**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one sampled resident (Resident #1) was free of significant medication error when on 9/14/24 he/she did not receive an ordered dose of his/her seizure medication Lamotrigine Extended Release (ER) 24 hour 200 milligram (mg), 2 tablets by mouth at bedtime for seizures and on 9/16/24 and 9/17/24 he/she received incorrect doses of this medication out of four sampled residents. The facility census was 104 residents. The Administrator was notified on 9/25/24 of Past Non-Compliance which occurred on 9/14/24, 9/16/24 and 9/17/24. An all nursing staff in-service was completed on medication administration and medication administration observations were completed by 9/19/24. The deficiency was corrected 9/19/24. Review of the facility policy on medication administration revised 1/1/22 showed: -Facility staff should verify that the medication name and dose are correct when compared to the medication order on the medication administration record (MAR). -Facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in the facility's medication administration schedule. -Facility staff should confirm that the MAR reflected the most recent medication order. 1. Review of Resident #1's admission Record face sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Epilepsy (a nervous system disorder that can cause unprovoked, recurrent seizures which are sudden, uncontrolled electrical disturbances in the brain). -History of falling. Review of the resident's undated Care Plan showed he/she had a seizure disorder and interventions included giving medications as ordered. Review of the resident's hospital Discharge Summary for Facility Orders dated 9/14/24 showed: -The resident's discharge date from the hospital was 9/14/24. -He/She had a history of seizure disorder and was followed by neurology. -He/She was to continue his/her medications. -His/Her discharge order showed a physican order for Lamotrigine Extended Release (ER) 24 Hour 200 mg by mouth, 400 mg were to be given at bedtime for seizures. Review of the resident's physician's Order Summary Report showed he/she had an order for Lamotrigine Extended Release (ER) 24 Hour 200 mg. Two tablets by mouth were to be given at bedtime for seizures. The order was dated 9/14/24 with a start date of 9/15/24 and an end date of 9/20/24. Review of the resident's MAR for 9/24 showed: -He/She did not receive the Lamotrigine on 9/14/24. -He/She had an order for Lamotrigine Extended Release (ER) 24 Hour 200 mg. Two tablets by mouth were to be given at bedtime for seizures. The order was dated 9/14/24 with a start date of 9/15/24 and an end date of 9/20/24. -There was no note as to why the medication was not administered. Review of the facility investigation on 9/14/24 with hospital discharge order, timeline showed: -The resident was admitted to the facility from the hospital on 9/14/24. -He/She had an order for Lamotrigine 200 mg, 2 tablets at bedtime. -On 9/14/24 the dose of Lamotrigine was not administered related to new admission and the medication did not arrive from the pharmacy. -On 9/16/24 the resident was transferred to the hospital for seizure-like activity. -Observation of the Lamotrigine medication card revealed the pharmacy delivered 100 mg tablets, 4 tablets to be given at bedtime until the 200 mg tablets were available. Staff did not give 4 tablets at bedtime. Observation of the resident's medication card for Lamotrigine Extended Release (ER) 24 Hour 100 mg. tablets, showed 4 tablets to be taken by mouth at bedtime for 3 days until the 200 mg strength was available and 5 pills were taken from the card. Observation of the resident's medication card for Lamotrigine Extended Release (ER) 24 Hour 200 mg. tablets, 2 tablets to be taken by mouth at bedtime, showed: -An incorrect deliver date of 9/14/24 was printed on the card. -One pill had been taken from the card. During an interview on 9/25/24 at 12:40 P.M., the resident said: -He/She had not had a seizure in 15 years. -He/She had pneumonia and believed stress threw him/her into a seizure. -The staff may have messed up his/her medications. -He/She was back to normal now. During an interview on 9/25/224 at 1:25 P.M., Licensed Practical Nurse (LPN) E said: -He/She would help the nurses by putting orders in the computer. -The hospital would send orders to the facility computer and they would download them. -The orders the hospital sent might not be the orders that the resident arrived with. -When the resident arrived, the nurses would make sure the orders they came with matched the orders on the computer. -They would do chart checks in the mornings to make sure the orders were correct in the computer, and that care plans and assessments were done. -This was how they caught the resident's medication error. -If a medication was not available or pharmacy didn't send it, they could get a medication from the Omnicell. -If the dose in the Omnicell (an automated medication dispensing cabinet) was not correct either they give the correct dose or call the physician. -If a medication was not available, they should let the physician know. -All of the nursing staff were aware of the Omnicell. During an interview on 9/25/24 at 1:40 P.M., LPN F said; -The managers would try to put the orders in the computer before a resident arrived. -The admitting nurse should double check the orders. -If there were discrepancies, they call the physician to clarify any questions. -All of the orders were supposed to be verified by the physicians. -The next morning, the managers would collect the charts and take them to the morning clinical meeting (or Monday if a resident were admitted on a weekend) and would go through and audit the orders. -If the pharmacy did not send the medication, it could be pulled from the Omnicell. -If the medication was not in the Omnicell, the should notify the physician and get an alternative. -He/She had been trained about this prior to the incident. During an interview on 9/25/224 at 2:25 P.M., LPN B said: -He/She only worked with the resident one time; this was the first time he/she worked with him/her. He/She did not admit him/her. -He/She would check the MAR and orders before giving medications. -He/She would check the MAR and the medication cards together. -The resident had two medication cards with different doses of the medication. -He/She pulled the card that matched the MAR. -He/She gave the lower dose of the medication. -He/She did not notify anyone about the other card. During an interview on 9/25/24 at 2:15 P.M., the Director of Nursing (DON) said: -The resident arrived at the facility on 9/14/24 from the hospital. This was a Saturday. -When he/she arrived, the pharmacy did not sent his/her seizure medication, however, it was available in the Omnicell. -The resident did not get the medication on the date of his/her admission. -Two doses were given incorrectly. -There was no policy or process to determine how many tablets were removed from each medication card by each staff person. -The charge nurse was responsible to enter orders in the computer and sent paper prescriptions to the pharmacy. -LPN A was in charge when the resident was admitted . He/She had been educated on the admission orders procedure before. He/She did not give an explanation for why he/she did not give the medication. -The breakdown occurred when the medication was not pulled from the Omnicell since it was available. -The pharmacy sent incorrect cards because the correct dose was not available, and then sent the correct dose. -He/She felt LPN C gave the dose correctly and LPN B and LPN D gave the lower dose, which was not enough. -When he/she interviewed the LPNs, LPN C was able to verbalize everything that was in the orders and was very clear about giving the 400 mg and that he/she double checked the orders without being prompted. LPN B and LPN D were not able to relay the orders and they had not taken anything out of the Omnicell. -The resident had a history of seizures, but when he/she was sent out to the hospital, it was not like a typical seizure; they were tremors. -The hospital kept the resident for pneumonia. -When the resident went back to the hospital, the facility did a root cause analysis and found the medication errors. -The expectation was when a resident was admitted , the nurse would enter all orders in the computer and fax any prescriptions to the pharmacy as soon as possible, so that medication could be received in a timely manner. -He/She would expect the physician would be called if order clarification was needed or if a medication was needed that the resident was not admitted with. -For any medications that were not available prior to pharmacy delivery, they could be pulled from the Omnicell. -Medications should be administered according to policy using the five rights. -Pharmacy did not notify him/her that the medication had been filled with a different dose. -If a wrong dosage or medication were sent, he/she would expect the pharmacy to be contacted to notify them and have the correct medication or dosage sent. -The admitting nurse did not call the physician for clarification of whether the dose ordered from the hospital should be given or notified that the pharmacy had sent an alternative dosage. -He/She would expect that the medication cards would be checked against the orders. During an interview on 9/25/24 at 2:45 P.M., the Administrator said: -The nurses were expected to follow policy and double check a resident's orders to make sure they were in the system and to make sure they matched the medication that came from the pharmacy. -The nurses were expected to make sure that a prescription was filled quickly and if there was a delay to reach out to the DON and the physician. During an interview on 10/3/24 at 11:45 A.M., LPN C said: -He/She gave the resident all four 100 mg tablets of Lamotrigine. -He/She checked the order before he/she gave them, because he/she felt like it was a large dose. -The medication came from pharmacy between 9:00 P.M. and 9:30 P.M. -When he/she gave the medication, the 200 mgs tablets were not yet available. -When a nurse would admit a resident to the facility, the orders should be double checked to make sure they were the most recent orders. -If the pharmacy did not send a medication, the Omnicell should be checked to see if they could be taken from it. -If the medication was not available, the nurse should notify the physician to see if an alternative could be ordered and the pharmacy to see when the medication could be sent. -The nursing staff were trained to know to do these things. During an interview on 10/6/24 at 12:00 P.M., LPN D said: -He/She thought when he/she cared for the resident, they had received the 200 mg tablets. -He/She would have administered two 200 mg tablets. -He/She would pull up the physician's orders and check the medication cards against them before administering the medication. -If he/she did not have the correct dose available, he/she would notify the DON, notify the pharmacy and notify the physician. MO00242293

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure two sampled residents (Resident #508) were free from abuse when on 6/2/24 Resident #507 hit Resident #508 which resulted in Resident #508 having an injury to his/her bottom lip and a bruise over the left eye out of 19 sampled residents. The facility census was 115 residents. The Administrator was notified on 6/7/24 of the past noncompliance which began on 6/2/24. The facility completed education on resident abuse and interventions for all staff and residents. The deficiency was corrected on 6/4/24. Review of the facility's Abuse and Neglect policy, undated, showed: -Each resident had the right to be free from abuse, neglect, misappropriation resident property, and exploitation. -This included, but was not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint. -Resident's must not be subjected to abuse by anyone including other residents. 1. Review of Resident #508's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/21/24, showed the resident was severely cognitively impaired. Review of the Resident #508's face sheet, undated, showed the resident diagnoses included: -Dementia (loss of memory, language, problem-solving and other thinking abilities), cognitive communication deficit (difficulty expressing thoughts and ideas), and generalized muscle weakness. Review of Resident #508's care plan, dated 12/23/23, showed: -The resident had impaired cognitive ability and though processes related to dementia. Review of Resident #508's Preadmission Screening and Resident Review (PASRR, DA-124C - a required form to be submitted for any resident who requested admission to a Medicaid certified bed regardless of the resident payment source; this included dually certified beds both Medicare and Medicaid) dated 2/23/24, showed: -The resident was diagnosed with anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress). -The resident exhibited moderate abnormal thought processes. -The resident required a secure unit for safe wandering. Review of Resident #507's quarterly MDS dated [DATE], showed: -The resident was severely cognitively impaired. -The resident was severely cognitively impaired without behaviors. Review of Resident #507's face sheet, undated, showed the resident was diagnosed with: -Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), -Cognitive communication deficit. -Generalized muscle weakness. Review of Resident #507's care plan dated 5/8/24, showed: -The resident had the potential to be physically aggressive related to dementia (loss of memory, language, problem-solving and other thinking abilities). -Interventions included: --Providing coloring sheets. --Placed on 1:1 observation. --Monitor and report any signs or symptoms of posing danger to self or others. --Take outside when possible. --Turn on music when resident was anxious. --Lab draws to rule out infection. -The resident had impaired cognitive ability/thought processes related to dementia. -Interventions included: --Administer medications as ordered. --Ask yes/no questions. --Cue, reorient and supervised as needed. Review of Resident #508's Physical Aggression Received form, dated 6/2/24, showed: -The resident was in his/her wheelchair in the dining area. -Resident #507 tried to sit on the resident. -The resident put his/her hands up to stop Resident #507 from sitting on him/her. -Resident #507 turned around and hit the resident causing a scratching on the lip which was treated with a cold wet cloth. -As a result, the resident slid out of his/her wheelchair. -The resident was transported to the emergency room for evaluation. Review of Resident #507's Physical Aggression Initiated form, dated 6/2/24, showed: -The resident was trying to sit on Resident #508. -Resident #508 told him/her no. -The resident turned around and hit Resident #508 in the face and mouth. -The resident hit Resident #508 again which caused him/her to slide out of wheelchair. -The resident was unable to give a description of why or what happened. -There were no predisposing environmental factors. -The predisposing physiological factors included confusion and impaired memory. Review of the facility's incident investigation, dated 6/2/24, showed: -On 6/2/24 at approximately 1:30 P.M. the Director of Nursing (DON) was notified of an altercation between Resident #507 and #508. -Certified Nursing Assistant (CNA) A was interviewed and reported he/she was assisting another resident and upon coming down the hall he/she saw Resident #507 attempting to sit on Resident #508's lap with Resident #508 saying 'No' and Resident #507 striking Resident #508. CNA A was unable to get to the residents quick enough to stop the incident but did remove Resident #507 from the area. -CNA C was interviewed and reported he/she was at the nurses station speaking to Certified Medication Technician (CMT) A regarding residents' medications. CNA C looked up and saw Resident #507 strike Resident #508 and saw Resident #508's wheelchair roll back, and the resident slid to the floor. He/she immediately went to intervene. -CMT A was at the nurses station documenting when he/she saw Resident #507 trying to sit on Resident #508's lap. Resident #508 said 'No' and began to stand up and Resident #507 struck Resident #508 in the face. CMT A said it happened very quickly and he/she was unable to get to the residents in time to stop the situation. -Immediate action taken: --Resident's separated. --Resident #507 was placed on 1:1 observation until sent to emergency room (ER) for evaluation. -Resident #508 was transported to the ER for evaluation of injuries. -Root cause analysis: --Resident #507 had a history and was care planned for mood problems related to heightened startled response. --Due to Resident #507 being startled when Resident #508 said 'No', Resident #507 reacted by striking Resident #508. -It was determined that Resident #507 was not attempting to hurt Resident #508 and responded only due to being startled. During an interview on 6/6/24 at 10:10 A.M., Certified Nurses Assistant (CNA) A said: -He/She was helping another resident and, on the way back down the hall he/she was coming around the nurse station and saw Resident #507 try to sit on Resident #508. -Resident #508 was sitting at the lunch table. -Resident #507 was in the dining room also. -Resident #507 approached Resident #508 and tried to sit on his/her lap, Resident #508 put his/her hands up and said No, then Resident #507 turned around and closed fist hit Resident #508. -He/She saw Resident #507 hit Resident #508 one time. -He/She dropped everything and ran over there. -He/She redirected Resident #507 and CNA C helped Resident #508. -He/She took Resident #507 to their room and asked him/her what happened and why he/she hit Resident #508 and he/she said he/she didn't know why. -Resident #508 was confused and asked what he/she did to get hit. During an interview on 6/7/24 at 8:19 A.M., CNA C said: -He/She was standing at the nurses station talking to CMT A about resident medications and scheduling dinner and showers and planning the evening. -He/She saw resident #507 moving to sit on resident #508. -He/She went to help separate them by taking resident #507 away and walked down the hall with resident #507. During an interview on 6/7/24 at 11:06 A.M., CMT A said: -He/She was sitting at the desk charting when Resident #508 and Resident #507 were in the middle of the dining room. -Resident #507 was trying to sit on Resident #508 and Resident #508 said no no no -CNA C told Resident #507 that they cannot sit on Resident #508. -Resident #507 turned around to walk away, turned back again and started hitting Resident #508 in her face. -CNA A was in the dining room and was able to intervene first. -He/She thought Resident #507 was going to hit the aide. -Resident #507 hit Resident #508 which caused Resident #508's to bleed. During an interview on 6/7/24 at 3:07 P.M., the Administrator said: -The facility investigation showed Resident #507 hit Resident #508 in the face when Resident #508 startled Resident #507. -He/She did not believe the incident was defined as abuse. MO00237042 MO00237029

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility staff failed to ensure the safe storage and accountability of a resident's narcotic medication (controlled substance medications that can cause physical and mental dependence) card by failing to verify and sign for the delivery of medications to the East Nurses Station resulting in the missing of 30 tabs of Oxycodone HCL (Hydrochloride) (a narcotic pain medication) 10 milligrams (mg) for one sampled resident (Resident #500) out of three sampled residents. The facility census was 116 residents. The Administrator was notified on 6/7/24 of the past noncompliance which began on 5/11/24. The facility in-serviced all nursing staff on the facility drug diversion policy. The deficiency was corrected 5/29/24. Review of the facility's policy from the pharmacy titled Skilled Nursing Facility Pharmacy Services and Procedures Manual dated January 2022 showed: -Facility staff should sign the delivery log as proof of delivery before pharmacy delivery representative leaves facility. -Once received by facility staff, medical record documents should be separated by room number and collated according to facility room number and name. -Facility should store controlled substances in a separate compartment within the locked medication carts and should have a different key or access device. -Facility should ensure that controlled substances are only accessible to licensed nursing, pharmacy, and medical personnel designated by facility. -After receiving controlled substances and adding to inventory, facility should ensure that controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with applicable Law). 1. Review of Resident #500's admission Record showed he/she was re-admitted on [DATE] with the following diagnoses: -Acquired absence (amputation) of right leg below knee. -End stage renal disease (ESRD-The kidneys have stopped working well enough to survive without dialysis or a kidney transplant). -Dependence on renal dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood). Review of the resident's Physician's Order Summary (POS) dated June 2024 showed: -Oxycodone HCL tablet 10 mg give one tablet by mouth (PO) every four hours as needed (PRN) for pain rated 4-6 related to other chronic pain dated 2/8/2024. Review of the pharmacy pink delivery manifest sheet dated 5/11/23 and signed by RN B showed: -Two narcotic medications filled from the pharmacy on 5/11/24 at 3:39 P.M. including Oxycodone Immediate Release 10 mg, 30 tabs for Resident #500. -RN B did not check mark either medication as received. Review of the facility's investigation of the drug diversion dated 5/13/24 - 5/17/24 showed: -Registered Nurse (RN) B signed for a narcotic that pharmacy reported sent and facility unable to locate on evening shift Saturday May 11, 2024. -RN B said he/she signed for a blue bag from pharmacy and did not open it and locked it in his/her cart. -A copy of the pharmacy's pink delivery receipt signed by the driver showed: --Two narcotic medications filled from the pharmacy on 5/11/24 at 3:39 P.M. including Resident #500's 30 tablets of Oxycodone 10 mg. --The pharmacy driver signed but did not date or time when delivered. -A copy of the pharmacy's pink delivery receipt signed by RN B showed: --Two narcotic medications filled from the pharmacy on 5/11/24 at 3:39 P.M. including Resident #500's 30 tablets of Oxycodone 10 mg. --RN B signed and dated as received on 5/11/24 at 9:25 P.M. --RN B did not check mark each medication to verify the delivery matched the delivery receipt and that each medication was received in the delivery. -A copy of the pharmacy's shipment summary. --Delivered to the facility on 5/11/24 at 9:33 P.M., and signed by RN B. -The former Director of Nursing's (DON) statement of incident dated 5/13/24 showed: --Licensed Practical Nurse (LPN) A reported a full card of Resident #500's Oxycodone Immediate Release was missing. --The former DON checked every card from pharmacy, each med room, each unit, and each shred box but was unable to locate the narcotic card. --RN B, who signed the pharmacy sheet for the medication on 5/11/24, was immediately suspended and taken off the schedule pending investigation. --He/She spoke with pharmacist who reported that the narcotic could have been delivered in a blue bag instead of red bag. --Red bags are used for narcotic delivery. --RN B reports that he/she signed for a blue bag from pharmacy Saturday evening and put it in his/her cart because he/she was busy. --Blue bag location unknown after that. -Nursing staff educated to open all packages from pharmacy to ensure no narcotics are in a blue bag and to ensure they are reading the pharmacy delivery sheet that they sign when accepting medications. -RN B's statement dated 5/13/24 no time noted showed: --It was an extremely busy evening. --He/She was trying to finish glucometer scans. --The delivery driver came up to him/her and he/she had to stop what he/she was doing. --He/She did not count the bag of meds. --He/She put them in the second drawer on the right side of the cart until he/she could get them put away. --He/She did not remember anything unusual about the evening except being so busy. Review of the in-service on signing in medications and narcotics from the pharmacy was given by the Pharmacy's General Manager on 5/29/24 showed 15 nursing staff attended. During an interview on 6/5/24 at 11:40 A.M., CMT C said: -When a new narcotic medication comes from the pharmacy, it comes with a narcotic count sheet. -The count sheet is put into the narcotic book under the resident's name. -The count sheet shows the date the medications were delivered at the top left hand. -The pharmacy delivers medications during the 3-11 evening shift. Review of resident #500's Oxycodone Immediate Release 10 mg narcotic sheets on 6/5/24 at 11:50 A.M., showed no documentation of a narcotic count sheet delivered on 5/11/24. During an interview on 6/5/24 at 11:55 A.M., LPN C said: -When pharmacy delivers medications, the person receiving verifies and signs that it is correct. -A nurse or a CMT can receive and sign for medications. -The receiving staff should open the package of medications when it comes and count with the pharmacy delivery person to be sure all medications and counts are correct. -Receiving staff should count all medications no matter what color bag they come in. -Staff put the narcotic medications in the front of medication locked box in the cart so the next shift sees they are there. -The staff receiving new narcotic medications counts them with the next on-coming staff. -Narcotics come just one card per narcotic per resident and all go into the medication cart lock box. -Put the narcotic medication cart in the medication cart lock box and put the count sheet in the narcotic book. -All narcotic medications come with a count sheet with the amount on the card. -The count sheet shows the date the medications were delivered on the top of it. During an interview on 6/5/24 at 2:11 P.M., RN B said: -He/She worked the evening shift which was 3:00 P.M. to 11:00 P.M., on the East side 200 hall. -The pharmacy delivery person walked up to him/her with a blue bag that medications come in. -He/She knew he/she didn't have time to count medications and looked down 400 hall on the other side of the nurse's station to see if that nurse was in sight to take the delivery. -He/She did not see anyone. -He/She took the bag and looked the delivery person in the eye and told him/her I'm going to have to trust you I don't have time to check them off. -The blue bag usually does not have narcotics in them. -He/She put the bag in the third drawer of the medication cart and locked it. -The delivery person handed him/her the paper to sign as to what was delivered. -He/She did not look at or read the delivery sheet, he/she just signed the paper. He/She did not verify with the pharmacy delivery person the medications that were received in the delivery bag. -He/She had never accepted any pharmacy deliveries before without opening the bag and counting to verify what was delivered before signing. -Medication deliveries were always correct in the past. -Protocol was to always count what was delivered and put medication in the med cart and the count sheet in the narcotic book. -If do not have time to put all medications away after verifying medications are correct with pharmacy, put them in the locked narcotic box until have time to put in right spot for each resident and papers in the book. -Around 11:00 P.M., he/she took the blue bag from the medication cart and put the one medication card away. -He/She did not remember what the medication was or if it had a naroctic sheet. -He/She had no idea that there was supposed to have been a narcotic card that was not there. -He/She did not verify the medication with the shipping manifest. -Counted after 11:00 P.M., with the oncoming nurse and everything was correct at that time. -The next day a CMT, believes it was CMT E, was working with him/her and went to give a resident, believes it was for resident #500, pain medication and there was no narcotic pain medication for the resident. -The CMT called the pharmacy to reorder the narcotic and the pharmacy said it had already been delivered. -The pharmacy said he/she was the person who signed for the delivery of the medications. -The former DON came in and they started looking through the medication carts, treatment carts, and everywhere and the missing medication was not found. During an interview on 6/6/24 at 9:28 A.M., the Pharmacy General Manager said: -All drug deliveries to facilities have a manifest that prints out on a pink sheet for controlled substances. -The controlled drugs go into a red sealed bag. -When the driver gets to the facility, he/she scans it by phone as delivered to the facility. -The nurse opens the sealed bag and verifies the delivered medications by checking each drug in the bag and signing the copy of the manifest in the bag. -Each drug on the manifest has a check box to be checked by receiving nurse. -The facility keeps a copy of the manifest and the driver brings the other copy back to the pharmacy. -The copy of the manifest showed no documentation that the receiving nurse checked marked any medication listed on the manifest. -Once the facility signs for each medication on the manifest and the pharmacy receives the signed copy back it is out of the pharmacy's hands. -If there is an error and a medication is not in the bag that is on the manifest the nurse receiving can call the pharmacy 24-hours a day and report what is missing. -Once the nurse signs the manifest it is expected that the facility received all that was in the bag. -The pharmacy was made aware of the missing narcotic when the facility called on 5/14/24. -He/She went to the facility and gave an in-service to the nurses on the security of controlled substances and verifying before signing. He/She could not recall the date of the in-service. During an interview on 6/6/24 at 11:27 A.M., the Administrator said: -The former DON was made aware and reported him/her on 5/13/24 that a narcotic medication card was missing when another nurse went to reorder the medication from the pharmacy and found out it had been delivered a few days earlier. -The medication was missing from the East 200/400 hall nursing medication cart. -The former DON went to the unit and went with RN B, through the medication cart, treatment cart, shred container, medication room, and anywhere he/she could think of in the facility and did not find the missing narcotic medication card. -The medication card was not visually seen or accounted for. -The pharmacy general manager came to the facility and gave an in-person in-service to all nursing staff to address future security of controlled substances, to open the delivery bag and to verify the medications before signing for them. MO00236116

