Based on interview and record review, facility staff failed to contact one resident's (Resident #3's) responsible party after the resident had a change in condition. The facility census 61. 1. Review of the facility's Notification of Physician policy, undated, showed staff are directed to immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or interested family member when there is a significant change in resident's physical, mental, or psychosocial status or a decision to transfer or discharge the resident form the facility. 2. Review of Resident #3's Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/22/25, showed staff assessed the resident as follows: -Severe cognitive Impairment; -Diagnoses of dementia with agitation, Senile degeneration of brain, Schizoaffective disorder bipolar type, Vascular dementia with anxiety, and personal history of traumatic brain injury. Review of the resident's care plan, dated 2/3/25, showed staff assessed the resident exhibits significant behaviors towards himself/herself and others. Staff are directed to keep the resident's family and hospice informed of any changes in condition. Review of the resident's medical record showed the resident has an active Durable Power of Attorney (DPOA). Review of the nurses's notes, dated 1/30/25 at 3:10 P.M., showed Licensed Practical Nurse (LPN) B documented the physician ordered a psychiatric evaluation at a Psychiatric Center for agitation and physical behaviors toward other residents. Resident is being monitored one on one, continues to pace up and down the hallway, rocking back and forth. Behaviors change in a moments notice. Review of the nurse's notes, dated 1/31/25 at 5:50 A.M., showed the Social Service Director (SSD) documented the resident's family called this morning to check on resident, states he/she was not informed the resident went out. Staff talked to family and let them know the resident was sent to the hospital yesterday afternoon. During an interview on 5/14/25 at 10:34 A.M., the family member said he/she was not notified of the resident being transferred to the hospital on 1/30/25. He/She said he/she spoke with SSD and found out the resident had been sent to the hospital. He/She said he/she was the active DPOA. During an interview on 5/14/25 at 11:30 A.M., the SSD said when a resident is transferred to the hospital the nurse should notify the family and document it in the system. He/She said he/she is not sure who's responsibility it is for making sure this is completed. During an interview on 5/14/25 at 12:23 P.M., the Director of Nursing (DON) said nurses are expected to notify family when a resident is transferred to the hospital. He/She the nurses are expected to document this in the system in the progress notes. He/She said he/she is responsible for making sure this is completed. During an interview on 5/14/25 at 12:50 P.M., the administrator said when a resident is transferred to the hospital it is the nurses responsibility to notify the family. He/She said the DON is responsible for making sure this is completed. During an interview on 5/14/25 at 2:37 P.M., LPN B said he/she was sure he/she notified the family of the residents transfer to the hospital but must have forgotten to chart it in the system. He/She said typically a progress note is made and he/she must have forgotten to add it. He/She said the DON would be responsible for making sure this is completed. MO00253661

Based on interview and record review, facility staff failed to keep Resident #1 free from physical abuse when floor technician E aggresively pulled the residents wheelchair which resulted in the resident falling out of the wheelchair and on to the ground. The facility census was 58. The administrator was notified on 4/30/25 of past Non- Compliance, which occurred on 4/22/25, when staff reported the allegation. Staff immediately suspended floor technician E, assessed the resident for physical and psychological harm, conducted an investigation, in-serviced staff on abuse and neglect, and terminated the employee on 4/30/25. 1. Review of the abuse, neglect, exploitation, and misappropriation of property fact sheet, dated 2017, showed abuse is the deliberate inflection of injury, unreasonable confinement, intimidation, or punishment, which results in physical harm, pain, or mental anguish. This includes verbal, sexual, physical, or mental abuse, as well as abuse enabled through the use of technology. Examples include scolding, ignoring, ridiculing, or cursing a resident and rough handling during care giving or moving a resident. 2. Review of the facility's investigation, dated 4/22/25, showed Certified Nurses Aide (CNA) F notified notified the administrator floor technician E roughly moved Resident #1's wheelchair, causing the resident to fall to the ground. The floor technician was immediately suspended pending the investigation and terminated on 4/30/25. The resident was assessed without injury and all necessary parties were notified. 3. Review of the Resident #1's Minimum Data Set, a federal mandated assessment tool, dated 3/12/25, showed staff assessed the resident as follows: -Cognitively intact; -Impairment to both lower extremities; -Utilized a manual wheel chair. During an interview on 4/30/25 at 10:28 A.M., the resident said CNA A took him/her out and floor technician E started yelling at him/her and wouldn't let him/her have a cigarette. He/She said floor technician E grabbed his/her wheelchair and moved it roughly causing him/her to fall to the ground. He/She said CNA A and a house keeper helped him/her back to his/her wheelchair. He/She said it hurt and made him/her feel bad and not want to go outside anymore. During an interview on 4/30/25 at 10:43 A.M., CNA D said he/she witnessed the floor technician E yell and refused to allow the resident to smoke because the resident was cursing at the staff. He/She said floor technician told the resident he/she was going to take him/her back inside because of his/her behaviors. He/She said floor technician grabbed the resident's wheelchair he/she was sitting up in and roughly moved it backwards, causing the resident to fall to the ground. He/She said floor technician E did not help the resident up. During an interview on 4/30/25 at 11:02 A.M., Dietary Manager (DM) said he/she was in his/her office when a dietary staff member told him/her, he/she may want to go outside they think a manager is needed. He/She said he/she went outside to find floor technician E yelling at the resident, while the resident was on the ground in front of his/her wheelchair. During an interview on 4/30/25 at 11:15 A.M., the housekeeper F said he/she and CNA A helped the resident back into his/her wheelchair with a gait belt. During an interview on 4/30/25 at 11:17 A.M., CNA A said he/she took the resident out to smoke because no one had come to get him/her. He/She said he/she pushed the resident up to the table and went to go back inside when he/she heard the resident and floor technician E yelling at each other. He/She said the resident and floor technician were cursing at each other and floor technician forcefully grabbed the resident's wheelchair causing the resident to fall to the ground. He/She and the housekeeper assisted the resident back to his/her wheelchair, made sure he/she was safe, and went to report the incident to the administrator. During an interview on 4/30/25 at 11:28 A.M., the administrator said he/she was notified by the DM and CNA A, floor technician E had been yelling. He/She said floor technician was immediately pulled from the floor and suspended pending their investigation. He/She said the resident was assessed without injury, all necessary parties were contacted, and staff were inserviced on abuse and neglect and resident rights on 4/25/25. He/She said the floor technician was terminated on 4/30/25. During an interview on 5/6/25 at 2:00 P.M., floor technician E said he/she went out with the resident's to smoke. He/She said the resident came outside cursing at him/her and calling him/her a bitch. He/She said he/she told the resident he/she couldn't behave that way and was going to take the resident back inside due to his/her behaviors. He/She said the resident then threw himself/herself to the ground when he/she tried to wheel him/her back inside. He/She said he/she was suspended. He/She said the resident is always acting crazy and cursing people out. MO00253114

Based on observation, interview and record review, facility staff failed to ensure resident's personal information was protected when staff left residents' Electronic Health Records (EHR) open and unattended in public hallways. The facility census was 44. 1. Review of the facility's Medication Administration Guidelines, undated, showed the record did not contain direction for protection of residents' privacy. 2. Observation on 04/30/24 at 8:49 A.M., showed Certified Medical Technician (CMT) A left the EHR screen with resident information on the screen unlocked in the hallway when he/she administered to a resident in their room. Observation on 04/30/24 at 8:51 A.M., showed CMT A left the EHR screen unlocked in the hallway with resident information on the screen when he/she adminsitered medication to a resident in their room. Observation on 04/30/24 at 9:05A.M., showed CMT A left the EHR screen unlocked in the hallway with resident information on the screen when he/she administered medication to a resident in their room. An unsecured box with drawers containing residents' medications was left on the medication cart. Observation on 04/30/24 at 9:40 A.M., showed Certified Nursing Assistant (CNA) G and Registered Nurse (RN) F left the EHR screen unlocked in the hallway with resident information on the screen when he/she administered medication to a resident with their backs turned in the television room. During an interview on 04/30/24 at 09:40 A.M., RN F said the EHR screens should always be locked while the medication cart is unattended. During an interview on 05/02/24 at 10:23 A.M., the Director of Nursing (DON) said all computers should have screens locked when unattended. If left open the residents' right for privacy would be violated. During an interview on 05/02/24 at 11:12 A.M., the administrator said the computer screens on medication carts should always be down to protect residents' privacy. During an interview on 05/14/24 at 2:30 P.M., CMT A said the screens on the carts should be locked when unattended to provide privacy.

Based on interview and record review, facility staff failed to complete the required Comprehensive Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for two (Residents #1, and #3) out of two sampled residents The facility census was 44. 1. Review of the facility's Minimum Data Set (MDS) and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI, dated October 2023, Omnibus Budget Reconciliation Act (OBRA)-required Assessment Summary showed assessment time frames as follows: -admission (Comprehensive) MDS completion date no later than 14th calendar day of the resident's admission and submitted no later than 14 calendar days from the care plan completion date; -Annual (Comprehensive) MDS completion date no later than Assessment Reference Date (ARD) of previous comprehensive + 366 calendar days or 92 days following the previous OBRA quarterly assessment and submitted no later than 14 calendar days from the care plan completion date. 2. Review of Resident #1's medical record showed the MDS assessments did not contain a completed Annual comprehensive assessment on or before 2/23/24. 3. Review of Resident #3's medical record showed the MDS assessments did not contain a completed Annual comprehensive assessment on or before 03/19/24. 4. During an interview on 05/01/24 at 10:16 A.M., the administrator said the facility does not currently have a full-time MDS nurse. He/She said there is a floor nurse lined up for the position when a floor nurse position is filled. He/She said a nurse from the corporate office is trying to fill in between their other duties. During an interview on 05/2/24 at 10:23 A.M., the Director of Nursing (DON) said he/she is new and not familiar with the MDS process. He/She said when the MDS position is filled full time, the MDS nurse will be trained by the corporate nurse. During an interview on 05/02/24 at 11:14 A.M, the administrator said the corporate nurse and the DON will help get the MDS assessments completed until the floor nurse can fill the role full time. He/She said the staff should use the RAI manual as a guide to complete and submit the MDS data timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to complete the required Quarterly Minimum Data Set (MDS), a federally mandated resident assessment, within the required timeframe for two of four (Resident #18 and #30) sampled residents. The facility census was 44. 1. Review of the facility's MDS and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the RAI manual version 3.0 RAI, dated October 2023, Omnibus Budget Reconcilliation Act (OBRA)-required Assessment Summary showed assessment time frames as follows: -Quarterly (Non-Comprehensive) MDS completion date not later than Assessment Reference Date (ARD) + 14 calendar days; -Quarterly assessment for a resident must be completed at least evbery 92 days following the previous OBRA assessment of any type. 2. Review of Resident #18's medical record showed the following MDS assessments: -Annual comprehensive MDS, dated [DATE], as production accepted; -Quarterly MDS dated [DATE] as production accepted; -The record did not contain a completed Quarterly assessment on or before 2/21/24. 3. Review of Resident #30's medical record showed the following MDS assessments: -Annual comprehensive MDS, dated [DATE], as production accepted; -The record did not contain a completed Quarterly assessment on or before 03/01/24. 4. During an interview on 05/01/24 at 10:16 A.M., the administrator said the facility does not currently have a full-time MDS nurse. He/She said there is a floor nurse lined up for the position when a floor nurse postion is filled. He/She said a nurse from the corporate office is trying to fill in between their other duties. During an interview on 05/02/24 at 10:23 A.M., the Director of Nursing (DON) said he/she is new and not familiar with the MDS process. He/She said when the MDS position is filled full time, the MDS nurse will be trained by the corporate nurse. During an interview on 05/02/24 at 11:14 A.M, the administrator said the corporate nurse and the DON will help get the MDS assessments completed until the floor nurse can fill the role full time. He/She said the staff shoud use the RAI manual as a guide to complete and submit the MDS data timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to correctly assess one resident (Resident #2) who received an anticoagulant (a blood thinning medication used to treat and prevent blood clots and to prevent stroke in people with atrial fibrillation medication) and failed to assess one resident (Resident #12) for their preferences and oral/dental status. The facility census was 44. 1. Review of the facility's Minimum Data Set (MDS) and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI, dated October 2023, Omnibus Budget Reconciliation Act (OBRA)-required Assessment Summary, Section N, showed instruction for anticoagulant coding as follows: -In circumstances where reference materials vary in identifying a medication's therapeutic category and/or pharmacological classification, consult the resources/links cited in this section or consult the medication package insert, which is available through the facility's pharmacy or the manufacturer's website. If necessary, request input from the consulting pharmacist. -The reference material says -Apixaban (an anticoagulant withe the brand name of Eliquis) is a novel oral anticoagulant (NOAC) approved by the US Food and Drug Administration (FDA) in 2012. -Anticoagulants such as Target Specific Oral Anticoagulants (TSOACs) which may or may not require laboratory monitoring, should be coded in N0415E, Anticoagulant. 2. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Took high risk medication categories of antipsychotic, antidepressant, antianxiety, and diuretic (a medication to help reduce fluid buildup in the body, commonly referred to as a water pill). -Diagnosis of atrial fibrillation. Review of the resident's physician order sheet, dated April 2024, showed an order for 5 milligrams (mg) of Eliquis, one tablet twice a day beginning 01/08/24. The MDS did not indicate the resident took a high-risk medication under the category of anti-coagulant. 3. Review of Resident #12's Quarterly Minimum Data Set, dated [DATE], showed staff did not assess sections: Section F - Preferences for Customary Routine and Activities; Section L - Oral/Dental Status. 4. During an interview on 5/1/24 at 10:16 A.M., the administrator said the facility does not currently have a full-time MDS nurse. He/She said there is a floor nurse lined up for the position when a floor nurse position is filled. He/She said a nurse from the corporate office is trying to fill in between their other duties. During an interview on 05/2/24 at 10:23 A.M., the Director of Nursing (DON) said he/she is new and not familiar with the MDS process. He/She said when the MDS position is filled full time, the MDS nurse will be trained by the corporate nurse. During an interview on 05/02/24 at 11:14 A.M, the administrator said the corporate nurse and the DON will help get the MDS assessments completed until the floor nurse can fill the role full time. He/She said the staff should use the RAI manual as a guide to complete and submit the MDS data timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain bathroom doorframes, sink counters, and floors in good repair. The facility census was 44. 1. Review of the facility's policies showed staff did not provide a policy regarding environment. Review of the facility's housekeeper job description, dated May, 2006, showed housekeeping staff expectations include: - Clean floors, to include sweeping, dusting, damp/wet mopping, stripping, waxing, buffing, disinfection, etc; - Clean, wash, sanitize, and polish bathroom fixtures, ensure that water marks are removed from fixtures. Review of the facility's maintenance manager job description, dated May 2006, showed maintenance staff performs minor plumbing repairs, including unplugging, repairing, and replacing toilets, lavatories, and sinks and replacing faulty gate and ball valves. 2. Observation on 04/29/24 at 7:45 P.M., showed resident occupied room [ROOM NUMBER]'s bathroom toilet base contained brown and the sink counter broken not secured with a piece of the top missing. Observation on 04/29/24 at 7:45 P.M., showed resident occupied room [ROOM NUMBER] floor tiles in the bathroom and living area with brown stains. Observation on 04/29/24 at 7:49 P.M., showed resident occupied room [ROOM NUMBER] the bathroom floor with [NAME] stains. Observation on 04/29/24 at 8:00 P.M. showed resident occupied room [ROOM NUMBER] floor tiles with streaks of brown throughout the entire room. Observation on 04/29/24 at 08:27 P.M., showed resident occupied room [ROOM NUMBER]'s bathroom countertop with white/tan discoloration areas and the base of the toilet floor tiles with dark yellow and rust colored stains. Observation on 04/30/24 at 8:30 A.M., showed resident occupied room [ROOM NUMBER] bathroom tiles with dark stains around the toilet and floor tiles. Observation showed the bathroom door frame rusted and rough to the touch. Observation on 04/30/24 at 8:40 A.M., showed resident occupied room [ROOM NUMBER] with heavily stained flooring tiles around the toilet base. Metal door frames in the bathroom were rusted at the base. Observation on 04/30/24 at 9:00 A.M., showed resident occupied room [ROOM NUMBER] bathroom with stained floors around the toilet base and excessive amounts of caulking around the toilet base. 3. During an interview on 05/02/24 at 8:10 A.M., housekeeper C said we clean the residents bathrooms daily. We are aware of the floors needing to be repaired. Maintenance has been told about the damage but has not repaired it. During an interview on 05/02/24 at 8:20 A.M., Maintenance D said he/she was aware of the damage in the bathroom and a list of repairs needed has been made. He/She said they were not aware of the rusted door frames. During an interview on 05/02/24 at 9:00 A.M., Certified Nurse Aid E said we tell housekeeping if an area needs to be cleaned. He/She said if there is damage in a room or anywhere, we tell the charge nurse or maintenance directly. During an interview on 05/02/24 at 9:21 A.M., the maintenance director said we do every day preventative maintenance or staff tell us about what repairs are needed. We are aware of the damaged bathrooms but are having trouble getting support to pay for the materials needed to repair the damage. During an interview on 05/02/24 at 10:40 A.M., the Director of Nursing said maintenance is responsible for repairs in the facility. If there is damage it should be repaired quickly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide written information of the facility's bed hold policy at the time of transfer to the hospital to the resident and/or resident's representative for three residents (Residents #14, #24, and #45) out of three sampled residents who were discharged to the hospital. The facility census was 44. 1. Review of the facility's Bed Hold Guidelines, undated, showed the facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given at the time of transfer to the hospital. 2. Review of Resident #14's medical record showed: -Transferred to the hospital on [DATE] and returned on 03/28/24; -Did not contain documentation staff notified the resident or the resident's representative of the facility's bed hold policy at time of discharge. 3. Review of Resident #24's medical record showed: -Transferred to the hospital on [DATE] and returned on 04/09/24; -Did not contain documentation staff notified the resident or the resident's representative of the facility's bed hold policy at time of discharge. 4. Review of Resident #45's medical record showed: -Transferred to the hospital on [DATE] and still hospitalized on [DATE]; -Did not contain documentation staff notified the resident or the resident's representative of the facility's bed hold policy at time of discharge. 5. During an interview on 05/02/24 at 8:33 A.M., the administrator said the charge nurse is responsible to complete bed holds when the resident is discharged to the hospital. He/She believed the licensed nursing staff were not aware they needed to be completed. During an interview on 05/02/24 at 8:42 A.M., Licensed Practical Nurse (LPN) F said bed holds should be given to the resident if sent to the hospital by the nurses. He/She said he/she cannot answer why the bed hold were not completed. During an interview on 05/02/24 at 10:23 A.M., the Director of Nursing (DON) said he/she is new to the position and knows there is a form to complete but is not sure who is responsible to complete them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to perform a significant change in status Minimum Data Set (MDS) assessment, a federally mandated assessment tool, for one (Resident #37) of one resident who elected hospice and one (Resident #14) of six sampled residents who had a decline in their ability to feed self with supervision, transfer with substantial/maximum assistance and perform toilet hygiene. The facility census was 44. 1. Review of the facility's MDS and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the RAI manual version 3.0 RAI, dated October 2023, Omnibus Budget Reconcilliation Act (OBRA)-required Assessment Summary showed assessment time frames as follows: -A significant change in status assessment (SCSA) is appropriate when there is a determination that significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent quarterly assessments and the resident's condition is not expected to return to baseline in two weeks; -A significant change is any decline in an ADL physical functioning area (at least 1) where a resident is newly coded as Extensive assistance, Total dependence, or Activity did not occur since last assessment and does not reflect normal fluctuations in that individual's functioning; -A significant change assessment must be completed within 14 days a determination has been made that a significant change in status has occurred and submitted within 14 days of the care plan completion date. -A SCSA is appropriate when There is a determination that a significant change (either improvement or decline) in a resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent Quarterly assessments and the resident's condition is not expected to return to baseline within two weeks. -A SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The (Assessment Reference Date) ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. 2. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required supervision from staff for eating, oral hygiene, and personal hygiene; -Required substantial/maximum assistance from staff for toilet hygiene, shower/bath, dressing of upper and lower extremities, sitting to lying, lying to sitting, sitting to standing, chair/bed to chair transfers, toilet transfers and tub/shower transfers; -Coughed or choked during meals or when swallowing medication; -Received a regular diet; -Diagnosis of dementia. Review of the resident's medical record showed: -The resident was discharged to the hospital on [DATE] and returned to the facility on [DATE]; -A physician order, dated 03/28/24 for nothing by mouth (NPO); -A physician order, dated 03/29/24 for Jevity (a type of artificial nutrition) 1.2 calorie, 300 milliliter (mL) bolus per gastric tube (tube placed into the stomach as a means to infuse food/fluids) four times a day ; -All oral medications ordered to be given by gastric tube; -The record did not contain a completed/submitted SCSA when the resident stopped eating and had a decline in ability to transfer and perform toilet hygiene. Observation on 04/29/24 at 7:40 P.M., showed the resident in bed with a gastric tube syringe and flush container on the overbed table. Observation on 04/30/24 at 8:47 A.M., showed the resident in bed with a gastric tube syringe and flush container on the overbed table. Observation on 05/01/24 at 2:00 P.M., showed Certified Nurse Aide (CNA) E and CNA H use a mechanical lift to transfer the resident to bed and provide incontinence care to the resident. The resident was dependent on staff for the transfer and hygiene. Observation on 05/01/24 at 02:35 P.M., showed Licensed Practical Nurse (LPN) I administered a bolus of Jevity 1.2 calorie nutrition to the resident by gastric tube. 3. Review of Resident #37's Quarterly MDS dated [DATE] showed staff assessed the resident as: -Cognitively impaired; -Diagnosis of dementia and stroke; -Did not use hospice services. Review of the resident's medical record showed: -admitted to hospice on 02/26/24; -The record did not contain an order for hospice, a care plan for hospice, or a completed/submitted significant change of status when the resident and/or representative elected hospice services. 