**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care and services to meet the needs of a resident on hospice (end of life care) for one sampled resident (Resident #29) out of five sampled residents. The facility census was 55 residents. Review of the facility's Hospice Program Policy dated 2001, revised 7/2017 showed: -Hospice services are available to residents at the end of life. -It was the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions, including the following: --Determining the appropriate plan of care. --Changing the level of services provided when it was deemed appropriate. --Providing medical direction, nursing and clinical management of the terminal illness. --Providing medications necessary for the palliation of pain and symptoms. -It was the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided in appropriately based on the individual resident's needs. --Administering prescribed therapies, including those therapies determined appropriate by hospice and delineated in the hospice plan of care. -Communicating with the hospice provider and documenting such communications to ensure that the needs of the resident are addressed and met 24 hours per day. -The coordinated care plan will reflect the resident's goals and wishes, as stated in his/her advance directives and during on going communication with the resident or representative, including: --Palliative goals and objectives. --Palliative interventions, medical treatment and diagnostic test. -The coordination care plan shall be revised and updated as necessary to reflect the resident's status including, but not limited to: --Diagnosis. --Problem list. --Symptom management (pain, nausea, vomiting etc.). Review of the facility's Medication Therapy Policy dated 2001, revised 4/07 showed: -Medication use shall be consistent with an individual's condition, prognosis, values, wishes, and responses to such treatments. -The physician will identify situations where medications should be tapered, discontinued, or changed to another medication. Review of the facility's Administer Medications Policy dated 1/1/24 showed: -To ensure safe and effective administration of medication in accordance with physician orders. 1. Review of Resident #29's admission Record showed he/she was admitted to the facility on [DATE], readmitted on [DATE] with the following diagnosis: -Hypertensive Heart Disease (prolonged high blood pressure) with Heart Failure (a chronic condition in which the heart does not pump blood as well as it should). -Chronic Diastolic (Congestive) Heart Failure (a condition in which the heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly). -Rheumatoid Arthritis (is an ongoing chronic condition that causes pain, swelling and irritation, called inflammation, in the joints). Review of the resident's Pain Assessment on 4/19/25 showed he/she: -Had pain in the last five days. -Frequently experienced pain in the last five days. -Pain effect on sleep rarely or not at all. -Interferes with therapy and day to day activities frequently. -Pain intensity on a score of zero being no pain to 10 being high pain score of six. -Verbal descriptor scale was moderate. -Staff should assess for pain. -Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw). -Frequency he/she complains of pain every one to two days. -Pain management with scheduled pain medications. -No as needed pain medication offered. -No non-medication interventions for pain. Review of the resident's Care Plan last reviewed on 4/29/25 showed: -He/She has chronic pain related to rheumatoid arthritis, left hip fracture and artificial left and right knee joints. --He/She will not have an interruption in normal activities due to pain. --Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. --Monitor/record/report to nurse any signs/symptoms of non-verbal pain (changes in breathing, vocalizations, mood/behavior changes, facial expressions, and body actions. --Monitor/document for side effects of pain medications. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 5/12/25 showed the resident: -Was severely cognitively impaired. -Was receiving hospice services. Review of the resident's Order Summary Report dated 5/14/25 showed: -Admit to hospice, order date 5/12/25. --NOTE: Resident was admitted on hospice on 5/9/25 when the contract was signed. -May crush medications as needed (PRN), order date 5/14/25 at 11:00 A.M., no start date. -Hyoscyamine Sulfate Oral Tablet Disintegrating 0.125 milligrams (mg), give one tablet by mouth every four hours PRN for increased secretions, order and start date of 5/14/25 at 7:00 A.M. -Lorazepam Oral Tablet 0.5 mg, give one tablet by mouth every four hours PRN for anxiety, order and start date of 5/14/25 at 10:54 A.M. -Morphine Sulfate Oral Tablet 15 mg, give one tablet by mouth every six hours PRN for pain/shortness of air (SOA), order and start date of 5/14/25 at 10:58 A.M. --NOTE: The hospice physician's order on 5/10/25 for liquid Lorazepam and liquid Morphine was not located in the resident's hospice orders. -Zofran Oral Tablet 4 mg, give one tablet by mouth every eight hours PRN for nausea, order and start date of 5/9/25. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated 5/1/25 to 5/31/25 showed: -Lorazepam Oral Tablet 0.5 mg, give one tablet by mouth every four hours PRN for anxiety, first dose given on 5/14/25 at 11:18 A.M. -Morphine Sulfate Oral Tablet 15 mg, give one tablet by mouth every six hours PRN for pain/shortness of air (SOA), first dose given on 5/14/25 at 11:18 A.M. --NOTE: The hospice physician's order on 5/10/25 for liquid Lorazepam and liquid Morphine was not located in the resident's hospice orders. -Tramadol-Acetaminophen Tablet 37.5-325 mg, give one tablet by mouth every six hours for pain, last dose given on 5/13/25 at 11:07 P.M. Review of the facility's hospice provider communication book on 5/14/25 showed: -Hospice start of care date was 5/9/25. -Patient consent form. -Election of hospice benefits. -Hospice election statement. -Visit Notes. -Medicine list printed on 5/12/25. During an interview on 5/14/25 at 12:21 P.M. the Hospice Physician said: -He/She gave verbal orders for the resident's medications on 5/10/25 for liquid sublingual (under the tongue) morphine (pain), lorazepam (anxiety) and hyoscyamine sulfate (increased secretions). He/She gave the orders verbally to the hospice nurse to be written in the hospice book for the facility to enter into the computer. -On 5/12/25 he/she was informed the medication orders disappeared from the facility between 5/10/25 and 5/12/25. -The orders were never entered into the resident's MAR or TAR and never given to the resident. -He/She gave the same orders again on 5/12/25 to the nurse to be filled for the resident's comfort. -He/She was told the facility requested no liquid medications and would like the medication orders to be given in tablet form due to drug diversion per the Director of Nursing (DON). -He/She always orders liquid in these medications due to the liquid form works better and faster than the tablet form. -The tablets could be crushed and mixed with something for the resident to swallow easier. -This resident was having difficulty swallowing before being admitted to hospice. -The medication orders were not put into the resident's MAR until 5/14/25. -The facility physician prefers the hospice physician to take care of the residents' medications once admitted to hospice. During an interview on 5/14/25 at 12:40 P.M., Family Member #1 said: -The resident just received some medications finally. -Hospice wrote out all the medication orders on 5/10/25 and gave the medication orders to the nurse. -The facility was not able to find the medication orders and all orders were rewritten on 5/13/25 by hospice. During an observation on 5/14/25 at 12:40 P.M. showed: -The resident was sitting up straight in bed. -Family member #1 was at the bed side trying to get the resident to drink some juice. -The resident was not responding to any verbal commands. -Resident had his/her eyes closed, with his/her mouth open, nasal cannula on for oxygen due to shortness of air. During an interview on 5/14/25 at 3:01 P.M. the facility Physician said: -Generally, he/she does not override a hospice physician. -He/She was not contacted by the facility to change the resident's liquid medications order by hospice to pills to be crushed. -He/She would expect the facility to follow the hospice physician's orders as prescribed. -Hospice takes over the medications once the resident was admitted to hospice. -The resident was not able to swallow medication whole. -The medications need to be crushed and put in applesauce or pudding to give to the resident. During an interview on 5/14/25 at 3:34 P.M. the DON said: -He/She was at the facility on 5/10/25, when hospice put the resident's orders in the communication book. -The resident's hospice physician had ordered liquid morphine, lorazepam, and hycosamine. He/She does not know what happened to those orders. -He/She asked the nurse that was on duty when the hospice physician gave the orders for liquid morphine, lorazepam, and hycosamine, however he/she could not remember what his/she did with the orders. -He/She want the resident's hospice physician to order tablets instead of liquid medications. -Does not know why the orders were not put into the computer for approval by the facility physician. -The nurse on duty or him/her self should have entered the orders in the computer received by the hospice physician at the time the hospice orders were received. -He/She expected staff to enter physician orders at the time they are received and to follow the physician orders. -Hospice takes over the resident's medications. -He/She had asked hospice to not use liquid medications due to possible drug diversion. -He/She called all contracted hospices and asked them to either discontinue the liquid medications for nonuse or write the order in tablet form. -The hospice orders were confusing for the facility nurse. -He/She went through the orders with the night nurse and hospice on 5/13/25. -The night nurse contacted the hospice physician to discontinue some medications and to enter new medication orders on 5/13/25. -He/She continued putting in the new orders for the morphine, lorazepam and hyoscyamine Sulfate on 5/14/25. -Hospice did tell him/her the resident needed his/her medications in liquid but did order tablet form. -Family member #2 wanted to start the comfort medications right away. -The resident could still talk on 5/13/25 and said he/she was not in pain. -He/She asked the resident if he/she could swallow his/her medications. -Resident said he/she would try. -He/She gave the resident his/her lorazepam tablet with some water. -The resident had a very hard time swallowing the pill. -He/She crushed up the resident's morphine and gave it in applesauce a little bite at a time. -He/She informed the resident that the medications could make him/her sleepy. -Medications were give at 11:18 A.M. on 5/14/25. -The facility does have liquid morphine and lorazepam in the E-Kit if needed. During an interview on 5/14/25 at 4:30 P.M. Family member #2 said: -The resident was admitted to hospice on 5/9/25. -On 5/12/25, hospice re-ordered comfort medications for the resident. -He/She sits with the resident during the evening and part of the night. -He/She asked the DON on 5/10/25 about the comfort medications due to the resident being restless and the DON said he/she was going to hold off on the medications because the resident was not in any pain. -He/She continued to ask the DON about comfort medications from 5/11/25 - 5/14/25. -He/She talked to the hospice nurse about the comfort medications being held. The hospice nurse did not understand why they were held. -On 5/13/25, the resident was very restless and cried out during the night. -The night nurse gave the resident some medication and the resident calmed down. -He/She was upset the resident had not received any comfort medications. MO00254214

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to follow facility policy for using mechanical lifts for one sampled resident, (Resident #24) out of five sampled residents. Facility staff failed to inspect the lift sling for safety on 5/10/25. During a transfer, the sling strap broke and the resident fell to the floor. The resident hit his/her head on his/her recliner causing two bumps on the back of his/her head. The facility census was 55 residents. Review of the facility's Safety Precautions, Lifting Policy dated 2001, revised on 12/2009 showed: -All personal shall follow safety precautions established by the facility when lifting of handling heavy objects. -When lifting or moving residents, makes sure that equipment is secure (wheelchair, beds, stretcher, etc.) -If there are mechanical devices available to assist in moving residents more safely, use them. -Tell the resident what you are doing. -Report any defective equipment to the supervisor as soon as practical. Review of the facility's undated Sling/Harness Check showed: -To properly inspect a Proactive Medical sling, staff should check for signs of damage like frayed seams, loops, or tears. -Ensure the sling is free from wear, fading, or any holes. -The label should also be intact and clearly visible, providing information about the sling's capacity. -Additionally, verify that the wear sleeves on the ends of the sling are intact and that all stitching is secure. -Replace if staff notice any damage or wear. -Follow the washing instructions on the sling label, ensuring temperatures do not exceed 185 degrees Fahrenheit and air-drying or low-temperature drying. 1. Review of Resident#24's admission Record showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Osteoporosis (a condition where bones become thin and weakened, increasing the risk of fracture). -Primary Osteoarthritis (a joint disease that causes pain, stiffness and loss of movement), right hip. -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Pain. -Muscle Weakness -Cognitive Communication Deficit (a communication difficulty caused by a cognitive impairment, can include language comprehension, language expression, pragmatics, reasoning, attention, memory, organization/planning, or insight/awareness). Review of the resident's undated Order Summary Report showed: -He/She will utilize sit to stand (a mechanical lift) for transfers when he/she is fatigued or in pain and as needed. -Eliquis (a medication which thins the blood) 2.5 milligrams(mg) tablet by mouth two times a day for heart disease. Review of the resident's undated Care Plan showed: -He/She utilizes a hand-held communication board that allows staff/family/ medical professionals to write out information for him/her to read and answer. -He/she had impaired functional status regarding bed mobility, transfers, walking, toileting, and locomotion. --Interventions were that he/she requires mechanical lift sit to stand with one staff assistance for transfers, start date of 9/20/23. -He/She was at risk for falling related to deconditioning, gait/balance problems, incontinence, and vision/hearing problems. --Interventions were to anticipate and meet resident's needs, call light was within reach, encourage resident to use it for assistance as needed, and prompt response to all requests for assistance. -He/She was on anticoagulant therapy (medications that prevent blood clots) for Atrial fibrillation (is an irregular and often very rapid heart rhythm). --Interventions were to monitor/document/report as needed (PRN) adverse reactions of blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting. Diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Review of the Hoyer (a mechanical lift using a sling to transfer a resident from one place to another) Sling Care Label on 5/13/25 showed: -Hand wash only water temperature no more than 120 degrees Fahrenheit (F). -Do not bleach will damage integrity of sling and strap materials which may result in failure causing injury or death to the resident and/or care giver. -Air dry only. -Inspect sling for wear prior to each use. -If signs of tearing, fraying, or wear are found discard the sling immediately. -Worn out slings are not safe for use and may result in injury or death. -Useful life of the sling is six months from the date of purchase under normal use. -However heavy use or excessive washing may reduce the useful life of the sling. NOTE: Observation of the sling showed no date on the sling when put in service. Review of resident's fall during staff assistance dated 5/10/25 at 11:00 A.M. showed: -The resident was being assisted by Certified Nursing Assistant (CNA) A using a Hoyer Lift to transfer the resident from bed to wheelchair. -The strap on the sling broke causing him/her to fall out of the sling. -He/She hit his/her head on a chair causing two raised bumps on the back of his/her head. -He/She was unable to give description. -No injuries observed at the time of incident. -He/She was sent to the hospital for evaluation and treatment. -Level of Pain: --Breathing score was zero, detail normal breathing. --Negative Vocalization score was one, detail occasional moan or groan, low level of speech with a negative quality. --Facial Expression score of one, detail sad, frightened, or frown. --Body Language score was one, detail tense. --Consolability score was zero, detail no need to console. -Alert to person, place, and situation. -No injuries observed post incident. Review of the resident's Incident Note dated 5/10/25 showed: -He/She was in the Hoyer Lift sling being transferred. -The strap broke causing him/her to fall to the ground. -He/She landed on his/her buttock but hit his/her head on his/her recliner chair. -Emergency Medical Services (EMS) was called and he/she was taken to the hospital for evaluation. -The physician, family, hospice and DON were informed of the incident. -All slings were inspected on 5/12/25 for wear and fray by the Maintenance Director. -All slings were in good condition and good for use. Review of the facility Statement of Inservice Training for Employees dated 5/10/25 showed: -Employee in-service started on 5/10/25 covered the use of lifts, safety measures regarding policy of two staff requirement for safety, and proper use of lifts. NOTE: Showed no training on inspecting Hoyer slings before using to transferring a resident. During an interview on 5/13/25 at 1:46 P.M. CNA B said: -He/She had Hoyer lift training during orientation and have had in-service training on the Hoyer lift and sling inspection as recent as 5/10/25. -Uses two staff to transfer residents with the sit to stand and Hoyer lifts. -He/She gets all of his/her residents that use a lift to transfer dressed and ready for breakfast, then he/she gets another nursing staff member to help him/her use the lift to transfer the resident. -He/She checks the sling for any damage before putting the sling under the residents. During an interview on 5/10/25 at 2:14 P.M. Maintenance Director said: -He/She does the checks on the Hoyer lifts and the slings at the same time. -The slings were just something he/she has always did once a month. -Laundry should also be checking the slings for wear and tear when washing and drying them. -The slings are to be hung to dry and not put in a dryer per manufacture of the slings. -The facility had been drying the slings in the dryer to dry. -The strap should not have just broke. -The strap had to be frayed or cut for it to break. -Looking at the strap he/she can tell it had a cut in it and where the strap ripped the rest of the way. -The sling should have never been used for any resident and been taken out of service. -Review of the written statement from CNA A dated 5/10/25 showed: -He/She and Registered Nurse (RN) A changed the resident before lunch and as he/she was getting the resident up from the bed to the chair the strap broke on the Hoyer sling. -The resident fell on his/her butt in a sitting position first, then hit his/her head on the chair. -The resident was completely alert during this time. During an interview on 5/13/25 at 2:47 P.M. CNA A said: -The resident needed changed and RN A assisted him/her in changing the resident. -He/She examined the sling and its straps before placing the sling under the resident. -He/She would look for holes, rips and/or tears in the sling and straps prior to using it. The sling was in good condition prior to using it. -He/She hooked up the black straps and RN A was spotter for the resident's head (positioned by the resident's head to help guide the resident during the mechanical lift transfer) during the transfer. -He/she was operating the Hoyer lift when the strap broke and the resident fell to the floor hitting his/her head on the chair. -He/She always checks the Hoyer slings before using them to transfer a resident. -He/She never transfers a resident with out a second staff member. -He/She was inserviced on 5/10/25 after the incident on Hoyer transfers and sling inspection before use. During an interview on 5/13/25 at 3:38 P.M. Laundry Aide A said: -When he/she started at the facility he/she was told to dry the Hoyer slings in the dryer. -He/She questioned it because at his/her last job he/she was told the slings were to hang dry. -Was told it was policy to dry in the dryer. -He/She puts the washer on the personals setting, no bleach. -When done in the washer he/she places the slings in the dryer to dry. -Not sure what the temperature is when drying but it gets really hot. -He/She was told on 5/12/25 to hang dry the slings. -The slings could need washed and dried daily if soiled. Review of the written statement from RN A supervisor dated 5/10/25: -He/She and CNA A were in the room changing the resident. -Resident was laid on the bed due to being a Hoyer Lift. -When done changing the resident he/she and CNA A were getting the resident up from the bed to the chair. -The strap on the Hoyer sling broke and the resident fell on his/her bottom and landed in a sitting position. -The resident did hit his/her head on the recliner and trash can. -Assessment was completed on the resident and observed two bumps on back of his/her head. -The resident was on blood thinner medications. -Neuro checks were started. ---The resident was sent to the hospital for evaluation and treatment due to hitting head and on blood thinners. ---The resident showed no signs or symptoms of distress. ---The resident was alert and oriented at time of transfer to hospital. During an interview on 5/13/25 at 3:47 P.M. RN A said: -He/She was in the resident's room helping CNA A change the resident before getting him/her up for lunch. -He/She did not see if CNA A checked the sling for wear and tear before putting the sling under the resident as he/she was up by the resident's head to spot during the transfer. -The nursing staff usually check the slings before using them. -He/She did not know what color of loops were to be used on the resident for positioning in a sitting position. -The sling was hooked up on the black straps when the strap broke. -He/She did not check the sling prior to use. During an interview on 5/13/25 at 4:26 P.M. the DON said: -He/She would expect all nursing staff to check the slings for wear and tear before using to transfer a resident with the Hoyer lift. -If there were signs of wear and tear the sling should be taken out of service and another sling should be used to transfer the resident. -The charge nurse should be notified of the damaged sling and given the sling to him/her. -Two nursing staff are to transfer residents with the Hoyer lift. -Nursing staff have hands on training during orientation and during in-services throughout the year as needed. -He/She was notified of the incident at 11:08 A.M. and reported to the facility on 5/10/25. -He/She started an investigation and nursing staff on shift were in-serviced on proper inspection of Hoyer slings and proper use of the Hoyer lift. -He/She forgot to put the sling inspection training on the in-service sheet and did not feel right adding it after staff members had already signed the sheet. -He/She is continuing education for nursing staff before working a shift. -All slings have been checked for wear and tear; no other slings showed any damage. -RN A was in the resident's room helping CNA A change and transfer the resident with the Hoyer lift from the bed to the wheelchair when the strap broke. During an interview on 5/14/25 at 3:01 P.M. the Physician said: -He/She would expect the nursing staff to examine the Hoyer sling for any damage before using the sling to transfer any resident. -If any damage the sling should not be used and taken out of service. MO00254063