Based on interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) program under Medicaid (a joint federal and state program that gives health coverage to some people with limited income and resources ) which ensures appropriate placement of residents with known or suspected of having mental impairments when the staff failed to refer one sampled resident (Resident #48) with a newly diagnosed mental disorder to a level two review out of 23 sampled residents. The facility census was 115 residents. Review of a facility policy titled Pre-admission Screening Assessment Resident Review, reviewed 9/2023, showed: -A negative level one screening permitted an admission to proceed unless a possible serious mental disorder or intellectual disability arose later. -Any resident with a new or possible serious mental disorder or related condition must be referred, by the facility, to the appropriate state-designated mental health or intellectual disability authority for review. 1. Review of Resident #48's admission Record showed: -An admission date of 1/15/24. -A diagnosis of schizophrenia (a serious mental disorder that affects a person's ability to think, feel and behave clearly) with an onset date of 1/17/24. -A diagnosis of vascular dementia (brain damage caused by multiple strokes). Review of the resident's Level One Nursing Facility Pre-admission Screening for Mental Illness, Intellectual Disability or Related Condition dated 1/16/24 showed the resident did not have a current, suspected or history of a major mental illness as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) including schizophrenia on this date. Review of the resident's medical record showed no documentation of a Level II evaluation or a referral/notification to the appropriate state-designated agency for review. During an interview on 5/6/24 at 10:00 A.M., the Social Services Director said he/she would expect an evaluation to be completed to determine if the resident needed a Level II PASARR after the new diagnosis of schizophrenia on 1/17/24 to ensure the resident's needs could be met by the facility. During an interview on 5/7/24 at 12:24 P.M., the Regional Director of Nursing said a facility social worker should have been doing all PASARR coordination around the time of the resident's admission and that he/she would have expected a follow up to be conducted after the residents new diagnosis of schizophrenia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR - a federally mandated program that requires all states to prescreen all people regardless of payer source or age seeking admission to a Medicaid certified nursing facility) for one sampled resident (Resident #5) out of 23 sampled residents. The facility census was 115 residents. Review of the facility PASARR policy last reviewed on 9/25/23 showed: -The facility will ensure that potential admissions are screened for possible serious mental disorders or intellectual disabilities and related conditions. -The Level I PASARR will be completed prior to admission to the facility. 1. Review of Resident #5's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Depression. -Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs(an abnormal high level of activity or energy). -Dementia (a group of thinking and social symptoms that interferes with daily functioning). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 1/16/24 showed: -He/She was originally admitted to the facility on [DATE]. -He/She was most recently admitted to the facility on [DATE] following many admissions to the hospital. -He/She had dementia. -He/She had depression. -He/She had bipolar disease. Review of the resident's medical record on 5/2/24 at 10:57 A.M. showed no documentation a Level I PASARR had been completed. During an interview on 5/2/24 at 2:07 P.M. the Social Service Director said: -He/She could not find a PASARR for the resident. -Should be done within 72 hours of admission. -The Social Worker should have done it. -The nurses could have done it. During an interview on 5/3/24 at 1:27 P.M. Social Service Assistant said: -This resident's PASARR was not done. -A PASARR should have been completed before or as soon as the resident came into the facility. -Some of the PASARRs were not done or were not completed. -A copy of the PASARR should have been downloaded into the resident's computer chart. During an interview on 5/7/24 at 12:25 P.M. the Director of Nursing (DON) said: -PASARR should have been completed at the time of admission. -The Social Worker should have been responsible for ensuring the PASARR was completed. -The facility was without a Social Worker for about a month. -The MDS Coordinator was now assisting the Social Worker to ensure that all of the residents had a PASARR. -This one was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide continuity of resident care by not reviewing and revising resident comprehensive care plans (a document that specified health care and supported needs and outlined how the facility met resident requirements) for two sampled residents (Resident #114 and Resident #9) out of 22 sampled residents and three closed records. The facility census was 115 residents. Review of the facility's Care Planning-Baseline, Comprehensive and Routine Updates policy, dated 1/4/24, showed: -The comprehensive care plan included a problem/focus statement, measurable goals, and interventions. -The comprehensive care plan must be updated with each Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) and periodically. -Care plans defined the resident's problems, risks, and issues. -Care plans clearly stated the resident's issues and psychosocial strengths, problems, needs, deficits, and concerns. 1. Review of the Resident #114's annual MDS dated [DATE], showed: -The resident scored a zero on the Brief Interview for Mental Status (BIMS-an assessment tool that showed a score between zero and 15 which showed the resident's mental status. This tool helped determine the resident's attention, orientation, and ability to register and recall new information. These items were crucial factors in care planning decisions). --This showed the resident was severely cognitively impaired. Review of the resident's progress notes, showed: -On 1/5/24 the Care Management team noted the resident was resistant to engaging with therapy. --The resident was provided encouragement several different ways at different times of the day. --The resident reported he/she did not need therapy. --The resident had minimal appetite. Review of the resident's care plan, dated 1/16/24, showed: -No risks, problems, issues, concerns, or deficits related to care, medication and treatment refusals were noted on the electronic care plan. -A paper copy of the care plan was requested and not received. Review of the resident's progress notes, showed: -On 1/18/24 the resident had a severely poor appetite for several days. --He/She had increased confusion and complained of generalized pain. --He/She completely refused to eat or drink. -On 1/17/24 the family was informed the resident continued to not eat and spit out his/her medication. -On 1/24/24 the resident refused his/her morning medication and breakfast. Staff and family attempted to feed resident. Resident spit out food on the floor. The nurse practitioner was notified. --The resident refused care, refused most oral intake. -On 1/23/24 The resident refused to eat dinner or drink any fluids. When Certified Nursing Assistant (CNA) attempted to feed the resident he/she tried to knock the food out of the CNA's hand. --Attempted to give resident morning medication with breakfast. Resident refused breakfast and morning medication. --The resident took off his/her gown. --The resident was combative with staff changing him/her. -On 1/25/24 the resident refused to eat dinner or drink fluids. --The resident's family stated that the resident's biggest hobby was watching old western shows on TV. --Staff reported no signs of depression however he/she had not been eating. --His/Her family brought in some of his/her favorite foods to eat and take his/her medications. -On 1/26/24 The resident changed his/her brief with family present. He/she tore his/her brief up and threw it on the floor. -On 1/31/24 The resident refused dinner and refused fluids that was offered to him/her. This nurse educated res about drinking fluids and eating. -On 2/1/24 The resident refused to eat or drink any fluids during dinner time and refused his/her medication. --He/She yelled at nurse and asked to leave the room. During an interview on 5/2/24 at 1:34 P.M., Certified Medication Technician (CMT) A said: -The nurses document resident behaviors on the Medication Administration Record (MAR)/Treatment Administration Record (TAR). -He/She reported any unusual behaviors to the nurse. -The care plan had behavior information on it. During an interview on 5/2/24 at 1:51 P.M., CNA B said: -He/She did not document any behaviors. -He/She reported anything out of the ordinary to the nurses who put it on the MAR/TAR. -Care plans and the [NAME] (an informational filing system that was used as a quick reference for nurses) had resident information, like behaviors. During an interview on 5/2/24 at 2:13 P.M., Licensed Practical Nurse (LPN) A said: -The [NAME] showed the resident's behaviors. -He/She did not pull up the [NAME] but stated it should have have resident behaviors on it. -He/She documented on the MAR/TAR any abnormal behaviors or signs/symptoms of medication side effects. -Nurses were able to update the care plan if needed. 2. Review of Resident #9's admission collection tool dated 7/27/23 showed he/she had broken teeth. Review of the resident's Quarterly MDS dated [DATE] showed: -His/Her BIMS score was 15 out of 15 indicating he/she was cognitively intact. -No dental issues was checked. Review of the resident's Care Plan dated 3/6/24 did not address the resident's broken teeth. Review of the resident's dental visit on 3/20/24 showed: -He/She was missing the following teeth, (1,16,17, 31, and 32). -He/She had root tips (broken teeth) on on the following teeth, (3, 5, 8, 14, 19, 29). -He/She had palatal [NAME] (a boney growth on the roof of your mouth). -He/She had trauma to the left lateral border of the tongue from broken teeth. Observation on 5/1/24 at 1:06 P.M. during initial tour showed the resident had broken/black teeth. During an interview of 5/1/24 at 1:13 P.M. during initial tour the resident said: -He/She had seen the dentist and was supposed to have all of his/her teeth extracted. -He/She has had bad teeth for many years. During an interview on 5/2/24 at 2:25 p.m., CNA F said: -He/She has to set the resident up for oral cares. -The resident does not have any dental issues. -He/She did not know if the resident had broken or missing teeth. During an interview on 5/2/24 at 2:30 P.M., CMT C said: -The resident did not have any dental issues. -He/She did not know if the resident had any teeth. -It would have been in the resident's care plan. -The resident's care plan did not show any dental issues. During an interview on 5/2/24 at 2:40 P.M. Registered Nurse (RN) A said: -He/She did not know if the resident had any teeth. -He/She did not know if the resident had any dental issues. -If they were missing teeth or had broken teeth that should have been care planned. -It was not in the resident's care plan and should have been. During an interview on 5/3/24 at 1:30 P.M. Social Service Assistant (SSA) A said: -If the resident had broken or missing teeth that should have been in their care plan. -It was not documented in the resident's care plan. -Nursing, Social Services, or MDS should have ensured dental issues were in the care plan. 3. During an interview on 5/7/24 at 12:24 P.M., the Director of Nursing (DON) said: -Resident #9's dental issues should have been documented on the care plan. -Resident #11's refusals of food, medication and/or treatments and cares should be documented on the care plan. -Care plans should be updated by the MDS Coordinator. -They can also be updated by risk management, any nursing staff, or social services. -The care plan was used to show the care the residents received. -It gave a picture of the resident and their needs -The care plans were updated quarterly and as needed. -It was important to update the care plan to provide current information regarding the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff applied a brace to a resident's hand for one sampled resident (Resident #13) out of 23 sampled residents. The facility census was 115 residents. Review of the facility's policy, Splints and Braces, dated 1/16/24 showed: -The use of a supportive and protective device designed for a patient's upper extremity, such as a sling, brace, or splint, helps provide support, facilitate functional use, reduce pain, maintain alignment, correct deformities, or provide protection for a healing injury. -Documentation associated with supportive and protective devices of the upper extremity includes: --Length of time the patient wore the device. --Patients ability to apply and tolerate the device. --Wearing schedule and monitoring the patient's skin integrity. 1. Review of Resident #13's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Hemiplegia (complete weakness on one side of the body) and Hemiparesis (partial weakness on one side of the body) following Cerebral Infarction (a disruption of blood flow to the grain which can cause parts of the brain to die off) affecting left side. -Need for assistance with personal care. -Muscle weakness. -Spastic Hemiplegia left side (muscle tightness and involuntary contractions in the limbs and extremities on one side of the body). -Contracture, left elbow, left wrist, and left hand (a fixed tightening of muscle, tendons, or ligaments). Review of the resident's Quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by the facility for care planning), dated 3/12/24 showed: -He/She had Hemiplegia or Hemiparesis. -He/She had functional limitation in range of motion (the extent of limit to which a part of the body can be moved). -Upper extremity (shoulder, elbow, wrist, hand), no impairment was checked. -He/She had had a Cerebral Vascular Accident (CVA-stroke (interruption of blood flow to the brain). -His/Her Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating he/she was cognitively intact. Review of the resident's 3/28/24 care plan showed: -He/She had an activity of daily living self-care performance deficit. -He/She had contracture to his/her left elbow, wrist, and hand related to CVA. -Staff was to apply left hand splint on for six to eight hours, on at breakfast and off after dinner. Review of the resident's May 2024, Physician's Order Sheet showed an order for staff to apply splint/brace to left resting hand. Apply to left hand for six to eight hours, on at breakfast, off after dinner, dated 10/13/20. Observation on 5/1/24 at 3:08 P.M. during initial tour showed: -The resident's left hand was contracted. -He/She was not wearing a brace. During an interview on 5/1/24 at 3:11 P.M. the resident said: -He/She was supposed to have a brace on his/her left hand. -The brace was in his/her nightstand. -He/She was not able to put the brace on by herself/himself. -He/She has asked staff to put the brace on him/her and they did not do it. Observation on 5/2/24 at 9:50 A.M. showed the resident did not have the brace on his/her left arm. Observation and interview on 5/3/24 at 11:50 A.M. showed: -The resident did not have the brace on his/her left arm. -He/She had asked the Certified Nursing Assistant (CNA) to put the brace on his/her arm. -The CNA said he/she would be back to put the brace on him/her, that was two hours ago and the CNA never came back to put the brace on him/her. Observation on 5/6/24 at 10:00 A.M. showed the resident did not have the brace on his/her left arm. During an interview on 5/6/24 at 11:00 A.M. Registered Nurse (RN) A said: -He/She thought the resident was supposed to have a brace or sling on his/her left hand during the day. -He/She had not seen a brace on the resident for a few weeks. -He/She had not seen the brace on the resident today and he/she should have had it on by this time. -He/She did not know if the resident had a brace in his/her room. -The resident would not have been able to put the brace on by himself/herself. -Staff should have documented on the Treatment Administration Record (TAR) that they had applied the brace. -The CNA's or Restorative Aide (RA) should have put the brace on the resident at breakfast and take it off after dinner. -The Charge Nurse was ultimately responsible for ensuring treatments such as the brace were being done. Review of the resident's May 2024 TAR showed: -Splint/brace to left resting hand, apply to left hand for six to eight hours, on at breakfast, off after dinner. --No documentation this was completed by the staff. -Assess pain level and circulation every shift. -Assess skin integrity around and under the splint/brace. Document + or - for skin integrity, dated 10/13/20. -There was a line for Day, Evening, or Night shift to assess the skin. -There was a line to assess pain level. -There was no line to document applying or removing the splint. During in interview on 5/7/24 at 9:30 A.M., CNA E said: -None of the residents wear a sling or brace on their arm. -The resident did not have a brace for his/her arm. -If the resident needed a brace for his/her arm, the nurse would have told him/her. -If the resident had a brace he/she would have put it on him/her when they got him/her dressed for the day. -If the resident had a brace for their arm it would have been documented on the TAR that it was applied to the resident. During an interview on 5/7/24 at 10:00 A.M., Certified Medication Technician (CMT) B said: -If a resident had an order for a sling or brace it should have been applied by the staff. -The CNA should have applied the brace when they got the resident dressed for the day. -He/She has not seen the resident with a brace on his/her arm. -The staff has not been applying the brace to this resident. -The brace should have been in the care plan. -The nurse was responsible to ensure the resident had the brace on. During an interview on 5/7/24 at 10:52 A.M., RN C said: -He/She had not seen the resident with a brace on his/her hand. -The staff was responsible for applying the brace. -The CNA or RA should have applied the brace when they dressed the resident. -Staff should have documented on the TAR when they applied the brace and when it was taken off. -It does not look like that has been done only assessing the resident for pain and assessing the skin. -The Charge Nurse was ultimately responsible for ensuring the the resident had a brace on if the physician had ordered it. During an interview on 5/7/24 at 12:25 P.M. the Director of Nursing said: -He/She would have expected the staff to put a sling or brace on a resident if there was a physician's order to do so. -The CNAs, RA, or nurse could have applied a brace to the resident. -They should have document applying the brace in the Progress Notes. -He/She was ultimately responsible to ensure treatments such as a brace were done by the staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately complete comprehensive fall investigations to include fall prevention measures that were in place to prevent falls, documentation of root cause analysis and any pertinent details of the incidents and environmental surrounding of the falls for one sampled resident (Resident #61), who was a risk for falls out of 23 sampled residents. The facility census was 115 residents. A fall investigation policy was requested and was not received at the time of exit. Review of the facility's Fall Management policy dated 12/4/23 showed: -To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients fall indicators. -With any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. -Identify environmental hazards and individual resident risk of and accident, including supervision. Evaluate/analyze the hazards and risk and eliminate them, if possible and if not possible reduce them as much as possible. -The interdisciplinary team will review any additional fall risk indicators and revise the resident care plan as indicated. 1. Review of Resident #61's admission Face Sheet showed the following diagnoses: -Dementia (is a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) with other behaviors disturbance. -Lack of coordination. -Cognitive communication deficit. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 4/18/24, showed he/she: -Had severe cognitive impairment. -He/she was rarely table to understand others and make his/her needs known. -Had two non-injury falls during look-back period. -Dependent on facility staff for transfer and care assistance. Review of the resident's Fall Care Plan revised on 4/18/24 showed: -The resident was at risk for falls. -The resident had an actual fall. He/She had unsteady gait and was found lying on the floor. -Interventions in place included place floor mats on side of bed on floor at night and when he/she in bed. -On 4/18/24 the resident had a fall and was sent to hospital for evaluation and treatment. Upon returned from hospital a nursing assessment was completed and therapy was notified of the resident fall. -NOTE: Did not find documentation of any new preventative fall interventions initiated after his/her fall on 4/18/24. Review of the resident's Health Status Note dated 4/19/24 at 3:30 A.M. showed the resident had an unwitnessed fall out of his/her bed. The note did not include any interventions that had been in place to prevent the resident's fall. Review of the resident's Fall Risk Report completed by the Director of Nursing (DON) dated 4/19/24 at 4:41 A.M. showed: -The resident had an unwitnessed fall in his/her room. -It was reported to this writer, the DON, that the resident had an unwitnessed fall out of his/her bed and had hit his/her head. -The resident was unable to give a description of what happen. -Had no documentation under predisposing environmental factors and situation factors. -Resident Predisposing Physiological Factors had checked marks by confused, drowsy and impaired memory. -Had documented no notification found under section for agencies or people notified. -Had no documentation of the resident's fall preventive measure prior to fall and any fall intervention put in place after his/her fall. -Had no documentation of a fall follow-up investigation was completed and no final root cause documentation. -NOTE: The incident report/investigation did not have detail comprehensive investigation to include but not limited to details of the observation of the resident surrounding, positioning of the resident and if his/her bed was in lowest position or if his/her fall mats were in place at the time of the resident fall. Review of the resident's Fall Risk assessment dated [DATE] showed a post fall score of 18 which indicated the resident high risk for falls. Observation on 5/2/24 at 11:00 A.M. the resident's room showed: -Had two fall mats on each side of his/her bed. -He/She had low air loss mattress that did not have any added soft side parameter barriers. Observation of the resident on 5/2/24 at 11:01 A.M. showed: -He/She was sitting specialized wheelchair in dining area with plastic building blocks in front of him/her on the table. -Wheelchair was unlocked and he/she had non-skid socks on. Review of the resident's unwitnessed Fall Risk Report dated 5/6/24 at 6:33 A.M. showed: -The resident had an unwitnessed fall in his/her room. -Nursing description: The resident was lying on floor on his/her back when the nurse entered the room, the floor free of clutter, fall mats in place and bed alarm within reach. -Resident had no verbal response to his/her fall. -Marked no if resident taken to hospital. -Had documented no injury observed at time of incident. -He/She had a pain scale level of 10 out of 10 (10 being worst pain). -NOTE: The resident had just fallen the morning of 5/6/24. --The injury sites documentation was not accurate placement with any current injuries noted. --Did not have details of surroundings and if the bed was in lowest position. No detail on position of the resident when found, and if was call light in reach. Review of the resident's Alert Note dated 5/6/24 at 7:56 A.M. showed: -The resident had fallen out of his/her bed onto the floor. -The resident's roommate had found him/her on floor. -The note did not include any interventions in place to prevent falls. Observation and interview of the resident on 5/6/24 at 9:40 A.M. showed: -He/She was sitting in a wheelchair located at the table in the special dining area. -He/She denied pain. -He/She said he/she had rolled out of his/her bed. -He/She was able to answer basic questions and was alert to name. -The charge nurse entered the dining area and began assessment of the resident to include vital signs and neuro checks. Observation of the resident's room on 5/6/24 at 9:46 A.M. showed: -He/She had two fall mats on each side of the bed. -The resident's roommate said he/she was in the room when resident had fallen earlier that morning. He/She had heard the resident fall but did not see him/her fall. -The resident's roommate said he/she thought the resident was possibly trying to reach for something. He/She was not sure if the resident's bed was in the lowest position to ground or if fall mats were on the ground. -The resident's bed was a Low Air Loss Mattress (LAM) and a fall mat on floor located on each side of his/her bed. Observation of the resident's bed on 5/6/24 at 1:29 P.M. showed he/she did not have a bed alarm in place. During an interview on 5/6/24 at 9:57 A.M. with Certified Nursing Assistant (CNA) D said: -The resident had fallen during night shift on 5/6/24. -He/She was not aware of the resident's previous fall on 4/19/24. -The resident fall preventive measure was, while the resident in bed, his/her bed should be in lowest position with fall mats on each side of the bed. -He/She was not aware of the resident's bed was position at time of fall or if fall mats were in place at time of the fall for either fall. During an interview on 5/6/24 at 12:48 P.M., Registered Nurse (RN) A said: -The resident had fallen out of bed that morning, and vitals were completed. -He/She was not aware of the resident's previous fall on 4/19/24. -He/She not aware of new fall prevention measures put in place. -The resident should have fall mats in his/her room and bed in lowest position when in bed. -The fall investigation or report should include complete details of the resident's fall. -Incident report or fall risk completed with detail of what happened, positioning of the resident, and any injury noted. -DON would be responsible for competing the DON investigation. -He/She not aware of the resident or any other resident with bed or chair alarms. During an interview on 5/6/24 at 1:25 P.M., Certified Medication Technician (CMT) A said: -The resident's fall prevention measures were a LAM, high/low bed, and fall mats. -He/She was not aware of any use of bed alarms at the facility. -The resident normal stays up in a wheelchair most of the day. -When he/she is in bed, the bed should be in the lowest position to the ground with fall mats in place. During an interview on 5/7/24 at 10:20 A.M., CNA C said: -If he/she found a resident on the ground or had witnessed falls, he/she would stay with the resident and have another staff get the nurse. -The nurse would complete an assessment of the resident and document findings. -If he/she witnessed a fall he/she would write a witness statement. -The nursing staff were responsible for documentation of the fall incident. -When the resident was in bed, the bed should be placed in the lowest position to the ground with fall mats on each side of his/her bed. -The CNA's would ask nursing staff or look at the CNA task sheet on how to care for the resident and if the resident was on fall precautions. During an interview on 5/7/24 10:32 A.M., the Wound Nurse said: -He/She would assess the resident that was found on the ground by checking vital signs, assess for any injury, notifying the resident's physician, family member and DON. He/She would obtain any witness statements and document findings in the risk management for falls with a detail note of the event. -Fall documentation should include the surroundings, position of bed and resident, and any old and new interventions that were put in place. -During the facility morning meeting, the facility staff would review any falls and the resident's current plan of care. At that time they would discuss if staff needed to make any changes to the resident's care plan or further evaluation. During an interview on 5/7/24 at 10:56 A.M., Licensed Practical Nurse (LPN) B said: -Fall risk incident reports should include a detailed description of the event to include the resident's position, any fall prevention measure that were in place at the time of the fall, such as bed low position fall mat in place and document any injury and immediate actions taken. -Staff would complete the resident's fall assessment and treat any injury as needed. -Staff should document the fall in the resident's nursing notes and fall risk incident and gather any witness statements. During interview on 5/7/24 at 12:23 P.M., DON, Regional Director Services, and Assistant Director of Nursing (ADON) said: -He/She would expect nursing staff to have a detailed and accurate comprehensive incident report sand fall investigations. -Nursing would be responsible to complete and document the resident's initial head toe assessment, environment assessment, outcome and complete risk management reports. -Nursing staff can also document the resident's incident in a detail progress note. -Nursing would be responsible for completing the fall comprehensive investigation report and the DON would complete his/her investigation which would include review of the nursing investigation, document follow-up findings or root cause and any fall preventative measure which may have been put in place after the resident fall. -During the morning clinic meeting, the team would review fall incidents and update the resident's care plan at that time. -He/She would expect documentation to be accurate, comprehensive, and follow-up investigation completed. -For fall investigation on 4/19/24 was a final report and he/she did not have any additional information at time of exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a resident who had a feeding tube and took food orally was getting adequate nutrition by not recording how much the resident took in orally and did not weigh him/her on a regular basis for one sampled resident (Resident #96) out of 23 sampled residents. The facility census was 115 residents. Review of the facility's policy, Resident at Risk, dated 4/25/23 showed: -Based on a resident's comprehensive assessment, the facility must ensure that a resident maintains acceptable parameters of nutritional status, such as usual body wight. -Acceptable parameters of nutritional status refers to factors that reflect an individual's nutritional status was adequate such as weight, food/fluid intake, -Artificial nutrition and hydration were medical treatments and refer to nutrition that was provided through routes other than the usual oral route, typically placing a tube directly into the stomach, the intestine, or a vein. -The facility establishes a consistent method of weighing residents, verifying weights upon admission, monitoring weights over time to identify weight loss or gain, verifying weights when changes occur, determining interventions, and reassessing interventions when appropriate. -Team members may have made recommendations to the resident's physician including but not limited to frequency of monitoring weights. -Review weights on new admissions weekly for the first four weeks after admission to establish a baseline, then monthly after that unless otherwise indicated. 1. Review of Resident #96's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Gastrostomy status (an opening into the stomach from the abdominal wall,made surgically for the introduction of food). -Anoxic brain damage (a complete lack of oxygen to the brain which results in the death of brain cells after four minutes of oxygen deprivation). -Autistic disorder( a serious developmental disorder that impairs the ability to communicate and interact). -Dysphagia (a difficulty in swallowing food or liquids). Review of the resident's care plan on 5/6/24 at 12:20 P.M., dated 2/9/24 showed: -He/She was on tube feedings. -Did not address when or how often the resident should have been weighed. Review of the resident's Physician's Order Sheet dated May 2024 showed: -There was no order to weigh the resident. -He/She was on a regular diet with puree texture (a pudding-like texture that was smooth, blended or pureed), Nectar (a consistency of slightly thicker liquid than water)/mildly consistency. -One to one assistance, small bites, slow rate, sit upright 90 degrees for nutrition, dated 9/15/23. -Enteral feed order- two times a day Jevity (a calorically dense, fiber fortified therapeutic nutrition) 1.5 at 50 milliliters (ml) per hour for 12 hours via pump, dated 9/15/23. Review on 5/6/24 at 12:30 P.M. of the resident's weights on the computer program showed the following weights for this year: -On 1/15/2024 the resident weighed 111.9 pounds (Lbs). -On 1/22/2024 the resident weighed 110.2 Lbs. -On 2/6/2024 the resident weighed 111.6 Lbs. -On 2/15/2024 the resident weighed 112.3 Lbs. -On 2/21/2024 the resident weighed 113.1 Lbs. -On 2/27/2024 the resident weighed 111.9 Lbs. -On 3/13/2024 the resident weighed 112.4 Lbs. -On 3/19/2024 the resident weighed 112.9 Lbs. -On 4/4/2024 the resident weighed 112.5 Lbs. -On 4/9/2024 the resident weighed 113.0 Lbs. -There was no documentation since 4/9/2024. During an interview on 5/6/24 at 1:00 P.M. Certified Nursing Assistant (CNA) E said: -There was a certain person who weighs the residents. -He/She did not know who it was or if they were working. -The nurse would have told staff if a resident needed to be weighed that shift. -The resident's weight should have been documented in the computer system under weights. -A person who had a feeding tube should have been weighed daily. -The weight should have been documented on the computer. During an interview on 5/6/24 at 1:10 P.M. Certified Medication Technician (CMT) C said: -It would show up on the Medication Administration Record if the resident needed to have been weighed. -The staff should have documented on the computer what the weight was under weights. -The Restorative Aide was supposed to have weighed the residents. -He/She did not know if that person was here today. -The resident should have been weighed weekly. -He/She verified the resident had not been weighed since 4/9/24. -He/She verified there was no physician's order for how often the resident should have been weighed, maybe weekly. During an interview on 5/6/24 at 1:20 P.M. Registered Nurse (RN) A said: -There was someone who was assigned to weigh the residents. -He/She did not know who that person was. -He/She did not know if that person was working today. -If that person was not working he/she did not know how it would have been conveyed to them that nursing staff should have weighed the resident. -Resident weights would have been documented on the computer system. -The last weight was on 4/9/24. -The resident does take food and if he/she doesn't eat a certain percent of his/her meal then he/she gets a tube feeding. -The resident should be weighed at least weekly. -There was no physician's order for how often the resident should have been weighed. -There was no documentation in the care plan which showed how often the resident should have been weighed. During an interview on 5/7/24 at 12:55 P.M. the DON said: -The resident had a feeding tube and should have been weighed weekly. -There was an Restorative Aide (RA) who was supposed to weigh the residents. -The RA has been sick lately. -A CNA or nurse could have weighed the resident. -The Charge Nurse was responsible to ensure the residents were weighed per the physician's order. -There was no physician's order how often to weigh the resident. -If there was no order they would weigh the resident monthly. -He/She and the Assistant DON have done audits to ensure weights were done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident's oxygen equipment was stored in a sanitary condition when not in use, failed to ensure oxygen tubing was changed out weekly, failed to ensure residents had water in the humidifiers on the oxygen concentrator for three sampled residents, (Resident #5, Resident #9, and Resident #51) out of 23 sampled residents. The facility census was 115 residents. Review of the facility's policy, Oxygen Administration/Safety/Storage/Maintenance, dated 9/26/23 showed: -Oxygen would have been administered in accordance with physician's orders. -Change oxygen supplies weekly and when visibly soiled. -Equipment should have been dated when setup or changed out. -Humidifier bottles should have been dated and replaced every seven days regardless of the water level. -Store oxygen and respiratory supplies in a bag labeled with the resident's name when not in use. 1. Review of Resident #5's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block air flow making it hard to breathe). Review of the resident's Quarterly Minimum Data Set (a federally mandated assessment tool completed by the facility for care planning) dated 1/16/24 showed: -He/She had a medically complex condition. -He/She had COPD. -Did not show he/she was on oxygen or respiratory treatments. -His/Her Brief Interview for Mental Status (BIMS) score was 15 out of 15 indicating he/she was cognitively intact. Review of the resident's May 2024 Physician's Order Sheet (POS) showed the following orders: -Oxygen one to four liters to keep oxygen saturation above 88% every shift, dated 4/4/24. -Ipratropium-Albuterol (medication used to prevent difficulty breathing for people with COPD) Inhalation Solution 0.5-2.5 (3) milligram(mg)/3 milliliters (ml) one vial inhale orally every four hours for shortness of breath, dated 4/4/24. Review of the resident's undated care plan showed: -He/She had COPD. -Staff would maintain oxygen settings as ordered. Observation on 5/1/24 at 1:14 P.M. during initial tour showed: -There was less than 1/4 inch of water in the humidifier, unable to humidify the oxygen going to the resident. -There was no date on the humidifier container. -There was no date on the oxygen tubing indicating when it was changed. -The nebulizer mask (a delivery method of aerosol medications) was sitting on the bedside tray table, not in a bag, did not have a date written on it. During an interview on 5/1/24 at 1:20 P.M. the resident said he/she did not know when the staff had changed out any of his/her breathing tubing, at least a couple of weeks. 2. Review of Resident #9's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -COPD. -Dependence on supplemental oxygen. -Sleep apnea (a serious sleep disorder in which breathing repeatedly stops and starts). Review of the resident's Quarterly MDS dated [DATE] showed: -He/She had a medically complex condition. -He/She had COPD. -He/She was on oxygen therapy. -He/She was on non-invasive mechanical ventilator (when oxygen is given as breathing support by using a face mask under positive pressure). -Continuous Positive Airway Pressure (CPAP- a machine that uses mild air pressure to keep breathing airways open while a person sleeps) was not checked. -His/Her BIMS score was 15 out of 15 indicating he/she was cognitively intact. Review of the resident's Care Plan dated 3/6/24 showed: -He/She had oxygen therapy and CPAP related to COPD. -Give medication as ordered by physician. -CPAP as ordered. Review of the resident's May 2024 POS showed the following orders: -Change oxygen tubing and nebulizer circuit every Sunday night shift related to COPD, dated 7/30/23. -Clean CPAP mask with warm soapy water, rinse, and air dry every date shift related to COPD, dated 10/18/23. -Fill CPAP humidifier with sterile or distilled water every night shift for shortness of breath, dated 7/28/23. -CPAP on while sleeping or napping and off while awake at bedtime for shortness of air, dated 7/28/23. Observation on 5/1/24 at 1:04 P.M. during initial tour showed: -There was no water in the resident's oxygen humidifier. -There was no date on the resident's water container. -The resident's CPAP mask was in a bag dated 4/18/24. During an interview on 5/1/24 at 1:06 P.M. the resident said: -He/She did not know when the staff changed out the oxygen supplies, at least two weeks. -The staff does not put the CPAP mask on him/her at night, he/she has asked them to repeatedly. -He/She wears oxygen at night. Observation on 5/3/24 at 10:00 A.M. showed: -There was no water in the resident's oxygen humidifier. -There was no date on the resident's water container. -The resident's CPAP mask was in a bag dated 4/18/24. 3. Review of Resident #51's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis: -COPD. -Panlobular Emphysema (a disease of the lungs in which the air sacs in the lungs were permanently damaged). -Dependence on supplemental oxygen. Review of the resident's Annual MDS, dated [DATE] showed: -His/Her BIMS score was 13 out of 15 indicating he/she was cognitively intact. -He/She was medically complex. -He/She had COPD. -He/She was on oxygen therapy. Review of the resident's care plan dated 3/28/24 showed: -He/She had COPD. -Staff was to change oxygen tubing weekly or as needed. -Oxygen was to be at four liters per nasal cannula (tubing that was placed in a patients nose to deliver oxygen) continuously. Review of the resident's May 2024 POS showed the following orders: -Change the oxygen tubing and nebulizer water container ever Sunday night, dated 5/13/21. -Oxygen at four liters per minute continuously per nasal cannula dated 5/13/21. Observation on 5/01/24 at 1:17 P.M. during initial tour showed: -The resident was wearing oxygen which was connected to a concentrator. -The oxygen bag dated 4/18 was taped to the concentrator. -There was no water in humidifier attached to the concentrator. -He/She had a second oxygen tubing on his/her wheelchair attached to an oxygen tank. -His/Her oxygen tubing that was on his/her wheelchair nasal cannula was a dirty brown in color. -The oxygen tubing was wrapped around the handles of the wheelchair hanging down to the floor, not in a bag and not dated. During an interview on 5/1/24 at 1:20 P.M. the resident said he/she did not know how often staff changed out his/her oxygen tubing, maybe monthly. Observation on 5/3/24 at 10:04 A.M. showed: -His/Her oxygen tubing was laying on of his/her bed on top of a bloody incontinent pad. -Two Certified Nursing Assistants (CNA)s had just left the room after doing cares with the resident and moving him/her into his/her wheelchair. Observation and interview on 5/03/24 at 11:12 A.M. during wound care with LPN C/Wound Care Nurse said: -The oxygen tubing attached to the resident's concentrator was still sitting on the bloody incontinent pad. -The nurse got the resident a new set of oxygen tubing. -His/Her oxygen cannula should not have been laying on a dirty pad, the CNAs should have changed the oxygen tubing. -The resident would sometimes take his/her oxygen off himself/herself. -The nurse changed out the water container on the humidifier. -The nurse did not date the new water container. -He/She said the CNA's were not able to change out the water container as they were locked up. -The facility did not add distilled water to the humidifier on the oxygen concentrator, they changed out the water container which came pre-loaded with distilled water. -He/She was not sure how often the water container should have been changed out maybe when the staff noticed it was empty. 4. During an interview on 5/7/24 at 9:30 A.M. CNA E said: -Oxygen when not in use should have been in a bag. -There should have been a date written on the bag that the tubing was changed out. -He/She did not know how often the oxygen tubing should have been changed out. -Any staff member could have changed out the oxygen tubing if they saw it was dirty. -The nurse was responsible for ensuring there was water in the humidifier. -The water container for the humidifier comes pre-made with special water already in it and it was locked up somewhere. During an interview on 5/7/24 at 10:00 A.M. Certified Medication Technician (CMT) B said: -Oxygen tubing should not be on the floor or bed, it should be in a bag with the date it was changed out written on the bag. -He/She did not know who was responsible for ensuring the tubing was changed out weekly. -The nurse was responsible for ensuring there was distilled water in the oxygen humidifier. -He/She did not know where it should have been documented at. -The oxygen tubing should have been changed out weekly. During an interview on 5/7/24 at 10:52 A.M. Registered Nurse (RN) C said: -There should not have been oxygen tubing touching the floor or on a dirty pad. -Oxygen tubing should have been stored in a bag with the date it was changed out written on the bag. -Oxygen supplies should have been changed out on Sunday by the night shift. -The nurses were responsible to change out the water container on the humidifier as it was pre-filled with distilled water and kept locked up. -He/She looks at the oxygen equipment in the morning when he/she starts to work to ensure it was clean and did not need changed out. -It was everyone's job to ensure the oxygen equipment was clean. During an interview on 5/7/24 at 12:25 P.M. the Director of Nursing said: -He/She would not have expected to see oxygen tubing on the floor, bedside stand or on a dirty incontinence pad. -Oxygen tubing should have been changed out every seven days by the night shift. -There should have been water in the humidifiers. -The charge nurse on Sunday night was responsible to ensure the oxygen equipment was changed out. -When the tubing or water was changed out, it should have a date written on it indicating when it was changed out. -If this wasn't done the charge nurse on Sunday nights missed it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review ,the facility failed to address the pharmacy's recommendation to the physician in a timely manner for one sampled resident, (Resident #23) out of 23 sampled residents. The facility census was 115 residents. Review of the facility's policy, Medication Regimen Review (MMR), dated 8/17/23 showed: -The Consultant Pharmacist would conduct MMR if required under a Pharmacy Consultant Agreement and would make recommendations based on the information available in the residents' health record. -The Pharmacist would address copies of residents' MRR to the Director of Nursing (DON) and the attending physician and to the Medical Director. -Facility staff should have ensured that the attending physician, Medical Director, and DON were provided with copies of the MRRs. -Facilities should encourage the physician or other responsible parties who had received the MRR and the DON to act upon the recommendations contained in the MRR. -For those issues that required physician intervention, the facility should encourage the physician to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. -The physician should have documented in the resident's health record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. -If the attending physician had decided to make no change in the medication, the attending physician should have documented the rationale in the residents' health record. -Facility should have alerted the Medical Director where MRRs were not addressed by the attending physician in a timely manner. -The attending physician should address the consultant pharmacist's recommendation no later than their next scheduled visit to the facility to assess the resident, either 30 or 60 days per applicable regulation. -The facility should have maintained readily available copies of the Consultant Pharmacists reports on file in the Facility as part of the resident's permanent health record. 1. Review of Resident #23's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors). -Dementia (a general decline in cognitive abilities that impacts a person's abilities to perform everyday activities). Review of the resident's Progress Notes dated 3/21/24 showed: -The pharmacy had made a recommendation Nuplacid was a antipsychotic and did the physician want to discontinue the medication. -The resident was on three medications for Parkinson's. -There was no documentation from the physician with an answer to the pharmacist's recommendation. During an interview on 5/3/24 at 1:00 P.M. Registered Nurse (RN) A said: -There was no documentation of an answer to the pharmacy note in the computer from the physician. -If the pharmacy has a recommendation sometimes they would call the physician directly. -The physician would just discontinue a medication. -He/She did not know where it would be documented that the physician disagreed with the pharmacy recommendation for a different reason. -The resident was still on the medication so he/she did not know what had happened. During an interview on 5/3/24 at 1:30 P.M. the Assistant Director of Nursing (ADON) said: -He/She did not see the MMR from pharmacy for the physician. -He/She did not see a response from the physician. -There should have been a response if they disagreed with the pharmacy recommendation within a week or so. -There was no documentation that the physician saw or responded to the note. During an interview on 5/6/24 at 10:45 A.M., Licensed Practical Nurse (LPN) D said: -If the pharmacist had a recommendation, they contact the physician directly. -If the physician agrees a medication should be discontinued, they write an order. -If the physician wants to continue a medication he/she did not know where that would have been documented. -He/She was not aware of how that was done. During an interview on 5/6/24 at 10:55 A.M. Registered Nurse (RN) A said: -The pharmacy contacts the physician directly if they have a recommendation. -He/She did not know how that was done. -He/She did not know where it was documented if the physician wanted to continue a medication against the pharmacy advice. -The discrepancy should have been taken care of in a week or so. -The Director of Nursing (DON) would have been ultimately responsible to ensure there was a response to the pharmacy recommendation. -He/She did not see a response to the pharmacist's recommendation on the chart. During an interview on 5/7/24 at 12:55 P.M. the DON said: -The pharmacist review the resident's medications monthly. -If the pharmacist had a recommendation, they email it to him/her. -He/She prints the pharmacist's recommendation and gives it to the physician. -The physician would document on the recommendation whether they agreed, disagreed, or there was an other reason usually within a week or so. -This one was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 27's admission assessment, dated 10/6/23, showed the resident had missing natural teeth. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact and showed no issues with the residents oral or dental status. Review of the resident's Order Summary Report, dated 5/6/24, showed: -A physician order for a referral to an oral surgeon that was placed on 3/25/24 and discontinued on 4/2/24. -A physician order placed on 4/2/24 for a referral to an oral surgeon for tooth extractions. During an observation and interview on 5/2/24 at 9:11 A.M., the resident was observed to have multiple missing and broken teeth, particularly in the front of his/her mouth. The resident said that the social services department had been working on getting him/her into an oral surgeon for a while, but he/she hasn't received an update. During interview on 5/3/24 at 11:00 A.M., the Social Services Assistant said that the resident had been working with the Assistant Director of Nursing (ADON) to get an appointment with an oral surgeon and was unaware of the progress of the scheduling. During interview on 5/03/24 at 11:10 A.M., the ADON said he/she tried getting the resident an appointment with the oral surgeon for about a month but was unsuccessful, the social services department then took over on working to get the resident an appointment and he/she was unaware of where they were at in the process. During interview on 5/6/24 at 10:08 A.M., the Director of Social Services said the ADON was working on the appointment for the oral surgeon and was unaware of the progress of scheduling. During interview on 5/7/24 at 12:24 P.M., the Director of Nursing said: -The social services department was responsible for making dental appointments. -There should have been documentation on the appointment making process. -He/She would expect follow up on the appointment for the oral surgeon by this time. During interview on 5/7/24 at 12:56 P.M., the ADON said he/she delegated the appointment making process around the 8th or 9th of April, just before going on vacation, and had worked on it for around a month prior to this. Based on observation, interview, and record review, the facility failed to ensure two sampled residents, (Resident # 9 and Resident #13) received dental services for broken teeth or missing teeth, and to provide a dental consultation for one sampled resident (Resident #27) who had a physician order for a consultation with an oral surgeon for dental extractions out of 23 sampled residents. The facility census was 115 residents. Review of the facility's policy, Dental Services, dated 8/23/23 showed: -The facility was responsible for assisting the patient in obtaining needed dental services, including routine dental services. -The facility would have provided or obtained from an outside resource routine and emergency dental services to meet the needs of each patient. -Must have a policy identifying those circumstances when the loss or damage of dentures was the facility's responsibility and may not charge a resident for the loss or damage of dentures was the facility's responsibility and may not charge a resident for the loss or damage of dentures in accordance with facility policy to be the facility's responsibility. -If necessary, or if requested, assist the resident: --In making appointments. --By arranging for transportation to and from the dental services location. -Must promptly, within three days, refer residents with lost or damaged dentures for dental services. -Routine dental services refers to an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning minor partial or full denture adjustments, smoothing of broken teeth, taking impressions for dentures and fitting dentures. -Arrangements would have been made promptly for routine and emergency dental services, including denture replacement when necessary. -Patients would have been assisted with making appointment and arranging for transportation to and from the dentist's office if necessary. 1. Review of Resident # 9's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of severe protein-calorie malnutrition (when a person does not eat enough protein to meet nutritional needs. Review of the resident's admission collection tool dated 7/27/23 showed: -He/She had broken teeth. -He/She needed supervision or cueing while eating. Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 8/10/23 showed: -His/Her BIMS score was 15 out of 15 indicating he/she was cognitively intact. -He/She was at risk for malnutrition. -No dental issues was checked. Review of the resident's Care Plan dated 3/6/24 showed: -Did not address the resident's broken teeth. -He/She needed extensive assistance with oral cares. Review of the resident's dental visit on 3/20/24 showed: -He/She had poor oral hygiene with heavy plaque build up. -He/She was missing the following teeth, (1,16,17, 31, and 32). -He/She had root tips (broken teeth) on on the following teeth, (3, 5, 8, 14, 19, 29). -He/She had palatal [NAME] (a boney growth on the roof of your mouth). -He/She had trauma to the left lateral boarder of the tongue from broken teeth. -A full mouth x ray was completed. -The dentist recommended the resident have extractions (teeth pulled) of teeth (3, 7, 8, 14, and 19). -After extractions the dentist suggested the resident have impressions for an upper partial (dentures). -The resident was in agreement with the plan. Review of the resident's progress note dated 3/27/24 showed a consent signed for resident to have tooth extractions with the dentist. Review of the resident's dental contract dated 3/27/24 showed he/she had signed an contract with an outside provider for tooth extraction on 3/27/24. Review of the resident's May 2024 Physician's Order Sheet showed the following orders: -Regular diet, thin consistency, dated 7/27/23. -May have dental care as needed, dated 7/27/23. Observation during initial tour on 5/1/24 at 1:06 P.M. showed the resident had many broken or black teeth. During an interview of 5/1/24 at 1:13 P.M. during initial tour the resident said: -He/She had seen the dentist and was supposed to have all of his/her teeth extracted. -The facility had not told him/her when or if there was an appointment to have his/her teeth extracted. -He/She would like to have dentures so he/she could eat more. -He/She could only eat certain foods and nothing hard like a raw carrot. During an interview on 5/2/24 at 2:25 p.m. Certified Nursing Assistant (CNA) F said: -He/She has to set the resident up for oral cares. -The resident does not have any dental issues. -They have to document that oral cares have been done in the computer. During an interview on 5/2/24 at 2:30 P.M. Certified Medication Technician (CMT) C said: -The resident did not have any dental issues. -He/She did not know if the resident had any teeth. -The Social Worker would have to make an appointment to see the dentist. During an interview on 5/2/24 at 2:40 P.M. Registered Nurse (RN) A said: -He/She did not know if the resident had any dental issues. -He/She did not know if the resident had any teeth. -The Social Worker would make an appointment to see the dentist. -He/She could not find in the computer any appointment to see the dentist for extraction. During an interview on 5/3/24 at 1:30 P.M. Social Services Assistant (SSA) said: -The resident had seen the dentist in March and was to follow up with the dentist for tooth extraction. -As of today there was no date scheduled for the resident to have his/her teeth extracted. -There should have been at least a future date of an appointment for the extraction. -Their office was responsible to ensure the residents saw the dentist when they needed to. 2. Review of Resident #13's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Need for assistance with personal care. -Hemiplegia and Hemiparesis following a cerebral infarction (Muscle weakness following a stroke-damage to the brain from an interruption of its blood supply). Review of the resident's May 2024 POS showed the following order may have dental care as needed, dated 10/15/19. Review of the resident's admission Collection Tool dated 10/15/19 showed: -He/She had teeth missing. -He/She had dentures. -He/She needed extensive assistance with hygiene. -He/She had no upper teeth and was missing lower teeth. -He/She wore full upper dentures. -He/She wore partial lower dentures. Review of the resident's Quarterly MDS dated [DATE] showed: -He/She was medically complex. -He/She had Hemiplegia. -The dental status area was blank. -His/Her BIMS score was 15 out of 15 indicating he/she was cognitively intact. Review of the resident's care plan dated 3/28/24 showed: -He/She required supervision for oral cares. -He/She wore dentures. -Staff was to coordinate arrangement for dental care, transportation as needed or as ordered. -Staff was to observe and report as needed any oral/dental problems needing attention. Review of the resident's Inventory of Personal Effects Sheet dated 4/17/24 showed: -Did not list dentures. -The resident or Responsible party did not sign or date the paper. Observation on 5/1/24 at 1:12 P.M. during initial tour showed: -The resident had many broken or missing teeth. -No denture box or dentures were observed. During an interview on 5/1/24 at 1:13 P.M. the resident said: -Had dentures when he/she came into the facility but had lost them. -He/She would like to have dentures again. -He/She had told the nurse maybe a couple of months ago. -He/She could not recall which nurse he/she told about wanting new dentures. During an interview on 5/2/24 at 2:25 p.m., CNA F said: -He/She has to set the resident up for oral cares. -The resident does not have any teeth or dentures. -The resident had not told him/her that the resident wanted new dentures. During an interview on 5/2/24 at 2:30 P.M., CMT C said: -The resident does not have any teeth or dentures. -The Social Worker would have to make an appointment to see the dentist. -The resident had not told him/her that the resident wanted new dentures. During an interview on 5/2/24 at 2:40 P.M., RN A said: -He/She did not know if the resident had any teeth. -The Social Worker would make an appointment to see the dentist. -He/She did not know if the resident had any dental issues. -If there was dental issues it should have been on their care plan. -The resident had not told him/her that the resident wanted new dentures. During an interview on 5/3/24 at 1:30 P.M., the SSA said: -The resident's admission assessment did not show any issue with his/her teeth. -There was no documentation that the resident had seen a dentist since he/she has been here and should have been seen. -The resident only has a few teeth. -They should have asked the resident if he/she wanted dentures annually. -The resident had not told him/her that he/she wanted new dentures. During an interview on 5/6/24 at 12:15 P.M., the SS Director said: -The Social Service department should have ensured the admission Inventory for the residents should have been completed upon admission. -They have not been doing it. -The resident or family member should have signed the inventory list verifying what belongings the resident came in with. -If there was a dental issues it should have been care planned. -If the resident wanted to see the dentist to see about getting dentures they should have made an appointment with the dentist as he/she is at the facility often. -This resident should have been seen by the dentist but was missed. -The resident had signed the permission sheet to have his/her teeth pulled so he/she could get dentures. -The resident had not told him/her that the resident wanted new dentures. 3. During an interview on 5/7/24 at 10:52 A.M., RN C said: -When a resident comes into the facility nursing does a full body assessment. -They would look into the resident's mouth and document on the assessment any dental issues. -If a resident had dental issues nursing would tell SS so that they could put them on the list to see the dentist. -A dentist should look into the resident's mouth at least once a year. -If there was an order to see an oral surgeon SS should have obtained a date for the appointment within a week. -The SS Director was ultimately responsible to ensure the residents had seen a dentist annually and to have made any follow up appointments. -He/She was not able to find any documentation for a follow up appointment for Resident #9. -He/She was not able to find any documentation the dentist had seen Resident #13. -He/She did not know if either of the residents had any teeth or dentures. -Resident #13 had not told him/her that the resident wanted new dentures. During an interview on 5/7/24 at 12:25 P.M. the Director of Nursing said: -There should have been documentation in the chart that a resident had seen the dentist. -It should have been documented in the progress notes or in SS notes. -The MDS nurse should have done an oral assessment upon admission. -SS was responsible to ensure the residents have dental appointments. -If it took longer than a week to obtain a dental appointment there should have been documentation in the chart as to why it was taking so long to obtain the appointment. -There was a document a few years ago stating Resident #13 did not want replacement dentures. -The resident had not told him/her that the resident wanted new dentures. -There was no documentation the dentist had seen Resident #13 since then. -The dentist should have seen the resident and documented the visit in the chart at least annually. -Nursing or the SS should have asked the resident it they wanted dentures at least annually. -It was not done because they had a staffing change.

Based on interview and record review, the facility failed to assess for, identify and provide supportive interventions for one sampled resident (Resident #18) with a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental disorder that develops in some people who have experienced a traumatic event), out of 23 sampled residents. The facility census was 115 residents. Review of a facility policy titled Trauma-Informed Care, dated 8/22/23, showed: -The facility would have used a multi-pronged approach to identify resident trauma including assessing for indicators upon admission, which would then be reviewed by the interdisciplinary team (IDT) to determine appropriate person-centered interventions to mitigate or eliminate triggers that may lead to re-traumatization. -The facility should have collaborated with resident trauma survivors and, if appropriate, resident's family, friends, or other healthcare professionals to implement an individualized plan of care with interventions. -The facility should have identified triggers that could re-traumatize residents with a history of trauma, attempting to do so even if a resident is reluctant to speak about possible triggers. 1. Review of Resident #18's admission Record on 5/6/24, showed the resident had a diagnosis of PTSD, dementia with mood disturbances, major depressive disorder, borderline personality disorder (a mental disorder characterized by unstable moods, behavior and relationships) and hemiplegia of the left side following intracranial hemorrhage (left sided paralysis stemming from a stroke). Review of the resident's Trauma Informed Care assessment, dated 11/20/23, showed: -The resident did not participate in the interview due to a cognitive deficit. -A box was checked for Other under interview participants with no further information in the provided areas. -A list of traumatic events including a generic any other event or stressful experience was noted to be unchecked. -The Not Applicable box was checked, indicating none of the events listed had been experienced by the resident. -No events, triggers, or detailed information about the resident's diagnosis of PTSD was given. Review of the resident's care plan dated 4/15/24, showed the resident had: -Potential to be physically aggressive, biting and kicking staff related to dementia. -Impaired cognitive ability and thought processes. -Nonverbal communication. -A risk for change in mood and behavior due to unnamed medical condition with interventions that included consulting with the resident's family regarding routine, providing medications as ordered, and getting a psychiatric consultation as needed. Review of the resident's medical records showed no documentation of psychiatric consultations, triggers, interventions, or further assessments of the PTSD diagnosis. During interview on 5/06/24 at 9:54 A.M., Certified Nursing Assistant (CNA) E said: -The resident often hit his/her legs. -The resident squeezed his/her legs together during personal cares and avoids the cares when possible. -He/She was not aware of any PTSD diagnosis or any potential triggers. During interview on 5/06/24 at 10:04 A.M., the Director of Social Services said: -He/She would be responsible for conducting the trauma assessments for residents. -A trauma assessment would include potential triggers. -The care plan should reflect the potential triggers and any interventions to avoid these triggers. -He/She would expect follow-up with the resident's family if the resident was unable to communicate previous traumatic experiences and potential triggers. During interview on 5/06/24 at 10:33 A.M., Registered Nurse (RN) B said he/she was unaware of a diagnosis of PTSD or any potential triggers and was not aware of any refusals of care. During interview on 5/07/24 at 12:24 P.M., the Director of Nursing (DON) said he/she would expect: -The care plan to have reflected the resident's PTSD diagnosis along with triggers and interventions. -Staff to have been aware of the residents PTSD status. -A paper trail to show progression or worsening of the resident's PTSD status.