4. During an interview on 5/01/24 at 10:16 A.M., the administrator said the facility does not currently have a full-time MDS nurse. He/She said there is a floor nurse lined up for the position when a floor nurse postion is filled. He/She said a nurse from the corporate office is trying to fill in between their other duties. During an interview on 05/02/24 at 10:23 A.M., the Director of Nursing (DON) said he/she is new and not familiar with the MDS process. He/She said when the MDS position is filled full time, the MDS nurse will be trained by the corporate nurse. During an interview on 05/02/24 at 11:14 A.M, the administrator said the staff shoud use the RAI manual as a guide to complete and submit the MDS data timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs for four (Resident #14, #20, #35, and #37) of six sampled residents. The facility census was 44. 1. Review of the facility's Minimum Data Set (MDS) and Care Planning guidelines, dated September 2013, showed it is the policy of this facility to use the most current Centers for Medicare and Medicaid Services (CMS) MDS Resident Assessment Instrument (RAI) manual, and any published interim RAI manual errata documents, as the authoritative guide for completion of the MDS and establishing and maintaining resident care plans. Review of the Resident Assessment Instrument (RAI) manual version 3.0 RAI, dated October 2023, showed: -Federal statute and regulations require nursing homes to conduct initial and periodic assessments for all their residents. The assessment information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -the resident's care plan must be reviewed after each assessment, as required by §483.20, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions; -Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan; -Facilities are responsible for assessing and addressing all care issues that are relevant to individual residents, regardless of whether or not they are covered by the RAI including monitoring each resident's condition and responding with appropriate interventions; -The comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 2. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as; -Cognitively impaired; -Required supervision from staff for eating, oral hygiene and personal hygiene; -Required substantial/maximum assistance from staff for toilet hygiene, shower/bathing, upper and lower body dressing; -Required substantial/maximum assistance from staff for toilet transfers, tub/shower transfers, chair/bed to chair transfers and sit to stand; -Frequently incontinent of bowel and bladder. Review of the resident's care plan, dated 04/10/24, showed the care plan did not contain updated information related to the resident mode of transfer changed to a mechanical lift, when the resident required more assistance for toileting/toilet hygiene, when the resident diet changed to nothing by mouth or the use of the gastric tube feeding. Review of the resident's Physician Order Sheet (POS), dated 04/01/24 through 05/01/24 showed: -On 03/28/24, Nothing by mouth; -On 03/29/24, Jevity (dietary supplement) 1.2 calorie, 300 milliliters four times a day. Observation on 05/01/24 at 02:00 P.M., showed Certified Nurse Aide (CNA) F and CNA H transfered the resident to bed with use of a mechanical lift, provided total incontence care and dressed the resident. Observation on 05/01/24 at 02:35 P.M., showed Licensed Practical Nurse (LPN) I administered Jevity 1.2 calorie 300 milliliters by gastric tube. 3. Review of Resident #20's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -History of falls; -Unclear speech; -Sometimes understands, responds adequately to simple, direct communication only; -At risk for developing pressure injury; -On a turn and reposition program; -Communication trigger; -Fall trigger; -Pressure Risk; -Diagnosis of cancer and schizophrenia. Review of the resident's care plan, dated 04/11/24, showed the care plan did not contain direction for risk for falls, risk for pressure injury, nutrition for pressure injury risk, or communication. Review of the resident's nurse notes, dated 04/16/24 at 03:49 P.M., showed the resident was getting out of bed and transferring to the wheelchair and slid off the side of the bed. The resident was assessed and assisted off the floor and to wheelchair. He/She denies pain and no abnormal positioning of the extremities were noted. No reddened areas or bruising noted to the skin. Fall was unwitnessed so a neurological exam was initiated. Review of the resident's Event Report, dated 04/16/24, showed the resident is to be up to wheelchair with assist of one staff. When he/she is up in the wheelchair he/she is to be out in the lobby for supervision. The care plan did not contain direction for fall prevention or updated with the new intervention after the fall. 4. Review of Resident #35's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -No behaviors or rejection of care; -Dependent on staff for personal hygiene; -Impaired functional range of motion in both upper and lower extremities; -Five percent or more of unplanned weight loss; -No specialized diet; -Diagnosis of Dementia. Review of the resident's POS, dated 04/01/24 through 05/01/24 showed: -On 07/03/23, Diet-soft and bite sized with ground meat and nectar thickened liquids; -On 08/14/23, Boost supplement twice a day. Review of the resident's care plan, dated 02/27/24, showed the care plan did not contain direction for facial hair preferences, contracture management, or change to diet and required assistance needed. Observation on 04/29/24 at 7:37 P.M., showed the resident in bed with long facial hair to chin and contractures to both arms and legs. Observation on 04/30/24 at 8:01 A.M. and 10:22 A.M., showed the resident at the nurse station with long facial hair to chin and contractures to both arms and legs. Observation on 04/30/24 at 11:56 A.M., showed the resident in the dining room. Staff fed the resident a ground meat diet with nectar thick liquids. Observation on 05/02/24 at 08:28 A.M., showed the resident at the nurse station with long facial hair to chin and contractures to both arms and legs. 5. Review of Resident #37's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively impaired and diagnosis of adult failure to thrive. Review of the facility's census record, showed the resident admitted to hospice on 02/26/24. Review of the resident's Care plan, dated 04/01/24, showed the care plan did not contain direction for hospice. 6. During an interview on 05/02/24 at 9:00 A.M., LPN I said he/she would be assuming the role of the MDS nurse and would be responsible for completing the care plans. He/She has had the title for two days but has been still helping on the floor until his/her position has been filled. He/She cannot answer for what was or was not completed prior to him/her. During an interview on 05/02/24 at 10:23 A.M., the Director of Nursing (DON) said care plans should be comprehensive and include anything that pertains to the resident by symptoms. He/She said care plans should reflect physician orders, hospice, personal preferences of the resident, contracture management, fall interventions/prevention, skin interventions/prevention, diet and nutrition, and individualized as best as possible. He/She said the care plans are updated as needed but at least quarterly. He/She said nurses and aides have access to the care plans and are a guide to direct care for the resident. During an interview on 05/02/24 at 11:14 A.M., the administrator said the facility uses the RAI manual for direction on completing the MDS and care plans. He/She said the DON and corporate nurse will be completing the assessments and care plans until a replacement can be found for the nurse moving into that position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, facility staff failed to meet professional standards of care when nursing staff did not obtain orders for water for one (Resident #14) out of one resident who received all hydration via gastric tube, failed to complete resident weights for three (Resident #6, #29, and #35) out of twelve sampled residents, failed to obtain wound measurements with weekly skin assessments for one resident (Resident #35) of three sampled residents with wounds. The facility staff document falls and fall follow-up for one (Resident #2) of two sampled residents. The facility census was 44. 1. Review of the facility's Enteral Nutritional Therapy (tube feeding) policy, undated, showed to follow the feeding with the prescribed amount of water. 2. Review of Resident #14's Physician Order Sheet (POS), dated 05/01/24, showed: -On 03/28/24, Nothing by mouth; -On 03/29/24, Gastric feeding of Jevity 1.2 calories (a type of nutrition) 300 milliliters four times a day; -The POS did not contain an order to flush the gastric feeding tube with water or designate an amount to flush with. Observation on 05/01/24 at 02:35 P.M., showed Licensed Practical Nurse (LPN) I adminsitered 60 milliliters of water through the gastric tube, 300 milliliters of Jevity 1.2, followed by 60 milliliters of water. During an interview on 05/01/24 at 2:35 P.M., LPN I said he/she flushes the gastric tube with 60 milliliters of water before and after the feeding with distilled water. He/She said he/she was instructed by a long-standing nurse to flush the gastric tube this way. LPN I said he/she would expect there to be an order to flush the gastric tube but does not know why there is not one. During an interview on 05/02/24 at 10:23 A.M., the Director of Nursing (DON) said if a resident has a gastric tube, there should be an order for water flushes to decrease the potential for dehydration. He/She expects the nurse to call the physician if there is no order in the medical record. He/She was not aware the record did not contain an order. 3. Review of the facility's Weight Monitoring policy, dated May 2015, showed: -In recognition of the fact that large weight variances: particularly weight loss trends, are significant risk factors for the ill and debilitated elderly, this facility will monitor weight changes monthly; -Weight will be obtained on each resident on admission and re-admission from the hospital; -Monthly weights for each resident will be completed by the nursing department by the 7th of the month; -A re-weight will be obtained no later than 2 working days for residents that show a significant weight change, under the direction of a licensed nurse; -Weights will be entered into the computer by a designated person in the facility; -New admits and re-admits from the hospital will be weighed weekly for four weeks; -Residents fed per tube will be placed on weekly weights for 4 weekly when their formula has been increased or decreased. Review of the facility's Wound Care and Treatment policy, undated, showed staff are to complete an on-going skin assessment with weekly documentation of status. The policy did not contain description of what to document to include measurements. 4. Review of Resident #6's POS, dated 08/23/23, showed the resident's weight was ordered to be assessed once a week on a Wednesday. Review of the resident's medical record, between 02/14/24 and 05/01/24, showed staff documented the resident's weight on 02/24/24, 03/05/34, and 04/03/24. 5. Review of Resident #29's POS, dated 03/24/23, showed an order for monthly weights. Review of the resident's medical records between 02/14/23 and 05/01/24, showed staff did not document weights for the month of April. 6. Review of Resident #35's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 02/26/24 showed staff assessed the resident as: -Cognitively impaired; -Presence of Stage III pressure wound (wound extends down under the tissue of the skin) on admission. Review of the resident's medical record showed: -Did not contain weekly wound assessments or measurements for the weeks of 04/14/24 and 04/21/24; -Did not contain a weekly weight for the week of 09/17/23, 09/24/23, 10/01/23, or 10/08/23 when the resident returned from the hospital on 9/17/23 as directed by facility policy; -Did not contain a weight for March 2024. 7. Review of Resident #251's POS, dated 04/22/24, showed an order for monthly weights. Review of the resident's medical record between 02/14//24 and 05/01/24 showed staff did not document weights for the month of April. 8. During an interview on 05/02/24 at 9:11 A.M., Restorative Aide K said there is a task that pops up on the Electronic Health Record that reminds us to obtain the weights. The policy says all residents are weighed monthly unless the task pops up sooner. The Restorative Aide is responsible to obtain the weights and document them in the medical record. He/She was not aware some were missing. During an interview on 05/02/24 at 10:23 A.M., the DON said the restorative aide is responsible to obtain and record the monthly weights. He/She said the Restorative Aide has access to the physician orders to see who has orders for weights more often than monthly. The DON said if the weights are not in the medical record, it means they are not done, or the staff forgot to document. He/She said if weights are not documented, residents may experience negative outcomes. 9. Review of the facility's Event Investigation policy, undated, showed staff are instructed to complete a Report of Event Form as soon as possible for falls or person found on a floor with the following information: -Record the date and time of the event; -Description of the event; -Witness name(s) and contact information; -Cognitive status; -Equipment involved; -Observations; -Exact location of an injury and measurement; -Vital signs; -Mental status/Neuro; -Range of motion; -Complaint of pain; -First aid given; -Seen by physician; -Transferred to hospital or emergency room; -Notification of physician; -New physician orders; -Responsible Party notification with the date and time of notification; -Actions taken to prevent recurrence; -Nurse completing form and date - Nurse signature with date; -DON and administrator signatures with date; -Follow up 72-hour monitoring initiated in the nurses' notes. 10. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnosis of Alzheimer's; -Required supervision for transfers; -No falls since prior Annual Assessment MDS, dated [DATE]; Review of the resident's medical record, showed staff did not complete a report of event form for the 11/24/23 and 01/22/24 fall. During an interview on 05/01/24 at 10:17 A.M., the DON said when a resident has fall, an Event Report should be filled out and if the fall is unwitnessed, the Event Report should generate a 72-hour neuro check. During an interview on 05/02/24 at 11:12 A.M., the administrator said an Event Report should be put in the computer and a 72-hour check form should be generated if the fall is unwitnessed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide appropriate personal hygiene for three residents (Resident #28, #35, and #251) out of 12 sampled dependent residents, The facility census was 44. 1. Review of the facility's Daily Care Needs guidelines, undated, showed after meals staff are diected to wash hands and face of the residents and remove any food particles from resident clothing. 2. Review of Resident #28's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/09/24 showed staff assessed the resident as: -Moderately cognitively impaired; -Dependent on staff for toileting hygiene, showering/bathing, and personal hygiene; -Did not reject care; -Diagnosis of debility, heart disease, lung disease, and dementia. Review of the residents care plan, reviewed 11/27/23, showed staff assessed the resident required assistance for transfers, bathing dressing and grooming daily, may experience bladder incontinence related to muscle weakness and incontinent care to be provided after each incontinent episode. Observation on 04/29/24 at 8:27 P.M., showed the resident with long facial hair, hair disheveled, and an unkempt in appearance. Observation showed the resident had yellow/green residue in the inside of his/her eyes, and wore a tan shirt, red jacket, and blue plaid flannel pants. Observation on 04/30/24 at 10:01 A.M., showed the resident with long facial hair, hair disheveled, an unkempt in appearance, and the resident wore the same outfit from the previous day. Observation on 05/01/24 at 9:21 A.M., showed the resident with long facial hair, hair disheveled, and an unkempt in appearance. During an interview on 04/29/24 at 8:27 P.M., the resident said he/she preferred to be clean shaven and clean looking. 3. Review of Resident #35's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Dependent on staff for personal hygiene; -Did not reject care; -Diagnosis of dementia. Review of the resident's care plan, dated 02/27/24, showed the care plan did not contain facial hair preferences for the resident. Observation on 04/29/24 at 7:37 P.M., showed the resident in bed with long facial hair on his/her chin. Observation on 04/30/24 at 8:01 A.M., showed the resident at the nurse station with long facial hair on his/her chin. Observation on 04/30/24 at 10:22 A.M., showed the resident at the nurse station with long facial hair on his/her chin. Observation on 05/02/24 at 08:28 A.M., showed the resident at the nurse station with long facial hair on his/her chin. During an interview on 05/01/24 at 01:46 P.M., Licensed Practical Nurse (LPN) F said dependent residents should be shaved on bath/shower days and in between if noticed. He/She said any nursing staff can shave residents. During an interview on 05/02/34 at 10:23 A.M., the Director of Nursing (DON) said residents should be shaved. He/She said if the resident refuses care, it should be documented in the nurse notes but would expect staff to make multiple attempts to complete the task. 4. Review of Resident #251's admissions MDS dated [DATE], showed facility staff assessed the resident as follows: - No assessment of cognition or functional ability; -Diagnosis of cancer, hypertension, benign prostatic hyproplasia, dementia, and schizoprehenia. Review of the resident's care plan, dated 04/22/24, showed the resident will have his/her ADL needs met daily as evidenced by maintaining the abilities he/she has now and obtaining assistance for transfers, bathing, toileting, dressing and grooming daily through next review. Observation on 04/30/24 at 10:00 A.M., showed the resident with disheveled hair. The residents clothing had food crumbs on them. Observation on 05/01/24 at 10:13 A.M., showed the resident wore the same outfit from the previous day, hair was disheveled and unkempt in appearance. During an interview on 04/30/24 at 10:06 A.M., the resident said he/she had one bath in a month. He/She said he/she stinks and the staff know he/she needs a bath. During an interview on 05/02/24 at 9:06 A.M. Nurse Aid (NA) J said residents are scheduled to get a shower two times a week or more if needed. During an interview on 05/02/24 at 9:12 A.M., CNA E said showers are scheduled twice a week and kept in a log book when completed. We have a shower aid. He/She said they offer to shave residents daily as well. During an interview on 05/02/24 at 10:24 A.M., the DON said showers and personal hygiene should be put in a progress note and on shower sheets. The DON said dependent residents should be showered twice a week and independent residents can go whenever they would like. He/She said clothing should be changed daily or after they are soiled. The DON said he/she were responsible but the charge nurses do the daily monitoring. During an interview on 05/02/24 at 11:14 A,M,. the administrator said dependent residents shower should be documented in the point of care feature of our electronic health records and refusals should be documented. Residents should receive one or two showers a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews, facility staff failed to ensure residents environment remained safe from hazards when staff failed to safely propel three (Resident #8, #22, and #34) out of 12 sampled residents while in wheelchairs. Facility staff failed to provide two (Resident #14 and #36) out of two sampled residents safe mechanical transfers, and facility staff failed to safely store medications in one residents room (Resident #13). The facility census was 44. 1. Review of the facility's Wheelchair, Use of policy, undated, showed staff were directed to lower footrests and place resident's feet on footrests if used and position feet and legs in good body alignment. 2. Review of Resident #8's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 01/30/24, showed staff assessed the resident as: -Cognitively impaired; -Required set-up assistance for wheelchair locomotion of 50 feet with 2 turns; -Independent wheeling 150 feet in wheelchair. Observation on 04/30/24 at 11:56 P.M., showed Nurse Aide (NA) J propelled the resident into the dining room in his/her wheelchair. The wheelchair did not have foot pedals and the resident's heels touched the floor. 3. Review of Resident #22's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent with wheelchair locomotion of 50 feet with two turns and 150 feet; -Diagnosis of dementia, muscle weakness and Parkinson's Disease (progressive disease that affects the nerves of the body). Observation on 04/30/24 at 11:47 A.M., showed NA J propelled the resident into the dining room for lunch. The wheelchair did not have foot pedals and the resident's heels touched the floor. 4. Review of Resident #34's Quarterly MDS dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Required set-up assistance for wheelchair locomotion of 50 feet with two turns; -Required supervision assistance for wheelchair locomotion of 150 feet; -Diagnosis of failure to thrive (weight loss, decreased appetite, and inactivity). Observation on 04/30/24 at 11:49 A.M., showed NA J propelled the resident to the dining room. The wheelchair did not have foot pedals and the bottom of the resident's feet touched the floor. 5. During an interview on 05/02/24 at 9:08 A.M., NA J said residents should never be pushed without putting on the foot pedals. It could cause an injury. During an interview on 05/02/24 at 10:41 A.M., the Director of Nursing (DON)said staff should have foot pedals on before the propel them in a wheelchair. A resident's foot could get caught and injure them. During an interview on 05/02/23 at 11:21 A.M., the administrator said we in-service on wheelchair propulsion once a year and during orientation. There is no exception to pushing a resident in a wheelchair without foot pedals. 6. Review of the facility's Hydraulic Lift policy, undated, showed staff were directed to open the legs of the the lift to the widest point and set brakes when lifting a resident for transfer. 7. Review of Resident #14's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Cognitively impaired; -Required substantial/moderate assistance with sitting to standing, chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers; -Diagnosis of dementia. Observation on 05/01/24 at 2:00 P.M., showed CNA H, CNA E and CNA K entered the room to transfer the resident to the bed. CNA H raised the resident from the wheelchair in the mechanical lift with the mechanical lift legs open. CNA K instructed CNA H to close the mechanical lift legs to push the resident to the bed and lower it. CNA H closed the legs of the lift and pushed the lift over the bed and lowered the resident. CNA H did not leave the mechanical lift legs open when he/she moved the mechanical lift with the resident to the bed. During an interview on 05/01/24 at 2:15 P.M., CNA K said he/she instructed the staff to close the legs of the hoyer because that is how he/she was trained to do it. 8. Review of Resident #36's Annual MDS, dated [DATE], showed facility staff assessed the resident as follows: -Did not contain the resident cognition status; -Total dependence with showering and toilet use. Observation on 05/01/24 at 3:30 P.M., showed CNA H and CNA E transferred the resident from the bed to a wheelchair. CNA H lifted the resident off the bed with the mechanical lift, pushed the resident towards the wheelchair with the mechanical lift legs closed. During an interview on 05/01/24 at 3:40 P.M., CNA H said he/she keeps the legs of the hoyer closed when moving the resident. He/She said aids are in-serviced on mechanical lifts. 9. During an interview on 05/02/24 at 10:45 A.M., the DON said the legs of a lift should remain open during a transfer for stability because if they are not open it becomes a safety issue. During an interview on 05/02/24 at 11:25 A.M., the administrator said the legs of a lift should be open wide for stability of the lift. If the legs are not opened the lift could flip over and injure the resident. 10. Review of the facility's medications, self-administration, self-storage, leave at bedside policy, undated showed: -If a resident expresses a desire to self-administer medication, the interdisciplinary team (IDT) must assess the resident's cognitive, physical, and visual ability to carry out this responsibility; -The mental status and any psychiatric diagnosis must be taken into account; -The Evaluation Assessment to self-administer medications will be used; -When the resident self-administers medication, the resident will be re-assessed on an ongoing basis for continued safety of this practice. The evaluation will be completed annually or with significant change by nursing and reviewed by the IDT to determine if the resident is still capable of self-administering medications; -A physician order will be obtained for each medication to be kept at bedside; -The resident care plan will instruct staff where medication is to be stored and who will document administration of medication. 