prevent further falls for four sampled residents (Resident #3, Resident #41, #62 and #9 ) out of 19 sampled residents. The facility census was 79 residents. Record review of the facility's Gait Belt policy and procedure dated 10/2008, showed all nursing personnel will be required to wear a gait belt at all times during their shift. Gait belts are to be used on any resident care planned for assist of one or more, or if at any time a resident's gait (balance) seems unsteady to nursing staff. Record review of the facility's Transferring A Resident policy and procedure updated 8/2009, showed residents who are unable to transfer themselves safely will be transferred per their care plan, weight bearing status (per physician's orders) or physical therapy recommendations. Methods of transfer are one to two staff with a gait belt; full body mechanical lift with two staff assisting and a sit to stand mechanical lift with one to two staff assisting. 1. Record review of Resident #10's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), stroke with right side paralysis, contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right elbow and bilateral knees, spinal stenosis (a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine), urine retention, kidney disease, anxiety disorder, blindness, and low back pain. Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care

Based on observation, interview, and record review, the facility failed to have a system in place to monitor and discard outdated supplies and to ensure medication refrigerators were at the appropriate temperatures resulting in temperatures that were out of range in two of three medication rooms. The facility census was 79 residents. 1. Observation on 6/13/19 at 1:35 P.M. of the medication room on East Wing with Licensed Practical Nurse D showed: -The medication refrigerator temperature was 38 degrees and -A box with a total of 38 syringes of Heparin Lock solution 5 mililiters (ml) single use syringe that expired on 1/31/19. Record review of the facility medication refrigerator Temperature Log for East Wing dated June 2019, showed: -The logs are kept in a folder at the nursing station and - There were missing temperatures for 6/1, 6/7 to 6/11/19. During an interview on 6/13/19 at 1:49 P.M. LPN D said: -The Assistant Director of Nursing (ADON) and or the Registered Nurse's (RN) are assigned to check the medication rooms and medication carts; -The night nurses also monitor the medication rooms and document the refrigerator temperature nightly and -The charge nurse also checks the mediation room for expired medication and expired supplies. 2. Observation and interview on 6/13/19 at 2:10 P.M. of the Closed Unit medication room with LPN C showed: -A small dorm like medication refrigerator with water standing on the bottom shelf and had two box of insulin pens that was soaked from the water; -The temperature inside was 48 degrees and was also verified by LPN C; -The freeze part had been defrosting and melting the ice which had caused water inside from the freezer tray to overflowing into the refrigerator section; -The refrigerator was still plugged in the wall outlet and LPN C had turned the control knob so would kick on; -The refrigerator had a box of 5 unopened Novolog insulin Flex pens sitting in the standing water and; - A box of 4 unopened Levemir Flex touch pen sitting in the standing water; -LPN C said the night nursing staff are responsible for checking the refrigerator and the temperature nightly; -He/she was going to check with the facility pharmacy about the storage of the insulin pens, and if he/she was going to have to waste them; -Inside the refrigerator also had resident's alcohol beverages; -Review of the closed unit temperature log showed the refrigerator was checked on 6/13/19 and showed the documentation of temp of 41 degrees, had no temp on 6/12/19 and on 6/11/19 the temperature was 44 degrees; -The LPN C was unsure how long the temperature had been running high which was causing the refrigerator to defrost; -In review of the each insulin's manufactures instruction paper with LPN C showed; --The recommended storage for unopened insulin was store in a refrigerator and to keep the temperature between 36 degrees to 46 degrees; -The temp was 2 degrees over the recommend high range for storage of the insulin and -LPN C had called the pharmacy on 6/13/19 to ask about the insulin. During an interview on 6/14/19 09:48 A.M., Certified Medication Technician (CMT) A said the medication cart and the medication rooms are monitored by the RN's monthly. During an interview on 06/14/19 11:26 A.M., LPN E said: -The Medication rooms are monitored by the charge nurse or by the nurse or CMT passing medications; -He/she was not aware of facility check list or policy for monitoring of the medication room. During an interview on 6/14/19 at 1:10 P.M., Director of Nursing (DON) said: -He/she expect the RN's to check the medication room for expired medications at least weekly; -The facility does not have a system in place for documenting or monitoring the review of the medication rooms and medication carts for expired items; -At this time, the night time nursing staff are responsible for monitoring of the medication refrigerator temperatures and to document nightly the temperatures; -He/she was informed of the medication room refrigerator temperature not being within the recommended range; -He/she would expect all nursing staff to monitor the refrigerator daily to ensure it is working properly and -The pharmacy is responsible for monitoring the medication carts and medication refrigerator monthly for expired medications and the labeling and storage of the medications.