Based on observation, interview, and record review, the facility failed to keep the Dry Storage (DS) room and walk-in freezer floors clean; failed to retain operable thermometers in all refrigerators to confirm adequate temperature ranges; failed to maintain sanitary and food preparation equipment; failed to change the deep fryer oil in a timely manner; and failed to maintain plastic cutting boards and utensils in good condition to avoid food safety hazards (cross-contamination), in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 115 residents with a licensed capacity for 172 residents at the time of the survey. 1. Observations on 5/1/24 between 10:32 A.M. and 11:05 A.M. during the initial kitchen inspection, showed the following: -There was a strip of plastic, a sugar packet, a half & half creamer pod, and an iodized salt packet under the racks in the DS room. -There was a small smudge of unknown residue on the blade of the manual can opener. -A white handled spatula hanging on a utensil rack by the food preparation table had chipped edges on its blade. -The light blue and red cutting boards were excessively scored to the point of plastic flaked off. -There was paper and plastic trash under the racks in the walk-in freezer. -The deep fryer oil had a multitude of crumbs floating on the top and was so black the bottom basket resting racks could not be seen. Observation on 5/3/24 at 10:11 A.M. during the follow-up kitchen inspection, showed the following: -There were pieces of plastic, paper, and a ketchup packet under the racks in the DS room. -The same bit of unknown residue was on the manual can opener blade. -The light blue, red, and yellow cutting boards were excessively scored. -Paper and plastic trash were under the racks in the walk-in freezer. During an interview on 5/3/24 at 10:13 A.M. the Dietary Services Manager (DSM) said the following: -The deep fryer was used about twice a week and the oil was changed every other week. -In the fall and winter, it was used more often so they tried to change the oil weekly then. Observations on 5/6/24 at 11:50 A.M. during the initial facility Life Safety Code (LSC) room-to-room inspections with the Maintenance Supervisor (MS) and the Administrator showed the white refrigerator in the Galley between the locked unit dining room and the rehab unit dining room did not have a thermometer in the bottom section. During an interview on 5/6/24 at 11:53 A.M. the Administrator said that all the food and beverages in that white refrigerator were for the residents. During an interview on 5/7/24 at 10:07 A.M. the DSM said the following: -The dietary aides cleaned the floors twice a week after their food deliveries. -Cooks and aides report damaged food preparation items to him/her and they are tossed out and replaced. -He/She would expect food to be free of foreign substances. -All refrigerators should have thermometers in them. Observations on 5/7/24 at 10:51 A.M. during another follow-up kitchen inspection showed the deep fryer oil had numerous crumbs floating on the top and was so black the bottom basket resting racks could not be seen.

Based on interview and record review, the facility failed to provide education to the resident or the resident's representative and obtain signed consent or refusal of the pneumococcal (any infection caused by the bacteria Streptococcus pneumoniae) vaccine, for two residents (Residents #48 and #166), failed to obtain signed refusal the pneumococcal vaccine for one resident (Resident #165) and failed to administer a consented pneumococcal vaccine to one resident (Resident # 61) out of five sampled residents. The facility census was 115 residents. Review of a facility policy titled Influenza and Pneumococcal Vaccine Policy for Residents, dated 7/30/2019, showed: -The facility was to offer each resident the pneumococcal vaccine unless medically contraindicated or the resident has already been immunized. -There should have been documentation in the medical record if there was reason to believe the resident was previously given the pneumococcal vaccine. -Refusals should have been documented in the medical record and re-addressed each year. -Education should have been provided in the form of a vaccine information statement (VIS) and a consent or refusal should have been signed. 1. Review of Resident #48's medical record showed: -An admission date of 1/15/24. -No pneumococcal vaccination history. -No evidence of a pneumococcal vaccine being offered or administered by the facility. -No signed consent or refusal for the pneumococcal vaccine. -No evidence of pneumococcal vaccine education provided to the resident or resident's representative. 2. Review of Resident #166's medical record showed: -An admission date of 4/13/24. -No pneumococcal vaccination history. -No evidence of a pneumococcal vaccine being offered or administered by the facility. -No signed consent or refusal for the pneumococcal vaccine. -No evidence of pneumococcal vaccine education provided to the resident or resident's representative. 3. Review of Resident #165's medical record showed: -A current admission date of 4/29/24, with an initial admission date of 3/10/21. -No pneumococcal vaccination history. -A status of Consent Refused for the pneumococcal vaccine under facility immunization tracking. -No signed refusal for the pneumococcal vaccine. 4. Review of Resident #61's medical record showed: -An admission date of 9/6/23. -No pneumococcal vaccination history. -A Informed Consent for Pneumococcal Vaccine verbally consented by resident's medical representative dated 9/7/23. -No evidence of pneumococcal vaccine education provided to the resident or resident's representative. -No evidence of administration of the pneumococcal vaccination. During interview on 5/07/24 at 9:40 A.M., the Assistant Director of Nursing (ADON) said: -He/She was responsible for ensuring the completion of pneumococcal vaccinations for residents. -Vaccine history was reviewed on admission, including the state vaccine registry. -The facility would offer the vaccine to residents able to consent and send letters to the medical representatives of those who were not. -The residents should have signed a form indicating a consent or refusal for the pneumococcal vaccine. -The pneumococcal vaccine administration or refusal should have been documented in the resident's medical record. During interview on 5/7/24 at 12:24 P.M., the Director of Nursing (DON) said: -The ADON was tasked with infection control, including ensuring the completion of the pneumococcal vaccinations of residents. -The DON was ultimately responsible for ensuring the resident's received education, the facility obtained a signed consent/refusal, administered the pneumococcal vaccine as appropriate and documented the resident's pneumococcal vaccination status in the medical record. -He/she would expect education, signed consents/refusals, vaccination administration information and the offering of the pneumococcal vaccination as appropriate to be done and documented by the facility.

Based on interview and record review, the facility failed to provide education to the resident or the resident's representative and obtain signed consent or refusal of the Coronavirus Disease 2019 (COVID-19), for three residents (Residents #48, #61, and #166) out of five sampled residents. The facility census was 115 residents. Review of a facility policy titled COVID-19 Vaccination Program Policy for Residents, dated 1/3/22, showed: -The vaccine should have been offered to each resident and staff member unless the immunization was medically contraindicated or the resident or staff member had already been immunized. -Education should have been provided to the resident or resident representative before being offered the COVID-19 vaccination. -There should have been documentation in the medical record of the education provided, each dose of the COVID-19 vaccine that was administered, and any contraindications or vaccine refusals. 1. Review of Resident #48's medical record showed: -An admission date of 1/15/24. -No COVID-19 vaccination history. -No evidence of a COVID-19 vaccine being offered or administered by the facility. -No signed consent or refusal for the COVID-19 vaccine. -No evidence of COVID-19 vaccine education provided to the resident or resident ' s representative. 2. Review of Resident #166's medical record showed: -An admission date of 4/13/24. -No COVID-19 vaccination history. -No evidence of a COVID-19 vaccine being offered or administered by the facility. -No signed consent or refusal for the COVID-19 vaccine. -No evidence of COVID-19 vaccine education provided to the resident or resident ' s representative. 3. Review of Resident #61's medical record showed: -An admission date of 9/6/23. -No COVID-19 vaccination history. -No evidence of a COVID-19 vaccine being offered or administered by the facility. -No signed consent or refusal for the COVID-19 vaccine. -No evidence of COVID-19 vaccine education provided to the resident or resident ' s representative. During interview on 5/07/24 at 9:40 A.M., the Assistant Director of Nursing (ADON) said: -He/She was responsible for ensuring the completion of COVID-19 vaccinations for residents. -Vaccine history was reviewed on admission, including the state vaccine registry. -The facility would offer the vaccine to residents able to consent and send letters to the medical representatives of those who were not. -The facility did not have a form for residents to sign that indicated a consent or refusal to accept the COVID-19 vaccine. During interview on 5/7/24 at 12:24 P.M., the Director of Nursing (DON) said: -The ADON was tasked with infection control, including ensuring the completion of the COVID-19 vaccinations of residents. -The DON was ultimately responsible for ensuring the resident's received education, the facility obtained a signed consent, administered the COVID-19 vaccine as appropriate and documented the resident's COVID-19 vaccination status in the medical record. -He/She would expect education, signed consents, vaccination administration information and the offering of the COVID-19 vaccination as appropriate to be completed and documented by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. A facility policy on resident TB screening, testing and mitigation was requested but not provided. Review of the facility Long-term Care - TB Risk Assessment, dated 2/6/24, showed: -The facility was a low-risk setting for the transmission of TB. -A two-step TST (where one antigen skin test is administered and observed for a reaction 48-72 hours later. Then, a second skin test is administered one to three weeks later and observed 48-72 hours after administration to determine if a person has antibodies for the TB bacteria) should have been completed upon resident admission. -A medical evaluation would be completed, including symptom assessment and chest x-ray is TST is positive. Review of Resident #27's medical record showed: - An admission date of 10/6/23. -No administration of a two-step TST upon admission. -No screening or evaluation of TB symptoms. -No documentation of a chest x-ray to rule out active TB infection. Review of Resident #61's medical record showed: -Administration of one step of a two-step TST (administered 1/18/24, evaluated 1/20/24). -No administration of a second step of the two-step TST. -No screening or evaluation of TB symptoms. -No documentation of a chest x-ray to rule out active TB infection. Review of Resident #165's medical record showed: -Administration of a two-step TST (3/11/21 and 3/21/21). -No annual screening or evaluation of TB symptoms. Review of Resident #166's medical record showed: -An admission date of 4/13/24. -No administration of a two-step TST upon admission. -No screening or evaluation of TB symptoms. -No documentation of a chest x-ray to rule out active TB infection. During interview on 5/07/24 at 9:22 A.M., the Assistant Director of Nursing (ADON) said Resident #166 is unable to receive a TST because they come back positive. However, the facility did not have a chest x-ray, other proof the resident did not have an active TB infection, or documentation to support inability to have a TST due to a previous positive. During interview on 5/07/24 at 9:40 A.M., the ADON said: - He/she was responsible for ensuring the completion of TB screening and skin tests. -He/She would put the orders in for resident's two-step TSTs on admission and the nurses were responsible for administering and evaluating the TST. -The nurses didn't always get the order completed or put the information into the resident's immunization record. -The residents should have an annual screening for TB in addition to their admission TST. -Any positives would need further evaluation to determine why the TST was positive. During interview on 5/7/24 at 12:24 P.M., the Director of Nursing (DON) said: - The ADON was tasked with ensuring TB screening and skin testing was completed, but the DON was ultimately responsible. -New admissions needed a two-step TST or chest x-ray on admission. -An annual evaluation needed to be completed to screen for TB. -Any readmission would need another TST if they were in the community for over 30 days. -The nurses were responsible for administering and documenting results of TSTs. 2. Review of the facility's policy, Hand Hygiene, dated 6/13/23 showed: -Associates perform hand hygiene (even if gloves were used) in the following situations: --Before and after contact with the resident. --After contact with blood, body fluids, or visibly contaminated surfaces. --Before performing a procedure such as dressing care. -Ensure that supplies necessary for adherence to hand hygiene were readily accessible in all areas where patient care was being delivered. Review of the facility's Insulin policy, dated 8/30/23 did not include directions for the staff to sanitize the hub before applying the needle. Review of the facility's Policy, Enhanced Barrier Precaution, dated 3/21/24 showed: -EBP is indicated for residents with wounds and/or indwelling devices even if the resident is not known to be infected or colonized with a multidrug-resistant organism (MDRO). -EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities which would include wound care. -The facility may choose to post signage on the door or wall outside of the resident room indicating the resident was on EBP. -Examples of high-contact resident care activities requiring gown and gloves include device care of use, including urinary catheters, and wound care for any skin opening requiring a dressing. Review of the Mayo Clinic instructional guide, How to use an Insulin Pen, on the Mayo Clinic Website, dated 6/13/14 showed: -Remove the cap from the insulin pen. -Wipe the rubber membrane with an alcohol wipe. -Apply needle. 3. Review of Resident # 51's face sheet showed he/she was admitted on [DATE] with a diagnosis of Malignant Melanoma of the skin (a type of skin cancer - when the cells that give the skin its color grow out of control). Review of the resident's Annual Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility for care planning) dated 3/14/24 showed: -The resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating he/she was cognitively intact. -He/She had a medically complex condition. -He/She had a skin tear, abrasion (a scraping or wearing away), or laceration (a deep cut or tear in the skin or flesh). -He/She had ointment or medications applied to (places) other than the feet. Review of the resident's 3/14/24 care plan showed: -He/She had excoriation ( a conscious repetitive picking of the skin that leads to skin lesion)/Yeast (a skin condition on the skin that creates a raised, red itchy bumps on the skin) on bilateral rear thighs upon admission. -He/She was witnessed on several occasions scratching and picking at areas. -Staff was to administer treatments as ordered. -The care plan did not address placing the resident on EBP related to his/her open wounds. Review of the resident's May 2024 Physician's Order Sheet (POS) showed the following order: -Apply antifungal cream to bilateral posterior thigh every day and evening shift for dry skin and itching, dated 2/10/22. Review of the resident's Weekly Skin Integrity Data Collection sheet dated 5/1/24 showed the following alterations in skin: -The resident had friction (the resistance that one surface encounters when moving over another) or shearing (a force acting in a direction that's parallel to a surface causing pressure). Observation and interview on 5/03/24 at 11:12 A.M. during wound care with Licensed Practical Nurse (LPN) C/Wound Care Nurse showed: -The resident did not need to be on EBP as the wound was not open. -The resident would often scratch his/her thighs until he/she would bleed. -The wound would heal and then open up again. -There was no EBP sign on the door. -There was no isolation supplies in the resident's room. -The nurse entered the resident's room without a gown or gloves on. -The nurse was stopped to put on isolation Personal Protective Equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses). -The resident had a large open area on his/her inner right thigh 8 x 3 inches with bloody meaty looking opened area. -The resident had a large open area on his/her left inner thigh 8 x 2 inches with red raw looking area. -The nurse cleansed the wounds per the physician's order. -He/She took off his/her gloves cleansed his/her hands and reapplied gloves. -He/She opened two packets of antifungal (medication used to treat skin infections) cream and squirted both packets of the cream into his/her right gloved hand. -He/She applied the cream to the residents right wound. -He/She applied the cream to the resident's left side wound without changing gloves or cleansing his/her hands. -The resident had the wound when he/she came into the facility a couple of years ago. -The resident went to the dermatologist (a physician who specialized in conditions that affect the skin) twice in the last couple of months. -The dermatologist said the resident had Dermatitis (An inflammation of the skin). -He/She maybe should not have applied the medicated cream to both wounds without changing gloves. -They just started EBP at the facility in April. -The resident should have had a EBP sign on his/her door stating they had to wear PPE. -He/She did the wound care on the resident daily. -The resident scratches the areas and then the area would open up again. -He/She should have worn a gown and gloves to treat the wound per the EBP protocol. -Any time there was a opening in the resident staff should have used EBP protocol. During an interview on 5/3/24 at 11:45 A.M. the resident said: -The areas on his/her thighs often itched. -He/She had scratch his/her thighs until they bleed. -The Wound Care Nurse puts medication on his/her thighs just like he/she did today. -Staff had not been wearing a gown only gloves when doing wound cares. During an interview on 5/7/24 at 9:30 A.M. Certified Nursing Assistant (CNA) E said: -The facility had provided education on EBP more than two weeks ago. -If there were any open wounds the resident would have been on EBP. -There should have been a sign on the resident's door which showed they were on EBP. -There should have been PPE at the resident's door. -The nurse was responsible for ensuring there was a sign on the resident's door and PPE available. During an interview on 5/7/24 at 10:00 A.M. Certified Medication Technician (CMT) B said: -The facility had provided education on EBP maybe three weeks ago. -The staff was expected to wear a gown and gloves when doing cares with the resident if they had an open wound. -There should have been a EBP sign on the resident's door. -There should have been an isolation cart with PPE at the resident's door. -The nurse should have been responsible for ensuring it was done. During an interview on 5/7/24 at 10:52 A.M. Registered Nurse (RN) C said: -The facility had recently provided education on EBP. -If a resident had a wound, open area, or tube the resident should have had a sign on their door stating EBP precautions were in place. -That resident should have had EBP precautions in place. -There should have been a EBP sign on the door and PPE at the door. -The nurse or charge nurse should have ensured EBP precautions were in place. -The nurse should have changed gloves and cleansed hands before applying medication to the second wound because it would spread infection from one wound to the other. During an interview on 5/7/24 at 12:25 P.M. the Director of Nursing (DON) said: -According to the Centers for Disease Control (CDC), any direct patient care when they have a wound should have EBP in place. -The facility has provided education on what was expected for EBP. -There should have been a EBP sign on that resident's door. -There should have been PPE at the resident's door. -The nurse should have used EBP because the resident had an open wound. -Any nurse could have initiated the EBP. -The nurse should have changed gloves and cleansed his/her hands before applying medication to the second wound because it would have spread germs from one wound to the other. 4. Observation on 5/3/24 at 7:50 A.M. during a medication pass with LPN B showed: -He/She took out Resident #107's Novolog (a rapid acting insulin used to control high blood sugars) insulin pen. -He/She did not clean the rubber hub before applying the needle and administering the insulin to the resident. Observation on 5/3/24 at 7:55 A.M. during a medication pass with LPN B showed: -He/She took out Resident #37's Lantus (a long acting insulin used to control high blood sugars) insulin pen. -He/She did not clean the rubber hub before applying the needle and administering the insulin to the resident. During an interview on 5/3/24 at 8:00 A.M. LPN B said: -He/She did not clean the rubber hub on the insulin pens because he/she forgot to. -The facility had provided education on using the insulin pens. During an interview on 5/7/24 at 10:52 A.M. Registered Nurse (RN) C said: -They have had education on using Insulin pens. -The nurse should have cleaned the rubber hub with an alcohol wipe before attaching the needle and administering the insulin to the resident. -The charge nurse or DON should have been responsible for ensuring the nursing staff were giving the residents insulin correctly. During an interview on 5/7/24 at 12:25 P.M. the DON said: -The staff has had education on how to use insulin pens. -The nurse should have cleaned the rubber hub with alcohol before attaching the needle to administer insulin to the resident. Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility, the facility failed to ensure proper hand hygiene was performed by staff during wound care for two sampled residents, (Resident #51 and Resident #35), failed to follow infection control practices to prevent potential cross-contamination during wound care for one sampled resident (Resident #35) and during suprapubic (s/p) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) care, including ensuring the catheter drainage bag remained off the floor for one sampled resident (Resident #52), Additionally the facility failed to initiate and perform Enhanced Barrier Protection (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) for two sampled residents, (Resident #51 and #52), failed to ensure staff sanitized the rubber hub prior to accessing and administering (medication used to treat high blood sugars) for two residents (Residents #107 and #37), and the facility failed to implement appropriate infection control procedures to mitigate the communication of infectious diseases when staff failed to ensure all residents were screened for tuberculosis (TB), a potentially serious infectious bacterial disease affecting the lungs, and failed to ensure a two-step TB skin test (TST) or a chest x-ray (tests to determine if a person is infected with the TB bacteria) was completed and documented in accordance with the facility policy for four (residents #27, #61, #165, #166), out of 23 sampled residents. The facility census was 115 residents with a licensed capacity for 172 residents at the time of the survey. 1. Observations on 5/1/24 between 10:13 A.M. and 11:05 A.M. during the initial kitchen Life Safety Code (LSC) inspection showed a three-sink area, and an area with a low-heat, chemical dish-washing machine, a handwashing sink, and an ice machine. Observations on 5/6/24 between 11:11 A.M. and 2:57 P.M. during the initial facility LSC room-to-room inspections with the Maintenance Supervisor (MS) and the Administrator showed the following: -There was a facility-wide fire sprinkler system. -There was a Laundry room with clothes washers next to the kitchen. -There were rooms with hot water heaters/boilers, and six standard bathtubs. -There were at least 85 resident rooms with sinks and bathrooms, two bathhouses, four clean/soiled utility rooms with sinks, and housekeeping closets with mop hopper sinks. -There was a satellite dining room near the Rehab Gym with an ice machine. Review of the facility's 10-page water-borne pathogen prevention program entitled, Water Management Program, last revised on 4/1/24 and provided by the MS, showed the following: -In Table 2., under the heading Inventory of System Components, some of the facility's plumbing components were mentioned, and Tables 3. and 4. had a list of Potential Hazardous Events and examples of Qualitative Measures of Likelihood, respectively, but there was no diagram or flowchart that identified and indicated specific potential risk areas of growth within the building with assessments of each area's individual potential risk level. -There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -Table 7. listed possible incidents with their response procedures, but there was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens, including testing protocols and acceptable ranges for control measures with a method of monitoring them at this facility, with interventions or action plans for when control limits were not met. -Tables 9. and 10. had 15 separate building descriptions and components to be completed, yet all were answered, 'No construction at this time. -Table 12. contained 4 protocols for vacant rooms with suggested responses to each, but there was no documentation of any being performed and/or a site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned. -Table 14. showed the quantities of several points of their water system throughout the building, but there was no written explanation of the water flow throughout the facility, with a schematic, diagram, or flowchart of the facility's complete water system. During an interview on 5/9/24 at 12:31 P.M., the MS said the following: -He/She had viewed educational materials on Legionella on the computer, but it really was not specific on program requirements. -He/She conducted an in-service for staff once and explained to them what Legionella was. Review of the in-service sign in sheets provided by the MS showed they were dated 3/31/23, 7/26/23, 8/31/23, 10/5/23, and 11/29/23, and consisted of the signature pages only, with no educational materials attached. During an interview on 5/9/24 at 2:32 P.M., the Administrator said that he/she had been educated on Legionella program requirements through viewing a recent PowerPoint training. 5. Review of Resident #35's admission Face Sheet showed the following diagnoses: -Pressure Ulcer (is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of his/her left hip Stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). -Pressure Ulcer of Sacral (sacrum, is a large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity) Area Stage IV. Review of the resident's admission MDS dated [DATE] showed: -The resident had a BIMS score of 15 out of 15 indicating he/she was cognitively intact. -He/She had a two wounds upon admission and Moisture-associated skin damage (MASD, is the general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture). -Required total staff assistance with all cares. Review of the resident's Skin Care Plan dated 3/7/24 showed he/she had break in skin integrity, Pressure Ulcer Coccyx/Sacrum and to Left Ischium (the lower and back part of the hip). Review of the resident's Physician order Sheet May 2024 showed: -Cleanse Coccyx/Sacrum and wound with Normal Saline (NS), Apply Skin Prep (a topical barrier between skin and adhesives) to surrounding edges, then apply Collagen Prisma Wound Dressing (It is a freeze-dried product designed to kick start the healing process while providing protection from infection) and apply Aquacel AG (a surgical Hydro fiber cover dressing with Ionic Silver for your wound care needs. Is suitable for a wide range of acute and chronic wounds) then cover with bordered foam dressing (convenient adhesive border helps secure the dressing in place and provides a barrier to outside contaminants) every dayshift on Monday, Wednesday and Fridays. As needed for if soiled or dressing removed. (Ordered on 4/12/24). -Cleanse Left Ischium with Normal Saline (NS), Apply Skin Prep to surrounding edges, then apply Collagen Prisma and apply Aquacel AG, then cover with bordered foam. Change dressing every dayshift on Monday, Wednesday, Friday and as needed for if soiled or dressing removed. (Ordered on 4/11/24). Observation of the resident on 5/3/24 at 8:00 A.M., showed: -The resident was on Enhanced Barrier Precautions. -Had signage posted due to wounds and other health factors. Observation on 5/3/24 at 9:00 A.M., of the resident's wound care showed: -Wound Nurse and unknown CNA entered the resident room and washed their hands with soap water, then applied protective gown and gloves on hands. -With gloves hands the Wound Nurse had removed the three old wound dressings dated 5/1/24. -The old dressings had soiled brown substance and slight wound odor noted. -Wound nurse removed his/her gloves and without washing or sanitizing his/her hands, donned clean gloves. -He/She then cleaned the resident's coccyx wound, sacral wound, and left ischium wound with the same gloved hands without changing gloves or sanitizing his/her hands between each wound. -Wound nurse removed gloves and without washing or sanitizing his/her hands, donned clean gloves. -He/She then then Apply Skin Prep to surrounding wound edges for each of the three wounds with same the gloved hands. -Without changing his/her gloves, he/she then applied the wound treatments to each wound. He/she did not change his/her gloves or sanitize hand between each wound dressing. -Wound nurse removed soiled gloves and then sanitized his/her hands to assisted in replacement of a draw sheet under the resident. -Wound nurse and CNA removed gloves and gown, washed hands with soap and water prior to exiting the resident room. During an interview on 5/7/24 10:20 A.M., CNA C said: -Hand hygiene should be done between dirty to clean areas and with every glove change to prevent cross contamination. -The facility had just started Enhanced Barrier Precaution for those resident with catheters, wounds, other medical condition that would be potential for cross-contamination during care. During an interview on 5/7/24 at 10:32 A.M., the Wound Nurse said: -He/She would wash his/her hands upon enter of the resident room prior to wound care. -He/She should sanitize or wash his/her hand between each glove change, when soiled, and from a dirty to clean process. -For residents on EBP, hands-on care staff should wear gloves and gowns, wash their hands upon entering the room, between glove changes, and from a dirty to clean process. -He/She said thought had he/she had sanitized his/her hands between each glove change by using the hand sanitizer that was in his/her scrub top pocket. -He/she should have completed each wound care separately to include hand hygiene and glove change between each wound care treatment to prevent cross-contamination during wound care and to reduce the risk of the resident getting wound infections. During an interview on 5/7/24 at 12:23 P.M., DON, Regional Director Services, Assistant Director of Nursing (ADON) said: -He/She would expect care staff to perform hand washing or sanitize hands between each glove change and between each wound care process. -He/she would expect wound care nurse and nursing staff to complete each wound care process separately, to change gloves and perform hand hygiene prior the start on the next wound to prevent cross-contamination. -He/She would expect glove changes and hand hygiene when hands or gloves were soiled or contact body fluid and from a dirty to clean process. -If wounds were open area, staff should change gloves between each wound process. 6. Review of Resident #52's admission Face sheet showed the following diagnoses: -History of urinary tract infection. -Neurogenic bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). Review of the resident's Quarterly MDS dated [DATE] showed: -The resident had a BIMS score of 15 out of 15 indicating he/she was cognitively intact. -He/She had a diagnosis of Neurogenic Bladder. -Required a indwelling catheter. -History of antibiotic use during look back period. Review of the resident's Care Plan revised on 4/12/24 showed: -The resident had a Suprapubic Catheter (S/P) related to Neurogenic bladder. -Position catheter bag and tubing below the level of the bladder. -Catheter care every shift. Review of the resident's POS 5/2024 showed: -He/She had physician order for a Suprapubic Catheter related to Neuromuscular Dysfunction of bladder, ordered on 8/28/23. -Suprapubic catheter to be irrigated with Acetic Acid Irrigation Solution 0.25 % (Acetic Acid, irrigation solution is used to prevent infection due to placement of a catheter into the bladder), use 50 centimeters (cc) via irrigation one time a day, related to his/her personal history of UTI. Plug catheter for 30 minute then unplug, (ordered on 11/7/23). -Cleanse suprapubic site with warm soap and water and replace split sponge daily every night shift. (Ordered on 9/20/22). -Catheter care every shift with warm soap and water every shift, keep catheter bag placed below the level of the bladder at all times. (Ordered on 9/8/22). Observation on 5/1/24 at 1:59 P.M. and 3:30 P.M., showed the resident's bed was in lowest position to ground, and the catheter drainage bag laid on ground without a protective barrier. Observation on 5/2/24 at 8:58 A.M., showed: -The resident bed was in low position. -His/Her catheter drainage bag hung on bed rail touching the ground without a protective barrier for the drainage bag. Observation 5/3/24 at 7:18 A.M., showed the resident's bed in the lowest position with the catheter drainage bag touching the ground. Observation on 5/3/24 at 8:38 A.M., showed the resident's bed was in lowest position to ground, with catheter drainage bag touching the floor with no barrier under the bag. Observation on 5/3/24 at 9:45 A.M., showed: -Upon enter of the resident room noted a EBP signage posted on the open door. -LPN B was going to flush the resident's suprapubic (SP) catheter. -He/She the entered the resident room and washed his/her hands. Placed gloves on his/her hands. -He/She did not don a protective gown prior to flushing the Foley catheter -He/she removed soiled gloves and washed his/her hands with soap and water. During an interview on 5/6/24 at 1:25 P.M., CMT A said: -SP catheters drainage bag should be keep below the bladder at all times. -When resident laid in bed with bed in lowest position, he/she would place on drainage back on bed frame ensuring catheter drainage bag does not touch ground to prevention infection. Observation on 05/07/24 at 9:15 A.M. the resident Foley catheter bag on touching ground no barrier, bed in lowest position. During an interview on 5/7/24 at 10:20 A.M., CNA C said: -If resident's bed low position the catheter drainage bag should be placed in a dignity bag and never touch ground. If found on ground should notify nurse and replace the catheter drainage bag. -The catheter drainage bag and tubing should not touch round due to possible pull catheter out and the possibility of cross contamination and infections. -Hand hygiene should wash your hand or sanitize your hands between a dirty to clean process and between each glove changes to prevent cross contamination. -Enhanced barrier precaution was new at the facility. -He/she should wear gown and gloves when provided direct resident care for those resident on EBP. During an interview on 5/7/24 at 10:56 A.M., LPN B said: -He/She had recent training related to EBP, a new process the facility putting in place. -If catheter care or wound care need to be completed, he/she would expect care staff to don a gown and gloves during those care to prevent cross contamination. -He/She did not wear a gown during catheter irrigation and SP site care, he/she did not see the EBP signage posted. During interview on 5/7/24 at 12:23 P.M., DON, Regional Director Services, and the ADON said: -If the resident was in bed, the catheter drainage bag should not be touching the floor or laid on ground. -He/She would expect a barrier for the catheter drainage bag if bed lowest position and not laid on floor/ground without a barrier, to prevent the potential for infection and cross contamination. -The facility had recent training for all staff related to EBP. -The facility would determine by facility EBP policy and per CDC standard of care, that any resident with open wounds, indwelling catheter, supra pubic would be placed on EBP. This would require any direct care for the wear a gown, gloves and possible mask. -He/She would expect nursing staff to have worn a gown and gloves to prevent cross contamination from potential splatters or spills when doing a catheter flush/irrigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free of misappropriation for one sampled resident (Resident #2) when Certified Nurses Aide (CNA) A used the resident's debit card to charge $4,607.20 for his/her own personal use out of seven sampled residents. The facility census was 119 residents. Review of the facility's Abuse and Neglect Policy dated 10/4/22 and revised on 7/18/23 showed: -The resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. -Residents must not be subjected to abuse by anyone. This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals. -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property of money without the resident's consent. 1. Review of Resident #2's admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] showed the following diagnosis: -Multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves); -Congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should); -Anxiety disorder (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome); -Schizoaffective disorder, depressive type (a combination of symptoms of schizophrenia and mood disorder); -Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs); -He/she passed away on 12/6/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 8/15/23 showed: -The resident was able to make self-understood and understand others. -The resident's Brief Interview for Mental Status (BIMS) score was 15 showing he/she was cognitively intact. -He/she had no delirium, inattention, disorganized thinking, altered level of consciousness, psychosis, hallucinations, delusions, physical, verbal, or other behaviors. -He/she was dependent of staff for all activities of daily living (ADLs) and required being pushed in his/her Broda chair by staff. Review of the resident's Care Plan dated 4/7/20 showed: -He/she is at risk for change in mood or behavior due to diagnosis of bipolar disorder, restlessness and agitation, and non-compliance with nursing care. -Desires to be consulted with decisions related to his/her care in order to improve current functional status. -Will allow staff to assist with basic care needs. -Will not harm self or others. -Consult with resident on preferences regarding customary routine. -Medications as ordered. -Psychiatric consult as indicated. Review of the resident's bank statement dated 12/6/23 showed the following charges: -10/25/23 World Acceptance for $582.00; -11/6/23 Prepay card for $400.00; -11/8/23 Sun Loan Company $1007.87; -11/8/23 Nine Torches $1500.00; -11/13/23 Sun Loan Company for $560.00; -11/16/23 Sun Loan Company for $557.53. Review of the facility investigation dated 12/8/23 showed: -On 12/8/23 at approximately 2:00 P.M., the resident's family member called the facility to ask about unusual charges on the resident's bank statement regarding his/her debit card usage. -A copy of the bank statement was emailed to the Administrator with the questionable charges circled. -The charges were: --10/25/23 World Acceptance for $582.00; --11/6/23 Prepay for $400.00; --11/8/23 Sun Loan Company $1007.87; --11/8/23 Nine Torches $1500.00; --11/13/23 Sun Loan Company for $560.00; --11/16/23 Sun Loan Company for $557.53; -A total of $4607.20 in unexplained charges; -The Administrator advised the family member to file a police report; -On 2/5/24, the detectives went to the facility and explained they had identified a person of interest and asked if CNA A was an employee at the facility; -CNA A was still working at the facility; -In an interview with CNA A, he/she denied having any knowledge of the charges made on the resident's debit card; -CNA A was suspended because he/she was under suspicion for using the resident's card information to make payments on various accounts that matched the charges on the resident's bank statement. -On 2/13/24, CNA A emailed his/her statement denying all allegations against him/her and that he/she never took anything for his/her own personal use. During an interview on 2/22/24 at 11:47 A.M., the Director of Nursing (DON) said: -He/she had only been working at the facility for three weeks and was not at the facility during the time of the misappropriation. -He/she had been informed about the misappropriation by the Administrator. During an interview on 2/29/24 at 11:13 A.M., the Administrator said: -On 12/8/23, he/she was notified by the resident's family member of possible fraudulent charges on the resident bank statement. -He/she advised the family member to call the police and make a report. -The family member called him/her back with the report number after filing the report with the police. -Detective A called the facility and he/she gave the detective the names of the employees who had access to the safe where the resident's debit card was locked. -The resident's debit card was locked up because he/she was giving the card to other residents to use. -He/she was not sure when the debit card was locked up, but it had been locked up for a while. -Detective A came to the facility and asked if CNA A was an employee at the facility. -He/she suspended CNA A over the phone on 2/5/24 pending the outcome of the investigation. -He/she reported the new information to the state agency on 2/5/24. -He/she received an email from CNA A on 2/13/24, stating he/she knew nothing about the debit card being used and asked when he/she could return to work. During an interview on 2/29/24 at 11:43 A.M., Social Service Assistant (SSA) said: -The resident's family member sent him/her a debit card in June 2022 and maybe $500.00 in cash. -The resident was passing around his/her debit card to other residents. -The DON took the resident's debit card and locked the card in his/her office. -The DON gave the debit card to Social Services with $200.00 cash that were locked in the safe before it was taken to the Administrator's office. -Only the Social Service Director (SSD) and SSA could open the safe. -Social Services took the debit card and cash to the Administrator's office and locked the card and money in the safe. -He/she has no idea on how CNA A got the information on the resident's debit card. -The resident did have bank statements mailed to his/her room. -It is possible the resident received a new debit card and did not tell staff. Review of the police report dated 3/4/24 showed: -Reported 12/8/23 at 2:46 P.M.; -Suspect listed was CNA A; -Victim was Resident #2; -Reporter was resident's family member; -Police Officer (PO) A was dispatched to the facility regarding a fraud; -PO A called the resident's family member to get more information; -The family member said he/she had just inherited the resident's bank account and found some fraudulent charges and emailed the bank statement to PO A; -The Administrator provided the names of the employees who had access to the safe where the card was held; -The case was handed over to Detective A; -On 1/16/24, Detective A went to World Finance and spoke with the manager regarding this incident; -The manager advised the transfer from the resident's account to World Acceptance was for World Finance; -He/she confirmed the payment was made to the business and the business had the account information for the loan paid; -Detective A submitted a formal request for the account information to the business; -On 1/18/24, Detective A responded to World Finance and picked up the transaction record for the account; -The account payment was made to an account opened in the name of CNA A; -On 1/24/24, Detective A contacted Sun Loan Company via telephone regarding this incident; -He/she spoke with the manager and was advised there was an account associated with CNA A and the payment had been made on the loan from the resident's account; -The manager stated he/she could not release any further information and forwarded this matter to the corporate office; -It should be noted the last disputed charge on the account was from Nine Torches. A search of the company yielded no reliable results; -On 1/31/24, Detective A received a call from Sun Loan Office. The employee advised a subpoena for their records would need to be submitted; -On 2/5/24, Detective A went to the facility and met with the Administrator regarding fraud; -The Administrator advised CNA A did work for the facility and was employed at the time of the incident; -Detective contacted Missouri Department of Health and Senior Services and advised them of the incident; -On 2/13/24, the facility sent an email with CNA A's time sheets and assignment sheets that showed CNA A was working during the incident; -On 2/21/24, Detective A took the subpoena to Sun Loan Company; -Detective A received the financial information regarding the account of CNA A; -The documents showed CNA A as setting up as a payment method and using the account belonging to the resident to pay for the personal loan in his/her name to the business; -On 2/28/24, Detective A contacted CNA A via phone and requested CNA A to meet with him/her at the police department; -CNA A stated he/she wanted to know what it was about, so he/she knew if he/she needed to bring his/her lawyer; -Detective A advised he/she needed to speak with CNA A regarding a matter at the facility; -CNA A stated he/she would call back by the end of the day to schedule a time; -As of 3/4/24, CNA A had not called to set up a meeting; -This matter to be forwarded to the Prosecutor's Office for review. During an interview on 3/4/24 at 12:08 P.M., CNA A said: -He/she worked at the facility from May 2023 until suspended in February 2023. -He/she did not know who the resident was and had not worked with the resident. -He/she did not know anything about the resident's debit being used to pay loans. -He/she talked to Detective A about the debit card and told him/her that he/she knew nothing about the debit card being used. During an interview on 3/4/24 at 12:35 P.M., Detective A said: -The police department received a call from the resident's family member about possible fraudulent charges on 12/8/23 and a police report was filed. -The report number was 23004830. -The family member emailed the bank statement to the police department. -He/she called the facility to get some more information and talked to the Administrator. -He/she contacted the loan companies and found out who took out the loans. -He/she then went to the facility and asked the Administrator if CNA A was an employee at the facility. -He/she made phone contact with CNA A but CNA A did not want to give a statement until he/she knew what the detective wanted to talk about to see if he/she needed a lawyer. -CNA A was to call back and set up a meeting time to give a statement but never called back. -The investigation showed that CNA A took out the loans and used Resident #2's debit card information as the source to pay the loan in payments. -He/she had sent the investigation to the prosecutor's office for review. During an interview on 3/5/24 at 12:46 P.M., the resident's family member said: -The resident would give his/her debit card to staff so they could make purchases for him/her out of the vending machines since the resident could not physically walk to the vending machines. -The resident was also buying staff sodas for getting him/her items from the vending machines as payment for their efforts. -The bank had refunded all the fraudulent charges back to the resident's bank account. -The debit card was locked up when the DON heard the resident was buying soda for the staff and other residents. -He/she was the one who called the police and filed the report after being advised by the facility Administrator to do so. MO00230341

