**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to make individual financial record available to the resident or resident representative through quarterly statements and upon request when facility staff failed to provide 5 residents (Resident #1, #2, #3, #4, and #5) or their responsible party with reconciled quarterly resident trust fund statements. The facility census was 88.Review of the facility's policy titled, Guidelines for Maintaining the Resident Trust Fund Account, revised on 08/04/22, showed the following:-The facility will establish and maintain a system that assures full, complete and separate accountings of each resident's personal funds entrusted to the facility on the resident's behalf;-A separate statement will be maintained for each resident that will show every disbursement and every deposit made on the resident's behalf;-The electronic accounting system is to be used to record resident trust deposits, disbursements, distribute interest and print quarterly statements;-The resident or responsible party will receive a copy of the resident's trust statement showing all transactions to resident's trust fund account on a quarterly basis;-This will be done each month in January, April, July and October by the 15th of the month.1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 02/03/21;-Diagnosis of dementia (a disease that causes a loss of memory, language, problem solving and other thinking abilities that interfere with daily life), vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), and physical debility;-Resident was his/her own responsible party.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 05/01/25, showed the following:-Resident unable to complete a brief interview for mental status;-Resident had a short- and long-term memory problem;-Resident had poor decision making for tasks of daily life and required cues or supervision.Review of the resident's care plan, revised 05/07/25, showed the following:-Resident had difficulty making self-understood;-Staff should ask resident questions requiring one-to-two-word answers;-Staff should anticipate needs as resident unable to communicate;-Resident had impaired decision making related to cognitive decline and dementia.During an interview on 06/25/25, at 10:00 A.M., the resident said he/she did not know how much money he/she had and did not receive any account statements from the facility.Review showed the facility could not provide reconciled quarterly statements for the resident's funds. 2. Review of Resident #2's face sheet showed the following:-admission date of 09/06/2018;-Diagnosis of severe depression with psychotic symptoms, schizoaffective disorder (mental health condition with symptoms of schizophrenia (mental health condition that affects how people think, feel, and behave) and mood disorders).-Had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment.Review of the resident's Care Plan, revised 06/04/25, showed the following:-Resident had schizoaffective disorder;-Staff should maintain a calm environment and approach to resident;-Resident had difficulty focusing attention at times.During interviews on 06/25/25, at 2:00 P.M., and on 07/01/25, at 1:45 P.M., the resident said he/she had never received a paper statement of how much money was in his/her account During an interview on 07/03/25, at 10:22 A.M., the resident's power of attorney (POA) for finance said the facility did not send financial statements.Review showed the facility could not provide reconciled quarterly statements for the resident's funds.3. Review of Resident #3's face sheet showed the following:-admission date of 09/26/24;-Diagnoses included dementia and depression;-Resident had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Resident unable to complete a brief interview for mental status;-Resident had a short- and long-term memory problem;-Resident had severely impaired decision-making ability;-Resident was inattentive and had disorganized thinking.Review of the resident's Care Plan, revised 05/09/25, showed the following:-Resident had behavioral symptoms towards others;-Staff should maintain a calm environment and approach to resident;-Avoid over stimulating the resident.;-Staff should monitor for fluctuating state of disorientation and decreased environmental awareness;-Resident resides in the memory care unit due to cognitive loss, dementia, and exit seeking.During an interview on 07/08/25, at 11:48 A.M., the resident's POA said he/she was responsible for the resident's financial affairs. He/she had not received any quarterly statements related to money in the trust.Review showed the facility could not provide reconciled quarterly statements for the resident's funds.4. Review of Resident #4's face sheet showed the following:-admission date of 07/23/24;-Diagnosis of depression, dementia, and anxiety disorder;-Had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment.Review of the resident's Care Plan, revised 05/07/25, showed the following:-Resident had verbal behavioral symptoms directed toward others;-Staff should maintain a calm and reassuring approach to resident;-Staff should monitor resident for states of disorientation.During an interview on 07/09/25, at 12:29 P.M., the resident's POA said he/she was responsible for the resident's financial matters. He/she did not receive quarterly statements from the facility. Review showed the facility could not provide reconciled quarterly statements for the resident's funds.5. Review of Resident #5's face sheet showed the following:-admission date of 06/13/14;-Diagnoses included schizoaffective disorder, delusional disorder, depression, and generalized anxiety. dementia, and anxiety disorder;-Resident had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Resident unable to complete a brief interview for mental status;-Resident had short- and long-term memory problems with delusions.Review of the resident's Care Plan, revised 05/21/25, showed the following:-Resident had socially inappropriate behavior;-Resident was pleasantly confused and often asked about parents.Review showed the facility could not provide reconciled quarterly statements for the resident's funds.6. During an interview on 06/25/25, at 12:55 P.M. the Corporate Financial Consultant said resident statements should be sent quarterly with a form for the resident or responsible party to sign and return.During interviews on 07/01/25, at 9:23 A.M. and 1:00 P.M., the new BOM said the following:-He/she had been unable to find many records in the BOM office since starting the job last week;-He/she found no resident funds records for months at a time;-Resident trust quarterly statements should be mailed with a letter to be signed by the resident or representative;-He/she was unable to find any letters or quarterly statements.MO00255783

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the right of all residents to be free from misappropriation when resident personal funds of five residents (Resident #1, #2, #3, #4, and # 5) were used to make multiple unauthorized purchases. A sample of residents was reviewed in a facility with a census of 88.Review of the facility's policy, Abuse, Neglect, and Misappropriation of Property, dated November 2017, showed the following:-Each resident will be free from verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion;-Residents will be protected from abuse, neglect, and harm while at the facility. Review of the facility's policy titled, Guidelines for Maintaining the Resident Trust Fund Account, revised on 08/04/22, showed the following:-This facility will establish and maintain a system that assures full, complete and separate accountings of each resident's personal funds entrusted to the facility on the resident's behalf;-A separate statement will be maintained for each resident that will show every disbursement and every deposit made on the resident's behalf;-The electronic accounting system is to be used to record resident trust deposits, disbursements, distribute interest, and print quarterly statements;-Disbursements from the resident's trust account will not be made without a signed Resident Trust Disbursement/Check request from the resident or the resident's legal representative;-The Administrator and the BOM shall be the signatories to any check written on the resident trust account. However, if either, the Administrator or the BOM are unavailable, the Social Service Designee (SSD) shall be an authorized signatory.-The facility will send a copy of the signed check to system services to be kept on file with the check approval. If the disbursement falls under the one of the items listed on agreement concerning management of personal funds, a copy of the signed agreement will take the place of a resident trust disbursement/check request.1. Review of Resident #1's face sheet (a document that gives a resident's information at a quick glance) showed the following:-admission date of 02/03/21;-Diagnoses included dementia (a disease that causes a loss of memory, language, problem solving and other thinking abilities that interfere with daily life), vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain), and physical debility.-Resident was his/her own responsible party.Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 05/01/25, showed the following:-Resident had a short- and long-term memory problem;-Resident had poor decision making for tasks of daily life and required cues or supervision.Review of the resident's care plan, revised 05/07/25, showed the following:-Resident had difficulty making self-understood;-Staff should ask resident questions requiring one-to-two-word answers;-Staff should anticipate needs as resident unable to communicate;-Resident had impaired decision making related to cognitive decline and dementia.Review of the resident's bank statement, dated 06/06/25 showed the following charges on the bank card:-A charge, dated 05/14/25, to TJ [NAME] for $47.72;-A charge, dated 05/14/25, to, Mama Jeans Market for $106.88;-A charge, dated 05/14/25 to [NAME] for $141.06;-A charge, dated 05/14/25, to Coach for $239.48;-A charge, dated 05/27/25, to Wal-Mart Supercenter for $106.55;-A charge, dated 05/30/25, to Mama Jeans Market for $33.07;-A charge, dated 06/02/25, to [NAME] Pro Store for $171.03;-A charge, dated 06/05/25, to TJ [NAME] for $67.36.Review of a facility investigation, dated 06/18/25, showed the following:-On 06/13/25, at 8:03 A.M., the Social Service Director (SSD) opened a resident bank statement and observed eight suspicious charges and notified the Administrator;-The resident had not been out of the facility in the past few years and was not in procession of any of the items on the bank statement;-The BOM and resident family member reported no knowledge of anyone accessing the bank account;-The police department had been notified and began an investigation;-On 06/16/25, the Administrator and the Director of Nursing (DON) reported to the police department to view a video of the BOM using the resident bank card at a local Walmart; -The Administrator and Director of Nursing (DON) identified the BOM of the facility in the video using the bank card. The video footage showed BOM using the resident's bank card for a purchase at Walmart on 05/27/25 for $106.55;-The Administrator and a police officer then returned to the facility and suspended the BOM;-Misappropriation of the resident's bank funds had occurred.During an interview on 06/25/25, at 9:20 A.M., the Administrator said the following:-The SSD accidentally opened the resident's mail and noticed several suspicious charges;-SSD knew resident had not left the facility to go shopping and thought the account had been hacked;-The SSD notified the Administrator and an investigation was started;-The Administrator contacted the bank and a hold was placed on the card;-The resident's family member was called and reported he/she had not been to the facility in two years and did not have access to accounts;-Administrator contacted the police and filed a report;-The police department contacted him/her, and a video was viewed of the BOM using the resident's bank card to make an unauthorized Walmart purchase;-The facility had began reviewing resident accounts and had noted other unauthorized charges.During an interview on 06/25/25, at 10:00 A.M., the resident said the following:-He/she never leaves the facility;-He/he had not been to Wal-mart or TJ [NAME] and had not requested anyone at the facility buy anything.2. Review of Resident #2's face sheet showed the following:-admission date of 09/06/18;-Diagnoses included severe depression with psychotic symptoms, and schizoaffective disorder (mental health condition with symptoms of schizophrenia (mental health condition that affects how people think, feel, and behave) and mood disorders).-The resident had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment.Review of the resident's care plan, revised 06/04/25, showed the following:-Staff should maintain a calm environment and approach to resident;-Resident had difficulty focusing attention at times.Review of a Cash Box Withdrawal and Reconciliation Report, dated 02/11/25, showed an amount of $190.00 withdrawn for the resident with the following receipts attached:-A receipt, dated 11/04/24 at 3:46 P.M., for Hobby Lobby with a total of $178.11;-A resident cash withdrawal for spending of $11.89.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/08/25, showed an amount of $125.35 withdrawn for the resident with the following receipts attached:-A receipt, dated 02/19/25 at 12:49 P.M., for Target with a total of $43.50;-A receipt, undated, for Books-A-Million with a total of $31.85;-A resident cash withdrawal for spending of $50.00.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/12/25, showed an amount of $425.85 withdrawn for the resident with a receipt dated 05/11/25 at 7:41 P.M. for Target with a total of $425.85 attached.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/19/25, showed an amount of $92.08 withdrawn for the resident with the following receipts attached:-A receipt, dated 05/15/25 at 11:55 A.M., for Walgreens with a total of $13.70;-A receipt, dated 05/16/25 at 3:18 P.M., for Dollar General with a total of $53.67;-A receipt, dated 05/16/25 at 6:59 P.M., for Chick fil A with a total of $24.71.Review of a Cash Box Withdrawal and Reconciliation Report, dated 06/03/25, showed an amount of $150.00 withdrawn for the resident with the following receipts attached:-A receipt, dated 05/28/25 at 5:33 P.M., for Ross Dress for Less with a total of $30.72;-A receipt, undated, for Books-A-Million with a total of $19.76;-A receipt, dated 05/29/25 at 8:47 A.M., for Dollar Tree with a total of $33.86;-A receipt, undated, for Hobby Lobby with a total of $26.40;-A receipt, dated 05/20/25 at an unknown time, for Walgreens with a total of $16.53;-A resident cash withdrawal for spending of $22.73.During interviews on 06/25/25, at 2:00 P.M., and on 07/01/25, at 1:45 P.M., the resident said the following:-The facility holds his/her money, and he/she liked to get $50 out per week to go to the beauty shop;-He/she is worried if he/she had too much money it would be stolen;-He/she did not leave the facility and his/her family brings in what he/she needs;-The SSD helped with ordering clothes from a catalog one time;-It is hard to get money from the BOM and he/she had to go back several times;-The BOM said that he/she was too busy to give the money out at times;-He/she had not requested staff purchase items from target, chick fil a, or TJ [NAME].During an interview on 07/03/25, at 10:22 A.M., The resident's power of attorney (POA) for finance said the facility notified him/her of the purchase of clothes from a catalog and a mattress only. He/she was not aware of any other charges. 3. Review of Resident #3's face sheet showed the following:-admission date of 09/26/24;-Diagnoses included dementia and depression;-Resident had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the following:;-Resident had a short- and long-term memory problem;-Resident had severely impaired decision-making ability;-Resident was inattentive and had disorganized thinking.Review of the resident's care plan, revised 05/09/25, showed the following:-Resident had behavioral symptoms towards others;-Staff should maintain a calm environment and approach to resident;-Avoid over stimulating the resident.;-Staff should monitor for fluctuating state of disorientation and decreased environmental awareness;-Resident resides in the memory care unit due to cognitive loss, dementia, and exit seeking.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/08/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/19/25, showed an amount of $112.03 withdrawn for the resident with the following receipts attached:-A receipt, dated 05/18/25 at 12:41 P.M., for Old Navy with a total of $50.42;-A receipt, dated 05/18/25 at 12:06 P.M., for Lululemon with a total of $41.93;-A receipt, dated 05/17/25 at 1:37 P.M., for Adidas with a total of $19.68.During an interview on 07/01/25, at 11:31 A.M., the resident said the following:-He/she did not go shopping, but his/her family brings things in;-He/she had never ordered anything from Lululemon, Old Navy, or Adidas;-He/she had no idea what Lululemon was;-He/she had never requested money from any account at the facility.During an interview on 07/08/25, at 11:48 A.M., the resident's POA said the following:-He/she was responsible for resident's financial affairs; -The resident had an account at the facility that is to be used for beauty services only;-The facility pays for beauty services directly out of the trust money;-He/she had advised the facility that the resident was not allowed to access funds for any other reason;-The resident gives her a list of items he/he needs and the POA purchased them for him/her;-He/she was not aware the facility was able to shop for the resident;-He/she had not been notified of any shopping trips for the resident;-The resident was unable to make any financial decisions.During an interview on 07/01/25, at 11:40 A.M., Certified Nurse Assistant (CNA) B said residents that reside on the memory care unit do not request money for the BOM. The staff will communicate to the social worker if a resident needs something. The residents do not leave the unit.4. Review of Resident #4's face sheet showed the following:-admission date of 07/23/24;-Diagnoses included depression, dementia, and anxiety disorder;-Resident had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment.Review of the resident's care plan, revised 05/07/25, showed the following:-Resident had verbal behavioral symptoms directed toward others;-Staff should maintain a calm and reassuring approach to resident;-Staff should monitor resident for states of disorientation.Review of a Cash Box Withdrawal and Reconciliation Report, dated 02/10/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 02/13/25, showed an amount of $148.38 withdrawn for the resident for shopping with an undated Walmart receipt for $148.38.Review of a Cash Box Withdrawal and Reconciliation Report, dated 02/24/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 03/25/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/08/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/13/25, showed an amount of $198.76 withdrawn for the resident with the following receipts attached:-A receipt, dated 05/13/25 at 11:29 A.M., for Target with a total of $15.38;-A receipt, dated 05/09/25 at 11:39 A.M., for TJ [NAME] with a total of $183.38.During an interview on 07/01/25, at 11:50 A.M., the resident said the following:-His/her money goes directly to the bank and he/she does not know much about it;-His/her family member provided whatever he/she needed;-He/she had never withdrawn any money from the business office;-He/she did not have anyone from the facility do any shopping for him/her.During an interview on 07/09/25, at 12:29 P.M., the resident's POA said the following:-He/she was responsible for resident's financial matters;-The resident is unaware that he/she is able to take any money out of the resident trust;-The resident had never taken any money out of the trust;-He/she had spoken with the resident and was advised the facility had never shopped for him/her.5. Review of Resident #5's face sheet showed the following:-admission date of 06/13/14;-Diagnoses included schizoaffective disorder, delusional disorder, depression, and generalized anxiety;-Resident had a responsible party.Review of the resident's quarterly MDS, dated [DATE], showed the following:-Resident unable to complete a brief interview for mental status;-Resident had short- and long-term memory problems with delusions.Review of the resident's care plan, revised 05/21/25, showed the following:-Resident had socially inappropriate behavior;-Resident was pleasantly confused and often asked about parents.Review of a Cash Box Withdrawal and Reconciliation Report, dated 02/13/25, showed an amount of $75.14 withdrawn for the resident with the following receipts attached:-A receipt, undated, for Books-A-Million with a total of $5.46;-A receipt, undated, for Books-A-Million with a total of $38.53;-A receipt, dated 02/07/25 at 3:44 P.M., for Natures Wonders with a total of $30.61.Review of a Cash Box Withdrawal and Reconciliation Report, dated 02/15/25, showed an amount of $100.00 withdrawn for the resident with a receipt dated 02/13/25, at 4:20 P.M., for an amount of 96.64 to TJ [NAME] and $3.36 spending money for resident.Review of a Cash Box Withdrawal and Reconciliation Report ,dated 03/04/25, showed an amount of $80.00 withdrawn for the resident with a receipt, dated 03/03/25 at 11:30 A.M., for Dollar Tree with a total of $72.48 attached.Review of a Cash Box Withdrawal and Reconciliation Report, dated 03/05/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 03/07/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 03/11/25, showed an amount of $68.51 withdrawn for the resident with the following receipts attached:-A receipt, dated 03/08/25 at 3:08 P.M., for Books-A-Million with a total of $21.73;-A receipt, dated 03/08/25 at 3:09 P.M., for Books-A-Million with a total of $5.83;-A receipt, dated 03/09/25 at 2:03 P.M., for Target with a total of $40.95.Review of a Cash Box Withdrawal and Reconciliation Report, dated 03/13/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 03/18/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 04/11/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 04/25/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/08/25, showed an amount of $50.00 withdrawn for the resident for spending money signed by the resident.Review of a Cash Box Withdrawal and Reconciliation Report, dated 05/02/25, showed an amount of $140.00 withdrawn for the resident signed by the resident with the following receipts attached:-A receipt, dated 04/18/25 at 11:25 A.M., for Dollar Tree with a total of $13.43;-A receipt, dated 04/30/25 at 11:26 A.M., for TJ [NAME] with a total of $91.12;-A resident cash withdrawal for spending of $35.45.During an interview on 07/01/25, at 11:05 A.M., the resident said he/she was unsure where his/her money was held. He/she does not need any money but would need to call his/her mom and dad to ask.6. During an interview on 06/25/25, at 12:55 P.M. the Corporate Financial Consultant said the following:-Residents are allowed to obtain $50.00 daily from the cash box;-Residents contact the BOM for money and then signs the Cash Box Withdrawal Form indicating the money was received;-Resident shopping is done by providing an estimate of the cost and verifying the money is available in account;-The resident signs the Cash Withdrawal Form and the receipt after shopping is completed;-The Cash Withdrawal Form and receipts are sent daily to the corporate specialist and reconciled.During an interview on 06/25/25, at 1:35 P.M., Licensed Pracitical Nurse (LPN) A said the following:-He/she would contact the BOM or SSD if a resident needed something;-Some residents have money on an account at the facility and some have family that provide items;-He/she did not receive any receipts for purchases and was unsure if the residents received one;-He/she thought there should be a receipt to account for the money spent;-It is misappropriation to use resident money for personal use. He/she would consider it stealing.During an interview on 06/26/25, at 1:45 P.M., the SSD said the following:-He/she noted suspicious charges on the resident's bank account statement and notified the Administrator;-The assistant SSD does the Walmart shopping for the residents;-The SSD will go to the BOM with the resident requested list and will do a guesstimate of charges for Walmart purchases;-He/she puts the money in separate envelopes for shopping;-The change and receipt are returned to envelope after shopping;-The resident and SSD or ASSD will sign the receipt and returns it to the business office.During an interview on 06/25/25, at 2:25 P.M., CNA C said misappropriation is a type of abuse. He/she would report abuse to the nurse as soon as possible. Financial abuse would be if someone used a resident's money or bank card. He/she would consider that stealing from residents.During an interview on 06/25/25, at 3:05 P.M., LPN D said he/she would report financial abuse to the DON immediately. It would be stealing to use a resident's money to buy something for personal use.During an interview on 07/01/25, at 12:55 P.M., CNA E said misappropriation is abuse and should be reported to the nurse immediately. It is not ok to use resident bank cards or funds to buy things for yourself. It would be stealing.During an interview on 07/01/25, at 1:20 P.M., CNA G said it was not ok to use resident money for anything unless it was for the resident. It would be stealing, and he/she would immediately report it.During an interview on 07/01/25, at 1:25 P.M., LPN F said misappropriation or stealing should be reported to the administration immediately. It would be stealing to use a resident's money for your own personal items.During an interview on 07/01/25, at 1:40 P.M, the DON said the following:-He/she and the Administrator went to the police department to identify the BOM was using a resident's bank card;-It is not ok to use resident funds to buy items for yourself. It would be abuse;-It is considered stealing or misappropriation to use resident funds for yourself and should be reported immediately.During interviews on 07/01/25, at 8:45 A.M. and 2:05 P.M., the Administrator said the following:-The Maintenance Director was identified as signing for resident funds;-The BOM and Maintenance Director would go to the bank together to cash checks for resident funds;-It is inappropriate and stealing to use resident funds for yourself;-It is the duty of the facility to ensure residents are protected from abuse;-Corporate and the facility are reviewing resident fund records;-Most residents interviewed have reported the signatures on cash box forms are not theirs;-The signatures are forged and appear to be cut and pasted on to the receipts.MO00255783

Based on record review and interview, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN - form CMS-10055) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two resident (Resident #39 and #85) who remained in the facility after discharge from Medicare Part A services. The facility census was 93. Review of the Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 (2024), undated, provided as the facility's policy, showed the following: -The SNF ABN provided information to the patient so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility. SNF's must use the SNF ABN when applicable for SNF prospective payment system services (Medicare Part A); -It is important to note that the SNF ABN, CMS-10055, is only issued if the beneficiary intends to continue services and the SNF believes the services may not be covered under Medicare, SNF's will continue to use the ABN form CMS-R-131 when applicable for Medicare Part B items and services. 1. Review of Resident #'39's Skilled Nursing Facility Beneficiary Protection Notification Review showed the following: -Medicare Part A skilled services started on 07/25/24; -Last covered day of Medicare Part A services on 08/10/24; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -The facility did not provide the resident or his/her legal representative the SNF ABN form CMS-10055 or alternative denial letter. During an interview on 10/24/24, at 12:08 P.M., the Business Office Manager (BOM) said the resident used 17 days and had 83 days left of insurance coverage. 2. Record review of Resident #85's Skilled Nursing Facility Beneficiary Protection Notification Review showed the following: -Medicare Part A skilled services episode start date on 05/29/24; -Last covered day of Part A services as 06/14/24; -The facility initiated the discharge from Medicare Part A services when benefit days were not exhausted; -The facility did not provide the resident or his/her legal representative the SNF ABN form CMS-10055 or alternative denial letter. During an interview on 10/24/24 at 12:08 P.M., the BOM said the resident used 17 days and had 83 days left of insurance coverage. 3. During an interview on 10/23/24, at 3:40 P.M. the Social Service Director (SSD) said the following: -She gives notices of medicare non-coverage (NOMNC) forms to residents; -The insurance company sends the NOMNC forms to the facility which she prints off and gives to the resident and/or responsible party; -She explains the last covered day and the payer source will be private pay the next day with additional charges for therapy; -She did not give the ABN forms to the residents; -She did not know to give ABN forms to residents. 4. During an interview on 10/24/24, at 12:08 P.M., the BOM said the following: -She explains to residents upon admission of what insurance pays for; -Residents have a right to appeal discharge from therapy; -The insurance company sends NOMNC forms to the corporate staff who send to the facility; -The SSD gives the NOMNC to the residents and/or responsible party; -She did not know staff did not give the ABN forms to the resident and/or responsible party; -The ABN form informs residents and/or responsible parties of insurance not covering the therapy and the right to appeal; -Both of the residents are on managed care and she did not know if the ABN should be given. 5. During an interview on 10/24/24, at 1:34 P.M., the Administrator said the following: -The corporate office sends the facility with the NOMNC forms; -The SSD gives the NOMNC forms to the resident and/or responsible party; -The facility did not issue ABN notices to the residents who were discharged from therapy and had remaining days.

Based on interview and record review, the facility failed to maintain an effective infection prevention and control program when staff failed to read administered tuberculosis (TB - a disease caused by germs that are spread from person to person through the air) skin tests in a timely fashion, per standards of practice, for three employees (Dietary Aide (DA) A, Licensed Practical Nurse (LPN) B, and Certified Nurse Aide (CNA) C. Facility had a census of 93. Review of the facility policy titled, Tuberculosis Control, not dated, showed the following: -Provide a tuberculin skin test to all employees during pre-employment procedures unless a previous reaction greater than 10 millimeters is documented; -An initial two step tuberculin skin test will be given; -If the result of first tuberculin skin test is negative (a negative tuberculin skin test is any measurement between zero to nine millimeters), give the second tuberculin skin test ten days later; -The tuberculin skin test is to be read 48 to 72 hours after administered. Review of 19 CSR 20-20.100 Tuberculosis Testing for Residents and Workers in Long-Term Care Facilities and State Correctional Centers showed the following: -All new long-term care facility employees and volunteers who work ten or more hours per week are required to obtain a Mantoux PPD (a skin test to test for TB) two-step tuberculin test within one month prior to starting employment in the facility. -If the initial test is zero to nine millimeters (mm), the second test should be given as soon as possible within three weeks after employment begins, unless documentation is provided indicating a Mantoux PPD test in the past and at least one subsequent annual test within the past two years. -It is the responsibility of each facility to maintain a documentation of each employee ' s and volunteer ' s tuberculin status. -All skin test results are to be documented in mm of induration. 1. Review of DA A's Staff Immunization Records showed the following: -Hire date of 05/06/24; -Second-step of the two-step TB test administered on 05/21/24. Staff read the test as negative on 05/22/24 (one day after administered). 2. Review of LPN B's Staff Immunization Records showed the following: -Hire date of 08/13/24; -Second-step of the two-step TB test administered on 08/27/24. Staff read the test as negative on 08/31/24 (4 days after administered). 3. Review of CNA C's Staff Immunization Records showed the following: -Hire date of 09/09/24; -First step of the two-step first TB test administered on 09/09/24. Staff read the test as negative 09/13/24 (4 days after administered). 4. During an interview on 10/23/24, at 3:19 P.M., the Assistant Director of Nursing (ADON) said the following: -TB skin tests should be read within 2 to 3 days and not sooner than 2 days; -TB skin tests should be repeated if read more than 3 days; -He/she expected staff to read and notify Human Resources (HR) when first test has been completed and set up for next screening. 5. During an interview on 10/24/24, at 1:32 P.M., the Human Resources (HR) Manager said the following: -He/she tracked employee TB skin test completion and scheduled them for any additional testing needed; -The TB skin test placed at orientation and read two days later by orientation staff or by facility staff; -Nursing reads the test and documents the results. He/she gives the form to set two week return for second TB skin test placed and read; -HR does not read TB skin test. He/she only sets up employees for completion of the testing requirements. 6. During an interview on 10/24/24, at 1:45 P.M., the Director of Nursing (DON) said the following: -The facility nurses place and read TB tests; -New employees have a TB skin test placed at orientation and are expected to return to the facility for reading in 48 hours; -If unable to return in 48 hours, they would have the employee take picture and send to her or have employee repeat test if could not return within 72 hours; -Employee should return in 2 weeks for another TB test; -The HR office monitors timeframes and reports to nursing staff if not TB test screening is not completed correctly. 7. During an interview on 10/24/24, at 2:25 P.M., the Administrator said the following: -He expected staff to read TB skin test results within appropriate times; -HR is responsible to schedule new employee TB test; -Staff go through the DON to get tests done; -Staff have first TB test read before working floor.

Based on interview and record review, the facility failed to ensure the staff member employed as the Dietary Manager had the required certifications, education, or experience to meet the regulatory requirements. The facility census was 93. Review of the facility policy titled, Dietary Manager, dated 01/01/98, showed the following: -Minimum qualifications of high school diploma or GED equivalent; -Two years of experience in a supervisory capacity in related field; -Certified Dietary Manager. 1. During an interview on 10/21/24, at 10:05 A.M., the Dietary Manager said the following: -He/she had only been the manager for two years and had been a CNA/CMT previously; -He/she was not certified; -He/she was given a voucher to take a test, but that was four or so, administrators ago. He/she was not sure what happened to it; The administrator was supposed to let him/her know when he/she would get certified, but he/she had not heard anything. Review of facility records showed the facility did not provide documentation the Dietary Manager being certified as a dietary manager, food service manager, or any similar certification, or other education or experience that met the regulatory requirements. During an interview on 10/24/24, at 11:35 A.M., the Administrator said the following: -He/she was unsure why the Dietary Manager didn't get certified except the Dietary Manager told him that several administrators before him/her had arranged for them to take a test, but they did not have the chance; -The Dietary Manager did get ready to test, that was arranged by a prior administrator, but ended up not going; -He/she was not sure as to why the Dietary Manager did not take the test; -He/she has spoken with the regional manager and they are going to set up the test to get it taken care of.

Based on observation, interview, and record review, the facility failed keep food safe from potential contamination or bacterial growth at all times when staff failed to air dry dishese before storage. The facility census was 93. 1. Record review of the 1999 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food. -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Record review of the facility's policy, Nutrition and Dining Services Manual, Section 8, dated April 2011, showed the following: -Items are to be air dried; -No moisture can be found on any stacked item. Observations on 10/21/24, at 10:05 A.M., showed the following: -Forty-seven tall, plastic drinking glasses, upside down, flat on a tray, still wet on the inside. The storage of the glasses prevent air movement that would allow the glasses to dry; -Forty plastic coffee cups, upside down, flat on a tray, still wet on the inside. The storage of the glasses prevent air movement that would allow the cups to dry. Observation on 10/23/24, at 11:30 A.M., showed the following: -Seventy-one glass plates, stacked on top on each other, trapping water between them; -Five plastic, adaptive plates, stacked on top on each other, trapping water between them; -Four metal bins for the steam table, upside down, stacked, still wet, trapping water between them. Observation on 10/24/24, at 9:25 A.M., showed thrity-two plastic plate covers, wet and stacked, with water still dripping from in-between. During an interview on 10/24/24, at 9:40 A.M., [NAME] D said he/she was not aware that dishes could not be stacked while still wet. During an interview on 10/24/24, at 9:50 A.M., Dietary Aide B said he/she was not aware that the dishes were being stacked up before being completely dry. During an interview on 10/24/24, at 10:05 A.M., [NAME] C, said he/she was aware that dishes cannot be stacked, while still wet, but was not aware that this was happening; During an interview on 10/24/24, at 10:15 A.M., Dietary Aide E said he/she knew to never stack dishes while still wet and would have said something if realized this was happening. During an interview on 10/24/24, at 10:30 A.M., the Dietary Manager said the following: -He/she said they had not been aware that the dishes were being stacked wet; -He/she is going to order some dry racks to help with this issue. During an interview on 10/24/24, at 2:45 P.M., the Administrator, said he/she would expect staff to follow policy and allow dishes time to air dry before putting them away.