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #209's admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). -Chronic (persisting for a long time or constantly recurring) kidney disease (CKD- is a condition characterized by a gradual loss of kidney function over time). Review of the resident's admission MDS, dated [DATE], showed the resident admitted with the following diagnoses: -Atrial Fibrillation ( A-Fib a condition where the upper chambers of the heart (atria) beat irregularly and rapidly). -Heart failure. Review of the resident's Electronic Health Record (EHR) on [DATE] at 12:30 P.M., showed no documentation of advanced directives in his/her record. Review of the resident's EHR on [DATE] at 9:00 A.M., showed: -No advanced directives listed on the resident's POS. -No advanced directives listed on the resident's EHR's Miscellaneous tab. -No care plan with an advanced directive listed. During an interview on [DATE] at 12:54 P.M., Certified Nursing Assistants (CNA) A said: -He/She found information about the resident on their care plan. -The care plan would show if the resident was a full code or a DNR. -He/She did not know what this resident's code status was. During an interview on [DATE] at 1:12 P.M., CNA B said: -The resident's code status would be on his/her care plan. -Care plans were in the resident's medical record. -He/She was not sure what the resident's code status was. Review of the resident's EHR on [DATE] at 1:12 P.M., showed: -No advanced directives listed on the resident's POS. -No advanced directives listed on the resident's Medication Administration Record. (MAR). -No advanced directives listed on the resident's EHR's Miscellaneous tab. -No care plan with an advanced directive listed. During an interview on [DATE] at 1:30 P.M., the Assistant Director said the resident did have advanced directives and a care plan. Review of the resident's EHR on [DATE] at 1:30 P.M.,showed: -The resident's code status on his/her profile page in the EHR was blank, there was no code status listed. -The resident's care plan indicated he/she was a full code dated [DATE]. During an interview on [DATE] at 10:44 A.M., LPN C said: -The resident's code status should have been on his/her POS, MAR, and care plan. -Resident care plans should have current information including his/her code status. -The SSD was responsible for ensuring a residents wishes regarding code status were documented. -The resident was listed as a full code. 3. During an interview on [DATE] at 3:30 P.M., the Director of Nursing (DON) Assistant Director, and the Executive Director said: -The SSD or designee was responsible for obtaining a code status from the resident or family. -The code status should have been on the resident's POS, and in the care plan. -The code status should match throughout the chart. -The Outside the Hospital Do Not Resuscitate sheet should have been complete. -There was a notebook at the nurses' station which showed which residents were a DNR. Based on interview and record review, the facility failed to have a consistent code status (a medical directive that specifies the type of resuscitation and medical interventions a patient wishes to receive in the event of a cardiac or respiratory arrest) in the resident's medical record for one sampled resident, (Resident #54); and did not have a code status listed in the electronic health record for one sampled resident (Resident #209) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Code Status Designation policy, dated [DATE], showed: -A code status would have been identified and supported by a physician's order to facilitate providing emergency care and services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing in accordance with the comprehensive care plan. -Upon admission, the Social Worker, or designee would have reviewed the resident's Advanced Directive (a legal document that states a person's wishes for medical care if they were not able to communicate them) and initiate action to secure a code status order. -The code status order would have been signed by a physician. -Each facility would have a method for identifying resident code status. 1. Review of Resident #54's face sheet showed: -A diagnosis of Cognitive Communication Deficit (a difficulty with communication caused by impairment in cognitive processes affecting how a person speaks, listens, reads, writes, and interacts socially). -There was no place for a code status to be listed. -There was no code status listed. Review of the resident's Physician's progress notes, dated [DATE], showed his/her code status was full code (if a person's heart stops they wish medical personal to perform life saving measures). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning), dated [DATE], showed: -He/She was able to understand others. -He/She was able to be understood. Review of the resident's Physician's progress notes, dated [DATE], showed his/her code status was full code. Review of the resident's Outside the Hospital DNR Order dated [DATE] showed: -The resident signed the document on [DATE]. -The physician signed the document on [DATE]. -The physician's name was not typed or printed. -The physician's license number was blank. Review of the resident's Physician's Progress notes, dated [DATE], showed his/her code status was full code. Review of the resident's care plan, dated [DATE], showed: -The resident passed away on [DATE]. -The resident's code status was revised, the resident was listed as a Do No Resuscitate (DNR not to perform cardiopulmonary resuscitation (CPR) if a patient's heart stops beating or breathing stops); dated [DATE]. -If the resident was found with no pulse or respirations, no lifesaving interventions would be implemented, dated [DATE]. During an interview on [DATE] at 9:10 A.M., Licensed Practical Nurse (LPN) C said: -There was a notebook at the nurses's station that had the resident's code status. -The resident was a DNR effective [DATE]. -The resident passed away on [DATE]. -The Social Service Designee (SSD) was responsible for ensuring residents wishes regarding code status were documented. -A resident's code status should have been on the DNR sheet, POS, and on the care plan. -The code status should have been the same throughout the chart. -If there was a change it should have been changed that day. -The DNR sheet should have been completed by the physician which would have included his/her signature, the physician's name typed or printed, and should have included the physician's number. During an interview on [DATE] at 9:50 A.M. Certified Medication Technician (CMT) C said: -A resident's code status should have been on the resident's face sheet. -This resident's code status was not on the face sheet. -They had a notebook at the nurses' station with the residents names who wished to have been a DNR. -The resident was a DNR. -The SSD or the nurses should have ensured the resident's code status was the same throughout the chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's family for one sampled resident (Resident #35) of a change in condition out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Accidents and Incidents-Investigating and reporting policy, dated revised July 2017, showed: -All accidents or incidents involving residents shall be investigated and reported to the administrator. -The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. -The following data, as applicable, shall be included on the report of incident/accident form: --The date and time the accident or incident took place. --The nature of the injury/illness (e.g., bruise, fall, nausea, etc.). --The circumstances surrounding the accident or incident. --Where the accident or incident took place. --The time the injured persons attending physician was notified. --The date/time the injured person's family was notified and by whom. --The disposition of the injured (i.e., transfer to hospital, put to bed). --Any corrective action taken. --Follow-up information. --Other pertinent data as necessary or required. Review of the facility's policy and procedure- Incident and Accident Investigation, dated 1/1/2024, showed: -To ensure a safe environment that strives to eliminate hazards and to provide adequate care, supervision and assuasive devices to prevent incidents and accidents. -To this end, all occurrences or events regarding a resident injury, including unexplained injuries will be investigated and reported to facility administration. -An Incident/Event Report or Point Click Care (PCC, computer based) Risk Management Report shall be completed upon identification of any incident, accident, or injury of unknown source. -Completion of the report will include timely notification of the attending physician and the durable power of attorney/responsible party. -The administrator and/or director of nursing services will report incidences, accidents, injuries of unknown source to state and federal agencies in accordance with all applicable regulations and statutes. 1. Review of Resident #35's admission Record showed he/she admitted on [DATE] with the following diagnoses: -Dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning). -Macular degeneration (deterioration of the macula, which is the small central area of the retina of the eye that controls visual acuity). -Poly osteoarthritis (five or more joints with inflammation of the of the bone with progressive cartilage deterioration). -Disorders of bone density (measurement of amount of minerals in bones, it helps determine risk of fractures and osteoporosis [bones become brittle and fragile from loss of tissue]). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning), dated 1/20/25, showed his/her cognition was severely impaired. Review of the resident's Health Status Note, dated 1/3/25 at 1:26 P.M., showed: -The resident complained of pain to his/her left forearm in the morning when the day shift arrived. -Deformity noted to his/her left forearm. -Message left with the resident's Physician's answering service. -His/her left forearm X-ray ordered. -Administrator notified. Review of the resident's Radiology Results Report, dated 1/3/25 at 4:03 P.M., showed: -There was an acute (sudden onset) spiral fracture (occurs when a rotating force is applied along the axis [imaginary line running through the center of a bone] of a bone, often occurs when the body is in motion while one extremity is planted) of the distal (away from the point of attachment) diaphysis (the long tubular shaft of a bone) of the Ulnar bone (the longer bone in the forearm located on the side of the little finger and extended from the elbow to wrist). Review of the resident's medical record showed no documentation the physician or family were notified until 1/8/25 when the physician was at the facility. Review of the resident's progress note, dated 1/8/25 at 4:39 P.M., showed: -The MDS Coordinator/Licensed Practical Nurse (LPN) rounded with the Physician who was seeing the resident for a fractured arm. -The Physician asked for results from the X-ray which had been sent to the nurses on 1/3/25. -The X-ray results reported the resident had a spiral fracture of arm. -The MDS Coordinator looked for a report of the fracture and none noted. -The MDS Coordinator reported to the Executive Director (ED) and the Director of Nursing (DON) the family had not been notified and the resident's arm was broken. -The ED reported the DON would call the family and that the resident should be sent out. -The Physician did see the resident and read the X-ray results. -The Physician gave orders for pain medication and for facility to contact family as what they would like to do about the resident's arm fracture. Review of the resident's Physicians Progress note, dated 1/8/25 no time listed, showed: -Chief complaint/Nature of presenting problem: follow-up x-ray/ new orders. -On 1/3/25 an X-ray of the resident's left forearm was obtained. -The X-ray report was received via fax and dated 1/6/2025 at 10:30:12 A.M. -The X-ray results were, acute spiral fracture of the distal diaphysis of the ulnar bone, with approximately 3.5 millimeter (mm) palmar displacement (where the fractured bone fragment is displaced towards the palm of the hand) of the distal fracture moiety (one of the portions into which something is divided). Severe diffuse osteopenia (condition characterized by a lower than normal bone mineral density). No joint subluxation (a partial dislocation or displacement of a joint) of dislocation was seen. No soft tissue emphysema (air trapped in tissues beneath the skin), radiodense soft tissue (a soft tissue within the body that appears denser on an x-ray image compared to other soft tissues) abnormality or foreign body was seen. -Overall Plan: --Follow-up in 4 weeks or sooner as deemed necessary. --Call if there was any significant changes in patient's medical condition. Review of the resident's Order Note, dated 1/8/25 at 4:52 P.M., showed: -The Administrator spoke with a family member of the resident and informed them that on Friday 1/3/25 the facility got an X-ray because the resident was saying his/her left forearm was hurting. -The Administrator let the family member know the resident had a fracture to the left arm. -The DON was contacting the doctor and when he/she found out what the doctor wanted to do, he/she would call the family member back and let them know the Physician's decision. Review of the resident's Communication note, dated 1/8/25 at 5:41 P.M., showed: -The DON called the resident's family member and informed them, the Physician had seen the resident and X-ray report. -The Physician said the options were to consult with orthopedics, keep the resident's arm immobilized in a sling or send him/her to the emergency room (ER) to be evaluated and see what options they recommended. -The family member did not want to send the resident to the ER, they would contact other family members and call the DON back tomorrow as to what the family decided. Review of the resident's progress note, dated 1/10/25 at 1:23 P.M., showed: -The MDS Coordinator spoke with the resident's family member concerning his/her left arm fracture. -The family member was very upset that the resident had a fracture of the left arm and was not notified until six days later. -The MDS Coordinator had not been notified of a fall or an injury until 1/8/25 when rounding with the Physician for a follow-up for a fracture. -The MDS Coordinator looked for progress notes and there were no reports of the injury or notes that the family had been informed of the X-ray and break of the left arm. -The MDS Coordinator reported this to the Executive Director. -The Executive Director notified a family member of the fracture to the resident's left arm. -The family member agreed that if the resident was not able to get into orthopedics by Tuesday 1/14/25 then the resident would be sent out to the hospital for evaluation/treatment to help with stabilizing the arm to decrease pain. -The MDS Coordinator would notify the family member of orthopedic appointment or if sent out. Review of the resident's progress note, dated 1/10/25 at 3:55 P.M., showed: -The resident was sent to the hospital via Emergency Medical Services (EMS) transport. -The resident's family member followed in private car. -The resident was sent to be evaluated for fracture of his/her left forearm per portable x-ray, sling in place, pulse and motor sensory intact to left forearm/left hand. Review of the resident's progress note, dated 1/10/25 at 10:28 P.M., showed: -The resident returned to the facility with a diagnosis of a fractured left forearm. -Plaster splint placed in ER to his/her left forearm. -Splint to be kept dry at all times. -Skin around the splint should be inspected daily. -Sling was to be kept to shoulder level when sitting or standing, rest on chest or on a pillow when lying down to prevent swelling under the splint for the first 48 hours. -Certified Nursing Assistants (CNA)s instructed of resident's splint care. Review of the resident's progress note, dated 1/15/25 at 4:54 P.M., showed: -The resident's family member came to talk with the MDS Coordinator, the resident was to have a follow-up Orthopedic appointment. -A note was left for the receptionist, who made appointments, to get an appointment. -Family member had concerns of the resident's safety at the facility due to the break in arm and not being notified or resident sent out when it was found. -The MDS Coordinator informed family member that the resident was safe, and care would be given, staff was educated on notifying family of new issues and concerns right away. -The MDS Coordinator informed the ED of family concerns. During an interview on 1/22/25 at 12:35 P.M., the resident's family member said: -The resident had a spiral arm fracture and the facility did not know when or how it happened. -The facility found out the resident was having pain on 1/3/25 and did an X-ray on 1/3/25. -The family found out about the X-ray and the fracture on 1/8/25 from the Executive Director. -The Interim DON called the family member to see if the family wanted the resident to see the doctor or to send the resident to the ER. -The family member said to make a Doctor's appointment by Friday 1/10/25. -The family member talked to the MDS Coordinator on Friday 1/10/25 and found out the resident could not get a doctor appointment and to send the resident to the ER. -A splint was put on the resident's left arm in the ER and was to see an Orthopedic doctor on Friday 1/24/25. Review of the resident's progress note, dated 1/22/25 at 2:26 P.M., showed: -The resident had a care plan meeting today and the resident's family member was there. -The family member expressed that it was very discouraging that the resident had a broken arm and it was not reported to the family member. -The family member stated the resident's arm could have been treated if he/she had been sent out earlier. -The DON said he/she did not know why the x-ray was not read and reported to the family. During an interview on 1/28/25 at 12:28 P.M., the DON said: -He/She was told on 1/3/25 the resident had complained about arm pain. -He/She went to check out the resident's arm. -An X-ray was ordered by the resident's physician. -The X-ray was done in the afternoon and the report didn't come right away. -He/She let the night charge nurse know to notify the doctor about the report and to find out what orders he/she may have. -There was no documentation to show if the resident's physician was notified of the X-ray results. -He/She did not see the X-ray report until Tuesday 1/7/25, when he/she returned back to the facility. -He/She started making phone calls to see if family wanted the resident sent to the ER or an orthopedic appointment. -The family said if it would take a while to get an orthopedic appointment to go ahead and send the resident to the hospital. -He/She notified the facility doctor of the incident on Tuesday 1/7/25. -He/She did not hear back from the facility doctor and he/she did not call him/her back. -The resident went to the hospital per family request as the facility was not able to get an orthopedic appointment right away. During an interview on 1/30/25 at 1:59 P.M., LPN C said: -The resident's family was notified by the Assistant Director of the X-ray and the X-ray results. -The resident's family was contacted by the DON as a follow up to the physician's visit with the resident to determine the family's wishes regarding treatment. During an interview on 1/30/25 at 10:09 A.M., the Assistant Director said: -He/She was notified by the MDS Coordinator that the resident's family had not been notified of the injury, X-ray, or X-ray results. -He/She called the resident's family and informed them of the injury, X-ray, and X-ray results. -He/She informed the family the DON would follow up after the physician saw the resident to discuss treatment options available. During an interview on 1/31/25 at 3:25 P.M., the DON, Assistant Director and the Executive Director said: -When a resident had a change in condition the facility doctor and the resident's family member or representative should have been notified as soon as possible. -Waiting five days to notify the doctor or family member was not acceptable. -The doctor and the family should have been notified of the X-ray results by the nurse who took the report off of the copier. -X-ray reports should come back the same day or at least in 24 hours. -The doctor should have been notified of the X-ray results by faxing the report to him/her. -The nursing staff or DON should have sent the resident out to the hospital when they knew of the X-ray results. -The charge nurse should have made nursing notes of the resident's X-ray being done and who they notified of it. MO00247918

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an injury of unknown origin timely to the physician as per policy and to the State Agency for one sampled resident (Resident #35) out of 14 sampled residents. The facility census was 55 residents. Review of the facility policy titled: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, showed: -Investigate and report any allegations within time frames required by federal requirements. Review of the facility policy titled: Recognizing signs and symptoms of abuse/neglect dated April 2021 showed: -All personnel are expected to report any signs and symptoms of abuse/neglect to their supervisor or to the Director of Nursing (DON). -The following are signs and symptoms of abuse/neglect that should be promptly reported. --Injuries that are non-accidental or unexplained. --Fractures, dislocations or sprains. Review of the facility policy titled: Abuse, neglect, exploitation or misappropriation reporting and investigating, dated September 2022, showed: -Reports of resident injuries of unknown source are reported to local, state and federal agencies. -If injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. -The Administrator or the individual making the allegation immediately reports his/her suspicion to the following persons or agencies: --The state licensing/certification agency responsible for surveying/licensing the facility. --The local/state Ombudsman. --The resident's representative. --The resident's attending physician. --The facility's medical director. ---Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury. 1. Review of Resident #35's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning), dated 10/20/24, showed: -He/She was severely cognitively impaired. -Had a diagnosis of Dementia (a group of conditions that cause a progressive decline in cognitive function, memory, and behavior). -Required maximum assistance to total dependence with all aspects of activities of daily living. Review of the resident's Health Status Note, dated 1/3/25 at 1:26 P.M., showed: -The resident complained of pain to his/her left forearm when day shift arrived. -Deformity noted to the resident's left forearm. -A message was left with the resident's Physician's answering service. -A left forearm x-ray was ordered. -The Administrator was notified. Review of the resident's X-ray Results Report, dated 1/3/25 at 4:03 P.M., showed: -There was an acute (sudden onset) spiral fracture (occurs when a rotating force was applied along the axis [imaginary line running through the center of a bone] of a bone, often occurred when the body was in motion while one extremity was planted) of the distal (away from the point of attachment) diaphysis (the long tubular shaft of a bone) of the Ulnar bone (the longer bone in the forearm located on the side of the little finger and extends from the elbow to wrist). Review of the resident's Quarterly MDS dated [DATE], showed his/her cognition was severely impaired. During an interview on 1/22/25 12:35 P.M., the resident's family member said: -The resident had a spiral arm fracture and facility did not know when or how it happened. -The facility found out the resident was having pain on 1/3/25 and did an X-ray on 1/3/25. -The family found out about the X-ray and the fracture on 1/8/25 from the Executive Director. During an interview on 1/28/25 at 12:28 P.M., the DON said: -He/She was told on 1/3/25 that the resident had complained about arm pain. -He/She went to check out the resident's arm. -A X-ray was ordered. -He/She wrote a progress note concerning the incident. -The X-ray was done in the afternoon and the results didn't come right away. -He/She let the night charge nurse know to notify the doctor about the results and to find out what orders he/she may have as to sending the resident out to the hospital or other treatment. Review of the resident's EHR on 1/28/25 showed: -No documentation of an X-ray being done on 1/3/25. -No documentation of the X-ray results of a spiral fracture of the left forearm. -No documentation of the resident's physician being notified. -No documentation of the State Agency being notified. During an interview on 1/31/25 at 3:25 P.M., the DON, Assistant Director and the Executive Director said: -The Assistant Director was not aware that an injury of unknown origin needed to be reported to the state. -The DON was not aware that an injury of unknown origin needed to be reported to the state. Review of the resident's EHR on 2/14/25 showed: -No documentation of the State Agency being notified of the injury of unknown origin (fracture) on or around 1/3/25. During an interview on 2/14/25 at 5:45 P.M., the Assistant Director said: -He/She did not know the injury of unknown origin needed to be reported to the State Agency. During an interview on 2/14/25 at 7:04 P.M., the DON said: -The X-ray results were not reported to the physician timely. -The injury of unknown origin was not reported to the State Agency. -He/She did not know injury of unknown origin had to be reported to the State Agency. During an interview on 2/14/25 at 7:34 P.M., Physician A said: -The facility should follow their policies and procedures and report incidents to the appropriate people. -The resident's injury of unknown origin should have been reported if the policy and procedure indicated it should have been reported. During an interview on 2/19/25 at 10:00 A.M. the Interim Administrator said: -The resident's physician should have been notified by the charge nurse on duty when the X-ray results were sent to the facility. -The DON or the Assistant Director should have followed up with the physician if there was no response documented by the charge nurse. -The Administrator of the facility at the time of the injury should have notified the state agency. MO00247918 MO00248157

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the discharge notification for one sampled resident (Resident #29) out of 14 sampled residents. The facility census was 55 residents. A copy of the facility's Ombudsman notification policy was requested and none was provided. 1. Review of Resident #29's admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Chronic Kidney Disease, stage 3A (CKD- is a condition characterized by a moderate loss of kidney function over time) 1/16/24. -Chronic Congestive Heart Failure (CHF-chronic condition in which the heart doesn't pump blood as well as it should) 1/5/24. -Fracture of base of neck of unspecified femur (fracture at the top of the femur [thigh bone] near the hip joint with the exact location not specified) 11/14/24. Review of the resident's progress note, dated 11/10/2024 at 3:28 P.M., showed: -Resident transported to a local hospital post fall with dizziness, left hip pain, pain in the head due to hitting head on the floor and a laceration on his/her nose with mild bleeding. -The resident's family member was called, the Director of Nursing (DON) and Administrator were notified. Review of the resident's medical record showed there was no letter notifying the Ombudsman of the resident's transfer to the hospital or of his/her return to the facility. A copy of the Ombudsman's notification of residents who were discharged /transferred from the facility to the hospital in November 2024 was requested on 1/27/25, none was provided by the end of the survey. During an interview on 1/30/25 at 10:09 A.M., the Assistant Director said: -He/She was not aware of the need to notify the Ombudsman on a monthly basis with a list of resident's who were discharged /transferred from the facility. During an interview on 1/31/25 at 3:25 P.M., with the DON, Assistant Director, and Executive Director present: -The DON said he/she was not sure if the facility notified the Ombudsman or not. -The Executive Director said Social Services had been sending the notices to the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident and/or the resident's representative(s) of the facility's bed-hold policy before transferring or discharging the resident to the hospital for one sampled resident (Resident #29) out of 14 sampled residents. The facility census was 55 residents. 1. Review of Resident #29's admission Record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Chronic Kidney Disease, stage 3A (CKD- is a condition characterized by a moderate loss of kidney function over time) 1/16/24. -Chronic Congestive Heart Failure (CHF-chronic condition in which the heart doesn't pump blood as well as it should) 1/5/24. -Fracture of base of neck of unspecified femur (fracture at the top of the femur [thigh bone] near the hip joint with the exact location not specified) 11/14/24. Review of the resident's progress note, dated 11/10/24 at 3:21 P.M., showed the resident was found on the floor in his/her room next to his/her recliner in what appeared to be an unwitnessed fall. Review of the resident's progress note, dated 11/10/24 at 3:28 P.M., showed: -The resident was transported to the local hospital post fall with dizziness, left hip pain, pain in the head due to hitting his/her head on the floor and laceration on nose with mild bleeding. -The resident's family member was called, the Director of Nursing (DON) and Executive Director were notified. Review of the resident's medical record showed there was no letter notifying the resident and/or the resident's representative(s) of the facility's bed-hold policy. Review of the resident's progress note, dated 11/14/24 at 2:41 P.M., showed the resident arrived back to the facility from the hospital. During an interview on 1/30/25 at 1:59 P.M., Licensed Practical Nurse (LPN) C said: -He/she was not aware of the facility having a bed hold policy. -He/she did not give a bed hold policy to the resident, family member or representative when a resident transfers to the hospital. -He/she notified the family member or representative of the resident being transferred to the hospital. During an interview on 1/30/25 at 10:09 A.M., the Assistant Director said: -The facility did not have a bed hold form to give to residents or send to family/representative when a resident was sent to hospital for more than three days. -The family member/representative should be notified by phone when a resident was sent out to the hospital. During an interview on 1/31/25 at 3:25 P.M., the DON, Assistant Director and Executive Director said: -The facility did do bed hold notices. -The nurse filled out the form and should give to the resident on discharge to the hospital. -The nurse should put a copy of the bed hold under the Social Services door so he/she was aware to send to the family/representative within 24 hours. -On a weekend the charge nurse should send a copy to the family/ representative. -The charge nurse had access to mailing materials, envelopes and stamps.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to create a baseline care plan within 48 hours of admission for one sampled resident (Resident #209) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Care Plans, Baseline policy, dated March 2022, showed: -A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission. -The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: --Initial goals based on admission orders and discussion with the resident/representative. --Physician orders. --Dietary orders. --Therapy services. --Social services. -The baseline care plan is used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered comprehensive care plan (no later than two days after admission). -The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) that includes, but is not limited to the following: --The stated goals and objectives of the resident/ --a summary of the resident's medications and dietary instructions. --Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. -Provision of the summary to the resident and/or resident representative is documented in the medical record. 1. Review of Resident #209's admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). -Chronic (persisting for a long time or constantly recurring) kidney disease (CKD- is a condition characterized by a gradual loss of kidney function over time). During an interview on 1/24/25 at 10:26 A.M., the resident said: -He/She wasn't sure if he/she had a care plan. -He/She signed something when he/she first came in. -He/She wasn't given a copy of what he/she had signed. Review of the resident's Electronic Health Record (EHR) baseline care plan on 1/24/25, 1/27/25, and 1/28/25 showed no data available, no record found. During an interview on 1/27/25 at 12:54 P.M., Certified Nurses Aide (CNA) A said: -He/She found information about residents on their care plan. -He/She did not know anything about base line care plans. During an interview on 1/27/25 at 1:12 P.M., CNA B said: -Care plans could be seen on the resident's medical record. -Care plans should be up to date. -The nurses took care of care plans. -He/She did not know anything about base line care plans. On 1/28/25 at 9:00 A.M., a copy of the resident's care plan was requested from the Director of Nursing (DON) and was not received by the end of survey. Review of the resident's paperwork handed to the surveyor on 1/28/25 at 2:42 P.M. by the DON showed the resident's care plan was initiated on 1/27/25 and updated on 1/28/25. Review of the resident's EHR care plan on 1/28/25 at 2:45 P.M., showed: -The care plan was dated as initiated on 1/2/25. --There was no data. ---It showed no record found. During an interview on 1/29/25 at 10:00 A.M., the MDS Coordinator said: -He/She had not completed or updated all the care plans. -He/She was called to work the floor a lot. -He/She had been in the position for two weeks and the MDS Coordinator before him/her was not doing the care plans correctly. -He/She said a baseline care plan should be done upon admission and the completed care plan should be within two weeks. --He/She did not do base line care plans as he/she did not have time. During an interview on 1/29/25 at 10:32 A.M., Licensed Practical Nurse A said: -The MDS Coordinator did the initial care plans. During an interview on 1/31/25 at 3:25 P.M., the DON, Assistant Director, and the Executive Director said: -A baseline care plan should be done within 72 hours of admission. -The MDS Coordinator was responsible for initiating the base line care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide continuity of resident care by not developing and implementing resident comprehensive care plans for one sampled resident (Resident #109) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated March 2022, showed: -A comprehensive care plan was developed for each resident. -The care plan was developed within seven days of the completion of the resident's required Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) and no more that 21 days after admission. -Each resident and/or their representative had the right to participate in care plan development. -Each care plan included: --Measurable objectives and time frames. --Description of services to be provided. --Resident's goals. 1. Review of the Resident #109's face sheet, undated, showed the resident admitted on [DATE] with the following diagnoses: -Dependence on supplemental oxygen. -Muscle weakness. -Heart failure. Review of the resident's admission MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 1/22/25 at 9:32 A.M., the resident said: -He/She did not remember having a care plan meeting when he/she was admitted to the facility. -He/She did not express familiarity with the care process when it was explained to him/her. During an interview on 1/23/24 at 10:09 A.M., the MDS Coordinator said: -He/She was called to work the floor a lot. -He/She had not completed all the care plans. -He/She had been in the position for two weeks and the MDS Coordinator before him/her was not doing the care plans correctly. -The comprehensive care plan should be completed within two weeks. -The resident's comprehensive care plan was not completed. Review of the resident's Electronic Health Record (EHR) on 1/24/25, 1/25/25, and 1/27/25 showed no base line or comprehensive care plan had been developed for the resident. During an interview on 1/27/25 at 12:54 P.M., Certified Nursing Assistant (CNA) A said: -He/She found information about the resident on their care plan. -He/She was unaware if the resident had a care plan completed. During an interview on 1/27/25 at 1:12 P.M., CNA B said: -Care plans can be seen on the resident's medical record. -He/She was unsure if the resident had a care plan. Review of the resident's EHR on 1/28/25 showed no care plan had been developed for the resident. During an interview on 1/28/25 at 9:30 A.M., Licensed Practical Nurse (LPN) A said: -Care plans were completed when the resident's MDSs were done. -The resident should have a care plan. -He/She had not looked for a care plan for the resident. Review of the resident's comprehensive care plan showed: -It was initiated on 12/31/24. -It was not completed until 1/28/25. During an interview on 1/29/25 at 10:32 A.M., LPN A said: -The MDS Coordinator was responsible for creating the care plans. -Nurses told the MDS Coordinator when something needed updated. -The MDS Coordinator then updated the care plans. During an interview on 1/31/25 at 3:25 P.M., the DON, Assistant Director, and the Executive Director said: -It was the responsibility of the MDS Coordinator to create all resident care plans. -It was the responsibility of the MDS Coordinator to keep all care plans accurate with current information.