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free of misappropriation for one sampled resident (Resident #5) out of seven sampled residents when the resident's debit card was used for $60.00 in unauthorized purchase, declined purchase of $11.60, check 496 cashed for $875.00 and check 500 cashed for $1000.00. The facility census was 121 residents. The Administrator and the Director of Nursing (DON) were notified of past non-compliance. The facility identified the missing debit card and checkbook on 10/12/23 and began investigating. A police report was made on 10/12/23 regarding the missing debit card and checks. The resident was assisted in recovery. Continued education regarding policy and procedure for Abuse and Neglect, Misappropriation of resident property. In-service began on 10/12/23 for all staff prior to the start of the shift and were completed on 10/13/23. Review of the facility's Abuse and Neglect Policy dated 10/4/22 and reviewed on 7/18/23 showed: -The resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. -Residents must not be subjected to abuse by anyone. This includes but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative, friends, or any other individuals. -Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property of money without the resident's consent. 1. Review of Resident #5's admission Record showed the resident was admitted on [DATE] showed the following diagnoses: -Memory deficit following a stroke. -Bilateral hearing loss. -Depression. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 7/20/23 showed: -The resident was able to make self understood. -The resident was able to understand others. -The resident's Brief Interview for Mental Status (BIMS) score was 12 showing he/she was cognitively intact. Review of the resident's Progress Note dated 10/12/23 showed: -His/her debit cards and checkbook were missing out of his/her room. -Social Service Assistant (SSA) went to the resident's room to look for the debit card and checkbook. -The checkbook was found in the resident's room. -SSA advised the resident to let him/her help him/her call his/her bank to cancel the debit card. -The resident said he/she was going to have a friend take him/her to the bank on 10/13/23. Review of Registered Nurse (RN) A's written statement dated 10/12/23 showed: -On 10/12/23 at 1:00 P.M. Certified Nurses Aide (CNA) D came to him/her and reported the resident stated he/she was missing his/her debit card and his/her checkbook. -He/she went and asked the resident if he/she had any concerns. -The resident said he/she was missing his/her debit card and his/her checkbook. -He/she went and reported the missing debit card and checkbook to the Director of Nursing (DON). Review of the police report dated 10/15/23 at 1:19 P.M. showed: -The police officer was dispatched to the facility on [DATE] at 2:17 P.M. in regard to stealing. -He/she made contact with Regional Director of Clinical Services (RDCS) who stated the resident told him/her that he/she was missing his/her debit card and could not find the card. -RDCS advised the resident to call the bank to see if the debit card was used at any time. -The bank advised the resident that there were two checks that had been cashed. -Disposition: Forward to investigations unit on 10/15/23 at 1:19 P.M. Review of the facility investigation dated 10/19/23 showed: -On 10/12/23 the resident reported his/her debit card and some checks were missing. -The DON and the SSA looked through the resident's room with his/her permission and the checkbook was found but not the debit card. -The Administrator, Physician, and Missouri Department of Health and Senior Services (MO DHSS) were made aware of the incident. -An investigation was initiated with the following completed immediately: --Interviewed appropriate staff. --Interviewed the resident on 10/12/23. -SSA took the resident to the bank on 10/13/23 and received copies of the checks and reported the debit card missing. -On 9/23/23 the resident's debit card was used at the convenient store for $11.60 but was declined. -On 9/29/23 check 496 was written for $875.00 and cashed at the resident's bank on 10/02/23 at 4:20 P.M. -On 10/2/23 check 500 was written for $1000.00 and cashed on 10/3/23 at 3:09 P.M. at the resident's bank. -On 10/11/23 the resident's debit card was used to pay a gas bill for $60.00. -The police were notified of the incident on 10/12/23 at 2:17 P.M., a report was done. -All staff were in-serviced on the Abuse and Neglect Policy on 10/12/23 & 10/13/23. Review of copies of the checks cashed on 11/6/23 showed: -Check #496 dated 9/29/23 for $875.00 was cashed on 10/2/23 at 4:20 P.M. -Check #500 dated 10/2/23 for $1000.00 was cashed on 10/3/23 at 3:09 P.M. During an interview on 11/6/23 at 10:27 A.M. the resident said: -He/she did not know when or who took his/her debit card and checks. -The facility did take him/her to the bank and everything was fixed. -He/she was offered a lock box to put his/her wallet and checkbook in for safe keeping. -He/she did not know the name that was on the checks for the gas bill and he/she did not authorize the use of the debit card or to write the checks. During an interview on 11/6/23 at 11:05 A.M., SSA said: -He/she took the resident to the bank on 10/13/23. -The bank verified the resident's debit card was used on 9/23/23 at a convenient store for $11.60 but was declined. -The same debit card was used to pay a gas bill for $60.00, the resident did not authorize this use. -The last check written by the resident was on 7/24/23. -The name on the gas bill account was not an employee of the facility. -The bank gave the resident copies of the two checks cashed but would not give the pictures of the person who cashed the checks. -The name the checks were written to were not employees of the facility. -Check #496 was dated 9/29/23 for $875.00, cashed on 10/2/23. -Check #500 was dated 10/2/23 for $1000.00, cashed on 10/3/23. -The signature on the checks was not the residents' signature. -The debit card was stopped and a new card was issued. -The checking account was closed and a new account was opened for the resident. -The bank was going to give the resident his/her money back and file a fraud complaint. -He/she took the residents' bank statements and locked them up. During an interview on 11/6/23 at 12:16 P.M., the DON said: -He/she was notified of the resident missing his/her debit card and checkbook. -The investigation was started right away. -The staff who worked with the resident were interviewed. During an interview on 11/6/23 at 1:58 P.M., RN A said: -He she was notified the resident had reported a missing debit card and checkbook. -He/she then reported the missing debit card and checkbook to the DON. During an interview on 11/7/23 at 12:09 P.M., CNA A said: -He/she had no idea of what was going on since he/she had not been at the facility due to him/her being sick. -He/she did not know anything about the resident missing checks or debit card. -The resident always kept his/her billfold and checkbook on his/her night stand. -He/she did not know the names on the checks of the gas account. During an interview on 11/8/23 at 2:28 P.M., RDCS said: -He/she gave the report to the police on 10/12/23 since the DON was out of the facility. -The resident's bank that he/she goes to all the time knew it was not the residents' signature when they printed the copies of the checks. -The checks were cashed at a different branch. -The resident never identified who took the debit card or checks. -Two checks were taken from the check book. The last check in the checkbook #500 and check #496. -Check #496 was cashed on 9/29/23 for $800.00. -Check #500 was cashed on 10/2/23 for $1000.00. During an interview on 11/16/23 at 10:16 A.M., the Administrator said: -The facility was not able to identify who took the resident's debit card and checks. -The resident was given a lock box to keep his/her wallet and checkbook in for safety. -The bank refunded the resident his/her money. -All staff were educated about misappropriation of resident's property before their next shift. MO00225783

Based on interview and record review, the facility failed to ensure that all alleged allegation of sexual abuse was reported immediately, but not later than two hours when on 4/30/23 Agency Certified Nurse Aide (CNA) B, Agency CNA C and Licensed Practical Nurse (LPN) D failed to report suspicious activity between residents. The failure has the potential to affect the safety of all residents. The facility census was 117 residents. 5/3/23, the Administrator was notified of the past noncompliance which occurred on 4/30/23. Facility staff were educated on reporting abuse and neglect policy before the start of the next shift. The deficiency was corrected on 5/1/23. Record review of the undated facility policy titled, Abuse and Neglect showed: -In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: --Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and to not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency). Record review of facility policy dated 10/4/22, titled Abuse-Reporting and Response - Suspicion of a Crime showed: -The facility will ensure reporting reasonable suspicion of crimes against a resident or individual receiving care from the facility within prescribed timeframe's to the appropriate entities, consistent with the Elder Justice Act. -Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from the facility. -Each covered individual shall report immediately, but not later than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 1. Facility investigation dated 5/2/23 showed on 4/30/23 at approximately 9:00 P.M., Agency CNA B stated he/she had seen Resident #1 lying on Resident #2's bed with his/her shirt on and no pants. During an interview with on 5/2/23 at 9:10 A.M., the Director of Nursing (DON) said: -The incident allegedly occurred on Sunday, 4/30/23 around 9:00 P.M. -Agency CNA B came back to work his/her shift on at 3:00 P.M., on 5/1/23, and reported to him/her that two residents had sex. -Agency CNA B kept changing the story and screaming and yelling, very hard to understand. -Facility policy was to call the police when alleged incidents such as this happens. -State agency should have been called per policy. During an interview on 5/3/23 at 8:00 A.M., Agency CNA B said: -After dinner on 4/30/23 he/she knocked on a resident door and saw a resident with another resident on the bed getting busy. -He/she doesn't know if the residents were actively engaging in sexual activity. -He/she didn't report this to anyone, as the administrator and the DON were not there. During an interview on 5/3/23 at 10:00 A.M., Licensed Practical Nurse (LPN) D said: -He/she had come onto the unit on 4/30/23 around 9:00 P.M., to do blood sugars. -It was reported to him/her by Agency CNA B that the residents were getting touchy-feely. - He/she didn't report this to anyone, as he/she didn't think about the residents having sex. During an interview on 5/3/23 at 5:10 P.M., Agency CNA C said: -He/she only saw the residents partially clothed in Resident #2's room. -He/she didn't see the residents touch each other. -He/she thinks that the residents were both in the same room partially clothed, and that was it. -He/she didn't report this to anyone, because the DON and the administrator were not there. During an interview on 5/3/23 at 2:15 P.M., the Administrator said: -He/she understood the policy and procedure for reporting, but did not think that the staff had a credible allegation of abuse to report initially. -All allegations of abuse were to be reported to the abuse coordinator, Director of Nursing or the Administrator. -Facility were educated on reporting following the incident. MO00217841

Based on interview and record review, the facility failed to ensure that an alleged violation involving abuse was reported immediately, but not later than two hours after the allegation was made, when Certified Nursing Assistant (CNA) A, grabbed Resident #1's left ankle and pushed him/her backwards while in bed, resulting in two skin tears to his/her lower left leg and bruising, out of seven sampled residents. The facility census was 120 residents. On 12/30/22 the Administrator was notified of the past noncompliance which occurred on 12/29/22. The facility administration denitrified the abuse as a reportable event and reported to the state agency. Facility staff were educated on reporting requirement. The deficiency was corrected on 12/29/22. Record review of the undated facility policy titled, Abuse and Neglect, showed: -In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: --Ensure that all alleged violations involving abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. --Not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. --Report to the administrator of the facility and to other officials in accordance with State law through established procedures. 1. Record review of Resident #1's facility face sheet, showed: -Resident admitted to the facility 12/21/2020 with diagnoses that include: --Cerebral Infarction (ischemic stroke, occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). --Dementia (a group of thinking and social symptoms that interferes with daily functioning). --Chronic Kidney Disease (Longstanding disease of the kidneys leading to renal failure). --Atherosclerotic Heart Disease (the buildup of fats, cholesterol and other substances in and on the artery walls). Record review of the facility investigation dated 12/29/22 showed: -On 12/29/22 at approximately 5:00 A.M., CNA A grabbed Resident #1 left ankle and pushed Resident #1 backwards towards the wall while in bed, resulting in two two skin tears to his/her lower left leg and bruising. -The resident went to the nurses station to Registered Nurse (RN) B, and stated that he/she really did it this time, as he/she was bleeding all over. --RN B dressed the area and resident returned to his/her room to clean him/herself up, changed his/her clothes and got back in bed. During an interview on 12/30/22 at 9:13 A.M., Director of Nursing (DON) said: -RN B did not report this incident to him/her until 10:00 A.M., when the incident took place around 5:00 A.M. -The nurse told him/her that he/she had known better than to wait to report, and was just too caught up in the moment and forgot. -The nurse accepted full responsibility for the error in reporting. During an interview on 12/30/22 at 10:00 A.M., the Administrator said: -CNA A had been terminated and RN B had been re-educated and suspended until the investigation is completed. -The incident should have been reported immediately. During an interview on 12/30/22 at 11:48 A.M., RN B said: -It was an oversight on his/her part not to notify the DON or the Administrator immediately. -He/she takes full responsibility and he/she knew he/she should have reported the incident. -He/she was just so wrapped up in the moment taking care of Resident #1. -CNA A had told him/her that the resident tried to kick him/her and the resident got a skin tear. -Resident #1 told him/her that he/she put him/her legs up in defense and the CNA pushed the legs down, and then the skin tear happened. -The resident came out to the nurses station where he/she was, and had blood all over. -He/she cleansed the area and bandaged the skin tears, which he/she actually thought were blood blisters initially. -CNA A came out of the room and said that Resident #1 had tried to kick her and got a skin tear. During an interview on 12/30/22 at 12:10 P.M., Nurse Practitioner C said RN B would be expected to report this immediately to his/her supervisor or the Administrator. MO00211852

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and recorded review, the facility failed to transcribe and verify advance directive orders for Full Code (all life saving measures, such as cardio-pulmonary resuscitation (CPR), are attempted if a person suffers cardiac or respiratory arrest) or Do Not Resuscitate (DNR - an order from a doctor that resuscitation should not be attempted if a person suffers cardiac or respiratory arrest) and updated the medical record and care plan to reflect the correct code status, for one sampled resident (Resident #11) out 29 sampled residents. The facility census was 112 residents. 1. Record review of Resident #11 admission Face-Sheet as of [DATE] showed he/she was admitted to the facility on [DATE] with the following diagnoses: -History of stroke affect the left side. -Heart failure. -Was full code status. -Was his/her own responsible person. Record review of the resident's Care Plan dated [DATE] showed the resident had an Advance Directives as a Full Code status. During an interview on [DATE] at 1:25 P.M., the resident said he/she was a DNR status, no CPR. Record review of the resident's soft chart on [DATE] at 1:57 P.M. showed the resident had purple DNR- no CPR form signed by physician and the resident dated [DATE]. Record review of the resident's Physician Order Sheet (POS) of active orders as of [DATE] at 3:58 P.M. showed physician order for: -The resident was a Full Code, active as of [DATE]. -The resident was a DNR, active as of [DATE]. -The facility had two active code status orders transcribed for the resident. During record review and interview on [DATE] at 9:23 A.M., Licensed Practical Nurse (LPN) B said: -The resident's chart was color coded as DNR and had the purple DNR sheet. -The resident's admission Face Sheet showed the resident as a full code. -Review of the resident's POS showed he/she had Full Code and DNR status. -The resident should have been a DNR status and the full code status should had been discontinued by the nurse who updated the order. -Medical Record staff were responsible for completing chart audits and to ensure code status orders were correct. -He/she was going to verify with medical records the resident code status and medical records will up date the resident chart. During an interview on [DATE] at 9:33 A.M., the Director of Nursing (DON) said: -The facility staff had updated the resident's code status on the [DATE] and verified (the code) status. -Both orders had remained in the system and did not discontinue the resident's full code. -The resident was a DNR status. During an interview on [DATE] at 12:09 P.M., the DON said: -Medical records would be responsible make sure to run a 24 hour report to check orders, including correct code status for the resident. -The facility plans to audit all medical records to ensure have proper code status transcribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the beneficiary notification was provided to one sampled resident (Resident #84), and/or his/her responsible party once the resident was discharged from Medicare out of three sampled residents selected for review. The resident sample was 29 residents. The facility census was 112 residents. 1. Record review of Resident #84's Face Sheet showed he/she was admitted on [DATE], with diagnoses including stroke with paralysis, diabetes, anemia (low iron), muscle weakness, arthritis, wounds, urinary tract infection, vitamin D deficiency, lack of coordination and abnormal gait. Record review of the resident's Beneficiary Protection Review showed: -The start date for the resident's Medicare Part A skilled services was [DATE]. -The last covered day of Medicare Part A service was [DATE]. -Medicare Part A service termination/discharge determination was initiated by the facility/provider when benefit days were not exhausted. -The document showed the facility did not provide the resident the appropriate forms informing him/her of the amount of coverage the resident still had and what the resident's responsibility would be if he/she wanted continued coverage after the last day of coverage expired. -There was no explanation for why the forms were not provided to the resident or responsible party. During an interview on [DATE] at 10:01 A.M., the Social Service Designee (SSD) said: -He/she was responsible for completing the Beneficiary Notices for residents who received Medicare Part A services. -He/she started working at the facility [DATE] and was not working at the facility when the Beneficiary Notices were completed on Resident #84. -He/she was unable to find copies of the Beneficiary Notices that were supposed to be provided to the resident to inform him/her of the last day of covered service. -The resident was still residing in the facility. -He/she did not know if the forms was ever sent to the resident or to his/her responsible party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent misappropriation of property when on 6/23/22 Certified Nurse's Assistant (CNA) E took Resident #61's debit card and made unauthorized purchases totaling $278.97 out of 29 sampled residents. The facility census was 112 residents. Record review of the facility's undated Abuse and Neglect Policy showed: - Each resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation of any type by any one. - Residents must not be subjected to abuse by anyone. This includes, but is not limited to staff, other residents, consultants, volunteers, staff from other agencies serving our residents, family members, the resident representative friends, or any other individuals. - Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Record review of pages 90 and 91 of the facility's Associate Handbook revised in 2013, showed: - Our daily business operations require adherence to legal and ethical principles and practices. - The facility was committed to: Refusing payment, kickbacks, or bribes to or from any present or prospective customers, suppliers, contractors (including physicians, hospitals, home health agencies), third party payors, or any other person in the /organization. - Being honest in all public statements, advertising and publicity; avoiding misrepresentation in all business dealings; and recognizing that permanent business relations can be maintained only on a basis of honesty and fair dealing. - Refusing any gifts, entertainment, or other benefit when the intent is to influence the recipient. 1. Record review of Resident #61's face sheet showed: - The resident was admitted on [DATE]. - The resident had diagnoses which included Chronic Obstructive Pulmonary Disease (COPD-- includes chronic bronchitis, in which the bronchi (large air passages) are inflamed and scarred, and emphysema, in which the alveoli (tiny air sacs) are damaged. This disease develops over many years) Unspecified Bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), anxiety disorder, mild cognitive impairment, primary osteoarthritis of the left knee and unsteadiness on the feet. Record review of the Resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 6/10/22 showed: - The resident was able to make self understood. - The resident was able to understand others. - The resident's Brief Interview for Mental Status (BIMS) score was 12 showing he/she was cognitively intact. Record review of the facility investigation dated 6/27/22 showed: - On 6/24/22 the Social Service Assistant (SSA) went to the Director of Nursing (DON), and stated that the resident had money missing out of his/her bank account. - The resident stated he/she gave his/her debit card and the Personal Identification Number (PIN) to Certified Nurse's Assistant (CNA) E on the evening of 6/23/22 after supper. - The resident stated he/she wanted to give a tip to CNA E, but he/she (the resident) did not have any cash. - The resident said CNA E returned his/her card around 11:00 P.M. the evening of 6/23/22. - The Administrator, Physician, and the Missouri Department of Health and Senior Services (MO DHSS) were made aware of the incident. - An investigation was initiated with the following. - CNA E suspended immediately pending investigation. - Appropriate staff were interviewed. - He/she (the DON) attempted to call CNA E three different times, but the CNA E did not answer or return calls. - An in-service on abuse and neglect was conducted. - Interviews with alert and oriented residents initiated. - Upon completion of the investigation the facility was able to substantiate that abuse/neglect had occurred. - During conversation with the resident's bank, they were advised that the resident's account had three charges/debits from the Gas Station in the local area for $42.99, $32.99 and $42.99. A fourth charge was from a convenience store in the local area for $160.00. - These charges totaled $278.97 which left $3.19 in the resident's account. - The local police department was notified, a police officer came to the facility and interviewed the resident. Record review of a written statement by the SSA dated 6/24/22 showed: - At 3:30 P.M. he/she and the resident called the resident's bank because the resident's card was declined. - The resident said he/she was not sure what CNA E used his/her (the resident's) card for, the night before. - The resident said he/she wanted to give a tip to CNA E so the resident told CNA E to take the credit card to the bank to withdraw some cash out for a $20.00 tip. - The resident said he/she gave his/her PIN to CNA E to with draw the cash. - The resident said his/her card was not returned to him/her until after 10:00 P.M. Record review of the resident's bank statement regarding the inquiries and withdrawals which took place when CNA E had the card in his/her possession (the evening of 6/23/22), showed: - An Automated Teller Machine (ATM) balance inquiry dated 6/24/22 $0 withdrawn. - An ATM Withdrawal posted 6/24/22 for $42.99. - An ATM withdrawal posted 6/24/22 for $32.99. - An ATM withdrawal posted 6/24/22 for $42.99. - An ATM withdrawal posted 6/24/22 for $160.00. - These withdrawals totaled $287.97. Record review of the Associate Acknowledgement Form showed CNA E signed that he/she understood, acknowledged the he/she understood important information about the facility's general personnel policies and about my privileges and obligations as an associate and that he/she was governed by the contents of the Associate Handbook, and Code of Conduct. CNA E signed that form on 3/15/22. During an interview on 8/2/22 at 2:11 P.M., the resident said: - He/she gave an employee his/her credit card on 6/23/22 for that employee to get a $10 tip. - He/she wanted CNA E to get a tip for packing away his/her groceries. - He/she trusted CNA E. - He/she called the bank the next day (6/24/22) and noticed his/her money was gone. - CNA E was supposed to bring it right back after he/she got the money and the employee did not. - He/she knew that employee and has not heard anything bad about that employee. - He/she felt mad when the employee took out more money than he/she should have. - The facility had not educated him/her about not giving gifts to employees. - On the night he/she gave CNA E the card and PIN, CNA E was by himself/herself. - He/she did not send CNA E to get any sodas for him/her on 6/23/22. - He/she wanted to give a tip because the employee CNA E packed away his/her groceries for him/her on a day, sometime before. - In the past he/she used a phone to order groceries and someone would go to the door and pick them up and that person, whoever it was would put the groceries away, for him/her. -He/she did not leave the facility to get groceries on his/her own. During an interview on 8/2/22 at 2:31 P.M., the DON said: - CNA E worked on the 3:00 P.M. to 11:00 P.M. shift. - The employee was suspended on 6/24/22 when it was alleged that he/she used the resident's debit card. - He/she called the police on 6/27/22. - CNA E was terminated on 6/29/22 following the facility investigation into the allegation of misappropriation which found to be substantiated. - CNA E never came in to provide a written statement, or returned any follow up calls. - The bank reimbursed the resident's money. - Employees can accept a gift like a candy bar, but certainly no employee is allowed to accept money from any resident or family. - He/she expected all staff to follow the facility's misappropriation policy. - He/she had gone over that residents should not give gifts to employees. - He/she spoke with the resident on 6/17/22 about not giving gifts to employee. -The resident would just want to give him/her (the DON) a tip, but he/she told the resident that employees could not take tips. - He/she was doing the shopping for the resident every Friday at the time because there was no Social Services at that time. -CNA E got the debit card from the resident around supper time and he/she (CNA E) did not give the card back until 11:00 P.M. on 6/23/22. - CNA E helped put away the groceries he/she (the DON) had purchased for the resident, using an app the resident used to deliver groceries. - Shopping for residents is not a normal part of the CNA's duties. - The resident did not get any sodas after CNA E returned. - He/she believed that Social Service did an in-service with the residents, but would have to confirm that for sure. During a phone interview on 8/3/22 at 5:03 P.M., CNA E said: - The resident gave him/her the debit card and asked him/her to purchase five cases of soda for the resident and asked him/her to make two cash withdrawals of $20.00 each and one for $140.00. - He/she did not normally do this for any residents. - He/she was on break when he/she went to the store. - He/she picked up 5 cases of soda and withdrew $160 and made no other charges on the resident's card. - When he/she returned, he/she gave the resident the $140 and the 5 cases of soda - He/she believed that someone else got a hold of the resident's card. - He/she did not go back to the facility to write out a statement because he/she felt disrespected by the DON's tone/statement. - The DON did not explain to him/her why he/she was needed at the facility. - He/she found out later that the resident was reporting issues with his/her debit card now being declined. - He/she did not use the resident's card at a gas pump. - The facility had not informed him/her that he should not take cards or cash from a resident. - He/she did not read the employee hand book to make himself/herself aware of the facility's policy regarding accepting gifts from residents. - Another CNA and an agency person (unknown name) drove him/her to the gas station because he/she did not drive a car. - None of the other employees who drove him/her, went into the gas station with him/her. - He/she got $140 and five cases of soda for the resident and a $20 bill (as a tip for himself/herself). - He/she did not remember what the price of the five cases of pop was. - The resident did not have any past history with him/her. - The resident gave him/her the PIN number. - The resident did not give him/her a tip. - He/she turned everything over to the resident. - The people who were with him/her did not use the resident's card at all and they did not even know about it. - The facility did not let him/her know that he/she could not take gift from residents. During an interview on 8/8/22 at 1:11 P.M., CNA F said: - He/she worked on the evening of 6/23/22. - He/she saw that CNA E when he/she came back to the facility and CNA E did not come back from his/her outing with anything for the resident. - The resident had been looking for CNA E while he/she was gone. - He/she was not sure when CNA E gave the card back to the resident. - The resident approached him/her and another employee (CNA G) about the whereabouts of CNA E. - The resident yelled out that CNA E did not bring back his/her groceries. - CNAs were taught not to take a debit or credit card from any resident and go shopping for that resident. - The employees are supposed to take the residents to the vending machine or leave a note for Social Services, if they needed items purchased. During a phone interview on 8/8/22 at 1:18 P.M., CNA G said: - Towards the end of the evening shift, the resident approached him/her and another employee (CNA F) and asked where CNA E was. - The resident said he/she looked for CNA E because he/she gave him/her a debit card. - The resident did not specify what CNA E was supposed to get for her. - He/she (CNA G) does not accept money from residents. - He/she saw CNA E at beginning of shift but did not see CNA E after dinner on that shift. During a phone interview on 8/8/22 at 8:44 P.M., Certified Medication Technician (CMT) A said: - The resident came to him/her and said that CNA E was supposed to get $20 as a tip. -The resident asked him/her for money to purchase a soda from the vending machine - After the resident spoke with him/her, he/she (CMT A) called CNA E and said to bring the card back to the facility. - CNA E left the facility by himself/herself. - He/she witnessed CNA E return to the facility around 10:45 P.M. - When he/she returned he/she had nothing for the resident. - CNA E had $20 in his/her hand; CNA E gave the debit card back to the resident and kept the $20 and placed it in his/her pocket. - Employees are supposed to refuse all gifts from residents. During an interview on 8/8/22 at 9:09 P.M. CNA H said: - He/she sat at the nurse's station next to CMT A on that evening shift, when the resident asked him/her and CMT A for money to purchase a soft drink from the vending machine. - CMT A asked the resident why he/she would need money. - The resident said he/she given his/her card to CNA E to get something from the gas station and CNA E had not returned from the errand yet. - He/she did not see anything in CNA E's hand when he/she (CNA E) came back from the store. - Employees are supposed to refer the residents to Social Services, if they ( the residents) want someone to go shopping for them. During an interview on 8/16/22 at 12:55 P.M., the Administrator said he/she expected all employees to politely decline any gifts or tips from residents or residents' families and to decline any kind of monetary gifts or tips. Complaint MO 00203059