11. Review of Resident #13's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact with a diagnosis of dementia. Review of the resident's Physician Order Sheet (POS), dated 04/01/24 through 05/31/24, showed the POS did not contain an order for the resident to self-administer any medication. Review of the resident's care plan, showed the care plan did not contain direction for self-administration of medication or self-storage of medication. Observation on 04/29/24 at 7:05 P.M., showed a bottle of nasal spray, inhaler, a medication cup contained two white oval tablets and another medication cup with two large flat tablets. Observation on 05/01/24 at 9:40 A.M., showed a bottle of nasal spray and an inhaler on the overbed table. During an interview on 04/29/24 at 7:05 P.M., the resident said he/she keeps his/her medication in the room all the time in case he/she needs it. He/She said the tablets were tylenol and stomach acid reliever. The resident said sometimes another resident does come into his/her room and gets into his/her stuff. During an interview on 05/02/24 at 8:42 A.M., LPN F said if residents have medication in their room, the resident should be assessed for safety and have an order to keep at bedside. He/She said this resident has an order to self-administer his/her medication. He/She said the facility does have residents who wander into other residents rooms if staff do not catch them ahead of time. During an interview on 05/02/24 at 10:23 A.M., the DON said there should be a physician order to self administer medication with the exception of narcotics which are held by the nurse or CMT. If there is not an order, staff are expected to call the doctor and obtain one. He/She said residents who want to self-administer medication should be screened for comprehension. The DON said if a resident keeps medication at bedside that is not appropriately assessed there is a potential for over or underdosing of the medication, in addition to other residents wandering into the room and taking them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to ensure all resident's drug regimens were free from unnecessary drugs when staff failed to ensure gradual dose reductions (GDR) were attempted for psychotropic medications for four (Resident #3, #12, #28, and #36) out of six sampled residents. The facility census was 44. 1. Review of the facility's Drug Review guidelines, undated, showed staff are instructed as follows: -All medication given to each resident will be reviewed on a monthly basis in order to review drug interactions, ensure adherence to stop orders, ensure accuracy in administration, and evaluate medications appropriate to diagnosis. -Problems identified shall be addressed according to need in consultation with physician. -Follow up on problems needs either the Director of Nursing's (DON's) or pharmacist's signature to show that the problem has been addressed. -Develop an interdisciplinary care plan to evaluate behavior pattern in relationship to current medication. -Notify physician of findings and recommendations. Obtain an order for attempts at reduction. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment, dated 12/18/23 showed staff assessed the resident as moderately cognitively impaired. Review of the resident's Physician Order Sheet (POS), dated 04/01/24 through 05/01/24, showed an order for Fluoxetine (treats depression) 20 milligram (mg) one tablet once a day. Review of the pharmacy recommendation, dated 03/01/24 showed the resident received Fluoxetine 20 mg daily due for review. Review of the resident's medical record did not contain a completed GDR. 3. Review of Resident #12's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Diagnoses of Alzheimer's Disease, anxiety, psychosis, schizophrenia, and bipolar disease; -Took high-risk medication in the categories of antipsychotic, antianxiety, hypnotic, and antidepressant. Review of the resident's POS, dated 04/01/24 through 05/01/24, showed the staff are directed to adminster: -Buspirone (treats anxiety) 10 mg, two tablets three times a day; -Quetiapine (an antipsychotic) 50 mg two times a day; -Quetiapine100 mg at bedtime; -Haloperidol lactate solution 5 mg/ milliliter (mL) (treats mood disorders) 2 mls by injection as needed every six hours; -Divalproex Sprinkles (use to treat seizures and bipolar disorder) 125 mg, two tablets three times a day; -Trazodone (treats depression) 50 mg at bedtime; -Fluoxetine (treat depression, obsessive-compulsive disorder; -Phenytoin sodium extended (treats seizures) 100 mg three times a day. Review of the pharmacy recommendation, dated 04/08/24, showed the resident received psychotropic medications due for review to include Divalproex 125 mg, Quetiapine 50 mg twice daily and Quetiapine 100 mg at bedtime, Fluoxetine 60 mg at bedtime, Buspirone 10 mg take two tablets three times daily, and Trazodone 50 mg take one tablet at bedtime. Review of the resident's medical record, showed the record did not contain a completed GDR. 4. Review of Resident #28's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderately cognitively impaired; -Diagnoses of dementia and depression; -Took high-risk medication in the category of antidepressant. Review of the resident's POS, dated 04/01/24 through 05/01/24, showed an order for Mirtazapine (an antidepressant) 15 mg, one half tablet at bedtime. Review of the pharmacy recommendation(s), dated 04/08/24, showed the resident received psychotropic medication due for review. Review showed the Mirtazapine tablets 7.5 mg, at bedtime last GDR evaluation 08/02/23. Review of the resident's medical record did not contain a GDR after 08/02/23. 6. Review of Resident #36's Annual MDS, dated [DATE], showed the staff assessed the resident as: -Severely impaired cognition; -Diagnosis of anxiety and depression. Review of the resident's POS, dated 04/01/24 through 05/01/24, showed the following orders: -Trazodone 25 mg at bedtime; -Quetiapine 25 mg at bedtime; -Buspirone 10 mg twice a day; -Sertraline 100 mg once a day; -Clonazepam 0.5 mg as needed twice a day. Review of the pharmacy recommendations, dated 03/01/24, showed the resident received clonazepam as needed. All as needed psychotropic medications must include a duration. Review showed the resident received psychotropic medication Sertraline 100 mg tablet daily, Buspirone 10 mg tablet twice a day, Quetiapine 25 mg at bedtime, Trazodone 25 mg at bedtime, and Clonazepam 0.5 mg twice a day due for review. Review of the pharmacy recommendation, dated 04/08/24, showed the Medication Regime Review (MRR) and GDR request from 3/2024 not addressed. Review of the resident's medical record did not contain a completed GDR. 6. During an interview on 05/02/24 at 10:23 A.M., the Director of Nursing (DON) said when a GDR with recommendations comes in from the pharmacy, the physician should be called about the recommendation, or if the physician is coming in the next day or two, have the physician review the recommendations during the facility visit. The DON said the physician should review and document why they agree or disagree. The DON said the physician should sign the pharmacy recommendation sheet and the nurse should document the recommendation was reviewed and the decision made. During an interview on 05/02/24 at 11:12 A.M., the administrator said pharmacy recommendations should be reviewed by the physician and signed, as well as documentation of reasoning if the physician disagrees.

Based on observation, interview, and record review, facility staff failed to monitor and store medication in a safe and effective manner when staff did not dispose of expired medications and left resident's medication on top of the cart. The facility census was 44. 1. Review of he facility's Storage of Medications policy, undated, showed facility staff were directed as follows: -All medications for residents must be stored at or near the nurse's station in a locked cabinet, a locked medicine room, or one or more locked mobile medications carts; -No discontinued, out dated, or deteriorate drugs or biological may be retained for use. All such drugs must be returned to the issuing Pharmacy or destroyed in accordance with established guidelines. 2. Observation on 05/01/24 at 8:29 A.M., showed the facility medication room contained: -One bottle of extra strength Acetaminophen/diphenhydramine HCI with an expiration date of 08/23; -Two bottles of Therma-M with an expiration date of 03/24; -Five bottles of mucus relief with an expiration date of 04/23; -One bottle of Zinc with an expiration date of 12/23; -Two bottles of Cranberry 450 mg with an expiration date of 02/24. During an interview on 05/01/24 at 8:40 A.M., Certified Medication Technician (CMT) A said all out of date medication should be destroyed. During an interview on 05/02/24 at 8:59 A.M. CMT B said out of date medication should be destroyed. CMT's and nurses are all responsible for monitoring medication storage rooms and carts. During an interview on 05/02/24 at 10:36 A.M., the Director of Nursing (DON) said he/she has CMT's monitor medication storage for out of date or damaged medication. The DON said out of date medications should be destroyed or returned to the pharmacy. The DON said there should be no out of date medication in use or stored in the medication storage room. During an interview on 05/02/24 at 11:25 A.M., the administrator said CMT's and nurses are responsible as a team to monitor medication for out of date or damaged medication. The pharmacy also reviews the medication storage once a month. 3. Observation on 04/30/24 at 08:51 A.M., showed CMT A left an unsecured box with drawers containing residents' medications on top of the medication cart when he/she passed medications to residents. 4. Observation on 05/01/24 08:35 A.M., showed the 100 hall medication cart with a plastic container which contained multiple drawers with resident medication on top unattended. The plastic container could not be locked and was left on top of the medication cart at all times. During an interview on 05/01/24 at 8:40 A.M., CMT A said the plastic box with the drawers has been on the cart since he/she started. He/She was not sure why it was used. During an interview on 05/02/24 at 8:59 A.M. CMT B said CMT's and nurses are all responsible for monitoring medication storage rooms and carts. The plastic box on the top of the cart may be a privacy issue. During an interview on 05/02/24 at 11:25 A.M., the administrator said the unlocked plastic box with drawers on top of the medication cart is a risk to other residents and should be removed for their safety. It was used for regularly used medications and extra storage of meds.

Based on interview and record review, facility staff failed to designate a person to serve as the Dietary Manager (DM) with the appropriate qualifications. The facility census was 44. 1. Review of facility policies showed staff did not provide a policy related to the qualifications of kitchen staff. 2. Review of the DM's personnel record showed the record did not contain documentation of when the DM assumed the DM role. The record did not contain documentation of previous food service experience or food service management certification. During an interview on 04/30/24 at 08:19 A.M., the DM said he/she was not certified yet, but was currently working on the certification and was about half way done. The Dietary Manager said he/she did not know all of the requirements. During an interview on 05/02/24 at 10:23 A.M., the Director of Nursing (DON) said the Dietary Manager should be certified, and if new to the job at the facility they thought he/she should be certified within four to six months. If the Dietary Manager is not certified, they may not know the guidelines, and residents may not get the right food, or have allergies to some food, and this could cause harm. During an interview on 05/02/24 at 11:12 A.M., the administrator said the Dietary Manager should be certified.

Based on observation, interview, and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to perform appropriate hand hygiene during medication administration for two (Resident #4 and #21) of five sampled residents. The facility staff failed to ensure all employees were screened for Tuberculosis ((TB) a potentially serious infectious bacterial disease that mainly affects the lungs), when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) and annual PPD tests completed and documented as per policy and state law for three employees ( Dietary Aide O, Certified Nurses Aide (CNA) E , and Certified Medication Technician (CMT) P) out of 10 sampled employees . The facility census was 44. 1. Review of the facility's Medication, Administration Guidelines, showed the guidelines did not address hand hygiene between administration of medication between one resident and another resident, pouring tablets or pills out from a medication bottle, or eye drops. Review of the facility's Instillation of Eye Medication Guidelines, showed the guidelines did not address infection control during administration of eye medication. Review of the facility's Infection Prevention and Control Program policy, undated, showed the policy did not address hand hygiene between administration of medication between one resident and another resident, pouring tablets or pills out from a medication bottle, or administration of eye drops. 2. Observation on 04/30/24 at 8:51 A.M., showed CMT A did not perform hand hygiene after he/she administered medication to a resident, used a keyboard, prepared medication, lowered a computer screen, and before he/she administered medication to Resident #21. 3. Observation on 04/30/24 at 09:05 A.M., showed CNA A removed Resident #4's Tylenol tablets from a bottle into his/her bare hand, placed the tablets in into a medication cup and administered the medication. 4. Observation on 04/30/24 at 9:09 A.M., showed CMT A did not perform hand hygiene or put on gloves before he/she administered eye drops to Resident #4. 5. During an interview on 05/02/24 at 10:23 A.M., the Director of Nursing (DON) said during medication administration when pouring tablets from a bottle, the tablets should be poured and measured in the cap of the bottle, then placed in the resident's medication cup. When the CMT instills eyedrops, hand hygiene should be completed, and gloves put on before administering the eyedrops. The DON said hand hygiene should be done between every resident. During an interview on 05/02/24 at 11:12 A.M., the administrator said during medication administration, hand hygiene should be done before and after anything is touched, and pills should never be in the bare hands of staff. During an interview on 05/14/24 at 2:30 P.M., CMT A said hand hygiene should be performed between each resident, and pills should not be poured into bare hands. If eyedrops are administered, staff should perform hand hygiene and put on gloves. CMT A said he/she didn't realize he/she missed performing hand hygiene every time needed, and said staff had a recent in-service on how to put in eyedrops. 6. Review of the facility's policies showed staff did not provide a policy for Catheter Care. 7. Review of Resident #251's admission Minimum Data Set (MDS), a federally mandated assessment completed by staff, dated 03/27/24, showed staff assessed the resident as follows: -Had an indwelling catheter -Diagnosis of benign prostatic hyperplasia (when the prostate and surrounding tissue expands, can place pressure on the bladder and the urethra, which is the tube that urine passes through. This may cause: difficulty starting to urinate or a frequent need to urinate). 8. Review of Missouri state regulations 19 CSR 20-20.100 Tuberculosis (TB) testing for residents and workers in long-term care facilities showed: -Long-term care facilities shall screen their residents and staff for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit test (TST). Each facility shall be responsible for ensuring that all test results are completed, and that documentation is maintained; -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a two-step TB test; -All employees are required to obtain Mantoux PPD two-step TB test within one month prior to starting employment in the facility. If the initial test is zero to nine millimeters (mm), the second test should be given three weeks after employment begins, unless documentation is provided indicating a PPD test in the past and at least one subsequent annual test within the past two years; -If the resident's or employee's initial test is negative, the second test should be given one to three weeks later. The CDC (Centers for Disease Control) states TB tests should be read 48 to 72 hours after administration; -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of TB disease; -Employees with an initial zero to nine mm TB two step test shall have one step tuberculin testing annually and the results recorded in a permanent record; -All positive findings shall require a chest X-ray to rule out active pulmonary disease; -Individuals with a positive finding need not have repeat annual chest X-rays. They shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. Review of the facility's Guideline for screening for tuberculosis in long term care facilities, undated, showed it is important for each facility to have tuberculosis control program in place. This must include the documentation of the tuberculosis status of each resident, staff member, and volunteer of each long-term care facility. Provide a tuberculin skin text (Mantoux, five tuberculin units (TU) of purified protein derivative (PPD) to all employees during pre-employment procedures, unless a previous reaction >10 millimeters (mm) is documented. If the initial skin test results is 0-9mm, a second test should be given at least one week and no more than three weeks after the first test. The results of the second test should be used as the baseline in determining treatment and follow up of these employees. 9. Review of CNA E's personnel file, showed a hire date of 06/09/23. The file did not contain documentation a two-step TB test was completed 10. Review of CMT P's personnel file, showed a hire date of 07/24/23. The file did not contain documentation a two-step TB test was completed 11. Review of Dietary Aide O's personnel file, showed a hire date of 12/12/23. The file did not contain documentation a two-step TB test was completed During an interview on 05/1/24 at 11:47 A.M., the administrator said the charge nurses and MDS Coordinator are responsible for administering and reading the TB tests. He/She said the results were put into a binder. He/she said they have not had a MDS coordinator and could not find the TB binder. He/She said he/she has started a binder and has started over since he/she is overseeing it for the time being. During an interview on 5/1/24 at 12:02 P.M., RN G said the charge nurse and MDS are responsible to administer and read new hire and annual TB tests. He/She said there is a folder where they are logged. He/She said they currently do not have a MDS coordinator and he/she does not know who is in charge of making sure this is completed by the nurses or why it has not been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to complete neurological checks and fall follow up documentation for three (Resident #1, #2, & #3) of three residents who had a fall and failed to complete weekly skin assessments for two residents (Resident #4 and #5). The facility census was 41. 1. Review of the facility's Fall Champion Program, undated, showed the post fall follow up period is 72 hours which includes assessment and document of the resident's condition in healthcare tracking program Progress Notes and neurological checks. 2. Review of Resident # 1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/23/23, showed staff assessed the resident as: -Cognitively intact; -No falls since admission or prior assessment. Review of the resident's care plan, dated 11/27/23, showed staff assessed the resident at risk for falls due to history of falls. Staff are directed to provide proper, well-maintained footwear with nonskid soles, adjust bed to lowest level, and encourage resident to pull call light for help when it's needed. Review of the event report, dated 1/4/24, showed staff documented the resident found on the floor because he/she slipped out of his/her wheelchair. Review of the resident's medical record did not contain documentation staff completed the 72 hours follow up fall documentation for the 1/4/24 fall. 3. Review of Resident # 2's Annual MDS, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; -No falls since admission or prior assessment. Review of the resident's care plan, dated 11/27/23, showed staff assessed the resident had a history of falls related to antidepressant medication use, incontinence episodes, and a history of falling. Staff are directed to assist for all transfers because the resident is non-ambulatory, keep bed in lowest position with brakes locked, keep call light in reach at all times, keep personal items and frequently used items within reach, and provide proper, well-maintained footwear. Review of the event report, dated 1/21/24, showed the resident had an unwitnessed fall and sent to the emergency room. Review of the resident's medical record did not contain documentation staff completed the 72 hours follow up fall documentation for the 01/21/24 fall. 4. Review of Resident # 3's Annual MDS, dated [DATE], showed the staff assessed the resident as: -Cognitively intact; -One fall without injury since admission or prior assessment; -One fall with injury since admission or prior assessment. Review of the resident's care plan, dated 11/27/23, showed the resident had a history of falling related to weakness. Staff are directed to keep call light in reach at all times, keep personal items and frequently used items within reach, provide proper well-maintained footwear, and provide toileting assistance as needed. Review of the event report, dated 1/7/24, showed the resident had an unwitnessed fall between the wall and bed. Review of the resident's medical record did not contain documentation staff completed the 72 hours follow up fall documentation for the 1/7/24 fall. Review of the event report, dated 1/9/24, showed staff documented the resident found on the floor in his/her room. Review of the resident's medical record did not contain documentation staff completed the 72 hours follow up fall documentation for the 1/9/24 fall. 5. During an interview on 2/8/24 at 2:48 P.M., the administrator said nurses are responsible for completing neurological checks and follow up charting for residents who fall. He/She said they've not had a Director of Nursing (DON) and one of their corporate nurses is there to help. He/She does not know why they are not being done because the nurses know they should be. During an interview on 2/8/24 at 2:55 P.M., Licensed Practical Nurse (LPN) A said he/she knows neurological checks and follow up fall charting should be done, but has not completed them. He/She said he/she does not know where the sheets are kept and when he/she asked where the sheets were, he/she did not get a straight answer. He/She said neurological and follow up charting should be completed for 72 hours and does not know who is responsible for making sure they are completed. During an interview on 2/8/24 at 3:36 P.M., Registered Nurse (RN) C said nurses are responsible for completing neurological and follow up fall charting for 72 hours. He/She said he/she does not know who is responsible at this time to make sure it's completed. During an interview on 2/8/24 at 3:59 P.M., RN F said nurses should be completing neurological and follow up charting for 72 hours. He/She said he/she would be responsible for making sure they're completed but does not know why they are not being done. During an interview on 2/8/24 at 8:27 P.M., LPN D said nurses are responsible for completing neurological and follow up charting. He/She said charting should be done for 72 hours and he/she does not know why they are not being completed. He/She said the DON would be responsible for making sure staff completed these tasks but does not know who is responsible at this time. 6. Review of the facility's wound care prevention strategies, undated, showed staff were directed to perform on-going skin assessment with weekly documentation of status. 7. Review of Resident #4's Quarterly MDS, dated [DATE], showed staff assessed the resident as moderately cognitively impaired. Review of the resident's care plan, dated 3/14/22, showed staff assessed the resident with a history of scratching his/her skin. Review of the resident's weekly skin assessments form, dated 8/1/23 to 2/21/24, showed staff documented they completed a weekly skin assessment for the week of 1/17/24. The resident's medical record did not contain completed skin assessments for any other weeks. 8. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as severely cognitively impaired. Review of the resident's care plan, dated 6/7/23, did not contain pressure ulcer or skin care interventions. Review of the resident's weekly skin assessments form, dated 8/1/23 to 2/21/24, showed staff documented they completed a weekly skin assessment for the weeks of 8/31/23 and 10/28/23. The resident's medical record did not contain completed skin assessments for any other weeks. 9. During an interview on 2/21/24 at 1:07 P.M,, the Director of Nursing (DON) said his/her expectation is that skin assessments are completed weekly by the nursing staff. He/She said he/she is new and is not sure why they have not been completed in the past. During an interview on 2/21/24 at 1:45 P.M., LPN G said he/she the nurses are in charge of weekly skin assessments. He/She said he/she is not sure why they are not getting done besides sometimes the nurses are just too busy. During an interview on 2/21/24 at 1:48 P.M., the administrator said there is a weekly skin assessment schedule at the nurses station that says which days residents are supposed to have their skin assessments completed. He/She said he/she does not know why they are not completed because he/she thought they were being done. MO00231241 MO00230643 MO00232110