Based on observation, interview, and record review, the facility failed to educate all regular staff of the existence, whereabouts, and contents of a written, on-site policy regarding the acceptance, usage, and storage of foods brought into the facility for residents by family and other visitors, to ensure the food's safe and sanitary handling and consumption. This deficient practice had the potential to affect all residents who ate food brought in by visitors. The facility census was 79 residents with a licensed capacity of 113 residents. 1. During an interview on 6/10/19 at 9:29 A.M., the Interim Dietary Manager (IDM) said there was a policy for outside food brought in for residents by family or visitors and that he/she would try to find it. Record review on 6/10/19 at 11:10 A.M., of the policy entitled Food Regulation/Policy provided by the IDM which he/she obtained from the binder in their office entitled Food Service Manuals, showed a one page document that addressed the policy with three bullet points that did not specifically outline any of the following: - Accepting only food in approved sealable containers; - Labeling and dating the food; - Where and how to store the food; - How long the food would be kept before disposal; - Consulting the resident's physician or dietician as needed; - Assuring the food meets the resident's particular diet needs; - Assessing the resident's ability to feed themselves, and - Assessing any swallowing difficulty concerns or suggested food textures. During an interview on 6/11/19 at 9:12 A.M., Registered Nurse (RN) A said that if food is brought in for a resident: - Staff should check that it is sealed; - Put the resident's name and date on it; - He/she had worked at this facility for 12 or 13 years, and - He/she did not know if there was a written policy, but thought it was gone over at an in-service once. During an interview on 6/11/19 at 3:47 P.M., Licensed Practical Nurse (LPN) A said that if food is brought in for a resident: - Staff should check to make sure it is within their diet limits; - Put it in the resident's refrigerator with the date and time on it; - He/she believed they were told about the procedures in orientation, and - He/she were not sure if there was a written policy anywhere. Observations on 6/12/19 at 11:59 A.M. showed that there were two sealed containers with resident's names and dates on them in the resident refrigerator next to the main dining room. During an interview on 6/13/19 at 11:02 A.M., the IDM said: - Outside food should be labeled and dated; - Residents are cautioned on how long food can be kept and if it conflicts with their diet; - They try to leave those decisions up to the residents so they maintain a feeling of choice, and - The direct care staff should be familiar with the policy provided earlier.

Based on observation, interview, and record review, the facility failed to properly contain waste in close-lidded dumpster to prevent the harboring and/or feeding of pests. This deficient practice potentially affected all residents who ate food from the kitchen. The facility census was 79 residents with a licensed capacity for 113. 1. Observations during the kitchen inspection on 6/10/19 at 10:11 A.M., and at 12:23 P.M., showed that just outside the back kitchen door a large dumpster had one of two lids propped open and a smaller dumpster next to it had two of two lids open on both occasions. Observations during the outer perimeter Life Safety Code inspection on 6/10/19 at 2:25 P.M., showed the large dumpster outside the kitchen had one of two lids propped open and the smaller dumpster next to it had two of two lids open. Observation on 6/11/19 at 9:17 A.M., showed the large dumpster outside the kitchen had one of two lids propped open and the smaller dumpster next to it had two of two lids open. Observation on 6/11/19 at 3:55 P.M., showed both lids open on both dumpsters outside the kitchen and a staff member coming out with a rolling trash bin, throwing trash bags and broken down cardboard boxes into the dumpsters, and going back into the facility without closing any of the dumpster lids. Observation on 6/12/19 at 2:25 P.M., showed the large dumpster outside the kitchen had one of two lids propped open and the smaller dumpster next to it had two of two lids open. During an interview on 6/13/19 at 11:02 A.M., the Interim Dietary Manager said they believed that staff should have been instructed and reminded about closing the dumpster lids to prevent attracting pests, but that the Dietary Department didn't use them that often as they mostly used their garbage disposal for waste. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: In Chapter 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (A) Inside the food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the food establishment.