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #56's Face Sheet showed he/she was admitted [DATE] with a diagnosis of Chronic Kidney Disease, Stage 3 (kidneys have mild to moderate damage, and are less able to filter waste and fluid out of the blood). Record review of the resident's quarterly MDS dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 12 which demonstrated the resident was cognitively intact. Record review of the resident's care plan dated 7/7/22 showed: -He/she wished to attain prior level of functioning. -He/she wished to return home. During an interview on 8/3/22 at 2:22 P.M., the resident said: -He/she had never been to a care plan meeting but would have liked to have attended. -He/she felt he/she didn't have a say in his/her care. -He/she would have liked the opportunity to ask providers questions about their decisions. -He/she did not know what was in his/her care plan. -The staff told him/her what to do and how; he/she had no say. 3. Record review of Resident #61's Face Sheet showed he/she was admitted [DATE] with a diagnosis of Unspecified dementia without behavioral disturbances (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Record review of the resident's care plan dated 5/31/22 showed: -He/she requested assistance with electronic devices. -He/she enjoyed food related activities. -He/she wanted to be invited to functions. Record review of the resident's annual MDS dated [DATE] showed the resident had a Brief Interview for Mental Status (BIMS) score of 12 which demonstrated the resident was cognitively intact. During an interview on 8/3/22 at 2:02 P.M., the resident said: -He/she would have liked to go to a care plan meeting but had never been invited and did not know when they occurred. -He/she wanted to attend so he/she could have had a say in his/her care. -He/she did not like it at all that decisions were made without talking to him/her. -He/she had taken care of himself/herself all his/her life and wanted to continue making his/her own decisions. 4. During an interview on 8/3/22 at 1:33 P.M., the Social Services Director (SSD) said: -The facility had not had care plan meetings for a while. -The facility did not invite the residents or their representatives to care plan meetings due to lack of a SSD. -He/she expected the resident and their family to be invited to the care plan meetings. During an interview on 8/4/22 at 1:16 P.M., Certified Nursing Assistant (CNA) O said he/she expected the resident and family to be involved in the care plan process. During an interview on 8/4/22 at 2:18 P.M., CNA L said he/she expected the resident and their family to be involved in the care plan process. During an interview on 8/5/22 at 9:41 A.M., CNA F said he/she expected the resident and their family to be involved in the care plan process. During an interview on 8/5/22 at 9:57 A.M., CNA P said he/she expected the resident and their family to be involved in the care plan process. During an interview on 8/5/22 at 10:12 A.M., Registered Nurse (RN) B said the nursing staff did not update the care plans but they can access them in the resident's electronic record. He/she said the care plan should be updated to show the current health status of the resident. During an interview on 8/5/22 at 10:29 A.M., the Staffing Development Coordinator said he/she expected the resident and their family to be invited to their own care plan meeting. During an interview on 8/5/22 at 11:09 A.M., RN B said he/she expected the resident and their family to be invited to their own care plan meeting. During an interview on 8/8/22 at 12:09 P.M., the Director of Nursing (DON) said: -He/she expected the resident and their family to be invited to their own care plan meeting. -He/she would sometimes go over the care plan with the resident after the care plan meeting. -The interdisciplinary team can put care plan interventions into the resident's care plan but the MDS person should input all updates and information but the Assistant Director of Nursing (ADON) or her should monitor. They communicate with the nurses verbally on updates to the resident's care plan and they also update the interventions in the resident's electronic record. Based on observation, interview and record review, the facility failed to ensure the care plan for one sampled resident (Resident #77) was updated to show the resident developed a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction); to include the resident and/or resident's representative during the development of their individualized care plan for two sampled residents (Resident #56 and #61) out of 29 sampled residents. The facility census was 112 residents. Record review of the facility's policy 'Comprehensive Care Plans and Revisions' dated 3/2/22 showed the care plan was to be prepared by an Interdisciplinary Team (IDT) that included the resident and the resident's representative. 1. Record review of Resident #77's Face Sheet showed he/she was admitted on [DATE], with diagnoses including end stage renal disease, high blood pressure, pressure ulcer, diabetes, heart disease, weakness and fatigue, and dysphagia (difficulty swallowing). Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 6/17/22, showed the resident: -Was alert with confusion and memory loss. -Needed total assistance with mobility, transfers, dressing, toileting; extensive assistance with hygiene. -Was at risk for pressure sores, had no current pressure sores and no healing pressure sores. -Received interventions (pressure relieving devices for bed, chair and nutritional interventions) to prevent pressure sores. Record review of the resident's Care Plan dated 6/24/22, showed the resident had potential/actual impairment to his/her skin integrity and fragile skin and had two areas of shearing to the left gluteal fold. It showed the resident had the potential for pressure ulcer development related to his/her history of pressure ulcers on admission, limited mobility, cognitive impairment, poor circulation, incontinence, renal failure, and history of protein calorie malnutrition. The interventions instructed staff to: -Assess location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to the physician. -Clean and dry skin after each incontinent episode. -Educate resident/family/caregivers of causative factors and measures to prevent skin injury. -Encourage good nutrition and hydration in order to promote healthier skin. -Follow facility protocols for treatment of injury. -Identify/document potential causative factors and eliminate/resolve where possible. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. -Administer treatments as ordered. -Serve diet as ordered, monitor intake and record. -Assist the resident to turn/reposition at least every 2 hours, more often as needed or requested. -Assist the resident with use of bed rails, transfer bar, etcetera, to assist with turning. -Provide pressure relieving/reducing device bed/chair. Record review of the resident's Nursing Notes showed: -On 7/18/22 staff notified the nurse that the resident had a break in his/her skin integrity. The nurse observed a pressure sore to the resident's left buttock that measured 1.3 centimeters (cm) length by 1.2 cm width by 0.1 cm depth. Treatment was in place. The physician and responsible party were notified. -On 7/20/22 the IDT discussed the pressure sore to the resident's left buttock discovered on 7/18/2022. The wound measures 1.3 cm (L) by 1.2 cm (W) by 0.1 cm (D). There is no drainage. The resident denied any pain at the wound. The wound was cleansed with hypochlorous acid (a topical antimicrobial that can decrease the bacterial bioburden of chronic wounds without impairing the wound's ability to heal), Aquacel Ag (a moisture-retention dressing, which forms a gel on contact with wound fluid and has antimicrobial properties) was placed and covered with a bordered foam dressing. The physician, and resident, who was his/her own responsible party, were all notified. The resident was a double amputee who was non complaint with turning and repositioning. He/she would sit up in bed and in his/her chair most of the time. Wound care would again re-educate him/her on the importance of repositioning and the dangers of the pressure ulcers. Wound care would monitor and treat the wound. The dressing would be changed on Monday, Wednesday and Fridays and as needed. Record review of the resident's Wound Risk assessment dated [DATE] showed the resident scored 16 which was mild risk. Record review of the resident's Physician's Order Sheet (POS) dated August 2022 showed physician's orders to: -Cleanse the resident's left buttocks with Hypochlorous acid, apply skin prep (a liquid film-forming dressing that, upon application to intact skin, forms a protective film to help reduce friction during removal of tapes and films) and Aquacel AG. Cover with bordered foam every day shift and as needed for wound care. -Prosource Plus (concentrated liquid protein), two times a day for dialysis and wound healing. Record review of the resident's Care Plan showed the care plan was not updated to show the resident developed a pressure sore and wound care treatments were initiated. It did not show that the resident was often non-compliant with turning and repositioning and sat up in bed/wheelchair most of the day which would impact healing. It did not show that the wound care team was treating the resident's wound three times weekly. Observation and interview on 8/3/22 at 12:01 P.M., showed the resident was sitting in his/her bed in his/her room. He/she had above the knee amputations to both legs. He/she said: -He/she had a wound on his/her bottom that was acquired in the facility. -The wound doctor came in yesterday and told him/her to try to stay off of his/her left side so the wound could heal. -He/she received wound care treatment from the nurse but he/she did not know how often they were supposed to complete it, but they put a cream on it. - He/she said his/her wound was healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #58) who had a pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and identified as a resident who required turning and repositioning every two hours received the necessary treatment of turning and reposition to promote healing, out of 29 sampled residents. The facility census was 112 residents. Record review of the facility's policy 'Skin Integrity and Pressure Ulcer/Injury Prevention and Management' dated 8/5/21 showed staff were to reposition residents every 2-4 hours. Record review of Medlineplus.gov's article 'How to Care for Pressure Sores' dated 5/30/20 showed treatment for pressure ulcer/sore/injury includes repositioning every 2 hours if in bed. 1. Record review of Resident #58's Face Sheet showed he/she was admitted [DATE] with the following diagnoses: -Dementia without behavioral disturbances (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). -Stage III pressure ulcer (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) on the coccyx (tailbone) added 6/15/21. Record review of the resident's quarterly Minimum Data Set (MDS--a federally mandated assessment tool completed by facility staff used for care planning) dated 6/17/22 showed: -The resident had a Brief Interview for Mental Status (BIMS) score of 00 which demonstrated the resident had a severe cognitive impairment. -The resident was totally dependent in all activities of daily living (ADLs). -The resident was not on a turning/repositioning program. -There was no indication that the resident had any pressure ulcers. Record review of the resident's care plan dated 6/23/22 showed: -The resident required turning and repositioning. -The resident was totally dependent and required 2 staff for repositioning and turning in bed. -The resident was bedfast (confined to bed, as by illness or age; bedridden) all or most of the time. -Facility staff were to follow facility policies/protocols for the prevention/treatment of skin breakdown. -The resident had a Stage III pressure ulcer to the coccyx added 6/20/22. -NOTE: The date the Stage III pressure ulcer was added to the care plan did not match the date the Stage III pressure ulcer was added to the resident's face sheet. Record review of the resident's Order Summary Report dated 8/4/22 showed no order for turning and repositioning the resident. Continuous observation on 8/3/22 from 11:51 A.M. to 3:10 P.M. showed: -The resident was laying on his/her back. -The resident was not able to turn or reposition himself/herself. -Staff did not turn or reposition resident. Continuous observation on 8/4/22 from 8:31 A.M. to 11:01 A.M. showed: -The resident was positioned on his/her back with the head and foot of his/her bed elevated. -The resident was positioned in a manner where the majority of his/her body weight was on his/her coccyx where the pressure ulcer was located. -The resident was not able to turn or reposition himself/herself. -Staff did not reposition the resident. Observation on 8/4/22 at 12:05 P.M. showed: -Licensed Practical Nurse (LPN) C and LPN D turned the resident to his/her right side to provide wound care. -LPN C and LPN D returned the resident to laying on his/her back with the head of the bed elevated approximately 30 degrees. Observation on 8/4/22 at 1:05 P.M. showed: -The resident remained on his/her back with the head of his/her bed elevated. -The resident was not able to turn or reposition himself/herself. During an interview on 8/4/22 at 1:16 P.M., Certified Nursing Assistant (CNA) O said: -He/she repositioned residents every 2 hours if they had a risk of developing or already had a pressure ulcer. -He/she did not document repositioning. -He/she ensured residents were repositioned by making rounds every 2 hours and repositioning all at-risk residents. Observation on 8/4/22 at 2:16 P.M. showed: -The resident remained on his/her back with the head of his/her bed elevated. -The resident was not able to turn or reposition himself/herself. During an interview on 8/4/22 at 2:18 P.M., CNA L said he/she would turn a resident with a pressure ulcer on their coccyx from side to side every 2 hours to keep pressure off the wound. Observation on 8/5/22 at 8:58 A.M. showed: -The resident was lying flat on his/her back with his/her legs rolled slightly to the right side. -The resident was not able to turn or reposition himself/herself. Observations on 8/5/22 at 9:35 A.M. showed: -The resident remained on his/her back with his/her legs rolled slightly to the right side. -The resident was not able to turn or reposition himself/herself. During an interview on 8/5/22 at 9:41 A.M., CNA F said he/she repositioned residents every 2 hours from side to side or will stand the resident up if the resident was able. During an interview on 8/5/22 at 9:57 A.M., CNA P said: -He/she ensured residents were repositioned every 2 hours and that the wound dressing remained clean, dry, and intact. -If he/she didn't know the last time a resident was repositioned, he/she would reposition all residents at the beginning of his/her shift and then every 2 hours thereafter. During an interview on 8/5/22 at 10:29 A.M., the Staffing Development Coordinator said: -Residents should be positioned to relieve as much pressure as possible from the wound. -Residents were to be repositioned every 2 hours or more if needed. Observation on 8/5/22 at 11:03 A.M. showed: -The resident remained on his/her back with his/her legs rolled slightly to the right side. -The resident was not able to turn or reposition himself/herself. During an interview on 8/5/22 at 11:09 A.M., Registered Nurse (RN) B said residents with a pressure ulcer were to be repositioned every 2 hours. Observations on 8/5/22 at 12:41 P.M., 1:45 P.M., and 2:29 P.M. showed: -The resident remained on his/her back with his/her legs rolled slightly to the right side. -The resident was not able to turn or reposition himself/herself. During an interview on 8/8/22 at 12:09 P.M., the Director of Nursing (DON) said: -Residents were to be repositioned every 2 hours or more if needed. -Nurses were responsible for ensuring residents were repositioned. -There was no place to document repositioning a resident. -The resident's pressure ulcer required him/her to be repositioned every 2 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate supervision during medication administration by leaving the resident's medication at bedside for one sampled resident (Resident #91) out of 29 sampled residents. The facility census was 112 residents. Record review of the facility's Administration of Medications Policy revised 5/6/22 showed: -The facility will ensure medication are administered safely and appropriately per physician order to address resident's diagnoses, signs and symptoms. -A Physician order that include dosage, route, frequency, duration, and other required consideration for administration of medications. 1. Record review of Resident #91's Face sheet showed he/she was admitted to the facility on [DATE] had diagnosis including: -Acquired absence of left eye. -Cancer of the face. -Cognitive communication Deficit. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/101/22 showed he/she: -Was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 12 out 15. -He/she was able to understand others and make his/her needs known. -Required supervision and assistant of setup of one staff member for all cares. Record review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated July 2022 and August 2022 showed: -Had no physician order for self-medication or assessment for safety of self-administration. -No documentation of the resident able to safely self administer medication. -No documentation that medication left at resident bedside per his/her request. Observation on 8/1/22 at 9:50 A.M., of the resident showed: -He/she was sitting at side of his/her bed. -He/she had four pills on Kleenex laid on his/her bed, -He/she said that staff left medication for him/her to take at his/her own pace. Observation on 8/2/22 at 10:35 A.M., of the resident showed: -The resident had three pills on Kleenex on his/her bed and supplemental drink on the bedside table. -He/she had one round pink pill and two round white pills. -The resident said he/she will take the medication as he/she needed, one at a time. Record review of the resident's medical record showed the resident had no physician's order or safety assessment completed for self-medication. Observation on 8/05/22 at 10:04 A.M., of the resident showed: -He/she had one white pill on Kleenex place on his/her bed. -Had a supplemental drink on his/her bedside table. During an interview on 8/05/22 at 10:37 A.M., Registered Nurse (RN) A said: -He/she was not aware of any current physicians orders for any resident to administer own medication. -Nursing and Certified Medication Technician (CMT) should not leave medication at bedside for the resident. -Would require to obtain a physician order for the resident to be able to leave medication at bedside. -Nursing staff would have to complete a medication safety assessment for that resident to assess the his/her ability to safely self-administer medication. During an interview on 8/5/22 at 12:00 P.M., RN B said: -The resident should have a physician order for self medication and safety assessment completed. to asses the resident's ability to safety take own medication. -The resident will get upset easily if rushed with taking medication and wants to take one pill at a time at his/her own pace. -The resident will sometime place them in his/her mouth and then remove pills to take later. -The resident had taken all his/her medication that morning prior to RN B leaving the resident room. During an interview on 8/8/22 at 12:09 P.M., Director of Nursing (DON ) said: -He/she would expect the CMT or nursing staff to stay with the resident until the resident had taken all of his/her medication. -The resident's medication should not be left in the resident room unsupervised by facility staff. -The resident would require a nursing assessment on his/her ability to safely administer medication and would require a physician order to keep at bedside to take later.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #58's Face Sheet showed he/she was admitted [DATE] with the following diagnoses: -Dementia without behavioral disturbances (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). -Personal history of UTI added 11/28/18. Record review of the resident's quarterly MDS dated [DATE] showed: -The resident had a BIMS score of 00 which demonstrated the resident had a severe cognitive impairment. -The resident was totally dependent in all activities of daily living (ADLs). -The resident had an indwelling urinary catheter. Record review of the resident's care plan dated 6/23/22 showed the resident had a suprapubic urinary catheter (cath). Record review of the resident's POS dated 6/24/22 showed the physician ordered the resident two antibiotics (a medicine that inhibits the growth of or destroys microorganisms) with a diagnosis of UTI. Record review of the resident's electronic health record titled 'Intake and Output' (I & O) documentation from 7/17/22 to 8/2/22 showed: -The staff missed documenting output 4 out of 20 days. -The staff recorded the output (each time drainage bag was emptied) once daily with the exception of 2 days. -Urine output was lower than anticipated on 3 days, no notes of any complications or assessments completed. Continuous observation on 8/3/22 from 11:51 A.M. to 3:10 P.M. showed: -Staff did not check the resident's urine drainage bag or catheter tubing for kinks. -Staff did not empty the resident's urine drainage bag. -Staff did not clean the resident's insertion site or tubing. -NOTE: Urine drainage bag noted to be at maximum capacity at 2:09 P.M. Observation on 8/3/22 at 3:10 P.M. showed the resident's urine drainage bag remained at capacity and bulging. Continuous observation on 8/4/22 from 8:31 A.M. to 11:01 A.M. showed: -Staff did not check urine drainage bag or catheter tubing for kinks. -Staff did not clean insertion site or tubing. During an interview on 8/4/22 at 1:16 P.M., CNA O said: -Catheter care every shift meant to clean around the insertion site and make sure the bag was empty. -Sometimes he/she was required to measure the volume of urine drained and record it. During an interview on 8/4/22 at 2:18 P.M., CNA L said: -Catheter care every shift meant to keep the area clean and empty the drainage bag. -He/she did not know if cleaning the insertion site/tubing should have been specified in the physician's order. Record review of the resident's Order Summary Report dated 8/4/22 showed: -The physician ordered cath care every shift. In the notes section, the description read, Keep catheter placed below the level of the bladder and ensure secured device is in place as needed. -NOTE: No order for frequency of emptying drainage bag, cleaning of catheter, recording urine volume/color/consistency/odor. During an interview on 8/5/22 at 9:41 A.M., CNA F said: -Catheter care every shift meant to clean the insertion site and tubing of catheter. It would also include emptying the urine drainage bag at least once a shift or more if bag was full. -Urine volume should be recorded in the resident's electronic health record. During an interview on 8/5/22 at 9:57 A.M., CNA P said: -Catheter care every shift meant to clean the insertion site and tubing. -There was no place to document cleaning of catheters. During an interview on 8/5/22 at 10:29 A.M., the Staffing Development Coordinator said: -Catheter care every shift meant to clean the insertion site and tubing. -Cleaning of the catheter was to be documented on the Treatment Administration Record (TAR). -Staff were to empty the urine drainage bag each shift or more frequently if drainage bag was full. During an interview on 8/5/22 at 11:09 A.M., RN B said: -Catheter care every shift meant to clean around the insertion site, clean the catheter tubing, and ensure the drainage bag was below the bladder. -Staff were to empty the urine drainage bag at least once per shift but more often if the bag was full. -Staff were to document the volume drained in the resident's electronic health record. 4. During an interview on 8/8/22 at 12:09 P.M., the Director of Nursing (DON) said: -He/she would not expect to have detail physician order on type of care need for the resident Suprapubic catheter. -Physician Orders stating catheter care every shift means: cleaning catheter site and tubing. -The staff knew meaning of catheter care because the facility had in-services on what catheter care meant. -Catheter Care of site would be documented on the resident's TAR. --NOTE: TAR did reflect 'cath care: Keep catheter placed below the level of the bladder and ensure secured device is in place as needed' as completed daily. However, there was no documentation that cleaning had taken place or a description of the insertion site. -Would except detailed description of Suprapubic site upon admissions as part of the admission skin assessment. -He/she would expect nursing staff to clean the catheter site each shift. -There was nowhere you could specifically document that cleaning of the catheter had been completed. -If there were issues with catheter, nursing staff could document in the resident's progress notes. -If there were no problems with the insertion site he/she did not expect any documentation. -The facility did not document or track I&O's for the residents. -The residents kardix and care plan should have care need for the resident with catheter. -CNA and nursing staff were responsible for emptying the resident's catheter bag at least every shift and as needed. -He/she would expect care staff to be checking the resident's catheter bag each time they entered the resident's room for placement and if the catheter bag needed to be emptied. -The resident's catheter bag should not be touching the floor. -If the resident's bed was in the lowest position, he/she would expect the catheter bag be placed in or on a barrier such as a wash basin. MO 00204631 and MO 00202932 Based on observation, interview and record review, the facility failed to ensure infection control practices were maintained during the placement of a Suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) drainage bag (catheter bag, a bag that hold drained urine) and to ensure to follow physician orders for care and monitoring of SP catheter for one sampled resident (Resident #84) who was at risk for Urinary Tack Infections (UTI - an infection of one or more structures in the urinary system); and to ensure a resident's suprapubic catheter drainage bag was monitored for fullness and the catheter drainage bag was emptied in a timely manner for two sampled residents (Resident #37 and Resident #58), who had been recently treated for an urinary tract infection out of 29 sampled residents. The facility census was 112 residents. Record review of Missouri Certified Nursing Assistant (CNA) Manual Nursing Assistant in Long term Care Facility Student Reference, Revised 2010 showed: -Indwelling catheter (is a catheter tube passed through the urethra into the bladder to drain urine) care should be provided at least every shift and if soiled. -Perineal care is very important in maintaining the resident comfort. More frequent care was required for residents who were incontinent or for those who have an indwelling catheter. Make every effort to respect the modesty of residents and be gentle when cleansing this sensitive area. -The catheter drainage tubing and bag must be maintained below the level of the bladder. -The catheter drainage tubing and bag must not touch the floor. -The catheter drainage bag should be checked for urine and kinks in tubing every 2 hours. -Drainage bag must be emptied when starting to get full and at the end of each shift. Record the amount emptied. -Suprapubic catheter care includes monitoring the skin at insertion site and observing the dressing for any drainage. Record review of the facility's Suprapubic Catheter Care policy revised 9/20/21 showed: -The facility would provide daily suprapubic catheter care in accordance with professional standards of practice, as outlined by [NAME] (is an evidence-based procedure guidance for nurses at the point of care.) through the procedure linked below. -Site care for established catheter cleanse the site with soap and water and dry with towel or gauze. -Assess the stoma (site) for irritation, erosion, and urine leakage and assess the surrounding skin for redness, swelling, warmth and tenderness. Notify physician if there signs of infection present. -Monitor the resident's intake and output. Observe the urine for appearance, odor, color and any unusual characteristic. Monitor for signs and systems of infection. -Document the volume of the resident output. Record the catheter insertion site, and the date and time catheter dressing changes, the type of dressing used and the resident tolerance. Record review of the facility's Indwelling Urinary Catheter (Foley, inserted through urethra into bladder) Management Policy issued 4/1/22 showed: -Keep catheter drainage bag below level of the bladder and do not let the bag rest on the floor. -Empty the collection bag regularly and avoid splashing or spilling the urine. 1. Record review of Resident #84's admission Face-sheet showed he/she was admitted to the facility on [DATE] with diagnosis of: history of urinary tract infection and neuromuscular dysfunction of the bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). Record review of the resident's Suprapubic Catheter Care Plan revised on 6/22/22 showed: -The resident had a neurogenic bladder (the nerves that carry messages back-and-forth between the bladder and the spinal cord and brain don't work the way they should). -The resident had a 18 French units (Fr, size) /10 milliliter (ml) (balloon size, inflated with normal saline to hold catheter in place) suprapubic catheter, change catheter every month. -Nursing staff were to irrigate the SP catheter as ordered. -Catheter care every shift by all facility care staff. -Position catheter bag and tubing below the level of the bladder. -Check tubing for kinks each shift during CNA rounds. -Monitor and report to physician any signs and symptoms of infections. Record review of the resident's Progress note dated 6/23/22 at 9:26 A.M. showed: -The resident had no urine output from suprapubic catheter during the night shift. -The catheter was changed with #16 FR/10Cubic centimeter (cc) Foley. -The resident had clear urine obtained at that time of insertion of the supra pubic catheter and was connected to catheter drainage bag. Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/1/22 showed he/she: -Was cognitively intact had Brief Interview for Mental Status (BIMS) score of 12 out 15. -He/she was able to understand others and make his/her needs known. -Required total assistant of two staff for all cares and transfers. -Had a suprapubic catheter in place. During an initiation of complaint with the resident on 7/12/22 at 9:29 A.M., the resident said: -His/her catheter was supposed to have been flushed every night. -Nursing staff have not been flushing his/her suprapubic catheter nightly. -Nursing staff tried to flush his/her catheter on 7/11/22, but it was clogged. -He/she thought the catheter being clogged was due to being so long since the last time catheter was flushed. Record review of the resident's Treatment Administration Record (TAR) and Medication Administration (MAR) dated 7/1/22 to 7/31/22 showed: -A physician order for night nursing staff to irrigate the resident catheter with 50-100 cc of normal saline daily, during the night shift as part of his/her catheter care. Was ordered on 3/23/22. -No documentation of the resident having his/her catheter irrigated on 7/8/22 and 7/12/22. Observation on 8/1/22 at 9:51 A.M. showed: -The resident's bed was in the lowest position, within inches from the floor. -The resident's suprapubic catheter drainage bag was attached to the bed frame and the bottom of the bag was lying on the ground without a barrier. Record review of the resident's Physician's Order Sheet (POS) printed on 8/3/22 showed the resident physician order for: -Catheter care every shift and to keep the his/her catheter bag placed below the level of the resident bladder. -To cleanse the Suprapubic site with normal saline and apply split gauze (dressings help keep patients skin dry and clean around drains) and secure with tape. -The night nursing staff were to irrigate the resident's catheter with 50-100 cc of normal saline daily on every night shift and as needed for catheter care. Was active order dated 3/23/22. -New Physician's order dated 8/2/22 at 3:00 P.M. for nursing staff to irrigate the resident's Suprapubic catheter with 50-100 cc Sterile Water, every shift for catheter patency. -Nursing staff were to change the resident Suprapubic catheter every four weeks and to change the resident Suprapubic tubing (a tube with retaining balloon passed through into the bladder to drain urine) with 18 FR/10 ml (size of catheter tubing and amount to inflate balloon) catheter, change once a month every 1 month(s) starting on 7/ 28/22 for 28 day(s). Related to infection control and patency. Observation on 8/4/22 at 8:50 A.M., of the resident showed: -His/her bed was in the lowest position, within inches from the floor. -His/her Suprapubic catheter drainage bag was attached to bed frame and the bottom of the bag was lying on the ground with no barrier. Observation 8/5/22 at 9:05 A.M., of the resident showed: -He/she was lying in his/her bed, which was in lowest position to ground. -His/her catheter bag was hanging on bed frame and was lying on the ground without barrier. During an interview on 8/5/22 at 9:08 A.M., the resident said: -The CNA's were to assist him/her with catheter care and colostomy care. Observation on 8/5/22 at 9:47 A.M. of the resident showed: -He/she was lying in his/her bed. -The bed was in lowest position and his/her catheter bag was lying on the ground. During an interview on 8/5/22 at 12:15 P.M., CNA K and CNA L said: -CNA's would check on residents every two hours, for any care needed including catheter care and emptying the catheter bag. -If a resident was incontinent more frequently, they would monitor the resident more often to change them. -The placement of the resident's catheter bag should be below the level of the bladder and ensure the bag was not touching the floor. -If the bed was required to be in lowest position to floor, he/she would have placed a towel under the bag. 2. Record Review of Resident #37's admission Face-sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: -A recent Urinary Tract Infection on 7/8/22. -COVID (a new disease caused by a novel (new) coronavirus) positive on 7/27/22. Resident on isolation in a private room. -Neurogenic Bladder. -Paraplegia (loss of movement of both legs and generally the lower trunk). Record review of the resident's suprapubic catheter care plan revised on 3/8/22 showed: -The resident had a neurogenic bladder. -The resident had a 20 Fr/10 ml suprapubic catheter. -Catheter care every shift by all facility care staff. -Position catheter bag and tubing below the level of the bladder. -Check tubing for kinks each shift during CNA rounds. -Monitor and report to physician any signs and symptoms of infections. -Provide cares for the resident in pairs. Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was cognitively intact. -He/she was able to understand others and make his/her needs known. -Required total assistance from two staff for all cares and transfers. -Had a suprapubic catheter in place. Record review of the resident's infection note dated 7/9/2022 at 12:16 A.M. showed: -The resident had begun antibiotic for UTI, pulled from emergency kit and administered Intramuscularly (IM) in the left hip site. No adverse effects observed from the antibiotic. Record review of the resident's POS reviewed on 8/1/22 and printed on 8/3/22 showed: -The resident's suprapubic catheter size was 20 Fr/10 ml., Nursing staff were to provide catheter care with warm water and soap every shift. -Physician's order to cleanse the resident's Suprapubic site with warm soap and water and replace split sponge one time a day. -Nursing staff to flush the resident's Suprapubic catheter with 60 ml normal saline every 24 hours (one time a day). -The resident catheter bag to be changed as needed for infection, obstruction or when the closed system was compromised. -Catheter care every shift, Keep catheter bag placed below the level of the bladder. -New order dated 8/1/22 at 11:00 P.M., Change the resident's S/P catheter with 20 FR/ 10 cc bulb monthly on the 1st. Starting on the 1st and ending on the 2nd every month for S/P catheter. Record review of the resident's behavioral note dated 8/2/2022 at 6:37 P.M. showed: -The resident said his/her suprapubic catheter was not working. -The resident's SP Foley catheter bag had 2000 milliliters (ml) at 3:30 P.M., and 500 ml at 7:30 P.M. -The resident was upset stating my catheter was not right, you guys do not know how to put a catheter in. -The resident was yelling, no this is different. Staff will continue to monitor. Record review of the resident's Kardix report as of 8/3/22 showed: -Facility staff were to provide cares for the resident in pairs. -He/she was to have catheter care every shift. -Position catheter bag and tubing below the level of bladder. Record review of the resident's medical record showed the facility had no documentation of the resident's amount of urine from his/her catheter bag or ongoing detailed documentation of the assessment of the resident Suprapubic site. Observation on 8/3/22 at 12:45 P.M.,of the resident showed: -His/her catheter bag was completely full and was starting to bulge out. -Wound nurse emptied the catheter bag prior to leaving the resident's room. During an interview and observation on 8/4/22 at 9:15 A.M., showed the resident's: -SP Foley catheter drainage bag was 1/2 full. -The resident said facility staff last emptied the catheter bag, along with colostomy bag around 3:00 A.M. on 8/4/22. During an interview on 8/4/22 at 10:20 A.M., CNA M said: -He/she would check on the resident at least every two hours. -Resident was on isolation would check more often. -He/she would check the resident's catheter bag each time he/she would enter the resident room and empty the drainage bag as needed. Observation on 8/4/22 at 10:28 A.M., showed CNA M entered the resident's room to check on the resident and to empty the resident catheter bag. During an interview on 8/4/22 at 10:57 A.M.,CNA N said: -He/she would monitor the residents at least every two hours and as needed if soiled. -When he/she was checking on the resident, he/she would check the resident catheter bag for placement and empty the resident's catheter bag if needed. -He/she was not required to record the resident urine output at that time. During an interview on 8/5/22 at 10:29 A.M., Registered Nurse (RN) A said: -CNA's were responsible for ensuring the resident's catheter drainage bags were emptied at least every shift. -At that time the nursing staff were not recording amounts of urine drained or the output of the resident. -The resident was on medication and took in extra fluids that contributed to his/her excessive urine output. Observation on 8/5/22 at 2:10 P.M., of the resident's catheter care showed: -RN A gathered supplies. -The resident's catheter bag was hanging on his/her bed rail and was over filled with yellow urine, to the point was ready to burst. -RN A had to empty the catheter bag before he/she could provide care. -He/she had spilled some of urine on floor due to be over filled. -The resident had over 4000 cc's of urine in his/her catheter drainage bag. -RN A had to make four trips to dump the graduate container and splashed some on the floor as he/she walked to the bathroom. --The graduate can hold up 1000 cc of fluid. -He/she had cleaned the resident's Suprapubic site with personal care wipes. He/she used one wipe at a time and did the same with resident's catheter tubing. -The resident had no redness or drainage noted to site and he/she had no complaint of tenderness to the site. -After RN A finished catheter site care, he/she placed split gauze pad around catheter tubing site. -The facility nursing staff document care had been completed by check mark and nursing assigned initials in the resident TAR. -RN A removed his/her gloves after all cares completed and washed his/her hands. -RN A did not clean the supra pubic site with soap and warm water as noted in the residents physician ordered. During interview on 8/5/22 at 2:15 P.M., the resident said: -At least once a week, his/her catheter bag overfills and burst. -Upon exiting the room, two CNA's entered the room to finish the resident's personal care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure physician orders were carried over for colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen stoma) care to include the type of appliances, skin barriers and skin care; and to document a detailed assessment of the colostomy site for one sampled resident (Resident #37) out of 29 sampled residents. The facility census of 112 residents. Record review of the facility's Colostomy Care policy revised 9/20/21 showed the facility will provide colostomy (ostomy) and Ileostomy (is an surgical opening in stomach, an ileostomy connects the last part of the small intestine (ileum) to the abdominal wall) care in accordance with professional standards of practice, as outlined by [NAME] (is an evidence-based procedure guidance for nurses at the point of care) through the procedure linked below: -A physician order will be obtained for ostomy (artificial or surgical opening) care to include specific physician preference regarding appliances, skin barriers and skin care. -To prevent pouch breakage, every pouch needs to be emptied when its one-third to one-half full. -Itching and burning of the skin are signs of irritation, and the pouch should be changed when irritation is reported. -Document the date and time of the applying or changing of the pouching system. Note the character of the drainage, including color,amount, type and consistency. -Describe the appearance of the stoma and the peritoneal(surround) skin. 1. Record review of Resident #37 admission Face-sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of colostomy status, Neurogenic Bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder), and paraplegia (loss of movement of both legs and generally the lower trunk). Resident on isolation in a private room. Record Review of the resident's Ostomy Care Plan revised 3/8/22 showed licensed nursing staff and Certified Nursing Assistants (CNA's) were to provide ostomy care as needed. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/24/22 showed he/she: -Was cognitively intact had Brief Interview for Mental Status (BIMS) score of 15 out 15. -He/she was able to understand others and make his/her needs known. -Required total assistance of two staff for all cares and transfer. -Had an ostomy in place at the time of admission. Record review of the resident's Weekly Skin Assessment Sheets dated 7/20/22 and 7/25/22 showed no documentation related to the assessment of the resident's ostomy site. Record review of the resident's skilled nursing note dated 7/30/2022 at 10:16 A.M., showed: -The resident remained on isolation protocol. -Abdomen was flabby with Colostomy in place & functioning. -Care provided. Record review of the resident's medical record showed no detailed assessment documented of the resident colostomy stoma and surrounding skin. Record review of the resident's current Physician's Order Sheet (POS) showed: -There was no physician's order for the resident's colostomy to include but not limited to: the care, type and size of appliance needed, ongoing monitoring and assessment of the resident's colostomy site. Record review of the resident's Treatment Administration Record (TAR) and Medication Administration record (MAR) dated July 2022 and August 2022 showed: -There was no physician's order for colostomy care and assessment. -There was no documentation that showed the resident's colostomy care had been provided by CNA's and/or licensed nursing staff. Record review of the resident's undated [NAME] report (gives a brief overview of each patient) showed: -Facility staff were to provide cares for the resident in pairs. -Provide ostomy care. Record review of the resident's Weekly Skin Assessment sheet dated 8/1/22 showed no documentation related to the detailed assessment of the resident's ostomy site. Observation on 8/3/22 at 12:45 P.M., showed: -The resident's colostomy was located on his/her left lower abdomen. -His/her colostomy bag had greenish loose stool and was about half full. -The resident said the area around the stoma was red and irritated. -The Wound Nurse said the nursing staff would look at the site. --NOTE: staff did not observe the site at that time. During an interview on 8/4/22 at 9:41 A.M., the resident said: -On 8/3/22 requested his/her colostomy bag to be changed, but he/she said did not happen. -The last time his/her colostomy bag was emptied was on 8/4/22 at around 3:00 A.M. -Currently had the wrong bag on and needed the correct ring applied. -The skin around his/her stoma was very irritated at that moment. During an interview on 8/4/22 at 10:20 A.M., CNA M said: -CNA's were responsible for emptying and changing the resident's ostomy as needed. -Any changes to the resident skin would be reported to the charge nurse. -He/she provided a bed bath to the resident on 8/3/22, but did not see the ostomy stoma. -The resident had not reported any concerns to him/her. -The resident wanted the evening shift to change the colostomy. During an interview 8/4/22 at 10:57 A.M., CNA N said: -He/she monitored the resident at least every two hours for resident care needs. -CNA's were allowed to provided ostomy care as needed. During interview on 8/4/22 at 12:03 P.M., Licensed Practical Nurse (LPN) C said the licensed nursing staff would be responsible for documentation of the skin assessment of the residents colostomy site. During an interview on 8/4/22 at 1:54 P.M., CNA M said: -He/she had just completed the resident's colostomy care including changing bag and wafer attachment. -The skin around the resident's colostomy stoma was reddened and irritated. -He/she had notified the charge nurse and the wound care nurse. -CNA's do not have a place to document care or findings, he/she would notify charge nursing. Record review of the resident's progress note dated 8/4/22 at 2:33 P.M. showed: -LPN C observed area around the resident stoma and was mildly irritated. -CNA M had changed the colostomy and the resident refused to let this nurse take it off. -The resident said if the colostomy was removed it would irritate the skin more. -The licensed nurse would reassess the area when the resident's colostomy was changed next. During interview on 8/5/22 at 10:29 A.M., Registered Nurse (RN) A said: -He/she was unable to find in the resident's physician's order for ostomy care. -He/she would expect to have physician's order for ostomy care and treatment to include to changing ostomy system every three days, size waver (ring hold the drainage bag), to apply skin prep and to assess the skin every three days. -Ostomy care would be documented on the resident's TAR. -Physician orders were placed by nursing staff, then charts were reviewed by the Assistant Director of Nursing (ADON) and Director of Nursing (DON). -The facility nursing staff normally would not document descriptive detailed assessments on established ostomy sites. -The licensed nursing staff do not complete a comprehensive assessment upon admission with descriptive details of a resident's ostomy site or supra pubic site if it is not a new site or stoma. -He/she was not aware the resident had redness to his/her skin around the ostomy site. -The licensed nursing staff should look at the ostomy site as part of the weekly skin assessment and should document on the skin assessment and in progress notes if changes were seen to the skin. Record review of the resident's skilled nursing note dated 8/5/22 at 11:59 A.M. showed: -The resident remained on isolation protocol. -His/he abdomen was soft and flabby with a Colostomy in place and functioning well. -Ostomy Care was provided. -There was no detailed assessment of the ostomy site. Record review of the resident's Weekly Skin Assessment sheet dated 8/8/22 showed no detailed assessment related to the resident's ostomy site. Observation on 8/8/22 at 8:40 A.M. showed: -The resident was in the middle of getting his/her ostomy site cleaned by CNA M. -The resident's skin around the stoma was reddened and irritated. -The resident said the wound nurse had not seen the stoma site yet. -CNA M went notified wound nurse. -The wound nurse came to assess the resident's skin. During an interview on 8/8/22 at 10:05 A.M., the Central Supplies Coordinator said: -The resident had requested a particular brand of colostomy ring/wafer because the brand ordered would not stay on and in place. -There currently was a shortage of the bag the resident had requested and preferred. -When he/she placed orders for the resident's ostomy bag, the link goes to another company. -The bags do fit the ring if sealed correctly. -Facility staff need to make sure they hear a click when they attach the colostomy bag to the ring, to ensure it was sealed. -He/she had educated a CNA who was going to show the other CNA's how to correctly attach the colostomy bag to the ring. During an interview on 8/8/22 at 12:09 P.M. the DON said he/she: -Would expect CNA's to be responsible for emptying the ostomy bag. --CNA's should not change the colostomy bag or assess the stoma site. -Would expect licensed nurses to change the ostomy bag and wafer/ring and monitor the site at that time. -Would expect licensed nursing staff to provide the resident ostomy care. -Licensed nurses should document the colostomy care on the resident's TAR. -Licensed nurses should document in the resident progress notes any issues or any change in the resident's skin. -Would expect licensed nurses to document a detailed description of the resident's colostomy site on his/her admission assessment. -Would expect the resident's skin assessment to be completed by the licensed nurse and/or wound nurse. # MO 00204631

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #8 admission Face sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including but not limited to: -Gastrostomy (surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube). -Hemiplegia and hemiparesis (paralysis/weakness affecting one side of the body) affect the left side. Record review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was cognitively impaired. -He/she was sometimes able to understand others and was not able make his/her needs known. -Required total assistant of two staff members for all cares and transfer. -Had a feeding tube in place, received 51% or more of nutrients through the Enteral feedings. Record review of the resident's POS with a active date of 8/3/22 showed the physician's order: -Enteral feeding of Jevity 1.5 calorie (supplemental formula feeding) to run at 45 ml per hour. -Flush every 4 hours for hydration thru G-tube for 125 ml of water every 4 hours. -Disconnect from feeding at 2:00 P.M. (infuse feeding for 22 hours) one time a day. -Reconnect tube feeding at 4:00 P.M. one time a day. -The orders were not comprehensive detail for the resident Enteral feeding and the care of the PEG tube site, how the facility would care for the tube site, how the facility would monitor the tube to ensure it was patent, and the recommended total calorie intake in 24 hours. Observation on 8/03/22 at 11:07 A.M. showed the resident in bed: -He/she was connected to the tube feeding via pump. -Had Jevity 1.5 cal bottle dated 8/2/22 at 10:15 P.M. -The rate set at 45 ml per hour had been given 1863 ml of feeding. -Water flushes set at 125 ml every 4 hours and had been given 1001 ml of water flushes. Interview on 8/3/22 at 2:36 P.M., RN B said he/she had disconnected tube feeding at 2:00 P.M. During an interview on 8/04/22 at 1:45 P.M., RN B said: -He/she had already completed the resident's PEG Tube care and 2:00 P.M. medications. -The resident's medication are given by G-Tube at 6:00 A.M. and 2:00 P.M. and tube would be flushed at those times. -The resident would be off tube feeding at 2:00 P.M. for two hours. Observation on 8/05/22 at 1:45 P.M. the resident medication pass and water flush by RN A showed: -He/she disconnected the tube feeding from the pump. -RN A did not check for gastric residual or measure the tubing before he/she flushed the G-tube with 30 ml water and gave medication through G-tube. -RN A said if he/she was doing a bolus feeding (feeding given as ordered, would poured into syringe attached to the G-Tube) then he/she would check gastric residual volume before feeding and would flushing the tube before and after feeding. -He/she would check placement of the G-tube by measurement of the tube. During an interview on 8/8/22 at 9:55 A.M., RN B said he/she should check placement by measurement and checking for residual before flushing the tube. During an interview on 8/8/22 at 12:09 P.M., DON said: -Tubing feeding physician's orders should include placement check by tube length, the time feedings (on time and off time), ml intake/ type of formula; amount and when to flush and should be physician's order for monitoring and cleaning G-tube site . -He/She would expect nursing staff to be checking residual prior to starting the tube feeding. -He/she would need to verify the facility policy protocol when to check GRV, related to flushing the G-tube site before medication administration. Based on observation, interview, and record review, the facility failed to ensure physician's orders were complete for the resident's tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is called enteral feeding or tube feeding) to show how the facility was to care for the tube site, the parameters for removing the resident's tube feeding, and monitoring the tube to ensure patency for two sampled residents (Resident #94 and Resident #8); to document the adjustment of the resident's nutritional caloric needs when the resident was not receiving tube feeding for one sampled resident (Resident #94), who received continual tube feeding; to check Gastric Residual Volume (GRV) prior to flushing the G-tube for one sampled resident (Resident #8) out of 29 sampled residents. The facility census was 112 residents. Record review of facility's Enteral Nutritional Therapy Policy and procedure revised 7/1/21 showed: -The facility followed Lippcott procedures for best practice. -Verify physician orders, including the resident identifiers, prescribed route based on the Enteral feeding tube location, Enteral feeding devices, prescribed formula, administration method, volume, and rate, the type and frequency of water flushes. -Observe for changes in the external tube length . -GRV, aspirate the external tube contents and volume with an eternal syringe and inspect the visual characteristic of the tube aspirated. 1. Record review of Resident #94's Face Sheet showed he/she was admitted on [DATE], with diagnoses including end stage renal disease, heart failure, anemia (low iron), dysphagia (difficulty swallowing), pressure ulcer (open wounds that form whenever prolonged pressure is applied to skin covering bony outcrops of the body), muscle weakness, lack of coordination, oxygen dependence, depression and dependence on dialysis. Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/13/22, showed the resident: -Was alert with severely impaired memory. -Was totally dependent on staff for bathing and toileting, needed extensive assistance with bed mobility, transfers, toileting and limited assistance with dressing. -The resident weighed 133 pounds and received 51 percent or more of his/her nutrition and 501 cubic centimeters (cc) or more, daily through a feeding tube. Record review of the resident's Nutritional assessment dated [DATE], showed: -The resident had a significant weight change, and was at risk due to being underweight, received dialysis three days per week and had wounds. -The resident's daily fluid needs were 1650 milliners (ml) per day and 79 grams of protein per day. -The nutrition support was needed (through tube feeding) and the resident was receiving 60 ml per hour per tube feeding pump. It showed the tube feeding was to be continuous. -The total amount of calories the resident received from tube feeding was 2484 ml, the total amount of protein received through tube feeding was 112, and the total amount of water received through the tube feeding water flush was 1303 ml. -The Registered Dietician (RD) noted the tube feeding provided the resident's nutritional need which was 2480 calories, 79 grams of protein and 1650 ml fluid. -The RD noted the resident was a new admission and his/her tube feeding supported the resident's calorie and protein needs. The resident had skin breakdown and received dialysis. The goals included stable weight /weight gain, restart intake by mouth with a puree diet (foods are processed a smooth pudding texture), discontinuing fluid restriction, obtaining the resident's weight and height and continued monitoring. -The assessment showed the resident received dialysis three days per week, but it did not show the amount of time the resident was removed from his/her tube feeding (when the tube feeding was stopped and restarted) during dialysis and whether the calculations for nutritional need included the time the resident was off of the tube feeding. Record review of the resident's Medication Administration Record (MAR) dated July 2022 and August 2022, showed physician's orders for tube feeding two times a day for nutrition Nepro (nutritional supplement) at 60 ml per hour for 22 hrs. Flush with 200 ml of water every 4 hours (order dated 7/22/22) and to verify the position of the feeding tube, verify the measurement of the tube (40 centimeters (cm) and ensure the tube sat flush with a dry dressing underneath (order dated 7/8/22 and discontinued on 8/1/22). The MAR showed the physician's orders were followed, but there were no orders showing when the resident was removed from tube feeding or the start/stop time for dialysis. There were no physician's orders for any treatments to the tube feeding site or orders/instruction for monitoring the tube. Record review of the resident's Treatment Administration Record (TAR) July 2022 and August 2022 showed there were no physician's orders for maintaining the resident's feeding tube site or for monitoring/maintaining the resident's feeding tube. Record review of the resident's Care Plan dated 7/15/22, showed the resident received tube feeding due to difficulty swallowing. Interventions showed: -The resident would remain free of side effects or complications related to tube feeding through review date. -Keep the resident's head of bed elevated 45 degrees during and thirty minutes after tube feeding. -Check for tube placement and gastric contents/residual volume per facility protocol and record, listen to lung sounds every shift. -Verify placement of tube by measurement of 40 cm. -Discuss with the resident, family and caregivers any concerns about tube feeding, advantages, disadvantages, potential complications. -Obtain lab/diagnostic work as ordered. Report results to the physician and follow up as indicated. -Observe and report as needed any signs and symptoms of aspiration, fever, shortness of breath, dislodged tube, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, Constipation or fecal impaction, diarrhea, nausea/vomiting, and dehydration. -Provide local care to tube site as ordered and observe for signs and symptoms of infection. The resident would receive tube feeding care every night shift. -The RD will evaluate the resident quarterly and as needed and make recommendations for changes to the tube feeding as needed. -The resident is dependent on nursing staff with tube feeding and water flushes. See the physician's orders for current feeding orders. Record review of the resident's Physician's Order Sheet (POS) dated August 2022 showed physician's orders for: -Tube feeding two times a day for nutrition Nepro (nutritional supplement) at 60 milliliters (ml) per hour for 22 hrs. Flush with 200 ml of water every 4 hours (order dated 7/22/22). -Tube feeding-verify the position of the feeding tube, verify the measurement of the tube (40 centimeters (cm) and ensure the tube sat flush with a dry dressing underneath (order dated 8/1/22). -The orders did not show how the facility would care for the tube site, the hours the resident would be off of the tube feeding, how the facility would monitor the tube feeding intake to insure nutritional intake was met daily, and how the facility monitored the tube to ensure it was patent. Observation on 8/2/22 at 10:53 A.M., showed the resident was not in his/her room. His/her tube feeding was set up beside his/her bed and showed the liquid nutrition was to infuse at 60 ml per hour. There was 945 ml in the bottle which was hung at 8:45 A.M. The water bottle was also hung at 8:45 A.M. and showed the resident was to receive 200 ml every four hours and the bottle had 800 ml in it. Staff coming down the hall said the resident had just left for dialysis and would not be back until late in the afternoon. At 3:30 P.M., the resident had not returned to the facility. During an observation and interview on 8/4/22 at 9:32 A.M., showed the resident was up in his/her room in his/her wheelchair wearing oxygen. Licensed Practical Nurse (LPN) B had disconnected the resident's tube feeding and was adjusting his/her oxygen tubing. LPN B said: -The resident did not receive food orally and his/her only nutrition came from his/her tube feeding. -The resident's tube feeding was continuous except for when he/she was at dialysis. -The resident did not take his/her tube feeding with him/her and he/she did not know if the resident received any tube feeding while at dialysis. -The resident was usually at dialysis for 4-5 hours three days weekly. -They disconnected the resident from his/her tube feeding when he/she went to dialysis and when he/she returned to the facility, they reconnected his/her tube feeding. -The resident was getting ready to go to dialysis. During an interview on 8/5/22 at 10:12 A.M., Registered Nurse (RN) B said: -The resident was on tube feeding prior to admission and the physician's orders were from the nephrologist who was seeing him/her at the hospital. -The physician's order was never clarified to show how long the resident was to be disconnected from the tube feeding, how they were to keep the tube patent or maintaining the tube and tube feeding site. -They checked the resident's tube when they gave the resident medications and reconnected his/her tube feeding and they monitored his/her skin around the site for signs/symptoms of infection every shift. -He/she did not know if the Registered Dietician compensated the resident's nutrition received for the time that the resident was at dialysis. -The physician's order should be clarified to show how long the resident can be off of tube feeding, how they are to monitor the tube feeding site and keeping the tube patent. -Currently they don't track the resident's intake, but they should track how much the resident is receiving nutritionally, so they know if the resident is meeting the nutritional parameters set by the dietician. During an interview on 8/8/22 at 12:09 P.M., the Director of Nursing (DON) said: -The physician's order should include the when the resident can be removed from tube feeding and the frequency. -The resident's physician's order was clarified (during the survey) to show the hours the resident was at dialysis. -The physician's of the order should also show how they monitor and clean the tube site. -They were not monitoring and documenting the resident's intake, but they were able to figure out how much nutrition the resident needed to receive on days he/she was at dialysis to ensure the resident was getting the amount of liquid nutrition recommended by the RD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #59) had a current physician's order for the administration of oxygen; to ensure the oxygen tubing, nasal cannula (a device used to deliver supplemental oxygen through a plastic tube into the nose in a sanitary manner) and breathing treatment face masks were covered when not in use for two sampled residents (Resident #94 and #44); and to ensure physician's orders for breathing treatments were obtained and followed for one sampled resident (Resident # 44) out of 29 sampled residents. The facility census was 112 residents. Record review of Food and Drug Administration (FDA).gov's article Pulse Oximeters and Oxygen Concentrators dated 2/19/21 showed: -Too much oxygen can cause oxygen toxicity (lung damage that happens from breathing in too much supplemental oxygen; in severe cases it can even cause death). 1. Record review of Resident #59's Face Sheet showed he/she was admitted [DATE] with the a diagnosis of dependence on supplemental oxygen Record review of the resident's quarterly Minimum Data Set (MDS a federally mandated assessment tool to be completed by facility staff for care planning ) dated 6/10/22 showed: -The resident was cognitively intact. -The resident required oxygen therapy. Record review of the resident's Care Plan dated 8/4/22 showed: -Oxygen settings via nasal cannula as ordered. -NOTE: Oxygen dosage was not indicated. Record review of the resident's Order Summary Report dated 8/4/22 showed: -Oxygen tubing and equipment were to be cleaned every Sunday night. -NOTE: No order for oxygen. Observation on 8/4/22 at 8:38 A.M. showed the resident was receiving oxygen via nasal cannula at 2 liters per minute. During an interview on 8/4/22 at 8:46 A.M., the resident said he/she had been on oxygen for approximately 3 years. During an interview on 8/4/22 at 2:18 P.M., Certified Nursing Assistant (CNA) L said: -Oxygen required an order specifying the liters per minute and frequency. -Nurses verbally told the CNA's the current oxygen dosage. 2. Record review of Resident #94's Face Sheet showed he/she was admitted on [DATE], with diagnoses including end stage renal disease, heart failure, anemia (low iron), dysphagia (difficulty swallowing), pressure ulcer (open wounds that form whenever prolonged pressure is applied to skin covering bony outcrops of the body), muscle weakness, lack of coordination, oxygen dependence, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and dependence on dialysis (a treatment for people whose kidneys are failing. When you have kidney failure, your kidneys don't filter blood the way they should). Record review of the resident's admission MDS dated [DATE], showed the resident: -Was alert with severely impaired memory. -Was totally dependent on staff for bathing and toileting, needed extensive assistance with bed mobility, transfers, toileting and limited assistance with dressing. The resident used a wheelchair for mobility. -Received oxygen therapy. Record review of the resident's Physician's Order Sheet (POS) dated August 2022 showed physician's orders for: -Oxygen at 4 liters per minute continuously per nasal cannula. -Change oxygen tubing every night shift on Sunday. Record review of the resident's Care Plan dated 7/15/22, showed the resident had heart failure and needed assistance with daily living skills (mobility, toileting, dressing, grooming) and used continuous oxygen via nasal cannula at 4 liters per minute. Observation on 8/2/22 at 10:53 A.M., showed the resident was not in his/her room. There was an oxygen concentrator (a medical device that concentrates environmental air and delivers it to a patient in the form of supplemental oxygen) next to the resident's bed and the humidifier bottle was filled with water and was dated 8/1/22. It was not turned on. The nasal cannula and tubing were draped under the concentrator handle and were uncovered. The resident had just left the building. Observation on 8/5/22 at 9:18 A.M., showed the resident was in his/her room in bed. His/her oxygen concentrator was on and running at 4 liters per minute. The resident was not wearing his/her nasal cannula. The nasal cannula and oxygen tubing were draped across the oxygen concentrator and were uncovered. During an interview on 8/5/22 at 10:12 A.M., Registered Nurse (RN) B said: -The resident was supposed to wear his/her oxygen continuously, but the resident would sometimes take it out of his/her nose. -The nursing staff would often have to encourage him/her to wear it. -The resident's nasal cannula and tubing should be covered when not in use. -The nursing staff should check to ensure the nasal cannula was stored in a bag as they made rounds in the resident's room. 3. Record review of Resident #44's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including dementia, high cholesterol, high blood pressure, depression, diabetes (the body ' s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), and history of Covid-19 (an infectious disease caused by the SARS-CoV-2 virus). Record review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert with confusion. -Was independent with mobility, transfers, toileting, dressing, grooming and ambulated with a cane/walker. -Did not receive oxygen therapy. Record review of the resident's POS dated showed no physician's orders for oxygen or breathing treatments. Observation on 8/1/22 at 10:16 A.M., showed the resident was ambulating in his/her room. There was a breathing treatment machine sitting on top of the night stand that was next to the resident's bed. There was a face mask sitting inside of the breathing treatment machine, uncovered. The machine was off. Observation and interview on 8/4/22 at 9:13 A.M., showed the resident was in his/her room hanging up a shirt. His/her breathing treatment machine was sitting on his/her night stand. The facemask was sitting inside of the machine, uncovered. The resident said he/she had breathing treatments, but he/she did not remember when he/she last had one or the frequency he/she took them. Observation on 8/4/22 at 1:36 P.M., showed the resident was in his/her room sitting on his/her bed drinking a soda and eating a package of chips. The breathing treatment machine was sitting on the nightstand beside the resident's bed. The facemask was sitting inside of the machine, uncovered. There were liquid droplets inside of the container attached to the facemask. Observation and interview on 8/4/22 at 1:44 P.M., CNA P went into the resident's room and looked at the breathing treatment machine. He/she said: -He/she had never seen the resident receive any breathing treatments during the day or at night when he/she worked at the facility. -It looked as if there was some water droplets in the cup, and the resident may have had a breathing treatment, but he/she had not seen the resident receive it. During an interview on 8/4/22 at 1:49 P.M., Licensed Practical Nurse (LPN) E said: -All nasal cannulas and facemasks should be covered when not in use for infection control purposes. -The nursing staff should check that the nasal cannulas and facemasks were stored in bags as they made rounds and checked on residents. -He/she gave the resident a nasal spray today but not a breathing treatment. -He/she did not see an order for a breathing treatment on the resident's POS. -The resident had Covid-19 not long ago, and he/she may have used the breathing treatment at that time, but was no longer using it. -The physician's order for the breathing treatment may have been ordered but it may have been discontinued. -There should have been an order to discontinue the breathing treatment and they should have removed the machine from his/her room. -Since the resident did not have an order for a breathing treatment, the machine should not be in the resident's room. During an interview on 8/4/22 at 1:54 P.M., LPN F said: -He/she looked in the resident's medical record and he/she did not see any orders for breathing treatments for the resident. -He/she did not know if the resident ever received breathing treatments or not, but he/she removed the machine from his/her room. 4. During an interview on 8/8/22 at 12:09 P.M., the Director of Nursing (DON) said: -Oxygen nasal cannulas, tubing, and breathing treatment facemasks should be stored in a bag that is dated, when not in use. -The charge nurses were to change the oxygen tubing, cannulas and breathing treatment facemasks on Sunday. -The Assistant Director of Nursing (ADON) was supposed to check those resident rooms who used respiratory equipment on Monday morning to ensure it was done. -The charge nurses should check to ensure all oxygen nasal cannulas, tubing and breathing treatment facemasks were in bags and the bags were labeled. -There should be an order for all oxygen and breathing treatments. -Oxygen orders needed to specify how many liters per minute. -If the resident did not have physician's orders for a breathing treatment, there should not be a breathing treatment machine in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the physician's dialysis orders included the dialysis access site and how the nursing staff were supposed to treat and monitor the site, to include frequency of monitoring; to consistently document monitoring of the resident's dialysis site; to maintain ongoing communication with the dialysis center for continuity of care; to ensure communication was available to nursing staff so they were aware of the resident's treatments and to ensure the care plan showed the correct dialysis access site, monitoring and care for one sampled resident (Resident #94) who received dialysis, out of 29 sampled residents. The facility census was 112 residents. Record review of the facility Dialysis policy and procedure dated 12/29/21, showed the facility assures that each resident receives the care and services for the provision of dialysis consistent with professional standards of practice including the arrangement of safe transportation to and from the dialysis facility, ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The procedure showed: -The resident shall receive consistent care, pre and post dialysis. -The vascular access site shall be checked daily with physician notification for any known or suspected problems. -Assess vascular access for signs and symptoms of bleeding, clotting, swelling and pain on every shift. Notify physician if dark blood or separation of blood and plasma is observed. -Notify the physician of any change in mental status. -Document any pertinent or relevant observations or information including compliance. -Document care of the vascular access site and other appropriate information (fluid restriction, education etcetera). Obtain pre and post dialysis vital signs (temperature, blood pressure, respirations and pulse) and complete the Dialysis Communication Form. -Transcribe any orders from the dialysis center (to the physician's order sheet). -Physician's orders should indicate the length of time on dialysis. -Document in the clinical record, dialysis treatment completed, order changes, condition of the dialysis site, complaints from the resident and physician, responsible party notification. 1. Record review of Resident #94's Face Sheet showed he/she was admitted on [DATE], with diagnoses including end stage renal disease, heart failure, anemia (low iron), and dependence on dialysis (a process for removing waste and excess water from the blood, and is primarily used to provide an artificial replacement for lost kidney function in people with renal failure). Record review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/13/22, showed the resident: -Was alert with severely impaired memory. -Was totally dependent on staff for bathing and toileting, needed extensive assistance with bed mobility, transfers, toileting and limited assistance with dressing. The resident used a wheelchair for mobility. -The resident weighed 133 pounds and received 51 percent or more of his/her nutrition and 501 cubic centimeters (cc) or more, daily through a feeding tube. -Had end stage renal disease and received dialysis. Record review of the resident's Physician's Order Sheet (POS) dated August 2022 showed physician's orders for: -Renal multivitamin daily for supplement. -Heparin 1000 units (Tuesday, Thursday, Saturday) given with dialysis. -Dialysis on Tuesday/Thursday/Saturday. Send with lift sling under resident. -Do not take blood pressure on right arm with fistula/shunt. -There was no documentation showing how staff was to monitor the dialysis site. Record review of the resident's Care Plan dated 7/15/22, showed the resident received dialysis on Tuesday/Thursday/Saturday (location was provided). Interventions showed staff was to: -Assess shunt site for bruit and thrill. -Provide dialysis treatments as ordered. -Do not take blood pressure on arm with shunt. -Initiate fluid restriction as ordered. -Observe for bleeding at dialysis access site. Record review of the resident's Dialysis Communication forms showed: -There were only four forms, dated 7/7/22, 7/14/22, and 7/18/22, that showed the facility documented vital signs (temperature, blood pressure, respirations, and pulse) were taken before the resident went to dialysis, but there was no documentation showing return communication from the dialysis center on the resident's treatment, weight, the amount of fluid removed or anything regarding the resident's treatment. -On 8/2/22 the document showed the dialysis center provided information showing the resident's post treatment vital signs and communication regarding the resident's care at dialysis. Record review of the resident's Medical Record showed there was no documentation showing how the nursing staff monitored the resident's dialysis site. Record review of the resident's Treatment Administration Record (TAR) dated July 2022 and August 2022, showed there were no physician's orders for monitoring the resident's dialysis site, and there was no documentation showing the nursing staff was monitoring the resident's dialysis daily. Record review of the resident's skilled nursing notes showed: -There was documentation showing the nursing staff checked the resident's dialysis site on 7/7/22 (for three shifts), 7/9/22 to 7/13/22 (for three shifts), 7/14/22 (for two shifts), 7/15/22, 7/16/22, 7/18/22 (for two shifts), 7/19/22, 7/21/22 (for two shifts), 7/24/22, 7/28/22. -Documentation showed the nursing staff checked the resident's dressing and noted no bleeding. Except on the dates noted, nursing staff did not document they were checking/monitoring the resident's dialysis site on every shift daily. -There was no documentation showing nursing staff checked the resident's dialysis site in August 2022. Record review of the resident's Nursing Notes showed there were five notes regarding the resident's dialysis treatment: -7/7/22 dialysis called to inform the nursing staff the resident refused dialysis. The resident's physician and responsible party were notified. -7/12/22 the dialysis center called to state they were stopping the resident's dialysis early due to the resident's catheter access was not working well. -7/19/22 the resident returned from dialysis with a physician's order to send him/her to the hospital for replacement of his/her dialysis catheter due to poor function. The resident departed via ambulance 5:30 P.M. The physician and responsible party were notified. -7/20/22 showed the resident returned to facility with no new orders and no skin issues. -There were no nursing notes regarding monitoring of the resident's dialysis site or treatments and there was no documentation showing any noted in August 2022. Record review of the resident's dialysis Treatment Reports (from the dialysis center) showed reports from July 2022 to August 2, 2022 were all faxed to the facility on August 1, 2022. The reports showed detailed information of the resident's treatment at each visit that included the amount of fluid dialyzed, the resident's weights before and after treatment, vital signs and information specific to the residents treatment. Observation and interview on 8/3/22 at 11:06 A.M., showed the resident was laying in his/her bed alert and was dressed in a hospital gown. The resident's dialysis site was on the right side of his/her neck that was covered with a dressing with tape. He/she said this was where they connected the dialysis port. The resident did not say whether the nursing staff checked the site on every shift daily, but he/she said they had looked at the site. Observation and interview on 8/4/22 at 9:32 A.M., showed the resident was up in his/her wheelchair. Registered Nurse (RN) B took the resident up to the front of the building to wait for transportation. At 10:12 A.M. RN B said: -They received the physician's orders for the resident's dialysis from the hospital physician upon admission. -He/She did not know if the physician's dialysis orders had been clarified. -They have not received any documentation from dialysis regarding the resident's nutritional status or treatments. -They use the Dialysis Communication form as a tool to send with the resident to dialysis so they can maintain communication with the dialysis center regarding the resident's dialysis care each time he/she goes to dialysis. -The nurse documents the resident's vital signs and any health information they need to communicate to the dialysis center on the form and send it with the resident to dialysis. The resident was to return the form with documentation from the dialysis center with information regarding the resident's treatment while at dialysis. -Once they receive the form, they were supposed to give it to the Director of Nursing, and sometimes they will file the reports in the resident's medical record. -They send the form with the resident each time he/she goes to dialysis, but the resident rarely brings the form back. -He/She has called the dialysis center to find out what happened to the form and they have told him/her that they sent the form back, but they did not receive them back regularly. -The dialysis center says they make copies of the communication form, but they do not send them to the facility and they do not regularly send documentation from his/her dialysis treatments, weights and only sometimes do they send copies of lab results. -The facility staff did not weigh the resident after he/she returned from dialysis so they do not regularly know if there were any changes in the resident's weight. -He/She did not know if they had ever requested the dialysis center to send the communication form directly to the facility or through a fax from the dialysis center to obtain the feedback from the resident's treatments, but she would call the dialysis center today. During an interview on 8/5/22 at 10:33 A.M., RN B said: -He/She called the dialysis center and spoke with them regarding the resident's treatments. He/She said that they told him/her they would send the resident's treatment sheets showing the care provided to the resident while he/she attended dialysis. -The nurses really did not know much about the resident's ongoing treatments when he/she is at dialysis. -The resident's dialysis access is not a shunt, but it is a catheter in his/her neck and the nursing staff was supposed to just look at it (the site) to check for bleeding, swelling and redness (signs and symptoms of infection). -They were not supposed to remove the resident's dressing. -The resident's physician's orders should show how they monitor the resident's dialysis site. -All of the communications regarding the resident's dialysis should be in the same place so the nurses had access to it, but some of the documentation is in the DON's office and some is in the resident's paper charting. -The resident has also been non-compliant with dialysis at times and that should be in his/her care plan. -At 12:06 P.M., RN B said the dialysis center had faxed documentation regarding the resident's treatment on 8/5/22. Record review of the document showed a detailed dialysis Treatment Report showing the dialysis treatment and results on that day. RN B said that they should be receiving this report each time the resident returns from dialysis so they are more informed and can monitor the resident's treatment, but they had not been receiving this report from dialysis. During an interview on 8/8/22 at 12:09 P.M., the DON said: -The physician's order for dialysis should show the dialysis center, contact information and when the resident received dialysis. -The physician's order should show the dialysis site and include how the facility is to monitor the dialysis site. -The physician's order should include where and how the nurse was to monitor the dialysis access site and should include monitoring for bleeding, redness, swelling, and any additional signs symptoms of infection. -He/She expected nursing staff to send the Dialysis Communication Form with the resident, but sometimes the residents did not return with the form. -If the nursing staff received the communication form from the dialysis center, the nursing staff was supposed to give the report to him/her. -If they did not receive the communication form he/she expected the nurse to call the dialysis center to request it. Or they could fax the form to the facility directly. -Communication with the dialysis center should occur whenever there is an issue. The DON said he/she will call them or they will call her-they communicate on an as needed basis. -He/She kept the communication forms and dialysis treatment reports in one book. The nursing staff will give the documentation to him/her to place in the resident's dialysis book.