Based on interview and record review, the facility failed to ensure physician orders were changed and transcribed correctly when the physician agreed with the pharmacists review for changes for two sampled residents (Resident #40 and #29 ) out of 14 sampled residents. The facility census was 55 residents. 1. Review of Resident #40's Medication Regimen Review (MRR) by the pharmacist, dated 12/2/24, showed: -The resident had an order for Fluticasone 110 microgram (mcg) inhaler one puff every six hours as needed for shortness of breath. -The pharmacist documented that Fluticasone was not a rescue medication to be used as needed and that having it scheduled would decrease the inflammation and help with breathing. -The pharmacist documented that the usual dosage for Fluticasone was one to two inhalations twice a day and recommended that the Fluticasone order be changed from as needed to twice a day. -The resident's primary care physician marked that he/she agreed with the recommendation and wrote an order to change the order to two puffs twice a day. Review of the resident's Physician's Order Sheet (POS) dated January 2025 showed a physician's order dated 12/12/24 for Fluticasone 110 mcg inhaler, two puffs every six hours as needed for shortness of breath. 2. Review of Resident #29's MRR notes, dated 4/4/24, showed: -The resident was on Digoxin (a medication to treat Congestive Heart Failure) and had not had a Digoxin level lab drawn since February 2023. -Please order these labs on the next convenient lab date and annually if they are due. --The physician agreed on 5/1/24. Review of the resident's MRR notes, dated 5/1/24, showed: -Digoxin levels were not included in lab results from 4/10/24. -Digoxin levels were not included in lab results in May 2024. -Please make sure labs were being done as ordered. --The physician agreed on 6/6/24. Review of the resident's POS dated January 2025 showed: -Digoxin level to be drawn annually in May. -The date of the order was 10/23/24. --NOTE: The date of the order was five months after the original recommendation from the pharmacist. Review of the resident's medical record lab results showed: -The digoxin level results were not documented as being drawn on 10/23/24. -The staff were not able to locate the digoxin level results ordered on 10/23/24. 3. During an interview on 1/29/25 at 10:32 A.M., Licensed Practical Nurse (LPN A) said: -The MRRs go to the Director of Nursing (DON). -He/She had not been given any MRR responses to enter medication order changes for any residents. During an interview on 1/31/25 at 12:05 P.M. with the DON and the Executive Director: -The Executive Director said: --The orders should have been transcribed correctly. -The DON said: --The charge nurse should have ensured the orders were transcribed correctly. --He/She had not checked to make sure the orders were transcribed correctly.

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the interests as well as the physical, mental, and psychosocial well-being for one sampled resident (Residents #109) out of 14 sampled residents. The facility census was 55 residents. A policy regarding resident activities was requested and not received. 1. Review of Resident #109's face sheet, undated, showed the resident was admitted to the facility 12/31/21 with the following diagnoses: -Muscle weakness. -Morbid (severely overweight) obesity. -Heart failure. Review of the facility activity log dated October 2024 showed: -On 10/8/24, 10/9/24, 10/16/24,10/17/24, 10/22/24, 10/23/24, 10/24/24,10/25/24, 10/28/24, and 10/31/24 the resident did not attend activities. Review of the facility activity log dated November 2024 showed: -On 11/5/224, 11/6/24, 11/8/24, 11/12/24, 11/14/24, 11/15/24, 11/18/24, 11/19/24, 11/21/24, 11/22/24, 11/26/24, 11/27/24, and 11/29/24 the resident did not attend activities. Review of the facility activity log dated December 2024 showed: -On 12/2/24, 12/3/24, 12/4/24, 12/5/24, 12/6/24, 12/9/24, 12/10/24, 12/11/24, 12/12/24, 12/16/24, 12/17/24, 12/18/24, 12/19/24, 12/20/24, and 12/24/24 the resident did not attend activities. Review of the resident's Initial Activities Review, dated 1/2/25, showed: -The resident expressed he/she would like to go to activities. -He/She needed assistance to get to activities. -Assistance should be provided to get the resident to the activity. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 1/6/25, showed: -The resident was cognitively intact. -It was very important to the resident to do his/her favorite activities. Review of the resident's care plan, dated 1/28/25, showed: -The resident would express satisfaction with type of activities and level of activity involvement when asked. -Invite and encourage the resident to attend activities. -Modify daily schedule to accommodate activity participation. -The resident needed a variety of activity types and locations to maintain interests. -The resident needed assistance/escort to activity functions. During an interview on 1/22/25 at 9:32 A.M., the resident said: -There was an activities calendar on the wall across the room. -It was too far away to read so he/she asked for a copy to keep at bedside and never received one. -He/she would like to go to activities. -The staff do not like to get him/her out of bed as he/she needed a mechanical lift for transfers. -He/She was not able to go to activities because staff did not get him/her up. During an interview on 1/27/25 at 12:54 P.M., Certified Nursing Assistant (CNA) A said: -The resident never asked to go to activities. -The resident did not want to get out of bed. -He/She needed a mechanical lift and the lift required two CNAs to use. -There were not always two CNAs available at the time the resident needed it. -He/She was unaware if the resident requested a calendar to keep at bedside. During an interview on 1/27/25 at 1:12 P.M., CNA B said: -The Life Enrichment Coordinator (Activities Director) or his/her assistant handed out activity calendars. -He/She did not know if the resident wanted to go to activities. -He/She did not ask the resident if he/she wanted to go to activities. During an interview on 1/28/25 at 9:30 A.M., Licensed Practical Nurse (LPN) A said: -The resident did not ask for a lot and was very timid about asking for things. -When he/she offered to get the resident up for meals or activities then the resident got up. -He/She did not know if the resident wanted to go to activities, he/she did not ask the resident about going to activities. During an interview on 1/28/25 at 1:22 P.M., the Activities Director said: -The resident did not go to activities. -The resident had one-on-one activities in his/her room. -He/She had been in the resident's room a few times. -Residents who needed mechanical lifts did not come to activities. -The CNAs refused to get the residents up. -He/She had not told the Director of Nursing (DON) about staff not getting the resident up for activities. -The resident would enjoy the group activities and would come with encouragement. -The resident had a calendar at bedside. During an interview on 1/29/25 at 8:54 A.M., the resident said: -He/She was told by the CNAs they needed a days notice if he/she wanted to do something that required a mechanical lift (bathing, meals in the dining room, activities). -He/She was told by the CNAs he/she couldn't go to activities due to not enough staff to use the mechanical lift. -He/She did not remember when he/she was told he/she couldn't go to activities because of staffing. -He/She would really like to go to some activities, but there seemed to be an excuse every time for why staff couldn't get him/her out of bed to go. Observation on 1/29/25 at 8:54 A.M., showed: -There was no sling (device that covers and supports the shoulders, back and hips) under the resident. -The resident was in bed. During an interview on 1/31/25 at 4:55 P.M., the DON said: -The CNAs were responsible for getting resident's up using the mechanical lift. -Residents complained about the CNAs not wanting to get resident's up using the lift. -He/She expected the CNAs to comply with resident requests when a lift was needed. -He/She expected staff to offer to take residents to activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure skin and wound assessments were completed for residents who were at high risk for and had pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), failed to provide pressure ulcer treatments as prescribed by the physician, and failed to provide interventions to reduce pressure ulcers for two sampled residents, (Resident #3 and #39) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Wound Care Policy, dated 1/1/24, showed: -The purpose was to identify factors that placed the residents at risk for the development of pressure ulcers and to implement appropriate interventions to prevent the development of clinically avoidable wounds. -To promote healing of existing pressure ulcers. -Upon identification of the development of a wound, the wound assessment would have been documented on the Initial Wound Assessment Form. -Residents should have been examined thoroughly at least weekly by a licensed nurse to identify existing pressure ulcers. -Findings from the weekly assessment should should have been documented by the licensed nurse on a Body Audit Assessment Form. -(Certified Nursing Assistants (CNA)s should have completed a comprehensive CNA Shower Review on all residents when they were bathed or showered and given to the charge nurse. -After review by the charge nurse the comprehensive CNA shower review should have been given to the Wound Nurse or designee, for appropriate follow-up. -The comprehensive CNA shower review should have been reviewed by the Director of Nursing (DON) routinely. -Any skin impairments, including pressure ulcers should have been assessed and documented weekly by the Wound Nurse or designee, on the Wound Evaluation Flow Sheet or the Computer Weekly Wound Assessment. -Documentation should have covered all pertinent characteristics of existing ulcers, including location, size, depth, maceration (skin than was exposed to moisture for too long, causing it to soften and break down), color of the ulcer and surrounding tissues, and a description of any drainage, eschar (dead tissue that forms over healthy skin), necrosis (dead skin), odor, tunneling (when a channel or tunnel forms under the surface of a wound extending into deeper tissues), or undermining (when the edges of a wound have eroded or separated from the surrounding healthy tissue, creating a cavity or pocket underneath the skin). -Pressure reducing devices should have been provided on beds and chairs for at-risk residents. 1. Review of Resident #3's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Muscle weakness. -Hemiplegia (muscle weakness or paralysis on one side of the body). Review of the resident's Treatment Administration Record (TAR), dated December 2024, showed: -Coccyx (the tailbone) wound dressing change one time a day for coccyx wound. --Cleanse wound with wound cleanser, pat dry, apply Xeroform (a petrolatum gauze dressing used to treat wounds) or calcium alginate (an absorbent dressing used to help heal wounds) and cover with sacral (the bone that connects the spine to the pelvis) wound dressing change as needed dated 10/2/24. ---The dressing was not documented as completed 10 times out of 31 opportunities. -Apply protective house stock barrier cream/Bordered foam (dressing with an adhesive border) to the Stage I (Intact skin with non-blanchable redness of a localized area usually over a bony prominence) pressure ulcer on the buttock area, every morning and at bedtime for wound healing, dated 6/4/24. --The dressing was not documented as completed seven times out of 62 opportunities. Review of the resident's skin monitoring: comprehensive CNA Shower Review, dated December 2024, showed: -The resident had only one shower in December on 12/18/24. -He/She had a red area on his/her buttocks. Review of the resident's medical record showed no documentation of skin or wound documentation. Skin and wound assessments for December 2024 were requested and none were provided. Review of the resident's Physicians' Order Sheet (POS), dated January 2025, showed the following orders: -Apply protective house stock barrier cream/Boarder foam to Stage I buttock area, every morning and at bedtime for wound healing, dated 6/4/24. -Coccyx wound dressing change one time a day for coccyx wound. Cleanse wound with wound cleanser, pat dry, apply Xeroform or calcium alginate and cover with sacral wound dressing change as needed, dated 10/3/24. -NOTE: There were no pressure reducing devices listed. Review of the resident's TAR, dated January 2025, showed: -Coccyx wound dressing change one time a day for coccyx wound. --Cleanse wound with wound cleanser, pat dry, apply Xeroform or calcium alginate and cover with sacral wound dressing change as needed. ---The dressing was not documented as completed seven times out of 29 opportunities. -Apply protective house stock barrier cream/bordered foam to stage 1 buttock area, every morning and at bedtime for wound healing, dated 6/4/24. -The dressing was not documented as completed five times out of 57 opportunities. Review of the resident's skin monitoring: comprehensive CNA Shower Review dated January 2025 showed: -The resident had only one shower in January on 1/27/25. -He/She had a red area on his/her buttocks. Review of the resident's medical record showed no documentation of skin or wound documentation. Skin and wound assessments for January 2025 were requested and none were provided. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning), dated 1/16/25, showed: -Did not show if the resident was cognitively intact. -He/She was at risk of pressure ulcers. -Pressure ulcer was not checked. -He/She needed assistance from staff for bathing/showering. -He/She was a Hemiplegic. Review of the resident's care plan, dated 1/27/25, showed: -The resident was bedfast all or most of the time. -The resident required a mechanical lift with assistance of two staff for transfers. -The wound to the resident's coccyx was to have been cleansed with wound cleanser, barrier cream applied Xeroform foam dressing with Boarder dressing applied. -Staff were to monitor for signs of infection. -He/She had a self-care performance deficit related to limited range of motion, Quadriplegia (weakness in upper and lower limbs). -He/She had the potential impairment to skin integrity related to decreased bed mobility. -Staff were to educate caregivers of measures to prevent skin injury. -Staff were to identify and document potential causative factors and eliminate or resolve where possible. -Staff were to provide treatments as ordered. -NOTE: There were no pressure reducing devices listed in the care plan. Observation on 1/22/25 at 10:40 A.M., 1:00 P.M., and 2:30 P.M., showed the resident: -Was in bed, flat on his/her back watching television. -There were no pressure reducing devices on the bed. Observation on 1/23/25 at 10:00 A.M., 12:25 P.M., and 3:00 P.M. showed the resident: -Was in bed, flat on his/her back asleep. -There were no pressure reducing devices on the bed. Observation on 1/24/25 at 1:45 P.M. and 2:30 P.M., showed the resident: -Was in bed, flat on his/her back watching television. -There were no pressure reducing devices on the bed. Observation on 1/30/25 at 9:10 A.M., of wound care with Licensed Practical Nurse (LPN) C and Certified Medication Technician (CMT) C showed: -The resident was in his/her bed, flat on his/her back. -The resident had a 6 centimeter (cm) by 2 cm Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) on his/her coccyx. -The wound had no drainage and was pink/red in color. -The area around the pressure ulcer was reddened. -There were no pressure reducing devices on the bed. During an interview on 1/30/25 at 9:45 A.M., CMT C said: -They don't always have two CNAs to use the mechanical lift to move the resident from his/her bed into his/her Broda chair (a type of wheel chair that was able to tip the person backwards so they did not have to sit upright) so he/she was in bed a lot. -When a resident received a bath, a bath sheet should have been filled out which would have showed if there were any scratches or sores and then the bath sheet was given to the charge nurse. -The nurses should have done skin or wound assessments. During an interview on 1/30/25 at 9:50 A.M., LPN C said: -The resident spent a lot of time in the bed. -They tried to get him/her up into the Broda chair when they could. -He/She would assess the wound when he/she did wound care. -He/She did not document what the wound looked like in the computer. -He/She had not taken any extra training to have been able to stage a wound. -He/She was not able to say what stage the resident's wound was. -The resident would have benefited from a Low Air Loss mattress (LAL a mattress that alternated the pressure). -The facility did not have any LAL mattresses. -He/She had not asked the physician for a LAL mattress. -He/She was not able to voice any other measures to reduce or prevent pressure ulcers. -At this time the facility did not have a Wound Nurse. -There was no one assigned to complete wound or skin assessments. -Wound treatments should have been documented when completed. During an interview on 1/30/25 at 9:55 A.M., the MDS Coordinator said: -They did not have a Wound Care nurse and he/she had been trying to help out. -There should have been weekly documentation of what a wound looked like and no one had been documenting on the appearance of the wound. -A Registered Nurse (RN) would have had to stage and assess the wounds. -There was a wound care company that came to see some of the residents, but did not see this resident. -Wound care has not always been done as there was not enough staff. -The CNA's should document on the bath sheets if a resident had an open wound or scratch. -The CNA's would give the charge nurse the bath sheet and he/she should have looked at the resident's wounds. -The resident did not get out of bed often and could have benefited from a LAL mattress. -The facility did not have a LAL mattress. -He/She had not called to obtain an order for a LAL mattress. -Treatments should have been done as ordered. If the treatment was not done there should have been documentation explaining why the treatment was not done. 2. Review of Resident #39's admission MDS, dated [DATE], showed: -The resident was cognitively intact. -The resident had no skin issues. -The resident had no pressure ulcers. Review of the resident's Skin Monitoring and CNA Shower Review, dated November 2024, showed: -On 11/7/24 the shower sheet did not show any skin issue, signed by a CNA and a nurse. -On 11/11/24 the shower sheet showed the resident had a sore on his/her coccyx area, signed by a CNA and a nurse. -On 11/14/24 the shower sheet showed the resident had a sore on his/her coccyx area, signed by a CNA. -On 11/21/24 the shower sheet showed the resident had a sore on his/her coccyx area, signed by a CNA. Review of the resident's Skin Monitoring and CNA Shower Review, dated December 2024, showed: -On 12/5/24 the shower sheet showed the resident had a sore on his/her coccyx area, signed by a CNA and a nurse. -On 12/9/24 the shower sheet showed the resident had bruising around the outer arm pit, signed by CNA and a nurse. -On 12/12/24 the shower sheet showed the resident had bruising under the right arm pit and a sore on his/her coccyx area, signed by a CNA. -There were no other shower sheets for the resident dated after 12/12/24. Review of the resident's quarterly MDS, dated [DATE], showed: -He/She was cognitively intact. -He/She was at risk for pressure sores. -He/She had limited range of motion on both sides, upper and lower extremities. -He/She was dependent on staff for bathing. -He/She did not have any skin issues or pressure ulcers marked. Review of the resident's TAR, dated December 2024, showed the following order: -Cleanse the coccyx with wound cleanser, gently pat dry, and cover with sacral dressing daily and as needed. -The dressing was not documented as completed two out of five opportunities. Review of the resident's Skin Monitoring and CNA Shower Review, dated January 2025, showed: -No documentation of a shower or skin review dated 1/1/25 to 1/13/25. -On 1/13/25 the shower sheet showed the resident had open sores on both sides of his/her coccyx area and his/her peri area was red, signed by a CNA and Director of Nursing (DON). -On 1/20/25 the shower sheet showed the resident had skin irritation on both sides of his/her abdomen and a sore on his/her coccyx area, signed by a CNA, nurse and DON. Review of the resident's TAR, dated January 2025, showed the following order: -Cleanse the coccyx with wound cleanser, gently pat dry, and cover sacral dressing daily and as needed, dated 12/27/24. -The dressing was not documented as completed two times out of 30 opportunities. During an interview on 1/22/25 at 3:40 P.M., a family member said: -The family was upset about the staff not getting the resident up from bed into a wheel chair as often as he/she should have been and now had a pressure ulcer on his/her coccyx area. -The family member had talked to administration regarding wound care and they have not done anything. -The family member had pictures of the resident's coccyx on his/her phone take three weeks ago. -The resident currently had three open areas on his/her coccyx/sacral area which were: --Wound #1 was open and measured 10 centimeters (cm) in length by 2 cm in width. --Wound #2 was open and was round about the size of a quarter. --Wound #3 was open and was round about the size of a dime. Observation on 1/23/25 at 11:00 A.M. and 2:30 P.M. showed the resident did not have a LAL mattress. Observation on 1/24/25 at 9:36 A.M. showed the resident did not have a LAL mattress. During an interview on 1/24/25 at 9:36 A.M., the resident said: -The staff were not getting him/her up out of bed enough. -He/She had bed sores on his/her back. -Treatments were not done daily. -He/She would receive excuses from staff when the treatments were not done (would be back later to do it). Observation of wound care on 1/28/25 at 10:16 A.M., with LPN B, CNA E, and CNA F showed: -The resident had one pressure ulcer about the size of a quarter that was pink on his/her coccyx. -No drainage was seen. -The other two areas on his/her coccyx were pink and closed. During an interview on 1/28/25 at 10:40 A.M., CNA E and CNA F said: -When staff gave a resident a shower, bath, or bed bath they should have documented if the resident had any open areas on their skin. -Staff would give the nurse the shower/skin sheet and then the DON should have signed it. -If it was not signed it was not done. -The residents were not getting up as often as they should have. Once in the morning and once for dinner. -The resident did not have any pressure reducing devices in his/her bed or chair. During an interview on 1/30/25 at 10:00 A.M., LPN C said: -No one at the facility was currently doing skin or wound assessments. -The resident had open areas on his/her sacral area for a few weeks. -A RN should do the assessments. 3. During an interview on 10/28/25 at 10:45 A.M., LPN B said: -The residents should have been offered a shower twice a week and at that time the CNA should have notified the nurse if there were any skin issues. -The CNA should have documented on the shower/skin assessment form any skin issues that they had found. -The CNA then should have told the nurse so the nurse could see the skin issue. -All shower/skin assessment sheets would then go to the DON so he/she could ensure showers were done twice a week. -If there was a skin issue the nurse would have documented it and notified the Physician. -He/She did not think there was a Wound Nurse at the facility currently. -Wounds on Resident #3 and Resident #39 should have been looked at by the Wound Nurse or DON to stage them. -A LPN could not stage a wound. -He/She could not find any documentation regarding Resident #3 or Resident #39's wounds and something should have been documented weekly. -Treatments to Resident #3 and Resident #39 should have been completed as ordered. -There should not have been any blank areas on Resident #3 or Resident #39's TAR's. If there was no documentation the treatment was not done. -The DON would have addressed the pressure reducing devices with the physician. -Resident # 3 and Resident #39 both should have had pressure reducing devices in place in their bed and/or wheelchair. During an interview on 1/31/25 at 3:30 P.M., the DON said: -If a resident had open areas on his/her skin such as a pressure sore the nurse should have assessed the wound weekly. -He/She was not aware that a LPN was not able to assess or stage a wound unless they had taken a class for that, only a RN was able to assess. -They did not have a Wound Nurse and no one was currently documenting the progression of wounds. -There should have been a description of the wound and measurements. -If a resident was not able to move in bed and was at risk for pressure sores he/she would have expected the staff to turn the resident every two hours, get them out of bed, had a LAL mattress and document those interventions were done. -They did not have a process in place to monitor the residents' wounds. -Resident #3 and Resident #39 should have had pressure reducing devices in their bed and/or wheelchair. -Resident #3 and Resident #39 did not currently have pressure reducing devices in place. -All ordered treatments should have been documented as complete. -The preventative measures should have been on the resident's care plan. MO00247435 MO00247918