Based on observation, interview, and record review, the facility failed maintain a clean and comfortable environment when the facility staff failed to maintain all light fixtures, walls, floors, sinks, and ceilings in in the dining and kitchen areas clean and free of debris. The facility census was 93. Record review of the facility policy, Nutrition and Dining Services Manual, Section 10, dated April 2011, showed the following: -Specify days the cleaning schedule will be done; -Specify who is responsible to do the cleaning by shift and position; -Post the schedule prior to the beginning of each week; -The employee will initial in the column under the day the task is completed. 1. Observation on 10/21/24, at 10:00 A.M., of the main dining room showed the a light fixture above the serving counter covered in cobwebs. Observation on 10/21/24, at 10:05 A.M., of the kitchen showed the following: -The handwashing station not clean. Splash-marks remained from soap that looked like dried bubbles on the wall behind the sink. Debris, including hair and dirt, was located in and around the sink. -The floor was sticky; -The floor near the stove and food prep area was greasy. -The floor behind the ice machine was dirty with a bright red substance. -The area above the walk-in refrigerator and freezer, had metal strips going to the ceiling and filters that were covered with cobwebs and a lint/grease mixture that moved with the airflow. Observation on 10/23/24, at 11:30 A.M., of the kitchen showed the following: -The handwashing station was not clean with dirt and grease marks present; -The floor behind the ice machine had a bright red substance present; -The area above the walk-in refrigerator and freezer, had metal strips going to the ceiling and filters that were covered with cobwebs and a lint/grease mixture that moved with the airflow. Observation on 10/24/24, at 9:25 A.M., of the kitchen showed the following: -The handwashing station was not clean with dirt and grease marks present; -The floor behind the ice machine had a bright red substance present; -The area above the walk-in refrigerator and freezer, had metal strips going to the ceiling and filters that were covered with cobwebs and a lint/grease mixture that moved with the airflow. During an interview on 10/24/24, at 9:40 A.M., [NAME] D said the following: -All staff take turns cleaning different areas of the kitchen; -Staff does follow a cleaning schedule; -It has been a while since he/she had seen anyone clean above the walk-in units. He/she had noticed that it is not very clean up there. During an interview on 10/24/24, at 9:40 A.M., Dietary Aide B said the following: -Everyone has their own areas where they are supposed to be cleaning; -The Dietary Manager makes a cleaning schedule and they follow it each week; -Night shift is who cleans the baseboards and floors; -Maintenance should be cleaning above the walk-ins; -He/she will clean his/her own station and then everyone pitches in, where needed. During an interview on 10/24/24, at 9:40 A.M., [NAME] C said the following: -He/she will clean his/her own station where he/she is working from; -This is done everyday; -Sometimes the kitchen staff will meet in the evenings or at a different times and work together to deep clean. During an interview on 10/24/24, at 9:40 A.M., Dietary Aide E said the following: -There is a cleaning schedule that they all follow when working the kitchen; -Sometimes staff will stay in their own areas to clean or sometimes do whatever is needed; -He/she knows the kitchen is not as clean as it should be. During an interview on 10/24/24, at 9:40 A.M., the Dietary Manager said the following: -He/she would expect staff to be washing the base boards and sweeping and mopping the floor; -There should not be debris or dirt in or around the hand washing station. It should be sanitized; -He/she was unaware of the floor behind the ice machine not being cleaned. During an interview on 10/24/24, at 3:50 P.M., the Administrator said the areas in the kitchen should be clean and maintained that way.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide services per standards of practice when staff failed to provide ordered restorative nursing services for three residents (Resident #6, #7, and #8) and failed to care plan restorative services for one resident (Resident #7) out of four sampled residents. The facility census was 83. Review of the facility's Restorative Nursing Manual, undated, showed the following: -The Restorative Nursing Program (RNP) is an integral part of maximizing the daily restorative care process for the residents; -The RNP is a part of the logical step-down process in resident care; -A pro-active approach is necessary to prevent future negative outcomes; -It is the purpose of this facility to see that each resident receives, and the facility provides, the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care; -It is the entire staff's responsibility to prevent deterioration and further functional loss of each resident in the facility. The objective of the RNP program is to provide restorative care necessary to meet the needs of all residents to enable them to achieve the standard of care as described by OBRA (Omnibus Budget Reconciliation Act) 1987; -Restorative services are to be made available per residents' assessed needs; -A mechanism for monitoring and on-going evaluation of the RNP programs must be established. 1. Review of Resident #6's face sheet (a brief resident profile) showed the following: -admission date of 10/18/23; -Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by staff), dated 01/22/24, showed the following: -Severe cognitive impairment; -Dependent on staff for transfers. Review of the resident's care plan, last revised on 01/31/24, showed the following: -Limited in ability to self-transfer related to hemiplegia and hemiparesis; -Follow physical therapy (PT) and occupational therapy (OT) recommendations. Review of the resident's current Physician Order Sheet (POS) showed the following: -An order, dated 02/01/24, for restorative aide (RA) to see resident two to five times weekly for 90 days to address passive range of motion (PROM - the range of motion that is achieved when an outside force (such as a therapist) exclusively causes movement of a joint) of left upper extremity (LUE) to maintain joint integrity for upper body (UB) dressing and hygiene. Please complete range of motion (ROM) to LUE, all joints, and apply resting hand splint for prolonged stretch to fingers; -An order, dated 02/12/24, for PT evaluation and treat as indicated. Review of the facility's Restorative Therapy Logbook and the resident's electronic medical record (EMR), dated February 2024, showed the following: -Staff document restorative therapy of ROM to LUE provided to the resident on four days (02/20/24, 02/21/24, 02/22/24, and 02/29/24); -Staff documented restorative therapy of applying resting hand splint on four days (02/20/24, 02/12/24, 02/22/24, and 02/29/24); -Staff documented being pulled to the floor on ten days (02/11/24, 02/14/24, 02/15/24, 02/18/24, 02/19/24, 02/23/24, 02/24/24, 02/25/24, 02/26/24, and 02/28/24); -Staff did not document any resident refusals. Review of the resident's current Physician Order Sheet (POS) showed the following: -An order, dated 03/28/24, for discharge from PT services and continue with restorative aide program two to five times weekly for 90 days for transfer training and static standing. Promote sit to stand transfers with hemi-walker and left ankle foot orthotic (LAFO), verbal cues for proper hand placements, maintain standing for two minutes, and perform sit to stand three to five repetitions. Review of the facility's Restorative Therapy Logbook and the resident's EMR, dated March 2024, showed the following: -Staff documented restorative therapy of ROM to LUE provided to the resident on ten days (03/03/24, 03/04/24, 03/05/24, 03/10/24, 03/11/24, 03/12/24, 03/13/24, 03/14/24, 03/18/24, and 03/25/24); -Staff documented restorative therapy of applying resting hand splint to resident on ten days (03/03/24, 03/04/24, 03/05/24, 03/10/24, 03/11/24, 03/12/24, 03/13/24, 03/14/24, 03/18/24, and 03/25/24); -Staff did not document restorative therapy regarding transfer training and static standing; -Staff did not document any residents refusals or being pulled to the floor on any dates. Review of the facility's Restorative Therapy Logbook and the resident's EMR, dated 04/01/24 to 04/09/24, showed the following: -Staff documented restorative therapy of ROM to LUE provided to the resident on two days (04/02/24 and 04/03/24); -Staff documented restorative therapy of applying resting hand splint to resident on two days (04/02/24 and 0403/24); -Staff did not document restorative therapy regarding transfer training and static standing; -Staff did not document any residents refusals or being pulled to the floor on any dates. 2. Review of Resident #7's face sheet showed the following: -admission date of 09/02/23; -Diagnoses included muscle weakness, and history of falls. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Dependent on staff for most activities of daily (ADLs - dressing, grooming, bathing, eating, and toileting). Review of the resident's March 2024 POS showed the following: -An order, dated 03/19/24, for restorative services two to three times weekly for 90 days for transfers, bed mobility, and left knee hamstring stretching. Review of the resident's care plan, last revised 03/20/24, showed staff did not care plan related to ADL's or therapy services. Review of the facility's Restorative Therapy Logbook and the resident's EMR, dated February 2024, showed the following: -Staff documented restorative therapy of hamstring stretch on one day (02/28/24); -Staff documented restorative therapy of stand/pivot on one day (02/28/24); -Staff documented pulled to the floor on two dates (02/25/24 and 02/26/24); -Staff did not document any resident refusals. 3. Review of Resident #9's face sheet showed the following: -admission date of 07/19/23; -Diagnoses included hemiplagia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side. Review of the resident's quarterly MDS, last revised 01/29/24, showed the following: -Severe cognitive impairment; -Dependent on staff with ADLs with the exception of set up for eating. Review of the resident's care plan, last revised 01/31/24, showed the following: -Resident received therapy services related to transfers and toileting; -Will participate in therapy. Review of the resident's current POS, showed an order, dated 02/21/24, for restorative therapy program two to five times weekly for 90 days for bed mobility and both lower extremities (BLE) strengthening. Review of the facility's Restorative Therapy Logbook and the resident's EMR, dated February 2024, showed the following: -Staff documented bed mobility restorative therapy provided on one day (02/29/24); -Staff documented BLE strengthening restorative therapy provided on one day (02/29/24); -Staff documented pulled to the floor on three days (02/25/24, 02/26/24, and 02/28/24); -Staff did not document any resident refusals. 4. During an interview on 04/04/24, at 3:14 P.M., the Director of Rehabilitation said the following: -He/she writes up a restorative therapy plans for residents coming off of skilled therapy and gives the to Restorative Aide (RA) E to complete with the resident and completes a general order for the physician to sign; -He/she does not oversee restorative therapy services. 5. During an interview on 04/05/24, at 11:46 A.M., RA C said the following: -He/she helps out with restorative therapy when not providing transportation for residents at the facility; -RA E tells him what the residents require restorative services; -He/she documents completing restorative services residents in the EMR and does not document in the restorative logbook. 6. During an interview on 04/05/24, at 12:27 A.M., RA E said the following: -Therapy writes an order for restorative therapy, which may include physical or occupational therapy, type of exercise, how many times per week, and the duration; -He/she tries to focus restorative therapy with residents on 100/200/300 halls at the beginning of the day and then 400/500 after, but the schedule is fluid; -He/she documents RA sessions in the restorative log and in the EMR; -He/she documents resident refusals in the restorative log as an R and ill residents as S; -He/she puts an X on the restorative log when she is pulled from restorative therapy to work the floor. 7. During an interview on 04/05/24, at 2:26 P.M., Licensed Practical Nurse (LPN) F said the following: -Residents usually receive restorative therapy following skilled therapy services; -The physician can order restorative therapy, but skilled therapy completes the evaluation; -Restorative aides are pulled to work the floor when staff members call in for their shift; -He/she does not know how often this happens, but it seems to occur in spurts. 8. During an interview on 04/05/24, at 2:43 P.M., LPN D said the RA is pulled from restorative therapy to work the floor when staff members call in for their shift and doesn't always get restorative therapy completed. 9. During an interview on 04/05/24, at 4:36 P.M., the Assistant Director of Nursing (ADON), Director of Nursing (DON) and the Administrator said the following: -When a resident completed a skilled therapy treatment plan, therapy orders restorative therapy, completes an evaluation and sends the information to RA E; -RA E documents restorative therapy sessions in the restorative logbook and in the EMR. RA C documents in the EMR; -RA E gets pulled to the floor; -RA C picks up some slack with restorative therapy, but he/she works four days per week and provides transportation for the residents; -If RA E is pulled to the floor and RA C is providing transportation, restorative therapy is not completed. MO00234013

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was served at a temperatures that were palatable and appetizing for five residents (Resident #1, #2, #3, #4, and #5) who often ate in their rooms. The facility census was 83. Review of the facility policy titled, Food Temperatures, dated April 2011, showed the following: -Hot food should be at least 120 degrees Fahrenheit (F) when served to residents; -A test meal should be sent with the hall trays when there are food temperature complaints until the temperatures are at the appropriate levels; -Plate lowerators are functioning and turned on prior to the meal service according to manufacturer's direction; -Lowerators are not over-filled so that all items are being heated; -Food is not placed in the steam table more than 30 minutes before meal service; -Food is not held in warm ovens more than 30 minutes before meal service It is recommended that food not be hold on the steam table for longer than two hours. 1. Observation on 04/04/24, at 12:12 P.M., showed the following: -A test tray was requested and received from the insulated food cart on 500 hall at the end of the meal service; -The meal included country fried steak, cream gravy, mashed potatoes, breaded okra, and cherry pie; -Temperatures were taken of the items served hot; -The country fried steak measured 111 degrees F, the mashed potatoes measured 114 degrees F, and the breaded okra measured 95 degrees F. 2. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff), dated 12/28/23, showed the following: -admission date of 06/20/23; -Moderate cognitive impairment; -Regular diet; -Setup assistance with eating. During an interview on 04/04/24, at 10:18 A.M., the resident said the following: -Staff often serve lukewarm food; -Staff will reheat food if requested. 3. Review of the Resident #2's quarterly MDS, dated [DATE], showed the following: -admission date of 10/10/23; -Cognitively intact; -Regular diet; -Setup assistance with eating. During an interview on 04/04/24, at 10:35 A.M., the resident said the following: -He/she eats meals in his/her room; -The meals are usually not warm by the time staff bring the meal to his/her room; -Staff will reheat the food upon request. 4. Review of Resident #3's quarterly MDS, dated [DATE], showed the following: -admission date of 05/24/22; -Mechanically altered diet; -Setup assistance with eating. During an interview on 04/04/24, at 12:47 P.M., the resident said the following: -He/she eats most meals in his/her room; -Most of the time, staff serve the food at temperatures not warm enough, including today; -The resident described the food temperature as not cold, but uncomfortable; -He/she has never asked staff to reheat the meal. 5. Review of the Resident #4's quarterly MDS, dated [DATE], showed the following: -admission date of 11/10/23; -Severely cognitively impaired; -Mechanically altered and therapeutic diet; -Setup assistance with eating. During an interview on 04/05/24, at 11:23 A.M., the resident said the following: -He/she eats meals in the dining room; -Meals are not always warm enough, but staff will reheat or get a new plate for the resident. 6. Review of Resident #5's quarterly MDS, dated [DATE], showed the following: -admission date of 05/15/23; -Cognitively intact; -Regular diet; -Setup assistance with eating. During an interview on 04/05/24, at 11:35 A.M., the resident said the following: -The resident eats meals in his/her room; -Staff often serve lukewarm meals; -Staff served the resident a cold hamburger recently; -Staff will reheat meals when resident requests; -The food temperatures have been an ongoing issue. 7. During an interview on 04/04/24, at 2:35 P.M., Certified Nurse Assistant (CNA) A said the following: -Residents complain quite often that food is served too cold; -He/she offers to reheat the meals using the microwave in the therapy room. 8. During an interview on 04/04/24, at 3:22 P.M., CNA B said the following: -He/she passes hall meals in the evenings and residents often complain about the temperatures not being hot enough; -He/she offers to reheat the meal in the microwave in the therapy room if a resident complains. 9. During an interview on 04/05/24, at 1:32 P.M., the Dietary [NAME] G said the following: -Staff obtain temperatures of food on the steam table during before every meal service and document on the log; -Meat temperatures should be 175 degrees F and vegetable temperatures should be 190 degrees F on the steam table; -Food temperatures should be holding at 145 degrees F when served to residents; -Staff serve meals to the residents in the dining room first; -Staff pass 400/500 hall trays last; -The food is hot when it leaves the kitchen, but aides do not get the meals passed quickly enough; -He/she is aware there have been complaints regarding food temperatures; -If food temperatures are not acceptable for a resident, staff will replace with a new plate, offer an alternative, or reheat the meal in the therapy room microwave. 10. During an interview on 04/05/24, at 1:41 P.M., the Dietary Manager said the following: -Staff obtain temperatures of foods on the steam table right before serve out of meals; -Acceptable food temperatures on the steam table should be between 135 to 160 degrees F, and serve out to tables should be 135 degrees F; -The temperatures are documented for each meal in a log; -Meals for the 500 hall are loaded onto an insulated food cart and are the last to be delivered during meal service; -The test tray temperatures taken on 04/04/24 were not acceptable; -If food temperatures are not acceptable for a resident, staff will replace with a new plate, offer an alternative, or reheat the meal in the therapy room microwave. 11. During an interview on 04/05/24, at 2:43 P.M., License Practical nurse (LPN) D said the following: -Residents often complain about the temperature of food trays on all of the halls; -Meals are served to 500 hall from an insulated food cart; -Staff will reheat meals in the therapy room microwave for residents. 12. During an interview on 04/05/24, at 4:36 P.M., the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator said the following: -Staff should obtain temperatures of all food items on the steam table prior to serve out of meal and document in the log; -There are two serve out areas with steam tables one for the dining room and 100/200/300 halls and one for 400/500 halls; -While staff serve the dining room and 100/200/300 halls, other staff are loading the insulated food carts for 400 and 500 halls with 400 hall trays passed first; -If a resident complains about the temperature of the food, staff should preferably obtain a fresh plate for the resident, offer an alternative, or reheat the meal in the microwave and obtain a temperature before serving; -The test tray temperatures from 04/04/24 were not acceptable. MO00234013

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents were treated with dignity and respect when one staff (Certified Nurse Aide (CNA) A) provided cares to three residents (Residents #1, #2, and #3) in an unrespectful and undignified manner when the CNA rushed residents, raised his/her voice at residents, and spoke in a disrespectful tone of voice when answering the residents' call lights. The facility census was 89. Review of the facility policy Resident Rights, undated, showed each resident shall be treated with consideration, respect a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. 1. Review of Resident #1's face sheet (document with admission information) showed the following: -admission date of 12/01/23; -Diagnoses included dementia (brain damaged by injury or disease which involves progressive impairments in memory, thinking, and behavior which negatively impacts a person's ability to function and carry out every day activities) without behavioral disturbance, anxiety (a feeling of worry, nervousness, or unease), fracture of upper left femur (leg), Type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)), cerebral infarction (stroke), osteoarthritis (degeneration of joint cartilage and underlying bone which causes pain and stiffness, especially in hip, knee, and thumb joints), renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids), urine retention, pain, weakness, adult failure to thrive (a syndrome of weight loss, decreased appetite, and poor nutrition and inactivity), visual hallucinations (seeing images when there is nothing in the environment to account for it), anemia, and urinary tract infection (bladder infection). Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 01/23/24, showed the following: -Moderately impaired cognition; -No behaviors observed and no hallucinations; -Partial to moderate staff assistance to roll left to right in bed; -Substantial/maximal assistance where helper does more than half the effort for toileting; -Substantial/additional assistance where helper does more than half the effort for resident's personal hygiene; -Occasional urinary and bowel incontinence. Review of the resident's care plan, dated 12/8/23 and updated 01/17/24, showed the following: -An alteration musculoskeletal status related to recent left hip fracture; -Staff to anticipate and meet needs; be sure call light is within reach and respond promptly to all requests for assistance; and give analgesics as ordered by the physician; -History of visual hallucinations; -Staff to maintain a calm environment and a calm, slow, understandable approach to the resident; -History of cerebral infarction (stroke) affecting cognition; -Staff to adjust tonal quality and speak distinctly; face the resident when speaking to resident; obtain resident's attention before speaking; and provide quiet, non-hurried environment, free of distractions for conversation; -Do not rush resident; -Resident requires one person assistance. During an observation and interview on 02/02/24, at 11:35 A.M., the resident said on consecutive nights, when he/she put on his/her call light, CNA A would come into the room, not knowing what he/she needed, and would yell at him/her, What do you want now? I can't keep coming all night. This happened every night CNA A came to his/her room. This happened when he/she was in another room too. CNA A grabbed his/her arms to move him/her. He/she was a two person assist to toilet and CNA A scared him/her. The staff were to come in, roll him/her, and put a diaper on him/her, and roll him/her to the other side. If done properly, it would not hurt. He/she has to toilet frequently and is on medicine for a urinary tract infection and swelling. He/she had to go to the bathroom every one and one-half hours and it irritated CNA A. He/she did talk to Licensed Practical Nurse (LPN) C, the night charge nurse, who went and talked to the Director of Nursing (DON) and said there were other residents who complained about CNA A. CNA A was unnecessarily rough and he/she was fearful. During an interview on 02/02/24, at 2:39 P.M., LPN C said it had been a busy night the night the resident had complained and asked to speak to him/her about something. The resident said CNA A was rough with him/her, yelled at him/her, and he/she did not want the aide to work with him/her. The resident said he/she didn't want to use the call light at night because when he/she did CNA A yelled at him/her during cares and was rough with him/her. LPN C did notify the DON about this. He/she said CNA A was a loud flamboyant person, talked loud, and even a whisper was loud. During an interview on 02/02/24, at 1:44 P.M., CNA A said he/she was good friends with the resident even before his/her fall when on another hall. The resident had been extra needy with the call light to get up to go to the bathroom and wanted covered up. He/she was going back and forth and then changed him/her. The resident apologized to him/her about using the call light frequently that night. Before he/she changed him/her, the resident was sitting up in bed and asked to lie down. CNA A said, You ready? Let me get your legs. One, two, three and when he/she moved the resident's legs up and over on the bed, the resident complained of his/her legs hurting. This was at approximately 2:00 A.M. to 3:00 A.M. CNA A covered the resident and left the room. Immediately, the resident turned on the call light and said he/she was wet. There were three other rooms with call lights on before the resident's call light went on. His/her call light had been going off a lot that night. CNA A was not to use a gait belt on (transfer belt placed around the resident's waist) the resident or to transfer him/her to take to the toilet since the resident was not weight bearing due to the fracture. He/she went to change the resident, pulled down the brief, counted one, two, three and rolled him/her to the side where the window was. The resident cried out, Ow, oh God, you are hurting me! when rolled to the left side, the resident said, Why are you so aggressive? CNA A said, I have to roll the resident. I don't allow the residents to grab my hand, but allow them to grab my forearm to turn them in bed. The resident thought he/she was mad at him/her. He/she was not rough but only when roll and move residents, they all say staff were being too rough to them. They are fragile and hurt with any type of movement. During an interview on 02/02/24, at 2:17 P.M., CNA E said he/she had worked with CNA A before and CNA A told him/her that the resident had told CNA A that he/she was rough with him/her and CNA A went to get LPN C. Resident #1 told LPN C that CNA A was rough with his/her words, but did not say what was said. CNA A talks loud. 2. Review of Resident #2's face sheet showed the following: -admission date of 12/28/23; -Diagnoses included vesicointestinal fistula (an abnormal connection between the bladder and the bowel), urinary tract infection, Type 2 diabetes mellitus, atrial fibrillation (abnormal heart rhythm), obesity, depression, mild cognitive impairment, left shoulder osteoarthritis, right hip bursitis (painful swelling in joint), anxiety, pneumonia (upper respiratory infection), urine retention, anemia, and shortness of breath. Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was interviewable; -Partial/moderate staff assistance to roll left and right in bed. Review of the resident's care plan, dated 01/05/24, showed the following: -Required assistance with ADL's (activities of daily living) related to disease process and general fatigue/weakness; -Staff to not rush resident who requires substantial assistance; -Staff to keep call light within reach; -Difficulty communicating with others related to hearing impairment; -Staff to be extremely patient, face the resident when speaking, provide quiet, non-hurried environment, free of background noises and distractions, repeat phrases as needed and rephrase if needed, and speak clearly and adjust tone as needed; During observation and interview on 02/02/24, at 9:49 A.M., the resident who was in bed, said he/she has pain in his/her left hip now and sometimes Tylenol helps the pain and sometimes it did not. The resident had a Foley catheter (a flexible tube inserted into the bladder to drain urine). He/she said once or twice on the night shift, one gal was rough with him/her. He/she told CNA A to be gentle with him/her and with his/her left leg to roll him/her to the right side. CNA A was moving him/her quickly to roll over. CNA A got his/her body on top of him/her and tried to hold him/her and felt his/her elbow dig into his/her left hip. CNA A was trying to hold him/her over so he/she wouldn't flip back over. CNA A pulled the blanket over him/her, but did not make sure the call light was in reach. CNA A's whole attitude was like, What do you want? CNA A had no patience and never apologized to him/her. A couple of times this aide was rough and he/she did not report this to anyone. During an interview on 02/02/24, at 2:39 P.M., LPN C said the resident had complained to him/her about CNA A. The resident said CNA A almost acted like he/she did not want to be there at the facility. He/she did things rapidly and he/she had no bedside manners but just wanted to get done and out of the resident's room. LPN C said the aide goes in and out of rooms quickly. 3. Review of Resident #3's face sheet showed the following: -admission date of 01/19/24; -Diagnoses included fracture of right femur (the longest and strongest thigh bone), fracture of upper humerus (bone from the shoulder to the elbow), anxiety, acute kidney failure (condition in which the kidneys suddenly can't filter waste from the blood), depression, osteoporosis, and insomnia (persistent problem falling and staying asleep). Review of the resident's admission MDS, dated [DATE], showed the following: -The resident was interviewable; -Partial/moderate staff assistance to roll left and right (in bed); -Substantial/maximal assistance where the helper does more than half the effort to assist the resident from lying to sitting on side of bed and sit to stand to transfer; -Occasionally incontinent of urine. Review of the resident's care plan, dated 01/26/24, showed the following: -May have difficulty in communication related to hearing loss; -Staff to face resident when speaking and repeat phrases as needed and rephrase if necessary; -Staff to speak clearly and adjust tone as needed; -Required assistance with ADL's related to recent fractures, non-weight bearing status, weakness, and pain; -Staff to not rush resident; -Resident required two person assistance; -The resident has functional/urgency bladder incontinence; -The resident used disposable briefs; -Staff to change when wet or soiled and as needed. During observation and interview on 02/02/24, at 3:46 P.M., the resident, who was in his/her room, said there were a couple of incidents at night that he/she had not appreciated. One night, he/she needed the bed pan and a clean incontinence brief to put on. The girl (CNA) got out of shape! He/she was scooted down too far in bed and the aide said, What do you want? and asked the same question twice to the resident even after he/she requested some Tylenol twice. She was real nasty that night! About three to four nights ago, CNA A didn't want to assist him/her in bed and he/she had to occasionally wait to go to the toilet. 4. During an interview on 02/02/24, at 12:47 P.M., CNA D said the resident reported to him/her on 02/01/24, about 7:00 A.M., when they went to get the resident up, that CNA A would not listen to him/her, grabbed his/her left arm, and would not change him/her because he/she was wet. CNA A would not take the resident to the bathroom. CNA D said the resident was soaking wet with urine. He/she went to get the night charge nurse, LPN C, and the resident said to them that CNA A over talks him/her, was loud, does not listen to him/her, and snaps, What do you need?. CNA A was very short with him/her. During an interview on 02/02/24, at 2:45 P.M., CNA F said he/she worked nights with CNA A and he/she gets in a little bit of hurry when he/she worked side-by-side with CNA A. He/she had to tell CNA A to slow down before. During an interview on 02/02/24, at 2:39 P.M., LPN C said CNA A was a loud flamboyant person, talked loud, and even a whisper was loud. During an interview on 02/07/24, at 1:30 P.M., CNA H said staff were to treat with dignity and respect by not moving fast when doing cares for them and let them know what you were going to do like turn them to the wall. They were to explain to them and get assistance from other staff if need to pull them up in bed and/or turn them. During an interview on 02/07/24, at 1:36 P.M., Certified Medication Technician (CMT) I said dignity and respect was when staff go into a resident's room, they were to be positive, have a smile since this was their house. Staff can't be aggressive, negative, and yell at them. They should do personal cares slowly because a resident can be sore and in pain. During interviews on 02/07/24, at 11:55 A.M. and 1:24 P.M., LPN G said if a resident told him/her that staff person was rough with him/her, he/she would ask them to describe what rough meant. Staff were to treat someone like they deserve to be treated with dignity and respect. Staff were to go slow when turning residents, and respect their wants and needs. They were not to be rough in speech, not yelling, but be respectful. During an interview on 02/07/24, at 1:50 P.M., Registered Nurse (RN) J said staff were to treat the residents like a good family member, and speak respectfully. Staff were not to yell but may have to speak louder so they can hear. Staff were to be gentle with cares and listen to the resident, and make them comfortable. During interviews on 02/02/24, at 4:08 P.M., and on 02/07/24, at 1:55 P.M., the DON said she expected staff to treat people the way they wanted to be treated. It was how you spoke, asked, and responded to a resident to provide for their needs and make them comfortable. Respect them as a human being. During interviews on 02/02/24, at 9:07 A.M., and 4:25 P.M., and on 02/07/24, at 9:10 A.M., the Administrator said he interviewed CNA A who said he/she never grabbed anyone's arm. CNA A is a little person and he/she does roll residents during cares. He said CNA A told him that he/she tells the resident, One, two, three. And then rolls them over. CNA A was bubbly and his/her voice was loud. LPN C said that CNA A sings and was loud and would go into a resident's room and turn on their light. The Administrator said he had talked to CNA A about leaving the light off until he/she asked the resident if it was okay to turn on the light (in the night). CNA A has an excited startling voice. He had talked to CNA A about complaints of not finishing duties in rooms and would just leave the room. A few other residents had requested for CNA A not to take care of them. Staff were to treat everyone as family and speak respectfully. The look, facial expressions, tone of voice can be disrespectful. Talk to the residents as a human being, to [NAME] and love them and to make them feel safe. MO00230640