Based on observation, interview and record review, the facility failed to store items in the resident use refrigerator which were not labeled with a date they were placed in the fridge or a resident's name, or had expired according to the date on the package. The facility also failed to maintain the resident use refrigerator free of food stains within the refrigerator. This practice potentially affected an unknown number of residents whose food was stored in that refrigerator. The facility census was 112 residents. 1. Record review of the facility's policy entitled Food from Outside Sources, revised on 6/6/22, showed: - Food stored in the refrigerator should be labeled with the resident's name and room number. - Adhere to expiration date on prepackaged food items; items should be discarded if past expiration date. Observations on 8/2/22 at 1:50 P.M. showed: - One container of hot pico-de-gallo, which expired on 7/11/22, for one resident. - One container of a barbecue meal with a name and room number but with no date that it was brought to the facility. - Numerous stains on bottom shelf of refrigerator. - A sign on fridge which stated: Cover, Label and Date. During an interview on 8/2/22 at 1:55 P.M., the Staffing Coordinator said the housekeeping department cleans the fridges in the resident rooms but the dietary department cleans the resident food storage refrigerator. During an interview on 8/2/22 at 2:03 P.M., Dietary Aide (DA) D said the person who delivered food carts to C Hall, is supposed to supervise the refrigerator and he/she did not know the last time the cleaning of refrigerator was done.

Based on observation, interview and record review, the facility failed to ensure one trash container in the kitchen was closed, when not in use. This practice affected the kitchen. The facility census was 112 residents. 1. Observations on 8/1/22 at 9:32 A.M., 11:41 A.M., and 1:50 P.M. showed one trash container without a lid. During an interview on 8/2/22 at 11:45 A.M., the Dietary Manager (DM) said the lid had been missing about 30 days or so, he/she was not sure where it was misplaced, and he/she has not had time to search for it. Record review of the 2009 Food and Drug Administration (FDA) Food Code Chapter 5-501.110 entitled Storing Refuse, Recyclables, and Returnables, showed: Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. Chapter 5-501.113 entitled Covering Receptacles, showed: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: (A) Inside the food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the food establishment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent conditions such as the existence of molded potatoes, wet floor mats next to the hand washing sink close to the dish washing area and the existence of a volume of food particles on the dishwasher drainage tray which could harbor gnats (small flies) in the kitchen; to clean up dead insects carcasses in from the floor of dietary storage room [ROOM NUMBER] and to clean up dead insects from the floor of the 500 Hall sprinkler room. This practice affected two non-resident use areas, the kitchen and adjoining storage rooms and the 500 Hall sprinkler room. The Facility census was 112 residents. 1. Observations on 8/1/22, showed: - At 9:18 A.M., numerous gnats flew around in the kitchen with more gnats around the potato storage area. - At 9:42 A.M., dead insects were present on floor of dry goods storage room [ROOM NUMBER]. - At 10:07 A.M., there were several flies flying around in the kitchen. - At 10:23 A.M., and 12:13 P.M., and 1:10 P.M., a full dish washer food tray with gnats which flew around. During an interview on 8/1/22 at 2:09 P.M., the DM said dietary staff should be in the storage room twice per week or more to sweep all areas of those storage rooms. During an interview on 8/1/22 at 2:30 P.M., Dietary Aide (DA) F said he/she only discarded the contents of the food tray around 2:10 P.M., but he/she understood the contents should have been discarded after the breakfast meal and then discarded again after the lunch meal. During an interview on 8/1/22 at 2:44 P.M., DA C said if there were flies and gnats which flew around the potatoes, dietary staff need to check the potatoes. He/she did not check the potatoes himself/herself. During an interview on 8/1/22 at 2:48 P.M., DA B said he/she had been working in dietary for almost a year and has not been trained in taking look at the produce. During an interview on 8/1/22 at 2:49 P.M., the Dietary Manager said: -The kitchen did not have any fly zappers (a device which uses use ultraviolet tubes to attract flying insects into the unit, before 'zapping' them dead when they touch a high voltage killing grid) because the kitchen hygiene maintenance company (a company which develops and offers services, technology and systems that specialize in water treatment, purification, cleaning and hygiene in a wide variety of applications) did not supply them, they try to maintain the drains free and clear. -The contents of the dishwasher food tray should be dumped after every meal. During a phone interview on 8/1/22 at 5:48 P.M., the Registered Dietitian (RD) said he/she has done a walk through with the DM and discussed his/her concerns with the DM. 2. Observation with the Maintenance Director on 8/3/22 at 10:13 A.M., showed numerous dead insect carcasses on the floor of the 500 Hall sprinkler room. During an interview on 8/3/22 at 10:14 A.M., the Maintenance Director said the floor in sprinkler room needed to be swept. Record review of the 2017 Food and Drug Administration (FDA) Food Code, showed the following: Chapter 6-202.15 Outer Openings, Protected. (A) Except as specified in paragraphs (B), (C), and (E) and under paragraph (D) of this section, outer openings of a Food Establishment shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings; (2) Closed, tight-fitting windows; and (3) Solid, self-closing, tight-fitting doors. Chapter 6-501.111 Controlling Pests. The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: A) Routinely inspecting incoming shipments of food and supplies; B) Routinely inspecting the premises for evidence of pests; C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and D) Eliminating harborage conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify three sampled residents (Resident's #61, #7, and #100) in a timely manner about a spend down plan, when their resident trust balances remained above $4,835 which is within $200 of the absolute limit of $5,035. The facility also failed to send in a Third Party Liability Form to Missouri (MO) HealthNet within 30 days of the death of two sampled residents (Resident's #1000 and #1001). This practice potentially affected three current and two discharged residents. The facility census was 112 residents. 1. Record review of Resident #7's ledger sheet dated 1/2022 through 8/2022, showed: - On [DATE], the resident had a balance of $7,167.45. - On [DATE], the resident had a balance of $6,022.92. - On [DATE], the resident had a balance of $6,086.11. - On [DATE], the resident had a balance of $7,357.05. - On [DATE], the resident had a balance of $6,212.53. - On [DATE], the resident had a balance of $6,270.73. - On [DATE], the resident had a balance of $7,541.67. - On [DATE], the resident had a balance of $6,397.16 Record review of Resident #100's ledger sheet dated 6/2022 through 8/2022, showed: - On [DATE], the resident had a balance of $5,501.43. - On [DATE], the resident had a balance of $5,796.09. - On [DATE], the resident had a balance of $5,846.09. Record review of Resident #61's ledger sheet dated 2/2022 through 8/2022, showed: - On [DATE], the resident had a balance of $5,249.54. - On [DATE], the resident had a balance of $5,163.12. - On [DATE], the resident had a balance of $5,180.44. - On [DATE], the resident had a balance of $4,995.88. - On [DATE], the resident had a balance of $5,009.65. - On [DATE], the resident had a balance of $5,176.44. -On [DATE], the resident had a balance of $4,807.21. Record review of letters sent to Resident's #7, #100 and #61, from the Business Office, showed the residents were notified about their resident fund balances which exceeded $5,035.00, on [DATE]. During interviews on [DATE], from 11:04 A.M. through 11:37 A.M., the Division Field Comptroller said: - The previous Business Office Manager (BOM) did not notify Resident #7 about his/her balances remaining above $5,035.00. - Resident #7 was only notified on [DATE]. - A check was sent over on [DATE] from the facility that Resident #100 used to reside at, for $5,207.10, so that resident started off over the limit. - Resident #61 was over the limit since February 2022. - The previous BOM did not meet the performance measure of prompt notification of residents when their funds exceeded allowable amounts. - The previous BOM left the position on [DATE]. 2. Record review of the Closed Account Summary Report with a date range of [DATE] through [DATE] showed: - Resident #1000 died on [DATE]. - Resident #1001 died on [DATE]. During an interview on [DATE] at 12:37 P.M., the Division Field Comptroller said: - The previous BOM was trained in various aspects of resident trust including filling out and sending in the TPL forms after residents pass away and notifying residents about balances which exceed the limits. - The previous BOM may not have sent the TPL form into MO Health Net for Resident #1000. - He/she could not find a TPL for #1001.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain bed sheets free from stains and to change those sheets for three days (8/1/22, 8/2/22 and 8/3/22) of the survey for one sampled resident (Resident #45); to maintain the rubber grip of the assistance pole in resident rooms 306, 406, in in an easily cleanable condition and without rips or tears; to maintain the floors of resident rooms 307, 309, 414, 405, 403, 401, 206, 205, and 214 free of a buildup of grime and debris; to maintain the restroom ceiling vents in resident rooms 413, the 300 Hall Ladies' Shower room and 302 free from a heavy buildup of dust; to maintain the commode riser in the 200 Hall men's shower room in an easily cleanable condition; and to maintain the mattress in Resident #159's room in an easily cleanable condition. This practice potentially affected at least 40 residents who reside in or used those areas. The facility census was 112 residents. Record review of the facility's policy 'Laundry Services-General Policy' dated 2/20/22 showed torn, stained, or other inappropriate linens were to be immediately repaired or replaced. 1. Record review of Resident #45's Face Sheet showed he/she was admitted [DATE] with the following diagnoses: -Unspecified lack of coordination. -Muscle Weakness (Generalized). -Unsteadiness on feet. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff used for care planning) dated 6/9/22, showed the resident had a Brief Interview for Mental Status (BIMS) score of 12 which demonstrated the resident was cognitively intact. Observation on 8/1/22 at 8:49 A.M. showed the resident's fitted sheet had a large black spot with multiple smaller black spots measuring approximately 1.5 feet in diameter (total of all spots). Observation on 8/2/22 at 1:54 P.M. showed the resident's fitted sheet had a large black spot with multiple smaller black spots. During an interview on 8/2/22 at 1:54 P.M., the resident said staff had changed his/her bed five times since Thanksgiving. Observation on 8/3/22 at 2:15 P.M. showed the resident's fitted sheet had a large black spot with multiple smaller black spots and smears of blood. During an interview on 8/4/22 at 1:16 P.M., Certified Nurses Assistant (CNA) O said bedding should be changed every bath day or any time the bedding is soiled. During an interview on 8/4/22 at 2:18 P.M., CNA L said: -All residents' bedding should be changed a minimum of twice a week. -He/she changed the bedding if it was soiled regardless of whether it was a bath day or not. Observation on 8/5/22 at 9:00 A.M. showed: -Staff had replaced the resident's fitted sheet with a clean one which now had blood smears totaling approximately 1 foot in length on it. -The resident had his/her personal towel covering the blood spots. -His/her personal towel also had significant blood smeared on it. During an interview on 8/5/22 at 9:41 A.M., CNA F said he/she would have changed any bedding if blood was present. During an interview on 8/5/22 at 9:57 A.M., CNA P said he/she would have changed any bedding that was soiled. During an interview on 8/5/22 at 10:29 A.M., the Staffing Development Coordinator (SDC) said bedding needed to be changed on shower days and any time staff found the bedding soiled. During an interview on 8/5/22 at 11:09 A.M., Registered Nurse (RN) B said staff were to change the resident's bedding the day the resident is bathed or any time the bedding was soiled. During an interview on 8/5/22 at 2:01 P.M., the resident said he/she didn't want to use their own towel to cover the blood on the sheets but the facility did not provide an underpad. During an interview on 8/8/22 at 12:09 P.M., the Director of Nursing (DON) said: -Staff were expected to change the resident's bedding on shower days. -Staff were expected to change the resident's bedding if it was seen to be stained and/or soiled. 2. Observations with the Maintenance Director on 8/3/22 showed the following: -At 12:20 P.M., the black rubber grip on the transfer assistance pole in the restroom of resident room [ROOM NUMBER], was torn and not in an easily cleanable condition. -At 2:22 P.M., the black rubber grip on the transfer assistance pole in the restroom of resident room [ROOM NUMBER], was torn and not in an easily cleanable condition. During an interview on 8/4/22 at 12:20 P.M,, the Central Supply Coordinator said no one notified him/her about the torn gripping on the transfer assistance poles. Observation with the Central Supply Coordinator on 8/4/22 at 12:20 P.M., showed a 6-7 inch (in.) tear in the black rubber grip. During an interview on 8/4/22 at 12:21 P.M., the Maintenance Director said it was the therapy department which placed the grips on those poles. 3. Observations with the Maintenance Director on 8/3/22, showed: -At 12:23 P.M., there was a buildup of dust and debris behind the bed in resident room [ROOM NUMBER]. -At 2:00 P.M., there was a buildup of grime behind the night stand in resident room [ROOM NUMBER]. -At 2:24 P.M., there was a buildup of grime and debris behind the beds in resident room [ROOM NUMBER]. -At 2:27 P.M., there was a buildup of grime and debris behind the nightstand in resident room [ROOM NUMBER]. -At 2:31 P.M., there was a buildup of dust and beverage stains under the vending machines in the vending machine room. -At 3:12 P.M., a buildup of dust and debris was present behind both beds in resident room [ROOM NUMBER]. -At 3:15 P.M., a buildup of grime and debris was present behind both beds in resident room [ROOM NUMBER]. -At 3:29 P.M., dust and food particles were on the floor of resident room [ROOM NUMBER]. During an interview on 8/4/22 at 10:58 A.M., the Housekeeper said the following after observing resident rooms 309, 403 and 206: -He/she expected the housekeepers to clean behind the beds. -He/she would have the floor technicians to strip (a process by which a scraper is used to scrape away substances and objects that are stuck on the floor) the floors and move all objects out of that room , then place all objects back. -Every 3-4 months he/she would like all the floors in the resident rooms stripped and waxed. 4. Observations with the Maintenance Director on 8/3/22, showed at 2:04 P.M., there was a buildup of lint on the restroom ceiling vent of resident room [ROOM NUMBER]. During an interview on 8/3/22 at 2:05 P.M., the Maintenance Director said the ceiling vents needed to be cleaned. -At 2:41 P.M., there was a heavy buildup of duct inside the ceiling vent in the 300 Hall shower room. -At 2:45 P.M., there was a buildup of lint on the restroom ceiling vent of resident room [ROOM NUMBER]. 5. Observation on 3/8/22 at 2:49 P.M., showed a 2 in. crack, in the cushion of the commode riser in the 200 Hall Men's Spa. During an interview on 8/4/22 at 12:14 P.M., the Central Supply Coordinator said no one notified him/her about the cracked cushion on the commode riser in the 200 Hall Men's spa room. 6. Record review of Resident #159's quarterly MDS dated [DATE], showed: - The resident was able to make self understood. - The resident was able to understand others. - The Resident was totally dependent on two facility staff for transfers, - The resident required extensive assistance of two facility staff for bed mobility, and - The resident's Brief Interview for Mental Status (BIMS) score was 12 showing he/she was cognitively intact. Observation on 8/3/22 at 3:07 P.M., showed a 14 in. area of coating that was peeling away from the mattress in the resident's room, which rendered the mattress as not easily cleanable. Observation with CNA D on 8/4/22 at 11:05 A.M., showed the area of coating that was peeling away from the mattress in the resident's room. During an interview on 8/4/22 at 11:06 A.M., CNA D said the bed was made by the night shift employees and none of them mentioned anything about the damaged mattress. During an interview on 8/4/22 at 11:26 A.M., the Staff Development Coordinator said he/she had not had a chance to do education to staff about how to report damaged equipment to the Central Supply Coordinator. During an interview on 8/4/22 at 11:34 A.M., the resident said he/she did not know that the mattress was damaged like that. During an interview on 8/4/22 at 12:04 P.M., the Central Supply Coordinator said: -No one notified him/her about Resident #159's mattress. -The staffing Coordinator was the first person to notify him/her. -In general, if CNA's see damaged items, they should just go ahead and notify him/her. -His/her extension was available at the nurse's stations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Record review of Resident #56's Face Sheet showed he/she was admitted on [DATE] with the following diagnosis: -Chronic Kidney Disease, Stage 3 (kidneys have mild to moderate damage, and are less able to filter waste and fluid out of the blood). Record review of the resident's Occupational Therapy (OT) notes dated 5/2/22 showed: -OT rated the resident's Modified Barthel Index (MBI-a 100 point rating scale of a person's ability to perform 10 kinds of ADLs) at 40 out of 100. -The resident required maximum assistance for ADLs. Record review of the resident's quarterly MDS dated [DATE] showed: -The resident had a BIMS score of 12 which demonstrated the resident was moderately cognitively impaired. -The facility did not address the resident's preferences for bathing. -The resident required one personal to physically assist in bathing. Record review of the resident's care plan dated 7/7/22 showed: -The resident was incontinent of bowel and bladder. -The resident was at risk for break in skin integrity. -The resident required assistance with mobility and ADLs. Record review of the resident's bath sheets showed: -The resident was last offered a bath on 7/21/22. -One staff member was required to assist the resident in bathing. -NOTE: Bath sheets were received from the facility on 8/4/22. Observation on 8/4/22 at 10:24 A.M. showed the resident asked staff to take a bath. Observation on 8/4/22 at 10:54 A.M. showed: -An unnamed Certified Nursing Assistant (CNA) told the resident he/she could not have a bath that day. -The resident's hair was slick and had tangles/matting present. During an interview on 8/4/22 at 1:16 P.M., CNA O said: -Baths were recorded on paper bath sheets and given to the nurse to sign, then the Director of Nursing (DON) to review. During an interview on 8/4/22 at 1:24 P.M., the resident said: -He/she felt yucky when he/she did not get bathed. -He/she hadn't been bathed in at least a week. -He/she could smell their own body odor. -He/she had repeatedly requested a bath but staff kept telling him/her they couldn't today but maybe tomorrow. 6. During an interview on 8/4/22 at 10:04 A.M., RN B said: -The facility had some staff that were unable to enter a resident's isolation room. -Those facility staff had a medical letter that stated a work accommodation was needed. -The facility staffing coordinator would assign another nurse or CMT to provide care for the residents on isolation. During an interview on 8/4/22 at 10:20 A.M., CNA M said: -He/she would check on residents at least every two hours. -He/she would provide personal care as needed. During an interview on 8/4/22 at 2:18 P.M., CNA L said: -Staff were to bathe all residents twice a week. -Residents have set days they were to be bathed. -If a resident refused a bath on their scheduled day, the staff were required to ask the resident the following two days to bathe. If the resident continued to refuse, staff were to write refused x3 on the bath sheet and turn it in to the nurse. During an interview on 8/5/22 at 9:41 A.M., CNA F said: -Staff were to bathe residents twice a week. -Residents could request a bath off schedule for more baths than twice a week. During an interview on 8/5/22 at 9:57 A.M., CNA P said: -Staff were to bathe residents twice a week. -Residents could ask for more frequent bathing. During interview on 8/5/22 at 10:29 A.M., Staffing Development Coordinator said: -Staff were to bathe residents at least once a week. -He/she would prefer residents be bathed twice a week. -If a resident asked for an additional bath, the facility would try to accommodate him/her. During an interview on 8/5/22 at 10:37 A.M., RN A said: -Residents should be checked on every 2 hours. During an interview on 8/5/22 at 11:09 A.M., RN B said: -Staff were to bathe residents twice a week. -If a resident asked for an additional bath he/she would accommodate the resident. During an interview on 8/5/22 at 1:47 P.M., the Social Services Director said: -He/she did not ask residents their bathing preferences. During an interview on 8/8/22 at 12:09 P.M., the DON said: -Staff were to bathe residents twice a week. -If a resident requested an additional bath, he/she expected it to be done that day. -He/she would expect nursing staff to ensure to follow through or complete the care or assistance of the resident. Complaint #MO00202932, MO00204723, and MO00203632 Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) had their call lights answered in a timely manner and received the necessary services to maintain good personal hygiene for three sampled residents (Resident #84, #37, and #56) and two supplemental residents (Resident #107 and #79) out of 29 sampled residents and seven supplemental residents. The facility census was 112 residents. Record review of the facility's policy Activities of Daily Living (ADLs) dated 7/17/21 showed the facility must provide care and services for bathing, dressing, grooming, and oral care. 1. Record review of Resident #84's admission Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses of: history of Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system) and neuromuscular dysfunction of the bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/1/22 showed he/she: -Was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. -Was able to understand others and make his/her needs known. -Required total assistant for two staff for all cares and transfer. -Had a suprapubic (S/P) catheter (a urinary bladder catheter inserted through the skin about one inch above the symphysis pubis) in place. During an interview on 7/12/22 at 9:29 A.M., the resident said: -Nursing staff had not been flushing his/her suprapubic catheter nightly. Observation and interview on 8/1/22 at 9:51 A.M. the resident showed: -His/her bed was in the lowest position to inches from the floor. -Resident had no odors and sheet where dry. 2. Record review of Resident #37 admission Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to: -Recent UTI. -COVID 19 (a new disease caused by a novel (new) coronavirus) positive. Resident was on isolation in a private room. -Neurogenic Bladder (neurogenic bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). -Paraplegia (loss of movement of both legs and generally the lower trunk). -Had a colostomy (a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon). Record review of the resident's Quarterly MDS dated [DATE] showed he/she: -Was cognitively intact with a BIMS score of 15. -Was able to understand others and make his/her needs known. -Required total assistant from two staff for all cares and transfers. Observation on 8/3/22 at 2:22 P.M. of 300 hallway showed: -The resident's call light was on. -There was no facility care staff in hallway or at the desk. -The Central Supply Coordinator and a housekeeper were coming down the hallway. -At 2:25 P.M., Central supply Coordinator, knocked on the resident's door and opened the door, he/she asked the resident what he/she needed. -The resident's call light was left on. -Central Supply Coordinator notified nursing of the resident's request. -He/she said the resident was asking about getting a shower, he/she was supposed to have a shower that day. -He/she said the resident recently changed shower days to the day shift. -The shower aid was suppose be at the facility at 2:00 P.M. -He/she had went looking for the shower Aide. Observation on 8/3/22 at 2:42 P.M., showed two shower Aids had entered the resident's room. During an interview on 8/4/22 at 9:41 A.M., the resident said: -His/her catheter bag was last emptied along with his/her colostomy bag on 8/4/22 at around 3:00 A.M. -On 8/3/22 the resident had request his/her colostomy bag to be changed and reported it did not happen. 3. Record review of Resident #107's Quarterly MDS dated [DATE] showed he/she: -admitted to the facility on [DATE] with diagnosis of debility cardiorespiratory condition. -Was moderately cognitively impaired with a BIMS score of 10 out 15. -Was able to understand others and make his/her needs known. -Required total assistance from two staff for all cares and transfers. -Was incontinent of bowel and bladder. During an interview on 8/1/22 at 2:26 P.M., the resident said: -He/she had a difficult time getting facility staff to change his/her brief when wet. During an interview on 8/4/22 at 11:00 A.M., the resident said: -The facility staff come in to the room and care for resident's roommate, they do not ask if he/she needs anything. 4. Record review of Resident #79's Quarterly MDS dated [DATE] showed he/she: -Was admitted to the facility on [DATE]. -Had diagnoses of stroke, end stage kidney disease. -Was cognitively intact with a BIMS score of 15 out 15. -Was able to understand others and make his/her needs known. -Required supervision of one staff for setup and monitoring for all cares. During interview on 8/2/22 at 4:04 P.M., the resident said he/she had concerns with the staff not explaining cares or treatments they were providing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff maintained current cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure consisting of chest compressions, often combined with artificial breathing, to manually preserve intact brain function, circulation and breathing to an unresponsive person) certification; to know if CPR certified staff were available each shift who could provide CPR to residents who needed it, and to monitor which staff had maintained CPR certification. The facility census was 112 residents. Record review of the undated Facility Abuse and Neglect Standards of Care policy, showed the facility must develop and implement written policies and procedures that include training as required. A CPR Policy and Procedure was requested and not received prior to the survey exit. 1. Record review of five sampled employees from list provided by the Administrator of current certified CPR staff on [DATE] showed the following three employees did not have current CPR verification: -Registered Nurse (RN) B had no current CPR verification and was still a current employee. -RN C had no current CPR verification and was still a current employee. -Certified Nurse Aide (CNA) F had no current CPR verification and was still a current employee. Record review of Facility Daily Staffing Sheets from [DATE] through [DATE] showed: -There was no distinction on the staffing sheets showing who was CPR certified to ensure immediate availability to provide emergency basic life support (CPR) 24 hours per day. -There was at least one CPR certified staff member working all shifts in the facility (when compared to the CPR Certified staff list). During an interview on [DATE] at 10:41 A.M., the Administrator said: -The Staffing Coordinator was responsible for keeping track of CPR certifications/training and the Director of Nursing (DON) should be tracking. -Facility should have current copy of staff CPR cards and some way of verifying if staff CPR was current, expired or needing CPR training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure sufficient staff to provide treatment and services including answering call lights timely for two sampled residents (Residents #84 and #37) and two supplemental residents (Residents #107 and #70) out of 29 sampled residents and seven supplemental residents. The facility census was 112 residents. 1. Record review of Resident #84's admission Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses of: history of Urinary Tract Infection (UTI - an infection of one or more structures in the urinary system) and neuromuscular dysfunction of the bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). During an interview on 7/12/22 at 9:29 A.M., the resident said: -He/she had been forgotten by facility staff and cares were not completed for the resident. -He/she had reported he/she had his/her call light on for a extend period of time of two hours before any staff had showed up. Observation and interview on 8/1/22 at 9:51 A.M. the resident showed the resident said at times takes awhile for staff to answer call lights. 2. Record review of Resident #37's admission Face Sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to: -Recent UTI. -COVID 19 (a new disease caused by a novel (new) coronavirus) positive. Resident was on isolation in a private room. -Neurogenic Bladder (neurogenic bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). -Paraplegia (loss of movement of both legs and generally the lower trunk). -Had a colostomy (a piece of the colon is diverted to an artificial opening in the abdominal wall so as to bypass a damaged part of the colon). Record review of the resident's Quarterly Minimum Data Set (MDS- federally mandated assessment tool completed by facility staff for care planning) dated 5/24/22 showed he/she: -Was cognitively intact with a Brief Interview Mental Status (BIMS) score of 15. -Was able to understand others and make his/her needs known. -Required total assistant from two staff for all cares and transfers. During an interview on 7/27/22 at 6:25 P.M. the resident said since he/she had tested positive for COVID-19, no one would come into his/her room to assist him/her. Record review of the resident's progress notes dated 7/29/2022 at 12:04 A.M. showed: -At approximately 11:45 P.M. on 7/28/22, Certified Medication Technician (CMT) from east unit informed the nurse that, the resident had called the police. -The resident said that no staff have being in his/her room since 6:00 P.M. -The resident's dinner was delivered to him/her at about 6:30 P.M. -The resident had ordered food through a delivery company and it was delivered at 8:00 P.M. and staff took the food to him/her. -Resident got his/her bedtime medications at 7:50 P.M. and the resident was given pain medication at 8:40 P.M. During an interview on 8/1/22 at 3:15 P.M., the resident said: -He/she had concerns with facility staff not providing care while he/she had been on isolation. -The day shift nurses were not completing treatments as his/her physician had ordered. -His/her call light was not answered in a timely manner -He/she had to call the non-emergency number to have fire or police to call the facility to get facility staff come provide care for him/her. Observation on 8/3/22 at 12:41 P.M., showed: -The resident's meal plate arrived from the kitchen. -The resident was on isolation. -An unknown Certified Nursing Assistant (CNA) told the dietary aide to not go into the room. -The unknown CNA did not enter the resident room. -The Dietary Aide placed the resident's plate on top of the food cart warmer. -The wound team went in to provide the resident his/her treatment. -The resident's meal plate remained on top food cart not in the warmer during care. Observation on 8/4/22 at 8:15 A.M., of resident's call light showed his/her call light was observed on at 8:15 A.M. and answered at 9:13 A.M. for a total of 58 minutes wait time. 3. Record review of Resident #107's Quarterly MDS dated [DATE] showed he/she: -admitted to the facility on [DATE] with diagnosis of debility cardiorespiratory condition. -Was moderately cognitively impaired with a BIMS score of 10 out 15. -Was able to understand others and make his/her needs known. -Required total assistance from two staff for all cares and transfers. -Was incontinent of bowel and bladder. During an interview on 8/1/22 at 2:26 P.M., the resident said staff do not answer the call light especially during the shift change. During an interview on 8/4/22 at 11:00 A.M., the resident said: -He/she felt the facility staff did not want to answer his/her call light, they ignored the resident. -He/she felt his/her needs did not matter. -He/she felt he/she was the only resident that was being ignored and not cared for. 4. Record review of Resident #79's Quarterly MDS dated [DATE] showed he/she: -Was admitted to the facility on [DATE]. -Had diagnoses of stroke, end stage kidney disease. -Was cognitively intact with a BIMS score of 15 out 15. -Was able to understand others and make his/her needs known. -Required supervision of one staff for setup and monitoring for all cares. During an interview on 8/2/22 at 4:02 P.M., the resident said: -His/her call light was not answered timely. -When facility staff did answer the call light, they would come in, turn off call light then leave without providing any care. -Facility staff were not returning to the resident's room to address the resident needs. -He/she felt facility staff did not like the resident and that his/her needs did not matter. -He/she felt he/she was the only resident that was being ignored and not cared for. 5. Observation on 8/2/22 at 2:38 P.M. of call lights and staffing showed: -Arrived onto the 100 hall and 300 hall. -Was unable to locate facility care staff or support staff in the area. -No nurse behind the desk or in hallway. -There were resident's call lights going off on the 100 hall and on 300 hall. -At around 2:40 P.M. noted two Hospice (end of life care) Aides had exited a resident room and were trying to find someone to open the dirty linen closet. -At 2:43 P.M. another call light was turned on for a room on the 300 hall. -No care staff or support staff in the area. -At 2:44 P.M. Registered Nurse (RN) B exited a room on 300 hall. During an interview on 8/2/22 at 2:44 Registered Nurse (RN) B said: -He/she had to put a resident in bed because there was no day shift CNA. -RN B said he/she was not sure why the day shift CNA had left before shift change. -He/she should had notified staffing to let them know they were short staff. -Possible one may of requested to leave early, and other one not for sure why they left. Observation on 8/2/22 at 2:45 showed: -At 2:45 P.M. the call lights that were turned on on the 100 and 300 halls had not been answered by facility care staff or support staff. -At 2:46 P.M. a non- care staff came walking down hallway. -At 2:48 P.M., evening shift CMT had arrived for his/her shift. -At 2:50 A.M. Assistant Director of Nursing (ADON) and non-care staff were seen answering call lights on the 100 hallway. -RN B asked the evening shift CMT to assist with resident on the 300 hallway. -The call lights on 300 hall way remained unanswered. -Evening shift CNA's had not shown up for their shift and no day shift CNA's were found. For 100 and 300 halls. -At 2:54 P.M. non-care staff answered a call light on the 300 hall. -By 2:55 P.M. all call lights were answered by the ADON and non-care staff member. -Non-staff member went to get CNA K from another unit to assist in resident care for a resident on the 300 hall. -CNA K had to grab clean sheets and gown for that resident. -At 3:05 P.M. the evening shift CNA's had not arrived on the unit. -At 3:08 P.M., Resident #37's call light was turned on when the x-ray staff entered the resident's room. --At 3:10 P.M. Resident #37's call light was answered by non-care staff. -The resident was requesting his/her colostomy be changed. -At 3:15 P.M., evening shift CNA's had arrived and CNA R entered Resident #37's room. During an interview 8/2/22 at 3:25 P.M., RN A said: -Evening shift staff will be two CNA's, one CMT and a RN. -He/she would be on site until 7:00 P.M. 6. Observation on 8/3/22 at 11:14 A.M., showed: -The call light for room [ROOM NUMBER] was on. -The call light was answered at 11:26 A.M. for total twelve minutes to answer. Observation on 8/3/22 at 2:53 P.M. of the 300 hallway showed: -CNA U was checking all residents before shift change. -No CNA on the 100 was visible. -CNA U said the shift change at 3:00 P.M. -At 3:00 P.M. during shift change, the evening shift CNA for the 100 and 300 hall had toured with CNA U. -The evening shift CNA reviewed the task book and then escorted a resident from 100 hallway to the shower room. Observation on 8/4/22 at 2:40 P.M., of the 300 hallway showed: -Had two call lights going off. -CNA T and RN B were sitting behind the nurse's station. -CNA T at the nurse's station, was observed with his/her cell phone out and was watching a soap-opera. -At 2:45 P.M., a housekeeping staff member and maintenance responded to the two call lights and then notified RN B the residents requested to be changed. -CNA T and RN B did not respond right away. -RN B said CNA T was assigned to the 300 hallway. -CNA T got up and responded to one call light and assisted the resident. -At 2:55 P.M. the other call light remained on. -RN B did not respond to the call light that remained on. Observation on 8/5/22 at 10:04 A.M. of 300 hallway showed: -RN B was at the nurse's station. -There was no CNA visible on the hallway. -There were call lights on. -At 10:12 A.M. CNA entered the resident room, call light remained on. -At 10:16 A.M. RN B went to answer one of other call lights. -At 10:16 A.M., Non-care staff responded to a call light, to see what he/she needed. The resident requested assistance with his/her hair. -At 10:18 A.M. CNA V went to assist the resident. -It took 14 minutes for someone to respond to the resident's call light and assist the resident with cares. 7. During an interview on 8/4/22 at 10:20 A.M., CNA M said: -Call lights should be answered in timely manner. During an interview on 8/4/22 at 10:57 A.M. CNA N said: -He/she answered resident call lights as soon he/she could. -CNA's monitor or check on the residents at least every two hours. During interview on 8/5/22 at 10:29 A.M., Staffing Development Coordinator said: -He/she didn't know the staff to resident ratio. -The facility was staffed according to acuity. -If the halls need some extra staff they would provide the staff. During an interview on 8/5/22 at 10:37 A.M., RN A said all facility staff can answer call lights and then let care staff know the resident care needs. During an interview on 8/8/22 at 12:09 P.M., the Director of Nursing (DON) said: -He/she would expect call lights to be answered in a timely manner to meet the resident needs. -Any facility staff member can answer the resident call lights. -If a call light was answered by a support staff he/she would expect them to tell nursing and nursing should go in to assist the resident as soon as able. MO00204723