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to investigate a fall, failed to assess a resident after a fall, and failed to implement new interventions after a fall for one sampled resident (Resident #30) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's policy titled Accidents and Incidents - Investigating and Reporting, dated as revised July 2017, showed: -All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on the facility property shall be investigated and reported to the Administrator. -The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. -The Report of Incident/Accident form shall include: --The date and time the accident or incident took place. --The nature of the injury/illness (bruise, fall, nausea, etc.). --The circumstances surrounding the accident or incident. --Where the accident or incident took place. --The name(s) of witnesses and their accounts of the accident or incident. --The time the physician was notified and the time of the physician's response and his/her instructions. --The date and time of the resident's family member notification. --The condition of the resident including vital signs. --Where the resident was sent. --Any corrective action taken. --Follow-up information. --Other pertinent data as necessary. --The signature and title of the person completing the report. -The Report of Incident/Accident form shall be completed and submitted to the Director of Nursing (DON) for each occurrence. -Incident/accident reports were reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of the facility's policy titled Incident and Accident Investigation, dated 1/1/24, showed: -Accidents/incidents will be reported to the department supervisor and the supervisor will report to the Administrator and the DON. -An Incident/Event Report or Electronic Health Record (EHR) Risk Management Report shall be completed upon the identification of any accident/incident. -All accidents/incidents will be investigated and reported to the Administrator. -A licensed nurse shall initiate an assessment and gathering preliminary investigative data. -An investigation will be coordinated and analyzed by the Administrator and/or DON to determine systemic changes necessary to prevent further occurrences. -The administrative staff shall complete the investigation and document a summary of the findings on the Risk Management Event Investigation Report. -The Risk Management Event Investigation Report will be present to the Quality Assurance Committee for discussion. -Accidents and incidents shall be tracked to identify trends and reported in the Quality Assurance meetings. -A performance improvement plan and/or disciplinary action shall be developed as indicated. 1. Review of Resident #30's admission Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning), dated 5/15/24, showed: -He/She was severely cognitively impaired. -Was dependent on staff for most of cares. -Had a diagnosis of Cancer. Review of the resident's quarterly MDS, dated [DATE], showed the following staff assessment of the resident: -Moderately cognitively impaired. -Had no functional limitation in range of motion in any extremities. -Required maximum assistance with toileting hygiene, dressing, and personal hygiene. -Required moderate assistance with bathing and going from sitting to standing. -Used a manual wheelchair. -Did not stand. -Was always incontinent of bowel and bladder. -Some of his/her diagnoses included cancer and high blood pressure. -Had not fallen in the past three months. Review of the resident's care plan, dated 11/18/24, (the last time the resident's care plan was updated) showed it did not include anything about falls/skin injuries. Review of the resident's incident note, dated 1/16/25 at 10:31 A.M., showed: -The resident was found on the floor with his/her wheelchair next to him/her and the brakes were not engaged. -The resident's feet were under his/her bed and he/she was on his/her right side. -A huge bump with bruising was forming on his/her right temple area. -The resident was not moved. -Vital signs were documented as taken but the results were not recorded. -Emergency Medical Services (EMS) was called. -EMS arrived applied a c-collar and placed the resident on the stretcher for transport to the hospital. Review of the resident's EHR showed: -There was no documentation an assessment had been completed after the resident's fall on 1/16/25. -There was no documentation an investigation into the cause of the resident's fall had been completed. Review of the resident's care plan showed: -There were no new interventions put into place after the resident's fall on 1/16/25. -There were no new interventions put into place to prevent further falls. Review of the resident's fall risk evaluation, dated 1/16/25, showed the resident: -Did not fall in the past three months. -Was alert and oriented. -Was chairbound. -Was incontinent. -Had no noted drop between blood pressure between lying down and standing. -Had adequate vision. Review of the resident's vital signs documented in the resident's medical record showed: -The resident's pain was mild on 1/16/25 at 10:16 A.M. -No blood pressure, pulse, respirations, oxygen saturation levels, blood glucose levels or neurochecks (neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs) were documented on 1/16/25. During an interview on 1/30/25 at 9:08 A.M., the MDS Coordinator said: -The resident usually turned on his/her call light and didn't usually try to get up on his/her own. -The resident would yell out for help if his/her call light wasn't in reach. -There had not been a MDS completed after the resident's fall on 1/16/25 as it was not due yet. -Falls should be captured on the MDS. -Care plans should include falls. -The resident's fall on 1/16/25 should have been on the care plan. During an interview on 1/30/25 at 11:26 A.M., the DON said: -Staff found the resident on the floor beside his/her bed (on 1/16/25). -He/She didn't know any cause of the resident's fall or any of the resident's other injuries. -He/She did not know an investigation was required when a resident fell, to determine the root cause or contributing factors of the fall or injury. -When a resident fell, the nursing staff should do neurochecks, assess their cognition compared to their baseline, take vital signs, check the movement of their extremities, and do a full assessment of the resident. -EMS was called and took the resident to the hospital. -The resident's vital signs should have been documented. During an interview on 1/30/25 11:50 A.M., the DON said: -There was a risk management form they could enter after a fall, but he/she could not open it. -There were no incident reports or investigations on the resident's fall. Observation on 1/30/25 at 2:09 P.M. showed the resident was in his/her room in his/her wheelchair asleep and had a large bruise that was dark purple, yellow, and green on the right side of his/her face that covered his/her forehead, was around the resident's right eye and down to his/her cheek. During an interview on 1/31/25 at 9:41 A.M., Licensed Practical Nurse (LPN) C said: -They found the resident on the floor (on 1/16/25). -He/She assessed the resident after finding him/her on the floor. -The assessment should be in the EHR. -He/She took his/her vital signs but did not do neurochecks because he/she did not want to move the resident. -No new measures were taken to prevent the resident from falling again. -The DON was responsible for investigating the cause of accidents and incidents and determining new measures to put in place. MO00247918 MO00248157

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess a resident who had a feeding tube (a medical device inserted into the stomach to provide nutrition when a person could not eat) by not checking placement of the feeding tube or checking for residual (withdrawing stomach contents from a feeding tube to determine how much formula was left after a feeding) before administering medications and a liquid feeding; failed to ensure documentation was completed when tube feeding was administered; and failed to ensure nursing staff had received education for taking care of a resident with a feeding tube for one sampled resident (Resident #3) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Enteral Nutrition (liquid nutrition for persons who could not eat) policy, dated November 2018, showed: -The nurse would have confirmed that the order for enteral nutrition was complete. -Complete orders would have included: --Tip placement. --Instructions for placement. -The provider would have considered the need for supplemental orders: --Confirmation of tube placement. --Checks for gastric residual volume. -Staff caring for residents with feeding tubes were to have been trained on how to recognize and report complications such as: --Tube misplacement or migration (movement from original surgical site). 1. Review of Resident #3's face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Dysphagia (difficulty swallowing foods or liquids). -Gastrostomy (G-tube - a thin, flexible tube inserted through the abdominal wall and into the stomach). -Gastro-Esophageal Reflux Disease (GERD - a digestive disease in which stomach acid irritates the food pipe lining). -Diarrhea (loose watery stools that occur frequently). Review of the facility's Skills Fair, dated 11/18/24 to 11/21/24, showed education on gastrostomy tubes was not included. Review of the resident's Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff for care planning, dated 10/16/24 showed: -The cognitive section was not filled out. -The activities of daily living section was not filled out. -Refusal of care was not exhibited. -The nutrition section did not have feeding tube marked as present. Review of the resident's nurse's Medication Administration Record (MAR), dated December 2024, showed: -Give one carton of Jevity 1.2 calorie (a therapeutic nutrition formula that provides calories, protein, fiber, vitamins, and minerals for tube feeding) three times a day at 4:00 A.M., 4:00 P.M., and 8:00 P.M. with 100 milliliter (ml) flush of water. --Hold for residual (amount of liquid food left in tube) greater than 60 ml. --Out of 93 opportunities six were blank, 41 opportunities showed the resident received more than 100% of the tube feeding. -Cholestyramine light (used to treat high cholesterol) packet four grams give one packet via peg tube before meals for diarrhea , mix in eight ounces of water per peg tube. Flush well. --Administer prior to scheduled tube feedings. --Five out of 93 opportunities were blank. -Metoclopramide Hydrochloric Solution 5 milligram (mg) per 5 ml via peg tube before meals and at bedtime related to GERD. --Five out of 124 opportunities were blank. Review of the resident's Treatment Administration Record (TAR), dated December 2024, showed: -Tube feeding every day and night shift, check and record residuals every shift. --Five out of 62 opportunities were blank. --62 out of 62 opportunities did not have a residual amount documented (including zero residual). -Flush tube with 20 to 30 ml of water before and after administration of medication pass. -31 out of 169 opportunities were blank. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning), dated 1/16/25, showed: -He/She had a feeding tube. -GERD was not checked. Review of the resident's care plan, dated 1/27/25, showed: -He/She had a peg tube in place for feeding. -He/She had a potential nutritional problem related to peg tube in place for feeding. -Staff were to administer medications as ordered, monitor for side effects. Review of the resident's POS, dated January 2025, showed: -Nothing by mouth (NPO). -Check and record tube feeding residuals every day and night shift. --Contact the physician if residual exceeds 30 cubic centimeters (cc). -Give one and one half cartons of Jevity 1.2 twice a day at 8:00 A.M. and at 12:00 P.M. with 100 ml water flush. --Hold for residual greater than 60 ml. -Give one carton of Jevity 1.2 three times a day at 4:00 A.M., 4:00 P.M., and at 8:00 P.M. with 100 ml water flush. --Hold for residual greater than 60 ml. -Cholestyramine light packet four grams give one packet via peg tube before meals for diarrhea , mix in eight ounces of water per peg tube. Flush well. --Administer prior to scheduled tube feedings. -Metoclopramide Hydrochloric Solution 5 mg per 5 ml via peg tube before meals and at bedtime related to GERD. -Flush tube with 20 to 30 ml of water before and after administration of medication pass. Review of the resident's nurse's MAR, dated January 2025, showed: -Give one carton of Jevity 1.2 three times a day at 4:00 A.M., 4:00 P.M., and at 8:00 P.M. with 100 ml flush. --Hold for residual greater than 60 ml. --Two out of 85 opportunities were blank. --20 out of 85 opportunities showed the resident received more than 100% of the tube feeding. --Four out of 85 opportunities showed less than 100 % given with no nurses notes explaining why less than 100% was given. Review of the resident's TAR, dated January 2025, showed: -Check and record tube feeding residuals every day and night shift. --Seven out of 56 opportunities seven were blank. --56 out of 56 opportunities had no documentation of residual including zero residual. -Flush tube with 20 to 30 ml of water before and after administration of medication pass. --28 out of 141 opportunities were blank. Observation on 1/29/25 at 12:00 P.M., of medication administration via peg tube showed LPN C: -Did not check placement of the peg tube before administering the medications in the peg tube. -Did not check residual before giving medications. During an interview on 1/29/25 at 12:00 P.M., LPN C said: -Staff should document on the MAR or TAR how much residual was obtained when checked. -Staff should document on the MAR or TAR how much tube feeding was administered and if it was tolerated by the resident. -The documentation of the amount of tube feeding given should not have been more than 100%. -Staff should have documented how much residual there was, including if there was zero residual. -No one had documented any residual amounts, including zero residual. -The DON was responsible for ensuring medications were given and documented correctly. -He/She did not know if the DON had been checking any physician's orders or staff charting. During an interview on 1/31/25 at 9:20 A.M., LPN B said: -When giving medications he/she would flush the peg tube with water. -He/She had education in nursing school about medication administration using a peg tube, but none from the facility. -He/She had been administering medications and tube feedings to the resident via peg tube. -He/She was not told about how to check placement, check residual, when to hold meds or tube feeding, and to have the head of the bed up. -He/She had not charted the residual or amount of feeding the resident received. During an interview on 1/31/25 at 3:30 P.M. the DON said: -He/She did not know how to check placement of a feeding tube. -He/She would have to look up how to check placement of the feeding tube. -He/She would have to look up how to check residual. -He/She would have to educate himself/herself and then educate the staff on the procedure. -The facility had not provided staff with education on peg tubes, it was not done during the skills fair. -If there was not an order to give the medications together then they should have been administered separately. -Staff should follow the physicians' orders. -He/She had not done any audits to ensure charting was done correctly nor to see if staff was doing cares correctly. -If something was not charted it was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify and implement interventions related to pain management for one sampled resident (Resident #9) who expressed pain during a wound care treatment out of 3 sampled residents. The facility census was 57 residents. Review of the facility's Wound Care and Pain Management Policy, dated 4/10/25, showed: -The purpose of the policy was to ensure wound care was delivered in a manner that minimized pain, promoted healing and enhanced the resident's comfort, dignity and quality of life. -All residents who received wound care had associated pain assessed, managed and documented as part of the wound care process. -Pain management was individualized, evidence-based and in accordance with the resident's care plan (a document the provides services designed to meet a resident's health or personal care needs). -Pain was assessed before, during, and after wound care procedures using the standardized pain scale (rates pain from zero to 10. Zero means no pain, and ten means the worst pain ever felt). -The pain management strategies included: --Medication administration at least 30 minutes prior to wound care treatment, per physician orders. --Non-medication strategies (distraction, relaxation techniques, music therapy, repositioning, warm/cold therapy). --Pain management documented in the care plan. --Documentation of pain before, during and after wound care. --Interventions provided. --Residents response to interventions. --Any changes in pain pattern or intensity. --Monitor the effectiveness of pain interventions. -Staff responsibilities included: --Certified Medication Technicians (CMT) reported pain during treatments to the charge nurse. --Licensed Nurses conducted pain assessments, administered interventions, documented appropriately. --Wound Care Nurse recommended and oversaw pain-minimizing wound care strategies, --The Director of Nursing (DON) ensured compliance, conducted audits, provided staff education and provided monthly reports. 1. Review of Resident #9's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility for care planning), dated 1/10/25, showed the following staff assessment of the resident: -Had long-term and short-term memory problems. -Had impaired cognitive skills for decision-making. -Did not reject care. -Was dependent on staff for all care needs. -Received hospice care. -Had pain and received scheduled and as needed pain medications. -NOTE: The skin section was blank and did not have any information regarding the resident's wounds. Review of the resident's current undated care plan showed: -The resident had an open area on his/her right cheek. -Interventions included: --Administer treatments as ordered and monitor for effectiveness. --Assess and treat for pain. --Assess, record, and monitor wound healing. --Measure length, width, and depth where possible. --Assess and document status of wound perimeter, wound bed, and healing progress. --Report improvements and declines to the resident's physician. --Change treatment plan if no progress in two to three weeks as indicated. --Use caution during transfers and bed mobility. Review of the resident's most recent skin check, dated 3/26/25, showed: -The resident had a new skin issue on his/her coccyx (tailbone). -The wound was a round, open, and tunneled wound. -There was pain present during the dressing change. -Wound pain interventions included medicating prior to dressing change and changing the resident's body position. -The dressing was moderately (26-75%) saturated. Review of the resident's quarterly MDS dated [DATE], showed the following staff assessment of the resident: -Had long-term and short-term memory problems. -Had impaired cognitive skills for decision-making. -Did not reject care. -Was dependent on staff for all care needs. -Received scheduled pain medications. -Did not receive any pain medications as needed or any non-medication interventions for his/her pain in the past five days. -Exhibited indicators of pain daily including non-verbal sounds such as moaning, groaning, and/or crying; facial expressions such as grimacing, wincing, wrinkled forehead, furrowed brow, and/or clenching his/her teeth and/or jaw. -Received opioid (pain medications used to treat severe pain) medication. -Had one Stage 3 pressure ulcer (full thickness tissue loss; subcutaneous fat may be visible but bone, tendon or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; it may include undermining or tunneling). -Received hospice (end of life) care. Review of the resident's care plan, dated 4/25/25, showed: -The resident had a Stage III pressure ulcer on his/her right buttock related to heart disease, right-sided weakness, chronic pain, incontinence, and weight loss. -The resident had and open area on his/her right cheek. -Interventions included: --Administer treatments as ordered and monitor for effectiveness. --Assess and treat for pain. --Use caution during transfers and bed mobility. Review of the resident's physicians' order sheet (POS), dated April 2025, showed: -2/7/24 Coccyx treatment: Cleanse area with normal saline, apply Pixie Dust (can help the human body grow new tissue) to wound bed, then fill area with Iodoform (an antiseptic and disinfectant), then cover with bandage daily and as needed if soiled or dislodged every shift Monday, Wednesday, and Friday. -4/17/25 Wound care to right cheek: Cleanse with wound cleanser, apply skin prep (a topical barrier between skin and adhesives) to the surrounding ulcer, cover the raised area with Xeroform (a wound dressing), apply Calcium Alginate (a highly absorbent dressing) and secure with transparent tape for wound draining every day and as needed every day shift. -A physician's order for Hydromorphone HCl (a narcotic pain medication for moderate to severe pain) tablet 2 milligrams (mg), give 1 mg (1/2 of the 2 mg tablet) in the morning and at night. -A physician's order for Hydromorphone HCl tablet 2 mg, give 1 mg (1/2 of the 2 mg tablet) every three hours as needed for pain. -A physician's order for a Fentanyl patch 72 hour 75 micrograms (mcg) per hour. Apply one patch transdermally every 72 hours for chronic pain. Review of the resident's Treatment Administration Record (TAR), dated April 2025, showed it was documented the resident refused wound care to his/her right cheek on 4/26/25 and 4/27/25. Review of the resident's Medication Administration Record (MAR), dated April 2025, showed: -The resident received Hydromorphone HCl (a narcotic pain medication for moderate to severe pain) tablet 2 milligrams (mg), give 1 mg (1/2 of the 2 mg tablet) in the morning and at night. --Two out of 60 opportunities were missed. -A physician's order for Hydromorphone HCl tablet 2 mg, give 1 mg (1/2 of the 2 mg tablet) every three hours as needed for pain. --This was given on 4/13/25 with a pain rating of five out of 10; on 4/21/25 with a pain rating of 10 out of 10; on 4/22/25 with a pain rating of five out of 10; on 4/24/25 with a pain rating of 10 out of 10; and on 4/29/25 with a pain rating of four out of 10. --It was not administered on 4/30/25 prior to wound care. -A physician's order for a Fentanyl patch (patch containing narcotic pain medication) 75 mcg per hour. Apply one patch transdermally every 72 hours for chronic pain. Documented given as ordered. Review of all the resident's hospice (end of life) nurse patient visit summary, dated 4/29/25, showed: -The cancerous lesion measured 5.8 centimeters (cm) x 6.2 cm x 1.5 cm. -The wound had serosanguinous (containing blood and watery drainage) foul smelling drainage with moderate to large amount of drainage. Observation on 4/30/25 at 12:56 P.M., of wound care with Licensed Practical Nurse (LPN) B and Certified Nurse Assistant (CNA) B, showed: -The resident said ouch during the procedure on several occasions. -The resident was moaning and groaning on a consistent basis during the entire procedure. -The resident was tightening up his/her body muscles during the procedure on several occasions. Review of the resident's MAR dated April 2025 showed no documentation of pain medication being given on 4/30/25 prior to or after wound treatment. During an interview on 4/30/25 at 1:30 P.M., the Director of Nursing (DON) said: -The resident refused his/her wound care on 4/26/25 and 4/27/25, because they were out of adhesive remover and it was hurting him/her when they were trying to remove it. -The staff did not attempt any other ways to remove the dressing without the adhesive remover. During an interview on 4/30/25 at 2:30 P.M., LPN B said: -He/She noticed the resident was in pain during the wound care procedure. -The resident did have a Pro Re Nata (PRN-as needed) pain medication ordered. -He/She should have pre-medicated the resident with the resident's PRN pain medication to help with pain prevention prior to the wound care treatment. During an interview on 5/1/25 at 10:50 A.M., the DON said: -Residents who had PRN pain medication should be pre-medicated prior to wound care treatment if needed for pain control. -He/She expected nurses to stop wound care during the procedure and medicate a resident if the resident was showing signs of pain during the procedure. -He/She expected nurses to make pain relief a priority for their residents during wound care treatments.