Based on interview and record review, the facility failed to report an allegation of abuse immediately to management and to the State Survey Agency (Department of Health and Senior Services- DHSS) within the two-hour requirement when one resident (Resident #1) alleged abuse by a staff member. The facility census was 86. The Administrator and Director of Nursing (DON) were notified on 05/30/23 of the Past Non-Compliance which occurred on 05/29/23, at approximately 1:50 P.M. Facility staff notified Department of Health and Senior Services (DHSS) of the noncompliance, started an investigation, educated the staff member involved, began in-servicing of all facility staff as they began their shifts, and began monitoring charts and interviewing residents weekly to ensure no other incidents occur. The noncompliance was corrected on 5/30/2023. Review of the facility policy titled Investigation, undated, showed all allegations of abuse to be reported no later than two hours to the State Survey Agency, and if applicable, law enforcement. 1. Review of Resident #1's face sheet showed an admission date of 05/27/23 and diagnoses that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), chronic kidney disease stage 3 (moderate kidney damage), Type 2 diabetes (a chronic condition that affects the way the body processes sugar), and cardiomyopathy (a condition of the heart that makes it hard for the heart to deliver blood to the body). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), showed the resident was moderately cognitively impaired. Review of the resident's care plan, updated 05/29/23, showed the following: -Resident resists care; -He/she would not allow staff to change him/her when incontinent. Resident stated he/she would tell staff when they needed changed; -Resident is at risk for pain related to wound on coccyx (tailbone) and left arm. Review of the Social Services Director's (SSD) statement dated 05/28/23, at 5:00 P.M., showed the resident's next of kin reported to the SSD that a CNA B had shoved the resident and the resident had threatened to call the police. The resident had refused to let the CNA perform cares for the resident. (The SSD did not document reporting the allegation of possible abuse to management or DHSS.) Review of the resident's nursing notes dated 05/29/23, at 11:28 A.M., showed resident refused cares and threatened to call police on a certified nursing assistant (CNA). The resident would not let nurse perform treatment. Staff notified the next of kin and will attempt cares again in thirty minutes. Review of the resident's nursing notes dated 5/29/23, at 1:51 P.M., showed the resident had some behaviors that morning including refusing cares and treatments. Staff notified family members by telephone. Resident was fighting with CNA during brief change and threatening to call police for abuse. Nurse transferred resident to bed. Resident complained of pain to arm and resident accused nurse of abuse. Staff will continue to observe. (The staff did not document reporting the allegation of possible abuse to management or DHSS.) During an interview on 05/31/23, at 10:00 A.M., the resident said a couple days before, he/she fell asleep with his/her leg hanging off the bed and an aide came in, slung his/her leg back on the bed, and shoved him/her back in the bed. The aide then said, Great, now I have to change you. During an interview on 05/31/23, at 10:23 A.M., the SSD said she was working as a Certified Medication Technician on 05/29/23. She had been told that the resident was having some behaviors and was still needing to do some admission paperwork for the resident. She had gone to the office to find out what kind of behaviors the resident was having. She decided to wait for the resident's family member to come in before continuing the paperwork. When the family arrived, she went in with the family. She said the family said the resident had threatened to call the police because an aide was being rude, but never mentioned abuse and did not mention shoving. She would consider shoving abuse. Review of the Administrator's statement, dated 05/30/23, showed upon arriving to work, he looked at notes and found the section in the resident's chart with the resident stating to a CNA that he/she was going to call the police for abuse. After that progress note, he found a note of the resident telling Licensed Practical Nurse (LPN) A he/she was going to report him/her for abuse. After reviewing, the Administrator interviewed the resident who stated the CNA shoved him/her back against his/her bed to lay him/her down to be changed and hurt his/her arm in the process. The resident said the aide was being rough and that he/she was calling the police. The resident said he/she had called his/her next of kin who was coming to the facility to file a grievance. The Administrator said he would have to report it to the State Agency and asked who all he/she had told, and the resident stated his/her next of kin. The allegation was reported to the state on 05/30/23. Review of LPN A's witness statement dated 05/30/23, at 10:50 A.M., showed on 05/29/23, at approximately 11:00 A.M., CNA B walked up to him/her to report the resident was refusing to let the aide change his/her soiled brief. LPN A walked into the resident's room to talk to the resident about the importance of good hygiene. The resident stated I don't want anyone touching me. I am going to call the police for abuse. The nurse contacted family to report that resident was making false allegations and refusing cares. (The LPN did not document reporting the allegation of possible abuse to management or DHSS.) During an interview on 05/31/23, at 12:05 P.M., LPN A said on 05/29/23, he/she walked in the resident's room and the resident was slumped over in his/her wheelchair. The nurse asked if the resident wanted assistance and the resident said yes. The nurse assisted the resident to the bed. After the resident got to the bed, the resident said, You hurt me, you are hurting me. I am calling the police. The nurse left the room and later CNA B came to the nursing station and said the resident would not allow him/her to change his/her brief. The nurse went in and the resident said he/she didn't want anyone touching him/her. The nurse said he/she wasn't aware abuse allegations could be verbal. He/she thought they should just be reported if there were allegations of physical abuse. He/she thought the resident was just talking out of his/her head. The LPN said he/she did not report the allegation of abuse to management or DHSS. During an interview on 05/31/23, at 10:12 A.M., LPN C said if a resident says they are abused, staff make sure they are safe, let the Assistant Director of Nursing (ADON), Director of Nursing (DON), or Administrator know, contact the State Agency within two hours, and start the investigation. During an interview on 05/31/23, at 10:15 A.M., Certified Medication Technician (CMT) D said if a resident reports they are abused, staff should make sure the resident is safe, report to the charge nurse, report to the State Agency within two hours, and an investigation is started. During an interview on 05/31/23, at 10:18 A.M., LPN E said if a resident says they are abused, staff should remove them from the situation if possible, report to the State Agency within two hours, and begin the investigation. The resident should be assessed for injuries. During an interview on 05/31/23, at 12:15 P.M., the ADON, DON, and Administrator said if a resident makes an allegation of abuse, they expect staff to immediately make sure the resident is safe, let the charge nurse know, contact the ADON, DON, and Administrator. The ADON and DON are in charge of starting the investigation. They are always available. The charge nurses have access to the online reporting feature to report to the State Agency and are able to report the allegation within two hours if the management are not. They do expect the allegation to be reported within two hours. MO00219154

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote resident self-determination when staff failed to provide routine baths or showers to one resident (Resident #10). The facility had a census of 83. The facility did not have a shower policy. 1. Record review of Resident #10's face sheet (a brief resident profile) showed the following information: -admitted on [DATE]; -Diagnoses included Type 2 Diabetes Mellitus with diabetic nephropathy (damage to kidneys caused by diabetes), complication of amputation stump, bipolar disorder (mental health condition causing extreme mood swings), and depression. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 03/12/2023, showed the following: -Cognitively intact; -Independent with transfers; -Required physical help with part of bathing activity. Record review of the resident's current care plan, last revised 03/15/2023, showed the following: -Had an activities of daily living (ADLs - dressing, grooming, bathing, eating and toileting) deficit and required assistance with ADLs; -Resident at risk for decline in ADLs related to decreased functional status/rehabilitation potential; -Interventions included resident required 1-2 person(s) assistance; -Staff not to rush resident. Record review of the resident's Skin Monitoring: CNA Shower Review sheets showed the following: -Staff documented providing the resident one shower during the month of March 2023 (03/09/2023). -Staff did not document providing the resident any showers during the month of February 2023. -Staff documented providing the resident two showers during the month of January 2023 (01/04/2023, 01/18/2023). -Staff documented providing the resident three showers during the month of December 2023 (12/07/22, 12/14/22, 12/21/22). Observation on 03/13/23, at 10:14 A.M., showed the resident as clean and well groomed. During an interview on 03/13/23, at 10:14 A.M., the resident said he/she had a bath last Thursday (03/09/2023), but prior to that has not had a bath in one and a half months. The resident said his/her scheduled shower days are Mondays and Thursdays. The resident said he/she feels yucky when he/she does not get a bath. During an interview on 03/20/23, at 10:25 A.M., Certified Nurse Aide (CNA) R said showers are mostly given in the evenings. There is a shower schedule at the nurses' station. There is one aide on each hall. They provide all the care, including showers, toileting, everything. The facility no longer has a designated shower aide and there is not enough staff to get showers done. Typically, there are 2-3 showers scheduled per day that are supposed to be completed. Sometimes, he/she gets one shower completed, sometimes none. If a resident requests a shower, the aide tries to make time and give the shower to that resident. There is a shower record on the electronic medical record (EMR) under ADLs where the aide documents the shower given. If a resident refuses a shower, staff document it and have the resident sign the skin sheet (Skin Monitoring: CNA Shower Review sheet). The aide had not given any showers yet on this day, but did complete two showers the day before. The residents probably get one shower a week, but staff try to give two showers a week. During an interview on 03/20/23, at 11:00 A.M., Licensed Practical Nurse (LPN) J said he/she believes all residents get weekly baths. There is a shower schedule on the nurses' station desk. Showers are scheduled twice a week by room number. If a resident refuses a shower, the CNA will have the resident sign the skin sheet (Skin Monitoring: CNA Shower Review sheet) and the nurse signs it also. The LPN could not show or find documentation of any additional baths given to Resident #10. During an interview on 03/20/23, at 12:00 P.M., the social services assistant said he/she is able to view additional shower dates in the EMR. After looking in the EMR, he/she could not find any additional dates that staff assisted Resident #10 with showers. During an interview on 03/20/23, at 4:25 P.M., the MDS Coordinator said he/she adds the days the residents prefer baths to the care plan. All residents should receive two baths per week. However, due to staffing, that is not happening. No one has complained to him/her about not getting enough baths. During an interview on 03/20/23, at 12:40 P.M., the assistant director of nursing (ADON) said normally residents should receive showers twice per week. Resident #10 does not normally refuse showers so it is likely the resident went that long without a shower. The main documentation for showers is the skin observation form (Skin Monitoring: CNA Shower Review sheet). The ADON looked in the EMR regarding shower documentation for Resident #10. She noted two shower records, 1/19/2023 and 3/10/2023 for Resident #10. The ADON has had residents complain about not getting showers. Prior to Covid, the facility had a designated shower aide and now they do not have the staff to give baths routinely. If she hears complaints, staff try to get the resident to the shower. Sometimes, it is sporadic if they do not have a shower aide. The facility does not have enough staff to get showers completed. The facility is aware, they just do not have the staff. The facility used to have a designated shower aide, but now there is not enough staff to have a designated person. During an interview on 03/20/23, at 3:40 P.M., the director of nursing (DON) said that CNAs or certified medication technicians (CMTs) give showers. Some residents have missed showers. It is expected that one bath per week to be given as the bare minimum. The nurse should remind the aides and organize them to ensure that baths are given. If a resident requests a shower, the facility tries to get the staff to give the shower. The facility currently does not have a designated shower aide and the facility has enough trouble to keep enough aides just to work the floor (to provide basic activities of daily living). The facility is just trying to keep things going the best they can with what they have. Resident #10 has not complained to her about showers. During an interview on 03/20/23, at 5:10 P.M., the interim administrator said staff should follow the policy on baths when questioned regarding expectations of the facility regarding providing baths to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to give written transfer notice to the resident and/or resident's representative for two residents (Residents #17 and #69) who were transferred out to the hospital. The facility census was 83. Record review of the facility provided copy of the form letter being sent to a resident's responsible party, titled Emergency Transfer Notice, showed the following information: -The letter is to serve as your emergency notice of transfer from the facility due to the need for urgent medical care which cannot be met by the facility; -More information on the discharge process can be received from State Long Term Ombudsman and address and phone number listed; -The name and address of facility transferred to; -Phone number of the facility and administrator signature. Record review showed the facility did not provide a policy regarding emergency transfer notice to residents or resident representatives. 1. Record review of Resident #17's face sheet showed the following information: -admitted to the facility on [DATE]; -re-admission date of 12/22/2022; -Diagnoses included: Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), chronic ischemic heart disease (heart problems caused by narrowed heart arteries that supply blood to the heart muscle), cognitive communication deficit, urinary tract infection (an infection in any part of the urinary system, includes the kidneys and bladder). Record review of the resident's medical record showed staff documented the following information: -On 12/21/2022, at 7:09 P.M., nursing aide staff alerted the nurse staff that resident had an episode during evening cares at 6:35 P.M., where he/she became flaccid (party of the body hanging loosely or limply) and incontinent of bladder (loss of bladder control). This was not normal for resident. Upon entry into room at 6:40 P.M., the vital signs showed blood pressure 148/78, pulse 68, oxygen saturation 98% on room air, and temperature of 96.8 degrees. The resident appeared diaphoretic (sweating heavily), however, was responding within normal limits to questions asked. Notified the on call provider and received orders to call the family to see if okay to send to the hospital for evaluation and treatment. Called resident's family and received approval to send the resident to the hospital. Notified the DON and the on call provider of approval to send for evaluation. The resident left via ambulance at 6:58 P.M., with face sheet and code status.; -On 12/22/2022, at 5:27 A.M., the resident returned from the emergency room by ambulance. The resident arrived on the stretcher to his/her room at 4:00 A.M Per documentation from emergency room the resident had a diagnosis of UTI. The resident was given intravenous (IV) fluids and antibiotics at the hospital. The resident had new orders for Keflex (antibiotic used to treat a variety of bacterial infections) 500 mg, 1 capsule every 8 hours for 7 days. The resident was assisted into his/her bed by the ambulance staff and facility staff. The resident's family member was made aware of the resident's return and diagnosis. Vital signs obtained upon arrival were blood pressure 133/69, pulse 68, temperature 98.1, and oxygen saturation of 94%; -On 03/07/2023, at 6:22 P.M., the nurse received a call from the laboratory at 5:55 P.M., in regards to a critical hemoglobin (Hgb - protein in red blood cells that carries oxygen) of 6.5 (normal range 12 to 17). Provider was called and gave the order to send the resident to the emergency room for a blood transfusion. Called the resident's family at 6:06 P.M. to update on the current situation. Notified the DON and the ambulance was called and the resident was transported to the emergency room at 6:15 P.M.; -On 03/08/2023, at 3:23 A.M., the resident returned to facility at 3:05 A.M. from the emergency room. The resident arrived on a stretcher with two medical attendants. The resident was assisted into bed by the two attendants and facility staff. Vital signs included blood pressure 99/59, pulse 91, temperature 98.2 degrees and oxygen saturation 96% on room air.; -On 3/08/2023, at 6:44 A.M., staff called the provider to let him/her know that resident returned back to facility, notified the family of resident's return. Record review of the resident's electronic and paper medical records showed staff did not document notification to the resident or resident's responsible party in writing of the resident's transfer to the hospital on [DATE] or 3/8/23. Record review on 3/17/23 of the facility provided ombudsman Transfer Log Notice for the month of December 2022 and for the month of March 2023 showed Resident #17's name not listed on the transfer notice log to the ombudsman. Social Services Director (SSD) H wrote that resident did not stay overnight so a written transfer notice was not sent to the responsible party. 2. Record review of Resident #69's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included: Atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), urinary tract infection, type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), chronic pain syndrome, chronic obstructive pulmonary disease, and chronic kidney disease (CKD - kidneys are damaged and cannot filter blood the way they should). During record review of the resident's progress notes showed staff documented the following information: -On 03/12/2023, at 1:06 P.M., the resident complained of not feeling well, the resident had wheezing in his/her lungs bilaterally, productive cough, oxygen saturation at 75%, and refusing to wear oxygen. The nurse had put oxygen on the resident multiple times and when the aide told the resident he/she needed to wear it the resident said he/she didn't have to and told the aide to shut up. The resident's eye balls were rolling in the back of his/her head and sweating. The on call provider was contacted and gave an order to send the resident to the emergency room for evaluation. The ambulance staff arrived and left the facility around 1:00 P.M.; -On 3/12/2023, at 5:30 P.M., the resident arrived back to the facility via ambulance services at 5:30 P.M., via stretcher, report was called from the hospital and the only thing they could find wrong with the resident was that when he/she takes off the oxygen his/her oxygen saturation drops down shortly thereafter. The resident was alert and oriented upon arrival, no new orders were given by the hospital, will continue to observe. Record review of the resident's electronic and paper medical records showed staff did not document notification to the resident or resident's responsible party in writing of the resident's transfer to the hospital on 3/12/23. Record review, on 3/17/23, of the facility provided Transfer Notice Log for the month of March 2023 showed Resident #69's name was not on the March 2023 transfer notice log for 3/12/23. SSD H wrote that resident did not stay overnight so a written transfer notice was not sent to the responsible party. 3. During an interview on 3/17/2023, at 9:50 A.M., Licensed Practical Nurse (LPN) G said when a resident is sent to the hospital the nursing staff send a face sheet with diagnosis, a medication list, and any pertinent documentation such as lab results. The nursing staff will notify the resident's family by phone of the transfer. The nursing staff does not send any written notice of hospital transfer or bed hold policy to the family. 4. During an interview on 3/17/2023, at 11:50 A.M., LPN J said when a resident is transferred to the emergency room, the staff send a face sheet and medication sheet. The nurse calls the family with resident transfer status. 5. During an interview on 3/17/2023, at 11:52 A.M., the Director of Nursing (DON) said she would be completing in-services that day regarding the need to send bed hold guidelines to the resident's responsible party. She said the facility had not been sending bed hold notices. 6. During an interview on 3/17/2023, at 11:55 P.M., with SSD H and SSD I, the staff said they send a written hospital transfer notice the day after a resident is sent to the hospital. They enter the transfer onto the Transfer Notice Log with the date the notice was mailed to the family. They then mail the log to the ombudsman on the first day of the following month. He/she puts a date at the top of the log when it was mailed to the ombudsman. SSD H said he/she had never previously seen the Bed Hold Guidelines form the DON provided to them on that day. SSD H said that he/she had not mailed a bed hold form to any family members. They do not keep a copy or proof of the mailed letters to family. SSD I said when a resident was sent to the emergency room and was not out of the facility overnight, the staff do not send a written transfer notice to the family. 7. During an interview on 3/20/2023, at 4:30 P.M., with the DON, ADON, Administrator, and Quality Assurance nurse, the DON said when a resident was transferred to the hospital a written emergency transfer notice is mailed to the family by the business office the day after admission to the hospital. A written transfer notice is not sent out to the family if the resident does not stay overnight at the hospital. The nursing staff verbally discussed bed hold information with the resident or responsible party, and it was provided on resident admission to the facility. The bed hold notice had not been attached to the transfer notice when mailed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify and coordinate with the State-designated authority following newly evident or possible serious mental illness for one resident (Resident #70) who had a negative level one Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals who have a mental disorder or intellectual disability are not inappropriately placed in nursing homes for long-term care. The PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability and be offered the most appropriate integrated setting for their needs (in the community, a nursing facility, or acute care setting) and receive the services they need in those settings). The facility census was 83. Record review showed the facility did not provide a policy regarding PASARR requirements. 1. Record review of Resident #70's Level 1 Nursing Facility Pre-admission Screening for Mental Illness/Mental Retardation or related condition, dated 9/28/2021, showed the following information: -Does not show any signs of symptoms of major mental disorder; -Had not been diagnosed as having a major mental disorder; -Primary reason for nursing facility placement not due to dementia; -Had not had serious problems in levels of functioning in the last six months; -Had not received intensive psychiatric treatment in the past two years; -Not known or suspected to have mental retardation that originated prior to age [AGE]; -Not known or suspected to have a related condition. Record review of resident's face sheet (gives basic profile information at a glance) showed the following information: -admitted on [DATE]; -admission diagnoses included congestive heart failure (CHF), type 2 diabetes, low thyroid function, dysthymic (persistent depressive) disorder, kidney disease, high blood pressure, gastro-esophageal reflux disease (GERD: stomach acid backs up into the esophagus), and acute respiratory failure; -Diagnosis, dated 10/1/2021: schizophrenia (mental disorder including symptoms of delusions, hallucinations, and disorganized thinking/speech); -Diagnosis, dated 6/26/2022: schizoaffective disorder (schizophrenia plus mood disorder such as depression or severe mood swings); -Diagnosis, dated 1/23/2023: dementia. Record review of the resident's medical record showed staff did not refer the resident after a significant change in status, for a Level II PASARR review. During an interview on 3/20/2023, at 1:44 P.M., MDS C said the facility is required to complete a Level I Pre-admission Screening for Mental Illness/Mental Retardation or Related Condition for all new residents, within 72 hours of admission. If the process has already been started during hospitalization, they will receive the access code to continue. They will be notified by the assessing agency if there is a need to proceed with a Level II screening. A new diagnoses of mental disorder, such as schizophrenia would trigger the need for a new Level I. MDS C said he/she was very new at the time of Resident #70's new diagnosis and probably was not aware of the situation or of the need to complete a new Level I or Level II if indicated. During an interview on 3/20/2023, at 4:30 P.M., with the Administrator and the Director of Nursing (DON) said the MDS staff is responsible for completing the DA-124/Level I screening for a resident prior to admission. They should request a new Level I if a resident is given a new diagnoses of mental illness or condition, such as Resident #70's new diagnosis of schizophrenia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to revise the comprehensive care plan for three residents (Residents #24, #36, and #39) of 18 sampled residents to reflect the residents' current care needs. The facility census was 83. Record review of the facility policy, titled Care Plan Comprehensive, with no date, showed the following: -An individualized care plan team with input from the resident, family, and/or legal representative will develop and maintain comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain; -A well-developed care plan will be oriented to: -Preventing avoidable declines in functioning or functional levels; -Managing risk factors to the extent possible or indicating the limits of such interventions; -Addressing ways to preserve and build upon residents strengths; -The interdisciplinary care plan team is responsible for the periodic review and updating of care plans: -When a significant change in the resident's condition occurred; -At least quarterly; -When changes occur that impact the resident's care (example: change in diet, discontinuation of therapy, changes in care areas that do not require a significant change of assessment). 1. Record review of Resident #36's face sheet showed the following information: -admitted on [DATE]; -Diagnosis included: acute kidney failure (kidneys suddenly become unable to filter waste products from your blood), obstructive and reflux uropathy (urine cannot flow either partially or completely) through the bladder or urethra (duct by which urine is conveyed out of the body from the bladder) due to some type of obstruction, dysuria (painful or difficult urination), benign prostatic hyperplasia (enlarged prostate (located just below the bladder and in front of the rectum)) with lower urinary tract symptoms (symptoms involving urination), bladder disorder, and dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) without behavioral disturbance. Record review of the resident's physician orders, current as of 3/20/23, showed the following information: -Order dated 8/22/22, arrange appointment with urologist for follow up regarding the Foley catheter (thin, flexible catheter used especially to drain urine from the bladder); -An order dated 8/22/22, with no end date, catheter size 16 French (French unit is roughly equal to the circumference of the catheter in millimeters) with 10 milliliter (ml) bulb; -An order dated 8/22/22, with no end date, change catheter monthly on the 22nd of the month; -An order dated 8/22/22, with an end date of 12/5/22, catheter care every shift. Record review of the resident's treatment administration record showed the following: -On 12/22/22, staff documented that the catheter was changed; -On 1/22/23, staff documented that the catheter was changed; -On 2/22/23, staff documented that the catheter was changed. Record review of the quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/6/23, showed the following: -Severe cognitive impairment; -Resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Resident required extensive assistance of one staff for eating and locomotion; -Required a wheelchair; -Resident had an indwelling catheter; -Resident was not incontinent of urine due to having a catheter; -Resident was frequently incontinent of bowel. Record review of the resident's care plan, dated 9/1/22, showed the following: -Resident required an indwelling catheter related to diagnosis of acute kidney failure, bladder disorder, and urinary retention; -Staff should assess for continued need of catheter; -Staff should change the catheter bag per orders; -Staff should not allow tubing or any part of the drainage system to touch the floor; -Staff should position the bag below the level of the bladder; -Staff should perform catheter care per orders; -Staff should store the collection bag inside a protective dignity pouch. Record review of the resident's medical record showed staff documented in the nurse progress notes the following information: -On 12/01/22 at 2:05 A.M., the nurse aide reported that he/she heard the resident yelling. The CNA entered the resident room and observed that resident had blood covering his/her genital area. This nurse entered resident room seconds after the CNA and observed that resident had pulled his/her Foley catheter out, with the bulb still inflated. The resident stated, I took it out on purpose. The resident then stated in a clear voice I don't want it back in. The nurse aides cleaned the bleeding from the genital area and staff will monitor for continued bleeding; -On 12/01/22 at 1:01 P.M., the resident continues on 30 minute checks. The resident was up for his/her meals in the dining hall today. Notified the physician on call that the resident pulled his/her catheter out. Notified the DON of the situation and will try to insert catheter but the resident was combative and hurting the staff; -On 12/04/22 at 12:57 P.M., the resident continues on 30 minutes checks. The resident was asked if he/she was in pain and replied yes, pain pill was given. No Foley catheter in place. Will continue to monitor. During observation and interview the following was noted: -On 3/13/23 at 9:20 A.M., the resident was in a Broda chair (wheelchairs provide supportive positioning through a combination of tilt, recline, adjustable leg rest angle, wings with shoulder bolsters and height adjustable arm) at the nursing desk. No catheter or dignity bag visible; -03/14/23 at 12:00 P.M., the resident was in a Broda chair in the dining room. The resident's spouse was assisting with the resident's meal and said the resident did not have a catheter at this time; -On 3/15/23 at 12:19 P.M., the resident was in dining room in a Broda chair with no catheter noted; -On 3/17/23 at 1:35 P.M., the resident was in a Broda chair at the nursing desk. No catheter was noted. During an interview on 3/20/23 at 3:05 P.M., Licensed Practical Nurse (LPN) E said that staff should call the doctor to get a discontinue order if the resident no longer needs a catheter. He/she said if a resident pulled out a catheter, the doctor should be notified to see if he/she wants to discontinue the order or have staff re-insert the catheter. The resident pulled his/her catheter out, and staff should have notified the physician and the order should have been discontinued. He/she was unsure why there was still an order or care plan information related to Resident #39's catheter. During an interview on 3/20/23 at 4:30 P.M., the Director of Nursing (DON) said that the catheter order should have been discontinued in the resident's chart. Staff should notify the MDS staff to have discontinued care items removed from the care plan to ensure care plan accuracy. 2. Record review of Resident #39's face sheet showed the following information: -admitted [DATE]; -Diagnosis included: Cerebral infarction (stroke), hemiplegia and hemiparesis (loss of strength) following cerebral infarction affecting left non-dominant side, repeated falls, chronic obstructive pulmonary disease (COPD - group of diseases that cause airflow blockage and breathing-related problems), and dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) with behavioral disturbance. Record review of the resident's physician order sheet, current as of 3/20/23, showed the following: -An order dated 12/9/22 for occupational and physical therapy to evaluate and treat for diagnosis of history of falling; -An order dated 3/2/23 for occupational therapy (OT), physical therapy (PT), and speech therapy (ST) to evaluate and treat to help with weakness and awareness and safety; Record review of the facility provided Restorative Therapy log book showed the following information: -An order dated 1/24/23, discontinue physical therapy services and continue with Restorative Aide program, 2 to 5 times per week for 90 days, for Nustep (exercise machine which combines lower and upper body movement for a full body workout) times 15 minutes for strengthening; -Resident listed on restorative program from 1/24/23 through 4/24/23; -Flow sheet for January, February, and March had no staff initials or information documented. Record review of the resident's care plan, last reviewed 3/20/23, showed the following information: -The resident was at risk for decline in activities of daily living (ADL) and requires more assistance; -The resident will participate in ADLs as he/she is willing and able and will review next care plan; -PT/OT/ST to evaluate and treat; -Staff should provide assistance for ADLs as needed and as resident allows. -Staff should praise the resident for efforts. During observation and interview, the following was noted: -On 3/13/23 at 2:43 P.M., the resident was resting in bed. He/she said he/she had been out to smoke a little while ago and was now tired; -On 3/15/23 at 11:00 A.M., the resident was in his/her room. He/she said that he/she had not exercised with any staff for a couple of months; - On 3/17/23 at 12:10 P.M., the resident was in dining room and had not worked with the restorative aide for exercise. During an interview on 3/20/23 at 2:07 P.M., Transport/RNA said he/she works with residents on restorative orders when he/she is able to, but most of his/her job was transport. If appointments cancel, he/she is able to do restorative therapy. He/she marks it in the 3-ring binder when he/she works with residents on restorative therapy. The transportation calendar is booked for April and part of May. He/she has not helped Resident #39 with restorative therapy since he/she went to see the resident for the first time and the resident had a friend visiting and did not want to participate. 3. Record review of Resident #24's face sheet showed the following: -admitted to the facility on [DATE], -Diagnoses included pulmonary embolism (blood clot in the lungs), chronic obstructive pulmonary disease (COPD; breathing disorder), Alzheimer's disease, congestive heart failure (CHF), chronic pain, anxiety disorder, insomnia, cerebrovascular disease (abnormal blood flow in the brain), mild asthma (breathing disorder), mild cognitive impairment, psychological and behavioral factors associated with disorders or diseases classified elsewhere, Schizoaffective disorder (mental condition with symptoms including delusions, hallucinations, disorganized thinking/speech, and mood swings), major depressive disorder, dementia without behavioral disturbance, abnormal weight loss, restless leg syndrome, Parkinson's disease (disorder of the central nervous system that affects movement), dizziness and giddiness, and post-traumatic stress disorder (PTSD). Record review of psychological services progress notes showed the following: -8/9/2021: Patient refused psychological services on this date; -9/22/2021: Discharge - Patient refused services. If patient shows a relapse or increase in symptoms, or shows the ability to benefit from treatment, he/she may be referred again for therapy if he/she remains in or returns to the facility. Continued treatment is encouraged; continue self-help strategies. Patient is not considered to be a risk of harm to self or others. Record review of the resident's Care Plan, last updated 2/22/2023, showed the following: -Category: psychosocial well-being; resident has adjustment disorders. Goal: Resident will participate in weekly therapy sessions with Deer Oaks to express feelings and environmental adjustment. Approach (start date 5/14/2021): resident will be encouraged to participate with weekly sessions with Deer Oaks. Record review of the resident's physician order sheet (POS), current as of 3/20/2023, showed the following: -12/20/2020: Deer Oaks may provide psychological services; -2/2/2022: Lexapro (antidepressant) 10 milligram (mg) tablet; one tablet by mouth once a day; -3/9/2022: Ativan (lorazepam; antianxiety) 0.5 mg tablet; one tablet twice a day; -4/12/2022: Remeron (antidepressant) 15 mg tablet; one tablet at bedtime; -10/3/2022: Abilify (antidepressant) 2 mg tablet; one tablet daily; -12/31/2022 (stop date 5/15/2023): Lorazepam intensol concentrate 2 mg/milliliter (ml); 0.5 mg by mouth every two hours as needed; -Lorazepam intensol concentrate 2 mg/ml; 0.25 ml by mouth twice a day. During an interview on 3/20/2023 at 1:44 P.M., MDS C said the nurses should tell him/her when there are changes/additions to be made to a resident's Care Plan. Resident #24's Care Plan should have been updated when psychological services discharged the resident in 2021. During an interview on 3/20/2023 at 4:30 P.M., with the Administrator, the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and the corporate Quality Assurance nurse, the Administrator said MDS staff is responsible for completing and updating residents' Care Plans. The nursing staff should give update/changes/additions information directly to MDS or during the daily stand-up meeting. The DON said Care Plans should be updated regarding services or treatments that are discontinued, such as Resident #24's discharge from (psychological services.) 4. During an interview on 03/20/23 at 11:40 A.M., LPN S said care plans are completed by the MDS coordinator staff. If there is any care or service that needed to be added or removed from the care plan, the nurses should notify the MDS staff. Care plans should be up to date with resident's current level of care. 5. During an interview on 3/20/23 at 1:40 P.M., MDS C said care plans should be updated any time there is a change in condition. If an MDS is coded with something that was not present at the time of coding, the MDS staff can do a correction to the MDS. Care plans should have care items removed as soon as staff become aware of it through conversations. The staff nurses can make changes but they generally just let the MDS staff know what changes to be made. 6. During an interview on 3/20/23 at 4:00 P.M., Registered Nurse (RN) T said when there are changes to a resident's care it is entered on the 24 hour report and discussed at the morning meeting. If there is a change that needs to be made to the care plan, staff should notify the MDS staff to remove or change the item in the care plan.