Based on record review and interview, the facility failed to ensure they assessed residents using the quarterly Minimum Data Set (MDS), a federally mandated assessment completed by staff, no less frequently than once every three months for seven residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7). The facility census was 46. 1. Review of the Resident Assessment Manual (RAI), dated 10/1/17, showed the Quarterly assessment is an Omnibus Budget Reconciliation Act of 1987 (OBRA) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The Assessment Reference Date (ARD) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type are as follows: -Assessment Completion refers to the date that all information needed has been collected and recorded for a particular assessment type and staff have signed and dated that the assessment is complete; -For required Comprehensive assessments, assessment completion is defined as completion of the Care Area Assessment (CAA) process in addition to the MDS items, meaning that the registered nurse (RN) assessment coordinator has signed and dated both the MDS (Item Z0500) and CAA(s) (Item V0200B) completion attestations. Since a Comprehensive assessment includes completion of both the MDS and the CAA process, the assessment timing requirements for a comprehensive assessment apply to both the completion of the MDS and the CAA process; -Assessment Completion date for quarterly MDS assessments, is ARD plus 14 calendar days; -Transmission Date for quarterly MDS assessments, is Completion date plus 14 calendar days. 2. Review of Resident #1's electronic health record, showed staff opened a Quarterly Minimum Data Set (MDS) assessment with an ARD of 8/23/23. Review of the opened assessment showed the assessment as in progress. Further review showed all sections of the assessment as in progress or no information. The record did not contain a completion date. Review of the facility's validation reports, (report generated by Centers for Medicare & Medicaid Services after a facility submits assessments to show if an individual MDS is accepted or rejected), dated 5/1/22 through 10/13/23, showed the report did not contain the resident's assessment. Review of the facility MDS assessment files did not contain a signed or printed assessment for the resident. 3. Review of Resident #2's electronic health record, showed staff opened a Quarterly MDS assessment with an ARD of 9/3/23. Review of the open assessment showed the assessment as in progress. Further review showed all sections of the assessment as in progress or no information. The record did not contain a completion date. Review of the facility's validation reports, dated 5/1/22 through 10/13/23, showed the report did not contain the resident's assessment. Review of the facility MDS assessment files did not contain a signed or printed assessment for the resident. 4. Review of Resident #3's electronic health record, showed staff opened a Quarterly MDS assessment with an ARD of 8/27/23. Review of the open assessment showed the assessment as in progress. Further review showed all sections of the assessment as in progress or no information. The record did not contain a completion date. Review of the facility's validation reports, dated 5/1/22 through 10/13/23, showed the report did not contain the resident's assessment. Review of the facility MDS assessment files did not contain a signed or printed assessment for the resident. 5. Review of Resident #4's electronic health record, showed staff opened a Quarterly MDS assessment with an ARD of 8/23/23. Review of the open assessment showed the assessment as finalized. Further review showed all sections of the assessment as finalized or no information. The record did not contain a completion date. Review of the facility's validation reports, (report generated by CMS after a facility submits assessments to show if an individual MDS is accepted or rejected), dated 5/1/22 through 10/13/23, showed the report did not contain the resident's assessment. Review of the facility files of MDS assessments, showed the file did not contain a signed or printed assessment. 6. Review of Resident #5's electronic health record, showed staff opened a Quarterly MDS assessment with an ARD of 9/17/23. Review of the open assessment showed the assessment as in progress. Further review showed all sections of the assessment as in progress or no information. The record did not contain a completion date. Review of the facility's validation reports, dated 5/1/22 through 10/13/23, showed the report did not contain the resident's assessment. Review of the facility MDS assessment file did not contain a signed or printed assessment for the resident. 7. Review of Resident #6's electronic health record, showed staff opened a Quarterly MDS assessment with an ARD of 9/17/23. Review of the open assessment showed the assessment as in progress. Further review showed all sections of the assessment as in progress or no information. The record did not contain a completion date. Review of the facility's validation reports, dated 5/1/22 through 10/13/23, showed the report did not contain the resident's assessment. Review of the facility MDS assessment file did not contain a signed or printed assessment for the resident. 8. Review of Resident #7's electronic health record, showed staff opened a Quarterly MDS assessment with an ARD of 9/16/23. Review of the open assessment showed the assessment as in progress. Further review showed all sections of the assessment as in progress or no information. The record did not contain a completion date. Review of the facility's validation reports, dated 5/1/22- through 10/13/23, showed the report did not contain the resident's assessment. Review of the facility MDS assessment file did not contain a signed or printed assessment for the resident. 9. During an interview on 10/24/23, at 12:30 P.M., the Administrator said she expected the MDSs to be completed and submitted when they were due according to the RAI manual. She said, I was not aware they were so behind because I was told corporate was taking care of making sure those are completed. During an interview on 10/24/23 at 12:45 P.M., the MDS coordinator said he/she just got hired for the position but as of now has not even been scheduled in the MDS office to be able to complete the MDSs because he/she is always having to cover staffing on the floor. He/She said it was his/her understanding corporate was keeping those done and up-to-date. MO00225414

Based on record review and interview, facility staff failed to have systems in place to prevent misappropriation of one resident's (Resident #1) money allowing misappropriation of at least $150.00 from the resident's account. The facility census was 48. The Administrator was notified on 6/23/23 of past Non-Compliance, which occurred on 06/22/23. On 06/22/23, the Administrator identified a missing payment of $150.00 for Resident #1. The Administrator conducted an investigation, received a signed Agreement Concerning Management of Personal Funds, replaced the missing funds for Resident #1, setup a Resident Trust Account, and in-serviced the Business Office Manager (BOM) on the procedure when the facility received resident funds. The investigation process determined there were four staff members who had access to the safe and unable to determine an alleged perpetrator. Staff corrected the deficient practice on 06/22/23. 1. Review of the facility's policy titled, Guidelines for Maintaining the Resident Trust Fund Account, dated 08/04/22, showed the facility will establish and maintain a system that assures full, complete and separate accountings of each resident's personal funds entrusted to the facility on the resident's behalf. The resident or a resident's legal representative must sign an agreement concerning management of personal funds. Deposits will be made to the resident's trust account within 24 hours of receipt as long as the bank is open for business and the resident is still in-house. Deposits will be entered into Matrix to the resident's trust account within 24 hours of the deposit. The facility did not provide a policy for monitoring resident funds to ensure it was deposited into a Resident Trust Account. Review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, Abuse Policy, undated, showed: -It is the policy of this facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment or involuntary seclusion; -The policy did not provide guidance for staff in regard to the investigation process. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/04/23, showed staff assessed the resident as cognitively intact. Review of the facility's investigation, dated 06/22/23, showed the Administrator received a $150.00 cash payment on 05/05/23 and placed the funds and receipt in the safe. The administrator informed the prior BOM of the received funds and he/she needed to deposit the funds and setup a resident trust account for Resident #1. Review showed the Administrator noticed the trust account was not set up for the resident and the resident's $150.00 was not available. The investigation process determined there were four staff members who had access to the safe and unable to determine an alleged perpetrator. Review showed the Administrator received a signed Agreement Concerning Management of Personal Funds, replaced the missing funds, setup a Resident Trust Account, and in-serviced the current BOM on the procedure when the facility received resident funds. Review of the facility's hand written receipt, dated 05/05/23, showed a payment in the amount of $150.00 was received from Resident #1's family member. Review of the Agreement Concerning Management of Personal Funds, dated 06/22/23, showed the resident signed the form. Review of the Resident's Resident Trust Account, dated 06/22/23, showed the trust was setup. Review of the Resident's bank account, dated 06/22/23, showed $150.00 was deposited. During an interview on 06/22/23 at 12:22 P.M., the Administrator said the resident's family member gave her $150.00 for beautician services on 05/05/23. The BOM was not in the office, so she hand wrote a receipt for the money and placed the funds and receipt in the safe. She said when the BOM returned, she told him/her the cash was in the safe, so he/she needed to get the funds deposited and setup a Resident Trust Account. She said the resident got his/her hair colored on 6/20/23, so the hair stylist inquired about getting paid on 6/22/23. The Administrator said she looked to see if a trust account was setup for the $150.00, but could not locate the account and the money was not in the safe. She said she checked other accounts to verify the money was not inaccurately put in the account and could not locate the funds anywhere. She said she contacted the prior BOM on 06/22/23, who said the receipt and the funds were still in the safe, since he/she did not have time to setup the account prior to leaving the position. She said staff are directed to deposit cash, the same day received, into the local bank account, setup a Resident Trust Account if not already setup, write out a check from the petty cash account and deposit into the resident's trust account. She said she, the maintenance person who originally setup the safe combination, and the previous and current BOM knew the code to the safe. She said the facility repaid the $150.00 to the resident and will pay the beautician out of that money. She said there was previously no monitoring of the funds received prior to this incident. She said she will be checking with the BOM and she will monitor if the deposits were made and the expectation is to deposit funds daily. During an interview on 06/22/23 at 12:49 P.M. the current BOM said he/she was educated to provide the resident and/or guardian a receipt, make copy of cash or check, fill out deposit slip, setup a Resident Trust Account and deposit the money in the bank on a daily basis. He/She said the cash box has to be counted every day. He/She said he/she had never seen the missing cash in the safe. During an interview on 06/22/23 at 2:20 P.M., the previous BOM, said the administrator told him/her about the funds, but he/she never saw the money in the safe. He/She left his/her position before he/she had a chance to setup the trust account. He/She said the BOM and Administrator had access to the safe. He/She said he/she did not look in the safe on a daily basis. He/She said he/she checked the safe every couple of days to verify if there was cash that needs to be deposited. He/She said the safe was always locked. He/She said he/she did not take the money, since he/she had never seen the money. MO00220380

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide written notice to residents or the resident's representatives regarding resident transfers to the hospital for two of two sampled residents (Resident # 20 and #27). The facility census was 50. 1. Review of the facility's Discharge/Transfer of Resident Policy, undated, showed: -Purpose - To provide safe departure from the facility and to provide sufficient information for the aftercare of the resident. -Equipment - Notice of Transfer or Discharge, if necessary -Guidelines - Explain discharge guidelines and reason and give copy of Transfer & Discharge Notice as required. Include resident representative. 2. Review of Resident #20's medical record showed the following: -Transferred to the hospital on [DATE]; -Returned to the facility on [DATE]; -Transferred to the hospital on 3/29/23; -Returned to the facility on 3/31/23; -Staff did not document they notified the resident and resident representative of the transfer. 3. Review of Resident #27's medical record showed the following: -Transferred to the hospital on 4/10/22; -Returned to the facility on 4/18/22; -Staff did not document they notified the resident and resident representative of the transfer. 4. During an interview on 4/13/23 at 5:20 P.M., the administrator and the corporate nurse said the facility was not providing written notifications of transfers or discharges to the residents or representatives. They said they realized written notifications should have been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to provide written information to the resident and/or the resident's representative of their bed hold policy at the time of transfer to the hospital for two sampled residents (Resident #20 and #27). The facility census was 50. 1. Review of the facility's Discharge/Transfer of Resident Policy, undated, showed: -Purpose - To provide safe departure from the facility and to provide sufficient information for the aftercare of the resident. -Equipment - Bed Hold Forms. -Guidelines - Explain discharge guidelines and reason and give copy of Transfer & Discharge Notice as required. Include resident representative. The Guidelines did not include mention of the Bed Hold Form. 2. Review of Resident #20's medical record showed the following: -Transferred to the hospital on 3/29/23; -Resident returned to the facility on 3/31/23; -Transferred to the hospital on [DATE]; -Resident returned to the facility on [DATE]; -Staff did not document they notified the resident or the resident's responsible party of the facility's bed-hold policy. 3. Review of Resident #27's medical record showed the following: -Transferred to the hospital on 4/10/22; -Resident returned to the facility on 4/18/22; -Staff did not document they notified the resident or the resident's responsible party of the facility's bed-hold policy. 4. During an interview on 4/13/23 at 5:20 P.M., the administrator and the corporate nurse said the facility was not providing written notification of the facility's bed hold notification to the residents or representatives upon transfer of a resident. They said they realized written notifications should have been done.

Based on observation, interview and record review, facility staff failed to provide orders for dialysis (the clinical purification of blood as a substitute for the normal function of the kidney), and have ongoing communication with the dialysis clinic for one resident (Resident #24) who received dialysis. The facility census was 50. 1. Review of the facility's Dialysis Care of a resident receiving policy, undated, showed staff are directed as follows: Communication between the Facility and Dialysis Unit: -The Dialysis Communication Record will be sent with the resident on each dialysis visit; -All care concerns in the last 24 hours will be addressed, including last medications given and facility contact person; -The dialysis unit will complete the lower portion of the report to include weight prior to and after, any dialysis, any labs completed, medication given, follow up information and any new physician orders; -The lower portion will be signed by the dialysis nurse and returned to the facility; -The records will be maintained in the medical record. 2. Review of Resident #24's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/11/23, showed facility staff assessed the resident as: -Cognitively intact; -Diagnoses of End Stage Renal Disease (longstanding disease of the kidneys leading to renal failure; -Receives dialysis. Review of the resident's care plan, dated 4/11/23, showed it did not direct staff on how to care for the resident regarding dialysis and did not direct staff to monitor the dialysis access site or complete vital signs or other assessments upon the resident's return from dialysis. Review of the Physician's Order Sheet (POS), dated April 2023, showed the record did not contain an order for dialysis. Review of the resident's medical record showed it did not contain dialysis communication records. During an interview on 4/11/23 at 10:30 A.M., the resident said he/she goes to dialysis on Mondays, Wednesdays, and Fridays. The clinic comes to pick him/her up for the appointments. During an interview on 4/13/23 at 5:00 P.M., Registered Nurse (RN) C said the facility has a form that is sent with the resident each time they leave, and it comes back with the resident. He/She said there should be a book the forms are kept in, however he/she was unable to find it. During an interview on 4/13/23 at 5:04 P.M., RN A said there does not need to be a physician order for dialysis. He/She said he/she has never seen a physician order for dialysis. During an interview on 4/13/23 at 5:10 P.M., the Administrator and Regional Nurse said they would expect a resident to have a physician's order for dialysis and they have a communication form they use, however the dialysis clinic does not return them. The regional nurse said the facility has attempted to get the form back from the dialysis clinic but were told patient care was more important then filling out the form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, facility staff failed to maintain a clean, comfortable and homelike environment. Facility staff failed to maintain resident restrooms free of floor discolorations, missing toilet bolt covers and caulk at the base of the toilet. In addition, bathroom cabinets had laminate peeled off and drawers missing. The facility staff also failed to maintain resident rooms free of discolored floor tiles. The facility census was 50. 1. Review of the facility's policies showed staff did not provide a Facility Maintenance Policy. Observation on 4/10/23 at 11:45 A.M., showed dark black/gray stains in and around the cracks in the bathroom tiles, rust colored discoloration around the toilet bowl, and missing caulk and bolts at the base of the toilet bowl in room [ROOM NUMBER]. Observation on 4/10/23 at 11:49 A.M., showed two black skid marks, approximately 3/8 of an inch wide and three feet long in the middle the floor in room [ROOM NUMBER]. Observation on 4/10/23 at 11:51 A.M., showed a drawer missing in the bathroom cabinet, cracked tiles in bathroom, dark black/gray stains in and around the cracks in the tiles, and rust colored discoloration on the middle of some tiles in room [ROOM NUMBER]. Observation on 4/10/23 at 12:24 P.M., showed chipped tile on the floor of room [ROOM NUMBER] with rust colored spots. The painted bathroom floor showed chipped paint, the toilet bowl without bolts, and white trim partially missing behind the toilet. Observation on 4/10/23 at 12:24 P.M., showed rust colored spots on the floor near the bed in room [ROOM NUMBER]. The bathroom cabinet had a drawer missing and laminate pulled off the front base with exposed raw wood. The floor had dark black/gray stains in and around the cracks in the tiles, a rust colored discoloration around the toilet bowl, missing caulk, and a missing bolt at the base of the toilet bowl. The bathroom door threshold was missing at the door except for approximately one foot. Observation on 4/11/23 at 10:09 A.M., showed a drawer missing in the bathroom cabinet, cracked tiles in bathroom and dark black/gray stains in and around the cracks in the tiles, and rust colored discoloration on the middle of some tiles in room [ROOM NUMBER]. Observation on 4/11/23 at 10:13 A.M., showed dark black/gray stains in and around the cracks in the bathroom tiles, a rust colored discoloration around the toilet bowl, and missing caulk and missing bolts at the base of the toilet bowl in room [ROOM NUMBER]. Observation on 4/11/23 at 10:14 A.M., showed chipped tile on the floor of room [ROOM NUMBER] with rust colored spots. The painted bathroom floor showed chipped paint, the toilet bowl without bolts, and white trim partially missing behind the toilet Observation on 4/11/23 at 10:18 A.M., showed two black skid marks, approximately 3/8 of an inch wide and three feet long in the middle the floor in room [ROOM NUMBER]. Observation on 4/11/23 at 10:26 A.M., showed rust colored spots on the floor near the bed in room [ROOM NUMBER]. The bathroom cabinet had a drawer missing and laminate pulled off the front and the base with exposed raw wood. The floor had dark black/gray stains in and around the cracks in the tiles, a rust colored discoloration around the toilet bowl, missing caulk, and a missing bolt at the base of the toilet bowl. The bathroom door threshold was missing at the door except for approximately one foot. Observation on 4/13/23 at 11:45 A.M., showed two black skid marks, approximately 3/8 of an inch wide and three feet long in the middle the floor in room [ROOM NUMBER]. Observation on 4/13/23 at 11:46 A.M., showed a drawer missing in the bathroom cabinet, cracked tiles in bathroom and dark black/gray stains in and around the cracks in the tiles, and rust colored discoloration on the middle of some tiles in room [ROOM NUMBER]. Observation on 4/13/23 at 11:47 A.M., showed dark black/gray stains in and around the cracks in the bathroom tiles, a rust colored discoloration around the toilet bowl, and missing caulk and missing bolts at the base of the toilet bowl in room [ROOM NUMBER]. Observation on 4/13/23 at 11:49 A.M., showed rust colored spots on the floor near the bed in room [ROOM NUMBER]. The bathroom cabinet had a drawer missing and laminate pulled off the front and the base with exposed raw wood. The floor had dark black/gray stains in and around the cracks in the tiles, a rust colored discoloration around the toilet bowl, missing caulk, and a missing bolt at the base of the toilet bowl. The bathroom door threshold was missing at the door except for approximately one foot. Observation on 4/13/23 at 11:52 A.M., showed chipped tile on the floor of room [ROOM NUMBER] with rust colored spots. The painted bathroom floor showed chipped paint, the toilet bowl without bolts, and white trim partially missing behind the toilet. During an interview on 4/11/23 at 10:45A.M., Resident #15 said his/her bathroom was ugly. During an interview on 4/13/23 at 4:35 P.M.,the maintenance director said work orders needed to be placed in order for him/her to know there are maintenance issues. During an interview on 4/13/23 at 5:20 P.M., the Administrator and the Quality Assurance Nurse said resident restrooms should be maintained and stains should not be between tiles or around toilet bowls. The Quality Assurance Nurse said poorly maintained bathrooms are repulsive. The upkeep of the restrooms is the maintenance department responsibility, and the floor staff should report any issues to the maintenance department or the administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to meet professional standards of care when they failed to weigh two residents (#4 and #41), check Depakote (to treat seizures, bipolar disorder or migraine headaches) levels for one resident (#11), and to take a blood pressure prior to administration of blood pressure medication for one resident (Resident #303) as ordered by the physician. Additionally, staff failed to failed to provide consistent documentation in regard to a resident's Advance Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one resident (Resident #20), and failed to ensure physician medications orders were signed for two residents (#31 and#40). The facility census was 50. 1. Review of the facility's policies showed the staff did not provide a policy for following physicians orders or for medication or treatment administration. 2. Review of Resident #4's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/10/23, showed staff assessed the resident as follows: -Severe cognitive impairment; -Utilized a feeding tube; -Diagnosis of gastrostomy (a surgical opening through the skin of the abdomen to the stomach. A feeding device is put into this opening so that nutrition can be delivered directly into the stomach bypassing the mouth and throat) and quadriplegia (paralysis that affects all a person's limbs and body from the neck down. Review of the resident's Physician Order Sheet (POS), dated April 2023, showed an order for weekly weights once a day on Wednesdays starting on 8/2/22. Review of the resident's electronic medical record showed staff did not document the resident's weight as follows: -For the month of August; -For the month of September; -On the week of 10/12/22; -On the week of 10/19/22; -On the week of 10/26/22; -On the week of 11/9/22; -On the week of 11/16/22; -On the week of 11/23/22; -On the week of 12/7/22; -On the week of 12/14/22; -On the week of 12/21/22; -On the week of 12/28/22; -On the week of 1/11/23; -On the week of 1/18/23; -On the week of 1/25/23; -On the week of 2/8/23; -On the week of 2/15/23; -On the week of 2/22/23; -On the week of 3/2/23; -On the week of 3/15/23; -On the week of 3/22/23; -On the week of 3/29/23. 