Based on interview and record review, the facility failed to ensure timely assistance was provided to two sampled residents (Residents #35 and #29) who were Medicaid pending (a person has applied for Medicaid, but had not yet been approved or denied benefits) out of four residents reviewed, in the procurement of Medicaid (a government program that provides health insurance for adults and children with limited income and resources) to assist with their expenses at the facility. The facility census was 55 residents. Review of the Medicaid Nursing Home Application- Helpful Information showed items often needed for Nursing Home Application include the following: -Bank Statements (any/all checking and Savings -Last 3 months to the current; -Life Insurance Policies (Cash Surrender Value & is the policy revocable or irrevocable -Stocks, Bonds, IRAs (Individual Retirement Accounts); -Funeral Burial Documents (Contract and irrevocable clause, if applicable); -Pension (verification Letter showing Gross wages and deductions); -Power of Attorney (POA) Guardian/Public Administrator Paperwork; -Deeds/titles to home property and vehicles; -Proof of Marriage; -Shelter expenses such as rent, mortgage, homeowners insurance, and real estate taxes; -Proof of income such as assets, life insurance, burial plan etc. (for spouse) and -Initial date of institutionalization lasting 30 days or more. 1. Review of the facility's midnight census report, dated 1/22/25, showed Resident #35 was listed as Medicaid pending as his/her Primary Payer. During an interview on 1/23/25 at 10:22 A.M., the Social Service Designee (SSD) said: -He/she had been in that position since September 2023. -He/she was unaware of which residents were in Medicaid pending status, when he/she got into that position. -He/she was unaware of the reason why Medicaid was discontinued for that resident in the first place. -Resident #35's Relative B spoke with him/her in November 2024. During a phone interview on 1/23/25 at 10:49 A.M., the resident's Relative B said: -He/she was informed in October 2024 by the previous Business Office Manager (BOM) that the resident became Medicaid pending because of a letter which came to the facility. -As of 1/23/25, he/she had not seen a copy of the letter that he/she was told about. -That letter was not shared with another relative who was able to visit the resident a little more often, because he/she (Relative B) resided at an out of town location. -The former BOM said something needed to be renewed, but the former BOM did not say exactly what needed to be renewed. -The application process for Medicaid only began in November 2024. -The facility's processes and follow through were pitiful. 2. Review of the facility's midnight Census Report, dated 1/22/25, showed Resident #29 was listed as Medicaid pending as his/her Primary Payer. During an interview on 1/31/25 at 9:35 A.M., the current BOM said: -The resident was admitted to the facility in October 2022. -The resident's Medicaid Status was inactive since February 2024. -The resident's Relative C said the previous BOM was supposed to be helping him/her fill out the paperwork correctly. During a phone interview on 2/5/25 at 10:16 A.M., the resident's Relative C said: -The current BOM had been helpful, but all the previous BOM's were no help. -His/her relative had been at the facility since October 2022. -He/she started filling out a renewal application for Medicaid in November 2023 for the resident. -He/she received no assistance from any of the BOM's at the facility, until the current BOM started. -He/she tried to answer the questions on the Medicaid application as honestly as he/she could. -He/she voiced concerns to the former BOM and was told he/she would provide help, but the former BOM did not do anything to help him/her complete the Medicaid application. -He/she had taken this as far as he/she could physically take it. -In November 2023, he/she sent a letter to MO Health Net, then he/she received a reply which stated the resident's case was closed on 12/29/23, he/she would need to reapply. -There have not been proper people in place to assist relatives in the process of completing Medicaid applications. 3. During an interview on 1/31/25 at 10:04 A.M., the Executive Director said: -He/she had one conversation about the Medicaid application and submission process. -He/she discussed a checklist. -The BOM had told him/her that those situations existed before his/her (the BOM's) time.

Based on interview and record review, the facility failed to ensure the narcotic (a class of drugs that produce insensibility or stupor due to their depressant effect of the central nervous system) medications were counted and signed by two nurses at the beginning and end of each shift, failed to ensure residents' narcotic medications were counted correctly for one supplemental resident (Resident #49), and failed to ensure narcotic medications were documented correctly when administered for one sampled resident (Resident #39) out of 15 sampled residents. The facility census was 55 residents. The facility narcotic drug count policy was requested and not received. 1. Review of The Controlled Substance Key Exchange Record, dated December 22, 2024 to December 31, 2024, with Licensed Practical Nurse (LPN) C showed: -There should have been two nurses signatures for two shifts per day. --Two nurses signatures for two shifts per day for seven days equaled 28 opportunities, which verified the narcotic count was correct. ---Nine out of 28 opportunities were blank. -The number of cards with narcotics in them should have been counted at the beginning and ending of each shift and a total documented on the Controlled Substance Key Exchange Record. --Four out of 14 opportunities were blank. 2. Review of The Controlled Substance Key Exchange Record, dated January 1, 2025 to January 27, 2025, with LPN C showed: -27 out of 106 opportunities were missed. -10 out of 53 opportunities to count narcotic cards were not counted. -On January 1, 2025 there were 42 narcotic cards. --From January 1, 2025 to January 27, 18 narcotic cards were added, 21 were subtracted for a total of 39 cards. 3. Review of Resident 39's Medication Administration Record (MAR), dated December 2024, showed: -Hydrocodone-Acetaminophen (a powerful pain medication with the risks of addiction, abuse, or misuse) tablet 7.5-325 milligram (mg) give one by mouth every four hours as needed for pain related to spinal stenosis and lower back pain. --The Hydrocodone-Acetaminophen was signed out 63 times. Review of the resident's Controlled Drug Receipt/Record/Disposition Form, dated 12/6/24 to 12/31/24, showed: -The medication was signed out 10 times more on the Controlled Drug Receipt/Record/Disposition form than the amount documented on the Nurses' Medication Administration Record (MAR). --The Hydrocodone-Acetaminophen was signed out 73 times. Review of the resident's MAR dated January 2025 showed: -Hydrocodone-Acetaminophen tablet 7.5-325 mg give one by mouth every four hours as needed for pain related to spinal stenosis and lower back pain. --The Hydrocodone-Acetaminophen was signed out 70 times. Review of the resident's Controlled Drug Receipt/Record/Disposition Form, dated 1/1/25 to 1/28/25, showed: -The medication was signed out 15 times more Controlled Drug Receipt/Record/Disposition form than the amount documented on the Nurses' MAR. --The Hydrocodone-Acetaminophen was signed out 82 times. 4. Review of Resident #49's Controlled Drug Receipt/Record/Disposition Form, dated January 2025, showed: -Oxycodone 5 mg tablet, give one half tablet (2.5 mg) by mouth every four hours as needed. -On 1/8/25 the resident had 30 pills. -On 1/27/25 at 9:30 A.M. there were 18 pills documented as given with 12 pills remaining. - Observation on 1/27/25 at 9:35 A.M. showed the actual count was 11 pills remaining, as verified by LPN C. 5. During an interview on 1/27/25 at 11:00 A.M., LPN C said: -Two nurses should count the number of narcotic cards at the same time and sign the narcotic count sheet which verified they had counted and the number was correct, it should have been done at the start and end of each shift. -Counting narcotic cards was not done consistently at the facility. -If the pill count on the narcotic card was not correct the Director of Nursing (DON) should have been told. -He/She had never said anything to the DON about the nurses not signing the narcotic count or that the count was not correct. -The DON was ultimately responsible for ensuring the nursing staff was counting the narcotics and that the count was correct. During an interview on 1/29/25 at 2:00 P.M., LPN A said: -The oncoming and off going nurses should count the narcotics together and sign at the time that they had counted. -The count should be correct and have been the same as the count of medications given on the MAR. -If the count was wrong the DON should have been notified. -He/She had noticed some blank spots on the count sheet and had told the previous DON, but nothing was done. During an interview on 1/31/25 at 3:30 P.M., the DON said: -Narcotics should have been counted at the beginning and end of each shift with both nurses to verify the count was correct. -If the count was not correct or there were blanks indicating both nurses had not verified the count he/she should have been notified. -He/She had not been auditing the narcotic count to ensure it was correct. -He/She had not been notified by anyone on 1/27/25 of the narcotic count being off.

2. Review of Resident #2's MRR notes, dated 1/4/24, 2/1/24, 3/1/24, 4/4/24, and 5/1/24, showed the MRR was completed and referred to the MRR report for any noted irregularities and/or recommendations. Review of the resident's medical record showed no response to the MRR's that were dated 1/4/24, 2/1/24, 3/1/24, 4/4/24, and 5/1/24. The MRR's and the responses to the MRR's dated 1/4/24, 2/1/24, 3/1/24, 4/4/24, and 5/1/24 were requested from the facility and not received. 3. During an interview on 1/29/25 at 10:32 A.M., Licensed Practical Nurse (LPN A) said: -The MRR's go to the Director of Nursing (DON). -The DON was responsible for ensuring the MRR's were completed. -He/She had not been given any MRR responses to enter medication order changes for any residents. During an interview on 1/31/25 at 12:05 P.M. with the DON and the Executive Director: -The Executive Director said: --The DON was responsible for ensuring the MRR's were completed. --The order should have been transcribed correctly. -The DON said: --He/She was not aware he/she was responsible for making sure the MRR's were completed. --The charge nurse should have ensured the orders were transcribed correctly. --He/She had not checked to make sure the MRR's were completed or orders were transcribed correctly. Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) Pharmacy recommendations were followed and the Physician responded for two sampled residents (Residents #209, and #2) out of five residents sampled for medication review. The facility census was 55 residents. Review of the facility's Medication Regimen Reviews policy, dated as revised May 2019, showed: -The consultant pharmacist performed a MRR for every resident in the facility receiving medications. -MRR's were done upon admission and at least monthly. -Within 24 hours of the MRR, the consultant pharmacist provided a written report to the attending physicians for each resident identified as having non-life-threatening medication irregularity. -The MRR included the resident's name, the name of the medication, the identified irregularity and the pharmacist's recommendation. -The attending physician should document in the medical record that the irregularity was reviewed and what (if any) action was taken to address it. -The consultant pharmacist provided the Director of Nursing (DON) and Medical Director with a written, signed, and dated copy of all MRR's. -Copies of the MRR reports, including physicians' responses, are maintained as part of the permanent medical record. Review of the facility's Medication Therapy policy, dated April 2007, showed all medication orders should have been supported by appropriate care processes and practices. 1. Review of Resident #209's progress notes, dated 1/5/25, showed Medication Regimen Review Complete: See report for any noted irregularities and/or recommendations. Review of the resident's MRR, dated 1/5/25, showed: -Please update the diagnosis to Benign Prostatic Hypertrophy (BPH a condition where the prostate gland, located below the bladder in men, enlarges without being cancerous) per admission orders for Tamsulosin (used to treat the symptoms of an enlarged prostate) capsule 0.4 milligram (mg). -There was no physician response on the resident's MRR or in the resident's progress notes. Review of the resident's POS, dated January 2025, showed: -Tamsulosin Oral Capsule 0.4 mg -Give 1 capsule by mouth one time a day for chronic kidney disease. --NOTE: The diagnosis was not updated as recommended by the pharmacist.

Based on observation, interview, and record review, the facility failed to ensure residents' medications that needed to be refrigerated were refrigerated, failed to ensure there were no loose pills in the medication cart, failed to ensure the temperature was checked daily for the medication refrigerator which stored the resident's prescribed medications, failed to ensure there was soap in the only soap dispenser in the medication room, and failed to ensure the only sink in the medication room was clean. The facility census was 55 residents. Review of the facility's Storage of Medications policy, dated November 2020, showed: -Drugs and biologicals used the the facility were to have been stored in locked compartments under proper temperature, light and humidity controls. -Only persons authorized to prepare and administer medications had access to locked medications. -The nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 1. Observation on 1/27/25 at 9:15 A.M., with Licensed Practical Nurse (LPN) C of the Medication cart on A hallway showed: --The Gabapentin bottle had the following instructions; refrigerate after opening. The bottle was in the medication cart and was not refrigerated. -There were two round white pills loose in the bottom of the medication cart drawer. 2. Review of the medication refrigerator temperature log on A hallway, dated December 2024, showed: -The refrigerator temperature should have been between 36 to 46 degrees Fahrenheit for medication storage. -Only 20 out of 31 days were documented as done and there were 11 missed opportunities to document the refrigerator temperature. 3. Review of the medication refrigerator temperature log on A hallway, dated January 2025 on 1/27/25, showed: -The refrigerator temperature should have been between 36 to 46 degrees Fahrenheit for medication storage. -Only 12 out of 27 days were the temperature documented as done and there were 15 missed opportunities to document the refrigerator temperature. 4. Observation on 1/27/25 at 9:30 A.M., of medication room A showed: -There was no soap in the only soap dispenser. -The sinks were stained with a brown reddish color. 5. During an interview on 1/27/25 at 9:45 A.M., LPN C said: -There should not have been any loose pills in the drawer of the medication cart. -The charge nurse was responsible for ensuring the medication carts were cleaned. -Medication that was to have been refrigerated should have been refrigerated. -The night nurse should have ensured the refrigerator with the residents' medications in it was checked every night and documented on the temperature log. -The medication room should have been cleaned daily by the housekeeping staff. During an interview on 1/29/25 at 2:01 P.M., LPN A said: -There should not have been any loose pills in the medication cart drawers. -Anyone who used the medication cart was responsible for keeping it clean. -If a medication said it was to have been in the refrigerator it should have been in the refrigerator. -Nursing should have ensured that housekeeping was cleaning the medication room daily and that it was stocked. -The Director of Nursing (DON) should have ensured the night nurse was checking the temperature of the medication refrigerator. During an interview on 1/31/25 at 3:30 P.M., the DON said: -If a medication showed it needed to have been refrigerated on it, it should have been refrigerated. -The person who used the medication cart should have ensured it was kept clean. -There should not have been any loose pills in the drawers of the medication cart. -The day nurse was responsible for ensuring the medication refrigerator was within acceptable range and documenting it daily. -Housekeeping under supervision of the nursing staff was responsible for cleaning and ensuring the medication room was stocked with soap and paper towels. -He/She did not know how often the medication rooms were cleaned by housekeeping.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the physician's orders pertaining to the diet texture were correct and followed, and failed to discontinue a diet order after the resident was reassessed for a change in diet texture for one sampled resident (Resident #30) out of 14 sampled residents. The facility census was 55 residents. 1. Review of Resident #30's admission Face Sheet showed the resident was admitted with the following diagnoses: -High blood pressure. -Hyperlipidemia (condition in which there are abnormally high levels of lipids (fats) in the blood). -Malignant neoplasm (an abnormal mass of tissue that forms when cells grow and divide uncontrollably. of unspecified site. Review of the resident's physician's orders, dated 5/8/24, showed a physician's order for a regular diet with a regular texture. Review of the resident's admission Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning), dated 5/15/24, showed: -Severe cognitive impairment. -The resident required a mechanically altered diet. -The resident required supervision or touching assistance for eating. Review of the resident's physician's orders, dated 5/15/24, showed a physician's order for a regular diet with a pureed (food that is blended, chopped, mashed, or strained until it becomes a soft and smooth consistency) texture. Review of the resident's Speech Therapy order, dated 7/5/24, showed: -The resident should be upright in his/her chair and in the dining room for all meals, unless family was present. -Encourage drinks between bites to clear food. -Stay up for 30 minutes after eating. -NOTE: There was no type of diet texture mentioned in the order. Review of the resident's care plan, dated 7/25/24, showed: -The resident had a diagnosis of Oropharyngeal dysphagia (swallowing difficulty that occurs in the mouth or throat). -The problem was the resident had a nutritional problem or potential nutritional problem related to a diagnosis of dysphagia. -The goal was to explain and reinforce the importance of maintaining the diet ordered. -The interventions were: --Monitor/document/report any signs or symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or appeared concerned during meals. Review of the resident's Dietary Profile, dated 8/20/24, showed the resident's current diet order was for a regular texture with partial assistance required. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident had moderate cognitive impairment. -The resident required a mechanically altered diet. -The resident required supervision or touching assistance for eating. Review of the resident's Dietary Profile, dated 11/18/24, showed the resident's current diet order was for a regular texture with independent in eating. Review of the resident's care plan, dated 11/18/24, showed: -Focus: The resident had nutritional problem or potential nutritional problem related to malignant neoplasm, essential primary hypertension, and hyperlipidemia. -Goals: The resident would maintain adequate nutritional status as evidenced by maintaining weight within 5% of 140.2, pounds with no signs and symptoms of malnutrition, and consuming at least 50% of at least two meals daily through review date. -Interventions included: --Explain and reinforce to the resident the importance of maintaining the diet ordered. --Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. --Monitor/document/report any signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in his/her mouth, several attempts at swallowing, Refusing to eat, Appears concerned during meals as needed --Monitor/record/report to his/her physician as needed for signs and symptoms of malnutrition, such as Emaciation (Cachexia), muscle wasting, significant weight loss: 3 lbs. (pounds) in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. --Occupational Therapy (OT) to screen and provide adaptive equipment for feeding as needed. --Provide, serve diet as ordered. Monitor intake and record every meal. --The Registered Dietitian (RD) should evaluate and make diet change recommendations as needed. Review of the resident's POS, dated January 2025, showed the following diet orders: -Regular diet regular consistency with regular thin consistency liquids. -Regular diet puree consistency. Observation on 1/24/25 at 7:57 A.M., during the breakfast meal showed: -The resident was served a regular diet meal which consisted of coffee cake, omelet, and oatmeal with regular thin liquids. -The meal was not cut into smaller pieces for the resident. -The resident coughed on and off during the entire meal. -The resident coughed when he/she took drinks. -Facility staff did not assist the resident. Observation on 1/24/25 from 12:10 P.M. through 12:38 P.M., during the lunch meal showed: -The resident was served chicken, broccoli, and a roll at a regular consistency. -The staff member cut up the chicken for the resident. -The resident's relative A cut the broccoli for the resident. -The resident's relative A assisted with feeding. -The resident had occasional coughing while eating. During an interview on 1/24/25 at 12:14 P.M., the resident's relative A said: -The resident ate slow. -The resident had trouble using the utensils. -The facility had not asked him/her anything related to the resident's dietary assessment. During an interview on 1/27/25 at 3:09 P.M., Certified Medication Technician (CMT) C said he/she has noticed that the resident coughed while he/she ate in the dining room. During an interview on 1/27/25 at 3:10 P.M., Certified Nursing Assistant (CNA) F said he/she had noticed that the resident coughed while he/she ate his/her food. During an interview on 1/27/25 at 3:11 P.M., Licensed Practical Nurse (LPN) C said: -The original physician's order for regular diet was started on 5/8/24 and discontinued on 5/15/24. -Between 5/8/24 and 5/15/24, the resident was evaluated by Speech Therapy and at the end of that period, they should have discontinued one of the diets, and fixed the orders. -On 7/5/24, there was an upgrade in the resident's diet from pureed texture diet to regular texture diet. -The Registered Dietitian (RD) came to the facility once per month. During an interview on 1/27/25 at 3:36 P.M., the MDS Coordinator said: -There were two orders, one for a regular diet dated 5/8/24 and one for a pureed diet started on 5/15/24. -The order for the regular diet should have been discontinued on 5/15/24, while the order for the pureed diet had an indefinite end date. -An order was done by Speech Therapy in July 2024, to put the resident on a regular diet. -Speech Therapy saw the resident on 7/5/24, but the Speech Therapist did not communicate what diet texture the resident should have. -The order for a regular textured diet in May, 2024, was not discontinued by the physician. -At the completion of the most recent MDS in November 2024, the resident should have still received a pureed diet. -The order for the pureed diet was in effect currently and the order for the regular diet was also in effect at this time. Review of the resident's Progress Note, dated 1/27/2025, documented by the MDS Coordinator, showed: -The resident had two diets in his/her orders. -The MDS had the resident assessed for a pureed diet (mechanically altered). -A regular textured diet was prescribed to the resident during a swallow study. -The Speech Therapist did not conform the start and stop dates for the different texture of diets. -The order for regular diet had continued on the orders along with the orders for pureed textured diet. -The resident had been served a regular diet. -The order put in by a nurse did not specify which diet texture to serve. -The current order for pureed texture was given to the dietary manager so the correct textured diet would be served to the resident. During an interview on 1/28/25 at 1:22 P.M., the Speech Therapist said: -There was a different Speech Therapist who evaluated the resident in July 2024. -There was an evaluation of the resident from 7/5/24 through 7/22/24, due to a request from someone (but he/she did not know who). -If the Speech Therapist was going to change a diet order, one diet should have been discontinued then started a new order. -The speech evaluation showed the resident tolerated an upgraded diet in July with no issues. -It looked like the Speech Therapist in July 2024 recommended a diet upgrade from a pureed texture to a mechanical soft. -The resident had not been referred to Speech Therapy for a reevaluation in the last three months. -He/she could not speak to which order would be correct until a full evaluation was done. -The Speech Therapist recommended a regular diet back in July 2024. Observation on 1/29/25 from 12:05 P.M. to 12:37 P.M., during the lunch meal showed: -The resident sat at the table in the dining room with, one small cup of ice water at the table. -The resident was served pureed ham, pureed sweet potatoes, pureed broccoli. -The resident unrolled silverware from napkin and placed silverware and napkin on table. -The resident started to feed himself/herself with a spoon by eating the pureed ham. -The resident ate six bites of ham. -The resident ate four bites of the dessert. -The resident ate most of the ham but not the broccoli nor the sweet potatoes. During an interview on 1/30/25 at 3:11 P.M., the Director of Nursing (DON) said: -The resident did not eat very much. -The resident fed himself/herself. -Sometimes the resident ate well. -Family brought food to the resident frequently. -He/she was not aware of the conflicting orders. -The nurse who placed the order for the pureed diet should have had the order for the regular diet discontinued. During a phone interview on 1/31/25 at 10:56 A.M., the Registered Dietitian (RD) said: -He/she did an annual assessment of the resident in September 2024. -As far as he/she knew, the resident should be served a pureed diet. -The resident's medical record indicated pureed diet. -The order was changed from regular to pureed on 1/27/25. -There had been some degree of turnover in the dietary department. MO 00248157

Based on interview and record review, the facility failed to maintain authorization forms for three sampled residents (Residents #5, #2, and #39) out of four residents sampled for the resident trust review. The facility census was 55 residents. Review of the facility's policy entitled Resident Trust Policy and Procedures, dated March 2023, showed: -Purpose: Baptist Homes and Healthcare Ministries need to be good stewards of the money entrusted to us by our residents and their families. -This policy and procedures document outlines a general guide and specific steps on how to handle resident trust funds across the organization. -General Information regarding responsibilities of holding Resident Funds: --Personal Funds of the resident shall be used exclusively for the resident, which must be authorized in writing. The individuals who can authorize such transactions may be the resident, his/her legal guardian, or a legal representative (who may not be an employee at the facility, including the Administrator). The facility is allowed to purchase a burial plan for the resident when written authorization is obtained. 1. Review of the Resident Fund records for Resident #5 showed the absence of signed authorization forms which allowed the facility to manage funds on behalf of the residents. 2. Review of the Resident Fund records for Resident#2 showed the absence of signed authorization forms which allowed the facility to manage funds on behalf of the residents. 3. Review of the Resident Fund records for Resident #39 showed the absence of signed authorization forms which allowed the facility to manage funds on behalf of the residents. During an interview on 1/23/25 at 3:31 P.M., the Business Office Manager (BOM) said: -The previous BOM did not keep track of the authorization forms, which were signed by the residents. -He/she had only been in the position since December 17, 2024.