Based on observation, interview, and record review, the facility failed to develop and implement an effective system to ensure a resident's choice of code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was readily accessible to staff and documented consistently throughout the medical record for one resident (Resident #10). The facility census was 83. Record review of the (undated) facility policy titled, Advance Directive, showed the following: -The facility will respect advance directives in accordance with state law. -Upon admission of a resident to the facility, the social services designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive. -Upon admission of a resident, the social services designee will inquire of the resident and/or his/her family members, about the existence of any written advance directives. -Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record under the advance directive tab. 1. Record review of Resident #10's face sheet (a brief resident profile) showed the following information: -admission date of 03/04/22; -Diagnoses included Type 2 Diabetes Mellitus with diabetic nephropathy (damage to kidneys caused by diabetes), complication of amputation stump, bipolar disorder (mental health condition causing extreme mood swings), depression. -Staff did not note the resident's code status on the face sheet. Record review of the resident's Outside The Hospital Do-Not-Resuscitate (OHDNR) Order, dated 03/04/22, showed a diagonal line drawn across the form with full code (staff to provide emergent treatment if his/her heart or breathing were to stop) written, signed and dated by the resident. Record review of the resident's OHDNR Order dated 03/08/22, showed the resident signed and dated for staff to withhold emergent treatment if his/her heart or breathing were to stop (DNR). Record review of the resident's physician order sheet (POS) showed an order, dated 04/19/22, for DNR as the resident's code status. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 03/12/23, showed the resident as cognitively intact. Record review of the resident's current care plan, last revised 03/15/23, showed staff did not address the resident's code status wishes. Record review of Resident #10's electronic medical record (EMR), conducted on 3/15/23, showed a header at the top of the screen next to the resident's name, noting the resident's code status as full code in green font. Observation on 03/13/23, at 1:00 P.M., showed the name tag on the resident's outer doorframe, with the resident's name, as green in color. During an interview on 3/20/23, at 10:25 A.M., CNA R said the resident's name tag on the doorframe outside the resident's room shows the resident's code status. If it is red, the resident is a DNR. If it is green, the resident is a full code. Observation on 3/20/2023, at 10:38 A.M., showed Resident #10's doorframe had a green name tag, indicating full code status. During an interview on 03/20/23, at 2:05 P.M., the resident said he/she is currently a full code, meaning he/she wants cardiopulmonary resuscitation if he/she were to stop breathing or his/her heart stopped beating. During an interview on 03/20/23, at 11:00 A.M., Licensed Practical Nurse (LPN) J said code status is on the EMR, face sheet, and in the physician orders. The LPN looked at the residents' code status on the EMR and showed this surveyor the header at the top of the screen next to the resident's name, noting the resident's code status as full code in green font and the face sheet showed the resident as full code. The LPN also found a current DNR order, dated 04/19/22. The LPN said everything should match and did not know for sure why it did not match. The LPN did not know the process of code status determination. During an interview on 03/20/23, at 11:15 A.M., Social Services Director (SSD) H said the advance directive is in the admission packet. If a resident wants to be a full code, he/she draws a diagonal line across the advance directive page, then writes in full code and has the resident date and sign the bottom of the page. The nurse will get an order from the physician and place it in the EMR. Name tags for outside of the resident's room are then color coded. A green name tag is placed if the resident is a full code, a red name tag is placed if the resident is a do not resuscitate (DNR). In the EMR, the header at the top of the computer screen also shows code status. If a resident changes his/her mind about code status, social services will get a new form and have the resident and physician sign it. Then, the document is uploaded into the EMR record. All advance directives are reviewed during care plan meetings and social services will check all the name tags outside resident rooms every one to two weeks to assure every resident's name tag is correct and up to date. Social services changes information in the computer to make sure everything matches. Social services does not do anything with the POS. She did not know about the POS part of it. She did not know Resident #10's code status off the top of her head. She looked in the computer and said it showed full code in the header at the top of the resident's EMR computer screen. She also found a full code (Outside The Hospital Do-Not-Resuscitate (OHDNR Order) form signed in March 2022. During an interview on 3/20/2023, at 12:55 P.M., the assistant director of nursing (ADON) said Resident #10 must have changed his/her mind about code status. She was the one who entered the DNR order in the POS. She said she checks the POS every day. She checks the orders, progress notes, any abnormal vital signs, and they discuss it in the morning meetings every day. At 1:27 P.M., the assistant director of nursing (ADON) found a DNR (Outside The Hospital Do-Not-Resuscitate (OHDNR Order), dated 3/8/22 for Resident #10 in the resident's admission packet. During an interview on 03/20/23, at 4:25 P.M., MDS Coordinator (MDS) C said the facility no longer addresses advance directives on the care plans because that information is on the resident's face sheet, electronic medical record (EMR) header, and color coded name tag outside each resident's door (green=full code, red=do not resuscitate). The care plan would be the last place anyone would look for code status during a code. So, the facility puts the code status in the places staff would look first during an emergency. During an interview on 03/20/23, at 3:40 P.M., the Director of Nursing (DON) said code status is determined during the admission process. It is part of the admission packet put together by social services. The nurse gets an order from the physician, has the resident sign the order then uploads the order (Outside The Hospital Do-Not-Resuscitate (OHDNR Order) form into the EMR. Then social services will put that code status on the face sheet and place the color coded name tag (green for full code and red for DNR) outside the resident's door. The social services assistant will normally stay after normal work hours, if needed, to make certain it is all done and correct. Resident #10's code status shows DNR in one place and full code in other places. The DON said she personally double checked all code status on all residents a year ago and isn't sure how this resident's status got missed. During an interview on 03/20/23, at 5:10 P.M., the interim administrator said code status is addressed by social services at the time of admission. Nursing gets an order from the physician and has the resident sign the order (Outside The Hospital Do-Not-Resuscitate (OHDNR Order form). If the resident changes his/her mind, facility staff revokes the first form and then social services initiates the changes. Every resident should have a physician order addressing code status, whether the resident is a full code or a DNR. Everything in the chart should match including the EMR header, face sheet, and the name tag outside of the resident's room. Everything should match so staff can look at any of these places to determine code status of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of meaningful activities based on residents' interests and abilities when the staff did not provide activities as scheduled and did not track attendance of activities to evaluate if activities needs were being met for two residents (Residents #10 and #13). The facility had a census of 83. Record review of the facility policy titled, Activity/Recreational Therapy Manual, last reviewed on 03/12, showed the following: -The purpose is for the facility to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. -To enhance the quality of the residents daily life; -The Activity Director will develop a monthly activity calendar based on the residents' needs and interests. -Group activities will be scheduled at times when the maximum number of residents can participate in a specific type of activity; -When available equipment, supplies and personnel are available; -Activity involvement is to be documented in the resident chart under progress notes. 1. Record review of Resident #10's face sheet (a brief resident profile) showed the following information: -admission date of 03/04/22; -Diagnoses included Type 2 Diabetes Mellitus with diabetic Nephropathy (damage to kidneys caused by diabetes), complication of amputation stump, bipolar disorder (mental health condition causing extreme mood swings), depression. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 03/12/23, showed the following: -Cognitively intact; -Activity preferences showed it was very important to the resident to do things with groups of people and it was very important to do his/her favorite activities. Record review of the resident's current care plan, last revised 03/15/23, showed the following: -At risk for decline in activities of daily living (ADLs - dressing, grooming, bathing, eating and toileting); -Required one-two person assistance for ADL's; -The care plan did not address the resident's preferred activities. Record review of the resident's electronic medical record (EMR), showed no progress notes documented related to activities the resident participated in or attendance to the exercise class from the dates 12/01/22 through 03/15/23. During an interview on 03/13/23, at 9:49 A.M., Resident #10 said the facility has exercise posted on the calendar, but has not had any exercise class for at least a year. There are no activities on the weekends. He/she would enjoy exercise and activities on the weekends. Observation on 03/15/23, at 10:40 A.M., showed the March 2023 activity calendar posted on the wall in the main center hall, indicating a group exercise activity scheduled for 3/15/2023 at 10:30 A.M. Observation showed no group exercise in progress in the dining room, restorative dining room or in the therapy room. Resident #10 lay in bed with his/her eyes closed. 2. Record review of Resident #13's face sheet (a brief resident profile) showed the following information: -admission date of 12/07/22; -Diagnoses included chronic kidney disease, coronary artery disease (damage in the heart's major blood vessels), coronary angioplasty implant and graft (balloon and stent placement to open artery), osteoporosis (weak and brittle bones), anxiety. Record review of the resident's admission MDS, dated on 12/14/22, showed the following: -Cognitively intact; -Activity preferences showed it was very important to the resident to do things with groups of people and it was very important to do his/her favorite activities. Record review of the resident's current care plan, last revised on 12/08/22, showed the following: -At risk for falling; -At risk for a decline in ADLs; -Resident will need assistance to ambulate and transfer; -Staff did not address the resident's activity preferences and plan. Record review of Resident #13's current physician order sheet (POS), showed the following orders: -An order dated 01/25/23, to discontinue physical therapy services and continue with restorative aid program, 2-5 times per week for NuStep for 15 minutes to maintain bilateral lower extremity strength. Record review of the resident's EMR showed staff did not document any progress notes related to activity attendance or exercise class from the dates 12/01/22 through 03/15/23. During an interview on 03/14/23, at 2:04 P.M., Resident #13 said he/she would like more exercise. He/she would like exercise videos played in the dining room during group activities. Observation on 03/15/23, at 10:40 A.M., showed the March 2023 activity calendar posted on the wall in the main center hall, indicating group exercise activity scheduled for 3/15/2023 at 10:30 A.M. Observation showed no group exercise in progress in the dining room, restorative dining room or in the therapy room. Resident #13 lay in bed with his/her eyes closed. During an interview on 03/15/23, at 11:15 A.M., Resident #13 said the exercise had been posted on the board twice per week every week, but there has not been one exercise class since he/she has been living at the facility (admitted [DATE]). The resident said he/she wants the exercise class because it makes him/her feel better to exercise his/her muscles and he/she sleeps better. It is important to move around and keep busy. He/she walks around the building; but, he/she would enjoy doing an exercise class and his/her physician told the resident to exercise. During an interview on 03/20/23, at 2:30 P.M., the transportation aide said he/she helps with restorative when he/she can. He/She knows Resident #13 is on the restorative care list but he/she has not worked with that resident. 3. During an interview on 03/15/23, at 10:50 A.M., the Activities Director confirmed that group exercise was on the calendar for this day and time. He/she was unable to do group exercise today. Wednesdays are not good for him/her because he/she had care plan meetings on that day and time. The Activities Director said he/she leads the activities and decides on the day and times of the activities. He/she said that the restorative aide or transportation aide will lead the group but neither were available today so they did not do the exercise today. He/She said they have not had a restorative aid for several months. 4. During an interview on 03/20/23, at 10:24 A.M., Certified Nurse Aide (CNA) R said the Activities Director tells the residents about the activities for the day during breakfast. The CNA said he/she has not heard any complaints about activities. 5. During an interview on 03/20/23, at 11:00 A.M., Licensed Practical Nurse (LPN) J said the Activities Director schedules activities and lists them on the activities board in the hall. The LPN said he/she is not sure what activities are being done and not sure if the exercise group is being done. 6. During an interview on 03/20/23, at 12:15 P.M., the Speech and Language Pathologist (SLP) said they keep a restorative book in the therapy room with resident's information. The SLP said the therapist will fill out the paperwork and write orders on residents they feel would benefit from additional restorative care (group exercise class). The SLP said the 100, 200 and 300 halls go to the dining room around 10:30, two or three times per week for the restorative group exercise class. The transportation aide leads the exercise class, unless he/she is pulled away, then the Activities Director leads it. The SLP said he/she doesn't go to the dining room so he/she is not certain if the group exercise class is getting done. 7. During an interview on 03/20/23, at 12:40 P.M., the Assistant Director of Nursing (ADON) said therapy used to help with the group exercise class (restorative care), but they have not had the time to help for quite some time. The ADON said the transportation aide helps with restorative when he/she has the time. The ADON said the facility does not have enough staff to do restorative care. 8. During an interview on 03/20/23, at 2:30 P.M., the transportation aide said he/she helps with restorative when he/she can. He/she documents in the restorative book in the therapy room with an initial by the date in which the restorative care is provided. Therapy oversees the exercise class on the activity calendar. It has been 3 or 4 years since he/she has led that exercise class. He/she only works one on one with the residents that are not able to do things for themselves. 9. During an interview on 03/20/23, at 2:40 P.M., LPN E said he/she is not sure what activities are being done during the day as he/she doesn't normally work day shift. The residents really enjoy the activities, but has had residents complain about not having activities on the weekends. 10. During an interview on 03/20/23, at 4:25 P.M., the MDS Coordinator said activities should be included in the residents' care plans. The activities director or assistant activities director should complete an activities evaluation on every resident on admission and annually and that should be documented. She was not familiar with the group exercise activity. 11. During an interview on 03/20/23, at 3:40 P.M., the Director of Nursing (DON) said the group exercise activity is led by the activities director or assistant activities director. The transportation aide helps on the 400 hall with ball toss when he/she has the time. She does not know if the group exercise class is being done as she does not follow up with any activities. 12. During an interview on 03/20/23, at 5:10 P.M., the interim administrator said she did not know if the group exercise activities were being done or not because he/she has not seen any. But if not, the transportation aide should be doing them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #13's face sheet (a brief resident profile) showed the following information: -admission date of 12/07/22; -Diagnoses included chronic kidney disease, coronary artery disease (damage in the heart's major blood vessels), coronary angioplasty implant and graft (balloon and stent placement to open artery), osteoporosis (weak and brittle bones), and anxiety. Record review of the resident's current care plan, last revised on 12/08/22, showed the following: -Resident is at risk for falling; -Resident is at risk for decline in ADLs; -Resident will need assistance to ambulate and transfer; -Staff did not address the resident's restorative plan/program. Record review of the resident's admission MDS, dated on 12/14/22, showed the following: -Cognitively intact; -Independent with transfers and walking. Record review of Resident #13's physician order sheet (POS), current as of 03/13/23, showed the following orders: -An order dated 01/25/23, discontinue PT services and continue with RNA program 2-5 times per week for recumbent trainer for 15 minutes to maintain bilateral lower extremity strength. Record review of the current list of residents on the Restorative Program, showed Resident #13 with start date of 1/25/2023, and discharge order date of 4/25/2023. Record review of the resident's restorative log form, dated January 2023, located in the restorative book, showed the following information: -Restorative program of recumbent trainer for 15 minutes; -Staff did not document any initials on the form to show the restorative care program was provided as ordered for the resident. Record review of the resident's restorative log form, dated February 2023, located in the restorative book, showed the following information: -Restorative program of recumbent trainer for 15 minutes; -Staff did not document any initials on the form to show the restorative care program provided as ordered for the resident. Record review of the resident's restorative log form, dated March 2023, located in the restorative book, showed the following information: -Restorative program of recumbent trainer for 15 minutes; -Staff did not document any initials on the form to show the restorative care program provided as ordered for the resident. Record review of the resident's electronic medical record (EMR), did not show any progress notes related to restorative exercise provided for the resident. During an interview on 03/14/23, at 2:04 P.M., the resident said at the resident council meeting he/she would like more exercise. He/she would like exercise videos played in the dining room during group activities. Observation on 03/15/23, at 10:40 A.M., according to the monthly activities calendar, group exercise was scheduled for this day at this time. No group exercise occurred in the dining room, restorative dining room or in the therapy room. During an interview on 03/15/23, at 10:50 A.M., the Activities Director confirmed that group exercise was on the calendar for this day and time. She was unable to do group exercise today. Wednesdays are not good for him/her because he/she had care plan meetings on that day and time. The Activities Director said that he/she leads the activities and decides on the day and times of the activities. The restorative aide or transportation aide will lead the group but neither were available today so they did not do the exercise today. They have not had a restorative aide for several months. During an interview on 03/15/23, at 11:15 A.M., the resident said the exercise class had been posted on the board twice per week every week, but that there has not been one exercise class since he/she has been living at the facility (12/07/22). He/she wants the exercise class because it makes him/her feel better to exercise his/her muscles and he/she sleeps better. It is important to move around and keep busy. He/she walks around the building but would enjoy doing an exercise class and said that his/her physician told him/her to exercise. 3. During an interview on 03/20/23, at 12:15 P.M., Speech and Language Pathologist (SLP) said they keep a restorative book in the therapy room with residents' information. The SLP said the director of rehab organizes the restorative program. He/she tries to keep up with it and make sure the checklists are completed. As residents are discharged from therapy services, the therapists will fill out the paperwork and write/get orders on residents that they feel would benefit from additional restorative care. They complete the order sheet, create an instruction sheet for what the restorative program should include, how often it should be completed, and how long the program should last. It is usually for a 90 day period. The SLP said that 100, 200 and 300 halls go to the dining room around 10:30 A.M., two or three times per week for the restorative group exercise class. The transportation aide leads the class, unless he/she is pulled away, then the Activities Director leads it. The SLP said he/she doesn't go to the dining room so he/she is not certain if the group exercise class is getting done for the 100, 200, and 300 halls. 4. During an interview on 03/20/23, at 12:40 P.M., Assistant Director of Nursing (ADON) said therapy used to help with the group exercise class (restorative care), but they have not had the time to help for quite some time. The ADON said the transportation aide helps with restorative when he/she has the time. The ADON said that the facility does not have enough staff to do restorative care. 5. During an interview on 3/20/23, at 2:07 P.M., Transportation Aide/RNA said that he/she works with residents for restorative when he/she has available time. He/she said that most of the time is taken for transportation. If something is canceled, there is time to do restorative. He/she thought that a staff from therapy had also been working with residents for restorative services. When able to do restorative work, he/she documents in the 3 ring binder log book with an initial by the date he/she provides the restorative care. The first time he/she went to work with Resident #39, he/she had a visitor and did not want to participate. Therapy oversees the exercise class on the activity calendar. It has been 3 or 4 years since he/she has done that exercise class. He/she only works one on one with the residents that are not able to do things for themselves. He/she knows Resident # 13 is on the restorative care list, but he/she has not worked with that resident. 6. During an interview on 03/20/23, at 3:40 P.M., Director of Nursing (DON) said that the group exercise activity is led by the activities director or assistant activity director. The transportation aide is working on helping on the 400 hall with ball toss when he/she has the time. The DON said she does not know if the group exercise class is being done as he/she does not follow up with any activities. There has not been a full time RNA and they expect the staff to follow physician orders. 7. During an interview on 03/20/23, at 5:10 P.M., the Interim Administrator said she did not know if the group exercise activities were being done or not because she has not seen any. But if not, the transportation aide should be doing them. There has not been a full time RNA and they expect the staff to follow physician orders. Based on observation, interview, and record review, the facility failed to provide restorative nursing services to maintain or improve residents' functional status as directed by therapy for two residents (Resident's #39 and #13) out of 23 sampled residents. The facility census was 83. Record review of the (undated) facility policy titled, Criteria for Restorative Nursing Assistant (RNA) program, a section of the Restorative Nursing Manual, showed the following information: -Referral to the RNA program may be made by nursing, Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), and physician, as well as through the Minimum Data Set (MDS- a federally mandated assessment completed by staff) process, Certified Nurses Aide (CNA), and family/resident input; -Upon assessment by nursing, PT, OT, or ST, the referral to the RNA is made; -The nurse or therapist initiating the referral transfers the assessment information to the Restorative Nursing Treatment Plan; -An appropriate inservice or instruction will be provided to the RNA concerning the resident's specific restorative needs; -RNA initiates treatment and documentation per facility protocol, such as 24 hour nursing report and treatment log. Record review of the (undated) facility policy, titled Documentation, a section of the Restorative Nursing Manual, showed the following information: -Documentation provides a written format of each resident's treatment, response to treatment, and baseline to measure progress or lack of progress. -RNA initials are required on the daily documentation record at the conclusion of the daily treatment. Specific treatment should be identified here, how many repetitions, etc.; -More frequent documentation will be required if there is a change from the treatment plan or in the resident's response to the treatment. This will be documented on the day of occurrence; -Specific goals for the resident should be written on the RNA treatment plan; -Monthly summaries will be completed by the RNA and co-signed by a nurse; -A summary will be written monthly and should include treatment provided, specific repetitions/distance achieved, use of assistive devices, endurance/tolerance level, the extremities that were exercised, amount of assistance needed and why, progress and comparison with previous month, any unusual incidents, resident's response to the treatment plan; -The monthly summary will be documented on the Restorative Nursing Daily Record by the RNA and co-signed by a nurse designated by the DON, summarizing the progress or lack of progress, of the resident. All information will be made available for the weekly rehab/Medicare meeting as needed; -A restorative book will be maintained, which includes treatment plan for each resident, daily and monthly documentation for each resident, and list of programs and a list of residents currently on each program; -This documentation information will be transferred to the medical record when the form is complete. 1. Record review of Resident #39's face sheet showed the following information: -admitted [DATE]; -Diagnoses included: Cerebral infarction (stroke), hemiplegia and hemiparesis (loss of strength) following cerebral infarction affecting left non-dominant side, repeated falls, chronic obstructive pulmonary disease (COPD - condition involving constriction of the airways and difficulty or discomfort in breathing), dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) with behavioral disturbance. Record review of the resident's physician order sheet, current as of 3/20/23, showed the following: -An order dated 12/9/22 for OT and PT to evaluate and treat for diagnosis of history of falling; -An order dated 3/2/23 for OT, PT, ST to evaluate and treat to help with weakness, awareness, and safety; Record review of the facility provided Restorative Therapy log book showed the following information: -An order, dated 1/24/23, to discontinue PT services and continue with RNA program, 2 to 5 times per week for 90 days, for recumbent trainer (exercise bike) times 15 minutes for strengthening; -Resident listed on restorative program from 1/24/23 through 4/24/23; -Flow sheet for January, February, and March had no staff initials or information documented. Record review of the resident's care plan, last reviewed 3/20/23, showed the following information: -The resident was at risk for decline in activities of daily living (ADL) and required more assistance; -The resident will participate in ADL's as he/she is willing and able and will review next care plan; -PT/OT/ST to evaluate and treat; -Staff should provide assistance for ADL's as needed and as resident allows. -Staff should praise the resident for efforts. During observation and interview the following was noted: -On 3/13/23, at 2:43 P.M., the resident rested in bed. He/she said he/she had been out to smoke a little while ago and was now tired; -On 3/15/23, at 11:00 A.M., the resident was in his/her room. He/she said that he/she had not exercised with any staff for a couple of months; - On 3/17/23, at 12:10 P.M., the resident was in dining room and had not worked with the restorative aide for exercise.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician orders to discontinue the use and care of an indwelling catheter (a sterile tube inserted into the bladder to drain urine) for one resident (Resident #36), failed to remove the catheter from the care plan and Minimum Data Set (MDS, a federally mandated assessment instrument completed by staff), and failed to document accurately when they charted the changing of catheter as completed when the resident no longer had a catheter. A sample of 23 residents was selected for review in a facility with a census of 83. Record review of the facility undated policy, titled Physicians Orders showed the following: -The following information is provided to assist staff in recording physicians' orders: -Foley catheter orders should include: -Why it is needed; -Specify the size (example, #18 French Foley catheter to straight drain) and the frequency to change; -Catheter care specifics what is to be used or according to facility procedure. Record review of the facility undated policy, titled Charting and Documentation, showed the following: -Documentation of catheter care should include: -Type or procedure performed and who performed it; -Date and time the procedure was performed; -Type and size of catheter used; -Reason for catheter; -Resident's response to treatment; -Change in resident's condition; -Urine output; -Any special care as well as new problems that may have developed; -If the goal of the treatment was not attained, indicate the possible reasons; -Other pertinent data as necessary; -Date and time the procedure was discontinued; -Signature and title of the person recording the data. 1. Record review of Resident #36's face sheet showed the following information: -admitted on [DATE]; -Diagnosis included: acute kidney failure (kidneys suddenly become unable to filter waste products from your blood), fracture of first cervical vertebra (first disk in the neck), obstructive and reflux uropathy (urine cannot flow (either partially or completely) through the bladder, or urethra (duct by which urine is conveyed out of the body from the bladder) due to some type of obstruction), type 2 diabetes mellitus(condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), dysuria (painful or difficult urination), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), benign prostatic hyperplasia (enlarged prostate (located just below the bladder and in front of the rectum)) with lower urinary tract symptoms (symptoms involving urination), bladder disorder, dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) without behavioral disturbance. Record review of the resident's physician orders, current as of 3/20/23, showed the following information: -Order dated 8/22/22, arrange appointment with urologist for follow up regarding the indwelling catheter (thin, flexible catheter used especially to drain urine from the bladder); -An order dated 8/22/22, with no end date, catheter size 16 French (scale was used to describe the external diameter of a catheter) with 10 milliliter (ml) bulb; -An order dated 8/22/22, with no end date, change catheter monthly on the 22nd of the month; -An order dated 8/22/22, with an end date of 12/5/22, catheter care every shift. Record review of the Resident's care plan, dated 9/1/22, showed the following: -Resident required an indwelling catheter related to diagnosis of acute kidney failure, bladder disorder, and urinary retention; -Staff should assess for continued need of catheter; -Staff should change the catheter bag per orders; -Staff should not allow tubing or any part of the drainage system to touch the floor; -Staff should position the bag below the level of the bladder; -Staff should perform catheter care per orders; -Staff should store the collection bag inside a protective dignity pouch. Record review of the resident's medical record showed staff documented in the nurse progress notes the following information: -On 12/01/22, at 2:05 A.M., the nurse aide reported that he/she heard the resident yelling. The CNA entered the resident room and observed that resident had blood covering his/her genital area. This nurse entered resident room seconds after the CNA and observed that resident had pulled his/her catheter out, with the bulb still inflated. The resident stated, I took it out on purpose. The resident then stated in a clear voice I don't want it back in. The nurse aides cleaned up the bleeding from the genital area and staff monitored for continued bleeding; -On 12/01/22, at 1:01 P.M., the resident continues on 30 minute checks. The resident was up for his/her meals in the dining hall today. Notified the physician on call that the resident pulled his/her catheter out. Notified the DON of the situation and will try to insert catheter but the resident was combative and hurting the staff; -On 12/04/22, at 12:57 P.M., the resident continues on 30 minutes checks. The resident was asked if he/she was in pain and replied yes, pain pill was given. No catheter in placed. Will continue to monitor. Record review of the resident's treatment administration record showed the following: -On 12/22/22, staff documented the catheter was changed; -On 1/22/23, staff documented the catheter was changed; -On 2/22/23, staff documented the catheter was changed. Record review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 1/6/23, showed the following: -Severe cognitive impairment; -Resident required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Resident required extensive assistance of one staff for eating and locomotion; -Required a wheelchair; -Resident had an indwelling catheter; -Resident was not incontinent of urine due to having a catheter; -Resident was frequently incontinent of bowel. During observation and interview the following was noted: -On 3/13/23, at 9:20 A.M., the resident was in a Broda chair (wheelchairs provide supportive positioning through a combination of tilt, recline, adjustable leg rest angle, wings with shoulder bolsters and height adjustable arm) at the nursing desk. No catheter or dignity bag visible; -On 03/14/23, at 12:00 P.M., the resident was in a Broda chair in the dining room. The resident's spouse was assisting with the resident's meal and said the resident did not have a catheter at this time; -On 3/15/23, at 12:19 P.M., the resident was in dining room in a Broda chair with no catheter noted; -On 3/17/23, at 1:35 P.M., the resident was in a Broda chair at the nursing desk. No was catheter noted. During an interview on 3/20/23, at 11:40 A.M., Licensed Practical Nurse (LPN) S said that if there are orders on the resident's chart that are no longer being used, he/she would contact the doctor for a discontinue order. He/she said that a catheter should be discontinued in the orders if a resident no longer had a catheter. The LPN said staff should notify the MDS staff to remove discontinued orders from the care plan. During an interview on 3/20/23, at 1:40 P.M., the MDS Coordinator said that care plans should be updated any time there is a change in condition. If a resident no longer has a catheter, it should be removed from care plan. If an MDS is coded with something that was not present at the time of coding, the MDS staff can do a correction to the MDS. Care plans should have care items removed as soon as staff become aware of it through conversations. The staff nurses can make changes but they generally just let the MDS staff know what changes to be made. During an interview on 3/20/23, at 3:05 P.M., LPN E said that staff should call the doctor to get a discontinue order if the resident no longer needs that care. He/she said if a resident pulled out a catheter, the doctor should be notified to see if he/she wants to discontinue the order or have staff re-insert the catheter. The resident pulled his/her catheter out, and staff should have notified the physician and the order should have been discontinued. The LPN said that staff should accurately document cares, if not documented it was not done, and staff should not document an item as completed when it was not done. During an interview on 3/20/23, at 4:00 P.M., RN T said that if staff receive any changes to orders they should put that information on the 24 hour sheet that is reviewed at the morning meetings. If there is an order that is not being used, there is a standing order to discontinue any order that is not used for 60 days. If there is an order for a catheter and the doctor discontinued that order, then staff should enter the discontinued order into the medical chart. During an interview on 3/20/23, at 4:30 P.M., the Director of Nursing (DON) said that the catheter order should have been discontinued in the resident's chart. Staff are to notify the MDS staff to have discontinued care items removed from the care plan. Staff are to document accurately all cares completed.