3. Review of Resident #41's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Diagnosis of vascular dementia ( problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain). Review of the resident's POS, dated April 2023, showed an order on 3/34/23 for weekly weights on Mondays. Review of the resident's electronic medical record showed staff did not assess the resident's weight as follows: -On the week of 3/27/23; -On the week of 4/3/23; -On the week of 4/10/23. During an interview on 4/13/23 at 5:10 P.M., Certified Nurse Aide (CNA) I said the nurse will typically do weights or they might ask the CNAs. He/She said they believe they are done once a month for all residents. During an interview on 4/13/23 at 5:04 P.M., Registered Nurse (RN) A said physician orders for weights should be done as indicated on the orders. He/She said the restorative aide is responsible for obtaining the resident weights. He/She said the Assistant Director of Nursing (ADON) gives the restorative aide a list of residents who need their weights taken. 4. Review of Resident #11's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -admit date [DATE]; -Mild cognitive impairment; -Received antipsychotic, antidepressant, antianxiety, anticoagulant medications 7 out of 7 days in the look back period (7 day period of time before the assessment is completed to capture the status of a resident); -Diagnosis of Anxiety disorder, Depression, and Stroke. Review of the Resident's POS, dated 3/20/23 through 4/20/23, showed the following orders: -Divalproex (brand name Depakote) 125 milligram (mg) 1 cap twice daily (BID); -Divalproex 125mg 2 caps at Bedtime (HS); -An order dated 2/7/19 for Depakote level every 6 months, February and August Review of the resident's medical record showed: -Did not contain a Depakote level in 2/2022; -Did not contain a Depakote level in 8/2022; -Did not contain a Depakote level in 2/2023. During an interview on 4/13/23 at 3:45 P.M., RN C said I think maybe the order would need to be added in every year since it is only twice a year, and maybe it didn't get put back in. RN C said he/she does not know who is responsible for checking the order. During an interview on 4/13/23 at 5:10 P.M., the administrator and corporate nurse said the Assistant Director of Nursing (ADON) is responsible for making sure orders for labs are put in the system. 5. Review of Resident #303's Face Sheet, showed: -The resident was admitted [DATE]; -The resident was diagnosed with essential primary hypertension (elevated blood pressure). Review of the resident's POS, dated April 2023, showed an order for Lisinopril 5 milligrams (mg), two tablets one time a day. Special instructions: Hold for systolic blood pressure (blood pressure is measured using two numbers -the first number, called systolic blood pressure, measures the pressure in your arteries when your heart beats) less than 100. Observation on 4/12/23 at 8:13 A.M., showed Certified Medical Technician (CMT B) administered two 5 mg tablets of Lisinopril to the resident. CMT B did not take the resident's blood pressure prior to administering the medication as ordered. During an interview on 4/13/23 at 5:04 P.M., RN A said physician orders should always be followed. He/She said some medications require blood pressures to be done prior to giving the medication. He/She said nurses are responsible for obtaining the resident's blood pressure and notifying the CMT of the reading before they pass the medications. He/She said the resident's blood pressure should always be taken prior to administering the medication. He/She said a resident whose blood pressure is already low is at risk for hypotension (Low blood pressure, which can cause fainting or dizziness because the brain doesn't receive enough blood) if given the blood pressure medication. During an interview on 4/13/23 at 5:20 P.M., the Quality Assurance Nurse and the Administrator said staff should follow physician orders for taking weights and blood pressures. 6. Review of the facility's Advance Directive Policy, undated showed: -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. Review of Resident #20's Face Sheet in his/her Electric Medical Record (EMR) showed staff documented the resident as DNR (do not resuscitate) status. Review of the resident's POS, dated 2/16/23, showed an active order of code status as Full Code. Review of the resident's paper chart showed the record did not contain documentation of an Advance Directive. Review of the resident's medical record showed the record did not contain clarification of the resident's code status. During an interview on 4/13/23 at 4:35 P.M., CNA I said staff know what a resident's code status is by the sticker on their door and what is in their chart. If the two did not match then they would let the charge nurse know so it can be fixed. During an interview on 4/13/23 at 5:04 P.M., RN A said resident code status is obtained upon admission. He/She said the resident's code status is kept in the resident's hard chart, in their electronic medical record, and the charge nurse has a copy on their report sheets. He/She said they should have a physician's order for the resident's code status and each resident should have either a red or green colored sticker on their door. He/She said if the code status did not match he/she would clarify with the physician. During an interview on 4/13/23 at 5:20 P.M., the Quality Assurance Nurse and the Administrator said when a resident is admitted , the wishes of the resident regarding their order for a code status should be entered into the resident's EMR as well as documented in the hard chart and marked with color coded stickers. 7. Review of the facility's Physician Orders policy, undated, showed: Telephone/Verbal Orders: -Only a licensed nurse or therapist may accept telephone/verbal orders from a licensed physician or dentist. -Such Orders must be countersigned by the issuing physician or dentist. 8. Review of Resident #31's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Diagnosis of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). Review of the resident's POS, dated April 2023, showed an unsigned order on 3/23/23 for Carb/levo tab 25-100 mg 1 tablet three times daily. Observation on 4/11/23 at 11:49 P.M., showed CMT B administered 1 tablet of Carb/levo tab 25-100 mg to the resident. 9. Review of Resident #40's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Diagnosis of hypertension (high blood pressure) and vitamin deficiency. Review of the resident's POS, dated April 2023, showed unsigned orders for the following: - An order on 10/14/22 for Ascorbic acid 500 mg tablet once daily; - An order on 12/3/22 for Blue-Emu lidocaine 4% medicated adhesive patch applied once daily; - An order on 10/14/22 for Daily multivitamin-minerals tablet daily; - An order on 10/14/22 for Garlic 500 mg capsule once daily; - An order on 10/14/22 for Calcium carbonate-vitamin D3 600 mg-10 microgram (mcg) tablet twice a day; - An order on 10/14/22 for Furosemide 40 mg 1 tablet twice daily. Review of the resident's eMAR showed the resident received the following medications: - Ascorbic acid 500 mg given once a day for the month of March and April 1-13; - Blue-Emu lidocaine patch given once a day for the month of March and April 1-13; - Daily multivitamin-minerals tablet given once a day for the month of March and April 1-13; - Garlic 500 mg capsule given once a day for the month of March and April 1-13; - Calcium carbonate-vitamin D3 600 mg- 10 mcg tablet twice a day for the month of March and April 1-12; -Furosemide 40 mg tablet twice a day for the month of March-April 1-12. During an interview on 4/13/23 at 2:40 P.M., RN C said if the order in the electronic medical record shows that it is not signed, the physician has not signed off on approval of the order and the medications or treatments should not be done. He/She said staff would need to obtain verbal orders, fax the physician's office to get them signed, or obtain a signed copy from pharmacy. During an interview on 4/13/23 at 5:20 P.M., the Quality Assurance Nurse and the Administrator said staff are permitted to take verbal orders and add them to the physician order sheets. Physicians are to sign the orders within a reasonable time such as one week. The physicians are able to remotely sign the orders electronically from their offices as well as in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide assistance with personal hygiene for four residents (Resident #1, #2, #11, and #17) dependent on staff for care. The facility census was 50. 1. Review of the facility's policies showed the staff did not provide a bath (shower) policy. 2. Review of Resident #1's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 2/23/23, showed staff assessed the resident as: -Moderate cognitive impairment; -Required limited assistance from one staff member for bathing, dressing, personal hygiene, and toileting; -Diagnoses of hemiplegia or hemiparesis; -Does not reject care; -No behaviors towards others; -Occasionally incontinent of urine and always incontinent of bowel. Review of the resident's care plan, dated March 2023 showed staff are directed to assist with showers at least two times per week, wash hair as needed (PRN), and provide nail care on bath days. Review of the resident's shower record, dated January 2023, showed staff documented the resident received a shower on 1/12, 1/16, 1/23, 1/26 and 1/30. Review of the resident's shower record, dated February 2023, showed staff documented the resident received a shower on the 2/2, 2/6, 2/15, and 2/27. Review of the resident's shower record, dated March 2023, showed staff documented the resident received a shower on the 3/9, 3/13, 3/20, 3/23, 3/27 and 3/30. Review of the resident's shower record, dated April 1, 2023 to April 13, 2023 showed staff documented the resident received a shower on 4/10. Observation on 4/10/23 at 10:38 A.M., showed the resident in his/her room. The resident wore a navy blue long sleeve shirt and gray pants, he/she had greasy unkempt hair, hair on his/her chin and white residue around his/her mouth. Observation on 4/11/23 4:00 P.M., showed the resident in his/her room. The resident wore the same navy blue long sleeve shirt and gray pants as he/she wore the previous day. Further observation showed the resident with facial hair and greasy, unkempt hair. Observation on 4/12/23 10:45 A.M., showed the resident in his/her room. The resident wore the same navy blue long sleeve shirt and gray pants as he/she wore the previous day. Further observation showed the resident with facial hair and greasy, unkempt hair. Observation on 4/13/23 at 4:20 P.M., showed the resident in the community/living room. The resident wore the same navy long sleeve shirt and gray pants. Further observation showed the resident with facial hair and greasy, unkempt hair. During an interview on 4/10/23 at 10:38 A.M., the resident said he/she has not had a shower since last Monday. He/She said he/she is lucky to get a shower once a week. The resident said staff shaves his/her face during his/her showers. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed facility staff assessed the resident as follows: -Moderate cognitive impairment; -Required limited assistance from one staff member with bathing, dressing, personal hygiene, and toileting; -No behaviors directed towards others; -Rejected care 1-3 days during the look back period (period of time used to completed the assessment); -Occasionally incontinent of urine and always incontinent of bowel. Review of the resident's care plan, dated April 2023, showed it did not contain direction for staff in regard to the resident's personal hygiene. Review of the resident's shower record, dated January 2023, showed staff did not document they assisted the resident with a shower. Review of the resident's shower record, dated February 2023, showed staff documented the resident received a shower on 2/28. Review of the resident's shower record, dated March 2023, showed staff documented the resident received a shower on 3/24 and 3/28. Review of the resident's shower record, dated April 1, 2023 to April 13, 2023 showed it did not contain documentation the resident received a shower. 4. Review of Resident #11's quarterly MDS, dated [DATE], showed facility staff assessed the resident as: -Moderate cognitive impairment; -Required extensive assistance from two staff members with personal hygiene, and toileting; -Totally dependent on staff for bathing; -No behaviors directed towards others; -Did not reject care; -Frequently incontinent of urine and bowel. Review of the resident's care plan, dated April 2023 showed it did not contain direction for staff in regard to the resident's personal hygiene. Review of the resident's shower record, dated January 2023, showed staff documented the resident received a shower on 1/14. Review of the resident's shower record, dated February 2023, showed staff documented the resident received a shower on 2/4, 2/5, 2/11, 2/22, and 2/25. Review of the resident's shower record, dated March 2023, showed staff documented the resident received a shower on 3/8, 3/24, and 3/27. Review of the resident's shower record, dated April 1, 2023 to April 13, 2023, showed staff documented the resident received a shower on 4/10. Observation on 4/10/23 at 12:30 P.M., showed the resident in the dining room with unkempt hair. Observation on 4/13/23 at 11:45 A.M., showed the resident sat in his/her wheelchair in the hallway with unkempt hair. 5. Review of Resident #17's Quarterly MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Required limited assistance from one staff member with bathing, personal hygiene, and toileting; -No behaviors directed towards others; -Did not reject care; -Occasionally incontinent of urine and always incontinent of bowel. Review of the resident's care plan, dated April 2023 showed it did not contain direction for staff in regard to the resident's personal hygiene. Review of the resident's shower record, dated January 2023, showed staff documented the resident received a shower on 1/13, 1/17, 1/27, and 1/31. Review of the resident's shower record, dated February 2023, showed staff documented the resident received a shower on 2/17, 2/21, 2/25, and 2/28. Review of the resident's shower record, dated March 2023, showed staff documented the resident received a shower on 3/7, 3/10, 3/21, 3/24, and 3/24. Review of the resident's shower record, dated April 1, 2023 to April 13, 2023 showed it did not contain documentation the resident received a shower. Observation on 4/11/23 at 3:00 P.M., showed the resident in his/her bed with crusty white substance on his/her shirt. Observation on 4/12/23 2:00 P.M., showed the resident in his/her bed with greasy, unkempt hair. Observation on 4/13/23 at 8:00 A.M., showed the resident with greasy hair. During an interview on 4/11/23 at 3:00 P.M., the resident said he/she is lucky if he/she gets a shower once a week. 6. During an interview on 4/13/23 at 4:05 P.M., Certified Nurse Assistant (CNA) E said residents get two showers a week. Social services will meet with the resident when they come in, and come up with a plan for shower days. It is documented when a resident showers or refuses. If a resident refuses one day they can do it on Sunday or they can tell the nurse so they can help encourage them to shower. During an interview on 4/13/23 at 5:04 P.M., Registered Nurse (RN) A said the CNAs are given a weekly shower schedule and are responsible for ensuring the residents receive their showers. He/She said if a resident refuses a shower the CNA should notify the charge nurse. He/She said it is the charge nurse's responsibility to talk to the resident and confirm the refusal. He/She said the nurses are responsible for verifying that the residents are showered or that they refused. He/She said the shower sheets are turned in to the Administrator. During an interview on 4/13/23 at 5:20 P.M., the Quality Assurance Nurse and the Administrator said residents should be clean, well groomed, and offered showers twice a week.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure the resident's environment remained free of accident hazards when facility staff failed to ensure razors/sharps and hazardous chemicals were stored in safe manner not accessible to residents. In addition, facility staff failed to maintain the hot water temperature below 120 degrees Fahrenheit in the resident rooms. The facility census was 50. 1. Review of the facility policy and procedure manual showed they did not have a policy for hazardous chemical storage, sharps storage for razors or nail clippers. Observation on 4/11/23 at 10:29 A.M., showed the 300 hall shower room unlocked and unattended with the following: -Two sharps containers, with the tops open contained uncovered disposable razors; -A can of shaving cream; -A bottle of body wash; -A mop bucket filled with dirty water and a mop; -A can of Spray Deodorant labeled, Keep out of reach of children, if swallowed, get medical help or contact a Poison Control Center right away -A bottle of Therapeutic shampoo labeled, If swallowed, get medical help or contact a Poison Control Center right away; -A bottle of 2-in1 Dandruff Shampoo labeled, If swallowed, get medical help or contact a Poison Control Center right away; -A jug of Classic Whirlpool Disinfectant and Cleaner labeled, Danger: Corrosive Causes irreversible eye damage and skin burns. Do not get in eyes, on skin, or clothing. Wear Protective eyewear (goggles, face shield or safety glasses, protective (rubber or chemical resistant) gloves, and protective clothing. Harmful if swallowed or absorbed through the skin. Wash thoroughly with soap and water after handling and before eating, drinking or chewing gum, using tobacco, or the toilet. Remove contaminated clothing and wash before reuse. Keep out of reach of children. Observation on 4/11/23 at 11:25 A.M., showed the 100 hall shower room unlocked and unattended and contained whirlpool cleanser, razors, shampoo, body lotion, body wash, and shaving cream. Observation on 4/12/23 at 12:50 P.M., showed a bottle of toilet bowl cleaner with bleach stored unsecured in the resident occupied room [ROOM NUMBER]. Observation on 4/12/23 at 1:12 P.M., showed a 32 ounce (oz.) bottle of all purpose cleaner, degreaser and spot remover stored unsecured by the bed in the resident occupied room [ROOM NUMBER]. Observation also showed a 40 oz. bottle of bathroom disinfectant cleaner, made with ammonium chloride, stored unsecured by the toilet in the resident's room. Observation on 4/12/23 at 3:00 P.M., showed the 400 hall shower room unlocked and unattended and contained whirlpool cleanser, razors, shampoo, body lotion, body wash, finger nail clippers, and shaving cream. Observation on 4/13/23 at 10:31 A.M., showed the 400 hall shower room unlocked and unattended and contained whirlpool cleanser, razors and deodorant. Observation on 4/13/23 at 10:34 A.M., showed the 200 hall shower room unlocked and unattended and contained shaving cream, body cleaner, and shampoo. During an interview on 4/13/23 at 5:00 P.M., Nurse Assistant (NA) F said shower rooms should be kept locked. NA F said any kind of chemicals should be kept locked up. Razors are kept in the locked storage room on the 400 hall unless they are used they go in the sharps box. During an interview on 4/13/23 at 5:04 P.M., Registered Nurse (RN) A said all shower rooms should be locked. He/She said the nurses are responsible for making sure the doors are locked and they carry the key to all of the shower rooms. He/She said the shower rooms should be locked because staff would be unable to monitor what happens in the shower rooms, and residents could become injured. He/She said razors and chemicals should not be left out where residents can get to them. He/She said razors and chemicals should be locked up in the clean storage room, in a locked cabinet, or in a locked shower room. During an interview on 4/13/23 at 5:20 P.M., the Quality Assurance Nurse and the Administrator said shower rooms should be kept locked and razors and chemicals should not be accessible to the residents. 2. Review of the facility policy and procedure manual showed the manual did not contain a policy for monitoring hot water temperatures or for determining the maximum hot water temperature. Review of the facility's Weekly Water Temperature Log sheet showed: -Resident rooms should reach temperatures of 105-120 degrees, maximum. -If a resident's room water temperature is above 120 degrees, adjust the water heater, look for a hot water leak, or check mixing valves. If too high of temperature still occurs, call for service. Review of the Facility's Weekly Water Temperature Log, dated 2/27/23 to 3/3/23, showed a water temperature of 121 degrees F in room [ROOM NUMBER] without corrective action taken. Review of the Facility's Weekly Water Temperature Log, dated 4/4/23, showed a water temperature 121 degrees F in room [ROOM NUMBER] without corrective action taken. Observation on 4/13/23 at 4:11 P.M., showed a hot water temperature measured with a calibrated thermometer of 126.4 degrees Fahrenheit (F) from the sink faucet of room [ROOM NUMBER]. Observation on 4/13/23 at 4:15 P.M., showed a hot water temperature measured with a calibrated thermometer of 125.6 degrees F from the sink faucet of room [ROOM NUMBER]. Observation on 4/13/23 at 4:20 P.M., showed a hot water temperature measured with a calibrated thermometer of 124.3 degrees Fahrenheit (F) from the sink faucet of room [ROOM NUMBER]. Observation on 4/13/23 at 4:39 P.M., showed a hot water temperature measured with a calibrated thermometer of 121.3 degrees Fahrenheit (F) from the sink faucet of room [ROOM NUMBER]. During an interview on 4/13/23 at 4:25 P.M., the Maintenance Director (MD) said he performs monthly and quarterly water temperature checks. Weekly water temperature are done on two rooms on each hall one room at the beginning and one at the end of each hall. The MD said he believes the cut off temperature is 125 degrees, and if it is above that he would adjust the water heater. During an interview on 4/13/23 at 4:35 P.M., CNA I said he/she does showers with residents and always checks the water temp with his/her elbow, I also have the resident do the same thing. CNA I said if its too cold or hot he/she would tell the maintenance director. During an interview on 4/13/23 at 5:20 P.M., the Quality Assurance Nurse and the Administrator said the facility did not have a policy on water temperature. They said the Maintenance Director took care of monitoring the hot water heaters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to ensure that as needed (PRN) psychotropic medication orders were limited to 14 days unless specific duration and clinical rationale were provided for two residents (Resident #2, and #34), and failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for one resident (Resident #5). The facility census was 50. 1. Review of the facility's Drug Review policy, undated, showed the following: All medication given to each resident will be reviewed on a monthly basis in order to: -Review drug interactions; -Evaluate medications appropriate to diagnosis; -Medications should not show unnecessary or excessive use and should have a diagnosis to support them; -The policy did not given direction for Gradual Dose Reductions. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/6/23, showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). Review of the resident's Physician Order Sheet (POS), dated April 2023 showed the following: -An order on 11/1/22 for Olanzapine (antipsychotic medication) 10 milligram (mg) intramuscular (IM) BID (twice a day) as needed (PRN); -The order did not contain a 14 day stop date for the medication. Review of the resident's medical record showed the physician did not document a clinical rationale to continue the medication without a GDR. 3. Review of Resident # 34's Annual MDS, dated [DATE] showed a diagnosis of anxiety and depression. Review of the resident's POS, dated April 2023 showed the following: -An order on 3/27/23 for Seroquel (antipsychotic medication) 25 mg three times a day as needed (PRN); -The order did not contain a 14 day stop date for the medication. Review of the resident's medical record showed the record did not contain a specific duration or clinical rationale by the physician for the use beyond the 14 days. During an interview on 4/13/23 at 5:04 P.M., Registered Nurse (RN) A said he/she was not sure of the facility's policy on PRN psychotropic drugs. He/She said he/she did not know of any special rules for PRN psychotropic drug stop times, but said he/she knows pharmacy comes monthly to review the medications and orders. He/She said if he/she did have a concern he/she would consult with the physician. 4. Review of Resident # 5's Quarterly MDS, dated [DATE] showed the following: -Received antipsychotic, antidepressant, and hypnotic medications 7 out of 7 days in the look back period (7 day period of time before the assessment is completed to capture the status of a resident); -Diagnosis of anxiety (intense, excessive, and persistent worry and feat about everyday situations), and depression (a group of conditions associated with the elevation or lowering of a person's mood). Review of the resident's POS, dated April 2023 showed an order for the following psychotropic medications: -On 8/9/22 Ambien (hypnotic/sedative medication) 5 mg daily at bedtime (HS); -On 6/1/22 Abilify (antipsychotic medication) 2 mg at HS; -On 12/14/22 Remeron (antidepressant medication) 15mg at HS; -On 1/12/22 Trintellix (antipsychotic and antidepressant medication) 10 mg BID. Review of the resident's medical record showed staff did not document an attempt for a GDR for the resident's psychotropic medications and the physician did not document a clinical rationale to continue the medication without a GDR. During an interview on 4/13/23 at 5:04 P.M., RN A said he/she was not sure what a GDR was. He/She said he/she did not know of any instances where the resident's medications would be gradually reduced for these types of medications. He/She said he/she knows pharmacy comes monthly to review and make recommendations on resident medications and orders. During an interview on 4/13/23 at 5:20 P.M., the Quality Assurance Nurse and the Administrator said PRN psychotropic medications should have a two week stop date and GDR recommendations must be addressed by the staff and the physician.