Based on observation, interview and record review, the facility failed to ensure recipes for seafood casserole and pureed (cooked food that has been ground pressed, blended or sieved to the consistency of a creamy paste or liquid) carrots, were available for dietary staff to follow. This practice potentially affected 107 residents who ate food from the facility kitchen. The facility census was 112 residents. 1. Record review of the requested recipe for 100 servings of Baked Seafood Casserole dated 4/18/22, later provided by the Dietary Manager (DM) showed: - Ingredients included: -- 18 pounds (lbs.) 12 ounces (oz.) of imitation crab meat. -- 9 lbs. 8 oz. of shrimp. -- 2 and ¼ quart and ½ cup mayonnaise. -- 1 quart and ¼ cup chopped green peppers. -- 2 cups minced onions. -- 3 quart ½ cup fine chopped celery. -- 1 tablespoon (Tbsp.) and 1 and ¼ teaspoons (tsp) salt. -- A ½ cup and 1 tsp Worcestershire sauce. -- 1 gallon (gal.) and 1 cup crushed potato chips. -- 2 oz. paprika. -- No pasta was included in the recipe. - Directions: -- Completely cover with crushed potato chips and sprinkle with paprika and bake at 400 ºF (degrees Fahrenheit) for 25 minutes until the internal temperature reached 165 ºF, for 15 seconds. -- For ground and puree texture modifications, omit potato chips. -- For ground and chopped menu items, grind or chop food at appropriate consistency. Observation on 8/1/22 from 11:32 P.M. through 12:35 P.M. showed: - The DM who also the cook that day, had no recipe available to use. - At 11:32 A.M., the Dietary Manager (DM) took pasta out of package and placed the pasta in a pot with boiling water. - At 11:33 A.M., the DM poured mozzarella cheese in another pan with milk in it, to make the sauce. - At 11:38 A.M., the DM placed frozen shrimp in another pot to boil. - At 11:46 A.M. the pasta was finished, drained of its excess water and poured into a pan to be placed on the steam table. - At 11:55 A.M., the DM continued to stir the creamy sauce and gradually added mozzarella cheese. - At 12:06 P.M., the DM poured the sauce over the pasta in the steam table. - At 12:10 the DM poured the cooked shrimp over the creamy pasta in the steam table. - At 12:29 P.M., the DM took out six portions of the creamy pasta with shrimp and pureed it for 20 seconds. - At 12:31 P.M., the DM added creamy sauce and granulated garlic and operated the food processor again to puree the creamy pasta. - At 12:35 P.M., the DM tasted pureed pasta. During an interview on 8/1/22 at 11:39 A.M., the DM said he/she had no recipe book open while making the seafood casserole. During an interview on 8/1/22 at 2:05 P.M., the DM said he/she needed to print recipes and had not printed the recipes yet. During a phone interview on 8/11/22 at 1:13 P.M. the RD said: - He/she expected the DM to have recipes available for dietary staff to look at when preparing food. - He/she expected the dietary staff to follow recipes as written, there was no pasta in the baked seafood casserole recipe and that is the problem with not having a printed recipe to follow. 2. Record review of the requested recipe for 100 servings of seasoned carrots, dated 4/18/22, later provided by the DM showed: -Ingredients: -- 20 lbs. of carrots -- 1 Tbsp. of salt -- 1 and ¼ cup + 1 Tbsp. of margarine -- 1 tsp of black pepper - Directions: -- Steam carrots until heated through and tender. -- Season with salt, pepper and margarine. -- Toss lightly to mix. -- Hold at minimum required temperature or higher for service. Observations on 8/1/22 at 11:15 A.M., showed: - The DM opened cans of carrots and poured the contents into a pan to be placed into the oven for heating. No black pepper, no margarine and no salt was added. - The DM who also the cook that day, had no recipe available to use.

Based on observation, interview and record review, the facility failed to ensure the hot items (seafood casserole and the carrots) at the lunch meal were at or close to 120 ºF (degrees Fahrenheit), potentially affecting at least 4 residents on the 200 Hall. The facility census was 112 residents. 1. Observation on 8/1/22 from 1:11 P.M. through 1:13 P.M., showed: - Lunch was delivered to Resident #84. - Resident #84 refused his/her the meal. - The state surveyor asked for permission to measure the temperature of the hot food items on his/her plate. - Resident #84 said yes, the state surveyor could check the temperature. - The temperature of the carrots was 109.9 ºF and the temperature of the seafood casserole was 108.8 ºF. During an interview on 8/1/22 at 1:16 P.M., Certified Nurse's Assistant (CNA) A said he/she did not see anyone from dietary come out and check the food temperatures. During an interview on 8/1/22 at 1:43 P.M. Resident #84 identified by his/her quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 7/1/22 as a resident who understands others, a resident who was able to himself/herself understood, and had a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) score was 15, which showed he/she was cognitively intact, said sometimes breakfast foods were cold. During an interview on 8/2/22 at 12:05 P.M., the Dietary Manager (DM) said the last time he/she checked food temperatures was a few weeks ago. Complaint MO 00202932.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and interview, the facility failed to have a call light system that was accessible for two sampled residents (Residents #5 and #44) out of 29 sampled residents, who wanted to use a call light but did not have one available for them, and two residents (Residents #67 and #92), who required assistance from facility staff to transfer from their beds. The facility census was 112 residents. 1. Record review of Resident #5's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 7/23/22, identified the resident as: - A resident who was somewhat cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident ' s attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) score of 10. - A resident who needed supervision or encouragement for bed mobility, transfers, and walking in his/her room Observation on 8/1/22 at 10:16 A.M., showed: - The resident was lying on his/her bed. - The absence of a cord from the wall mounted call light device to the resident's bed. During an interview on 8/1/22 at 10:17 A.M., the resident said: - He/she needed to have assistance with cares and the staff provided his/her care. - He/she had a poor memory. - He/she needed someone to put his brief on. - He/she did not have a call light in his/her room and has never had a call light to use. - He/she usually had to call out for help or get into his/her wheelchair to go to the nursing station. 2. Record review of Resident #44's quarterly MDS dated [DATE], identified the resident as: - A resident who was cognitively intact with a BIMS score of 11. - A resident who needed supervision or encouragement for bed mobility, transfers, and walking in his/her room. Observation on 8/1/22 at 10:37 A.M., showed the resident was ambulating out of his/her room. Observation on 8/1/22 at 10:38 A.M., showed the absence of a cord from the wall mounted call light device to the resident's bed. During an interview on 8/1/22 at 10:38 A.M., the resident said: - He/she did not have a call light in his/her room. - When he/she needed the nurse he/she just called out verbally for assistance. - The nurses come around to check on them, but if they need something when the nurse is not immediately available, he/she would yell out for help. 3. Record review of Resident #67's quarterly MDS dated [DATE], identified the resident as: - A resident who had a BIMS score of 7. - A resident who required extensive assistance from one facility staff member, for bed mobility and transfers. - A resident who used a wheelchair for mobility. Observation on 8/3/22 at 10:32 A.M., showed the absence of a cord from the wall mounted call light device to the resident's bed. 4. Record review of Resident #92's admission's MDS dated [DATE], identified the resident as: - A resident who had a BIMS score of 10. - A resident who required extensive assistance from two facility staff members for bed mobility and transfers. - A resident who used a wheelchair for mobility. Observation on 8/3/22 at 10:43 A.M., showed the absence of a cord from the wall mounted call light device to the resident's bed. 5. Observation with the Maintenance Director on 8/3/22 at 10:23 A.M., showed the absence of call light cords, which reached the bed in resident room [ROOM NUMBER]. During an interview on 8/3/22 at 10:24 A.M., the Maintenance Director said the facility never had call light cords in the area of the rooms where the residents reside, just in the restrooms. Observation with the Maintenance Director on 8/3/22 from 10:25 A.M. through 10:47 A.M., showed the absence of call light cords from the call light devices on the wall in all 500 Hall rooms (resident rooms 500 through 517). During an interview on 8/3/22 at 2:39 P.M. Certified Nurse's Assistant (CNA) W said: - He/she was new to the facility and this was her second day. -The CNAs usually walked the halls if a resident requests something, they will accommodate the resident's needs. - He/she said she thought the residents had call lights, but he/she had never seen a call light sounding on the unit. During an interview on 8/3/22 at 2:52 P.M., Licensed Practical Nurse (LPN) G said: - There were not call lights on the unit because it was more of a safety hazard for the residents on the unit due to their dementia. - To his/her knowledge, they have never had call lights in the rooms but there are call lights in the bathrooms. - There were residents who can use the call lights on the unit. During an interview on 8/3/22 at 2:56 P.M., CNA X said: - He/she had worked at the facility for 33 years and about 5 years ago the call lights in the rooms were removed. - Call lights were only in the bathrooms. - In the past, when there were higher functioning residents on the unit, they have given them bells to use to call for staff, but they have not had call lights in the room for years. During an interview on 8/5/22 at 2:33 P.M., the Maintenance Director said some facility staff said that residents would not know what to do with them and that some residents in the dementia unit would hurt themselves. During an interview on 8/5/22 at 3:53 P.M., the Director of Nursing (DON) said: - There were issues in the past with residents trying to harm themselves with call lights. - The facility did not do an exception process to his/her knowledge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure there was enough dietary staff available to ensure the lunch meal was served in a timely manner on 8/1/22. This practice potentially affected 107 residents who ate food from the kitchen. The facility census was 112 residents. 1. Record review of the undated document entitled Meal Times, showed. breakfast should be served at 8:00 A.M., lunch should be served at 12:00 P.M., dinner should be served at 6:00 P.M. and the facility served room trays first. Record review of the dietary section of the Resident Council Minutes dated 6/23/22 showed (Residents) were not getting meals on time in the evening. Record review of the dietary section of the Resident Council Minutes dated 7/28/22 showed Always late serving, no response was noted to the dietary concerns noted in the previous months minutes. Observations of the lunch meal preparation on 8/1/22 from 9:23 A.M. through 1:30 P.M., showed: - The dietary staff included one Dietary Manager (DM), four Dietary Aides (DAs). - At 12:06 P.M., the DM who was serving as the cook that day, made mechanical soft Salisbury steak. - At 12:24 P.M., the DM made pureed (cooked food that has been ground pressed, blended or sieved to the consistency of a creamy paste or liquid) carrots. - At 12:31 P.M., the DM made pureed pasta dish. - At 12:40 P.M., the first plate of food was prepared to go on a food cart at 12:40 P.M. - At 12:52 P.M., (52 minutes after 12:00 P.M.) the first cart arrived at the 500 Hall which housed the Special Care Unit. - At 1:01 P.M., (61 minutes after 12:00 P.M.) a food cart arrived at the 200 Hall. During an interview on 8/1/22 at 1:04 P.M., the Staffing Coordinator who delivered food trays to the 200 Hall residents, said lunch should be served around 12:15 P.M. Observation on 8/1/22 at 1:11 P.M. showed Resident #84 was served his/her food at 1:11 P.M. During an interview on 8/1/22 at 1:18 P.M., Certified Nurse's Assistant (CNA) A said within the last five days, the food has arrived to the hall late, about half of the time. During an interview on 8/1/22 at 1:23 P.M., CNA C said they (the aides) should start serving food between 12:00 P.M. and 1:00 P.M., but meals arrive late daily and he/she did not start delivering meals that day until 1:22 P.M. During an interview on 8/1/22 at 1:25 P.M., Resident #59, identified by his/her quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 6/10/22, as a resident who understands others, a resident who was able to himself/herself understood, and had a Brief Interview for Mental Status (BIMS) score was 15, which showed he/she was cognitively intact, said: - The lunch meal is late about one to two times per week. - Sometimes, he/she receives his/her meal about 1.5 hours after the start time of 12:00 P.M. During an interview on 8/1/22 at 1:29 P.M., Resident #4, identified by his/her quarterly MDS dated [DATE] as a resident who understands others, a resident who was able to make himself/herself understood, and had a BIMS score was 15, which showed he/she was cognitively intact, said: - They are supposed to have lunch between 12:00 P.M. and 12:30 P.M. - Late meals were becoming more normal. During an interview on 8/1/22 at 1:43 P.M. Resident #84 identified by his/her quarterly MDS dated [DATE] as a resident who understands others, a resident who was able to himself/herself understood, and had a BIMS score was 15, which showed he/she was cognitively intact, said: - The food arrives late sometimes. - Once breakfast did not arrive until around 9:00 A.M. - Food arrives late about 2 out of 5 days per week. - When the food comes late, it causes him/her to feel awful. During an interview on 8/1/22 at 1:56 P.M., the Administrator said: - There was an employee who was supposed to come in, but that employee never came in to work that day. - He/she saw that the food went out late that day. - He/she and the DM would put together a plan to make sure there were not any further issues. During an interview on 8/1/22 at 2:38 P.M., the DM said: - Timing and preparation are things that they (he/she and the dietary staff) talk about the most. - Sometimes, they have methods that work well. - Serving food in a timely manner is something that they need to get better at doing. - He/she did not feel that he/she had enough dietary staff to get the food to the residents on time. - They recently lost 4 people in the last two weeks. - There was not a preparation cook at that time, which could help in getting meals out faster. During an interview on 8/1/22 at 2:49 P.M., DA C said he/she was not trained in making meals, so he/she could not help as much in the food service part. During a phone interview on 8/1/22 at 5:48 P.M., the Registered Dietitian (RD) said: - He/she has done a walk through with the DM and discussed his/her concerns with the DM. - He/she spends a lot of time with clinical documentation, when he/she did his/her visits to the facility. - The facility does not have a lot of staff in dietary department. - He/she had not looked at the process of food delivery. Complaint MO 00202932

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent the following: the buildup of grime on floors throughout the kitchen; to ensure 3 out of 4 cutting boards with numerous stains and grooves, were not used; to store utensils in a manner that was free from contamination; to clean the nozzles of the dishwasher spray wands from debris; to maintain the gaskets of a reach-in fridge in good repair; to maintain the area around the spigots of the juice machine free from the old juice stains; to maintain the ceiling of the kitchen free from dust and cobwebs (a spider's web, especially when old and covered with dust.); to maintain the outside of bottles in the storage rooms free from stains; to ensure both handwashing stations were equipped with paper towels and soap; to maintain the floor of the walk-in free from stains and grime; to ensure that molded produce (onions and potatoes) were not stored with good produce; to prevent two non-dietary employees from entering the kitchen without hair nets; to maintain the can opener blade clean and free of debris; and to ensure one dietary employee washed his/her hands after touching the lid to the trash can several times. This practice potentially affected at least 107 residents who ate food from the kitchen. The facility census was 112 residents. 1. Observations on 8/1/22 from 9:23 A.M. through 2:11 P.M., showed: - A spoodle (a utensil midway between a spoon and a ladle), a cup and food debris under the six burner stove. - A buildup of grime on the floor under the dishwasher, and the floor under the shelves in two storage rooms. - The presence of debris in the nozzles of the dishwasher spray wands. - 3 out of 4 cutting boards were not easily cleanable due to stains and numerous grooves. - The presence of debris around the blade of the table top can opener. - Utensils were not stored free from contamination in the utensil container on the lower shelf of the prep table because there was no cover. - The gaskets on one of the reach in refrigerators were in disrepair. - A buildup of old juice stains around the spigot of the juice machine. - The presence of cobwebs on the ceiling over the kitchen entrance. - The presence of a heavy dust buildup on two vents with dust. - One bottle of browning and seasoning sauce and bar-b-cue sauce with spilled liquid on the bottles on the lower shelf of storage room [ROOM NUMBER]. - The presence of food stains on floor of walk-in fridge. - One container of a green colored liquid which was not labeled or covered in the walk-in fridge. - Many molded potatoes in the potato box and one molded onion in onion box. - The absence of paper towels at hand washing station next to dishwasher area and the absence of soap from the hand washing station close to the automated dishwasher. - Certified Nurse's Assistant (CNA) C went to ice machine located towards the back of the kitchen, without a hairnet. - Speech Therapist (ST) A entered the kitchen and went to the food preparation table without a hairnet. - The Dietary Manager (DM) used the can opener without cleaning the blade and surrounding area. - The DM touched trash container lid, then went back to opening cans, without washing hands four times. - The DM touched lid of trash container then went back opening sliced pears and tropical fruit. During an interview on 8/1/22 at 11:35 A.M., Dietary Aide (DA) B said: - He/she noticed the debris inside the dishwasher spray wands. - He/she has been working for two months and he/she has not been trained in cleaning the nozzles. - He/she has not been informed on who to contact to clean the dishwasher nozzles. During an interview on 8/1/22 at 1:58 P.M., the Administrator said: - He/she saw the container with utensils and that container did not have a lid. - The dietary staff should not be using anything that is contaminated with debris. During an interview on 8/1/22 from 2:08 P.M. through 2:22 P.M., the DM said: - Dietary staff should be in the storage room twice per week or more to sweep all areas of those rooms. - The dietary staff do not keep soap or paper towels because the housekeeping department keeps those supplies that is housekeeping. - He/she did not know they were not any paper towels at handwashing station close to the dishwasher. - He/she expected staff to wipe down containers after they were used. - Dietary staff does not normally pull shelves out for cleaning. - He/she expects dietary staff to pull the shelves out in the walk-in and clean the floors. - The last time the floor was cleaned was 7/25/22. - He/she has to let facility staff know that they should not come into kitchen without hairnets. - He/she notified maintenance about about 1 month ago that the vents needed to be cleaned, but could not remember if he/she put the request to clean the vents in writing. - No one checked the potatoes when they came in Thursday 7/28/22. - Dietary staff is supposed to check the produce on truck days. - Before today he/she had not notified the company about obtaining new gaskets and the gaskets on the reach in refrigerator have been torn like that for a while. - He/she expected dietary staff to clean the area around the juice spigots daily. During an interview on 8/1/22 at 2:48 P.M., DA B said: - He/she has been working in the dietary department for almost a year. - He/she has not been trained in taking a look at the produce. - He/she has only been trained in doing the dishes, drinks and setting up the carts and has not been trained in anything food related. During an interview on 8/1/22 at 2:49 P.M., DA C said: - He/she has not checked the potatoes. - He/she sometimes cleaned the storage rooms. - He/she said that people have stopped wiping down the bottles. During an interview on 8/1/22 at 3:11 P.M., CNA C said he/she did not see the line in the kitchen that they (non-dietary staff) should not cross. During a phone interview on 8/1/22 at 5:48 P.M., the Registered Dietitian (RD) said he/she had done a walk through with the DM and discussed his/her concerns with the DM and he/she spent a lot of time with clinical documentation. During an interview on 8/2/22 at 11:47 A.M. the DM said: - The cook who was on duty that day (7/28/22), should have checked the potatoes. - The dietary department has not placed a larger foot operated trash container in the kitchen at this time, to cause employees to avoid touch the lid to discard trash. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: -In Chapter 2-402.11 (A) Except as provided in paragraph (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. - In Chapter 3-305.14, During preparation, unPACKAGED FOOD shall be protected from environmental sources of contamination, - In Chapter 4-202.11, regarding Food-Contact Surfaces; Multi-use FOOD-CONTACT SURFACES shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; and 4) Finished to have SMOOTH welds and joints; In Chapter 4-501.11, showed Good Repair and Proper Adjustment. A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. - In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced. - In Chapter 4-601.11, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. - In Chapter 4-602.13, non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues; - In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean. - In Chapter 6-501.14, part A, Intake and exhaust air ducts shall be cleaned and the filters changed so they are not a source of contamination by dust, dirt, and other materials.

Based on interview and record review, the facility failed to protect the resident fund balance for two sampled residents (Residents #4 and #23) from going into the negative due to a withdrawal mechanism that withdraws the resident's share of their expenses from an account at a financial institution outside the facility. This practice affected two residents out of four total residents with negative balances. The facility census was 119 residents. 1. Record review of Resident's #4's amount on the trial balance printed on 10/3/19 showed a negative balance of $728.98. During an interview on 10/3/19 at 2:54 P.M., Business Office Manager (BOM) A said: -A Medicare premium of $134. 00 was taken out of Social Security due to the resident's Medicaid going inactive; -The facility tried to take the $676.00 from an account at an outside financial institution, but the money was not there; and -As a result, the Resident Fund Management System (RFMS) pulled the money from the resident's resident trust fund. During an interview on 10/4/19 at 8:36 A.M., BOM A said: -Resident #4's account was a separate account from an outside financial institution; -The system tried to withdraw $674.00 from his/her local bank account on 8/2/19, but there was not enough in that outside account to cover the withdrawal; -At the current time, the system had no way of keeping his/her account separate from the local bank outside the facility and -A refund was requested on 9/9/19 for $729.00, which included the amount that was attempted to be withdrawn of $676.00 and bank fees of $53.00 which was originally imputed to Resident #4's resident trust account. Record Review of financial documents showed an authorization signed by Resident #4 on 7/30/18 for the facility to withdraw between $0 and $1000.00, monthly. 2. Record review of Resident's #23's amount on the trial balance printed on 10/3/19 showed a negative balance of $918.00. During an interview on 10/4/19 at 8:56 A.M., BOM A said: -On 8/22/19, a withdrawal of $965.00 was successful from the resident's outside account; -On 8/26/19, a withdrawal of $965.00 was not successful because of the previous withdrawal just four days earlier; -The system had no way of keeping the withdrawal from the outside financial institution separate from the resident trust account; -A full refund including any incurred fees, was requested from the facility's operating account and -That withdrawal was his/her error.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the accuracy of assessments for one sampled resident (Resident #79) out of 33 sampled residents. The facility census was 119 residents. 1. Record review of Resident #79's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 8/20/19 showed that he/she: -Was admitted to the facility on [DATE]; -Utilized a wheelchair for mobility; -Had no impairment in upper or lower extremity range of motion; -Utilized an undefined restraint in chair or out of bed daily and -Was cognitively intact. Record review of the resident's care plan dated 8/20/19 showed that restraints were not addressed. Record review of the resident's Physician's Orders Sheet (POS) showed no order for restraints. Observations on 9/30/19, 10/1/19, 10/2/19, 10/3/19, and 10/4/19 showed the resident: -Was sitting up in his/her wheelchair; -Had no apparent trunk weakness or difficulty sitting up on his/her own and -Had no noticeable restraint in wheelchair. During an interview on 10/3/19 at 1:30 P.M., the resident said that he/she had never had a belt or any other restraint in his/her wheelchair. During an interview on 10/4/19 at 3:05 P.M., MDS Coordinator A said: -If a resident had restraint marked on his/her MDS the resident should have a restraint in place; -The resident did not have a restraint when he/she was up in his/her wheelchair; -He/she was not sure why restraint was marked on the resident's MDS and -The MDS should be accurate and paint a picture of the resident. During an interview on 10/4/19 at 4:20 P.M., the Director of Nursing (DON) said that he/she expected assessments to be accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #27's face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses and conditions: -Full code status; -Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning); -Protein-Calorie malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat); -History of falls; -Major Depressive Disorder (a persistent feeling of sadness and loss of interest); -Anxiety Disorder (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome.); -Osteomyelitis (inflammation of bone or bone marrow, usually due to infection); -Anorexia (an emotional disorder characterized by an obsessive desire to lose weight by refusing to eat); -Cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and -Chronic Obstructive Pulmonary Disease (COPD lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible). Record review of the resident's care plans dated 7/9/19 showed the following conditions, diagnoses, and medications were not addressed in a care plan: -Code status; -Falls; -Psychotropic medication (Any medication capable of affecting the mind, emotions, and behavior) usage; -Pain; -Urinary/bowel incontinence (lack of voluntary control over urination or defecation); -Infection of Clostridium Difficile (C-Diff a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon); -Isolation; -Respiratory difficulties and medications and -Dementia/Cognitive impairment. Record review of the resident's POS dated September 2019 to October 2019 showed: -A comfort feeding diet order for puree texture, thin consistency; -Enteral tube feeding (nutritionally complete feeding that goes directly into the gut via a tube through the stomach); -Abdominal binder on at all times to aid in maintaining placement and minimize dislodgement of the feeding tube; -Contact isolation every shift for Clostridium Difficile; -Full code status; -Albuterol Sulfate nebulization solution 2.5 milligram (mg) /3.0 Milliliter (ml) for shortness of breath; -Alprazolam (used to treat anxiety) 0.25 mg tablet every evening; -Hydrocodone-Acetaminophen (a narcotic pain medication) 5-325 mg give one tablet every four hours as needed for pain; -Lactobacillus (a bacteria which produces lactic acid from the fermentation of carbohydrates) capsule give two capsules every evening for prophylaxis for antibiotic usage and c-diff; -Namenda (used to treat moderate to severe confusion) 2.5 ml once a day for dementia; -Remedy Calazime paste apply to the peri area (surface region in both males and females between the pubic symphysis and the coccyx) and buttocks (either of the two round fleshy parts that form the lower rear area of a human trunk); -Vancomycin HCL (an antibiotic used against resistant strains of streptococcus and staphylococcus) give 125 mg two times a day from 9/17/19 to 10/5/19; -Vancomycin HCL give 125 mg once a day from 10/6/19 to 10/12/19; -Vancomycin HCL give 125 mg once a day every other day from 10/13/19 to 10/28/19 and -Ventolin (used to treat COPD and other conditions involving constrictions of the airway). Observation on 9/30/19 at 8:00 A.M., 10/1/19 at 2:00 P.M., and 10/2/19 at 9:09 A.M. showed the resident: -Had Personal Protective Equipment (PPE) cart outside the room; -Was wearing an adult incontinence brief; -Had tube feeding hanging and infusing; -Had a nebulizer (a device for producing a fine spray of liquid, used for example for inhaling a medicinal drug) at bedside and -Was wearing an abdominal binder. During an interview on 10/4/19 at 3:05 P.M., MDS Coordinator A said: -Some care plans were late because of the transition between two computer programs; -Care plans were initiated at the time of admission and as new conditions came up; -All resident's had a care plan for being at risk for skin integrity problems; -All resident's who had an actual wound would have a wound care plan in addition to the skin integrity care plan; -There was a list of specific conditions and diagnoses that he/she and MDS Coordinator B followed for all residents. If a resident was at risk for or actually had something on the list the resident would have a care plan that addressed that area. The list contained the following conditions and diagnoses: --Code Status; --Discharge plans; --Activities of Daily Living (ADL) / mobility functions; --Falls; --Skin integrity; --Psychotropic medication usage; --Pain; --Incontinence of bowel and bladder function; --Catheter/Ostemies (an artificial opening in an organ of the body, created during an operation such as a colostomy, ileostomy, or gastrostomy; a stoma); --Respiratory conditions and device usage (Oxygen, nebulizers, Bilevel Positive Airway Pressure(BiPap) and Continuous Positive Airway Pressure (CPap) (a non-invasive form of therapy for patients suffering from sleep apnea); --Special diets (mechanically altered and therapeutic); --Mood/Behaviors; --Certain diagnoses especially when medications are given (including but not limited to); Diabetes, Congested Heart Failure (CHF chronic progressive condition that affects the pumping power of your heart muscle), COPD, and Urinary Tract Infection (UTI); --Cognitive impairment; --Chewing or swallowing difficulties; --Abuse/neglect; --Dialysis (to include where, when, and transportation); --Hospice (End of life care to include company, specific services and supplies being provided) and -Care plans should be individualized and comprehensive. During an interview on 10/4/19 at 4:20 P.M., the Director of Nursing (DON) said: -Care plans should be comprehensive; -Care plans should include diagnoses and conditions that are currently being treated; -Care plans should give an accurate picture of the resident at all times; -The MDS and care plan coordinators had been inserviced on the accuracy and comprehensiveness of the care plans; -The MDS and care plan coordinators were given a list of diagnoses and conditions that had to be care planned and -He/she and the Assistant Director of Nursing (ADON) had been adding care plans because so many were missing. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan that reflected the resident's current heath care needs and status for two sampled residents (Residents #44 and #27 ) out of 33 sampled residents. The facility sample was 119 residents. 1. Record review of Resident #44's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses of dementia without behavioral disturbance, depression, difficulty walking, low iron, muscle weakness, high blood pressure, high cholesterol, arthritis pulmonary disease, and abnormal heart rhythm. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/24/19, showed he/she: -Was alert with some memory loss; -Needed supervision with transfers, walking, dressing, grooming , hygiene and needed limited assistance with bathing, and toileted independently; -Had no behaviors during the lookback period and -Took anti-psychotic, anti-depressant, and anti-anxiety medications during the lookback period. Record Review of the resident's Physician Order Sheet (POS) dated 9/2019, showed physician's orders for: -Risperidone (an antipsychotic. It is used to treat schizophrenia (a long-term mental disorder of a type involving a breakdown in the relation between thought, emotion, and behavior) bipolar disorder(a mental condition marked by alternating periods of elation and depression) 1 milligram (mg) at bedtime for anxiety (9/1/19); -Risperidone 0.5 mg once daily for anxiety (9/2/19); -Seroquel (an antipsychotic medication used to treat bi-polar disease) 25 mg every 12 hours as needed for anxiety (9/1/19) and -Lorazepam (an antianxiety medication used to treat anxiety) 0.5 mg daily for anxiety (9/2/19). Record review of the resident's Nursing Notes showed he/she exhibited no behaviors, depression or anxiety from 6/17/19 to 10/1/19. Record review of the resident's Social Service notes showed he/she exhibited no behaviors, anxiety or depression noted from 6/17/19 to 10/1/19. Record review of the resident's Care Plan updated 7/24/19 and 8/27/19, showed: -The resident had problem behaviors-socially disruptive, easily agitated, yelling at time, talking to non-existent persons. The interventions were to administer and observe the effectiveness of medications as ordered, explain care to the resident in advance in terms the resident can understand and if reasonable, discuss the behavior with the resident. Explain/reinforce why the behavior is unacceptable. Monitor and document his/her behavior; -The resident may become agitated if he/she doesn't have something to do. Interventions showed the resident liked to read and complete housework. It showed the resident enjoyed going outside, dancing with musical entertainment, family visits, and taking walks. The resident does not like large groups; -The resident received psychotropic medication due to diagnoses of dementia with behaviors and agitation. Interventions showed staff should allow as many choices as possible to help the resident maintain independence and control over his/her life, report periods of increased sadness/withdrawal to the physician, notify the physician of behavioral changes and complete a abnormal involuntary movement screening per protocol and as needed; -The resident's care plan did not adequately address and develop interventions for the the identified behaviors related to being socially disruptive, depression and talking to non-existing persons and -The care plan did not address how nursing staff was going to monitor the resident's psychotropic medications to include monitoring for any adverse reactions and notifying the physician. During an interview on 10/4/19 at 3:54 P.M., Licensed Practical Nurse (LPN) C said: -Staff can update the care plan with the new interventions but staff also notify the MDS and Care Plan Coordinators who were responsible for completing the resident care plans and -All interventions were passed along in the daily report and given to direct care staff immediately and during shift change in report. During an interview on 10/4/19 at 4:20 P.M., the Director of Nursing (DON) said all residents should have comprehensive care plans and they should be accurate.