Based on observation and interview, facility staff failed to post required nurse staffing total hours and failed to include the resident census in a prominent place readily accessible to residents and visitors on a daily basis at the beginning of each shift. The facility census was 83. Record review showed the facility did not provide a policy regarding posting staffing hours. 1. Observation on 3/12/23 at 5:00 P.M., showed the nurse staffing hours posted on the left side of the DON's office window, just inside the nurses station. The posting did not include the facility census and did not include the total staff hours worked. The postings included 3/12/23, 3/13/23, and 3/14/23 with names of staff scheduled. 2. Observation on 3/13/23 at 9:54 A.M., showed the nurse staffing hours posted on the left side of the DON's office window, just inside the nurses station. The posting did not include the facility census and did not include the total staff hours worked. The postings included 3/12/23, 3/13/23, and 3/14/23 with names of staff scheduled. 3. Observation on 3/14/23 at 2:00 P.M., showed the nurse staff hours posted on the left side of the DON's office window, just inside the nurses station. The posting did not include the facility census and did not include the total staff hours worked. 4. Observation on 3/15/23 at 12:14 P.M., showed the nurse staffing hours posted on the left side of the DON's office window, just inside the nurses station. The posting did not include the facility census and did not include the total staff hours worked. The postings included 3/15/23, 3/16/23, 3/17/23 with names of staff scheduled. 5. Observation on 3/17/23 at 10:37 A.M., showed the nurse staffing hours posted on the left side of the DON's office window, just inside the nurses station. The posting did not include the facility census and did not include the total staff hours worked. 6. Observation on 3/20/23 at 1:00 P.M., showed the nurse staffing hours posted on the left side of the DON's office window, just inside the nurses station. The posting did not include the facility census and did not include the total staff hours worked. 7. During an interview on 3/20/23 at 1:55 P.M., the ADON said staff have not had time to put the census and staff hours on the daily staffing sheet for a while. She said they had completed this in the past and will do it today. 8. Observation on 3/20/23 at 3:14 P.M., showed the ADON standing at the nurses station adding the total staffing hours and resident census to the daily staffing sheets for 3/1/23 through 3/10/23. 9. During an interview on 3/20/23 at 4:30 P.M., with the DON, ADON, Administrator, and corporate nurse, the ADON said that staff should complete the census and add the total shift hours every day to the posted staffing sheet. The DON said residents are able to see the schedule where it is located and like to see who is scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors when staff checked one resident's (Resident #23) blood glucose level and administered a sliding scale dose of insulin 40 minutes after the resident ate his/her meal. Staff also failed to prime the insulin pen and hold the insulin dose for six to 10 seconds at the site of administration as recommended by the manufacturer to ensure the resident received the full and correct dose of insulin. The facility census was 83. Record review of the (undated) facility policy, titled Diabetic Infection Control, showed the following: -Insulin injection pens are for single resident use; -The policy did not address timing of blood glucose checks or priming insulin pens before injection or holding insulin pens after injection. Record review of the website Medscape (medical reference website for healthcare professionals) showed the following information: -Typical times to check blood glucose levels include before eating or drinking. Record review of the Novolog (rapid-acting insulin) manufacturer's insert showed the following: -Remove the outer and inner needle cap; -Dial the knob on the pen to a dose of 2 units prior to administering to prime the pen; -You should see a drop or stream of liquid at the end of the needle, this means your pen is ready to use; -Repeat steps to prime one or two more times if needed, until you see a drop of insulin. -Now that pen is ready, dial the dose ordered by the physician; -The needle should go all the way into the skin; -Slowly push the knob of the pen all the way in to deliver the full dose; -Hold the pen at the site for ten seconds, to allow time for the insulin to get into the body, and then pull the needle out. -A meal should be eaten within five to ten minutes of taking a dose; -Dosage adjustments may be needed in regard with changes in food intake or time. 1. Record review of Resident #23's face sheet (a brief resident profile) showed the following information: -admitted on [DATE]; -Diagnoses included Type 2 diabetes mellitus (high blood glucose) and hyperglycemia (high blood glucose). Record review of the resident's care plan, last updated 01/04/23, showed the following: -At risk for decrease in nutritional needs related to his/her diabetes; -Staff to perform accu-checks (blood glucose test) as ordered by the physician; -Administer medications as ordered by physician. Record review of the resident's physician order sheet (POS), current as of 03/20/23, showed the following orders: -An order, dated 09/29/22, check blood glucose (sugar) before meals and at bedtime; -An order, dated 03/10/23, for Novolog U-100 Insulin aspart solution 100 unit/ml (unit of fluid volume); amount: 12 units with meals; subcutaneous (inject under the skin); hold if blood glucose is less than 150. Administer with meals: 07:00 A.M., 12:00 P.M., 5:00 P.M. -An order, dated 10/18/22, for Novolog U-100 Insulin aspart solution 100 unit/ml (unit of fluid volume); amount: Per Sliding Scale; -If blood sugar (BS) is less than 70, call doctor; -If BS is 140 to 180, give 3 units of insulin; -If BS is 181 to 240, give 4 units of insulin; -If BS is 241 to 300, give 6 units of insulin; -If BS is 301 to 350, give 8 units of insulin; -If BS is 351 to 400, give 10 units of insulin; -If BS is 401 to 450, give 14 units of insulin; -If BS is 451 to 500, give 16 units of insulin; -If BS is greater than 501, call the physician; -Give subcutaneous (inject under the skin); -Administer with meals: 06:00 A.M. - 08:00 A.M., 11:00 A.M. - 12:00 P.M., 4:30 P.M. - 6:00 P.M. Observation on 03/14/23 at 11:55 A.M., showed the resident leaving his/her room. The resident stopped at the medication cart that was in the hall and asked Licensed Practical Nurse (LPN) J to check her BS. LPN J said to the resident that he/she would catch him/her later. Observation on 03/14/23 at 12:00 P.M., showed the resident in the dining room eating lunch. The resident said staff had not checked his/her BS. LPN J was also in the dining room, passing out lunch trays. Observation and interview on 03/14/23 at 12:40 P.M., showed LPN J went to the resident's room and checked the resident's blood sugar (BS). BS level measured 423. LPN J said he/she did not have Resident #23's insulin pen in his/her medication cart and left to gather supplies. The LPN returned with a new insulin pen. The LPN donned gloves, cleansed the upper right arm of the resident with an alcohol wipe, applied a new needle to the pen, dialed the pen to 26 units then administered the insulin to the resident's right upper arm. The LPN pushed the knob and administered the dose, but did not hold the pen in the resident's arm for any length of time after pushing the knob. The LPN did not prime the new pen. During an interview on 03/20/23 at 1:00 P.M., LPN J said he/she had never used an insulin pen before, therefore was not familiar with how to use it. He/she did not know it needed to be primed before administering the insulin. He/she did not know the insulin pen needed to be held against the skin for 10 seconds after administration. He/she normally checks blood sugars before lunch, but sometimes he/she does not. During an interview on 03/20/23 at 12:40 P.M., the Assistant Director of Nursing (ADON) said she would expect staff to check the insulin order to make sure that the appropriate amount of insulin is being given. She expects staff to check the date on the insulin pen and prime the pen every time before using it. Staff should wash hands and don gloves prior to administering insulin. Staff should hold the insulin pen against the skin for 11 seconds. She expects the BS to be checked before eating the meal, not after the meal. If the nurse is not able to check the BS before the meal, then the nurse should call the physician to get additional orders and direction before administering the insulin. During an interview on 03/20/23 at 3:40 P.M., the Director of Nursing (DON) said she expects not to have any insulin pens in the building. If an insulin pen is being used; then, it needs to be primed before using it and held against the skin for 10 seconds. The nurse needs to wash his/her hands and wear gloves before administering and then wash hands again after. The BS should be checked before the meal, not after the meal. If the nurse checks the BS after the meal, then the nurse should call the physician to clarify the insulin orders. During an interview on 03/20/23 at 5:10 P.M., the interim administrator said insulin pens should be administered according to the manufacturer and physician's orders. Hand hygiene should be completed before and after each resident and that gloves should also be worn during administration. BS should be checked when ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a clean and homelike environment when staff failed to replace/fix ceiling tiles damaged by a water leak for one resident (Resident #10), failed to repair damage on two residents' (Residents #8 and #72) bedroom walls, and failed to change ceiling tiles that were stained from water leaks in the resident hallways and dining rooms. The facility census was 83. The facility did not have a specific policy pertaining to the repair of walls or ceiling tiles. 1. Record review of Resident #10's face sheet (a brief resident profile) showed the following information: -admission date of 03/04/22; -Diagnoses included type 2 diabetes mellitus with diabetic nephropathy (damage to kidneys caused by diabetes), complication of amputation stump, bipolar disorder (mental health condition causing extreme mood swings), depression. Record review of the resident's annual Minimum Data Set (MDS), a federally mandated comprehensive assessment instrument, completed by facility staff, dated 03/12/23, showed the resident as cognitively intact. Observation on 03/13/23, at 10:07 A.M., showed a 1.5 foot (ft) x 2 ft area on the ceiling in Resident #10's room. The area was various shades of brown ring stains with a 4 inch by 4 inch area near the center of the stain, that bulged downward. During an interview on 03/13/23, at 10:07 A.M., Resident # 10 said he/she told the maintenance assistant last month about the discolored ceiling tile in his/her room. He/she told the resident he/she would change the ceiling tile out. He/she also told the resident that they have a bucket in the ceiling above the resident's room collecting water due to the roof leaking. The resident was concerned because he/she has paintings and other belongings that could get ruined due to the leaking roof and damaged tile. Every time the resident has mentioned it to maintenance, the maintenance staff says he will get it done. 4. Record review of Resident #8's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included chronic obstructive pulmonary disease (COPD - chronic condition involving constriction of the airways and difficulty or discomfort in breathing), urinary tract infection (UTI - infection in part of the urinary system, including kidneys or bladder), and obsessive-compulsive disorder (disorder in which a person feels compelled to perform certain stereotyped actions repeatedly to alleviate persistent fears or intrusive thoughts). Observation on 3/14/23, at 11:05 A.M., of the resident's room showed the following: -The walls at the head of the resident's bed had a large area of approximately 10 by 10 inches of paint scraped off the wall and the surface was gouged. During an interview on 3/17/23, at 10:30 A.M., the resident said that his/her bed drifted into the wall at some point in the past. He/she was unsure if the staff were aware of the large area of damage on the wall. 5. Observation on 3/15/23, at 12:10 P.M., in the facility showed the following: -In the 500 hall, there were six ceiling tiles with brown ring stains varying in size from approximately 4 inches in diameter to approximately 12 inches in diameter; -In the 500 hall dining area, there were two air vents that had brown to black discoloration and paint chipped away from the vents, there was black fuzz appearance at the vent; -In the 500 hall dining area, there were ten ceiling tiles with brown to gray discoloration and varying sized of stained appearance from approximately 4 inches in diameter to covering over 50 percent of the ceiling tile; -In the 300 hall, there were two ceiling tiles near the skylight on ceiling with large brown wet stain appearance and discoloration, one tile of approximately 6 to 8 inches wide and the full length of the tile of approximately 20 inches with dark brown wet appearance and bowed downward out of the ceiling; -The 300 hall had eight ceiling tiles that were brown stained in appearance with varying sizes from approximately 4 inches to 10 inches in diameter; -The carpet in the 500 hall dining room, showed multiple red stains, such as Kool-Aid appearance stains, white stains and brown stains throughout the dining room carpet. The stains ranged from softball size to plate size. Observation on 3/17/23, at 3:39 P.M., in the main dining room showed the following: -Approximately 13 ceiling tiles with varying sized of brown and gray wet appearing stains throughout the dining room; -At the main entry to dining room, the first skylight had 2 tiles that were brown stained with approximate size of 10 inches in diameter; -Above the coffee and drink bar station there were two panels that covered the entire ceiling panel in dark brown stain appearance. 6. During an interview on 3/20/23, at 10:50 A.M., Housekeeping K, said that if he/she finds an environment concern when working, he/she will notify the housekeeping supervisor. If there is a dirty or stained carpet, he/she will notify the staff that cleans the carpet daily. And if finds damage to ceiling tiles, walls, or broken items, he/she will notify the maintenance staff. He/she had seen maintenance changing ceiling tiles in the past. 7. During an interview on 3/20/23, at 11:01 A.M., Certified Nurses Aide (CNA) L said that if he/she sees any stains, damage, or repairs needed, he/she will let the housekeeping supervisor or the maintenance department know. The housekeeping supervisor will notify maintenance. 8. During an interview on 3/20/23, at 1:30 P.M., the Maintenance Director said that there are currently new ceiling tiles on order. There are water leaks after every rain and they could change the tiles multiple times throughout the year. The ceiling tiles should be changed when soiled. The carpet stains are cleaned the best they can every day. The carpets look new compared to two years ago. 9. During an interview on 03/20/23, at 3:40 P.M., the Director of Nursing (DON) said she did not know of any water damage. Residents can report damage to herself, a nurse or maintenance. 10. During an interview on 3/20/23, at 4:30 P.M., the administrator said that every time it rains they would have to change ceiling tiles. The Corporate maintenance is aware and when they finish another job they will come fix the roof. She said they cannot get the red and white stains out of the carpet, it is from the thickened liquids, and they will be asking corporate if they can change the carpet to tile or flooring in order to manage spills better. 2. Record review of Resident #72's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). Observation on 3/17/2023, at 9:30 A.M., of the resident's room showed the following: -The mattress rested on the floor; on top were two pillows and a sheet left in disarray; -The walls to the head and side of the mattress were very marred; the paint was scraped off and the surface gouged. 3. Observation on 3/17/2023, at 3:55 P.M., in the main corridor leading toward the 200 resident hall, showed the following: -The ceiling above the left side smoke barrier door contained a large dinner plate sized black area, fuzzy in appearance. The black area faded outward to a rust color; approximately the size of a serving platter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #8's face sheet showed the following information: -admission date of 2/27/2022; -re-admission date of 10/7/2022; -Diagnoses included: Chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), urinary tract infection (an infection in any part of the urinary system, includes the kidneys and bladder), congestive heart failure (CHF - chronic condition in which the heart doesn't pump blood as well as it should), obsessive-compulsive disorder (personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others). Record review of the resident's discharge Minimum Data Sheet (MDS - a federally mandated assessment tool completed by facility staff), dated 10/4/2022 showed the resident discharged to the hospital with a return anticipated. Record review of the resident's entry MDS, dated [DATE], showed the resident was re-admitted to the facility. Record review of the resident's medical record showed staff did not provide any documentation regarding the facility's bed hold policy to the resident or resident's representative at transfer to the hospital. Record review of the resident's progress notes, dated 12/16/2022, showed staff documented the following: -1:18 P.M., staff documented a phone call with physician regarding lab results of white blood cell (WBC - number of white cells in the blood, part of the immune system to fight of infections) count results at 22.9 (normal 4 to 11), physician ordered to send the resident to the emergency room for evaluation. Staff contacted the ambulance for transport. -At 1:21 P.M., staff notified the resident's family member by phone of the transfer to the hospital; -At 1:55 P.M., resident left the facility by ambulance; -At 11:24 P.M., staff documented the resident returned to the facility per ambulance at 6:15 P.M. He/she arrived by ambulance stretcher, was alert and talkative. The diagnosis was urinary tract infection (UTI). He/she received intravenous (IV) antibiotics in the emergency room and has a new order for Levaquin (antibiotic to treat infections caused by bacteria) 500 mg tablet, to take 1 tablet by mouth daily for the next 10 days. During an interview on 3/17/2023, at 9:24 A.M., Resident #8 said that he/she had not been provided any information about a bed hold policy when he/she was sent to the emergency room a few months ago but he/she returned to the same room. 3. Record review of Resident #17's face sheet showed the following information: -admitted to the facility on [DATE]; -re-admission date of 12/22/2022; -Diagnoses included: Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), chronic ischemic heart disease (heart problems caused by narrowed heart arteries that supply blood to the heart muscle), cognitive communication deficit, urinary tract infection. Record review of the resident's medical record showed staff documented the following information: -On 12/21/2022, at 7:09 P.M., nursing aide staff alerted the nurse staff that the resident had an episode during evening cares at 6:35 P.M., where he/she became flaccid (party of the body hanging loosely or limply) and incontinent of bladder (loss of bladder control). This was not normal for the resident. Upon entry into the room at 6:40 P.M., the vital signs showed blood pressure 148/78, pulse 68, oxygen saturation 98% on room air, and temperature of 96.8 degrees. The resident appeared diaphoretic (sweating heavily), however, was responding within normal limits to questions asked. Notified the on call provider and received orders to call the family to see if okay to send to the hospital for evaluation and treatment. Called resident's family and received approval to send the resident to the hospital. Notified the DON and the on call provider of approval to send for evaluation. The resident left via ambulance at 6:58 P.M., with face sheet and code status; -On 12/22/2022, at 5:27 A.M., the resident returned from the emergency room by ambulance. The resident arrived on the stretcher to his/her room at 4:00 A.M. Per documentation from emergency room the resident had a diagnosis of UTI. The resident was given intravenous (IV) fluids and antibiotics at the hospital. The resident had new orders for Keflex (antibiotic used to treat a variety of bacterial infections) 500 mg, 1 capsule every 8 hours for 7 days. The resident was assisted into his/her bed by the ambulance staff and facility staff. The resident's family member was made aware of the resident's return and diagnosis. Vital signs obtained upon arrival were blood pressure 133/69, pulse 68, temperature 98.1, and oxygen saturation of 94%; -On 03/07/2023, at 6:22 P.M., the nurse received a call from the laboratory at 5:55 P.M., in regards to a critical hemoglobin (Hgb - protein in red blood cells that carries oxygen) of 6.5 (normal range 12 to 17). The provider was called and gave the order to send the resident to the emergency room for a blood transfusion. Called the resident's family at 6:06 P.M. to update on the current situation. Notified the DON and the ambulance was called and the resident was transported to the emergency room at 6:15 P.M.; -On 03/08/2023, at 3:23 A.M., the resident returned to the facility at 3:05 A.M. from the emergency room. The resident arrived on a stretcher with two medical attendants. The resident was assisted into bed by the two attendants and facility staff. Vital signs included blood pressure 99/59, pulse 91, temperature 98.2 degrees and oxygen saturation 96% on room air.; -On 3/08/2023, at 6:44 A.M., staff called the provider to let him/her know the resident returned back to the facility, and notified the family of the resident's return. Record review of the resident's electronic and paper medical records showed staff did not document notification to the resident or resident's responsible party in writing of the bed hold policy related to the resident's transfer to the hospital on [DATE] or 3/8/2023. Record review on 3/17/23 of the facility provided ombudsman Transfer Log Notice for the month of December 2022 and for the month of March 2023 showed Resident #17's name not listed on the transfer notice log to the ombudsman. SSD H wrote that resident did not stay overnight so a transfer notice was not sent to the responsible party. 4. Record review of Resident #69's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included: Atrial fibrillation (an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart), urinary tract infection, type 2 diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), chronic pain syndrome, chronic obstructive pulmonary disease, and chronic kidney disease (CKD - kidneys are damaged and cannot filter blood the way they should). Record review of the resident's progress notes showed staff documented the following information: -On 03/12/2023, at 1:06 P.M., the resident complained of not feeling well, the resident had wheezing in his/her lungs bilaterally, productive cough, oxygen saturation at 75%, and refusing to wear oxygen. The nurse had put oxygen on the resident multiple times and when the aide told the resident he/she needed to wear it the resident said he/she didn't have to and told the aide to shut up. The resident's eye balls were rolling in the back of his/her head and sweating. The on call provider was contacted and gave an order to send the resident to the emergency room for evaluation. The ambulance staff arrived and left the facility around 1:00 P.M.; -On 3/12/2023, at 5:30 P.M., the resident arrived back to the facility via ambulance services at 5:30 P.M., via stretcher. Report was called from the hospital and the only thing they could find wrong with the resident was that when he/she takes off the oxygen his/her oxygen saturation drops down shortly thereafter. The resident was alert and oriented upon arrival, no new orders were given by the hospital, will continue to observe. Record review of the resident's electronic and paper medical records showed staff did not document notification to the resident or resident's responsible party in writing of the bed hold policy related to the resident's transfer to the hospital on 3/12/2023. Record review, on 3/17/2023, of the facility provided Transfer Notice Log for the month of March 2023 showed Resident #69's name was not on March 2023 transfer notice log for 3/12/2023. Social Services Director (SSD) H wrote that the resident did not stay overnight so a transfer notice was not sent to the responsible party. 5. Record review of Resident #83's face sheet showed the following information: -admitted on [DATE]; -re-admitted on [DATE]; -Diagnoses included: cerebral vascular accident (stroke), chronic kidney disease, type 2 diabetes, and dementia. Record review of the resident's medical record showed staff documented the following information: -On 11/29/2022, at 12:28 P.M., the resident was transferred to the hospital by ambulance; -On 12/02/2022, at 12:51 P.M., the resident returned to the facility. Record review of the resident's discharge MDS, dated [DATE], showed the resident discharged with return anticipated. Record review of the resident's entry MDS, dated [DATE], showed the resident's re-entry to the facility. 6. During an interview on 3/17/2023, at 9:50 A.M., Licensed Practical Nurse (LPN) G said when a resident is sent to the hospital, the nursing staff sends a face sheet with diagnosis, medication list, and any pertinent documentation such as lab results. The nursing staff notifies the resident's family by phone. The nursing staff does not send any written notice of hospital transfer or bed hold policy to the family but the facility does hold the bed for the resident. 7. During an interview on 3/17/2023, at 11:50 A.M., LPN J said when a resident is transferred to the emergency room the staff send a face sheet and medication sheet. The nurse calls the family with resident transfer status, he/she said he/she did not know about the bed hold policy information. 8. During an interview on 3/17/2023, at 11:52 A.M., the Director of Nursing (DON) said she would be completing in-services that day regarding the need to send bed hold guidelines to the resident's responsible party. She said the facility had not been sending bed hold notices. 9. During an interview on 3/17/2023, at 11:55 P.M., with SSD H and SSD I, the staff said they send a written hospital transfer notice the day after a resident is sent to the hospital. They enter the transfer to the Transfer Notice Log and the date the notice was mailed to the family. They then mail this log to the ombudsman on the first day of the following month. He/she puts a date at the top of the log when it was mailed to the ombudsman. SSD H said he/she had never seen the bed hold guidelines form that DON provided. SSD H said that he/she had not mailed a bed hold form to any family members. They do not keep a copy or proof of the mailed letters to family. SSD I said when a resident was sent to the emergency room and was not out of the facility overnight, the staff do not send a written transfer notice to the family and had not sent the bed hold information for any transfers. 10. During an interview on 3/20/2023, at 4:30 P.M., with the DON, ADON, Administrator, and Quality Assurance nurse, the DON said that when a resident was transferred to the hospital an emergency transfer notice is mailed to the family by the business office after admission to the hospital. The nursing staff verbally discussed bed hold information, and it was provided on resident admission to the facility. The bed hold notice had not been attached to the transfer notice when mailed. Based on interview and record review, the facility failed to give written information to the resident and/or resident's representative regarding the facility's bed hold policy for five residents (Residents #8, #12, #17, #69, and #83) who were transferred out to the hospital. The facility census was 83. Record review of the facility's Bed Hold Guidelines (undated), showed the following: -This facility will notify all residents and/or their representative of the bed hold guidelines. This notification shall be given on admission to the facility, at the time of transfer to the hospital and at the time of non-covered therapeutic leave; -If the resident or resident representative wants to hold the bed, a signed authorization must be obtained with each discharge. Signed authorization must be received within 24 hours of the discharge if it occurs during the week. Signed authorization must be received by the first business day following the discharge if it occurs on a weekend or holiday; -If the resident or resident representative does not choose to hold the bed, the bed will be released and any personal belongings must be picked up within three days; -Bed holds are strictly voluntary. If the bed is not held and is not available when the resident wants to be re-admitted , the resident's name will be placed on a waiting list for the next available bed; -At the bottom of the guidelines page, the resident or responsible party are to indicate choice and sign/date to hold (at the defined daily rate) or not hold the bed. 1. Record review of Resident #12's face sheet (gives basic profile information) showed an admission date of 6/23/2014. Record review of resident's nurses' notes showed the following information: -On 1/18/2023, at 1:09 P.M., the resident was in the shower room receiving a shower. After the shower was completed, the aide was transferring the resident to a wheelchair. The resident started slipping; the aide lowered the resident to the floor. Resident complained of mild pain to the right leg; no swelling or abnormal alignment noted. Resident did not hit his/her head. Resident was assisted back up into the wheelchair and propelled him/herself without any issues. Staff notified the physician and attempted to contact the responsible party with no answer at that time. Report was given to oncoming shift staff; -at 5:30 P.M., the resident was noted to have bleeding from skin tears to both feet; three toes on the left foot were black and blue. Resident said he/she hadn't hit his/her feet on anything, but had a fall earlier in the day and his/her feet went under him/her; the aide caught him/her. Resident expressed a pain level of 10/10 to the right leg and was unable to lift it at that time; the resident described pain from the knee up past the hip. The Nurse Practitioner, Director of Nursing, and nurse on call were notified; the resident was transferred to the hospital. Record review of the resident's electronic and paper medical records showed staff did not document notification to the resident or resident's responsible party in writing of the facility's Bed Hold Policy when the resident was transferred to the hospital on 1/18/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure facility staff provided two residents (Residents #8 and #79), who were unable to complete their own activities of daily living (ADL), the necessary care and services to maintain good personal hygiene, including showers and nail care, out of a sample size of 23. The facility census was 83. Record review showed the facility did not have a policy available for showers. Record review of the facility provided undated policy, title Nails, Care of (Fingers and Toes), showed the following information: -Purpose to provide cleanliness, comfort, and prevent spread of infection; -The nursing assistant may perform nail care on the residents who are not at risk for complications of infection; -The licensed nurse or podiatrist must perform nail care on residents suffering from diabetes or vascular disease; -Staff should prepare equipment; -Staff should soak the resident hands for five minutes in a basin of warm water; -Scrub nails gently with brush if necessary; -Put hands on a towel. Trim and clean nails and file smooth; -Discard water, clean equipment and wash your hands; -Obtain clean water and soak resident's feet; -Scrub nails gently with brush and remove from basin; -Put feet on clean towel. Trim and clean nails and file smooth; -Apply lotion to hands and feet. 1. Record review of Resident #8's face sheet showed the following: -admitted on [DATE]; -Diagnosis included: Chronic obstructive pulmonary disease (COPD - condition involving constriction of the airways and difficulty or discomfort in breathing), obsessive-compulsive disorder (personality disorder characterized by excessive orderliness, perfectionism, attention to details, and a need for control), chronic pain, congestive heart failure (CHF - chronic condition in which the heart does not pump blood as well as it should). Record review of the resident's physician order sheet, current as of 3/20/23, showed the following: -An order dated 3/8/22, Wound Care Plus to evaluate and treat for toenail care. Record review of the resident's medical record showed the following: -On 10/12/22, Wound Care Plus documented that foot care was completed. Staff used a dremmel (hand-held rotary tool) over the left first and second toe and toenail clipping completed of all toes on both feet. -Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 2/18/23, showed the following: -Cognitively intact; -Required extensive assistance of two staff for bed mobility, transfer, toilet use; -Required extensive assistance of one staff for locomotion; -Required extensive assistance of one staff for dressing and personal hygiene; -Used a wheelchair for mobility. Record review of the resident's care plan, last reviewed 2/21/23, showed the following: -Resident required assistance with activities of daily living (ADL) related to weakness; -Staff should assist the resident as needed with ADL's; -Staff should not rush the resident; -Staff should document and report any decline in status to the physician. Record review of the resident's medical record showed the staff documented the following: -On 3/7/23, staff documented on the shower sheet that a bed bath was given and the resident refused to have his/her hair washed. Staff did not document any information about nail care; -On 2/28/23, staff documented on the shower sheet that a full bed bath was done. Staff did not document any information about nail care; -On 1/24/23, staff documented on the shower sheet that the resident requested a bed bath. Staff documented that fingernails/toenails were clipped; -On 1/9/23, staff documented on the shower sheet that the resident requested a bed bath. Staff documented that fingernails/toenails did not need to be cut. During observation and interview the following was noted: -On 3/14/23, at 10:52 A.M., the resident said that the aide that assisted him/her on Wednesday was very busy and doing two persons' job. He/she said that the aide massaged his/her left leg and foot and put cream on the dry skin. He/she said that the left toenails are thicker and require a special tool. He/she said someone had been coming in to cut toenails but not any longer. He/she said that his/her toenails and fingernails had not been trimmed for months. He/she said he/she would like to receive a bed bath three times per week. The resident said I smell and the deodorant the facility provides is not any good. The resident's fingernails appear jagged on the right hand and were approximately between one eighth and one quarter inch in length. The resident's left toenails appeared thick and yellow discolored and were approximately between one eighth and one quarter inch in length; -On 3/17/23, at 9:25 A.M., the resident said that his/her toenails had not been trimmed for about three months, he/she had been asking for staff to have someone work on his/her toes. His/her fingernails need trimmed as well but you have to find an aide that has time to trim fingernails. The resident's nails appeared approximately one quarter inch long and the right hand fingernails had jagged appearing edges. The resident's left toenails are thick and have yellow discoloration. The right foot great toenail was approximately one quarter inch long and remaining toenails were longer than the edge of the toe and curled downwards. The resident said he/she had not had a bath or shower for about two weeks and felt gross. He/she was able to get some deodorant to help with the smell; -On 3/20/23, at 10:30 A.M., the resident said he/she was scheduled for a bed bath the following day but the aide would not have time to cut his/her nails because he/she would have about ten baths to complete during the shift. 2. Record review of Resident #79's face sheet showed the following information: -admitted on [DATE]; -Diagnoses included: CHF, COPD, type 2 diabetes mellitus (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), generalized anxiety disorder. Record review of the resident's care plan, last reviewed on 3/20/23, showed the following: -Resident is at risk for decline in ADL's related to the progression of disease process; -Staff should not rush resident; -Staff should document and report any decline in status to the physician; -Resident requires one to two staff for assistance. Record review of the resident's medical record showed the staff documented the following: -On 1/4/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care; -On 1/12/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care; -On 1/19/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care; -On 1/23/23, staff documented on the shower sheet that shower was provided. Staff documented that the resident's fingernails were cut; -On 2/2/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care; -On 2/7/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care; -On 2/23/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care; -On 3/3/23, staff documented on the shower sheet that shower was provided. Staff did not document any information about nail care. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Resident was independent with set up of one staff required for bed mobility, transfers, walking, locomotion, toilet use, personal hygiene; -Resident required one staff supervision, cueing, for dressing and eating. During observation and interview the following was noted: -3/13/23, at 12:43 P.M., the resident was seated in a recliner in his/her room and said that his/her fingernails need trimmed, it had been months since they had been trimmed. He/she said staff did not have time to trim his/her nails; -On 3/17/23, at 3:18 P.M., the resident was ambulating in the hall and showed his/her fingernails. The fingernails were approximately between one eighth and one quarter inch in length. The index finger on both fingers had jagged edges and nails appeared discolored. The resident said that staff had not had time to trim his/her nails. -On 3/20/23, at 11:05 A.M., the resident was near the nurse's desk ambulating in the hall and said his/her nails had not been trimmed. 3. During an interview on 3/20/23, at 11:01 A.M., Certified Nurse Aide (CNA) L said that there was not a scheduled shower aide and that staff on duty should check the list on the shower wall for resident's that are scheduled. He/she said that the aides should complete nail care during showers unless the resident has diabetes. The nurses should do the nail care for diabetic residents or a podiatrist occasionally comes into the facility to diabetic nail care. 4. During an interview on 3/20/23, at 11:40 A.M., Licensed Practical Nurse (LPN) S said the CNA's usually do resident nail care with showers but the nurses can also complete nail care. The nurses will complete nail care on diabetic residents. The facility also has Wound Care Plus that will come for one year on a quarterly basis for a resident with a physician order that has thick or fungus nails. Wound Care Plus has the proper equipment for those residents. 5. During an interview on 3/20/23, at 4:13 P.M., the Director of Nursing (DON) said nurses should ensure the aides provide showers to residents once per week at a minimum. The facility no longer has a designated shower aide. 6. During an interview on 3/20/23, 4:30 P.M., the administrator said that showers should be done twice per week and the facility is working on getting staff to document in the electronic medical record. The paper shower sheets are a tool for nurses to see showers are done and any skin concerns the aides document. Nail care should be done during showers by aides unless the resident is diabetic or on a blood thinner, then DON and Assistant Director of Nursing (ADON) do the nail care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #23's face sheet showed the following information: -admitted on [DATE]; -Diagnoses included Type 2 diabetes mellitus (high blood glucose), hyperglycemia (high blood glucose), chronic obstructive pulmonary disease (COPD-lung disease making it difficult to breathe), schizoaffective disorder (a condition of psychosis and mood disorder). Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with bed mobility and transfers; -Not steady but able to stabilize without human assistance when moving from seated to standing position. Record review of the resident's current care plan, last revised 03/15/23, showed the following information: -On 12/27/22, staff documented that the resident is at risk for decline in activities of daily living (ADLs) related to COPD; -On 12/27/22, staff documented the resident may use partial side rails to assist with bed mobility and to enable more independence when in bed. Record review of the POS showed an order, dated 03/19/23, indicating the resident may have grab bars to assist with bed mobility, transfers, and repositioning while in bed. Record review of the resident's EMR showed the following information: -Staff did not document informed consent for the use of the grab bars; -Staff did not document a pre-use risk evaluation/assessment for the use of the grab bars/side rails. -Staff did not document any gap measurements for the grab bars. Observation on 03/13/23, at 2:05 P.M., showed the resident had U shaped grab bars attached to both sides of his/her bed. During an interview on 03/12/23, at 2:05 P.M., the resident said he/she uses the grab bars to help reposition in bed. The grab bars have been on his/her bed since admission to the facility. During an interview on 03/20/23, at 2:40 P.M., Licensed Practical Nurse (LPN) E said the resident has had grab bars on his/her bed since admission. The resident uses them to reposition. Nursing completes the assessment during the admission process. It is documented in the observation section of the EMR for side rail assessments. Grab bars/side rails are discussed at the morning meetings. The nurse did not know for sure about the consent form or the physician order. He/she does not get the consent form. He/she does not do any gap measurements and did not know for sure who does that. He/she would assume the grab bars would be on the care plan. 4. Record review of Resident #36's face sheet showed the following information: -admitted [DATE]; -Diagnoses included: Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), weakness, repeated falls, dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) without behavioral disturbance. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Extensive assistance of two staff required for bed mobility, transfers, dressing, toilet use, personal hygiene, and locomotion; -Frequently incontinent of bowel; -Had an indwelling catheter (catheter which is inserted into the bladder, via the urethra (duct by which urine is conveyed out of the body from the bladder) and remains in to drain urine); -Wheelchair used for mobility. Record review of the resident's care plan, last reviewed on 3/15/23, showed the following: -Resident has limited mobility or functional status and required use of supportive device for transfers and mobility while in bed; -Staff should explain the risks and benefits of using side rails to the resident and have resident sign consent. If the resident cannot sign consent, must obtain consent from his/her spouse; -Staff should keep physician and family informed of any changes; -Staff should obtain an order from the physician for device and obtain screening from therapy if needed; -Side rail assessment should be completed upon admission, quarterly and annually, or upon change of condition; -Staff should teach the resident safety measures and proper technique. Record review of the POS, current as of 3/20/23, showed the following: -An order dated 7/8/22, for side rail to left upper side of bed, at all times when in bed for repositioning, mobility, and transfers. Record review of the resident's EMR showed the following: -On 10/10/22, side rail consent risks and benefits discussed with spouse and signature obtained; -On 7/8/22, side rail verbal consent by the resident's spouse for left side rail only; -On 7/8/22, side rail measurements for the left side rail only; -On 10/4/21, side rail consent signed by resident's spouse. During observation the following was noted: -On 3/12/23, at 4:07 P.M., the resident was not in the room. The bed had bilateral half size side rails in the upright position. The right side rail had foam type covers. -On 3/13/23, at 12:43 P.M., the resident was seated in a Broda chair (type of wheelchair that provides supportive positioning through a combination of tilt, recline, adjustable leg rest angle, wings with shoulder bolsters and height adjustable arms) at nurses desk. The resident's room showed bilateral side rails in the up position in the resident room and floor mat propped against the wall; -On 3/15/23, 2:33 P.M., the resident was in a Broda chair at the nurses desk. The resident's room showed the bilateral side rails in the down position; -On 3/17/23, at 10:36 A.M., the resident was in a Broda chair at the nurses desk. Bilateral bed rails were in the up position on the resident's bed. During an interview on 3/17/2023, at 4:20 P.M., MDS D gave the surveyor a copy of the resident's informed consent for the use of bed side rails, but said the safety gap measurements were not completed on the right side rail prior to the surveyor's document request. 5. Record review of Resident #69's face sheet showed the following: -admitted on [DATE]; -Diagnoses included: Paroxysmal atrial fibrillation, type 2 diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, chronic pain syndrome, chronic kidney disease stage 4. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Extensive assistance of two or more staff for bed mobility, transfers, locomotion, toilet use, personal hygiene; -Extensive assistance of one staff for dressing; -Supervision and set up help for eating; -Required use of a wheelchair for mobility. Record review of the resident's care plan, last reviewed 3/15/23, showed the following: -Resident was at risk for deterioration in bed mobility and injuries due to side rail usage; -Staff should discuss with the resident and family of risks and benefits with use of side rails and sign a consent form every 30 months; -Staff may use partial side rails to assist the resident with bed mobility and to enable more independence when in bed. Record review of the POS, current as of 3/20/23, showed the following: -No orders for side rails or grab bar. Record review of the resident's EMR showed the following: -On 10/27/22, side rail consent form with no signature noted; -On 2/07/2023, staff documented in the progress notes, spoke with the resident and discussed the usage of side rails or grab bars. Discussed the benefits: Bed mobility, transfers and repositioning while in bed. Discussed the risks are skin tears, bruising and bodily injury if he/she tried to climb over them. The resident stated understanding and signed the consent form. Staff should continue to observe for safety and follow plan of care. During observation and interview, the following was noted: -On 3/14/23, at 11:18 A.M., bilateral grab bars in the up position on the bed. The resident said he/she used them to assist staff when repositioning; -On 3/16/23, at 1:05 P.M., the resident rested in bed with eyes closed. The head of bed was elevated and the grab bars were in the upright position; -On 3/20/23, at 9:20 A.M., the resident was in bed with breakfast tray on the bedside table. The resident's grab bars were in the upright position. During an interview on 3/17/2023, at 4:20 P.M., MDS D gave the surveyor a copy of the resident's informed consent for the use of bed side rails, but said the safety gap measurements were not completed on the grab bars prior to the surveyor's document request. 6. During interviews on 3/17/23 at 11:45 A.M. and on 3/20/23 at 1:30 P.M., the Maintenance Director said he does the safety gap measurements for most newly installed side rails. He does not complete measurements on grab bars, he only does measurements on side rails when first installed. The nursing staff notify him when a resident needs side rails, and they have a physician order for installing them. He did not do any routine monitoring or scheduled periodic safety re-checks of side rails. 7. During an interview on 3/17/2023, at 2:30 P.M., MDS D said he/she was not aware until that day that grab bars were considered side rails. They were not previously doing the safety measurements on those, but asked the Maintenance department to do those that day. 8. During an interview on 3/20/23, at 11:40 A.M., LPN S said if a resident or family wanted side rails or grab bars, the nurses should investigate the reason for use, staff will complete a side rail assessment, and maintenance will get the rails onto the bed. Staff should review the risks and benefit consent with the resident or family. Hospice will be notified if it is a hospice resident. 9. During an interview on 3/20/23, at 1:40 P.M., MDS C said nursing gets an order for the use of side rails for positioning and mobility and tells MDS staff. The MDS staff does the pro/con risk assessment and gets consent signed or verbal approval given. Side rail use should be added to the resident's care plan. Side rails should only be used for bed mobility, positioning, and seizure precautions; not as a restraint to prevent falls. He/she said the side rails should have gap measurements when installed. 10. During an interview on 3/20/23, at 3:40 P.M. and at 4:13 P.M., the Director of Nursing (DON) said some residents request side rails or grab bars for positioning. The MDS coordinator makes sure everything is in place including the assessment, consent and added to the care plan prior to putting them on the bed. Maintenance puts the rails on the bed and does the gap measurement. The assessments are found in the Observation section of the electronic medical record (EMR) and he/she did not know for sure where the consent could be located. 11. During an interview on 3/20/23, at 4:30 P.M., with the DON, ADON, Administrator, and corporate nurse, the staff said side rails require evaluation and consent. MDS completes consent and maintenance should measure and install side rails. There are some specialty beds that require rental from another company. Side rails should be documented in the physicians' orders and care plans. Based on observation, interview, and record review, the facility failed to obtain physician's orders for bed rail use for two residents (Resident #46 and #69); failed to complete a risk/benefit review and document alternatives attempted prior to bed rail use for two resident's (Resident # 23 and Resident #46); failed to obtain informed consent prior to the use side rails for two resident's (Resident #23 and Resident #46); failed to address the use bed rails in residents' care plans for two residents (Residents #12 and #46); failed to conduct an initial safety gap check for five residents (Residents #12, #23, #36, #46, and #69); and failed to ensure staff conducted periodic safety rechecks of all bed rails in use. The facility census was 83. Record review of the (undated) facility policy, titled Bed Rail Policy, showed the following: -Bed rails are adjustable metal or rigid plastic bars that attach to the bed; -They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. -The facility will ensure bed rail evaluations are performed on a regular basis; -Bed rail evaluations will include data collection analysis and determination of potential alternatives to bed rail use. 1. Record review of Resident #12's face sheet (gives basic profile information) showed the following: -admitted to the facility on [DATE]; -Diagnoses included left femur (hip) fracture, muscle weakness, right femur fracture, pain in right hip, history of Coronavirus infection, delusional disorder, anxiety, mild cognitive impairment, history of falling, cellulitis (inflammation of connecting tissue under the skin) of right lower leg, major depressive disorder, restless leg syndrome, and generalized osteoarthritis (degenerative joint disease). Record review of the resident's significant change Minimum Data Set (MDS; federally mandated comprehensive assessment tool completed by facility staff), dated 2/14/2023, showed the following: -Moderately impaired cognition; -Required extensive assistance of one person for bed mobility; -Required extensive assistance of two persons for transfers and toileting; -Frequently incontinent of bowel and bladder; -Wheelchair used for mobility. Record review conducted of the physician order sheet (POS) showed an order dated 3/10/2023: may have side rails for bed mobility, transfers and repositioning. Record review of the resident's electronic medical record (EMR) showed a documented risk informed consent by the responsible party for the use of bed side rails. Record review of the resident's care plan, last updated 2/14/2023, showed no information pertaining to the use of bed side rails. Observation on 3/17/2023, at 3:59 P.M., showed the resident sat in his/her wheelchair facing his/her television; the resident's eyes were closed and head tilted down. On the resident's bed, u-shaped grab bars were fastened to both sides of the bed. During an interview on 3/17/2023, at 4:20 P.M., MDS D gave the surveyor a copy of the resident's informed consent for the use of bed side rails, but said the safety gap measurements were not completed prior to the surveyor's document request. 2. Record review of Resident #46's face sheet showed the following: -admitted to the facility on [DATE]; -Diagnoses included dementia with behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, Alzheimer's disease, fracture of left femur (at the hip), pain in left hip, influenza, acute upper respiratory infection, cellulitis of left upper arm and both lower legs, polyneuropathy (disorder of multiple nerves throughout the body), repeated falls, restlessness and agitation, and generalized osteoarthritis. Record review of the resident's quarterly MDS, dated [DATE], showed the following: -Severely impaired cognition; -Required extensive assistance of one person for bed mobility and toileting needs; -Required extensive assistance of two persons for transfers; -Always incontinent of bowel and bladder; -Wheelchair used for mobility. Record review of the resident's POS, current as of 3/20/2023, showed no order pertaining to the use of bed side rails. Record review of the resident's EMR showed no documented pre-use assessment or informed consent for the use of bed side rails. Record review of the resident's care plan, last updated 2/8/2023, showed no information pertaining to the use of bed side rails. Observation on 3/14/2023, at 11:08 A.M., showed the resident lay in his/her bed. The resident was awake and moving his/her arms and legs. During an interview on 3/17/2023, at 4:47 P.M., MDS D said he/she was not made aware that the resident had side rails on his/her bed and had not completed a pre-use assessment or obtained informed consent for their use. MDS D said staff would need to contact the family to discuss side rail use and complete the safety gap measurement check.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to use appropriate hand hygiene while completing medication administration for 7 residents (Residents #10, #23, #35, #51, #55, #66, and #69). The facility census was 83. 1. Record review of the facility policy, titled Medication Administration, dated 2/7/13, showed the following information: -Medications are given to benefit a resident's health as ordered by the physician; -Staff should bring the cart to the resident room; -Knock on the door before entering the room; -Introduce yourself, call resident by name, and check picture ID in the medication book; -Wash hands; -Read the label three times before administering the medication; -Administer medication; -Remain in the room while the resident takes the medication; -Return the medication cart to designated location when medication pass is completed. Record review of the facility undated policy, titled Hand Cleanser (Antiseptic), showed the following information: -To cleanse the hands between resident contacts during care and to prevent spread of infection; -Place the container of antiseptic solution on the medication cart; -Wash and dry hands thoroughly in preparation for resident care; -Administer medication or provide care to resident as indicated; -Apply recommended amount of antiseptic cleanser into the palm of the hand; -Rub hands briskly until cleanser has evaporated. Record review of the facility undated policy, titled Gloves, showed the following information: -Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances and/or persons with a rash. -Gloves must be changed between resident; -Change glove between contact with different residents or with different body sites of the same resident. Record review of the undated facility policy, titled Handwashing, showed the following: -To reduce the transmission of organisms; -Adjust water temperature to comfortably hot water; -Soap hands well, rub briskly, paying special attention to area between fingers; -Use brush to clean under nails as necessary; -Rinse, use paper towel to turn off water and dry hands. 2. Record review of the Resident #69's face sheet showed the following information: -admitted on [DATE]; -Diagnosis included: chronic pain syndrome, Type 2 diabetes mellitus, cough, and chronic kidney disease (progressive damage and loss of function in the kidneys). Observation on 3/17/23 at 11:23 A.M., showed Certified Medication Technician (CMT) W at the nurses' station preparing medications for Resident #69 at the medication cart. The CMT did not complete hand hygiene prior to preparing the medications. He/she prepared Gabapentin (nerve pain medication) 300 milligrams (mg), Mucus Relief (Guaifensin - cough expectorant) 400 mg, Methadone (strong pain medication) 5 mg, took the cup of medications and a cup of water to the resident's room. The CMT handed the water cup and medication cup to the resident. The resident took the medication and requested straws for his/her drink cups. The CMT returned to the nurse station and medication cart. He/she charted in the electronic medical record. He/she did not complete any hand hygiene. He/she opened the medication cart and put straws in paper wrapping into his/her pocket. -At 11:35 A.M., the CMT walked down the hall to Resident #69's room and put the straws from his/her pocket on to the resident's bedside table. He/she walked back toward the nurse station and unlocked the medication room to put supplies in the room. He/she then returned to the nurse station and used hand sanitizer. 3. Record review of the Resident #66's face sheet showed the following information: - admitted on [DATE]; -Diagnosis included: malignant neoplasm (cancer) of the lung, chronic obstructive pulmonary disease (COPD - condition involving constriction of the airways and difficulty or discomfort in breathing), and anxiety disorder. Observation on 3/17/23 at 11:28 A.M., showed CMT W prepare medications for Resident #66. The CMT did not complete hand hygiene prior to preparing medications. He/she removed the Morphine sulfate (narcotic pain medication) 20 mg/milliliters (ml) box from the locked narcotic box in the medication cart. The CMT left the nurses station, walked across the dining area to the locked medication room, opened the medication refrigerator, and removed the locked red box. The CMT removed the Lorazepam (antianxiety medication) 2 mg/ml box. He/she walked down the hall to the resident's room. After entering the room, he/she applied gloves without completing hand hygiene. The CMT administered Morphine 0.5 ml by syringe to the resident's mouth and put the syringe and medication bottle back in the box. The CMT administered Lorazepam 0.5 ml by dropper to the resident's mouth and returned the dropper and medication bottle to the medication box. He/she removed his/her gloves and threw the gloves in the trash. The CMT returned to the medication room and returned the medication to the locked box in the refrigerator. He/she returned to the medication cart and put the medication into the locked medication cart. He/she did not complete any hand hygiene. 4. Record review of the Resident #51's face sheet showed the following information: -admitted on [DATE]; -Diagnosis included: depressive episodes, anxiety disorder, cognitive communication disorder, and chronic pain. Observation on 3/17/23 at 11:32 A.M., showed CMT W began preparing Resident #51's medication. He/she prepared Buspirone 10 mg and took the medication cup and water into the dining room and handed the cup to the resident. After the resident took the medications the CMT returned to the medication cart and charted in the electronic medication record. He/she did not complete hand hygiene. 5. Record review of the Resident #35's face sheet showed the following information: -admitted on [DATE]; -Diagnosis included: dementia (condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) with agitation, anxiety disorder, pain, and cerebrovascular disease (loss of blood flow to part of the brain, which damages brain tissue). Observation on 3/17/23 at 11:39 A.M., showed CMT W prepare medications for Resident #35. He/she opened the medication cart and prepared Lorazepam 0.5 mg and Acetaminophen (generic Tylenol) 325 mg, then crushed the medications together and mixed with yogurt. He/she took the medication cup and water into the secured unit. The CMT administered medication into the resident's mouth by spoon. He/she then handed the resident the water cup. He/she took the trash away from the resident and threw in trash can. He/she left the secured unit. The CMT returned to the nurse station and medication cart. The CMT did not complete hand hygiene. 6. Record review of the Resident #55's face sheet showed the following information: -admitted on [DATE]; -Diagnosis included: dementia without behavioral disturbance, generalized anxiety disorder, pain in throat, low back pain, and upper respiratory infection. Observation on 3/17/23 at 11:45 A.M., showed CMT W prepare medications for Resident #55. He/she did not complete hand hygiene and prepared Mucus relief 400 mg, Acetaminophen 500 mg, and Tramadol (pain medication) 50 mg. He/she crushed the medications and mixed it with yogurt. He/she went into the secured unit and and gave the resident the medication mixed with yogurt by mouth with a wooden spoon, and held the water cup to the resident's mouth to drink water. He/she then left the unit and returned to the med cart. He/she then used hand sanitizer. 7. Record review of Resident #10's face sheet showed the following information: -admitted to the facility on [DATE]; -Diagnoses included Type 2 diabetes mellitus with diabetic nephropathy (damage to kidneys caused by diabetes), complication of amputation stump, bipolar disorder (mental health condition causing extreme mood swings), and depression. Record review of the resident's physician order sheet (POS), current as of 3/17/2023, showed an order for Tizanidine (muscle relaxant) 2 mg tablets; one every six hours as needed. Observation on 3/17/2023, at 11:35 A.M., showed the following: -CMT A used hand sanitizer prior to dispensing medications for Resident #10; -CMT A opened the medication cart drawer, retrieved four cards of bubble packed pills, and placed them on top of the medication cart; -Holding the card of Tizanidine over a medication cup, the CMT punched out one pill. The pill did not land in the cup, but on the top surface of the cart; -CMT A applied gloves, picked up the pill and placed it in the medication cup; -CMT A took off the gloves and continued dispensing other scheduled medications into the medication cup. During an interview on 3/20/2023, at 10:35 A.M., Licensed Practical Nurse (LPN) E said if a pill dropped onto the surface of the medication cart, he/she would discard that pill and retrieve a new pill that wasn't contaminated. During an interview on 3/20/2023, at 1:54 P.M., CMT B said if a pill fell on the top of the medication cart, he/she would discard it and replace it; the dropped pill would be contaminated. 8. Record review of Resident #10's physician order sheet (POS), showed an order, dated 03/10/23, for staff to cleanse the right stump with Pure n Clean, cover with abdominal (ABD) pad and secure with kerlix (rolled gauze) and tape or surginet (elastic net bandage), daily and PRN (as needed) soilage. Observation on 3/14/23, at 11:44 A.M., showed LPN J pushed the supply cart to the doorway outside of Resident #10's room. The LPN gathered supplies including a clean towel, small trash bag, abdominal pad, a stack of gauze pads, tape and a bottle of wound cleanser. The LPN went into Resident #10's room. The LPN placed a clean towel on the resident's wheelchair and placed supplies on the towel. The LPN applied gloves without performing hand hygiene. He/she then sprayed a clean gauze pad with wound cleanser, and wiped the tape that was affixed to the resident's stump, lifting the tape and removing the bandage. The LPN placed the bandage and gauze pad in a trash bag. He/she removed his/her gloves and placed them in the trash bag. The LPN put on another pair of gloves, without washing or sanitizing hands. The LPN sprayed wound cleanser to the wound and patted it dry with a clean gauze pad. The LPN placed the gauze pad in the trash bag. The LPN then placed an abdominal pad to the wound and secured it with tape. The LPN said he/she needed more tape, left the room, went to the supply cart outside the room, moving a key lanyard with several keys attached, then removed his/her gloves. He/She did not perform hand hygiene. The LPN found a roll of tape and scissors inside the supply cart. He/she cut the tape with the scissors. The LPN then put on new gloves without performing hand hygiene, returned to the resident's room and placed additional tape to the bandage. The LPN dated and initialed the bandage, removed his/her gloves, and placed them in the trash bag. He/she gathered the trash bag, gathered all the remaining supplies and returned to the supply cart. The LPN then used hand sanitizer. During an interview on 03/20/23, at 1:00 P.M., LPN J said the nurse should wear gloves and perform hand hygiene before and after changing gloves and at the end of changing a dressing. During an interview on 03/20/23, at 3:40 P.M., the Director of Nursing (DON) said she expects staff to wash hands prior to starting wound care, at the end of wound care and prior to putting on gloves. The DON said gloves should be worn and changed between dirty and clean dressing change. He/she said staff should remove gloves before touching other things in the resident's room or on the supply cart. During an interview on 03/20/23, at 5:10 P.M., the interim administrator said staff should follow wound care policy, handwashing policy, glove policy and follow the physician orders. 9. Record review of Resident #23's face sheet (a brief resident profile) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included Type 2 diabetes mellitus, hyperglycemia (high blood glucose), chronic obstructive pulmonary disease (lung diseases making it difficult to breathe), and schizoaffective disorder (a condition of psychosis and mood disorder). Record review of the resident's physician order sheet (POS), current as of 03/20/23, showed the following orders: -An order, dated 09/29/22, check blood sugar before meals and at bedtime; -An order, dated 03/10/23, for Novolog U-100 Insulin aspart solution 100 unit/ml (unit of fluid volume); amount: 12 units with meals; subcutaneous (inject under the skin); hold if blood sugar is less than 150. Administer with meals: 7:00 A.M., 12:00 P.M., 5:00 P.M. -An order, dated 10/18/22, for Novolog U-100 Insulin aspart solution 100 unit/ml (unit of fluid volume); amount: Per Sliding Scale; -If blood sugar (BS) is less than 70, call physician; -If BS is 140 to 180, give 3 units of insulin; -If BS is 181 to 240, give 4 units of insulin; -If BS is 241 to 300, give 6 units of insulin; -If BS is 301 to 350, give 8 units of insulin; -If BS is 351 to 400, give 10 units of insulin; -If BS is 401 to 450, give 14 units of insulin; -If BS is 451 to 500, give 16 units of insulin; -If BS is greater than 501, call doctor; -Give subcutaneous (inject under the skin); -With meals: 6:00 A.M. - 8:00 A.M., 11:00 A.M. - 12:00 P.M., 4:30 P.M. - 6:00 P.M. Observation and interview on 03/14/23, at 12:40 P.M., showed LPN J go to Resident #23's room. LPN J sanitized his/her hands and said he/she was not able to check the resident's blood sugar prior to the meal. LPN J cleansed the resident's finger with an alcohol pad and performed the accu-check (blood sugar test) without wearing gloves. The resident's blood sugar reading on the glucometer was 423. LPN J sanitized his/her hands, left the resident's room, went to the medication room to get a new insulin pen. LPN J returned to the resident's room, without performing hand hygiene, applied gloves, opened the box of the new pen, removed the cap, and cleansed the area with an alcohol pad. The LPN applied a new needle to the pen. He/she then dialed the pen to 26 units, cleansed the resident's right upper arm with an alcohol pad, administered the dose. LPN J removed his/her gloves and did not perform hand hygiene. The nurse then pushed the medication cart down the hall to the nurse's station then sanitized his/her hands. 10. During an interview on 3/20/23, at 11:01 A.M., CNA L said staff should wash hands after meals, after restroom use. Hand sanitizer or hand washing should be done before and after every glove change, and hand hygiene should be done between dirty and clean process. During an interview on 3/20/23, at 11:30 A.M., CMT X said hand hygiene should be done between every resident and hands washed after the third resident during medication pass. If a pill lands on the top of the cart or on the floor, or anywhere but in the med cup, the pill should be discarded. During an interview on 3/20/23, at 11:40 A.M., LPN S said staff should wash their hands or use hand sanitizer every time entering and exiting a resident room. Staff should clean hands before touching anything in the resident room and should not touch anything with dirty hands or gloves. During an interview on 3/20/23, at 4:00 P.M., RN T said staff should clean hands before and after any resident interaction, including medications. Staff should discard any pill that fell on the medication cart or the floor. During an interview on 3/20/23, at 3:05 P.M., LPN E said staff should always wash or sanitize their hands before and after resident contact. During an interview on 03/20/23, at 12:40 P.M., Assistant Director of Nursing (ADON) said she expected staff to wash hands and put on gloves prior to performing accu-checks. During an interview on 03/20/23, at 3:40 P.M., DON said he/she expects staff to wash hands before and after performing accu-checks. Gloves should be worn during accu-checks. During an interview on 3/20/23, at 4:30 P.M., with the DON, ADON, Administrator, and corporate nurse. The DON said staff should not touch pills during medication administration and pills that are on the cart or the floor should be discarded and not given to a resident. During an interview on 03/20/23, at 5:10 P.M., Interim Administrator said he/she expects staff to use hand hygiene before, wear gloves while performing accu-checks, and hand hygiene should be done after. Staff should wash hands and wear gloves between accu-checks and insulin administration and between each resident.