Based on observation, interview, and record review, facility staff failed to ensure medications were stored in a safe and effective manner, additionally staff failed to ensure two medications carts were locked at all times. The facility census was 50. 1. Review of the facility's Medications, Storage of, from Nursing Guidelines Manual, undated, directed staff as follows: -Drugs must be stored in an orderly manner in cabinets, drawers, or carts; -An unattended medication cart must remain locked at all times. In the event the nurse is distracted from the task of passing medications by some unforeseen occurrence, the cart must be locked before leaving it, or secured in a locked medication room. 2. Observation on 4/12/23 at 11:00 A.M., showed the Certified Medication Technician (CMT)'s medication cart contained the following loose pills: -One small round yellow pill stamped with W40; -Half of a small oval white pill. During an interview on 4/12/23 at 11:04 A.M., CMT B said when they find loose pills in the medication carts they dispose of the pills into the locked trashcan on the side of their medication cart. He/She said each nurse/CMT is responsible for their own cart. Observation on 4/12/23 at 11:14 A.M., showed the nurse's medication cart contained half of a small oval white pill. During an interview on 4/13/23 at 5:04 P.M., Registered Nurse (RN) A said the nurses and CMTs are responsible for their cart during their whole shift. He/She said the nurse or CMT is responsible for the medications, checking for expired medications, cleaning and keeping the cart free of loose pills. During an interview on 4/13/23 at 5:20 P.M., the Quality Assurance Nurse and the Administrator said the CMTs and nurses should check their medication cart at then end of every shift for loose and expired medications. 3. Observation on 4/11/23 at 8:08 A.M., showed two medication carts and one treatment cart unlocked and unattended at the nurses station. Further observation showed several residents sat nearby. Observation on 4/11/23 at 11:44 A.M., showed the nurse's treatment cart was left unlocked and unattended at the nurse's station. Further observation showed several residents walked by the nurse's station. Observation on 4/11/23 at 12:22 P.M., showed the nurse's medication cart was left unlocked in the 300 hall way. Further observation showed the cart drawers contained lancets (small needle used to poke the skin) and resident insulin. Observation on 4/11/23 at 12:35 P.M., showed the nurse's treatment cart was left unlocked and unattended at the nurse's station. Further observation showed several residents stood near the cart. Observation on 4/11/23 at 2:19 P.M., showed the nurse's treatment cart was left unlocked and unattended in the 100 hallway. Observation on 4/11/23 at 4:46 P.M., showed the nurse's medication cart left unlocked and unattended at the nurse's station. Further observation showed thirteen residents sat nearby. Observation on 4/12/23 at 10:32 A.M., showed the nurse's medication cart was left unlocked and unattended in the hallway outside of a resident's room. During an interview on 4/13/23 at 5:04 P.M., Registered Nurse (RN) A said medication and treatment carts should not be left unattended when they are unlocked. He/She said the facility has several residents who like to wander. He/She said confused residents could get into the carts that are left unlocked and could get into harmful medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to ensure all residents were screened for Tuberculosis (TB) (a potentially serious infectious bacterial disease that mainly affects the lungs) when staff failed to ensure a two-step purified protein derivative (PPD) (skin test for TB) was completed and documented as per the facility policy for three residents (#1, #11, and #34). The facility census was 50. 1. Review of the facility provided Screening for Tuberculosis in Long Term Care Facilities guideline, undated, showed the guidance directs staff as follows: -All residents new to long-term care who do not have documentation of a previous skin test reaction >10mm or a history of adequate treatment of tuberculosis infection or disease, shall have the initial test of a Mantoux PPD two-step skin test to rule out tuberculosis within one month prior to or one week after admission as required by Department of Health Rule 19 CSR 20-20.100. -The two-step test is recommended due to the booster phenomenon, which can occur at any age, but is more pronounced with increased age. 2. Review of Resident #1's medical record, showed the following: -admitted on [DATE]; -Immunization record showed the resident received the first step TB on 2/19/20; -Immunization record did not contain results of the resident's first step TB; -Immunization record did not contain documentation a second step TB was administered. 3. Review of Resident #11's medical record, showed the following: -admitted on [DATE]; -Immunization record showed the resident received the first step TB on 12/26/19; -Immunization record did not contain results of the resident's first step TB; -Immunization record did not contain documentation a second step TB administered. 4. Review of Resident #34's medical record, showed the following: -admitted on [DATE]; -Immunization record showed the resident received the first step TB on 11/3/21; -Immunization record did not contain results of the resident's first step TB; -Immunization record did not contain documentation a second step TB administered. 5. During an interview on 4/13/23 at 5:04 P.M., Registered Nurse (RN) A said residents are required to have the two step TB testing done upon admission and then once annually after. He/She said if a resident refuses TB testing, a signed refusal of consent should be documented in the resident's electronic medical record and the ADON should be notified. Staff said they were unsure of why the residents did not have them done. During an interview on 4/13/23 at 5:10 P.M., the Administrator and Corporate nurse said residents are required to have the two-step TB testing done upon admission, and it is the charge nurse's responsibility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement interventions to prevent pressure ulcers for one resident (Resident #22) with a contracture. Additionally, the facility failed to correctly assess wounds for one resident (Resident #5). The facility census was 38. 1. Review of Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, defined the following: -Pressure ulcer/injury: localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful; -Stage 1 pressure injury: an observable, pressure-related alteration of intact skin whose indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following parameters: skin temperature (warmth or coolness), tissue consistency (firm or boggy), sensation (pain, itching) and/or a defined area of persistent redness; -Stage 2 pressure ulcer: partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or bruising. May also present as an intact or open/ruptured blister; -Stage 3 pressure ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss; -Stage 4 pressure ulcer: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be present on some parts of the wound bed; -Unstageable pressure ulcer: Known but not stageable due to coverage of the wound bed by slough and/or eschar. -Epithelial tissue: new skin that is light pink and shiny (even in persons with darkly pigmented skin). In Stage 2 pressure ulcers, epithelial tissue is seen in the center and at the edges of the ulcer. In full thickness Stage 3 and 4 pressure ulcers, epithelial tissue advances from the edges of the wound; -Granulation tissue: red tissue with cobblestone or bumpy appearance; bleeds easily when injured; -Slough: Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed; -Eschar: dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound; -Moisture Associated Skin Damage (MASD): superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration; -Venous Ulcer: caused by peripheral venous disease (narrowing of arteries which results in reduced blood flow to head, arms, stomach, and legs), which most commonly occur above the inner or outer ankle, or on the lower calf area of the leg; -Arterial Ulcer: caused by peripheral arterial disease, which commonly occur on the tips and tops of the toes, tops of the foot, or distal to the medial malleolus. 2. Review of the facility's wound care protocol, dated 2018, showed wound care decisions were complex. No protocol can take the place of the clinicians that are taking care of a resident. Treatment decision are always based on sound clinical judgement and not solely on a written protocol. Staff were directed as follows: -General wound and skin care guidelines included to wash hands before and after resident contact and establish a turning/positioning schedule. Usual schedules are at least every two hours while in bed and at least hourly in a chair. Use position products and draw sheets as indicated. Evaluate the need for a pressure reduction surface for bed and/or chair, as well as the need for heel/elbow protectors or specialized protection; -Stage I description: Non-blanchable erythema of intact skin; -Stage II description: partial thickness skin loss involving epidermis (surface layer of skin) and/or dermis (skin). The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe MASD; -Stage III description: full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia (thin sheath of fibrous tissue enclosing a muscle or other organs); -Stage IV description: full thickness skin loss with extensive destruction, tissue necrosis or damage to bone, or underlying structures such as tendons (tissue that attaches muscle to bone) or joint capsules; -It is essential that when neuropathic (pertaining to nerves) or vascular (pertaining to blood vessels) elements are present that wounds be properly evaluated, and the proper physician consultations be requested when necessary. When these wounds are not treated properly, healing will not occur, and extensive damage can be caused by incorrect treatment choices. 3. Review of Resident #22's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 03/03/21, showed staff assessed the resident as follows: -Totally dependent on staff for personal hygiene; -Has functional limitation in range of motion (ROM) (full movement potential of a joint) to his/her upper extremitity on one side; -At risk for pressure ulcers. Review of the resident's Physician's Order Sheets (POSs), dated 3/22/21 through 4/22/21, showed an order dated 4/12/21; Apply triple antibiotic ointment (TAO) to palm of left hand, cover with gauze sponge, and place rolled wash cloth in hand. Further review showed an ordered dated 4/15/21; Place rolled up washcloth in palm of left hand Every Shift; Days, Evenings, Nights. Review of Initial & Weekly Wound Documentation of weekly skin assessment, dated 4/12/21, showed staff documented the following: wound found and documented as a Stage II Pressure Sore on the left palm with onset date of 4/12/21. Further review showed the wound was acquired in-house. Review of Treatment Administration Record (TAR), dated 4/1/21 through 4/30/21 showed an order for treatment, dated 4/13/21. Apply TAO to palm of left hand, cover with gauze sponge, and place rolled wash cloth in hand. Review of the resident's care plan dated, 04/2021, showed intervention dated 4/16/21 added to the resident care plan which directed staff to place a rolled washcloth in the resident's left hand. Review of Initial & Weekly Wound Documentation of weekly skin assessment, dated 4/21/21, showed staff documented the following: existing skin issue, pressure sore, Stage I on the left hand and palm. Observation on 4/21/21 at 11:42 A.M., showed what appeared to be a small dark area with a red discoloration in the middle of the resident's left palm. During an interview on 4/22/21 at 4:00 P.M., the Assistant Director of Nursing (ADON) said the pressure sore on the palm of the resident's left hand was caused by the index and ring finger being stuck to the palm of his/her hand. During an interview on 4/22/21 at 4:30 P.M., the Director of Nursing (DON) said the wound was found on the palm of the resident's hand on 4/12/21 by the ADON. The ADON staged the pressure ulcer as a Stage II. The DON said she reassessed the wound the following week, and it had started to heal so she staged it as a stage I. The DON said the wound happened fast, and healed quickly, however it could have been prevented if there had been interventions in place for the resident's contracted hand. 4. Review of Resident #5's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assist of two staff for bed mobility, transfers, dressing; -Was dependent on two staff for toileting and personal hygiene; -Diagnoses included diabetes (disease causing high blood sugar), malnutrition (lack of sufficient nutrients in the blood), peripheral vascular disease (blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), open wound on right leg, cellulitis (common and potentially serious bacterial skin infection), edema (swelling); -Had no unhealed pressure ulcers; -Had three venous and arterial ulcers; -MASD. Review of the resident's weekly wound documentation, dated 4/14/21 at 1:14 P.M., showed staff assessed the resident as follows: -Type of skin condition: pressure sore and MASD; -Location: right calf and left calf, shear (occurs when the body slides on a surface that moves the skin in one direction and the underlying bones in the opposite direction) to left buttocks; -Present on admission and acquired in-house; -Right calf top wound 2.5 centimeters (cm) length (L) x 1.5 cm width (W), 50 percent eschar and 50 percent pink; -Right calf bottom wound 0.6 cm L x 1.1 cm W, 75 percent slough and 25 percent pink; -Left calf top wound 3 cm L x 2 cm W, 50 percent eschar and 50 percent slough; -Left calf bottom wound 1.2 cm L x 1.5 cm W, 50 percent eschar and 50 percent slough; -Left buttocks shear 0.5 cm L x 0.5 cm W x 0 cm depth (D), 100 percent pinkish red serous drainage (thin, watery); -Right buttocks shear 0.5 cm L x 0.5 cm W x 0 cm D; 100 percent pinkish red serous drainage; -Stage of pressure ulcer: not applicable; -Best description of the most severe type of tissue present in any pressure ulcer bed: slough-yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous; -Exudate: copious (large amount), purulent (containing pus), red/bloody, purplish dark red blood; -Foul odor; -Peri-wound intact/healthy. The assessment did not identify which wounds were caused by pressure or stage the wounds caused by pressure. Observation on 4/20/21 at 2:20 P.M., showed kling dressings (stretchy, conforming wrap) on bilateral lower extremities. The resident had a Stage II pressure wound on each side of the upper gluteal cleft. The left was approximately 3 cm L x 1 cm W and had red drainage. The right was approximately 1.5 cm round in diameter. During an interview on 4/20/21 at 2:20 P.M., Certified Medication Technician (CMT) J said the wound on the left gluteal cleft was twice as big when it first started. He/she went on to say the left wound had been there about a month and the right wound a couple of weeks. Observation on 4/21/21 at 9:15 A.M., showed the resident had three wounds on his/her outer right calf. The proximal (closest to the body) wound was approximately 2.5 cm L x 1.5 cm W. The wound bed was covered with 75 percent yellow slough, 10 percent black eschar, and 15 percent red granulating tissue. The peri-wound was red and inflamed. Below that were two adjacent wounds, both approximately 1 cm in diameter with red wound beds and macerated (moist skin in the state of deterioration) edges. The left outer calf had two wounds. The top wound was approximately 2 cm round in diameter and 100 percent covered with black eschar. The bottom wound was approximately 2 cm x 3 cm. The wound bed was marbled with yellow slough and red, granulating tissue. The peri-wound for both was red and inflamed. The right heel wound was approximately 4 cm L x 3 cm W, depth superficial and the wound bed was red in color with moderate amount of serous drainage. During an interview on 4/21/21 at 9:15 A.M., the ADON said all wounds were a Stage II and caused by the resident not floating his/her heels and lying in bed too much. He/she went on to say the right heel wound was originally a blister but burst open. Furthermore, he/she said either the DON or him/herself measure and stage the wounds weekly and the resident's nurse practitioner comes in once a week and measures as well. During an interview on 4/22/21 at 10:25 A.M., the DON said the last time he/she saw the resident's buttocks it had a red, diaper rash and shearing on the left side, with the wound bed being 100 percent pink epithelial tissue. He/she went on to say shearing is caused from friction (the act of rubbing the surface of an object against that of another) and friction is not caused by pressure. He/she said he/she thought the wounds on the resident's right calf were diabetic ulcers, but did not have that diagnosis yet so he/she was staging them as Stage II pressure ulcers. He/she said the top left calf wound was a Stage II and the bottom left calf wound was a Stage III. Furthermore, he/she said a Stage II cannot have slough or eschar and if it did it would be unstageable. Observation on 4/22/21 at 12:35 P.M., showed the resident had two open Stage II pressure sores to the right of his/her upper gluteal cleft. The top sore measured 0.4 cm L x 0.5 cm W and the bottom sore measured 0.7 cm L x 0.3 cm W. Both were less than 0.1 cm in depth and the wound beds were red. The resident had one Stage II to the left of his/her upper gluteal cleft measuring 1.5 cm L x 0.8 cm W. Wound bed was red and bleeding. Depth was less than 0.1 cm. During an interview on 4/22/21 at 12:35 P.M., the DON said the wounds to the right and left of the residents gluteal cleft were pressure stage I or II from shearing and he/she was not aware the resident had two sores on his/her right side.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure care plans were reviewed and revised to include appropriate fall interventions for one resident (Resident #6), and reflect an accurate code status for one resident (Resident #33). Further, staff failed to implement interventions to prevent injuries for falls and prevent pressure ulcers for one resident (Resident #5). The facility census was 38. 1. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2019, showed the facility is directed as follows: -The care plan must be reviewed after each assessment, as required by CFR 483.20, and revised based on changing goals, preferences and needs of the resident, and in response to current interventions; -The interdisciplinary team (IDT) must evaluate the information gained through the MDS assessment to develop a care plan that addresses those findings in the context of the resident's goals, preferences, strengths, problems, and needs; -Residents' preferences and goals may changes throughout their stay, so facilities should have ongoing discussions with the resident and resident representative so that changes can be reflected in the care plan; -As required at 42 CFR 483.21(b), the care plan is an interdisciplinary communication tool and it must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; -The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care; -The care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving; -The care plan is drive not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs; -A care plan is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice; -Provides information regarding how the causes and risk associated with issues and/or conditions can be addressed to provide for a resident's highest practicable level of well-being; -Individualized interventions that honor the resident's preferences; -Managing risk factors to the extent possible or indicating the limits of such interventions. 2. Review of Resident #6's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/3/21, showed staff assessed the resident as: -Had short term and long term memory problems; -Severely impaired decision making ability; -Total dependence on two or more staff for bed mobility, transfers, dressing, toilet use, and bathing; -Has active diagnoses of diabetes (condition resulting in too much sugar in the blood), anxiety (intense, excessive, and persistent worry and fear about everyday situations), manic depression (mood disorder defined by manic or hypomanic episodes (changes from one's normal mood accompanied by high energy states), and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly). Review of the resident's care plan, dated 11/26/20, showed staff were directed as follows: -Keep the call light and frequently used items within reach; -Encourage the resident to use the call light often; -Provide activities to divert attention; -Utilize relaxation techniques such as deep breathing; -Use a wheelchair for mobility and encourage the resident to self-propel. During an interview on 4/19/21 at 10:10 A.M., the resident said he/she did not know where his/her call light was and needed help. Observation on 4/19/21 at 2:40 P.M., showed the resident yelling out for someone to help clean him/her up. Additional observation showed the call light was under the resident's blanket. During an interview on 4/19/21 at 2:44 P.M., Registered Nurse (RN) A said the resident does not understand how to use the call light to call for help. During an interview on 4/29/21 at 3:17 P.M., Certified Nurse Aide (CNA) G said the resident doesn't always know how to use his/her call light. The resident gets confused easily and his/her mental status changes from day to day. The resident is unable to self-propel in his/her wheelchair. Additionally, he/she said the resident has difficulty participating in relaxation exercises such as deep breathing. The resident has difficulty participating in activities because he/she does not have full use of his/her hands. During an interview on 4/29/21 at 3:25 P.M., Licensed Practical Nurse (LPN) H said the resident has difficulty using his/her hands and he/she has trouble gripping items, such as call lights. 3. Review of Resident #33's admission MDS, dated [DATE], showed staff assessed the resident as cognitively intact. Review of the resident's care plan, dated 2/16/21, showed the resident had chosen Do Not Resuscitate (DNR) code status (order to instruct health care providers not to perform cardiopulmonary resuscitation if a patient's breathing stops or if a patient's heart stops beating). Further review of the resident's care plan showed the resident had also chosen a Full Code status (order to assist the patient with all measures to keep them alive). Review of the resident's physician order sheet (POS), dated April 2021, showed an order for full code status. During an interview on 4/22/21 at 3:34 P.M., CMT F said the resident's code status can be found on the resident chart and in the care plan. The MDS Coordinator is responsible for updating the care plan and code status. During an interview 4/22/21 at 3:51 P.M., LPN B said the resident's code status can be found on his/her face sheet and it should be included in the resident's care plan. Social Services is responsible for updating the code status and the MDS Coordinator is responsible for updating the care plan. If the resident's code status changed while they were at the facility, the care plan would show both. During an interview on 4/22/21 at 4:03 P.M., the Director of Nursing (DON) said the Administrator and Social Services Director (SSD) complete the paperwork for a resident's DNR code status once they arrive to the facility. The DON said the code status is included in the resident's care plan, especially if they have chosen to be a DNR. Additionally, the DON said the SSD is responsible for updating the code status and ensuring the documents are signed by the resident's representative and physician. The DON said he/she and the Assistant Director of Nursing (ADON) are responsible for updating the resident's care plan to reflect their current code status. He/She said Resident #33's code status reflected both full code and DNR because the resident keeps changing his/her mind. Additionally, the DON said the resident is a full code. 4. Review of Resident #5's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Requires extensive assist of two staff for bed mobility, transfers, and dressing; -Was dependent on two staff for toileting and personal hygiene; -Had diagnoses of diabetes, malnutrition (lack of sufficient nutrients in the blood), peripheral vascular disease (blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), and edema (swelling). Review of the resident's fall care plan, dated 1/18/21, showed the resident was at risk for falls related to a history of falling and instructed the staff as follows: -Fall mat placed beside bed with bed in lowest position for safety, dated 1/18/21; -Bed in lowest position with fall mat in place, dated 2/22/21. Review of the resident's wound care plan, dated 3/4/21, showed the resident was prone to skin tears, abrasions, bruising, wounds and pressure ulcers (localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of intense and/or prolonged pressure or pressure in combination with shear) from falling, refusing to be repositioned, moving legs around in bed, and sliding them down on top of pillows, preventing them from staying afloat. The care plan instructed staff as follows: -Monitor and report localized signs of infection such as swelling, redness, pain, tenderness or heat at infected area, and purulent drainage; -Perform dressing changes as prescribed. Low air loss mattress, dated 3/4/21; -Apply soft boots, dated 4/20/21; -Nursing staff to monitor for heels being floated every shift, dated 4/20/21 Review of the resident's physician orders showed a telephone order, dated 4/20/21, instructing staff to apply soft boots (foam boots used to protect the heels and ankles from pressure) when the resident was in bed and nursing staff were to check for heels being floated each shift. Observation on 4/20/21 at 2:20 P.M., showed the resident up in his/her wheelchair in his/her room with soft boots on lower extremities bilaterally. CNA K attempted to raise the bed without success. The bed made a clicking noise but only went up slightly. CNA K and Certified Medication Technician (CMT) J assisted the resident to bed using a mechanical lift. Staff removed the resident's soft boots and the resident was positioned with pillows. CNA K attempted to lower the bed unsuccessfully. The bed was against the wall on the left side. Staff did not place a fall mat next to the bed on the right side before leaving the room. Observation on 4/21/21 showed: -At 8:25 A.M., the resident was in bed positioned on his/her back. The resident's heels were directly on the bed and his/her soft boots were in the wheelchair. Further observation showed the bed was not in low position and there was not a fall mat next to the bed; -At 9:15 A.M., the resident was in bed on his/her back. The resident did not have soft heel boots on and did not have a fall mat next to the bed. The bed made a clicking noise when the ADON attempted to adjust the bed; -At 2:45 P.M., the resident was in the lobby in his/her wheelchair. The resident had soft heel boots on bilateral. During an interview on 4/21/21 at 3:06 P.M., CNA L said the resident's feet are to be propped up with pillows, and the resident is supposed to wear heel boots when up, not when in bed. Observation on 4/22/21 showed: -At 9:30 A.M., showed the resident in bed without soft heel boots on. A thin pillow under his/her calves and his/her heels rested directly on the mattress. There was no fall mat next to the bed; -At 11:00 A.M., showed the resident in bed without soft heel boots on. A thin pillow under his/her calves and his/her heels rested directly on the mattress. There was no fall mat next to the bed; During an interview on 4/22/21 at 11:05 A.M., CNA G said the CNAs were responsible for putting the resident's soft boots on when he/she gets in and out of bed and the resident was to have them on when he was up in the wheelchair and in bed. He/she did not know why the resident was not wearing his/her soft boots and he/she should have them on. During an interview on 4/22/21 at 11:20 A.M., LPN H said the resident should have soft boots on all the time and the charge nurse was ultimately responsible to make sure the boots were on. He/she went on to say the resident's heels should be floated anytime he/she is in bed. The charge nurse communicates new interventions to the CNA through verbal report. Furthermore, he/she said the CNA's may take the boots off to float the heels. During an interview on 4/22/21 at 1:50 P.M., CNA G said staff were supposed to lower the resident's bed to the lowest position. The resident does not have a fall mat. Furthermore, he/she did not feel the resident's bed was as low as it could go. He/she attempted to lower the bed, but the bed made a clicking noise and did not move. During an interview on 4/22/21 at 2:00 P.M., LPN H said staff lay the resident down between meals to help prevent falls. He/she went on to say the resident did not have any fall precautions once in bed. During an interview on 4/22/21 at 2:10 P.M., the DON said he/she would expect staff to follow the care plan and the charge nurse lets the CNAs know to get a fall mat after the resident falls. Interventions are passed on in report. He/she went on to say the CNA's did not have a care guide. Furthermore, he/she said the resident should have his/her bed in lowest position and should have a mat next to his/her bed. 5. During an interview on 5/5/21 at 10:01 A.M., the Administrator said the facility does not have a care plan policy. The facility follows the RAI guidelines for care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to obtain a physician's order for hospice services for two residents (Resident #6 and Resident #33). Facility staff failed to perform neurological assessments (evaluation completed by staff for early detection of nervous system damage following head trauma) as directed for one resident (Resident #5). Additionally, the facility failed to document the reason as needed (PRN) medication was administered, including the effectiveness of the medication. The facility census was 38. 