Based on interview and record review, the facility failed to maintain records of reconciled (a process that takes place when the deposits, credits and interest that are on record but were not accounted for on the final bank statement; are added to the final amount on the bank statement, then checks and charges that are on record, but were not listed on the bank account statement, are subtracted from the adjusted final amount) banks statements dated January 2024 to September 2024; failed to maintain the monthly ending petty cash (small amount of discretionary funds in the form of cash used for small cash disbursements) amounts from January 2024 to December 2024; failed to maintain signatures or receipts of withdrawals from one sampled resident's (Resident #5's) account; failed to post (make a record of ) deposits into the resident trust fund accounts in a timely manner for two sampled residents (Resident#5 and #2) of four residents selected for resident trust fund review. This practice potentially affected 44 residents who allowed the facility to manage their resident trust funds. The facility census was 55 residents. Review of the facility's policy entitled Resident Trust Policy and Procedures, dated March 2023, showed: -Purpose: Baptist Homes and Healthcare Ministries need to be good stewards of the money entrusted to us by our residents and their families. This policy and procedures document outlines a general guide and specific steps on how to handle resident trust funds across the organization. -General Information regarding responsibilities off holding Resident Funds: --The facility shall keep an accurate, maintained accounting system for the residents that choose to have their personal funds managed. These funds shall be safeguarded by the facility, using complete and separate accounting principles, which precludes any commingling of resident funds with facility funds. --Personal Funds of the resident shall be used exclusively for the resident, which must be authorized in writing. The individuals who can authorize such transactions may be the resident, his/her legal guardian, or a legal representative (who may not be an employee at the facility, including the Administrator). The facility is allowed to purchase a burial plan for the resident when written authorization is obtained. --Records related to the resident funds shall be maintained in the facility or shall be made available for review and copying, in their entirety, within 24 hours of a request for access by the Social Security Administration, Missouri Department of Health and Senior Services or other Federal and State Agencies. --Social Security checks (SSA) that include both room and board and the monthly personal allowance should be deposited in the resident trust account and then the room and board amount is transferred to the site account. 1. Review of the Reconciled Bank statements, dated January 2024 to December 2024, showed: -The absence of the bank statements from January 2024 to September 2024. -The absence of the monthly ending balances of petty cash dated January 2024 to December 2024. During an interview on 1/23/25 at 11:40 A.M., the Assistant Director said the reconciled bank statements should be uploaded to a file at the corporate level. During an interview on 1/23/25 at 11:44 A.M., the Business Office Manager (BOM) said there was no documentation of reconciled bank statements from January 2024 to September 2024. During an interview on 1/23/25 at 11:58 A.M., the BOM said the previous BOM has been gone since 11/5/24, and that BOM did not do reconciliations of the bank statements. During an interview on 1/23/25 at 3:17 P.M., the BOM said: -He/she was trying to figure out the record keeping processes of the facility. -The reconciliations from January 2024 to September 2024 should have been uploaded to the corporate file for the facility. 2. Review of the Petty Cash Count Sheet (a one day accounting of how much money was actually in the petty cash box and added to the amount of money that had already been withdrawn over a certain time period) showed a difference of $19.00 between the amount in the petty cash box and added to the amount that was already spent. -The beginning amount of the petty cash was $500.00 on 12/18/24. -The amount in the petty cash box was $180.00 -The amount of money that was already spent, was $301.00. -There was a difference of $19.00 between what the amount should have been $500.00 and the amount that was totaled on the Petty Cash Count sheet, which was $481.00. During an interview on 1/23/25 at 12:07 P.M., the BOM said the facility had not tracked any petty cash in October 2024, November 2024, and December 2024. During an interview on 1/23/25 at 1:37 P.M., the BOM said: -He/she started on 12/17/24 and he/she may have missed recording cash withdrawals on 12/18/24 and 12/19/24 just a few days after he/she started. 3. Review of Resident #5's Trust Statement showed: -A deposit of $1,493.00 which was transferred into the resident's account in October 2024. -The absence of the amount being posted (properly accounted for) in that month. -The amount of $1,493.00 was posted on 12/31/24, which caused the resident trust account to increase to $6,789.79, which was above the Missouri (MO) Health Net limit of $5,909.25. During an interview on 1/23/25 at 12:46 P.M., the BOM said: -There was a deposit for $1,493.00 that originally came in October 2024, but was not posted by the previous BOM. -That amount did not get posted until 12/31/24 by the current BOM, which caused the resident's account balance to exceed the MO Healthnet limit. 4. Review of Resident #2's Trust Statement showed: -A deposit of $1,395.00 which was transferred into that resident's account in October 2024. -The absence of the amount being posted in that month. -The amount of $1,395.00 was finally posted on 12/31/24 which caused the resident trust account to increase to $5,921.88, which is above the MO Health Net limit of $5,909.25. During an interview on 1/23/25 at 12:58 P.M., the BOM said: -There was a deposit of $1,395.00 that came in October 2024, but was not posted in October 2024 by the previous BOM. -That amount did not get posted until 12/31/24 by the current BOM which caused the resident's account balance to exceed the MO Healthnet limit. 5. Review of Resident #5's trust statement showed a withdrawal of $100.00 on 9/10/24 and a withdrawal of $50.00 on 10/10/24 with no receipt or signature for the withdrawals. During an interview on 1/23/25 at 12:51 P.M., the BOM said: -He/she started the position at the facility on 12/17/24. -There were no receipts or signatures for the withdrawals completed in September 2024 and October 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) (SNF/ABN-form Centers for Medicare and Medicaid Services (CMS)-10055) was provided to the resident or their representative for three sampled residents (Residents #41, #43, and #56) out of three sampled residents who were discharged from Medicare part A (insurance that covers inpatient hospital care, skilled nursing facility, lab tests, surgery, home health care for individuals who are [AGE] years of age and above or disabled). The facility census was 55 residents. Review of the facility's Medicare Advance Beneficiary and Medicare Non-Coverage Notices policy, dated as revised September 2022, showed when Medicare A stops coverage of the resident's extended care items or services, the facility should issue a SNF/ABN before the extended care items or services are terminated. Review of the CMS memo (S&C-09-20), dated 1/9/09, showed: -If the SNF believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled using the SNF/ABN (form CMS-10055). -The SNF/ABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have. Review of the CMS website, updated 8/28/24, showed SNFs use the SNF/ABN as the liability notice for Medicare Part A items and services. 1. Review of the facility's Beneficiary Notice worksheet of residents discharged from Medicare Part A within the last six months form showed: -Resident #56 was discharged from Medicare A on 12/8/24. -Resident #41 was discharged from Medicare A on 11/13/24. -Resident #43 was discharged from Medicare A on 8/31/24. Review of Resident #56, #41, and #43's beneficiary notices showed none of the residents were provided with an SNF/ABN. During an interview on 1/27/25 at 1:44 P.M., the Social Services Director said he/she was told not to do the SNF/ABN on residents discharged off Medicare A services and to only provide the SNF/ABN when the resident was on Medicare B benefits that were ending. During an interview on 1/31/25 at 3:25 P.M., the Contract Administrator said the SNF/ABN should have been completed for Resident #56, #41, and #43.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the ceiling vent in the dining room free of a heavy buildup of dust; failed to maintain the 80 Hall free of a persistent urine odor; failed to ensure the hot water in resident rooms 86, 84, 82 was at or above 105 ºF (degrees Fahrenheit); failed to ensure there was not a buildup of dust and debris on the floor in resident rooms [ROOM NUMBERS]; failed to prevent a heavy buildup of dust in the ceiling vents in 50 Hall Shower Room A, 20 Hall Shower Room A, and in the restroom of resident room [ROOM NUMBER]. This practice potentially affected at least 40 residents who resided in, or used those areas in the facility. The facility census was 55 residents. 1. Observation on 1/28/25 at 11:45 A.M., with the Maintenance Director showed a heavy buildup of dust in the ceiling vent in the dining room. During an interview on 1/28/25 at 11:46 A. M, the Maintenance Director said the ceiling vent looked like it had not been cleaned in a while. 2. Observations on 1/28/25 with the Maintenance Director showed the following rooms on the 80 Hall: -At 11:51 A.M. there was a strong urine odor in the hall in general. -At 11:53 A.M. there was a strong urine odor in resident room [ROOM NUMBER]. -At 11:58 A.M. there was a strong urine odor in resident room [ROOM NUMBER] -At 11:59 A.M., there was a strong urine odor in resident room [ROOM NUMBER]. -At 12:07 P.M., there was a string urine odor in resident room [ROOM NUMBER]. Observation on 1/28/25 from 12:15 P.M. to 3:00 P.M., showed: -The 80 Hall in general had a strong urine odor. -room [ROOM NUMBER] had a strong urine odor. -room [ROOM NUMBER] had a strong urine odor. -room [ROOM NUMBER] had a strong urine odor. -room [ROOM NUMBER] had a strong urine odor. During an interview on 1/29/25 at 2:24 P.M., Housekeeper A said the following regarding the urine smell in the 80 Hall: -He/she did not think the cleaning agents were strong enough to get the smell out. -He/she sprayed the cleaning agent on the floor and mopped the floors in the restroom of those rooms where most of the urine odor originated. -He/she sprayed the cleaning agent on the toilets and wiped the toilets down. -Some of the residents have problems and urinate on the floor and the urine may soak into the floor. -The smell did not go away even after cleaning. Observation on 1/29/25 at 2:31 P.M., showed: -The floor of the shared restroom between resident rooms [ROOM NUMBERS] was very sticky. -Shoes stuck to the floor while walking in that restroom. -There was a urine odor in the shared restroom. Observation on 1/30/25 at 10:00 A.M., showed there was a urine odor in the 80 hall in general. During an interview on 1/30/25 at 12:04 P.M., the Executive Director said he/she smelled the urine odor in the 80 Hall. During an interview on 1/31/25 at 9:09 A.M., the Executive Director said: -He/she had smelled the persistent urine odor in the 80 Hall. -He/she spoke with the Maintenance Supervisor about creating a Lead Housekeeper and trying to deep clean all the rooms on the 80 Hall. 3. Observation on 1/28/25 with the Maintenance Supervisor showed: -At 11:55 A.M., the hot water in resident room [ROOM NUMBER], was 81.3 ºF after the water was allowed to run for 2 or more minutes. -At 11:59 A.M., the hot water temperature in resident room [ROOM NUMBER], was 101.3 ºF -At 12:09 P.M., the hot water temperature in resident room [ROOM NUMBER] was 100 ºF. During an interview on 1/28/25 at 12:01 P.M., the Maintenance Director said: -He/she had only been working at the facility for a few weeks -He/she was not sure which hot water heater provided hot water to the resident rooms on the 80 Hall. 4. Observations on 1/28/25 with the Maintenance Director, showed a buildup of dust and debris in the following rooms: -At 12:24 P.M., there was a buildup of debris on the floor at the corner of the bed and the wall in resident room [ROOM NUMBER]. -At 2:16 P.M., there was a heavy buildup of dust on the floor in Shower Room A on the 50 Hall. -At 2:26 P.M., there was a heavy buildup of dust in the restroom ceiling vent in resident room [ROOM NUMBER]. -At 3:15 P.M., there was a buildup of cobwebs in the corner next to the bed on the floor in resident room [ROOM NUMBER]. Observations on 1/29/25 with the Maintenance Director, showed a buildup of dust and debris in the following rooms: -At 11:24 A.M., there was a heavy buildup of cobwebs behind the bed on the floor in resident room [ROOM NUMBER]. -At 11:31 A.M., there was a buildup of dust in the ceiling vent in Shower Room A of 20 Hall. During an interview on 1/29/25 at 11:35 A.M., the Maintenance Director said he/she expected housekeeping staff to clean the areas with the cobwebs and clean the areas behind the beds. During an interview on 1/29/25 at 2:32 P.M., Housekeeper B said: -His/her supervisors want the housekeepers to deep clean a couple rooms per day. -During a deep clean the housekeepers pull everything into the middle of the room. -During a regular clean, they dust the areas in the room they may spot clean. MO00247567