Based on observation, interview, and record review, the facility failed to keep food safe from potential contamination when food items were not dated or labeled after opening, or were left open and exposed to absorb ice crystals and odors and when staff failed to keep the kitchen free of an accumulation of grime and debris. This had the potential to affect all residents who ate food from the kitchen. The facility census was 83. Record review of the US Food and Drug Administration policy, under the section of Food Labeling and Handling, currently updated 3/4/23, showed the following: -Facility staff must ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated; -Food shall be stored in a safe manner (no open containers, without covers, spillage from one food item onto another, etc.) to prevent cross-contamination -Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable) or discarded. 1. Record review of the facility's policy titled Safe Food Handling, dated April 2011, showed the following information: -All food, including bulk items, should be tightly sealed with an identifying label and date; -The facility could not provide further policy regarding labeling items. Observation of the walk-in refrigerator on 3/13/2023 at 9:54 A.M., showed the following items were all undated and were not labeled: -Tall pitcher for liquid, half-full of juice; -Butter, approximately two sticks, in a plastic bowl; -Chicken salad sandwich, already made; -Chicken salad mixture, approximately enough for two sandwiches; -Ham cubes, in large plastic bag; -Ham slices, in two separate zip lock bags; -Bacon slices, in a large zip lock bag; -Bologna slices, in a large zip lock bag; -Cheese slices that have been separated into small bunches of approximately 10 slices each, and there are 8 packages in their own saran wrap (80 slices total). Observation of the walk-in refrigerator on 3/13/2023 at 10:00 A.M. , showed the following items were not properly closed and were exposed to the cold air, allowing for food to absorb odors and become stale: -Chicken salad sandwich, ready to eat, exposed and bread is hard; -Chicken salad mixture, dried out across the top; -28 small juice glasses, open and exposed inside the refrigerator; -4 small plastic bowls of applesauce with some cinnamon mixed in, -All of the items are exposed to the other items in the fridge. Observation of the walk-in freezer on 3/13/2023 at 10:05 A.M., showed the following: -One large box of biscuits were found to be open and exposed to the freezing air, showing ice crystals on all of the biscuits; -Potato wedges, no date/label and not closed correctly, and with ice crystals on them; -Six meat patties, the bag is open, exposed to the cold air, and have ice crystals on them. During an interview on 3/20/23 at 1:04 P.M., Dietary Aide M, said the following: -The dietary manager is the one who usually puts the food away; -All food needs to be labeled and dated; -If there are any leftovers, those should also be labeled and dated; -He/she will label/date any foods that he/she is personally in contact with or will ask; -Hasn't seen anything without a label, as far as he/she can remember; -Knows this should be done with all food, no matter what it is or where it's kept; -Hasn't seen any food left open in the freezer, but would throw out any that he/she saw. During an interview on 3/20/23 at 1:13 P.M., Dishwasher N, said the following: -He/she does not put any food away; -He/she mostly does dishes only; -He/she knows food needs to be labeled and dated correctly; -Food should never be left in the refrigerator or the freezer, opened and not labeled; -If food is exposed and open in the freezer and has ice crystals, he/she believes it should be thrown away. During an interview on 3/20/23 at 1:13 P.M., Evening [NAME] O said the following: -He/she always tries to label items in the dry food storage, refrigerator and the freezer; -He/she has seen that there are many items in the refrigerator and freezer that are not labeled and it is upsetting to him/her because he/she is tired of trying to keep up; -He/she is glad that state is here because it may make staff pay attention to what is not being done; -Any biscuits or any food items that are exposed to the freezer in an open container should be thrown away and never fed to residents; -He/she said the same is true with any items that have not been labeled; -If they make any desserts or pour juices, they should be covered up/wrapped appropriately and not just exposed to the open air, sitting out for anything to fall in them. During an interview on 3/20/23 at 1:13 P.M., Prep [NAME] P said the following: -He/she thinks the dietary manager is who usually labels and dates all new and incoming items; -Anything that is saved, for example, from today's lunch- should be labeled and dated before putting it away; -Everything must be covered up and that includes the biscuits or anything else in the freezer; -Food found opened and with ice crystals should be disposed of; -He/she said the entire freezer needs to be redone and gone through. During an interview on 3/20/23 at 3:20 P.M., both the administrator and the DON, said the following: -Both have already been informed of the condition of the kitchen and know there are some problems; -The dietary manager is fairly new and is still trying to figure things out; -The dietary manager is on vacation during this survey; -Both took notes of the concerns listed and said they did not realize items had been placed in the refrigerator uncovered or in the freezer exposed to the air and getting ice crystals on them; -There will be an in-service with the kitchen staff to ensure all labeling and storing food correctly to ensure it will be done the right way. 2. Record review of the Food and Drug Administration (FDA) 2013 Food Code showed nonfood-contact surfaces shall be kept free of an accumulation of dust, dirt, food residue, or other debris. Record review showed a facility policy regarding cleaning nonfood surfaces was not provided. Record review of the kitchen cleaning schedule shows the following: -The schedule is broke down to six days a week, Monday through Saturday; -The chores are divided between the cook/prep/AM Aides/PM Aides; -The ice machine is listed for Mondays but none of the other areas of concern are listed on the cleaning schedule. Observation of the kitchen, on 3/13/2023, at 10:20 A.M., showed a dark, stringy, substance that is made up of dust, dirt, food residue and/or debris, collected with grease and hanging or collected on almost all kitchen surfaces, including: -Range Hood, back and sides had large amounts across the entire surface area; -Brace bars that are connected to the ceiling and are holding up the dishwasher; -The metal door that raises/lowers for serve-out, from the kitchen to the dining room; -Metal shelving that holds cooking utensils, metal lids and cutting boards; -The cooking range fire alarm on the east wall, near the kitchen door; - The substance lined the blades and the cage area of the fan in the kitchen. The staff had the fan running with the fan blowing air across the kitchen; -The substance covered the wall behind the ice machine; -The substance covered the filter on the upper left side of the ice machine; -A greasy, fuzzy substance covered all five ceiling vents in the kitchen. The debris moved back and forth as air blew through the air vents; -The substance coated all of the electrical conduits on the ceiling. Observation of the kitchen on 3/15/23, at 8:52 A.M., showed the no changes from the observation from 3/13/23. During an interview on 3/15/23, at 8:55 A.M., [NAME] Q, said the following: -There was a cleaning schedule (and grabbed it from the wall); -The kitchen staff did not really follow the cleaning schedule; -He/she did not know why it was not followed and said staff just clean up after themselves to keep the kitchen clean. During an interview on 3/20/23 at 1:04 P.M., Dietary Aide M, said the following: -Management expected him/her to clean and follow the cleaning schedule, but he/she just tried to clean up after himself/herself; -He/she thought the schedule should be followed daily, but is not sure how often it's followed currently; -He/she had cleaned off the front of the ice machine and pointed to the front of the machine; -When asked about the wall behind the ice machine, he/she states he/she was unsure who was scheduled to clean the walls, but said it looked like no one ever cleaned it; -When he/she looked at the fan and the ceiling vents, he/she said they needed to be scrubbed and said he/she thought maintenance completed that task; -He/she said that he/she couldn't believe how bad the build-up actually was, now that it had been pointed out to him/her. During an interview on 3/20/23 at 1:13 P.M., Dishwasher N, said the following: -He/she die not realize there was a separate cleaning schedule that staff was expected to follow; -He/she saw what was pointed out, he/she said he/she found it to be gross; -He/she said with what they are seeing, he/she would not eat from this kitchen; -He/she will work with the kitchen staff to get it cleaner and to make sure it's not covered in the grease and lint. During an interview on 3/20/23 at 1:13 P.M., Evening [NAME] O said the following: -He/she wished the dietary manager was there to hear the issues because the kitchen staff weren't doing a very good job of understanding what is important to keep a kitchen clean; -He/she used to be the dietary manager of this very kitchen, but any time he/she wanted to do something and it cost more than a few dollars, management would throw a fit and would not allow it; -He/she thought the newer management did not understand what requirements were necessary to keep the kitchen going; -He/she said they saw how grimy the kitchen had become, and it was dirty with grease/lint build-up; -He/she said there was no excuse, because someone should be cleaning all of these things on a regular basis; -He/she believed if it was up high or above their heads, then maintenance was tasked with the cleaning; -He/she feels the rest of the cleaning was up to the kitchen staff to complete; -He/she said the kitchen needed a deep cleaning, starting immediately. During an interview on 3/20/23 at 1:13 P.M., Prep cook P, said the following: -He/she thought maintenance should be doing the vents, braces and everything up high; -He/she did the wires that go up to the ceiling, as high as he/she could reach, stating these get greasy and flies get stuck to them; -He/she said the manager does assign a few chores, but did not think the kitchen staff really listened to him/her; -He/she said the manager was not doing those things either to maintain a clean kitchen. During an interview on 3/20/23 at 2:15 P.M., Transport R said the following: -Who does the cleaning of the ceiling vents and the areas above the walk-ins depends on who was the boss; he/she was never sure who's supposed to clean the upper areas of the kitchen; -He/she had always cleaned the grime from those areas when he/she was maintenance and would come in at night to deep clean; -He/she was unsure if anyone was doing anything towards cleaning the worst areas at this time; -He/she acknowledged the areas above the walk-ins were bad and the filters were dirty, because, if those broke it could put a serious strain on facility operations. During an interview on 3/20/23 at 3:50 P.M., the Maintenance Director, said the following: -He/she had not been in the kitchen for quite a while, but was aware that it could use a good cleaning; -He/she had not personally done anything in or to the kitchen for some time; -As far as he/she knew, the kitchen did their own cleaning; -Maintenance would help with the vents in the ceiling, if needed, but for the most part, he/she thought the kitchen staff cleaned their own vents; -He/she did not currently have a kitchen cleaning schedule; -Maintenance used to do maintenance work/cleaning in the kitchen; -He/she only goes in there as an as needed basis; -He/she did change the filters above the walk in refrigerator and freezer; -He/she did not have a schedule he/she follows for when to change the filters; -He/she did not record when he/she changed the filters; -He/she acknowledged that the filters have not been changed in a really long time and they currently needed to be replaced. During an interview on 3/20/23 at 3:20 P.M., the Administrator and the Director of Nursing (DON) said the following: -Both had already been informed of the condition of the kitchen and knew there were some problems; -The dietary manager (DM) was fairly new and was still trying to figure things out; -The DM was having a hard time getting staff to listen to her and do their assigned duties; -They would be working with both kitchen staff and maintenance to determine who would be cleaning what, to ensure the grime is removed from the kitchen; -A better, more thorough cleaning schedule may be made or they would come up with something to fix these issues.