1. Review of the facility's policy Physician Orders, undated, showed staff are directed as follows: -For Treatment Orders: Specify what is to be done, location and frequency, and duration of the treatment; -For PRN Medication Orders: Specify the type, route, dosage, frequency, strength, and the reason for administration. 2. Review of Resident #6's Minimum Data Sets (MDS), a federally mandated assessment tool completed by facility staff, showed the facility completed a Significant Change MDS, on 2/3/21. Review of the resident's progress notes, dated 2/12/21, showed staff documented the resident admitted to hospice services. Review of the resident's care plan, dated 2/12/21, showed the resident receiving hospice services. Review of the resident's face sheet showed the resident's primary pay source as hospice. Review of the resident's physician's order sheets (POS's), dated February 2021 through April 2021, showed no order for hospice services. 3. Review of Resident #33's admission MDS, dated [DATE], showed staff assessed the resident as receiving hospice services. Review of the resident's progress notes, dated 6/11/20, showed the resident admitted to hospice services. Further review of the progress notes showed staff documented the resident continued to receive hospice services. Review of the resident's MDS assessments showed the following: -On 6/17/20, the resident received hospice services; -On 12/16/20, the resident received hospice services; -On 3/2/21, the resident received hospice services. Review of the resident's physician order sheets (POS's), dated June 2020 through December 2020, showed no order for the resident to receive hospice services. During an interview on 4/22/21 at 12:05 P.M., the Assistant Director of Nursing (ADON) said he/she is not sure if the facility had an order for hospice services. The resident was on hospice from 6/11/20 to 7/20/20. He/she completed the MDS assessments from October 2020 through March 2021. During an interview on 4/22/21 at 12:22 P.M., a hospice representative said the resident received hospice services from 7/22/20 until 8/21/20, when the resident signed a revocation. During an interview on 4/22/21 at 4:03 P.M., the Director of Nursing (DON) said he/she expects the staff to obtain a physician order for hospice to evaluate and treat a resident. He/she said Resident #33 no longer received hospice services at the time of his/her Significant Change MDS on 3/2/21. 4. Review of Resident #5's quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive assist of two staff for bed mobility, transfers, dressing; -Was dependent on two staff for toileting and personal hygiene; -Diagnoses included diabetes, malnutrition (lack of sufficient nutrients in the blood), peripheral vascular disease (blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), open wound on right leg, cellulitis (common and potentially serious bacterial skin infection), and edema (swelling). Review of the residents nurse's notes, dated 1/17/21 at 11:56 A.M., showed the resident found on floor beside his/her bed at 8:00 A.M., and no injuries were noted. The resident denied pain and neuros (neurological assessment) were initiated. The bed was placed by the wall and a fall mat placed beside the bed. The resident's spouse and doctor were notified. Vital signs (VS: blood pressure, pulse, respirations, temperature, and oxygen saturation) were within normal limits (WNL). Review of the resident's Neurological Checks 72 Hour Monitoring sheet showed the following instructions for staff: neurological checks required for 72 hours after an unwitnessed fall or head injury and are to be completed every 15 minutes four times in the first hour, every 30 minutes twice in the second hour, every hour twice in the next two hours, and every shift for the next 72 hours, ending 1/20/21. The staff documented they completed the following neuro checks: -1/17/21 at 8:00 A.M.; -1/17/21 at 8:15 A.M.; -1/17/21 at 8:30 A.M.; -1/17/21 at 8:45 A.M.; -1/17/21 at 9:15 A.M.; -1/17/21 at 9:45 A.M.; -1/17/21 at 10:45 A.M.; -1/17/21 at 11:45 A.M.; -1/17/21 at 6:08 P.M. The monitoring sheet did not include documentation of neurological checks for the resident on 1/18/21, 1/19/21 or on 1/20/21. Review of the resident's nurse's notes, dated 2/19/2021 at 11:23 P.M., showed staff documented the resident required maximum assist with transfer using a mechanical lift. The resident recently fell trying to crawl out of bed looking for his/her spouse, found on the floor, no injuries, range of motion all four extremities (limbs), denied pain, pupils equal, round, and reactive to light and accommodation (PERRLA), and face was symmetrical. The resident was assisted to bed and the bed was placed in lowest position. The resident's Post Fall 72-Hour Monitoring Report instructed staff to complete the assessment at the following intervals for follow up after all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks. Any change in resident condition requires a phone call to the primary care physician. The initial assessment followed by every 15 minutes times four, every 30 minutes times two, every hour times two, and once per shift for 72 hours. The staff completed neuro checks: -2/19/21 at 10:45 A.M.; -2/19/21 at 11:00 A.M.; -1/19/21 at 11:15 A.M.; -2/19/21 at 11:30 A.M.; -2/19/21 at 12:00 P.M. The monitoring sheet did not include documentation of neurological checks for the resident after 2/19/21 at 12:00 PM. During an interview on 4/22/21 at 3:14 P.M., Certified Nursing Assistant (CNA) F said if he/she found a resident on the floor, he/she would notify the charge nurse after making sure the resident is not in immediate danger. During an interview on 4/22/21 at 3:20 P.M., Licensed Practical Nurse (LPN) B said if he/she found a resident down, he/she would assess the resident and ask the resident if they knew what happened. He/she would get vital signs. He/she went on to say if the fall was unwitnessed, he/she would do neuro checks and check for visible injuries. He/she would call the physician and family. Furthermore, he/she said if there was no visible injuries, he/she would fax the doctor and monitor the resident for 72 hours. He/she added when completing neuro checks he/she had the resident squeeze his/her hands, checked the resident's pupils, and asked the resident questions. During an interview on 5/4/21 at 11:20 A.M., the ADON said staff were expected for follow the guidelines on the neuro check forms. During an interview on 5/4/21 at 11:38 A.M., the Administrator said the facility did not have a policy for neuro checks and staff are expected to follow the instruction on the neuro sheets. 5. Review of the Resident #5's POSs, dated 4/1/21 - 4/30/21, showed the following: -Diagnoses including- giant cell arteritis (inflammation of arteries in the head), diabetes (disorder causing high blood sugar levels), depression (having persistent feelings of sadness and loss), open wound right lower leg, cellulitis (common and potentially serious bacterial skin infection) of limb, stage II pressure ulcer (partial thickness loss of skin presenting as a shallow open ulcer) of sacral region (lower back), edema (swelling), heart failure, stage II pressure ulcer of buttock; -Hydrocodone/Acetaminophen 5/325 mg tablet, one tablet by mouth every six hours as needed (PRN) for pain; -Tramadol 50 mg, one tablet every six hour PRN for pain. Review of the resident's PRN flow sheet and medication flow sheet, dated 3/1/21 - 3/31/21, showed: -On 3/2/21 at 8:25 P.M., Hydrocodone/Acetaminophen (Norco: a narcotic pain medication) 5/325 milligram (mg) one tablet was given for complaint of right side facial pain. Documentation did not include effectiveness; -On 3/4/21, Tramadol (narcotic pain medication) 50 mg initialed as given. Documentation did not include, time, reason for use, or effectiveness; -On 3/5/21, Norco 5/325 mg is initialed as given. Documentation did not include the time, reason for use, or effectiveness; -On 3/6/21, Norco 5/325 mg is initialed as given. Documentation did not include the time, reason for use, or effectiveness; -On 3/10/21, Tramadol 50 mg is initialed as given. Documentation did not include the time, reason for use, or effectiveness; - On 3/10/21, Tramadol 50 mg is initialed as given. Documentation did not include the time, reason for use, or effectiveness; -On 3/13/21 at 4:10 P.M., Norco 5/325 mg one tablet was given for complaint of abdominal pain. Documentation did not include effectiveness; -On 3/13/21 at 5:20 P.M., Tramadol 50 mg one tablet was given for complaint of stomach pain. Documentation did not include effectiveness; -On 3/13/21, a second dose of Tramadol 50 mg is initialed as given. Documentation did not include the time, reason for use, or effectiveness; -On 3/15/21, Tramadol 50 mg one tablet was given for complaints of leg pain. Time of administration unclear due to a six and seven being written on top of each other and P.M., written next to this. Documentation did not include effectiveness; -On 3/16/21, documentation on the front of the flow sheet did not indicate Tramadol 50 mg had been administered. Documentation on the back of the flow sheet showed Tramadol 50 mg was administered at 2:00 A.M. The resident was assessed as having zero pain that shift; -On 3/17/21 at 2:00 P.M., Tramadol 50 mg was given for complaints of body pain. Documentation did not include how many tablets were given. The resident was assessed as having zero pain that shift; -On 3/21/21 at 10:30 P.M., Norco 5/325 mg one tablet was given for complaints of leg pain. Documentation did not include effectiveness; -On 3/28/21, Norco 5/325 mg is initialed as given. Documentation did not include the time, reason for use, or effectiveness. The resident was assessed as having zero pain that day; -On 3/28/21, Tramadol 50 mg is initialed as given twice. Documentation did not include the time, reason for use, or effectiveness. The resident was assessed as having zero pain that day; -On 3/31/21 at 12:00 P.M., Tramadol 50 mg one tablet was given for complaints of leg pain. Documentation did not include effectiveness. The resident was assessed as having zero pain that day. Review of the resident's PRN flow sheet and medication flow sheet, dated 4/1/21 - 4/30/21, showed: -On 4/2/21 at 4:10 P.M., Norco 5/325 mg one tablet was given for back pain. Documentation did not include effectiveness; -On 4/4/21 at 10:30 P.M., Norco 5/325 mg one tablet was given for leg pain. Documentation did not include effectiveness. The resident was assessed as having zero pain that day; -On 4/6/21 at 8:30 P.M., Norco 5/325 mg one tablet was given for ankle pain. Documentation did not include effectiveness. The resident was assessed as having zero pain that day; - On 4/7/21 at 7:30 P.M., Norco 5/325 mg one tablet was given for leg/ankle/foot pain. Documentation did not include effectiveness. The resident was assessed as having zero pain that day; -On 4/9/21, Norco 5/325 mg was initialed as given. Documentation did not include the time, reason for use, or effectiveness. The resident was assessed as having zero pain that day; -On 4/10/21 at 4:00 P.M., Norco 5/325 mg one tablet was given back pain and was effective. The resident was assessed as having zero pain that day; -On 4/12/21 at 3:00 P.M., Norco 5/325 mg one tablet was given for back and hip pain. Documentation did not include effectiveness. The resident was assessed as having zero pain that day; -On 4/13/21 at 1:00 P.M., Norco 5/325 mg one tablet was given for back and hip pain. Documentation did not include effectiveness. During an interview on 4/22/21 at 4:00 P.M., LPN B said PRN medications should be documented on the PRN flow sheet and the reason for use and effectiveness should be written on the back. He/she said he/she tries to check back in 30 minutes. During an interview on 5/4/21 at 11:20 A.M., the ADON said he/she would expect staff to document PRN administration date and time and follow-up on effectiveness within one to two hours. During an interview on 5/4/21 at 11:38 A.M., the Administrator said PRN medications are given as needed or requested with follow up of effectiveness and the facility did not have a policy regarding PRN medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services for two residents (Resident #31 and Resident #33) with catheters (tube placed directly into the bladder to drain urine) by failing to follow physician orders in regards to changing the catheters and providing catheter care. The facility census was 38. 1. Review of the facility's Insertion and Removal of Indwelling Catheter policy, dated March 2015, showed staff were directed to obtain a sterile (free from bacteria or other microorganisms) catheter in the size ordered by the physician. Review of the facility's Catheter Care (Indwelling) policy, dated March 2015, showed it did not contain direction for staff in regards to how often catheter care should be performed, or who was responsible for its completion. 2. Review of Resident #31's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/12/21, showed staff assessed the resident as: -Had an indwelling catheter; -Had active diagnoses of neurogenic bladder (condition in which someone lacks bladder control due to a brain, spinal cord, or nerve problem), diabetes mellitus (condition resulting in too much sugar in the blood), and paraplegia (paralysis of the legs and lower body). Review of the resident's Physician Order Sheet's (POSs), dated December 2020, showed the physician ordered the resident's catheter to be changed every two weeks. Additional review showed staff were directed to perform catheter care three times a day. Review of the resident's Treatment Administration Record (TAR), dated December 2020, showed staff did not document they performed catheter care, as ordered. Further review showed staff did not document why they did not complete the catheter care. Review of the resident's progress notes, dated December 2020, showed staff did not document why they did not complete catheter care. Review of the resident's TAR, dated February 2021, showed staff did not document they changed the resident's catheter. Additional review of the TAR showed staff did not document they performed catheter care, as ordered. Observation on 4/19/21 at 2:32 P.M., showed a catheter bag (bag at the end of catheter tubing to collect urine) hung on the side of the resident's bed frame. 3. Review of Resident #33's admission MDS, dated [DATE], showed staff assessed the resident as: -Totally dependent on two or more staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Had an indwelling catheter; -Had active diagnoses of neurogenic bladder, urinary tract infection (infection in any part of the urinary system including the kidneys, bladder, or urethra), and quadriplegia (paralysis from the neck down); -Received an antibiotic (medication used to treat bacterial infections). Review of the resident's POSs, dated August 2020 to November 2020 showed a physician order for staff to change the resident's catheter between the 8th and 10th of each month. Further review showed staff were ordered to change the resident's catheter on the 8th of each month, beginning December 2020. Review of the resident's TAR, dated August 2020, showed staff did not document they changed the resident's catheter as ordered. Further review showed staff did not document why they did not change the resident's catheter. Review of the resident's TARs, dated September 2020, showed staff did not document they changed the resident's catheter as ordered. Further review showed staff did not document why they did not change the catheter. Review of the resident's TAR, dated October 2020, showed staff did not document they changed the resident's catheter as ordered. Further review showed staff did not document why they did not change the catheter. Review of the resident's progress notes, dated 10/8/20, showed staff documented the resident received antibiotics for a urinary tract infection (UTI). Further review of the progress notes showed the resident received antibiotics 10/31/20, again for a urinary tract infection (UTI). Review of the resident's TARs, dated November 2020 to January 2021, showed staff did not document they changed the resident's catheter as ordered. Further review showed staff did not document why they did not change the catheter. Review of the resident's progress notes, dated 3/2/21, showed staff documented the resident received antibiotics for a UTI. Review of the resident's progress notes, dated 4/19/21, showed staff documented the resident returned to the facility after being hospitalized for a UTI and had been prescribed antibiotics. Review of the resident's POS, dated April 2021, showed an order dated 4/19/21, for cefpodoxime 200 milligrams (mg) every 12 hours (medication used to treat urinary tract infections). Observation on 4/22/21 at 2:19 P.M., showed the resident had a catheter bag attached to his/her bed frame. 4. During an interview on 4/22/21 at 3:51 P.M., Licensed Practical Nurse (LPN) B, said licensed staff are responsible for changing resident's catheters. He/she said when a catheter is changed, staff document the change on the resident's TAR. The LPN said when the catheter is unable to be changed, staff circle the date on the TAR and indicate the resident's refusal. Additionally, he/she said he/she would try again on a later date, but would document the refusal in a progress note. Furthermore, he/she said if the resident was hospitalized at the time of the scheduled catheter change, he/she would make a note in the resident's TAR regarding why he/she did not perform the catheter change during the scheduled time. LPN B said he/she did not know why Resident #31's catheter was not changed according to physician orders. He/She went on to say he/she did not know why Resident #33's catheter was not changed according to physician orders. During an interview on 4/22/21 at 4:03 P.M., the Director of Nursing (DON) said licensed staff are able to perform catheter changes. He/she said the catheter changes are charted in the resident's TAR. The DON said he/she does not know why Resident #31's catheter was not changed according to the physician orders. Additionally, he/she said he/she doesn't know why Resident #33's catheter wasn't change according to physician order. During an interview on 4/29/21 at 3:17 P.M., Certified Nurse Aide (CNA) G said catheter care should be completed every time staff perform peri care or empty the catheter bag. He/she said he/she is not aware of any physician orders to complete catheter care. Additionally, CNA G said there is no place to document when catheter care is completed. CNA G said if the catheter care wasn't completed, he/she would notify the charge nurse and the incoming shift. During an interview on 4/29/21 at 3:25 P.M., LPN H said catheter care is completed once per shift and according to physician orders. He/she said the TAR includes information for how often the care should be completed. LPN H said if catheter care is not completed during a shift, he/she passes that information on to the next shift nurse. Additionally, he/she said he/she circles the date and time the care did not occur in the TAR and makes a note about why the care was not completed. During an interview on 4/29/21 at 3:36 P.M., the DON said he/she expects catheter care to be completed every shift and as needed. The DON said if catheter care is not completed, he/she expects staff to document that in the TAR by circling the date and time and make a note about why the care was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to maintain a medication error rate of less than 5%. Out of 26 opportunities observed, 9 errors occurred, resulting in a 34.62% error rate. Facility staff failed to administer medications within the ordered timeframes for two residents (Resident #29 and Resident #9). The facility census was 38. 1. Review of the facility's Medication, Administration Guidelines policy, dated March 2015, showed staff are directed to verify the medication with the physician orders. Review of the facility's Medication Times Document, dated 4/19/21, showed medication administration times are: -Morning medications are administered from 7:00 A.M. to 11:00 A.M.; -Noon medications are administered at 12:00 P.M.; -Evening medications are administered from 4:00 P.M. to 7:00 P.M.; -Bedtime medications are administered from 8:00 P.M. to 11:00 P.M. 2. Review of Resident #29's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/23/21, showed the resident had diagnoses of anxiety and depression. Further review of the MDS showed the resident received an antipsychotic (type of psychiatric medication to treat psychosis), anxiolytic (medication used to reduce anxiety), and antidepressant (medication used to relieve symptoms of depression) medication. Review of the resident's physician's order sheets (POSs), dated April 2021, showed the following orders: -Clonazepam (medication used to treat anxiety) 0.5 milligrams (mg) two times a day; in the morning between the hours of 7:00 A.M. and 11:00 A.M., and in the evening, between the hours of 4:00 P.M. and 7:00 P.M.; -Docusate Sodium (used to treat constipation) 100 mg two times a day; in the morning between the hours of 7:00 A.M. and 11:00 A.M., and in the evening, between the hours of 4:00 P.M. and 7:00 P.M.; -Risperidone (used to treat mood disorders) 0.25 mg two times a day; in the morning between the hours of 7:00 A.M. and 11:00 A.M., and in the evening, between the hours of 4:00 P.M. and 7:00 P.M. Observation on 4/21/21 at 3:37 P.M., showed Certified Medication Technician (CMT) C administered 0.5 mg of Clonazepam, 100 mg of Docusate Sodium, and 0.25 mg of Risperidone. Staff did not administer the medication to the resident in the ordered time frame. 3. Review of Resident #9's Quarterly MDS, dated [DATE], showed the resident had diagnoses of ulcerative colitis (chronic, inflammatory bowel disease that causes inflammation in the digestive tract), Crohn's disease (chronic inflammatory bowel disease that affects the lining of the digestive tract), or inflammatory bowel disease (ongoing inflammation of all or part of the digestive tract); diabetes (disease that results in too much sugar in the blood); hyperlipidemia (condition in which there are high levels of fat particles in the blood); anxiety (intense, excessive, and persistent worry and fear about everyday situations); and depression (group of conditions associated with the elevation or lowering of a person's mood). Further review of the MDS showed the resident received an antidepressant. Review of the resident's POSs, dated April 2021, showed the following orders: -Buspirone (medication used to treat anxiety) 5 mg two times a day; in the morning between the hours of 7:00 A.M. and 11:00 A.M., and in the evening, between the hours of 4:00 P.M. and 7:00 P.M.; -Glipizide (medication used to treat diabetes) 5 mg two times a day; in the morning between the hours of 7:00 A.M. and 11:00 A.M., and in the evening, between the hours of 4:00 P.M. and 7:00 P.M.; -Olanzapine (medication used to treat mood disorders) 2.5 mg two times a day; in the morning between the hours of 7:00 A.M. and 11:00 A.M., and in the evening, between the hours of 4:00 P.M. and 7:00 P.M.; -Pravastatin (medications used to treat hyperlipidemia) 20 mg once a day in the evening; between the hours of 4:00 P.M. and 7:00 P.M.; -Senna-S (medication used to treat constipation) 8.6-50 mg two times a day; in the morning between the hours of 7:00 A.M. and 11:00 A.M., and in the evening, between the hours of 4:00 P.M. and 7:00 P.M.; -Risperidone 0.5 mg two times a day; in the morning between the hours of 7:00 A.M. and 11:00 A.M., and in the evening, between the hours of 4:00 P.M. and 7:00 P.M. Observation on 4/21/21 at 3:45 P.M., showed CMT C administered 5 mg of Buspirone, 5 mg of Glipizide, 2.5 mg of Olanzapine, 20 mg of Pravastatin, 8.6-50 mg of Senna S, and 0.5 mg of Risperidone. Staff did not administer the medication to the resident in the ordered time frame. 4. During an interview on 4/22/21 at 3:01 P.M., CMT I said when medications are ordered to be given during the evening, staff are able to administer medications anywhere from 3:00 P.M. to 8 P.M. During an interview on 4/22/21 at 3:51 P.M., LPN B said when medications are ordered to be given during the evening, staff are able to administer medications anywhere from 3:00 P.M. to 7:00 P.M. He/she said the earliest staff are able to administer the evening medications is 3:00 P.M. During an interview on 4/22/21 at 4:15 P.M., the Director of Nursing (DON) said the administrator expects the staff to focus on resident needs when they first arrive for their scheduled shift. He/She said this means medications should not be administered during the first hour, from 3:00 P.M. to 4:00 P.M., of the evening shift. Furthermore, he/she said evening or P.M. medications should not be administered until 4:00 P.M.