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately reflect the resident's status on Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) assessments for three sampled residents (Resident #9, #40, and #3) out of 14 sampled residents. The facility census was 55 residents. Review of the facility MDS 3.0 Process policy, dated 1/1/24, showed: -The facility should complete an accurate MDS. -The MDS should be signed by everyone completing any portions of the assessment to certify the accuracy of the portion of the assessment he/she completed. 1. Review of Resident #9's care plan, dated 7/25/23, showed the resident had a pressure ulcer (any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s)) that was a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) to his/her right face cheek related to heart disease, right sided weakness, chronic pain, incontinence, and weight loss. Review of the resident's Treatment Administration Record (TAR), dated November 2024, showed: -Treatment orders for the resident's coccyx wound dated 2/9/24. -Treatment orders for the resident's face cheek wound dated 7/3/24. Review of the resident's Physician's Order Sheet (POS), dated January 2025, showed: -A physician's order for hospice dated 7/28/23. -A physician's order for a wound treatment for the resident's coccyx dated 2/9/24 . -A physician's order for a wound treatment for the resident's right cheek dated 12/23/24. Review of the resident's quarterly MDS dated [DATE] showed: -The resident was not on hospice (end of life care). -The skin section was marked as not assessed. -Section GG (functional abilities): The resident was dependent on staff for all cares. Review of the resident's care plan, dated January 2025, showed the resident had a Stage IV pressure ulcer on his/her right cheek. Review of the resident's hospice nurse's note, dated 1/15/25, showed the hospice nurse documented that he/she completed the treatments on the resident's coccyx and cheek wounds. Review of the resident's care plan, updated 1/24/25, showed: -The resident had a venous/stasis ulcer (open lesion caused by poor circulation) of the coccyx treatment in place. -No care plan for the resident's cheek wound. Observation on 1/27/25 at 3:06 P.M. with Licensed Practical Nurse (LPN) E showed: -The resident had a wound on his/her coccyx and a wound on his/her face on the right cheek. -LPN completed the wound treatments on both wounds. During an interview on 1/30/25 at 9:08 A.M., the MDS Coordinator said: -Not marking the resident for hospice was a mistake. -The resident had been on hospice for a long time. -He/She started doing wound rounds with the wound doctor two weeks ago since no one else was doing it. -He/She rounded with the wound doctor, entered in wound treatment orders, and did not have time to do care plans or MDSs. -He/She was also assigned additional duties at times such as working as a floor nurse and giving showers so he/she was not able to update the MDS. -The MDS should be accurate. During an interview on 1/31/25 at 3:25 P.M., with the Director of Nursing (DON) present, the Executive Director said: -Hospice should have been marked yes. -The MDS Coordinator and the DON were supposed to complete the wounds section. -The MDS Coordinator had been pulled to other duties so he/she didn't have time to update the MDS. -The MDS should be complete and accurate. 2. Review of Resident #40's quarterly MDS dated [DATE] showed the resident was on an anticoagulant medication. Review of the resident's Medication Administration Record (MAR), dated November 2024, showed: -No orders for an anticoagulant (medication used to slow down the process of making blood clots) medication. -A physician's order, dated 9/27/24, for aspirin which was an antiplatelet (prevent blood cells called platelets from clumping together to form a clot) medication. During an interview on 1/30/25 at 9:08 A.M., the MDS Coordinator said he/she accidentally marked anticoagulant medication when antiplatelet medication should have been marked. During an interview on 1/31/25 at 3:25 P.M., with the DON present, the Executive Director said: -The charge nurse and the DON were responsible for completing the medication section. -The MDS should have reflected the correct medication classification. -The MDS should be complete and accurate. 3. Review of Resident #3's face sheet, undated, showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD-a condition causing constriction of the airways and difficulty or discomfort in breathing). -Bipolar disorder (mental health condition that caused extreme mood swings). -Vascular dementia (impaired supply of blood to the brain). Review of the resident's quarterly MDS, dated [DATE], showed the cognitive status section of the MDS was not completed. Review of the resident's care plan, dated 11/5/24, showed: -The resident had potential impairment to skin integrity and received wound management. -The resident had a peg tube (a thin, flexible tube inserted through the skin of the abdomen directly into the stomach) in place. -The resident had a suprapubic catheter (a medical device that drained urine from the bladder through a small incision in the abdomen). Review of the resident's Physician Order Summary, dated January 2025, showed: -The resident had a peg tube. -The resident had a urinary catheter (a tube placed in the body to drain and collect urine from the bladder). -The resident had a pressure ulcer on his/her coccyx (small bone at the end of the spine). Review of the resident's quarterly MDS, dated [DATE], showed: -The resident's cognitive status section of the MDS was not completed. -The resident showed no skin conditions present at time of assessment. --The resident had a pressure ulcer at the time of the assessment. -NOTE: The resident had a peg tube and a urinary catheter in place at the time of the assessment that were not identified on the assessment. Observation on 1/22/25 at 10:44 A.M., showed: -The resident had a wound on his/her coccyx. 4. During an interview on 1/23/25 at 10:09 A.M., the MDS Coordinator said: -He/She was called in to work the floor a lot and his/her MDS updates didn't always get done. -He/She had not been able to complete care plans. -Residents were assessed when they were admitted and again quarterly, or as needed with changes in the resident's condition. -Resident #3's peg tube should have been identified on the MDS. -Resident #3's urinary catheter should have been identified on the MDS. During an interview on 1/29/25 at 10:32 P.M., LPN A, said: -The MDS Coordinator completed the resident's MDSs. -Nurses did not complete the resident MDSs. -Nurses told the MDS Coordinator when something changed with the resident. During an interview on 1/31/25 at 4:44 P.M., the DON said: -Residents with pressure ulcer should have those reflected in the MDS. -He/She would expect to see peg tube and urinary catheter on the MDS. -He/She expected the MDS to reflect current and up to date resident information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #9's significant change MDS, dated [DATE], showed the resident had no wounds. Review of the resident's care plan, dated 7/25/23, showed: -The resident had a stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear) to his/her face on the right cheek. -The resident had a venous/stasis ulcer (open lesion caused by poor circulation) of the coccyx with a treatment in place. Review of the resident's quarterly MDS, dated [DATE], showed the resident had one stage III (full thickness tissue loss; subcutaneous fat may be visible, but bone, tendon or muscle is not exposed) pressure ulcer. Review of the resident's quarterly MDS, dated [DATE], showed the resident had four stage IV pressure ulcers. Review of the resident's care plan, updated 1/24/25, (third day of the survey) showed: -The resident had a venous/stasis ulcer of the coccyx with treatment in place. -The care plan did not include the resident's facial wound on his/her cheek. Review of the resident's Physician's Order Sheet (POS) dated January 2025 showed: -Physician's orders for a treatment to the resident's coccyx dated 2/7/24. -Physician's orders for a treatment to the resident's face on the right cheek dated 12/23/24. Observation on 1/27/25 at 3:06 P.M., with LPN E showed: -The resident had a wound on his/her coccyx and a wound on his/her face on the right cheek. -LPN E completed the wound treatments on both wounds. During an interview on 1/29/25 at 10:32 A.M., LPN A said: -The MDS Coordinator developed the care plans. -The nurses told the MDS Coordinator of any changes with the residents and then the MDS Coordinator was responsible for updating the care plan. During an interview on 1/30/25 at 9:08 A.M., the MDS Coordinator said: -The family told him/her they weren't aware of the wound on the resident's cheek. -He/She read somewhere that the resident had the cheek wound when he/she admitted to the facility. -He/She was told the resident's cheek wound was cut off. -He/She was responsible for developing the care plans. -He/She was assigned other duties such as working as a floor nurse and doing baths so sometimes he/she didn't have time to do care plans. 5. During an interview on 1/23/25 at 10:09 A.M., the MDS Coordinator said: -He/She was called to work the floor a lot. -He/She had not completed or updated all the care plans. -He/She had been in the position for two weeks and the MDS Coordinator before him/her was not doing the care plans correctly. -Care plan changes need to be updated quarterly and with any changes in resident's condition. During an interview on 1/27/25 at 12:54 P.M., CNA A said: -He/She found information about residents on their care plan. -He/She was unaware of when care plan updates were completed. During an interview on 1/27/25 at 1:12 P.M., CNA B said: -Care plans could be seen on the resident's medical record. -Care plans should be up to date. During an interview on 1/29/25 at 10:32 A.M., LPN A said: -Nurses do not update care plans. -Nurses told the MDS Coordinator when something needed updated. -The MDS Coordinator then updated the care plans. During an interview on 1/31/25 at 3:25 P.M., with the Director of Nursing (DON) present, the Executive Director said: -Any wounds that were present upon admission should be in the care plan. -Updates to care plans should stem from communication between the DON and the MDS Coordinator. MO00247435 Based on observation, interview, and record review, the facility failed to provide continuity of resident care by not reviewing and revising resident comprehensive care plans for four sampled residents (Resident #15, #28, #39, and #9) out of 14 sampled residents. The facility census was 55 residents. Review of the facility's Care Plans, Comprehensive Person-Centered policy, dated March 2022, showed: -A comprehensive care plan was developed for each resident. -The care plan was developed within seven days of the completion of the resident's required Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) and no more than 21 days after admission. -Assessments of residents were ongoing and care plans were reviewed and revised as information about the resident and resident's conditions change. -The interdisciplinary team (facility staff and health care professionals who work together to manage the physical, psychological, and spiritual needs of the resident) reviewed and updated care plans at least quarterly. Review of the facility's MDS Coordinator Job Description, dated March 2023, showed: -To ensure timely, accurate, and complete assessment of the resident's health and functional status during the entire assessment period. -Participate in the interdisciplinary team process to communicate opportunities, facilitate efficient and effective care plan development and management. -Communicate with care team regarding practitioner orders, care plans, and changes in condition. 1. Review of Resident #15's face sheet, undated, showed the resident admitted to the facility on [DATE] with the following diagnoses: -Otalgia (a condition which caused discomfort, aching, or sharp pain in one or both ears). -Unspecified hearing loss. -Anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress). Review of the resident's Hearing Aid Purchase Agreement, dated 7/3/24, showed the resident received a new hearing aid for his/her left ear. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident had minimal difficulty hearing. -The resident did not have hearing aids. During an interview on 1/24/25 at 8:57 A.M., the resident said: -He/She needed batteries for his/her hearing aid. -He/She asked staff to replace them. Observation on 1/24/25 at 8:57 A.M., showed: -The resident was speaking to the surveyor. -The surveyor had to speak loudly for the resident to understand what was being said. -The resident was fidgeting with his/her hearing aid and a pack of unused hearing aid batteries. During an interview on 1/27/25 at 12:54 P.M., Certified Nursing Assistant (CNA) A said: -He/She did not remember the resident having a hearing aid. -The resident had not asked him/her for batteries. During an interview on 1/27/25 at 1:12 P.M., CNA B said he/she was unaware if the resident had hearing aids. During an interview on 1/28/25 at 9:30 A.M., Licensed Practical Nurse (LPN) A said: -He/She had never seen the resident with hearing aids. -If a resident did wear hearing aids it should be on the resident's care plan so staff were aware of the use of hearing aids. During an interview on 1/30/25 at 10:44 A.M., LPN C said: -Resident care plans should have current information. -Hearing aids should be in the care plan. -Resident #15 had a hearing aid in his/her left ear. -He/She checked the EHR and did not see hearing aids on the care plan. During an interview on 1/31/25 at 3:25 P.M., with the Director of Nursing (DON) present, the Executive Director said: -Resident #15 had a hearing aid. -The hearing aid should have been addressed in the resident's care plan. 2. Review of Resident #28's face sheet, undated, showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Alzheimer's Disease (a brain disorder that included loss of memory, confusion, difficulty thinking, and changes in language, behavior, and personality). -Age related physical debility. -Anxiety. Review of the resident's Hospice (end of life care) contract, dated 8/27/24, showed the resident entered Hospice care on 8/27/24. Review of the resident's care plan, dated 11/13/24, showed no documentation of the resident receiving Hospice care. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident was severely cognitively impaired. -The resident was on Hospice. Review of the resident's Hospice Book, undated showed the resident had received visits from Hospice personnel throughout the months of December 2024 and January 2025. During an interview on 1/22/25 at 9:37 A.M., the resident's family member said the resident was on Hospice. During an interview on 1/30/25 at 10:44 A.M., LPN C said: -The resident care plans should have current information. -Hospice care should be in the care plan. -Resident #28 was on Hospice. -He/She checked the EHR and did not see Hospice on the care plan. During an interview on 1/31/25 at 3:25 P.M., with the Director of Nursing (DON) present, the Executive Director said: -Resident #28 was receiving Hospice services. -Hospice should have been addressed in the resident's care plan. 3. Review of Resident #39's admission MDS dated [DATE] showed: -He/She was cognitively intact. -The resident was dependent on staff for feeding assistance. Review of the resident's electronic care plan, dated 11/15/24, showed: -No goals or interventions regarding feeding assistance was addressed. -NOTE: a paper copy of the care plan was requested and not received Review of the resident's quarterly MDS, dated [DATE], showed: -The resident was cognitively intact. -The resident was at risk for malnutrition. -The resident was dependent on staff for feeding assistance. -He/She was diagnosed with muscle weakness. During an interview on 1/22/25 at 8:30 A.M. the resident's family member said: -The resident needed feeding assistance. -The staff were not feeding the resident. During an interview on 1/29/25 at 10:32 A.M., LPN A said: -The resident required total assistance from staff with feeding. During an interview on 1/30/25 at 10:44 A.M., LPN C said: -The resident was totally dependant on staff for feeding. During an interview on 1/31/25 at 3:25 P.M., with the Director of Nursing (DON) present, the Executive Director said: -The resident was dependent on staff for feeding assistance. -The resident's care plan should have reflected the total dependence on staff for feeding assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident #50's admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Seborrheic Dermatitis (a skin condition causing scaly patches and red shin, mainly on scalp, but can occur on oily areas of body), 9/6/23. -Need for assistance with personal care, 2/1/24. Review of the resident's Quarterly MDS, dated [DATE], showed: -No speech-absence of spoken words. -Frequently incontinent of bladder and always incontinent of bowel. -Aphasia (loss of ability to understand or express speech, usually caused by brain damage). -Needed assistance with bathing. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review, dated December 2024 and January 2025, showed: -The resident did not receive a shower seven out of nine opportunities in December 2024. -The resident did not receive a shower five out of 10 opportunities in January 2025. During an interview on 1/23/25 at 1:25 P.M., the resident's spouse said: -The resident did not speak, he/she would shake his/her head for yes and no questions, or point to an item. -The resident did not get a shower twice a week sometimes he/she had gone more than a week without a shower. -The resident was sometimes incontinent. -He/She tried to come every other day and sometimes the resident had the same clothes on from the last time he/she was there. -He/she would clean the resident up and put on clean clothes. -The resident was a very clean person and would not miss a shower if it was offered. -The resident wanted to feel clean and when he/she did not have a shower he/she did not feel clean. Observation on 1/24/25 at 10:45 A.M., showed the resident: -Had dirty/greasy hair. -Had many flakes of dry scalp on his/her shirt. -Was wearing two shirts and both collars were soiled. During an interview on 1/28/25 at 1:00 P.M., LPN A said: -The resident was non-verbal, but was easily directed to get things done. During an interview on 1/29/25 at 10:30 A.M., Certified Medication Technician (CMT) C said: -He/She was working as a CNA. -CNA C was usually the bath aide for this wing, he/she did not come in today. -He/She was not sure if the CNA's were responsible for giving showers when the bath aide was not at work. -He/She was not sure if the resident received showers twice a week or not or if he/she refused showers. Observation on 1/29/25 at 11:45 A.M., showed the resident: -Had dirty/greasy hair. -Had many flakes of dry scalp on his/her shirt. -Had on a shirt that had a soiled collar. During an interview on 1/30/25 at 10:00 A.M., LPN C said if the resident had been given a bed bath it was not documented. 7. During an interview on 1/27/25 at 1:40 P.M., CNA C said: -One of the bath aides had quit. -CNAs that worked were supposed to pick up the baths that were scheduled. -He/She was unsure if that was happening. -Residents told him/her they had not had showers. -Aides documented in the EHR under bath and showers when they were completed. -If the resident refused, he/she gave them time and then went back later to ask again. -If the residents still refused, he/she let the charge nurse know. -He/She completed bath sheets and gave them to the charge nurse to sign and she gave them to the Director of Nursing (DON). -There was a bath schedule: Monday/Thursday, Tuesday/Friday, and Wednesday/Saturday. -If there were not enough aides then residents didn't get their baths. During an interview on 1/28/25 at 9:30 A.M., LPN A said: -Residents were not getting consistent baths. -There were ten to 11 baths/showers scheduled each day. -CNA's were getting maybe two baths/showers done per day. -CNA's documented on shower sheets and gave them to the charge nurse. -There was no bath aide on Wednesday and the CNAs may have gotten four done. -Bathing was a huge issue. -He/She stepped in and gave baths when there was time. During an interview on 1/28/25 at 1:00 P.M., LPN A said: -The residents were not getting showers as they should have. -Many times, the shower aide did not show up for work. -They should have made out a shower sheet for all showers. -If the resident refused the shower, the shower aide should have offered to give the resident a shower a second time. -If the resident refused the shower both times, the resident and charge nurse should have signed the shower sheet indicating the showered had been refused. -The residents should have been offered two showers a week. During an interview on 1/29/25 at 10:00 A.M., the MDS Coordinator said: -The residents were not getting showers like they should have maybe once every two weeks. -If a person had any preferences it should have been care planned. -If a resident needed assistance with ADLs it should have been care planned. -He/She was now responsible for the care plans. During an interview on 1/30/25 at 10:00 A.M., LPN C said: -The residents should have been offered two showers a week. -The residents usually get one shower a week. -Sometimes the shower aides did not show up. -The CNA's should give the residents a shower if there was no shower aide. -If the resident refused a shower, it should have been on the shower sheet that they had refused. During an interview on 1/31/25 at 4:55 P.M., the Assistant Director said: -Each resident had a scheduled bath two times a week. -Normally there was a bath aide for each unit who was responsible for giving baths. -The bath aide on one unit quit last week. -CNA's were expected to provide showers when bath aides were not scheduled on the shift. -Nurses were expected to step in to give baths when aides could not. -If residents were unable to get baths/showers then they should have received a bed bath. -He/She would not expect a resident to go two weeks without a bath/shower. -The DON was responsible to ensure residents were getting two showers a week. During an interview on 1/31/25 at 3:30 P.M., the DON said: -The residents should have been offered a shower twice a week. -They currently only had one shower aide. -The CNA's should have offered a shower to the resident if there was no shower aide. -Who ever offered the shower should have documented on the shower sheet if a shower or a bed bath was given or if the resident refused. -The DON was ultimately responsible for ensuring the residents were getting their showers. -He/She would not have expected a resident to go more than a week without a shower. MO00247435 MO00247567 MO00247918 4. Review of Resident #3's face sheet showed he/she was admitted to the facility with the following diagnoses: -Cerebrovascular disease (a group of conditions that impact the brain's blood vessels and blood supply). -Muscle weakness. -Hemiplegia (muscle weakness or partial paralysis on one side of the body). Review of the resident's MDS, dated [DATE], showed: -The cognitive section was not completed. -The ADL section was not completed. -The resident did not refuse cares. Review of the resident's shower sheets, dated December 2024, showed: -The resident did not receive a shower on seven out of eight opportunities. Review of the resident's quarterly MDS, dated [DATE], showed: -There was no cognitive score. -He/She needed assistance with bathing. -He/She had Hemiplegia. Review of the resident's care plan, dated 1/27/25, showed: -The resident was totally dependent on one staff to provide a bath/shower twice a week and as necessary, dated 8/25/24. Review of the resident's shower sheets, dated January 2025, showed: -The resident did not receive a shower on seven out of eight opportunities. During an interview on 1/30/25 at 1:25 P.M. Licensed Practical Nurse (LPN) C said: -The CNAs should have provided the resident with a bath or shower if there was no bath aide. 5. Review of Resident #39's admission MDS dated [DATE] showed: -The ADL section was not completed. -The resident did not refuse cares. Review of Resident #39's shower sheets, dated November 2024 and December 2024, showed: -The resident did not receive a shower five out of five opportunities from 11/21/24 to 12/5/24. -The resident did not receive a shower seven out of seven opportunities from 12/10/24 to 12/31. Review of the resident's quarterly MDS, dated [DATE], showed: -There were no neurological problems. -He/She had limited range of motion on both sides, upper and lower extremities. -He/She was dependent on staff for bathing. -He/She was cognitively intact. Review of the resident's shower sheets, dated January 2025, showed: -The resident did not receive a shower seven out of seven opportunities from 1/1/25 to 1/21/25. During an interview on 1/27/25 at 3:30 P.M., the resident's family member said: -The resident had not been offered a bath or shower weekly. -Once the resident went three weeks without a shower. -The family had complained to the facility Administration and was told they were trying to hire more staff. Observation on 1/27/25 at 3:40 P.M., showed the resident: -Was not able to use his/her hands. -Needed assistance with all cares. -Had a slight body odor, and looked unkept. During an interview on 1/27/25 at 3:40 P.M., the resident said: -He/She wanted baths. -He/She felt dirty after going days or weeks without a bath. -He/She had told staff he/she wanted a bath. During an interview on 1/28/25 at 1:00 P.M., LPN A said the resident never refused a shower. During an interview on 1/30/25 at 10:00 A.M., LPN C said the resident never refused to take a shower. Based on observation, interview, and record review, the facility failed to provide necessary services to maintain personal hygiene by not helping residents complete Activities of Daily Living (ADL), bathing/showering, causing poor hygiene and physical discomfort for six sampled dependent residents (Resident #12, #44, #109, #3, #39, and #50) out of 14 sampled residents. The facility census was 55 residents. A policy regarding ADLs was requested but not provided. Review of the facility's Bath, Shower/Tub policy, undated, showed: -The purpose of the policy was to provide a step-by-step procedure that promoted cleanliness, provided comfort to the resident and to observe the condition of the resident's skin -Document the date and time the shower/tub bath was performed with the name, title of the individual who assisted the resident. -Document all assessment data regarding skin condition. -Document if the resident refused. 1. Review of Resident #12's face sheet, undated, showed the resident was admitted to the facility with the following diagnoses: -Unsteadiness on his/her feet. -Polyosteoarthritis (a degenerative joint disease that affected five or more joints at the same time). Review of the resident's care plan, dated 7/22/24, showed: -The resident had an ADL self-care performance deficit related to contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that caused the joints to be very stiff) of right and left knee with pain. -Interventions included: --Provide sponge bath if full bath/shower was not available. --The resident was totally dependent on one staff to provide bath/shower twice weekly on Tuesday and Friday. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 10/21/24, showed: -The resident was cognitively intact. -The resident was dependent on staff for showering/bathing. -The resident used a wheelchair for mobility. Review of the resident's Skin Monitoring Comprehensive Certified Nursing Assistant (CNA) Shower Reviews (Shower Sheets), dated December 2024 and January 2025, showed: -The resident did not receive a bath/shower eight out of nine opportunities in December 2024. -The resident did not receive a bath/shower eight out of nine opportunities in January 2025. During an interview on 1/22/25 at 10:28 A.M., the resident said: -He/She had trouble getting showers on his/her scheduled shower days of Tuesday and Friday. -There was a bath aide that worked on his/her unit, but the bath aide missed a lot of work and when the bath aide didn't come in on his/her bath days then he/she missed his/her bath. -It had been about two weeks since his/her last bath. -He/She did not like missing showers as he/she felt dirty after missing so many. During an interview on 1/27/25 at 12:54 P.M., CNA A said: -He/She was unsure of the resident's bath days. -He/She had given a bath to the resident, but it had been a while. -The resident had not asked for a bath. -If there was no bath aide, the CNAs were supposed to do the baths. -The baths did not always get done if there was no bath aide. During an interview on 1/27/25 at 1:12 P.M., CNA B said: -He/She had not done any bathing with the resident. -He/She thought there was a sheet the aides were supposed to fill when baths were given. -He/She thought the bath sheets were at the nurses station. -He/she couldn't remember specific dates, but the resident had complained about not getting baths. -He/She was unaware of what the resident's shower days were. -He/She was unsure if there was a bath aide working on the unit. -If there was no bath aide, the CNAs were supposed to do the baths. -The baths did not always get done if there was no bath aide. 2. Review of Resident #44's face sheet, undated, showed the resident was admitted to the facility with the following diagnoses: -Unspecified dementia (the loss of cognitive functioning, thinking, remembering, and reasoning that interferes with daily life and activities). -Weakness. -History of falling. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident was severely cognitively impaired. -The resident required substantial/maximal assistance (helper did more than half of the effort) with showering/bathing. -The resident used a wheelchair for mobility. Review of the resident's care plan, dated 10/11/24, showed: -The resident had an ADL self-care performance deficit related to dementia. -The resident required physical assistance from one staff member for showering. Review of the resident's Shower Sheets, dated December 2024 and January 2025, showed: -The resident did not have a shower eight out of nine opportunities in December 2024. -The resident did not have a shower eight out of nine opportunities in January 2025. During an interview on 1/22/25 at 1:06 P.M., the resident's family member said: -The resident was not getting baths from facility staff. -The resident was on Hospice (end of life care) and they had been providing supplemental baths when they came to the facility. -The facility was supposed to provide baths. During an interview on 1/27/25 at 12:54 P.M., CNA A said: -The resident was getting baths, probably from Hospice. -He/She documented bathing on shower sheets and charted it in the electronic health record (EHR). -He/She did not forget to chart bathing. -He/She ensured to chart so he/she knew it was done. During an interview on 1/27/25 at 1:12 P.M., CNA B said: -He/She never had to shower the resident. -The unit had a bath aide, but they put their notice in and had not worked since last week. -The resident was on Hospice, and they were here regularly. -The resident got baths from Hospice. -They came twice a week. -The resident had not asked him/her for baths or showers. 3. Review of Resident #109's face sheet, undated, showed the resident was admitted to the facility with the following diagnoses: -Dependence on supplemental oxygen. -Muscle weakness. -Heart failure. Review of the resident's baseline care plan, dated 12/31/24, showed: -The resident required assistance with bathing. -The resident had limited physical mobility related to morbid obesity. -The resident was weight bearing. Review of the resident's Shower Sheets dated January 2025 showed: -The resident did not receive a bath/shower six out of nine opportunities. During an interview on 1/22/25 at 9:32 A.M., the resident said: -He/She arrived right before New Year's Day. -His/Her first bath was on 1/15/25. -His/Her bath days were supposed to be Wednesdays and Saturdays. -He/She mentioned getting a bath or shower to the staff, but did not get one. -Staff say they would get the help they need and be right back and never come back. Observation on 1/22/25 at 9:32 A.M., showed the resident: -Was in bed. -Had a slight body odor. -Was in a gown and not dressed in street clothes. During an interview on 1/27/25 at 12:54 P.M., CNA A said: -He/She had been in the resident's room several times. -The resident did not get out of bed. -The resident needed a mechanical lift to get in and out of bed. -There was a shower aide on the unit. -If the shower aide missed work, then the day shift aides did half of the residents baths and the night shift did the other half of baths. -He/She did not always have time to bathe residents with his/her other responsibilities. -He/She was unaware if the resident preferred bed baths of full showers. -He/She could not recall the last time he/she gave a bath to the resident. During an interview on 1/27/25 at 1:12 P.M., CNA B said: -He/She was unsure if the resident refused baths. -He/She did not know the resident's bath preferences. -He/She would find the resident's preference in the care plan. -The resident had at least one bath since he/she had admitted to the facility. -He/She thought the resident was admitted around the first of the month.