Based on interview and record review, the facility failed to ensure all residents were free from abuse when a staff member (Housekeeping Staff (HS) A) acted in an abusive manor by cursing at while pointing his/her finger in the face of one resident (Resident #1). The facility census was 101. Record review of the facility policy, titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident Property, undated, showed the following: -It is the policy of the facility that each resident will be free from abuse; -Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of property and exploitation, corporal punishment, or involuntary seclusion; -Residents will be protected from abuse, neglect, and harm while they are residing in the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. 1. Record review of Resident #1's face sheet (a brief resident profile sheet) showed the following: -admission date of 11/29/2022; -Diagnoses included dementia with behavioral disturbances, fracture of left femur (thigh bone), and delirium (an acutely disturbed state of mind that occurs in fever, intoxication, and other disorders characterized by restlessness, illusions, and incoherence of thought and speech). Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 12/01/2022, showed the following: -Severe cognitive impairment. Record review of the resident's baseline care plan, dated 12/05/2022, showed the following: -The resident had a diagnoses of Alzheimer/dementia. Facility interventions included monitor medications, provide safe environment, monitor condition and report changes to the Director of Nursing (DON) or physician, monitor lab values and report to physician, provide comfort and care, turn and reposition due to fracture, and required a specialty mattress, -The resident required assistance of one to two staff for activities of daily living (ADLs) to include bed mobility, transfers, toileting, eating, walking, bathing, and locomotion with wheelchair. Record review of the facility's investigation, dated 12/04/2022, showed the following: -On 12/04/2022, at 10:10 A.M., Certified Medication Technician (CMT) B, Licensed Practical Nurse (LPN) C, and Certified Nurse Aide (CNA) D reported H) A had a verbal altercation with the resident; -Written statements were obtained by facility from the witnesses regarding the verbal abuse they witnessed and by the alleged perpetrator (AP) HS A; -The resident was unable to give a verbal or written statement due to his/her severe cognitive impairment; -The facility made an after hours/weekend report to the Department of Health and Senior Services (DHSS) abuse and neglect hot line to report the allegation of employee to resident verbal abuse on 12/04/2022, at 11:35 A.M. Record review of the written statement of CMT B showed the following: -On 12/04/2022, at 10:10 A.M., CMT B's written statement said the resident was sitting in front of the nurses' station when HS A came up to clean the bathroom across from the nurses' station. HS A moved a walker that was in front of the bathroom door. He/she placed the walker in front of the resident and the resident said get that shit out from in front of me. HS A moved the walker and then got in the resident's face and started yelling and pointing his/her finger while saying fuck you, you don't tell me what to do. The CMT said he/she pushed HS A away and resolved the issue. During an interview on 12/05/2022, at 11:00 A.M., CMT B confirmed his/her written statement and said the following: -He/she was the one who stopped the verbal altercation between HS A and the resident. The resident is very confused resident. The resident was sitting at the nurses' station in his/her wheelchair. The resident has behaviors and is not always nice to staff. The resident makes statements to people to get a rise out of them or to make people mad; -There was a walker in front of the bathroom door so HS A went and moved the walker so he/she could clean the bathroom. HS A put the walker in front of the resident and the resident said to get that shit away from me. HS A moved the walker and then got in the resident's face and said fuck you, don't fucking tell me what to do; -The CMT said he/she interceded and HS A walked away from the resident. The nurse on duty LPN C heard HS A be verbally abusive to resident. The LPN immediately contacted the DON and reported the incident and HS A was suspended. The facility started an investigation and had the witnesses and HS A write written statements; -The CMT said he/she would consider a staff person cursing at a resident abuse. Record review of the written statement of LPN C showed the following: -On 12/04/2022, at 10:10 A.M., the resident was sitting at the nurses' station when employee HS A went to remove a walker that was in front of the bathroom door. The resident said don't move that shit, get out of here. HS A pointed his/her finger in resident's face and said fuck you, you don't tell me what the fuck to do. The employee was separated from the resident and asked to leave. The DON and Administrator notified and an investigation started. During an interview on 12/05/2022, at 11:08 A.M., LPN C said the following: -If staff witness or hear abuse the abuser should be separated from the resident, staff notify the DON and administrator immediately, staff report to state abuse and neglect hotline within two hours, and assess the resident. The nurse should also notify the physician and family of any abuse allegations. If the abuser is an employee the employee should be suspended; -On 10/04/2022, at 10:10 A.M., he/she was sitting at nurses' station charting and the resident was sitting across from the nurses' station near the bathrooms. HS A came up to the bathrooms to clean them and moved a walker in front of the resident who was sitting in his/her wheelchair. The resident said to HS A don't move that shit. HS A moved the walker away from the resident and pointed his/her finger in the resident's face and said fuck you, don't tell me what the fuck to do.; -CMT B was standing at nurses' station and CMT told HS A you can't talk to residents that way. HS A walked away from the resident. The nurse had HS A go to social service office and the LPN contacted the DON immediately to report allegation of verbal abuse. The DON had staff write statements and had LPN suspend HS A pending investigation.; -The LPN said cursing at a resident like this is verbal abuse. Record review of the written statement of CNA D showed the following: -On 12/04/2022, at 10:10 A.M., he/she was charting on his/her computer when he/she heard employee HS A cursing at the resident. The CNA said he/she heard HS A tell resident you don't fucking talk to me like that, fuck you. HS A told by CMT B he/she could not talk to residents like that. During an interview on 12/05/2022, at 11:20 A.M., CNA D said the following: -On 12/04/2022, at 10:10 A.M., he/she was charting on computer on 100 hall. He/she said he/she did not see the incident of verbal abuse, but could hear HS A yell at the resident who was sitting across from nurses' station. He/she said he/she heard HS A yell fuck you, don't fucking talk to me like that. The CNA said he/she then heard the CMT tell HS A you can't talk to residents that way. The CMT sent HS A to social service office to separate the employee and resident. The CMT reported to the nurse. HS A was sent home and suspended; -The CNA said cursing at a resident is verbal abuse; -The CNA confirmed the written statement he/she had provided to the facility. During an interview on 12/05/2022, at 3:50 P.M., with the Administrator and DON said the following; -There should not be a case that an employee does not understand cursing is verbal abuse. The DON said they explain the tone of voice can be considered abuse if not appropriate; -The DON said yesterday approximately at 10:15 A.M., the charge nurse (LPN C) contacted her to report an allegation of verbal abuse and also reported to the Administrator the allegation of abuse; -The Administrator said he talked to the DON who filed the after hours and weekend on line report to the Department of Health and Senior Services abuse and neglect hotline. The DON had the witnesses and HS A write statements and then HS A was suspended pending investigation. -The Administrator said HS A said he/she did not realize you could not talk to a resident the way he/she did. MO00210722