Based on observation, interview, and record review, the facility failed to obtain a physician's order for an indwelling urinary catheter (a sterile tube inserted into the bladder to drain urine) and to care plan the resident's current health care status and needs for one sampled resident (Resident #41) out of 33 sampled residents. The facility census was 119 residents. Record review of the facility's Urinary Incontinence and Indwelling Urinary Catheter (Foley) Management Policy dated 12/11/18 showed: -Each resident will be identified and assessed for urinary incontinence and/or indwelling catheter upon admission, quarterly, and with significant change in urinary status and -Based on comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Record review of the facility's Physician's Orders Policy dated 1/2018 showed: -Medications, diets, therapy, and any treatment may not be administered to the resident without a written order from the attending physician. -Medication orders commonly used include the following: --Orders for medication-related devices (for example: nebulizers, catheters). Record review of the facility's Physician Order Processing Procedure - Electronic Process dated 4/10/19 showed: -admission orders are received prior to or upon admission or readmission. Orders may be written by the physician, nurse practitioner, or physician's assistant; obtained via telephone by the nursing staff from the physician; or transcribed from the transfer orders and -admission orders are entered into the electronic medical record. 1. Record review of Resident #41's assessments and tracking forms showed he/she: -Was discharged to the hospital with return anticipated on 9/23/19 and -Returned to the facility on 9/27/19. Record review of the resident's care plan dated 9/20/19 showed the following interventions: -Activities of Daily Living (ADL's) section: offer and assist with toileting upon awakening, before and after meals, at bedtime, and as needed; however, the resident will usually attempt to toilet self and -Incontinence section: the resident uses the toilet for urine elimination. Record review of the resident's Nurse Practitioner progress notes dated 7/15/19, 8/26/19, 8/27/19, 9/4/19, and 9/30/19 showed the resident had a Foley catheter. Record review of the resident's current Physician's Orders Sheet (POS) showed no physician's order for a catheter or for catheter care parameters. Observation on the following dates and times showed that the resident had catheter tubing and catheter bag in a privacy bag attached to his/her wheelchair: -9/30/19 at 10:03 A.M; -10/1/19 10:55 A.M; -10/3/19 at 1:21 P.M and -10/4/19 at 8:20 A.M. During an interview on 10/3/19 at 1:21 P.M., the resident said he/she had a catheter but did not know why. During an interview on 10/4/19 at 8:28 A.M., Certified Nurse's Assistant (CNA) D said: -Regarding catheter care, CNA's checked and changed bags, ensured privacy bags were in place, and reported anything out of the ordinary to the charge nurse and -Nurses were responsible for changing catheters and tubing. During an interview on 10/4/19 at 11:20 A.M., Licensed Practical Nurse (LPN) B said: -He/she expected a physician's order to be in place for any resident with a catheter; -The resident came back from the hospital recently with the catheter; -The resident's physician assessed the resident and his/her hospital discharge paperwork on 10/3/19 and decided the catheter was still needed and -He/she was not aware that a physician's order was not present in the resident's medical record. During an interview on 10/4/19 at 4:20 P.M., the Director of Nursing (DON) said he/she expected a physician's order to be in place for any resident utilizing a catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure fall interventions were implemented to ensure monitoring and safety for one sampled resident (Resident #8) who the facility deemed was at risk for falling and who had multiple falls out of 33 sampled residents. The facility census was 119 residents. 1. Record review of Resident #8's Face Sheet showed he/she was admitted on [DATE], with diagnoses including disorientation, Alzheimer's disease, dementia with behavioral disturbance, cognitive communication deficit, mood disorder, diabetes, kidney disease, abnormal heart rate, difficulty walking, muscle weakness, Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) incontinence and difficulty sleeping. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 6/21/19, showed he/she: -Was alert but had confusion and memory loss; -Had verbal behaviors during the lookback period; -Needed extensive to total assistance with bathing, dressing, transferring, walking, toileting, eating and used a walker/wheelchair for mobility and -Did not have a history of falls and had not had any falls during the lookback period. Record review of the resident's Care Plan dated 5/9/19, showed he/she had a deficit completing activities of daily living (bathing, dressing, toileting, grooming and mobilizing) and needed one person assistance with all cares. The resident also had impaired cognitive decision making due to dementia and Alzheimer's disease and received antidepressants due to feelings of depression. The care plan showed the resident had an alteration in mobility and safety due to a history of falls, poor safety awareness, poor cognition, weakness and was at risk for falls and injury. Interventions showed the staff would: -Complete a fall risk assessment per protocol and as needed; -Invite, encourage, remind and escort to activities consistent with the resident's interest to enhance physical strengthening needs; -Provide environmental adaptations-provide/observe use of adaptive devices; -Remind the resident and reinforce safety awareness; -Report falls to the resident's physician and responsible party; -Provide a low bed with fall mats and ensure the call light was within reach; -Ensure frequent use items were in reach and offer fluids as needed and -Lock the wheelchair brakes prior to transfers and ensure anti rollbacks were on the resident's wheelchair. Record review of the resident's Fall Risk Assessments showed a fall risk score of 10 or above was at risk for falls. The resident's fall risk assessments showed: -On 6/5/19 he/she scored an 18; -On 8/4/19 he/she scored an 18; -On 8/20/19 he/she scored a 20; -On 9/8/19 he/she scored a 24; -On 9/22/19 he/she scored a 24 and -In three months the resident's fall risk has increased. Record review of the resident's Nursing Notes showed: -On 8/20/19 staff found the resident sitting on the floor in his/her room next to an electric wheelchair (not belonging to the resident, but was in the room). The resident's back was against the wall and he/she was trying to barricade the door stating people were trying to kill him/her. He/she had just finished dinner and had self propelled back to his room in his/her wheelchair. Neurochecks were initiated. (there was a possibility the resident was able to turn on the electric wheelchair which may have contributed to his/her fall). The electric wheelchair was removed from the resident's room and his/her responsible party was notified. The resident recently returned to the facility after being sent to the hospital for increased agitation/combativeness and paranoia; -On 9/8/19 staff witnessed the resident rocking in his/her doorway in his/her wheelchair at 5:30 P.M. At 5:40 P.M. the housekeeper and Certified Nursing Assistant (CNA-unidentified) heard a noise and saw the resident laying on the floor. The CNA got the nurse who completed an assessment of the resident and no injuries were noted. The resident said he/she fell out of bed, but was found sitting by the bathroom door. Neurological checks were started and were within normal limits. The nurse notified the resident's physician and responsible party; -On 9/22/19 at 6:50 P.M., the CNA (unidentified) called the nurse to the resident's room. The resident was laying on the right side of his/her body on the floor next to his/her bed. The resident said he/she was trying to get into bed. The nursing assessment was completed and showed no injuries and -Neurological checks were started and the resident was placed into his/her bed. The nurse notified the resident's physician and responsible party. Record review of the resident's Care Plan last updated on 9/18/19, showed: -On 9/8/19-continue all previous interventions. The resident's responsible party was going to set up outside physical therapy services for the resident and -On 9/18/19-continue interventions in place. Keep the resident's door open for visualization if the resident will allow, check frequently. Observation on 10/1/19 at 9:15 A.M., showed the resident's door was closed. The resident was sitting in his/her room in his/her wheelchair. He/she was dressed for the weather, clean without odors with anti-slip socks on. There was a pressure relief cushion in his/her wheelchair. His/her room was clean, without odors and uncluttered. The resident did not have a roommate. There was a tv and radio in his room. The resident said the staff and residents were always laughing at everything, they think everything is funny. At this time, staff were in the hallway interacting with residents and began to laugh. The resident said that was what he was talking about, they think everything is funny. He/she said they took his/her shoes (the resident's shoes were sitting in front of his/her bed). He/she said he/she did not know why he/she was in the facility, but he/she has only been here a few months. He/she said the staff helped him with getting bathed and dressed but they don't know what they are doing. The resident was not able to say exactly what the staff was doing that was not up to the expectation. He/she did not respond to whether he had recent falls or whether he/she tried to get up without assistance. Observation on 10/2/19 at 6:22 A.M., showed the resident's door was closed. The resident was laying down in his/her bed with his/her eyes closed, resting comfortably. The resident's call light was within reach, his/her wheelchair was beside the head of his/her bed, and his/her bed was in a low position. There was no floor mat on the floor beside his/her bed. Observation on 10/04/19 at 7:40 A.M., showed the resident was sitting up in his/her wheelchair in the dining room waiting for breakfast (there were no staff in the dining room). The resident said that he/she had a problem because he/she forgets a lot and doesn't remember things. He/she said he/she tried to put on his/her clothes this morning and could not. He/she said he/she needed help. He/she said I guess that's why I'm here. The resident did not try to get up from his/her wheelchair. Staff came into the dining room at 8:00 A.M. During an interview on 10/4/19 at 7:43 A.M., CNA D said: -The resident does not like men to work with him/her so they try to have females work with him/her; -They have learned that the resident has difficulty with men and will become combative if men work with him/her in any capacity; -The resident has also become verbally aggressive with female nursing staff and anything can trigger the resident to become angry and aggressive; -The resident does not do well around a lot of people and likes to stay in his/her room; -Due to his/her confusion, the resident does not remember that he/she cannot walk, and tries to get up independently to transfer and to walk; -They have to watch the resident more frequently, but it is difficult because the resident often does not want to lay down during the day and he/she does not want to sit out in the common areas with others and -They have to remind him/her to sit in his wheelchair because he/she will try to stand up and transfer himself/herself. During an interview on 10/4/19 at 3:54 P.M., Licensed Practical Nurse (LPN) C said: -When a resident falls the nurse completed the fall assessment, assessed the resident for injury and completed neurological checks and notified the physician, responsible party and Director of Nursing; -They followed any physician's orders then completed a nursing note and the fall investigation; -They initiated an immediate intervention specific to the resident's fall; -They can update the care plan with the new interventions but they also notify the MDS and Care Plan Coordinators who are responsible for completing the resident care plans; -All interventions are passed along in the daily report and given to direct care staff immediately and during shift change in report; -For a resident who is at high risk of falling and has dementia, they should monitor frequently; -The resident should never be left alone unattended while in their room in a wheelchair and -If the resident is alone in their room the room door should be open and staff should check the resident every 15 minutes and as they pass by, otherwise they should lay the resident down in his/her bed. During an interview on 10/4/19 at 4:20 P.M., the Director of Nursing (DON) said: -He/she expects all fall interventions to be followed; -Resident #8's needs vary based on the day because of his/her behaviors and interactions with nursing staff; -He/she expects staff to check on the resident as frequently as needed to ensure his/her safety and -He/she would not expect staff to leave the resident in his/her room while up in his/her wheelchair unattended and/or with the door closed because of his/her high risk for falls and frequent falls that have occurred in his/her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure monitoring of one sampled resident (Resident #113), who had a significant weight loss, during meals was implemented to ensure the resident received physician ordered weight loss supplements, to ensure the resident received encouragement to eat during meals and to ensure the resident received a meal at the lunch service out of 33 sampled residents. The facility census was 119 residents. Record review of the facility's Weight Monitoring policy and procedure dated 3/1/13, showed the facility has a process in place to obtain, record, and track the resident's weights and ensure accuracy. All residents with the exception of new admissions and new enterals are weighed monthly unless their condition indicates more frequent weighing, as specified by the residents at risk committee. The document showed: -Any resident who experiences an unplanned weight loss, significant weight change, or undesirable weight change-notification will be made to the physician and responsible party; -Each resident with a weight change has a current nutrition assessment/progress note; -The Interdisciplinary Care Plan Team addresses the issue of unplanned weight loss/poor intake or weight gain, assesses the dining needs if indicated, provides realistic and measurable goals, indicates specific and individualized interventions, and more as needed. The resident's interdisciplinary care plan reflects the current interventions, evaluations, and revisions. The nutrition progress notes describe the changes, plan of action and progress or lack of progress; -Interventions for weight loss/declining intake may include, but are not limited to food is tried first; snacks/supplements (are intended to increase the number of calories consumed daily); alternative food preferences; large/double portions; whole milk; fortified cereal and other fortified foods;high calorie snacks between meals; -If the the above interventions have been implemented and the goal is not met, assess for more aggressive interventions, such as a fortified supplement (a physician's order is required for fortified supplements) and -Other factors that may impact weight and the significance of weight changes may include current medical conditions, calorie restricted diets, recent changes in dietary intake, edema (build up of fluid in the tissues), lifestyle changes and increased activity. 1. Record review of Resident #113's Face Sheet showed he/she was admitted on [DATE], with diagnoses including dementia with behavioral disturbance, high blood pressure, abnormal weight loss, cognitive communication deficit, weakness, acid indigestion, and anorexia (an eating disorder characterized by markedly reduced appetite or total aversion to food). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/30/19, showed he/she: -Was alert with significant cognitive deficits and memory loss; -Was independent with transfers, mobility, walking, but needed extensive assistance with bathing, dressing and toileting; -Needed supervision with eating, had no chewing or swallowing disorder; -Was not on a specialized or mechanical diet and -Had significant weight loss. Record review of the resident's Physician's Order Sheet (POS) dated 9/2019, showed physician's orders for: -Regular Diet; -2 cal supplement with the medication pass 90 milliliters (ml) three times daily for weight loss (8/8/19); -Supplement shake twice daily for abnormal weight loss (8/31/19) and -Ice Cream three times daily with meals. Record review of the resident's Weight record showed he/she was on weekly weights since January 2019. Monthly weights showed: -On 4/1/19 he/she weighed 227 pounds (lbs.); -On 5/6/19 he/she weighed 225 lbs; -On 6/4/19 he/she weighed 215 lbs; -On 7/8/19 he/she weighed 210 lbs; -On 8/8/19 he/she weighed 206 lbs; -On 9/2/19 he/she weighed 192 lbs and -He/she had a weight loss of 7.29% in 30 days, 9.38% in 3 months and 18.3% in 6 months. Record review of the resident's Care Plan dated 8/27/19, showed he/she refused to eat, resisted feeding due to dementia and was at risk for weight fluctuation related to his/her current health status. The interventions showed staff was to: -Educate the resident and family regarding weight fluctuation; -Encourage the resident to eat at least one bite of food at meals; -Encourage the resident's family to bring food in-favorite food items from home or restaurant and -Praise resident's progress, provide a calm environment. Record review of the resident's Care Management Note dated 9/20/19, showed: -The resident had continued weight loss despite numerous physician ordered interventions; -Feeding tube placement was offered if the resident's responsible party desired; -The resident's responsible party did not wish to pursue aggressive measures for the resident, felt the resident would not want a feeding tube and would pull it out and -The resident's plan of care was reviewed with the resident's responsible party and he/she was agreeable to labs, blood testing for prostate cancer and and x-rays, and upon receipt of test results he/she will consider Hospice (end of life care). Observation and interview on 9/30/19 at 12:38 P.M., showed nursing staff took a meal tray to the resident's room. The resident was served a seafood casserole with cooked carrots and bread with water and a red beverage. The resident was also served a shake supplement. The resident was sitting in his/her room dressed for the weather. He/she was not having any behaviors at this time. The Certified Nursing Assistant (CNA) did not stay in the room with the resident to observe whether the resident was eating or to provide any assistance or encouragement to eat. He/She returned to the main dining room to assist with residents in the dining room who needed to be fed. Certified Medication Technician (CMT) A said: -The resident was served a room tray due to being non-compliant with coming to the dining room to eat meals and -The resident refused to come to the dining room and has/will become combative if they try to get him/her to do anything that he/she does not want to do. Observation and interview on 10/2/19 at 12:48 P.M., showed the resident was sitting in the dining room at the dining table with peers. He/she was served a diet of meatballs, rice, green beans and a roll. Staff walked over to assist the resident and encourage him to eat. The resident ate some of a meatball. The resident was also served an orange drink and water. The resident did not have any assistive devices or utensils. He/she was physically able to eat independently without assistance. The resident ate half of his/her bread, then stopped eating and began mixing the remaining food on his/her plate. Staff provided the resident with a fruit cup for dessert. The resident did not eat it. Staff did not serve him/her a supplement or an ice cream cup. CMT B said: -The resident receives 2 cal (three times daily) med pass supplement with his/her medications and he/she gave it to the resident this morning and he/she drank half of it; -The resident received a fortified donut at breakfast because he/she wasn't eating; -The resident did not receive a health shake supplement at lunch, he/she was to receive it twice daily at 10:00 A.M. and at 2:00 PM; -The resident used to eat very well, but he/she had stopped eating as much and has been losing weight, which is why they started giving weight loss supplements and -The resident's family also comes in during dinner to try to feed the resident or get him/her to eat and he/she will only take a few bites. Observation and interview on 10/3/19 at 12:51 P.M., showed the resident was sitting in his/her bed in his/her room. There was a tray table that had a red beverage, water and a supplement on it. The resident had a plate sitting beside him/her in his/her bed that had two half slices of bread and scrambled egg on top of the bread. He/she did not have an ice cream cup. The resident was not eating the meal, he/she was pushing it around on his/her plate. CNA E said the resident refused to come to the dining room, so they allow him/her to eat in his/her room and check on him/her periodically to see if he/she has eaten or what he/she ate. CNA E said the resident does not eat very well. Observation and interview at 1:00 PM showed Licensed Practical Nurse (LPN) E went into the resident's room and said that the resident still had his/her breakfast tray because that was what he/she had received this morning for breakfast. LPN E removed the breakfast plate from the resident's bed and out of his/her room at this time. LPN E said: -The nursing staff are supposed to check on the resident throughout the meal if they give him/her a room tray (if he/she refuses to go to the dining room); -The resident should have not still had his/her breakfast tray because they had already served lunch (he/she took the tray out of the room and told staff to get the resident a lunch tray); -He/she made sure the resident received his/her supplements and ensured he/she drank his/her 2 cal supplement during the med pass; -He/she said the resident received his/her initial supplement at 10:00 A.M. and would receive the second supplement at 2:00 P.M. He/She said that they document that they give the supplement in the resident's medical record; -The ice cream comes from the kitchen and the nursing staff pass out the ice cream to the residents; -The resident will eat ice cream and they should be giving it as ordered, but he/she was not sure if they documented that anywhere; -The resident has had recent lab testing to see if there was a physiological reason for the resident's weight loss but the test results showed everything was normal and -The resident just has a poor appetite and this is why he/she is losing weight. Observation on 10/4/19 at 8:56 A.M., showed nursing staff escorted the resident into the dining room. The resident was cooperative and sat down at the dinner table. Nursing staff provided the resident with hot cereal and a donut cut into bite sized pieces. The Staffing Coordinator tried to encourage the resident to eat and the resident sometimes accepted assistance and sometimes refused. Nursing staff then provided the resident with scrambled eggs with ham and toast. Staff also provided a supplement shake and water and orange juice. The resident pushed the food around with his/her utensil, but did not put food to his/her mouth until the Staffing Coordinator actually began feeding the resident. The resident was not combative and actually accepted food and beverages (to include his/her 2 cal supplement) that was fed to him/her. The resident would say that he/she did not want to eat, but still accepted the food that was fed to him/her. The Staffing Coordinator was able to get the resident to drink 95% of his/her 2 cal supplement and health shake supplement. The Staffing Coordinator said: -He/she only works on the floor sometimes, but he/she was able to get the resident to eat some of his/her food and drink his/her supplements and -The resident was eating when he/she fed him/her and did not resist eating. During an interview on 10/4/19 at 2:40 P.M. with the Administrator and Director of Nursing (DON), the DON said: -He/she has been on the unit and has tried to feed the resident himself/herself and sometimes the resident will eat and sometimes he/she will not; -The nursing staff have tried bringing in a variety of foods to try to get him/her to eat and often times they are not successful; -They have discussed the resident's weight and nutrition with the interdisciplinary team and the resident's family, and have tried a variety of nutritional interventions and approaches to try to increase the resident's weight; -They have provided snacks throughout the day and provided a meal at night that they can warm so that they can provide the resident with a nutritious meal at anytime of the night if he/she will eat; -He/she expects for the interventions to be attempted even if the resident does refuse; -The nursing staff know that they are supposed to monitor the resident at least periodically during meals and they should never leave the resident's breakfast meal in his/her room until lunch; -He/she expects the nutritional interventions and physician's orders for nutritional supplements to be followed and -It seemed as if the resident was not being monitored.

Based on interview and record review, the facility failed to ensure freedom from unnecessary medication by not having documented clinical rationale in place for a prescribed psychotropic medication, and by failing to care plan needs related to a diagnosis of dementia for one sampled resident (Resident #66) out of 33 sampled residents. The facility census was 119 residents. Record review of the facility's Psychotropic Medication Use policy dated 12/1/17 showed: -The facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other Applicable Law relating to the use of psychopharmacological medications including gradual dose reductions; -The facility should not use psychotropic medications to address behaviors without first determining if there is a medical, physical, functional, psychological, social, or environmental cause of the resident's behaviors; -Psychotropic medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms; -Antipsychotic medications used to treat Behavioral or Psychological Symptoms of Dementia (BPSD) must be clinically indicated, be supported by an adequate rationale for use, and may not be used for a behavior with an unidentified cause and -Where a physician/prescriber orders a psychotropic medication for a resident, the facility should ensure that the physician/prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary. 1. Record review of Resident #66's current Physician's Order Sheet (POS) on 10/4/19 at 1:31 P.M. showed an order for Quetiapine Fumarate (Seroquel an antipsychotic medication that rebalances chemical messengers in the brain to improve thinking, mood, and behavior) 50 milligram (mg) tablet - give one tablet orally at bedtime for mood. Record review of the resident's medical record showed: -A diagnosis of Unspecified Dementia Without Behavioral Disturbance and -No diagnosis of a mood or behavioral disorder. Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 7/2/19 showed: -Mood section showed three out of nine symptoms for concern; --Little interest or pleasure in doing things; --Feeling down, depressed, or hopeless; --Feeling tired or having little energy and -Behavior section showed no psychosis or behavioral concerns. Record review of the resident's current care plan showed: -Dementia care and interventions were not addressed and -Mood and behavior disorder were not addressed. During an interview on 10/4/19 at 4:20 P.M., the Director of Nursing (DON) said: -He/she expected all residents at the facility to have current and accurate comprehensive care plans; -Any resident with a diagnosis of dementia should have a care plan for that diagnosis; -He/she would expect a resident who is prescribed an antipsychotic medication to have an appropriate diagnosis that supports the clinical indication for that medication; -He/she would expect any discrepancies between diagnosis and the clinical rationale for an antipsychotic medication to be reviewed and addressed by the pharmacist; then the DON would review the pharmacy notes and -He/she had not reviewed any such documentation from the pharmacist's reviews for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two sampled residents (Residents #116 and #101) out of 33 sampled residents were free of significant medication errors. The facility census was 119 residents. 1. Record review of Resident #116's face sheet showed he/she admitted to the facility on [DATE] with a diagnosis of Diabetes. Observation on 10/2/19 at 7:31 A.M. of medication pass showed Registered Nurse (RN) A: -Gathered supplies to perform an accucheck (a test used to determine the amount of sugar in a persons blood by obtaining a drop of blood) on Resident #116; -Obtained an accucheck result of 178; -Verified the resident's insulin order to be Lantus (a long acting insulin) 10 units; -Dialed the Lantus insulin pen to 10 units and gave the insulin to the resident and -Did not prime the Insulin pen with 2 units of insulin. 2. Record review of Resident #101's face sheet showed he/she admitted to the facility on [DATE] with a diagnosis of Diabetes. Observation on 10/2/19 at 7:45 A.M. of medication pass showed RN A: -Gathered supplied to perform an accucheck on Resident #101; -Obtained an accucheck result of 225; -Verified the resident's Insulin order to be Humulin NPH (an intermediate acting insulin) 14 units; -Dialed the Humulin insulin pen to 14 and gave the insulin to the resident and -Did not prime the insulin pen with 2 units of insulin. During an interview on 10/4/19 at 8:30 A.M., Licensed Practical Nurse (LPN) A said before giving insulin of any kind from an insulin pen 2 units of insulin have to be dialed up and wasted to prime the pen and needle. During an interview on 10/4/19 at 9:10 A.M. LPN C said Insulin pens are to be primed with 3 units of insulin before every administration of insulin. During an interview on 10/4/19 at 4:00 P.M. the Director of Nursing (DON) said: -All insulin pens were to be primed with 2 units of insulin before every insulin injection; -The licensed nurses had an in-service regarding insulin and insulin pens recently; -The licensed nurses had completed the insulin competencies at the time of the in-service and -There was no excuse for any of the licensed nurses to not prime the insulin pen before giving insulin to a resident.

Based on observation, interview and record review, the facility failed to follow the visitor foods policy by failing to ensure that food brought in for residents, was labeled and dated. This practice potentially affected an unknown number of residents who received food from visitors. The facility census was 119 residents. Record review of the facility's policy entitled Food Brought into Facility from Outside Sources,dated 11/17/17, showed: - All residents, family members and other visitors will be informed of the policy and receive education on safe food handling; - Food is stored prepared and distributed in accordance with professional standards for food safety, storing visitor food outside of the Food and Nutrition Services department in such a way to clearly distinguish it from food used by or prepared by the facility, and - The absence of a requirement for dating and labeling the containers of the food brought by visitors to the residents. 1. Observations with Certified Nurse's Assistant (CNA) C on 9/30/19 at 1:58 P.M., showed the following in the resident use refrigerator in the East Assist Dining room, - Two items wrapped in foil that was not dated or labeled; - One fast food container of food that was not labeled or dated; - One pink container with a cheesy item that was not dated or labeled, and - Two other bags of food that were not labeled or dated, During an interview on 9/30/19 at 2:02 P.M., CNA B said most of the unlabeled food was placed in that refrigerator by new employees who take the food from families and were supposed to label and date that food but did not. Observation with Licensed Practical Nurse (LPN) C on 9/30/19 at 2:06 P.M., of the resident use fridge on the Spring Bridge Unit, showed one open container of sour cream that was not dated.

Based on interview and record review, the facility failed to account for the change (money returned when a payment exceeds the amount due) that four sampled residents (Residents #70, #40 #12, and #46), signed out for, for a facility employee to go on a shopping trip on behalf of these residents. The facility census was 119 residents. 1. Record review of the receipts for Resident #70, showed he/she signed out for $30.00 and $29.70 was spent. There was no accounting of the $0.30 that was not spent. 2. Record review of the receipts for Resident #40, showed he/she signed out for spending of $150.00 on 7/12/19, and $149.55 was spent. There was no accounting of the $0.45 that was not spent. 3. Record review of the receipts for Resident #12, showed he/she signed out for spending of $175.00 on 7/12/19, and $174.84 was spent. There was the presence of a dime in an envelope, but no accounting of the $0.06 and no accounting of that dime recorded back into that resident's account. 4. Record review of the receipts for Resident #46, showed he/she signed out for spending of $125.00 on 7/12/19, and $123.44 was spent. There was no accounting of the $1.56 going back into the resident's account. During an interview on 10/4/19 at 9:28 A.M., Business Office Manager (BOM) A said the Social Service Designee (SSD) was supposed to give change back and it was not known if he/she gave the change to the residents or not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to maintain the commode risers in resident rooms 212, 209, 403, 413, and 307 free from rusty areas on those risers which rendered those risers not easily cleanable; to inform the therapy department about the condition of a specialized cushion and to inform the maintenance department about the loose right sided handle of Resident #70's wheelchair. The facility census was 119 residents. 1. Observations with Maintenance Director and Maintenance Person B on 10/1/19, showed: -At 12:30 P.M., rust was present on the commode riser in resident room [ROOM NUMBER]; -At 12:32 P.M., rust was present on commode riser in resident room [ROOM NUMBER]; -At 1:26 P.M., rust was present on the commode riser in room [ROOM NUMBER]; -At 1:42 P.M., rust was present on the commode riser in 413, and -At 2:59 P.M., rust was present on the commode riser in resident room [ROOM NUMBER]. During an interview on 10/2/19 at 2:11 P.M., the Central Supply Coordinator said if the housekeepers and the Certified Nurse's Assistant (CNAs) see rust on the commode risers they should notify him/her and again he/she was not notified of the rusty commode risers. 2. Record review of Resident #70's face sheet dated 11/1/17, showed diagnoses which included cerebral palsy (a disability resulting from damage to the brain before, during, or shortly after birth and outwardly manifested by muscular incoordination and speech disturbances), unspecified intellectual disabilities, gastro-esophageal reflux disease (GERD- back-up of stomach acid/heartburn), and acute respiratory failure. Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment tool required to be completed by facility staff for care planning) dated 8/17/19 showed: -A brief Interview for Mental Status was not conducted because the resident is never or rarely understood; -The resident was severely impaired in cognitive skills for daily decision making, and - The resident normally used a wheelchair for mobility. Observations on 10/2/19 at 3:03 P.M., showed a 10 inch (in.) long rip and another 3 in. damaged area in the covering of, and a loose and shaky right-sided handle Resident #70's wheelchair. During an interview on 10/4/19 at 11:09 A.M., the Director of Nursing (DON) said if he/she had known the wheelchair had a torn cushion covering then he/she would have notified the therapy department, because it is a custom cushion and facility staff should have notified the maintenance department about the loose right sided wheelchair handle. During an interview on 10/04/19 02:09 P.M., the Administrator, the DON, and the Regional Director of Clinical Services said the following in regards to interdepartment communications: -The system for communicating between departments-staff reporting equipment needs improvement; -There are work orders that the staff in all departments have access to and are supposed to fill out if they notice any issues regarding environmental or equipment; -Communicating between departments would be done in the standup meetings a daily with all department heads-they complete a grand round, then they address those issues in the stand-up meeting; -There are many new staff and the breakdown in communication has been with educating the line staff CNAs, Certified Medication Technicians (CMTs); -The housekeeping staff who are in the resident rooms daily should report any and all issues that they witnessed to their manager and the DON, and -They (the DON and the Administrator) will tell nursing staff to report any issues to the DON or the Administrator said that they should report any issues to their manager or to the Administrator if they cannot write a work order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #66's assessments and tracking forms showed he/she: -discharged from the facility with return anticipated on 7/19/19; -Re-entered the facility on 7/26/19 and -Was cognitively intact. Record review of the resident's medical record showed: -No documentation that written notification of the facility's bed-hold policy was provided to the resident and the resident's representative and -Nurse's notes and social service notes showed no documentation regarding providing notification of the bed-hold policy in writing to the resident and the resident's representative. 4. Record review of Resident #111's assessments and tracking forms showed he/she: -discharged from the facility with return anticipated on 6/11/19 and re-entered the facility on 6/18/19; -discharged from the facility with return anticipated on 8/27/19 and re-entered the facility on 9/2/19 and -Had severe cognitive impairment. Record review of the resident's medical record showed: -No documentation that written notification of the facility's bed-hold policy was provided to the resident and the resident's representative and -Nurse's notes and social service notes showed no documentation regarding providing notification of the bed-hold policy in writing to the resident and the resident's representative. 5. During an interview on 10/4/19 at 4:20 P.M., the Director of Nursing (DON) said: -A copy of the bed-hold policy was expected to have been completed and given to the resident and his/her representative if applicable upon discharge to the hospital, and a copy should be placed in the resident's chart; -In emergency situations, if the bed-hold documentation cannot be prepared prior to the resident leaving the facility, staff should have ensured that it was sent to the resident at the hospital as soon as possible after discharge; -They have discharge packets that include the bed hold policy, they pull out the bed hold policy and transfer form that goes with the resident when they go out to the hospital; -This information is to go with the resident every time they go to the hospital; -When they have an acute transfer out of the hospital due to the nature of why they went out, they will send the bed hold to the hospital and -Resident #91 and #118 had an acute issue and was sent to the hospital immediately and may not have been sent with the bed hold documentation or may not have signed the bed hold form. 2. Record review of Resident #118's assessments and tracking forms showed he/she: -discharged from the facility with his/her return anticipated on 7/8/19; -Re-entered the facility on 7/18/19 and -Was cognitively intact. Record review of the resident's nurses' notes and Social Services notes showed no documentation regarding providing the resident and his/her representative with a bed hold policy. Record review of the resident's medical record showed there was no documentation showing the bed hold policy was given to the resident/resident's representative at the time of discharge. Based on observation, interview and record review, the facility failed to ensure the bed hold policy was provided to four sampled residents during an acute hospital stay (Resident's #91, #118, #66, and #111) out of 33 sampled residents including two closed records. The facility census was 119 residents. Record review of the facility's Bed Hold /Reservation of Room policy and procedure, dated 5/2/19, showed the bed hold policy should be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours), or the resident's goes on therapeutic leave of absence. The facility will provide written information to the resident or resident's representative the nursing facility on bed hold periods and the resident's return to the facility to ensure that residents are made aware of a facility's bed hold policy and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility. The procedure showed before the resident transfers to a hospital or the resident goes on therapeutic leave, the facility will provide written information to the resident or responsible party that specifies: -The duration of the state bed hold policy, if any, during which the resident is permitted to return and resume residence in the facility and -The reserve bed payment policy in the state plan, if any. -The facility policies regarding bed hold; -In cases of emergency transfer, notice at the time of transfer means that the family, surrogate, or responsible party are provided with written notification within 24 hours of the transfer. 1. Record review of Resident #91's Face Sheet showed he/she was admitted on [DATE], with diagnoses including heart failure, high blood pressure, low blood pressure, anxiety disorder, atrial fibrillation (abnormal heart rhythm), difficulty walking and diabetes. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/25/19, showed he/she: -Was alert and did not have cognitive deficits and -Needed extensive assistance from staff for bathing, dressing, grooming toileting and mobilizing. Record review of the resident's Nursing Notes showed: -On 8/15/19, staff heard the resident screaming for help. Upon attempting to enter the resident's room staff noticed blood under his/her door. Staff noted the resident has fallen and was blocking the entrance. Upon gaining access to the resident the resident had fallen on top of his/her wheelchair and was laying prone on the floor with his/her face flat on the floor. The resident was bleeding severely from his/her nose. Staff assisted the resident upright in a sitting position and the resident said he/she was attempting to ambulate to the bathroom without requesting assistance from staff or using his/her call light. Staff also noted the resident did not have on appropriate footwear. Nursing staff notified the resident's physician and responsible party. Staff documented that they explained the bed hold policy to the resident and provided him/her a copy of the policy and -The resident returned to the facility on 8/19/19. Upon request of the signed bed hold document for the resident's hospitalization on 8/15/19, the facility was unable to provide this documentation. During an interview on 10/4/19 at 3:54 PM Licensed Practical Nurse (LPN) C said: -When a resident goes to the hospital, they will provide the resident with a copy of the bed hold policy and ask whether they want the facility to hold their bed or not before they go and have the resident sign the form; -If the resident is unable to understand or sign the form, they will call to inform the resident's responsible party and receive the verbal authorization to hold the resident' bed; -If they receive a verbal authorization, the nurse should document this in the resident's medical record so they have documentation of this information in case they are unable to have the form signed at the time the resident goes to the hospital and -They will usually have the document signed by either the resident or the resident's responsible party to ensure they have provided the bed hold information.

Based on observation, interview and record review, the facility failed to do or maintain the following: the area at the back of the six burner stove free of grease buildup; the area under the automated bread toaster free of bread crumbs, the lettuce to be fresh and not brown colored; the floor of the dry-goods storage room free of food debris; ensure the mop water from the previous night was discarded; three cutting boards to be free of numerous groves and maintained in an overall easily cleanable condition; ensure employees used proper infection control practices; the reach-in fridge free of spills; the dishwasher spray wands free of food debris; and failed to maintain the ice machine on the Spring Bridge Unit free of grime within the ice machine. This practice potentially affected at least 110 residents who ate food from the kitchen. The facility census was 119 residents. 1. Observations and interviews on 9/30/19 from 8:31 A.M. through 1:19 P.M., showed - At 8:33 A.M., there was a buildup of grease and debris, behind and under the six-burner stove, the convection oven and on the walls; - At 8:34 A.M., there was food debris behind the ice machine; - At 8:34 A.M., there were many bread crumbs under the automated toaster on one of the food prep tables; - At 8:37 A.M., there were grease deposits on backside of convection oven; - At 8:41 A.M., the lettuce in the walk-in fridge was brown colored; - At 9:02 A.M., there was food under the dishwasher, with numerous gnats crawling over the food; - At 9:04 A.M., there was food debris on floor of dry goods storage area; - At 9:12 A.M., food debris was present in the nozzles of the upper and lower dishwasher spray wands in the automated dishwasher; -At 9:16 A.M., there was the presence of spilled milk on the bottom of the dairy products fridge; - At 9:19 A.M., grime was present around nozzles of juice machine; - At 9:25 A.M., Dietary [NAME] (DC) A sliced celery after he/she opened trash container and did not wash his/her hands; - At 9:30 A.M., the Dietary Manager (DM) said the food debris under the dishwasher should be cleaned up every night; - At 9:36 A.M., the DM said convection oven is on wheels and soul be pulled out more often to clean behind it; - At 9:40 A.M., Dietary Aide (DA) A said that debris under the dishwasher, was there from last night; - At 10:00 A.M., DA B cleaned the prep table next to the dry good storage room but did not clean under the toaster; - At 1:02 P.M., three cutting boards were not in good condition; - At 1:03 P.M., the DM said the lead cook should check the cutting boards, and he/she had more in the back; - At 1:05 P.M., DC A said he/she cleaned the nozzles once per week; - At 1:09 P.M., the DM agreed the salad mix should have been used or thrown away; - At 1:21 P.M., DC A said the cleaning should be done at least twice per month in the storage room but at least once per month for deep cleaning, and - At 1:19 P.M., the DM noticed that under the toaster was not cleaned. 2. Observation on 10/1/19 at 10:12 A.M., showed the presence of grime inside the ice machine in the Spring Bridge Dining room. During an interview on 10/2/19 at 9:27 A.M., DA E said that cleaning the ice machine in the Spring Bridge dining room was not on the dietary department's schedule. Record review of the dietary department's cleaning schedule showed the following: -The following areas and tasks were to be completed daily, the range burners, the grill, the steam table, the can opener, the meat slicer, sweeping and mopping and -The following tasks were to be completed at least once per week: the oven, the steamer, the convection oven, and the walls behind appliances. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: - In Chapter 3-305.14, During preparation, unpackaged FOOD shall be protected from environmental sources of contamination, - In Chapter 4-202.11, regarding Food-Contact Surfaces; Multi-use FOOD-CONTACT SURFACES shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; and 4) Finished to have SMOOTH welds and joints; - In Chapter 4-601.11, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. - In Chapter 4-602.13, nonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues; - In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain a safe and sanitary environment in the following areas by not doing the following: communicate with the housekeeping department about a soda spill in the Admission's closet; failed to maintain the fans in the Garden Terrace shower room, the social service office, and resident room [ROOM NUMBER] free of a heavy buildup of dust; failed to maintain the restroom door in 206 in good repair to prevent it from dragging on the floor; and to ensure the metal framing of a white board in resident room [ROOM NUMBER] was maintained in a safe condition. The facility census was 119 residents. 1. Observations and interviews with the Maintenance Director and Maintenance Person B on 10/1/19, showed: - At 10:16 A.M., buildup of dust/debris including contents from a spilled soda can in the Admission's closet in Spring Bridge dining room; - At 10:39 A.M., a heavy buildup of dust was present on the fan in the Garden Terrace shower room; - At 12:25 P.M, a heavy buildup of dust was present on the fan in the social services office; - At 12:30 P.M., a heavy buildup of dust was present on the fan in resident room [ROOM NUMBER]; - At 12:45 P.M., the restroom door dragged on the floor which made it very difficult to close; - At 12:47 P.M., Maintenance Person B and the Maintenance Director said it was the loose hinge that caused that door to drag; - At 1:38 P.M., a white board in resident room [ROOM NUMBER] was damaged with a sharp metal edge protruding from it; - At 1:41 P.M., the Maintenance Director and Maintenance Assistant said they did not know how long that white board had been like that; and - At 2:51 P.M., the closet door in resident room [ROOM NUMBER] was not on the track and in disrepair. During an interview on 10/2/19 at 1:11 P.M., the Assistant Housekeeping Supervisor said he/she: -Did not know the fan in the Garden Terrace shower room had a heavy buildup of dust; -Did not know there was a fan in the shower room; and -The housekeeping department was not aware of the spilled soda and a heavy buildup of dust and debris in the Admission's department closet. During an interview on 10/04/19 02:09 P.M., the Administrator, the DON, and the Regional Director of Clinical Services said the following in regards to interdepartment communications: - The system for communicating between departments-staff reporting equipment needs improvement; - There are work orders that the staff in all departments have access to and are supposed to fill out if they notice any issues regarding environmental or equipment; - Communicating between departments would be done in the standup meetings a daily with all department heads-they complete a grand round, then they address those issues in the stand-up meeting; - There are many new staff and the breakdown in communication has been with educating the line staff CNAs, Certified Medication Technicians (CMTs); - The housekeeping staff who are in the resident rooms daily should report any and all issues that they witnessed to their manager and the DON, and -They (the DON and the Administrator) will tell nursing staff to report any issues to the DON or the Administrator said that they should report any issues to their manager or to the Administrator if they cannot write a work order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain the kitchen areas including the dry goods storage room free of harborage conditions for pests (gnats - small flies) and to maintain other areas around the facility free of pests or evidence of pests. This practice potentially affected all residents. The facility census was 119 residents. 1. Observations and interviews on 9/30/19 from 8:31 A.M. through 1:00 P.M., showed: - At 8:34 A.M., there was debris behind the ice machine with the presence of gnats behind the ice machine; -At 9:02 A.M., there was food under the dishwasher from the previous night with numerous gnats crawling over the food; - At 9:03 A.M., gnats flew around the room and crawled on the wall in the dry goods storage room next to table with toaster; - At 9:04 A.M., food debris on floor of dry goods storage area; - At 9:30 A.M., the Dietary Manager (DM) said the food debris under the dishwasher should be cleaned up every night; - At 9:36 A.M., the DM acknowledged the presence of the gnats in the dry goods storage room; - At 9:40 A.M., Dietary Aide (DA) A said the food under the dishwasher was there from the previous night; - At 11:13 A.M., numerous gnats crawled on the wall behind and above ice machine; - At 11:14 A.M., DA B said the gnats have been a problem in the kitchen for a couple weeks; - At 12:54 P.M., a gnat crawled on wall of dining room; - At 1:03 P.M., the DM said that day was the first day he/she saw the gnats in the storage room but has seen them in the dishwashing area before; - At 1:19 P.M., the DM noticed that under the toaster was not cleaned; and - At 1:21 P.M., DC A said the cleaning should be done at least twice per month in the storage room but at least once per month for deep cleaning. 2. Observations and interviews with Maintenance Director and Maintenance Person B on 10/1/19, showed: -At 9:41 A.M., the presence of mouse droppings on a ceiling tile at the smoke wall between the laundry and the dining room; - At 10:14 A.M., the presence of mouse droppings on Spring Bridge dining room window sill; - At 10:18 A.M., ants were present on the floor of the Garden Terrace dining room closest to the courtyard; - At 10:20 A.M., mouse droppings behind the basketball goal present in the Garden Terrace Dining room; - At 10:26 A.M., ants were present in the Garden Terrace medication room; - At 10:34 A.M., numerous dead insects on the floor of the sprinkler room in Garden Terrace area, - At 10:35 A.M., the Maintenance Director said that he/she was responsible to ensure the floor of the sprinkler room in Garden Terrace was swept free of dead insects; - At 10:58 A.M., there was a large cobweb with numerous dead insects in it in resident room [ROOM NUMBER]; and - At 1:33 P.M., there was a buildup of dead insects behind the bed in resident room [ROOM NUMBER]. During an interview on 10/2/19 1:52 P.M., the DM said there was a company that comes out once per month to spray around the drains and around the baseboards and walls and the dish washing area to reduce the number of gnats. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (A) Routinely inspecting incoming shipments of FOOD and supplies; (B) Routinely inspecting the PREMISES for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under §§ 7-202.12, 7-206.12, and 7-206.13; Pf and (D) Eliminating harborage conditions. 6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests. Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the PREMISES at a frequency that prevents their accumulation, decomposition, or the attraction of pests.