Based on observation, interview and record review, facility staff failed to serve food items to two out of two residents (Resident #6 and Resident #18) with a pureed diet order in accordance with the nutritionally calculated menus. The census was 38. Review of the facility's Food Level 4/Pureed policy, undated, showed: - The diet requires no chewing ability; - Foods on this diet can be eaten with a spoon and cannot be sucked through a straw; - Foods are modified to a consistency that is smooth with no lumps and is not sticky; - Once pureed, foods will be one consistent texture, thin liquids must not separate from solids. 1. Review of the Resident #6's medical record, showed: - readmission date of 1/27/21; - Diagnosis of disturbances of salivary secretion, abnormal weight loss, functional dyspepsia (recurring signs and symptoms of indigestion that have no obvious cause), and dysphagia (difficulty or discomfort in swallowing); - A physician's order, dated 1/30/21, for pureed diet. Review of the Resident #18's medical record, showed: - readmission date of 12/21/20; - Diagnosis of pneumonitis due to inhalation of other solids and liquids and abnormal weight loss; - A physician's order, dated 4/20/21, for pureed diet. Review of the pureed chili recipe showed: - Ingredients: chili con carne, food thickener; - Prepare chili con carne according to the regular recipe; - Blend three, six ounce scoops of chili until desired consistency, adding ½ tablespoon (tbsp) food thickener, as needed; - Note: Amount of thickener required may vary relative to liquid content of cooked product. For best results, alternate adding thickener with processing, checking product consistency periodically. Observation on 4/20/21 at 12:42 P.M., showed [NAME] D prepared pureed chili con carne for lunch service. [NAME] D placed three #6 scoops (2/3 cup) of chili into the food processor and blended. Staff did not add any other ingredients to the mixture. Further observation showed the pureed chili did not have a smooth consistency when poured into a service container, and the liquids separated from the solids. Review of the pureed hot dog with bun recipe showed: - Ingredients: hotdog with bun, water or stock, food thickener; - Prepare hotdogs and buns according to the regular recipe; - Prepare slurry; - Process hot dogs and buns until smooth, adding two ounces (oz) slurry per portion; - Note: Amount of thickener required may vary relative to liquid content of cooked product. For best results, alternate adding thickener with processing, checking product consistency periodically. Review of the slurry recipe showed staff are directed to whisk together 1 tbsp of thickener with one cup of fluid. Observation on 4/20/21 at 12:50 P.M., showed [NAME] D prepared pureed hotdogs for lunch service. [NAME] D placed four hotdogs into the food processor and blended. Staff did not add any other ingredients to the mixture. Further observation showed the hotdogs did not have a smooth consistency when transferred into a service container. Review of the pureed sausage patty recipe showed: - Ingredients: sausage patty, food thickener, water or stock; - Prepare sausage patty according to the regular recipe; - Prepare slurry; - Process until desired consistency, add one oz. of slurry per portion of meat; - Note: Amount of thickener required may vary relative to liquid content of cooked product. For best results, alternate adding thickener with processing, checking product consistency periodically. Observation on 4/21/21 at 7:47 A.M., showed [NAME] D prepared pureed sausage for breakfast service. [NAME] D placed four sausage patties into the food processor and blended. Staff did not add any other ingredients to the mixture. Further observation showed the sausage did not have a smooth consistency when transferred to a service container. During an interview on 4/21/21 at 7:50 A.M., [NAME] D said he/she received training on preparing pureed foods. [NAME] D said pureed foods should look like a pudding. [NAME] D said the pureed sausage was not smooth or have a pudding consistency. [NAME] D said the pureed foods served for lunch on 4/20/21 were not smooth with a pudding consistency. [NAME] D said the chili was too thin, and he/she should have added thickener to it. [NAME] D said there are recipes for all foods that are served to the residents, and they should be followed. [NAME] D said he/she did not know why he/she did not follow the recipes. During an interview on 4/21/21 at 10:28 A.M., the dietary manager (DM) said each menu item has a recipe which has been reviewed by the registered dietician (RD) for nutritional value. The DM said cooks should follow the recipes. The DM said pureed food should be the consistency of pudding and should not be a liquid or runny consistency. The DM manager said if purees are runny the liquid should be cooked out and thickener added as needed. The DM said cooks have been trained on preparing pureed food. The DM said she is responsible for ensuring the cooks follow the recipes. During an interview on 4/21/21 at 11:00 A.M., the administrator said the food items on the facility menu have a recipe. The administrator said she would expect the cooks to follow the recipe for all diet orders. The administrator said cooks have been trained on preparing pureed foods, and the DM is responsible for monitoring to ensure recipes are followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide an ongoing program of activities for all residents in the facility. The facility census was 39. 1. Review of the facility's April activity calendar showed the following scheduled activities: -On 4/19/21 at 10:00 A.M., group exercises and outside walking; -On 4/20/21 at 10:00 A.M., BINGO, at 2:00 P.M. coloring; -On 4/21/21 at 8:00 A.M., morning news, at 10:00 A.M., snack, at 2:00 P.M., crosswords; -On 4/22/21, at 10:00 A.M., noodle ball, at 2:00 P.M., cookies; -On 4/23/21 at 10:00 A.M., group exercise, 2:00 P.M. BINGO. 2. Review of Resident #2's Annual Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, showed staff assessed the resident as: -Moderate Cognitive Impairment; -Does not reject care; -Somewhat important for him/her to have books to read; -Very important for him/her to listen to music he/she likes; -Very important for him/her to keep up with the news; -Somewhat important for him/her to go outside when the weather is nice; -Requires Supervision of one staff member for bed mobility, transfers, walking on the hallway or other areas of building, and dressing; -Has active diagnoses of Dementia (is not a single disease in itself, but a general term to describe symptoms of impairment in memory, communication, and thinking) and anxiety (a feeling of fear, dread, and uneasiness). Review of the resident's plan of care, dated 4/15/21, showed staff were directed to: -Provide in-room activities of choice; -Provide reassurance and feelings of inclusion due to a history of abandonment or isolation. Observation on 4/20/21 at 9:45 A.M., showed the resident laid in his/her bed. During an interview on 4/20/21 at 9:45 A.M., the resident said he/she would go to activities if he/she knew where and when they were. He/She said they do not come get him/her. During an interview on 4/22/21 at 9:26 A.M., the resident said he/she would like more activities, and said he/she would like to be able to leave the facility for some. 3. Review of Resident #6's Significant Change MDS, dated [DATE], showed staff assessed the resident as: -Prefers to do things with groups of people; -Prefers participating in his/her favorite activities; -Prefers spending time outdoors; -Prefers participating in religious activities or practices; -Total dependence of two or more staff for bed mobility, transfers, dressing, toilet use, and bathing; -Total dependence of one staff for eating and personal hygiene; -Uses a wheelchair for mobility; Review of the resident's care plan, dated 5/22/20, showed staff were directed to: -Provide in-room activities of choice; -Provide reassurance and feelings of inclusion due to a history of abandonment or isolation; -Provide activities to divert attention. Observations on 4/19/21 showed the following: -At 10:10 A.M., the resident laid in his/her bed and called out for help; -At 12:07 P.M., the resident sat in his/her wheelchair in his/her room and cried out. He/She said staff had forgotten about him/her; -At 12:53 P.M., the resident sat in his/her wheelchair at the end of the 100 hallway near the nurse's station; -A 1:36 P.M., the resident sat in his/her wheelchair at the end of the 100 hallway near the nurse's station; -At 2:06 P.M., the resident sat in his/her wheelchair at the end of the 100 hallway near the nurse's station; Observation on 4/20/21 at 10:56 A.M., showed the resident laid in his/her bed. Observation on 4/21/21 showed the following: -At 9:51 A.M., the resident laid in his/her bed with his/her eyes closed; -At 10:47 A.M., the resident laid in his/her bed with his/her eyes closed. During an interview on 4/29/21 at 3:25 P.M., Licensed Practical Nurse (LPN) H said the resident used to listen to music and watch movies, but the facility stopped hosting activities because of COVID, and they haven't started them back up. 4. Review of Resident #10's Annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Does not refuse care; -Felt it was very important to be around animals such as pets, keep up with the news, do things with groups of people, do favorite activities, go outside to get fresh air, and to participate in religious activities; -Independent with bed mobility, transfers, and ambulation. Observation on 4/19/21 at 10:25 A.M., showed the resident ambulated out of his/her room into the hallway using a rollator walker, went back to his/her room, and returned to bed. The April activity calendar on the resident's wall showed group exercises were scheduled for 10:00 A.M. that morning but the activity had not occurred. Observation on 4/19/21 at 2:20 P.M., showed the resident in bed. The activity calendar on the resident's wall showed no scheduled activities for the afternoon. During an interview on 4/19/21 at 2:20 P.M., the resident said there had been no activities since Covid and the activity director did not provide in-room activities. He/she went on to say there was no bingo or exercises. He/she said staff provided an activity calendar, but they did not do what was on the calendar. He/she had to do exercises on his/her own. Observation on 4/20/21 at 11:00 A.M., showed a large activity calendar on the wall in the hallway. The calendar was blank. Observation on 4/21/21 at 2:45 P.M., showed the resident ambulated up the hallway and sat on the seat of his/her walker across from the nurse's station. The resident said he/she was waiting for supper and supper was served at 5:00 P.M. The resident said he/she had nothing else to do. 5. Review of Resident #19's Annual MDS, a federally mandated assessment completed by facility staff, showed staff assessed the resident as: -Cognitively intact; -Does not refuse care; -Resident was not assessed for preferences for customary routine and activities; -Requires supervision/setup only for bed mobility, transfers, and eating and personal hygiene. Observation on 4/20/21 at 9:15 A.M., showed the resident laid in his/her bed. Observation on 4/21/21 at 10:42 A.M., showed the resident laid in his/her bed. Observation on 4/22/21 at 3:00 P.M., showed the resident laid in his/her bed. During an interview on 4/21/21 at 10:42 A.M., the resident said there are no activities, he/she was told they are not having any activities due to the virus. He/she is bored. 6. Review of Resident #26's annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Felt it was very important to have reading materials, listen to music, be around animals, do things with groups of people, do favorite activities, go outside and get fresh air, and participate in religious activities; -Independent with transfers, ambulation, and dressing. Review of the resident's care plan directed the staff as follows: -Provide in-room activities of choice, dated 5/22/20; -Avoid group situations, keeping a safe social distance apart. Encourage and support in-room activities that are important and vital to the resident. Include activities aided by technology, as possible, dated 5/22/20; -The resident controls the remote and TV programming in the day room, dated 12/9/19; -Divert resident's behavior by encouraging activities away from the TV, dated 12/9/19; -Because the resident did not want a roommate, the resident would sleep all day and stay up at night and have the radio or TV on loudly so the roommate could not sleep, dated 12/9/19; -The resident requested to eat in his/her room because he/she was approached about being rude and disrespectful to tablemates, dated 3/5/19. The care plan did not include the resident's interests and hobbies or direction for staff on how to assist the resident with activities of choice. Observation on 5/12/21 showed: -At 9:45 A.M., the resident was in the day room watching TV with his/her feet propped up on his/her walker along with multiple other residents; -At 12:25 P.M., the resident was eating in the dining room; -At 1:10 P.M., the resident was in his/her room with the radio on. During an interview on 5/12/21 at 1:13 P.M., the resident said he/she enjoyed noodle ball, BINGO, and crafts. Some residents went outside for a walk today, but he/she did not go because of respiratory issues. He/she did a lot of crafts in his/her room in a previous facility he/she lived in, but this facility did not provide in-room activities. He/she wished the staff would hurry and start activities back up. He/she had a couple of friends he/she talked to and would listen to music but got bored. He/she does talk to staff about his/her activities of interest, but did not know who was going to do them. 7. Review of Resident #8's annual MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Felt it was very important to have reading materials, listen to music, do things with groups of people, do favorite activities, and go outside for fresh air; -Independent with set-up assist for bed mobility, transfers, dressing; -Independent with ambulation; -Locomotion on and off the unit did not occur. Review of the resident's care plan, dated 1/18/21, directed the staff as follows: -Provide in-room activities of choice; -Encourage exercise such as dancing, provide music in activities and during free time in room, on unit and off of unit; -Discuss activities offered while visiting with the resident; -Encourage the resident to drink fluids and have a snack during activities; -Encourage the resident to socialize during group activities; -Give the resident an activity calendar and remind him/her of upcoming activities; -Provide in-room activities/reading material if the resident chooses to have them; -Avoid group situations, keeping a safe social distance apart. Encourage and support in-room activities that are important and vital to the resident. Include activities aided by technology, as possible. Observation on 5/12/21 at 10:45 A.M., showed the resident in his/her room with the door shut and the radio playing. During an interview on 5/12/21 at 10:46 A.M., the resident said he/she enjoyed playing ball, arts and crafts, board games, and playing cards. There had not been activities since the AD left. He/she went on to say the AD did activities in the front of the building or in the dining room before COVID and activities had not started back up yet. A month ago residents went in the dining room and played hand ball and did hand prints last fall. Residents can get crafts to do on their own and sometimes his/her family member gets them for him/her, but not the facility. It had been a while since they played BINGO. Staff had not talked to him/her about activities he/she liked. 8. Review of Resident #17's annual MDS, dated [DATE], showed staff assessed the resident as: -Moderate cognitive impairment; -Made him/herself understood; -Understood others with clear comprehension; -Resident interview for daily and activity preferences not conducted because resident was rarely/never understood; -Staff interviewed regarding the resident's daily and activity preferences showed the resident enjoyed doing things with groups of people and participating in favorite activities; -Independent with transfers, ambulation, dressing, personal hygiene; -Locomotion on and off the unit did not occur. Review of the resident's care plan, dated 1/18/21, directed the staff as follows: -Encourage the resident to exercise and attend activities involving exercise; -Avoid group situations, keeping a safe social distance apart. Encourage and support in-room activities that are important and vital to the resident. Include activities aided by technology, as possible; -The resident could independently choose which activities he/she wanted to participate in; -Encourage the resident to participate in leadership role and possible see about helping out in resident council; -Likes to color but prefers to color with bigger picture coloring books; -Durable Power of Attorney approves resident to have outings with family which is very important to him/her; -Discuss activities offered while visiting with the resident; -Encourage the resident to drink fluids and have a snack during activities; -Encourage the resident to socialize during group activities; -Give the resident an activity calendar and remind the resident of upcoming activities; -Provide in room activities/reading material if the resident chooses to have them. Observation on 5/12/21 at 10:30 A.M., showed the resident in his/her room with the door shut. During an interview on 5/12/21 at 10:30 A.M., the resident said he/she enjoyed walking in the halls. The thing he/she liked the most was to be outside, but had not even recently been able to do that because of COVID. He/she added staff go out with the smokers, but he/she did not want to be around the smoke. He/she would walk around property before and staff had not said anything about being able to do that again. He/she went on to say he/she went to ball toss this morning, but did not participate because of a previous broken finger. He/she would rather be walking outside, but right now has to walk up and down the hallways. Furthermore, he/she said staff were good about talking to residents about things they like, but because of COVID, residents could not go outside. 9. During a group interview on 4/20/21 at 10:14 A.M., the residents said they were unable to remember the last time they had resident council. They went on to say the facility offered no activities and it had been months since they had BINGO. The residents added the administration said they were going to bring activities back, but nothing had happened. The residents said they would like to have bingo, crafts, noodle ball, and walks and complained about being isolated in the building too much. During an interview on 4/21/21 at 3:06 P.M., Certified Nursing Assistant (CNA) CNA L said there were no activities today because the Activity Director (AD) was on vacation. He/she said for a while the AD would pop popcorn and take it to the residents, and sometimes they would watch movies. Furthermore, he/she said the residents had not used the dining room for activities since COVID. During an interview on 4/22/21 at 12:17 P.M. the administrator said staff were not assigned to complete activities in the AD's absence and activities were a group effort. The AD had been on vacation, but no longer worked at the facility. The residents watched T.V. and listened to music in the lobby or did crossword puzzles. He/she went on to say typically there should be more activities. He she added activities the last six months had been difficult. When the residents were able they would play BINGO in the dining room using printed BINGO cards. He/she did not know the last time the residents played BINGO and did not know why residents were not playing BINGO at this time. When asked for the last three months of activity calendars, the administrator was only able to provide a calendar for April. He/she said he/she would expect the AD to follow what was on the calendar. He/she said he/she did not know if the AD had been following the calendar. 10. Review of the facility's activity participation binder, on 5/12/21, showed the following activities: -On 4/23/21, music in lobby with nine residents in attendance, one resident visited with family, two residents participated in exercises, and three residents went out to smoke; -On 4/26/21, music in lobby with nine residents in attendance, nine residents participated in exercises, eight residents had cookies and juice, three residents went out to smoke, and twelve residents watched a movie and ate popcorn; -On 5/10/21, manicures with nine residents in attendance, three residents went out to smoke, music in lobby with twelve residents, and movie and popcorn attended by 16 residents. During an interview on 5/12/21 at 9:45 A.M., the Administrator said they did not have a May activity calendar. He/she said staff had an inservice on 5/10/21 to discuss communal activities, encourage staff involvement with activities, come up with ideas for activities, and to document any activities in the activity participation binder. He/she added he/she had an activity director in mind, but was unable to promote the staff member at this time due to a staffing shortage.