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to update the care plan for one resident (Resident #58) when the resident returned from the hospital with a peripherally inserted central catheter (PICC) intravenous (IV) line for infusion of antibiotics due to an osteomyelitis (a bone infection) and cellulitis (an infection of the tissue), out of a selected sample of 21 residents. The facility's census was 103. 1. Record review of Resident #58's quarterly minimum data set (MDS - a federally mandated assessment tool completed by facility staff), dated 8/1/19, showed the following: -admitted on [DATE], re-entered from the hospital on 4/24/19; -Moderate cognitive impairment; -Required extensive assistance of two or more staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -Functional limitation in range of motion to bilateral lower extremities; -Used a wheelchair for mobility; -Suprapubic catheter (a urinary catheter that is surgically placed through the abdominal wall into the bladder); -Diagnoses included heart failure, infection of multi-drug resistant organism, diabetes, anxiety, and depression. Record review of the resident's hospital progress note, dated 10/23/19, and showed a hospital physician documented the following: -Diagnoses of acute metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), cellulitis of the right leg, bacteremia (bacteria in the blood) with streptococcus (a type of bacteria), and osteomyelitis of the right femur (thighbone); -Likely metabolic encephalopathy, now resolved, secondary to bacteremia and febrile (fever) illness; -Lactic acid (a blood test) level elevated secondary to probable sepsis (a potentially life-threatening condition caused by the body's response to an infection); -History of right and left below the knee amputation. Record review of the resident's progress note dated 10/24/19, at 8:35 P.M., showed the following: -admission assessment showed the resident arrived to the facility via ambulance services; -Diagnosis of metabolic encephalopathy; -Resident had mild confusion; -The resident had a Midline 18 gauge single lumen (PICC line) for IV antibiotic administration. Record review of the resident's progress notes, dated 10/24/19, completed by the nurse practitioner, showed the following: -Resident re-admitted from the hospital on [DATE]; -Diagnoses of acute encephalopathy, cellulitis of right leg, type 2 diabetes mellitus (uncontrolled with peripheral vascular complication), chronic kidney disease, stage 3, gram-positive bacteremia, secondary sepsis possible. Record review of the resident's treatment flowsheet showed the following: -An order, dated 10/24/19, for staff to administer a normal saline flush (the method of clearing intravenous lines) before and after IV antibiotic administration every 8 hours; -An order, dated 10/25/19, for Cefazolin (an antibiotic) 2 grams/100 milliliter (ml), administer IV every 8 hours (discontinuation date of 11/14/19) for diagnosis of sepsis. Record review of the resident's significant change MDS, dated [DATE], showed the following: -Resident on IV medication -Resident received antibiotic 7 out of the last 7 days. Record review of the resident's physician orders, dated 10/29/19, showed the following: -Remove the current PICC line due to leaking and place a PICC line for continued use of IV antibiotics; -Diagnosis of metabolic encephalopathy. Record review of the resident's physician orders sheets, dated 11/14/19, showed an order to administer Cefazolin 2 grams/100 milliliter (ml), IV every 8 hours (discontinuation date of 12/3/19) for diagnosis of sepsis. Record review of the resident's progress notes, dated 12/2/19, showed the nurse practitioner documented the following: -Resident currently receiving IV Cefazolin for right lower extremity cellulitis; -Nurse asked for evaluation of resident's rash on abdomen and upper legs. Record review of the resident's physician orders sheets, dated 12/3/19, showed an order to administer Cefazolin 2 grams/100 milliliter (ml),IV every 8 hours (discontinuation date of 12/13/19) for diagnosis of sepsis. Observation and interview on 12/8/19, at 10:01 A.M., showed the following: -The resident laid on a lift pad, on his/her bed, with a dressing over his/her PICC line site on his/her right upper arm. -The resident said the nurses administered antibiotics through the IV due to an infection in his/her leg. He/she was hospitalized approximately 6 weeks ago and had an IV ever since returning from the hospital. Record review of the resident's progress note dated 12/10/19, at 7:34 A.M., showed the resident continued with IV antibiotic via PICC every 8 hours through 12/13/19, and then it will be discontinued. Record review of the resident's care plan, reviewed and revised on 12/10/19, showed staff did not identify, develop and implement interventions related to the resident's long-term antibiotics use through a PICC IV line, including instructions regarding care and maintenance of the resident's PICC line and monitoring of the resident who received IV antibiotics. During an interview on 12/11/19, at 10:42 A.M., Nurse Aide (NA) O said the following: -Staff should follow residents' care plans; -Staff should check the care plans because they could change; -Staff should report changes to the nurse; -The Director of Nursing (DON) or MDS coordinator update the care plans. During an interview on 12/12/19, at 12:22 P.M., Licensed Practical Nurse (LPN)/MDS Coordinator P said the following: -Over the past year, the facility implemented a couple of different processes for updating resident's care plans to see what worked best: -LPN P was responsible for updating the acute (short term) care residents and a registered nurse (RN) was responsible for updating the long-term care residents; -LPN P completed the care plans for new admissions to skilled care; -Nurses completed the baseline care plan within the first 72-hours, after a resident was admitted ; -Comprehensive care plans should be completed within 21 days; -Care plans are updated on a quarterly basis or as needed with new issues, concerns, behaviors or antibiotic use; -The resident's care plan should have been updated regarding the care of the PICC line. During an interview on 12/12/19 at 3:30 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said the following: -The resident's PICC line and IV antibiotics should be included on a care plan; -The ADON said he/she started to include information about antibiotic therapy and would update the resident's care plan to include information about the PICC line and IV antibiotics; -The resident's care plan should include the following information: Staff should not obtain a blood pressure in the same arm as the PICC line; staff should monitor for signs and symptoms of infection at the PICC line site; staff should flushes the PICC line and change the PICC line dressings as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to identify, assess, and monitor one resident's (Resident #53) pressure ulcer and failed to follow appropriate infection control measures when cleaning one resident's (Resident #40) multiple pressure ulcers and failed to measure on resident's (Resident #40) pressure ulcers, according to professional standards, in a selected sample of 21 resident's. The facility's census was 103. Record review of the facility's pressure ulcer policy, dated March 2015, included the following information: -Purpose: To prevent and treat further breakdown of pressure ulcers; -Treatment of pressure ulcers will vary depending on the orders of the attending physician. The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measure to prevent pressure ulcers; -Observe skin. Any persistent reddened area that remains after pressure is relieved is considered a high-risk area for pressure ulcer to begin; -Change bed linen promptly whenever wet or soiled; -Keep sheets dry, free of wrinkles and free of debris; -Use pressure-reducing devices to relieve pressure; -Turn the resident every two hours and position with pads or pillows to protect bony prominences. 1. Record review of Resident #53's facesheet (a document that gives a resident's information at a quick glance) showed staff admitted the resident to the facility on 7/15/11. His/her diagnoses included paraplegia (paralysis of the legs and lower body). Record review of the resident's physician orders showed the following: -An order, dated 11/1/17, for staff to lay the resident down at least one hour between breakfast and lunch, and lunch and dinner; -An order, dated 7/20/19, for staff to conduct weekly skin assessments on Tuesdays, 2:00 P.M.-10:00 P.M. shift; -An order, dated 8/6/19, for staff to apply barrier cream to the resident's buttocks two times a day, as needed; -An order, dated 9/25/19, for staff to apply Calmoseptine (a moisture barrier ointment) to the resident's right ischial (ischium or the area under the gluteal fold) folds two times a day. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/23/19, showed the following information; -No cognitive impairment; -Required extensive assistance with bed mobility, dressing, toileting and personal hygiene; -Dependent upon staff for transfers and bathing; -Used a wheelchair for mobility; -Had an indwelling catheter (a flexible tube that drains urine from the bladder into a bag outside the body); -Always incontinent of bowel; -At risk for developing pressure ulcers; -No pressure ulcers; -Pressure-reducing devices for chair and bed; -Application of ointments/medications other than to feet. Record review of the resident's care plan, reviewed/revised 10/23/19, showed the following information: -The resident was unable to complete his/her own activities of daily living without assistance; -Resident transferred with assistance of two staff using a mechanical lift; -The resident required a wheelchair for mobility; -Offer toileting/incontinency check with care and services as needed; -Check skin frequently; -Resident required maximum assistance of one staff for dressing, bathing, grooming and personal hygiene; -At risk for skin breakdown due to paralysis, neuropathy (disease or dysfunction of one or more peripheral nerves, typically causing numbness or weakness) and limitation of movement; -Use one or two staff to reposition the resident in bed; -Turn every 2 hours or as requested by the resident; -Conduct a systemic skin inspection weekly. Pay particular attention to the bony prominences; -Monitor for and report any signs of skin breakdown (sore, tender, red or broken areas); -Resident requested staff to lay him/her down between meals. Record review of the resident's initial and weekly wound documentation, dated 11/4/19, showed the following information: -Date of onset: 10/4/19; -The resident had a healed Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue)) to his/her left gluteal fold. Record review of the resident's weekly skin assessment, dated 12/3/19, showed a nurse documented the resident did not have any new skin issues. The resident's skin was warm, dry and intact with an existing skin issue to the resident's left gluteal fold, and redness to his/her buttocks. Continue treatment as directed per the treatment administration record (TAR) and continue with the plan of care. During an interview conducted on 12/9/19, at 2:00 P.M., the resident said he/she lived at the facility for quite a while. At night, staff did not turn him/her often and eventually he/she developed a pressure ulcer on his/her buttocks. The resident thought the pressure ulcer was healed per staff. An observation on 12/10/19, at 10:25 A.M., showed the resident laid in bed positioned on his/her back with a pillow underneath his/her lower legs. An observation and interview on 12/10/19, at 5:05 P.M., showed the following: -The resident laid in bed. Certified Nurse Aide (CNA) K entered the resident's room to transfer him/her to his/her wheelchair. CNA K rolled the resident onto his/her left side and showed a golf ball-sized dark reddened area, with a nickel-sized area of dark brown tissue to the lower left, inside the reddened area, on the resident left ischium. A golf ball-sized area of serosanguinous drainage (fluids composed of clotted or diluted red blood cells mixed with serum, usually leaving a body from a wound. It can be different colors, including milky-white, yellowish, pale pink, or clear) was visible on the incontinent pad the resident laid on. No dressing covered the wound; -CNA K said the area on the resident's left ischium opened then healed; it came and went. Record review of the resident's weekly skin assessment dated [DATE], at 9:15 P.M., showed a nurse documented the resident had an existing skin issue. Continue the application of Calmoseptine to the resident's left ischial fold, two times a day. An observation and interview on 12/11/19, at 3:39 P.M., showed the resident laid in his/her bed. Licensed Practical Nurse (LPN) J rolled the resident onto his/her right side and showed a baseball-sized, non-blanchable dark reddened area on the resident's left ischium. Inside the reddened area, towards the bottom left, was a nickel-sized area of brown tissue with an opened area, at the bottom right edge of the wound. Also inside the reddened area, to the right of the brown tissue, was an approximate 2 cm x 0.2 cm opened wound, with a pink wound bed. -The LPN said the area on the resident's left ischium was not as red the last time he/she observed it. He/she did not remember the last time he/she observed the area, but knew it was not yesterday (12/10/19). The LPN said no one reported to him/her that the resident had an opened area on his/her ischium. Record review of the resident's medical record on 12/12/19, at approximately 12:00 P.M., showed staff did not document an assessment of the resident's newly opened ischial wound. During an interview conducted on 12/12/19, at 1:52 P.M., CNA L said since he/she started working at the facility, in April 2019), the resident has had a reddened area on his/her left ischium. The redness would open, then it would heal; it had done that a few times. This time it had been opened for about a week. The wound had a little drainage and looked about the same as it did a week ago. It was red with a darker red area near gluteal fold. The CNA reported the opened area to the charge nurse on the day he/she noticed the opened wound. He/she did not remember whom he/she told. The CNA applied A&D ointment (a moisture barrier cream) to the resident's buttocks and the nurses applied the Calmoseptine. Staff should tell the charge nurse anytime he/she noticed anything different with the resident, including new red or opened areas. During an interview conducted on 12/12/19, at 2:15 P.M., CNA M said the resident had an open spot on his/her buttocks that sometimes drained. The resident had this for about a month, but it opened and healed. If the CNA noticed a new or worsening skin issue, he/she reported it to the nurse. During an interview conducted on 12/12/19, at 2:25 P.M. and 4:22 P.M., LPN J said the following: -When staff told him/her a resident had a new wound, he/she assessed the area, which included measurement, color, if it blanched, Stage, odor, and drainage, and documented the assessment on the initial wound assessment form. He/she called the physician for orders, and notified the Director of Nursing (DON)/Assistant Director of Nursing (ADON); -The LPN gave the aides Calmoseptine to apply to resident's skin. Calmoseptine was used to treat superficial wounds; -The charge nurses completed the weekly skin assessments based on a predetermined schedule. The DON completed the weekly wound assessments. The weekly skin assessments included an abbreviated assessment-color, drainage, and odor. If the resident had an existing wound, the nurse would describe the wound and include the current treatment. -If the nurse identified a new wound when completing the weekly skin assessment, he/she would complete a full assessment, document the assessment on the initial wound assessment form, and notify the physician, DON and ADON; -LPN J did not document the resident's wound assessment yesterday, and he/she should have because the wound on the resident's ischium looked different then it previously did. Early this morning, he/she notified the ADON that he looked at the resident's wound, it was now opened, and he/she did not change the treatment; -The LPN described the resident's wounds as one Stage II pressure ulcer (the 2 cm x 0.2 cm wound), the area with dark brown tissue as an unstageable pressure ulcer (obscured full-thickness skin and tissue loss), and one baseball-sized Stage I pressure ulcer (Intact skin with non-blanching redness). During an interview conducted on 12/12/19, at 3:21 P.M., the ADON said the resident had an area on his/her ischium that would open and heal. He/she always had the reddened area. The nurses did not measure the redness. 2. Record review of Resident #40's facesheet showed staff admitted the resident to the facility on [DATE]. His/her diagnoses included dementia. Record review of the resident's admission MDS, dated [DATE], showed the following information: -Severe cognitive impairment; -Disorganized thinking (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) fluctuated (came and went, changed in severity); -Required extensive assistance for bed mobility, transfers, dressing, eating, toileting and personal hygiene; -Used a wheelchair for mobility; -At risk for developing pressure ulcers; -No pressure ulcers; -Had a pressure-reducing device for his/her bed; -Applications of ointments/medications other than to feet. Record review of the resident's care plan, reviewed 10/8/19, showed the following information: -The resident was at risk for skin breakdown related to decreased mobility; -Encourage and assist the resident to reposition with care and services, and as needed; -Pressure-reducing mattress to the resident's bed; -Pressure-reducing pad to the resident's wheelchair; -Provide incontinent care with each incontinent episode; -Moisture barrier product to perineal area; -Weekly skin assessments. Record review of the resident's initial and weekly wound documentation, dated 12/5/19, showed the following information: -The resident had a Stage II pressure ulcer on his/her right buttock that measured 4 cm x 1 cm. -Granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) was present in the wound bed with a scant amount of red/bloody drainage and no odor. The surrounding skin was intact/healthy; -Interventions included pressure-reducing device for his/her chair, turning/repositioning program, pressure ulcer care and application of nonsurgical dressings, with or without topical medications, other than to feet. Record review of the resident's care plan, updated 12/5/19, showed the following information: -The resident had a Stage II pressure ulcer on his/her right buttock; -Assess and record the condition of the skin surrounding the pressure ulcer; -Conduct a systemic skin inspection weekly. Report any further signs of further skin breakdown; -Keep skin clean and dry as possible. Minimize skin exposure to moisture; -Keep the resident off the affected area. Encourage the resident to turn and change position during cares and periodically throughout the day; -Wound treatment as physician ordered. An observation and interview on 12/10/19, at 12:50 P.M., showed the following: -LPN H prepared the resident's wound care supplies. He/she said the physician orders for treatment was to clean the pressure ulcers with wound cleanser, apply sure-prep (a skin protectant) to the skin around the wounds, apply Hydrogel (a topical medication to aide in wound healing) to the wound beds and cover with a bordered gauze dressing; -LPN H and Certified Medication Technician (CMT) I rolled the resident onto his/her left side and showed a pea-sized open area, a pencil eraser-sized white flaky scabbed area and a dime-sized crescent shaped open area to the resident's right buttock. The wound beds of both opened wounds were pink with no drainage and no odor. LPN H washed his/her hands, applied gloves and cleaned the resident's opened wounds with wound cleanser moistened gauze. He/she washed his/her hands and gloved, then applied sure-prep around the opened areas. Using the same cotton-tipped applicator, he/she applied Hydrogel to both opened wounds, possibly contaminating the wounds, and then covered them with a bordered gauze dressing. During an interview on 12/10/19, at 10:59 A.M., CNA G said the wound on the resident's right buttock was new. Staff reported the area to the nurse about a week ago. A scab covered the wound bed; the nurses instructed him/her to apply Calmoseptine to the area. The nurses monitored the resident's wound every day. During an interview on 12/10/19, at 2:03 P.M., LPN H said the following: -The resident developed a Stage II pressure ulcer on 12/4/19; -LPN H measured the area as one pressure ulcer, but the resident had three separate wounds. -The separate wounds were considered one wound because they were right next to each other. -When LPN H measured the area last week, it was 4 cm x 1 cm. During an interview conducted, on 12/12/19, at 3:21 P.M., the ADON said she would measure the resident's three areas separately. 3. During an interview on 12/10/19, at 10:59 A.M., CNA G said staff monitored residents' skin when they assisted them with dressing or incontinent care. Staff should report any new areas to the charge nurse. 4. During an interview on 12/10/19, at 2:03 P.M., LPN H said nurses completed weekly skin assessments on all residents. If staff found a new skin concern, they should report it to the charge nurse. Staff measured pressure ulcers weekly. 5. During an interview conducted on 12/12/19, at 2:25 P.M., LPN J said the following: -When performing a wound treatment to more than one wound, staff cleaned each wound separately and applied ointment to each wound with a clean cotton-tipped swab; -When a resident had more than one wound in a small area, the LPN measured each individual wound, not as one larger wound. 6. Interviews conducted on 12/12/19, at 3:21 P.M., showed the following: -The ADON said when performing a wound treatment to more than one wound, staff should clean each wound separately, with new gauze, and apply ointment to each wound using a clean cotton-tipped applicator. When measuring more than one wound within a small area, staff should measure each wound separately. If the wound was originally one area, then healed into three separate areas, staff should continue to measure the wounds as one; -The DON said when staff identified a new pressure ulcer, the nurse should assess the wound and document the assessment on the initial and weekly wound documentation form; -The ADON said after the nurse assessed the wound, he/she contacted the physician for orders then notified her (the ADON) and the DON. Nurses complete the weekly skin assessments. If a nurse identified a new pressure ulcer while completing the weekly skin assessment, the nurse should assess the new wound and document the assessment on the initial and weekly wound documentation form; -The corporate quality assurance nurse said when nurses document the resident had an existing wound on the weekly skin assessment, they should include a description/assessment of the existing wound; -The ADON said Calmoseptine was considered a treatment; therefore, the nurse should apply it; -The ADON said a Stage 1 pressure ulcer was not open and blanchable; a Stage 2 pressure ulcer-opened, pink tissue and wound bed; Stage 3 pressure ulcer-open wound, yellow nasty wound bed, and Unstageable pressure ulcer you could not visualize the wound bed, covered with eschar.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to evaluate one resident with a history of falls (Resident #21) in a timely manner for the need of an assistive device when requested by the resident. The facility failed to assess and document one resident's (Resident #53) reported incident involving a mechanical lift. A sample of 21 residents was selected for review in a facility with a census of 103. Record review of the facility's policy titled Fall Precaution and Management and Guidelines, (undated) showed the following: -Objective to identify residents at significant risk of falls and provide for additional precautions to reduced or manage risk; -A resident will be placed on the fall precaution program when any of the following conditions exist: a. Fall risk assessment score on John Hopkins Fall Risk Assessment Tool if 6 or greater, or as identified by the specific fall risk tool used; b. The resident is identified through use of the care area assessment (CAA) as requiring care planning interventions to prevent and/or manage falls; c. The resident had a fall and the Risk Management Committee recommends he/she be placed on the fall precaution program, with interventions implemented as directed in the resident's care plan; -A fall risk assessment to be completed: a. At the time of admission to the facility; b. Reviewed and updated upon readmission is and as appropriate following a hospitalization; c. When a fall occurs and the resident is not already on the fall precaution program; d. When a fall occurs and the resident is already on the fall precaution program, the risk assessment is to be reviewed and updated with newly identified interventions based upon a root cause analysis if and as appropriate; -Ongoing fall assessments will be done in conjunction with the fall CAA when triggered. Fall status will be evaluated at the time all care plan reviews for all residents. 1. Record review of Resident #21's quarterly minimum data set (MDS - a federally mandated assessment tool completed by facility staff), dated 9/29/19, showed: -Re-entered the facility on 6/15/19 from the hospital; -Cognitively intact; -Required supervision, oversight, encouragement, cueing and set-up help only with bed mobility, transfers, walking, dressing, and toileting; -Balance during transition, walking, moving from seated to standing, turning around, moving on and of toilet, and surface to surface transfers is not steady, but able to stabilize without human assistance; -No mobility device; -Identified no falls since prior assessment on 7/01/19; -Resident on antipsychotic, antianxiety, antidepressant, and hypnotic. Record review of the resident's face sheet showed the following diagnoses: -Encephalopathy (brain degeneration), hypotension (low blood pressure), bipolar disorder (mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)), anxiety disorder, type 2 diabetes mellitus with diabetic neuropathy (nerve damage), tachycardia (heart rhythm disorder (arrhythmia) in which the heart beats faster than normal while at rest), repeated falls, major depressive disorder, hypertension (high blood pressure), insomnia, muscle weakness, and pain. Record review of the resident's current care plan, reviewed and revised on 12/06/19, showed the following: -Resident at risk for falling related to generalized weakness, history of falls, confusion, poor balance, and some medications; -Interventions, dated 4/12/17, as follows: -Give resident verbal reminders not to ambulate/transfer without assistance; -Provide toileting assistance every two hours and as needed; -Obtain physical therapy consult for strength training, positioning, transfer training, gait training, devices, etc; -Encourage resident to stand slowly; -Provide resident an environment free of clutter; -Keep call light in reach at all times; -Keep frequently used items in reach; -Night light on in room; -Encourage resident to use hand grips and hand rails; -Orient resident when there has been new furniture or other changes to the environment; -If needed, equip resident with device that monitors rising; -Monitor for pattern of risk factors, poor awareness, and/or tendency to fall; -An intervention, dated 1/15/19, resident fell outside of facility, provide proper, well maintained foot wear. Record review of the resident's progress note dated 11/09/19, at 11:50 A.M., showed: -Nurse called to front hall by administration office; -Nurse witnessed resident holding the handrail and sliding down the wall onto his/her bottom and then lay down on his/her left side; -Resident denies pain and denies hitting head; -Resident states, I just got dizzy; -Assessed and notified family and left message for physician to notify; -Continue to observe. Record review of the resident's progress note dated 11/19/19, at 3:27 P.M., showed: -Therapy came to this nurse and reported the resident asked them for a walker because he/she is afraid he/she is going to fall when ambulating; -Resident ambulates to and from the dining room multiple times daily; -Nursing to monitor for ambulation difficulty and follow up with therapy and physician and address resident concerns. Record review of the resident's current care plan, reviewed and revised on 12/06/19, showed the following: -An intervention, dated 11/19/19, staff to send resident to emergency room for evaluation and treatment. (Staff did not address the resident's request for a walker.) Record review of the resident's progress note dated 11/27/19, at 3:42 P.M., showed a nurse documented the following: -Unwitnessed Fall: the resident was out with a family member to the beauty salon where he/she fell prior to returning to the facility; -As the resident was walking back to the facility, he/she fell again; -The resident reported feeling weak and dizzy; -Upon assessment, the nurse noted the resident had an irregular heart rate and his/her skin was very pale in color; -Staff took the resident to his/her room for further assessment; -The nurse notified the resident's physician and obtained an order to send the resident to the emergency room for further evaluation and treatment; -The nurse notified the resident's responsible party and the Director of Nursing (DON). Record review of the resident's progress note dated 11/28/19, at 12:35 A.M., showed a nurse documented the following: -At 10:20 P.M., the resident returned from the hospital; -Staff assisted the resident to bed; -The resident continues to appear pale and states he/she continues to feel dizzy and lethargic; -The resident stated he/she did not feel any better after receiving intravenous fluids at the emergency room. Record review of the resident's physical therapy plan of care, dated 12/04/19, showed the following: -The reason for referral: Moderate complexity evaluation examination addressed three body structures and functions of bilateral lower extremity weakness, balance deficits, decreased endurance and vertigo, activity limitations, and/or participation restrictions of gait and dynamic balance; -This resident presents to therapy due to a fall on 11/09/19 and 11/27/19 as a result of weakness resulting in a trip to the emergency room on [DATE] and resident returned on 11/28/19; -Resident continues to be weak, pale, and requested walker for ambulation. Resident has complained of weakness, vertigo (brief episodes of mild to intense dizziness), and shortness of breath with resulting impairments in safety with all functional transfers and gait. Record review of the resident's daily physical therapy daily treatment note, dated 12/04/19, showed: -Treatment diagnoses of generalized muscle weakness and unsteadiness on feet; -Instructed resident in strategies to increase ability to self-correct loss in balance; -Facilitation for postural alignment to promote safe transfers from varying surfaces with front wheeled walker (FWW); -Resident has not previously ambulated with FWW; -Compensatory strategy instruction for vertigo and cues for postural righting to decrease risk for falls with use of assistive device with all transitional movements; -Patient ambulated 100 feet x 2 reps and 75 feet x 1 rep using a FWW with contact guard assist (stand-by assist); -Reduce shuffling and/or unsafe gait by increasing single limb support time, step length and toe clearance. -Resident initiated use of walker on this date. (Two weeks after the resident originally requested a walker.) Record review of the resident's current care plan, reviewed and revised on 12/06/19, showed the following: -An intervention, dated 12/06/19, staff to provide the resident with verbal reminders not to ambulate without assistant or his/her walker. Observation on 12/08/19, at 3:08 P.M., showed the resident lying in bed with his/her walker at bedside and call light within reach. During an interview on 12/12/19, at 11:45 A.M., Licensed Physical Therapy Assistant (LPTA) E said the following: -Resident placed on therapy services on 12/4/19, physical therapist did an evaluation that day due to the resident's falls and the resident did go out to the emergency room and come back on 11/28/19; -Prior to 12/04/19, the resident was independent with ambulation; -The resident has a history of vertigo; -Therapy recommended the resident use a walker and walk with assistance; -Sometimes it takes several days to get insurance approval for a therapy evaluation. During an interview on 12/12/19 at 12:14 P.M., Registered Nurse (RN) C said the following: -A therapist came to the nurses' desk and told the nurse the resident would like a walker; -The nurse put the information on the 24 hour report sheet and passed it on to the evening shift nurse; -The nurse assumed the information would have then been discussed at the morning meeting with therapy and the department heads the following day. During an interview on 12/12/19, at 12:42 P.M., the Physical Therapist (PT) E said the following: -The therapist received a request of walker because the resident had a declining gait; -The facility could not just hand the resident a walker, so therapy admitted the resident to therapy services; -The resident had a fall approximately one week prior to the start of therapy; -The fall occurred outside of the facility on the sidewalk while returning from a beauty appointment with family; -At the time of the fall outside, the resident was walking without an assistive device -The resident walked independently prior to that fall; -The resident's family member informed the therapist, the resident had fallen earlier that same day while out of the facility; -He/she then had to wait for a physician's order and for insurance approval before he/she could evaluate the resident; -Therapy can do a fall screen without an order, if someone has a fall; -The fall screen is done to determine if a resident needs therapy; -A fall screen was not done for the resident because the facility was in the process of getting orders and insurance approval to evaluate and treat the resident; -The resident informed the therapist he/she wanted an order; -The therapist said another therapist requested the physician's order from nursing -The therapist said therapy would not give the resident a walker without an order; -The resident is currently using a front wheeled walker borrowed from the therapy department; -Currently the resident is supposed to use his/her walker and have stand by assistance from staff when walking. During an interview on 12/12/19, at 3:29 P.M., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said the following: -The resident is currently on therapy because he/she had a couple of falls over the last two weeks; -If a resident asks for a walker, nursing or therapy should request a physician's order for a therapy evaluation; -Once someone request a therapy evaluation, nursing should obtain a physician's order in a timely manner, within the same day, and the insurance company should approve the request within 24 to 48 hours from the time the time the facility obtains the order for therapy; -If a resident has insurance, the facility has to get an authorization. During an interview on 12/12/19, at 3:30 P.M., the administrator said the following: -Once therapy obtains a physician's order for a therapy evaluation, the therapist submits a payer verification form; -This form is submitted to the insurance company and usually within a few hours or the same day the facility gets approval; -If a resident requested a walker, to ensure the resident's safety, while awaiting approval for a therapy evaluation, nursing should encourage the resident to sit in a wheelchair, if he/she feels unsteady/unsafe. 2. Record review of Resident #53's facesheet showed staff admitted the resident to the facility on 7/15/11. His/her diagnoses included paraplegia (paralysis of the legs and lower body). Record review of the resident's care plan, initiated 2/2/17, showed the resident transferred with the assistance of two staff and a mechanical lift. Record review of the resident's care plan, initiated 3/29/18, showed the following: -The resident exhibited manipulative behaviors such as fabricating stories for attention and other attention seeking behaviors such as becoming emotional; -Assess the needs resident's was trying to meet through criticism's and/or behaviors, such as taking him/her back to his/her room sooner rather than later; -Convey an attitude of acceptance toward the resident. Do not take the resident's criticism's personally; -Listen objectively to the resident's complaints and clarify misconceptions; -Maintain a calm environment and approach to the resident; -Chart behaviors; -Support appropriate moods/behaviors. Avoid power struggles with the resident. Record review of the resident's quarterly MDS, dated [DATE], showed the following information: -No cognitive impairment; -Required extensive assistance with bed mobility, dressing, toileting and personal hygiene; -Dependent upon staff for transfers and bathing; -Used a wheelchair for mobility. During an interview conducted on 12/9/19, at 1:50 P.M., the resident said a few day ago staff did not ensure the mechanical lift's arm was secure causing it to hit him/her on the right side of his/her head. The resident said it really hurt; he/she saw stars. One of the aides left the room and got a nurse who shined a light into his/her eyes. The side of her face was a little sore after the incident. Record review of the resident's November 2019 physician progress note showed the physician documented the resident got bumped by the Hoyer (mechanical) lift on the left side of his/her forehead. The resident did not complain of pain or discomfort from the incident. A nurse reported the incident to the physician. The physician assessed the resident and found no redness or tenderness. Record review of the resident's progress notes, from 6/1/19-12/9/19, all disciplines, showed no documentation the resident exhibited behaviors, and no further documentation of the incident involving a mechanical lift, including how the nurse became aware of the incident, and an assessment of the resident for injuries. During an interview conducted on 12/10/19, at 5:30 P.M., Certified Nurse Aide (CNA) K said the resident told him/her the mechanical lift's arm hit him/her in the face, but the CNA did not do that and he/she did not hear about it from anyone else. During an interview conducted on 12/10/19, at 5:42 P.M., Registered Nurse (RN) C said the resident told several people that an aide hit him/her in the head with the mechanical lift. The resident had said this ever since he/she started working at the facility on 9/23/19. The resident had a history of making accusations about others. During an interview conducted on 12/10/19, at 6:30 P.M., Licensed Practical Nurse (LPN) J said the resident never told him/her staff hit him/her in the head with the mechanical lift and no staff ever reported it. During an interview conducted on 12/12/19, at 12:08 P.M., CNA L said he/she heard and knew about possible incident regarding a mechanical lift hitting the resident in the head. Every time the CNA brought the lift near the resident, the resident placed his/her hands up around his/her face. The CNA asked the resident why he/she placed his/her hands by his/her face and the resident said he/she was afraid the lift would hit him/her. The CNA assured the resident he/she would be careful. Within the last few months, an aide told CNA L that when he/she moved the lift arm near the resident, it touched the resident's face. CNA L did not remember who told him/her of this incident. After this occurred, the CNA did not notice any increase in the resident's fear of the lift hitting him/her and at the time, the CNA did not observe any redness or bruising to the resident's face. The CNA said he/she reported it to the nurse working who just wrote it down on a piece of paper. During an interview conducted on 12/12/19, at 2:15 P.M., CNA M said he/she had not heard of any incident regarding the resident and a mechanical lift. The resident did not tell him/her anything either. The resident seemed scared of the trapeze bar positioned above the resident's head, so the CNA placed his/her hand over it to protect the resident's head. During an interview conducted on 12/12/19, at 2:25 P.M., LPN J said if staff reported a staff member hit a resident with a mechanical lift, he/she would assess the resident, notify the DON and ADON and call the physician for further orders. He/she would start neurological checks if the lift hit the resident in the head. The LPN would document the assessment and any further orders or instructions in the resident's progress notes. Interviews conducted on 12/12/19, at 3:21 P.M., showed the following: -The DON said if a resident reported he/she was hit in the head with a mechanical lift, staff should document what happened and notify the DON and ADON. This was the first time the DON had heard of this incident. -The ADON said the nurses would also assess and document, for a few days, any bruising. The resident fabricated stories. And every time staff come into his/her room, he/she says he/she was hit in the head with a mechanical lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain an agreement with a dialysis (a process of cleaning the blood by a special machine necessary when the kidneys are not able to filter the blood) provider, failed to obtain a physician's order for dialysis before the resident received dialysis, and failed to consistently send and complete a dialysis communication form for one resident (Resident #253) in a selected sample of 21 residents. The facility's census was 103. 1. Record review of the facility's Dialysis, Care of a Resident Receiving policy, dated March 2012, showed the following sections: -Care of the AV (arteriovenous) shunt/fistula/grafts (abnormal connection or passageway between an artery and a vein); -Care of a subclavian (major arteries of the upper thorax, below the collarbone) or femoral vein (a large vein in the thigh) catheter; -Checking the thrill sensation (the sensation like a vibration, caused by blood flowing through the fistula; the thrill indicates the fistula is working); -Signs of infection; -When to call the physician; -Emergency care; -The access for dialysis comes out; -Signs of bacteremia with sepsis; -Signs of septic shock; -Residents with fluid restrictions due to dialysis; -Residents with special diet due to dialysis; -Emotional and social needs; -Communication between the facility and dialysis unit. Record review of Resident #253's face sheet (a general information sheet) showed the following information: -admitted to the facility on [DATE]; -Diagnoses included dependence on renal (kidney) dialysis, acute (sudden onset) respiratory failure with hypoxia (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), diabetes and lung disease. Record review of the resident's 14-day Minimum Data Set (MDS), a federally mandated assessment instrument, completed by facility staff, dated 12/9/19, showed the resident had moderately impaired cognition. Record review of the resident's December 2019 physician order sheet (POS) showed no order for dialysis. Record review of the resident's progress notes showed the following information: -On 12/7/19, at 6:37 P.M., a nurse documented the resident admitted to the facility. -On 12/8/19, at 8:20 A.M. and 12/9/19 at 8:22 A.M., a nurse documented the resident would receive dialysis three times a week. Record review of the resident's Baseline care plan, dated 12/8/19, showed the following information: -The resident needed oxygen treatment and dialysis (the baseline care plan did not include any further information regarding the resident's dialysis); -The resident was alert and cognitively intact; -Monitor medications and condition, and report to the Director of Nursing (DON) and physician when applicable, obtain lab values and report to the physician. -Needed assistance with bed mobility, transfer, toileting, walking and bathing. During Interviews on the following dates/times the resident said the following: -On 12/9/19, at 1:00 P.M., the resident said he/she admitted to the facility two days ago. He/she required dialysis, but had not went to dialysis since admitting to the facility. He/she completed dialysis at the hospital on Saturday; -On 12/10/19, at 3:08 P.M., the resident said he/she just returned from dialysis. Record review of the resident's progress notes showed the following information: -On 12/9/19, at 7:50 P.M., a nurse documented the resident would have dialysis three times a week on Tuesday, Thursday and Saturday, at 6:30 A.M.; -On 12/10/19 , at 5:20 P.M., a nurse documented the resident went to dialysis; -On 12/12/19, at 2:17 A.M., a nurse documented the resident received dialysis on Tuesday, Thursday and Saturday. Staff knew the resident needed up for breakfast and to obtain the resident's weight and vital signs prior to him/her leaving for dialysis. Record review of Dialysis Consultation Record (communication form), dated 12/10/19, showed facility sent the completed form to the dialysis center who completed their portion and returned it to the facility. Record review of the resident's December 2019 treatment administration flowsheet showed no order or instructions for staff to monitor and assess the resident's arteriovenous (AV) fistula. During an interview on 12/12/19, at 11:58 A.M., Registered Nurse (RN) C said the following: -The resident admitted to the facility on Saturday (12/7/19); -The resident had an AV fistula in his/her left arm and went to dialysis on Tuesday, Thursday, and Saturday, at 6:30 A.M.; -The nurses monitor the resident's AV fistula site, but the resident would not let anybody touch it; -The AV fistula area was cleaned yesterday and had a new bandage placed on it; -The facility was waiting on orders for laboratory tests from the dialysis center; -RN C just found out the resident did not have an order to monitor his/her AV fistula; -Staff usually checked the AV fistula daily. Usually the treatment would be on the treatment sheet, but there was not a treatment sheet for the resident's AV fistula; -The facility usually waited for orders to come from the dialysis center or clarified with the physician; -The resident's physician was here on Tuesday (12/10/19) but the resident was at dialysis. The physician has not yet seen the resident; -The facility was trying to obtain physician orders regarding the resident's dialysis treatment and AV fistula today; -The nurses documented the assessment of the resident's fistula in the resident's progress notes. -The nurses completed a dialysis communication sheet and send it with the resident when he/she went to dialysis; -RN C thought the nurse forgot to complete and send the form today. During an interview on 12/12/19, at 12:26 P.M., the Director of Nursing (DON) said the following: -Staff knew if a resident received dialysis by reviewing the resident's history and physician located in the resident's admission packet. The facility transcribed the orders from the hospital discharge sheet onto the resident's physician order sheet. -The resident's physician order sheet included the resident's medications, ordered laboratory tests, an order for checking the resident's bruit and thrill, how long the resident received dialysis, and the days the resident went to dialysis; -If a resident had a fistula port, staff should listen for a bruit (a vascular murmur), and monitor the area for bleeding and swelling; -The facility sent a face sheet and medication sheet with the resident to dialysis center. The dialysis center should send with the resident, when he/she returned to the facility, a report that showed the amount of fluid removed from the resident and any medications they administered to the resident; ; -The DON did not know of communication form to send to the dialysis center. The facility would call the dialysis center if they needed anything. During an interview on 12/12/19, at 3:21 P.M., the Assistant Director of Nursing (ADON) said the following: -Residents continued the same dialysis schedule they followed prior to admission to the facility; -The nurses completed a dialysis communication form and sent with the resident to dialysis. Dialysis center staff completed the form and sent it with the resident when he/she returned to the facility; -Today (12/12/19) was the resident's second treatment at the dialysis center. During an interview on 12/12/19, at 3:21 P.M., the Administrator said he did not know if there was an agreement with a dialysis provider to provide dialysis services to resident who resided at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the record was accurate and complete when staff did not document a change of condition for one resident (Resident #58) when the resident's condition declined and facility staff sent the resident to the hospital where the resident was diagnosed with osteomyelitis (a bone infection) and cellulitis (an infection of the tissue) out of a selected sample of 21 residents were selected for review in a facility with a census of 103. 1. Record review of Resident #58's quarterly minimum data set (MDS - a federally mandated assessment tool completed by facility staff), dated 8/1/19, showed the following: -admitted on [DATE], re-admitted to the facility from the hospital on 4/24/19; -Moderate cognitive impairment; -Required extensive assistance of two or more staff with bed mobility, transfers, dressing, toileting, and personal hygiene; -Functional limitation in range of motion to bilateral lower extremities; -Wheelchair for mobility; -Suprapubic catheter (a urinary catheter that is surgically placed through the abdominal wall into the bladder); -Diagnoses included heart failure, infection of multi-drug resistant organism, diabetes, anxiety, and depression. Record review of the resident's progress note dated 10/15/19, at 3:02 A.M., showed a nurse documented the following: -On 10/14/19, at 8:30 P.M., a nurse checked the resident's blood sugar and it read high (normal blood sugar range 80-100 milligrams (mg)/deciliter (dl)); -The nurse rechecked the resident's blood sugar with the same result; -The nurse notified the on-call physician and received an order to administer 4 units of sliding scale insulin and recheck in one hour; -The nurse rechecked the resident's blood sugar twice, and it still read high; -The nurse again notified the resident's on-call physician and received an order to administer an additional 7 units of insulin and observe through the night; -Resident was resting in bed, with his/her eyes closed, his/her blood sugar was 427 mg/dl. Record review of the resident's progress notes showed staff did not document any additional information on 10/15/19. Record review of the resident's progress notes, dated 10/16/19 to 10/17/19, showed staff did not document regarding the resident. Record review of the resident's vital sign flow sheet, dated 10/17/19, showed staff did not document vital signs. Record review of the facility's census showed the resident discharged to the hospital for inpatient care on 10/17/19 at 2:45 P.M. Record review of the resident's hospital progress note, dated 10/23/19, showed a hospital physician documented the following: -Diagnoses of acute metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), cellulitis (bacterial skin infection) of the right leg, bacteremia (bacteria in the blood) with streptococcus (a type of bacteria), and osteomyelitis of the right femur (thighbone); -Likely metabolic encephalopathy, now resolved, secondary to bacteremia and febrile illness; -Lactic acid (a blood test) level elevated secondary to probable sepsis (a potentially life-threatening condition caused by the body's response to an infection); -History of right and left below the knee amputation. Record review of the resident's progress notes dated 10/24/19, at 8:35 P.M., showed the following: -admission assessment showed the resident arrived to the facility via ambulance services; -Diagnosis of metabolic encephalopathy; -Resident had mild confusion; -The resident had a midline 18 gauge, single lumen catheter, for intravenous (IV) antibiotic administration. Record review of the resident's progress note, dated 10/24/19, completed by a nurse practitioner, showed: -Resident re-admitted from the hospital on [DATE]; -Diagnoses of acute encephalopathy, cellulitis of right leg, type 2 diabetes mellitus (uncontrolled with peripheral vascular (veins and arteries not in the chest or abdomen) complication), Stage 3 chronic kidney disease (moderate kidney damage), bacteremia, secondary sepsis possible. Record review of the resident's significant change MDS, dated [DATE], showed the following: -Resident on IV medication -Resident received antibiotic 7 out of the last 7 days. During interview Registered Nurse (RN) C said the following: -On 12/11/19, at 2:11 P.M., RN C said on 10/17/19, at approximately 9:30 A.M. or 10:00 A.M., staff reported the resident vomited and acted more confused. The nurse assessed the resident and found the resident did not know the nurse's name, which was unusual. The resident could not focus on what he/she looked at and his/her pupils were constricted (pupils that remain very small even in bright light). The nurse said another staff member may have checked the resident's vital signs, but he/she did not know if anyone recorded the results. The nurse contacted the resident's physician and after talking with the resident's family, the physician said to send the resident to the hospital. He/she did not know why he/she did not document a nurse or progress note about the resident's change in condition or transfer to the hospital; -On 12/12/19, at 12:14 P.M., RN C said the resident went to the hospital on [DATE] with a change in condition and decreased level of consciousness. The resident returned from the hospital on [DATE] with diagnoses of acute encephalopathy, and cellulitis and osteomyelitis of his/her leg. The resident returned from the hospital with a PICC line for infusing IV antibiotics. During an interview on 12/12/19, at 1:58 P.M., Certified Medication Technician (CMT) D said the following: -On 10/17/19, the resident had an episode in which he/she could respond, but his/her pupils were pinpoint; -The CMT notified the nurse and by the time the nurse entered the room, the resident was not responding; -The CMT thought staff obtained the resident's vital signs, but did not know if staff documented the vital signs. During an interview on 12/12/19, at 3:30 P.M., the Director of Nursing (DON) said the following: -The nurse should have documented the resident's change of condition assessment in the resident's progress notes; -The nurse should call the resident's physician and family to notify of the resident's change of condition and document the notification in the resident's progress notes; -Nursing staff should have checked the resident's vital signs, due to the resident's change in condition, and documented them in the vital signs section of the electronic health record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative nursing services to maintain or improve residents' functional status as directed by therapy for four residents (Resident #31, Resident #42, Resident #48, and Resident #75) out of 21 sampled residents. The facility census was 103. Record review of the facility's policy titled, The Restorative Nursing (RNA) Program, dated May 2006, showed the following information: -The restorative nursing program is an integral part of maximizing the daily restorative care process for the residents; -The RNA program is a part of the logical step-down process in resident care; -A pro-active approach is necessary to prevent future negative outcomes; -It is the purpose of this facility to see that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care; -It is the entire staff's responsibility to prevent deterioration and further functional loss of each resident in the facility. The objective of the RNA program is to provide restorative care necessary to meet the needs of all resident to enable them to achieve a standard of care; -Clear lines of authority, expectations, and responsibilities are necessary for implementation of the RNA program; -Restorative services are to be made available seven days a week, per residents' assessed needs; -Criteria for resident entry to, movement within, and discharge from the RNA program must be clearly established; -A mechanism for monitoring and on-going evaluation of the RNA programs must be established; -Restorative Nursing Aides (RNA's) must be adequately trained and provided with the on-going training and consultation. 1. Record review of Resident #'31's face sheet (admission record) showed the following: -The resident admitted to the facility on [DATE] and re-admitted on [DATE]; -Diagnoses included unsteadiness on feet, other abnormalities of gait and mobility, and restless legs syndrome. Record review of the resident's physical therapy progress and Discharge summary, dated [DATE], showed the following: -Treatment for gait training, neuromuscular re-education, therapeutic activities and exercise; -Received services from 6/12/19 through 7/23/19; -Discharge plans and instructions included recommendations for continued ambulation with restorative aide (RA) staff. Record review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/16/19, showed the following information: -Cognitively intact; -Required limited assistance with bed mobility, dressing, toilet use and personal hygiene; -Functional limitation in range of motion (ROM): lower extremity-impairment on one side; -Used a wheelchair for mobility. Record review of the resident's care plan, revised on 10/16/19, showed the following: -The resident was limited in mobility and used a wheelchair; -Obtain physical therapy and occupational therapy if needed; -The resident was limited in the ability to dress, toilet, bathe, or perform hygiene care related to decreased mobility and poor cognitive status; -The resident was at risk for alteration in comfort/pain related to decreased mobility, neuropathy (nerve damage), healing of the right hip incision, and osteoarthritis; -Follow physical therapy recommendations; -The resident was at risk for falling related to generalized weakness, poor balance, poor safety awareness, certain medications, history of falls and right hip deficits; -Physical therapy as ordered. (Staff did not care plan a specific restorative plan of treatment.) Record review of the resident's medical record showed no treatment plan or documentation the resident received restorative services as recommended. During an interview conducted on 12/9/19, at 11:05 A.M., the resident said he/she did not have a left hip. He/she had surgery four separate times on his/her hip and the 5th time was told they could not do anything further. His/her left leg was 2 inches shorter than his/her left and he/she wore a built-up shoe when he/she walked. He/she had extenders on his/her walker to assist him/her with walking upright. He/she did not have official physician orders for walking, but he/she would like to walk more or at least have the opportunity to walk more. Certified Nurse Aide (CNA) L asked the resident, about 2 times a week, if he/she wanted to walk to the dining room. CNA L was the only staff to ask. During an interview conducted on 12/12/19, at 12:08 P.M., CNA L said the resident's spouse used to assist him/her to walk, but he/she started to stumble a bit so the CNA decided to assist the resident when he/she could. The CNA assisted the resident the same as his/her spouse did; with a gait belt and the resident's walker. No one instructed the CNA on how of when to walk with the resident. CNA L assisted the resident yesterday. He/she did really well. However, he/she usually could walk from the dining room to his/her room, but yesterday he/she could only walk to the pictures near the dining room. Observations throughout the survey showed the resident was alert and oriented and required a wheelchair for mobility. 2. Record review of Resident #42's face sheet showed the following: -The resident was admitted to the facility on [DATE]; -His/her diagnoses included stroke, pressure ulcer of left hip, pain in left hip, muscle weakness (generalized), muscle spasm, and hemiplegia (paralysis of one side of the body) affecting the left non-dominant side. Record review of the resident's physical therapy progress and Discharge summary, dated [DATE], showed the following: -Treatment for gait training, neuromuscular re-education, therapeutic activities, and exercise; -Received services from 6/30/19 through 8/7/19; -Discharge plans and instructions included resident discharged to this same skilled nursing facility with recommendations including continued exercises and transfers with RA staff to maintain bilateral lower extremity strength. Record review of the resident's quarterly assessment, dated 10/6/19, showed the following information: -Moderately impaired cognitive skills; -Extensive assistance required with bed mobility, transfer, dressing, eating and toilet use; -Functional limitation in ROM: upper and lower extremity-impairment on one side. Record review of the resident's care plan, revised on 10/7/19, showed the following: -The resident required assistance with activities of daily living (ADLS) related to a stroke and left-sided weakness; -The resident was at risk for falling related to decreased mobility and weakness; -Assist the resident with transfers and ambulation as the resident allows; -The resident is at risk of decreased activity involvement. (Staff did not care plan a specific restorative plan of treatment.) Record review of the resident's medical record showed no treatment plan for restorative services. 3. Record review of Resident #48's face sheet showed the following: -The resident admitted to the facility on [DATE] and re-admitted on [DATE]; -Diagnoses included hemiplegia and hemiparesis (weakness of one entire side of the body) and contracture (develops when the normally stretchy (elastic) tissues are replaced by nonstretchy (inelastic) fiber-like tissue. This tissue makes it hard to stretch the area and prevents normal movement) of muscle in the right upper arm. Record review of the resident's physical therapy progress and Discharge summary, dated [DATE], showed the following: -Analysis of functional outcome/clinical impression: The resident did not make significant progress toward goals. The treatment plan adjustments to include restorative training for sit to stand and stretching; -Received services from 4/29/19 through 6/17/19; -Discharge plans and instructions: Resident discharged to this same skilled nursing facility with recommendations including continued RA program two to five times per week for 90 days for : strengthening and stretching. Record review of the resident's care plan, revised on 10/16/19, showed the following: -Resident resisted care and did not want to follow therapy recommendations; -The resident was at risk for deterioration with bed mobility related to left sided weakness related to stroke; -Physical and occupational therapy for strengthening; -The resident was limited in mobility and functional status and required the use of a wheelchair; -The resident was at high risk for falls and had a history of falls; -The resident was at risk for deterioration in bed mobility, transfer, locomotion on and off the unit, dressing, eating, toilet use and personal hygiene; -Follow physical, occupational and speech therapy recommendations. (Staff did not care plan a specific restorative plan of treatment.) Record review of the resident's annual assessment, dated 10/19/19, showed the following information: -Cognitively intact; -Required extensive assistance with bed mobility, transfer, dressing, and toilet use; -Functional limitation in ROM: upper and lower extremity-impairment on one side. Record review of the resident's progress note dated 10/25/19, at 12:08 P.M., showed a nurse documented a CNA reported for the last two weeks, the resident needed increased assistance with transfers. The resident was unable to stand as long, unable to hold onto the bathroom grab bar and was pushing back, against the CNA. PT aware. Would continue to observe. Record review of the resident's medical record showed no treatment plan or documentation the resident received restorative services as recommended. Observations during the survey showed the resident was alert and oriented. He/she used a wheelchair for mobility and self propelled the wheelchair. The resident's left hand remained in a closed position with his/her left elbow flexed and against his/her body. His/her left leg and foot rested on his/her wheelchair foot rest. During an interview conducted on 12/12/19, at 12:08 P.M., CNA L said the resident's left hand and arm were contractured. It hurt the resident to open his/her hand. The resident was slowly declining. A few months ago he/she could stand with assistance, but now he/she required use of the sit-to-stand mechanical lift for transfers. The CNA reported the resident's decline to the charge nurse. During an interview conducted on 12/12/19, at 12:43 P.M., the Physical Therapist (PT) said the resident received therapy several times. He/she could walk with a hemiwalker, but did not. The therapist thought it would be appropriate for the resident to receive therapy again because of a decline. She did not know of an actual decline, but the resident recently asked to receive therapy again. The PT did not not know of the progress note regarding the resident needing more assist with transfers, however, not all of the staff understand who and what the different therapist did so the nurse could have reported the possible decline to another therapist. During an interview conducted on 12/12/19, at 2:15 P.M., CNA M said the resident required more staff assistance; he/she had declined in his/her ability to transfer, especially within the last week. He/she used to transfer with a gait belt and assistance but now he/she required a sit-to-stand mechanical lift. The aide thought the day shift aide used the sit-to-stand mechanical lift to transfer the resident before he/she did. 4. Record review of Resident #75's face sheet showed the following: -The resident was admitted to the facility on [DATE] and re-admitted on [DATE]; -Diagnoses included osteoarthritis of knee, fracture of unspecified metatarsal bone (right foot), pain in right, and left shoulder. Record review of the resident's quarterly assessment, dated 11/13/19, showed the following information: -Cognitive skills intact; -Extensive assistance required with bed mobility and toilet use; -Functional limitation in ROM-no impairment in upper and lower extremity. Record review of the resident's care plan, last revised on 11/18/19, showed the following: -The resident is at risk for falling related to weakness; -The resident requires assistance with activities of daily living. Record review of the resident's physical therapy progress and Discharge summary, dated [DATE], showed the following: -Received services from 10/23/19 through 11/14/19; -Discharge plans and instructions: resident discharged to this same skilled nursing facility with recommendations including continued ambulation in community with supervision with four wheeled walker. Record review of the resident's care plan showed staff did not update the care with the discharge and continued restorative services. During an interview on 12/10/19, at 12:52 P.M., the PT F said he/she would have referred the resident to the restorative program. He/she said the resident could have benefited from the restorative service program. He/she said the discharge plans for the resident meant for him/her to receive restorative services. During an interview on 12/10/19 at 2:03 P.M. Licensed Practical Nurse (LPN) H said the resident would probably benefit from restorative services for his/her lower body. 5. During an interview on 12/10/19, at 12:52 P.M., CNA G said the following: -He/she is unaware of the process for residents to be placed on the restorative program; -The facility has a restorative department. The facility is hiring for the restorative aide position; -The facility has not had anyone in that position for awhile. 6. During an interview on 12/10/19, at 1:05 P.M., PT F said the following: -When a resident discharged from therapy, staff write an order and the physician signs it; -Therapy staff complete a recommendation for restorative services and give to the restorative aide; -Therapy completes training with the restorative aide for the task the restorative aide will be performing with that particular resident; -Restorative orders are always two to five times per week for 90 days; -The start and end date is on the order for restorative; -There has been no restorative aide for the past six months; -He/she would have referred all residents discharged off of therapy who were not independent ambulators. 7. During an interview on 12/11/19, at 1:47 P.M. the Director of Nursing (DON) said the following: -The maintenance director was the restorative aide from January 2019 to the end of May 2019; -There have been two other staff in the restorative position off and on since June 2019; -The facility has been without a restorative aide since November 1, 2019; -When a restorative aide was pulled to the floor as an aide, no one worked restorative services; -Physical therapist makes a recommendation for restorative services when a resident is discharged off of therapy; -Restorative program benefits include improving strength, range of motion and getting around; -Therapy has not referred residents for restorative since November 1, 2019; 8. During an interview on 12/12/19, at 10:15 A.M. the corporate quality assurance nurse said she was unable to find any restorative sheets for the listed residents regarding the discharged dates given for their recommendations for restorative services. 9. During an interview conducted on 12/12/19, at 2:25 P.M., LPN J said if staff reported to him/her a resident had a decline in his/her functional ability, he/she would notify the physician, who would write an order for a therapy evaluation. He/she would enter the order into the computer, and give a copy to therapy. If therapy was not at the facility, he would lay the order on the director of rehabilitation's desk. He would then document this in the progress notes.