Based on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional when the staff person identified as the Life Enrichment Coordinator reported he/she did not complete the state approved training course. The facility census was 55 residents. An Activities policy was requested and not received. 1. During an interview on 1/28/25 at 1:22 P.M., the Life Enrichment Coordinator said: -He/She did not complete the state approved training course. -He/She started it but with the changes in facility Administration it just didn't get done. -The previous Administrator was going to help pay for the course, but it was not paid for before he/she left the facility. During an interview on 1/28/25 at 1:42 P.M., the Human Resources (HR) Director said: -He/She thought the Administrator would be responsible for following up with the Life Enrichment Coordinator's certificate. -He/She was unaware if the Life Enrichment Coordinator was certified or not. -He/She assumed they were. During an interview on 1/31/25 at 4:55 P.M., the Executive Director said: -The Life Enrichment Coordinator was responsible for providing the activities program. -He/She did not know the Life Enrichment Coordinators education background. -He/She would expect the Life Enrichment Coordinator to have their certificate for the state approved training course. -He/She was not aware the Life Enrichment Coordinator did not have his/her certificate. -The facility should pay for the state approved course for the Life Enrichment Coordinator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete and document weekly wound assessments that described the type and characteristics of the resident's coccyx wound (documented as non pressure) and face wound on the cheek, failed to complete wound treatments as ordered, failed to have a system in place to review the progress of wounds, and failed to keep the resident's cheek, neck, and chest free of dried drainage from the resident's facial wound for one sampled resident (Resident #9), and failed to ensure a follow-up surgical appointment was made per discharge orders to remove surgical staples for one sampled resident (Resident #29) out of 14 sampled residents. The facility census was 55 residents. Review of the facility wound care policy, dated 1/1/24, showed: -Any skin impairments should be assessed and documented weekly by the wound nurse or designee on the wound evaluation flow sheet or the weekly wound assessment in the Electronic Health Record (EHR). -Documentation of wounds should cover all pertinent characteristics of existing ulcers, including location, size, depth, maceration (the softening and breaking down of skin resulting from prolonged exposure to moisture), color of the ulcer and surrounding tissues, and a description of any drainage, eschar (dead tissue that falls off (sheds) from healthy skin), necrosis (relating to localized death of living cells as from interruption of blood supply or infection), odor, tunneling or undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure is larger at its base than at the skin surface. Undermining often develops from shearing forces and is differentiated from tunneling by the larger extent of the wound edge involved in undermining and the absence of a channel or tract extending from the pressure ulcer under the adjacent intact skin). -The wound nurse or designee should maintain and update a list of residents who have been identified to be at high risk and an assessment and documentation schedule. -Residents with wounds should be reviewed during weekly risk management committee meetings for progress, interventions, and care plan revision as appropriate. 1. Review of Resident #9's EHR showed no skin assessments for the resident since 1/21/24. Review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 7/18/24, showed the resident had one Stage 1 pressure ulcer (a persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved) and one skin tear. Review of the resident's care plan, dated 7/23/24, showed: -Pressure ulcer will show signs of healing and remain free from infection by/through review date. -Administer treatments as ordered and monitor for effectiveness. -Assess and treat for pain. -Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. -Change treatment plan if no progress in 2-3 weeks as indicated. -Local wound care company to follow. Review of the resident's EHR showed there were no facility skin assessments dated 7/18/24 to 10/18/24. Review of the resident's EHR showed there were no progress notes that addressed the resident's skin issues dated 7/19/24 to 10/18/24. Review of the resident's quarterly MDS, dated [DATE], showed: -The skin section was not assessed. -The resident was dependent on staff for all cares. Review of the resident's Physician's Order Sheet (POS), dated November 2024, showed the following orders: -Cleanse the right facial cheek with normal saline, pat dry, apply skin prep to whole area, cover with Xeroform (cut to fit), sprinkle with pixie dust, secure with mepilex, change weekly and as needed for soiled until healed. -Cleanse the coccyx area with normal saline, apply pixie dust to wound bed, then fill area with Iodoform then cover with bandage on Monday, Wednesday, and Friday and as needed if soiled or dislodged. Review of the resident's Treatment Administration Record (TAR), dated November 2024, showed staff documented that the treatments to the resident's face wound on the cheek and the coccyx wounds were documented as completed as ordered. Review of the resident's hospice (end of life care) nurse visit summaries, dated November 2024, showed: -On 11/6/24, the resident's wound (location and type not specified) was 1.5-centimeter (cm) x 1.0 cm x 2.0 cm (length x width x depth). -On 11/13/24, the resident's coccyx wound was 1.7 cm x 1.0 cm x 2.0 cm with moderate tan drainage to dressing removed, had no odor, and was circular in shape with rolled edges. -On 11/20/24, the resident's coccyx wound was 2.0 cm x 1.5 cm x 1.5 cm with moderate tan drainage, had undermining with deepest of 2 cm at two o'clock, and was circular with rolled edges. -On 11/29/24, the resident's coccyx wound was 2.0 cm x 1.0 cm x 2.1 cm with blood-tinged tan drainage, had no odor, had undermining with deepest of 2 cm at two o'clock, and was circular with rolled edges. -There was no description of the wound on the resident's right cheek. Review of the resident's EHR showed: -There were no facility wound assessments dated November 2024 for the resident's right facial cheek wound. -There were no facility wound assessments dated November 2024 for the resident's coccyx wound. Review of the resident's POS, dated December 2024, showed the following orders: -Cleanse the right facial cheek with normal saline, pat dry, apply skin prep to whole area, cover with Xeroform (cut to fit), sprinkle with pixie dust, secure with mepilex, change weekly and as needed for soiled until healed end date 12/13/24. -Cleanse the right facial cheek with wound cleanser, allow to air dry, apply skin prep to surrounding skin, apply xerform to raised lesion, apply calcium alginate around the raised areas, cover with a non adherent pad and secure with transparent dressing, change every Monday, Wednesday, Friday and as needed for soiling. -Cleanse the coccyx area with normal saline, apply pixie dust to wound bed, then fill area with Iodoform then cover with bandage on Monday, Wednesday, and Friday and as needed if soiled or dislodged. Review of the resident's TAR dated, December 2024, showed: -The resident's wound treatment to his/her right face cheek was not completed as ordered two out of six opportunities (12/11/24 and 12/27/24). -The resident's wound treatment to his/her coccyx was not completed as ordered five out of 13 opportunities (12/11/24, 12/16/24, 12/20/24, 12/23/24 and 12/27/24). Review of the resident's hospice nurse visit summaries, dated December 2024, showed: -On 12/4/24, the resident's coccyx wound was 2.0 cm x 1.3 cm x 2 cm, had no odor, and had undermining with deepest of 2 cm at two o'clock. -There was no description of the wound on the resident's right cheek. Review of the resident's EHR showed there were no facility wound assessments dated December 2024. Review of the resident's POS, dated January 2025, showed the resident: -Was admitted to hospice due to a stroke on 7/28/23. -Cleanse the right facial cheek with wound cleanser, allow to air dry, apply skin prep to surrounding skin, apply xerform to raised lesion, apply calcium alginate around the raised areas, cover with a non adherent pad and secure with transparent dressing, change every Monday, Wednesday, Friday and as needed for soiling. -Cleanse the coccyx area with normal saline, apply pixie dust to wound bed, then fill area with Iodoform then cover with bandage on Monday, Wednesday, and Friday and as needed if soiled or dislodged. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident was severely cognitively impaired. -The skin section was not assessed. -Section GG - functional abilities was not assessed. -The resident was on hospice. -The resident had a stroke and hemiplegia (paralysis of one side of the body) or hemiparesis (a slight paralysis or weakness on one side of the body). Review of the resident's care plan showed: -The printed care plan, dated 1/24/25, that was provided by the facility at 1:10 P.M. did not include any wounds. -The care plan in the EHR showed: -No care plan for the resident's wound on his/her cheek. --The problem identified updated on 1/24/25 (at an unknown time) was the resident had a venous/stasis ulcer (open lesion caused by poor blood flow) of the coccyx. --The desired outcome was that the resident would not have any signs of infection through the next review date. --Interventions included: ---Evaluate wound for size, depth, margins, peri-wound skin, sinuses, undermining, exudates (any fluid that has been forced out of the tissues or its capillaries because of inflammation or injury), edema (swelling), granulation (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process), infection, necrosis, eschar, gangrene (dead tissue caused by an infection or lack of blood flow). ---Document progress in wound healing on an ongoing basis. ---Notify the resident's physician as indicated. ---Monitor, document, and report as needed for signs of infection such as green drainage, foul odor, redness, swelling, red lines coming from the wound, excessive pain, and fever. Review of the resident's POS, dated January 2025, showed: -Cleanse the coccyx area with normal saline, apply pixie dust to wound bed, then fill area with Iodoform then cover with bandage on Monday, Wednesday, and Friday and as needed if soiled or dislodged. -Treatment orders for the resident's coccyx were to be completed daily. -Cleanse the right facial cheek with wound cleanser, allow to air dry, apply skin prep to surrounding skin, apply xerform to raised lesion, apply calcium alginate around the raised areas, cover with a non adherent pad and secure with transparent dressing, change every Monday, Wednesday, Friday and as needed for soiling. -Treatment orders for the resident's right cheek were to be completed every Monday, Wednesday and Friday and as needed for soiling. Review of the resident's TAR, dated January 2025, showed: -The resident's wound treatment to his/her right cheek was not completed three times out of four opportunities (1/3/25, 1/10/25, and 1/17/25). -The resident's wound treatment to his/her coccyx was not completed four times out of four opportunities (1/3/25, 1/10/25, 1/17/25 and 1/24/25). Review of the resident's hospice nurse visit summaries, dated January 2025, showed: -On 1/8/25, the resident's coccyx wound was 2.0 cm x 1.0 cm x 2 cm, was oval, and had undermining all the way around with deepest of 2.1 cm at two o'clock. -On 1/15/25, the resident's coccyx wound was 2.0 cm x 1.0 cm x 2.1 cm, was round with rolled edges, and had undermining with deepest of 2.1 cm. -On 1/20/25, the resident's coccyx wound was 2.0 cm x 1.0 cm x 2.1 cm, was oval with rolled edges, and had undermining with deepest of 2.1 cm. -There was no description of the wound on the resident's right cheek. Review of the resident's EHR showed there were no facility wound assessments dated January 2025. Observation on 1/27/25 at 10:08 A.M. and 10:56 A.M., showed the bandage on the resident's right cheek was, dated 1/22/25, and there was dried reddish-brown drainage down the resident's chin, neck and top of his/her chest. Observation on 1/27/25 at 3:06 P.M., showed: -The bandage on the resident's right cheek showed the dressing was dated Wednesday, 1/22/25 (the treatment should have been completed on 1/24/25) and was saturated through. -There was dried reddish-brown drainage down the resident's chin, neck, and top of his/her chest. During an interview on 1/28/25 at 8:42 A.M., the Director of Nursing (DON) said: -There should have been skin assessments in the EHR. -He/She did not know who was responsible for completing them. During an interview on 1/28/25 at 10:56 A.M., LPN A said: -The resident's right facial cheek and coccyx dressing changes were supposed to be done by hospice staff on Mondays and Wednesdays. -The resident's right facial cheek and coccyx dressing changes were supposed to be done by facility nurses on Fridays and as needed. -It was the DON's responsibility to do the wound assessments. During an interview on 1/29/25 at 10:32 A.M., LPN A said: -The drainage from the wound on the resident's cheek had to be cleaned off the resident's cheek, neck, and chest almost daily. -Hospice did the resident's wound measurements. -The facility wound assessments should have been done by the DON and should have included measurements. -When hospice gave him/her the wound measurements, he/she tried to chart it in the EHR but if he/she couldn't, the documentation was in the resident's hospice book. -There was no process in place to monitor the wounds. -He/She would tell the MDS Coordinator when a care plan needed to be updated. During an interview on 1/30/25 at 9:08 A.M., the MDS Coordinator said: -No one was overseeing wound care. -No one was doing skin assessments. -He/She did not know who should have been doing skin assessments. During an interview on 1/31/25 at 3:25 P.M., the Assistant Director said: -The nurses should have completed wound treatments as ordered. -There should have been documentation of the description of the resident's wounds weekly. -There was no facility-wide tracking system in place to monitor residents' wounds. -They were not discussing wounds in any of their meetings. During an interview on 1/31/25 at 3:25 P.M., the DON said: -The nurses should have completed the wound treatments as ordered for Resident #9. -The nurses on duty were responsible for completing the wound treatments for Resident #9. -The nurses should assess the wounds when doing treatments for Resident #9. -The nurses doing the treatments should determine if the wounds were getting better or not. -The resident's physician should be notified if the wound was not getting better so a different treatment could be ordered. -There were skin assessments in the EHR that should have been completed weekly and they staff should have documented about the wounds in the progress notes for Resident #9. -Resident #9's wound assessments should have been completed and should have included descriptions and measurements of the wounds. -No one was classifying the wounds at this time. -The resident should have been kept clean from drainage from his/her cheek wound. 2. Review of Resident #29's admission Record showed he/she admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Chronic Kidney Disease, stage 3A (CKD- is a condition characterized by a moderate loss of kidney function over time) 1/16/24. -Chronic Congestive Heart Failure (CHF-chronic condition in which the heart doesn't pump blood as well as it should) 1/5/24. -Fracture of base of neck of unspecified femur (fracture at the top of the femur [thigh bone] near the hip joint with the exact location not specified) 11/14/24. Review of the resident's progress note, dated 11/10/24 at 3:28 P.M., showed the resident was transported to the hospital post fall with dizziness, left hip pain, pain in the head due to hitting head on the floor and a laceration on his/her nose with mild bleeding. Review of the resident's progress note, dated 11/14/24 at 2:41 P.M., showed: -The resident arrived back at the facility from the hospital. -The hospital found a left hip fracture with open reduction and internal fixation (ORIF-a surgical procedure to realign broken bones and stabilize them with metal hardware) conducted. -Weight-bearing as tolerated. Review of the resident's hospital discharge paperwork, dated 11/15/25, showed: -discharge date : [DATE]. -Discharge diagnosis: left hip fracture. -Orthopedic surgery evaluated. -Now status post Open Reduction Internal Fixation (ORIF) of the left hip on 11/11/24. -Weight Bearing As Tolerated (WBAT), Left Lower Extremity (LLE), range of motion (ROM - the range on which a joint can move) as tolerated. -Pain control as needed. -Follow up with doctor in two weeks for skin check and suture/staple removal, call to schedule appointment. Review of the resident's progress note, dated 11/15/2024 at 5:21 A.M., showed: -Resident's dressing to left hip was clean, dry and intact. -Nine staples to surgical site. -No swelling or drainage noted and minimal redness. Review of the resident's EHR showed: -No POS orders for follow-up appointment for skin check and suture/staple removal. Review of the resident's TAR, dated November 2024, showed no orders for dressing changes or monitoring surgical site. Review of the resident's EHR, dated 11/29/24 to 12/31/24, showed no other nursing documentation of the resident's left hip surgical incision site. Review of the resident's Care Plan, dated 12/18/24, showed: -Skin inspection: --The resident required skin inspection weekly on Sundays. --Observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. -The resident was a moderate risk for falls related to deconditioning, Incontinence, vision/hearing problems. -The resident had left hip fracture of femoral neck related to a fall on 11/10/24. --The resident would remain free of complications related to hip fracture, such as contracture formation (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), embolism (obstruction of an artery) and immobility through review date. --The resident would return to prior level of function after wound healing and rehabilitation by review date. --The resident's surgical incision would heal without signs/symptoms of infection or breakdown by review date. Review of the resident's Health Status Note, dated 12/31/2024 at 2:16 P.M., showed nine staples removed from the resident's left hip this shift, tolerated well, no redness to area and no bleeding noted. During an interview on 1/29/25 at 3:23 P.M., the Receptionist said: -He/She made all appointments for the residents. -The nurses would let him/her know if a resident needed an appointment made from physician orders. -He/She looked at the November 2024 log and the resident did not go out to a follow-up appointment on 11/28/24 to a surgeon revisit. -If he/she was told about a follow up appointment being needed for Resident #29, he/she would have set up a follow up appointment. During an interview on 1/30/25 at 1:59 P.M., LPN C said: -He/She was not aware that the resident had any staples in his/her hip when he/she returned from the hospital. -He/She was not working when the resident returned from hospital. -The nurse who received the hospital discharge paperwork should look at it and put orders into the POS and on the Medication Administration Record (MAR) or the TAR. -The nurse taking off the discharge orders should let the receptionist know when there was a follow-up appointment on orders to be made. During an interview on 1/31/25 at 10:09 A.M., the Assistant Director said: -The charge nurse should put new orders in the POS and on the MAR or TAR when a resident returned from the hospital when they received the packet or if it was faxed to the facility. --The charge nurse should see these in the PCC. -The charge nurse should also call the facility physician to see if he/she agreed with any changes in meds, etc., from the hospital. -The nurse should document in progress notes the resident returned to the facility with any orders. -The Assistant Director was not aware of an order for a follow-up appointment to the surgeon for skin assessment and staples to be removed. During an interview on 1/31/25 at 3:25 P.M., the DON, Assistant Director, and Executive Director said: -The nurse who received the discharge orders should have put them in the POS and let the receptionist know of the follow-up appointment to be scheduled. -The DON did not know the resident's staples were not removed until the end of December. -The DON did not know why the resident's follow up appointment was not set up. -The administrative and nursing staff have a standup meeting every morning to review what was going on with all residents and no one was aware the resident had staples. MO00247335

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen and nebulizer equipment was stored in a sanitary condition for two sampled residents (Resident #40 and #3) and one supplemental resident (Resident #51) out of 14 sampled residents and one supplemental resident. The facility census was 55 residents. Review of the facility's policy titled Oxygen Administration, dated as revised 6/8/23, showed: -Tubing and nasal cannula (tube in the nose) should be placed in a baggies when not in use. -Replace tubing and nasal cannula if they are on the floor. -The tubing and cannula should be changed weekly every Sunday night. 1. Review of Resident #40's care plan, dated 4/22/24, showed: -The resident had altered respiratory status with shortness of breath. -The resident was on hospice (end of life care). Review of the resident's quarterly MDS, dated [DATE], showed the resident was on hospice and did not use oxygen. Review of the resident's Physician's Order Sheet (POS), dated January 2024, showed physician's orders dated 11/25/24 for oxygen 2-3 liters per minute for shortness of breath as needed. Observation on 1/22/25 at 10:24 A.M., on 1/24/25 at 9:28 A.M., on 1/27/25 at 10:18 A.M., and on 1/28/25 at 10:20 A.M., showed there was an oxygen concentrator in the resident's room with tubing including the nasal cannula on the floor with no baggie present for storage. During an interview on 1/29/25 at 10:32 A.M., Licensed Practical Nurse (LPN) A said: -The resident had pneumonia a while ago and used the oxygen during that time. -The oxygen was as needed. -Anyone that went in his/her room should check to see that the oxygen tubing was not on the floor and should make sure it was bagged. -The night shift was responsible for changing the oxygen tubing weekly. 2. Review of Resident #3's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and making it difficult to breathe). Review of the resident's quarterly MDS, dated [DATE], showed Oxygen therapy was not checked. Review of the resident's POS, dated January 2025, showed the following order for Ipratropium-Albuterol Solution 0.5 - 2.5 (3) milligram (mg)/3 milliliter (ml) one vial inhale orally every 6 hours as needed for shortness of breath related to COPD. Review of the resident's care plan, dated 1/27/25, showed there was problem area or concern that addressed the resident's use of medications for COPD. Observation on 1/29/25 at 11:14 A.M., showed: -The resident's oxygen equipment was on a tray at the foot of his/her bed. -There was a bag on the tray. -The nebulizer pipe (a machine that turns liquid medicine into a mist that could be easily inhaled) was sitting on the tray not in the bag. -The oxygen tubing was not connected to the nebulizer pipe, it was dangling down off of the tray touching the floor. During an interview on 1/29/25 at 11:25 A.M., Certified Nursing Assistant (CNA) J said: -The tubing should be in a bag not touching the floor. -The nebulizer pipe should be in a bag. -The nurses were responsible for the oxygen tubing. During an observation on 1/29/25 at 11:25 A.M. showed CNA J: -Left the room without changing the tubing, cleaning the pipe or telling the nurse. During an interview on 1/29/25 at 11:30 A.M., LPN C said: -The tubing should be in a bag not touching the floor. -The nebulizer pipe should be in a bag. -The night CNA's were responsible for the oxygen tubing. During an observation on 1/29/25 at 11:30 A.M. showed LPN C: -Left the room without changing the tubing or cleaning the pipe. 3. Review of supplemental Resident #51's quarterly MDS, dated [DATE], showed: -He/She was severely cognitively impaired. -Had COPD. -Had Respiratory failure. -Oxygen therapy was not checked. Review of the resident's POS, dated January 2025, showed the following order: -Change nebulizer tubing mask every Sunday. -Change oxygen tubing every Sunday. -NOTE: Thee was no oxygen order. -NOTE: There was no nebulizer order. Observation on 1/20/25 at 10:12 A.M., showed: -The oxygen tubing was wound around the oxygen concentrator (a medical device that separates nitrogen from the air so you can breathe up to 95% pure oxygen), not in a bag. -The nebulizer pipe was sitting in the resident's drawer of night stand, not in a bag. Observation on 1/22/25 at 11:12 A.M., showed: -The oxygen tubing was wound around the oxygen concentrator, not in a bag. -The nebulizer pipe was sitting in the resident's drawer of night stand, not in a bag. Observation on 1/22/25 at 3:14 P.M. showed: -The oxygen tubing was wound around the oxygen concentrator, not in a bag. -The nebulizer pipe was sitting in the resident's drawer of night stand, not in a bag. 4. During an interview on 1/31/25 at 3:25 P.M., with the Director of Nursing (DON) present, the Executive Director said: -The oxygen tubing shouldn't be on the floor. -The oxygen tubing should be stored in a bag. -Anyone that walked in the room should take care of oxygen tubing on the floor. -If the tubing was on the floor, they should throw it away and change it out for new tubing. -Resident #51 was on oxygen and had nebulizer treatments. -Oxygen tubing should not have been touching the floor. -Oxygen tubing and the nebulizer should have been stored in a bag. -He/She would have expected staff to have changed out the oxygen tubing if they saw it hanging on the floor.

Based on interview and record review, the facility administrative staff failed to plan for and provide a sufficient number of nursing staff over a 48-hour period to relieve overworked staff that stayed on shift and worked over during a winter storm which caused the working nursing staff to not feel safe in administering routine medications to seven sampled residents (Residents #8, #2, #9, #40, #29, #35, and #50) out of seven sampled residents for medications administration. The facility census was 55 residents. Review of the facility's staffing, sufficient and competent nursing policy, dated revised August 2022, showed: -Licensed nurses and certified nursing assistants are available 24 hours a day, seven days a week to provide competent resident care services including: --Assuring resident safety. --Attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident. --Responding to resident needs. Review of the facility's undated Job description- Director of Nursing (DON) showed: -Will be responsible for planning, organizing, establishing, administering, and implementing a nursing program that will cooperate with all disciplines to provide for the maximum physical, mental, and spiritual well-being of each resident. -Responsible for the day-to-day operation of the nursing department. -To find replacements for absentees. -To be responsible for the supervision and nursing procedures and what to do in case of an emergency. -Flexibility in job assignments during emergencies and at the direction of the Administrator, as needed. Review of the facility's Director of Nursing Services (DNS) policy, dated revised August 2022, showed: -The director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: --Providing direct resident care when needed. --Ensuring sufficient and competent staffing levels to meet the needs of the residents. Review showed no facility emergency plan was documented. Review of the Facility Assessment, dated 1/16/25, showed: -The facility was licensed for 118 residents. -41 current full-time staff. -Three part-time staff. -Four as needed (PRN) staff. -Hours per a resident days (HPRD) showed --Day shift: ---Two Registered Nurses (RN) ---Two Licensed Practical Nurses (LPN). ---Four Certified Nursing Assistants (CNA)/Nurse Assistant (NA). --Night shift: ---No RN. ---Two LPNs. ---Four CNA/NAs. -Note: Facility Assessment did not list Certified Medication Technicians (CMT). -Contingency plan for staffing: --Planning for events that do not require activation of an emergency plan but do have the potential to affect resident care, including: ---How facility accounts for staff call-offs and process for covering shifts: ----Staffing phone/agency utilization if needed. ----Facility calls in Full-Time staff and agency to assist. ----Restorative Aide (RA) or shower aides also assist on floor if needed. ----Facility had a designated staff member that had on call phone. 1. Review of Resident #8's Medication Administration Record (MAR), dated January 2025, showed on 1/5/25: -The resident did not receive nine out of 11 medications ordered all day. -The medications the resident did not receive included medications for high cholesterol, diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), heart failure, hypothyroidism (below normal function of the thyroid gland which regulates metabolism), embolism and thrombosis of unspecified artery (a condition where blood clots form in an artery, which can cause the artery to narrow or become blocked), atrial fibrillation (the heart beats irregularly and rapidly), and high blood pressure. 2. Review of Resident #2's MAR, dated January 2025 showed on 1/5/25: -The resident did not receive four out of four medications ordered all day. -The medications the resident did not receive included medications for dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes), depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life), anxiety (a psychiatric disorder that involve extreme fear, worry and nervousness) and edema (swelling). 3. Review of Resident #9's MAR, dated January 2025, showed: -Throughout the day on 1/5/25, the resident did not receive one oral medication out of one oral medications ordered which was for edema. -Throughout the day on 1/5/25, the resident did not receive his/her inhaler three times a day for asthma. -Throughout the day on 1/5/25, the resident did not receive his/her eye drops four times a day for dry eye syndrome. -The resident had a treatment order for a skin tear to be done every three days. -The resident's skin tear treatment was not completed on 1/5/25 which resulted in the resident not having his/her skin tear treatment completed until 1/8/25 (three days late). 4. Review of Resident #40's MAR, dated January 2025, showed: -On 1/5/25 the resident did not receive seven out of eight medications ordered all day. -The medications the resident did not receive included medications for heart disease, pain, acid reflux, dementia, benign prostatic hyperplasia (enlargement of the prostate gland), allergies, and high blood pressure. -The resident did not receive his/her eye drops four times a day for dry eye syndrome throughout the day on 1/5/25. 5. Review of Resident #29's MAR January 2025 showed: -The resident did not receive 15 out of 15 medications ordered throughout the day. -The medications the resident did not receive included medications for vitamin deficiency, diuretic (drugs causing increased passing of urine), heart failure, Glaucoma (an eye condition that damages the optic nerve), sleep supplement, constipation, mineral supplement, Anticoagulant (medications that help prevent blood clots), eye drops, allergies, pain patch, ulcerative colitis (inflammatory bowel disease [IBD]) and pain. 6. Review of Resident #35's MAR January 2025 showed: -The resident did not receive 5 out of 5 medications ordered throughout the day. -The medications the resident did not receive included medications for anemia (a condition of lack of enough healthy red blood cells to carry adequate oxygen to the body's tissues), vitamin deficiency, Hypertension, primary (HTN-abnormally high blood pressure that's not the result of a medical condition), constipation, macular degeneration (deterioration of the macula, which is the small central area of the retina of the eye that controls visual acuity). 7. Review of Resident #50's MAR January 2025 showed: -The resident did not receive nine out of nine medications ordered throughout the day. -The medications the resident did not receive included medications for high cholesterol, vitamin deficiency, diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), Gastroesophageal Reflux Disease (GERD), Benign Prostatic Hyperplasia [BPH-enlargement of the prostate gland blocks the urethra (the tube that carries urine from the bladder out of the body) causing problems with urinating). Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus), Hypertension [primary or Essential] (HTN-abnormally high blood pressure that's not the result of a medical condition), Antifungal powder (a topical medication that treats fungal [fungus occurs as yeasts or molds] infections of the skin). 8. Review of LPN F's electronic time card print out showed he/she clocked in on Saturday January 4, 2025, at approximately 6:00 A.M. and stayed on shift through Monday January 6, 2025, until approximately 7:00 A.M., for a total of approximately 49 hours straight. Review of LPN B's electronic time card print out showed: -He/She clocked in on Saturday January 4, 2025, at approximately 6:00 A.M., until approximately 10:30 P.M., for a total of approximately 16.5 hours. -He/She clocked in on Sunday January 5, 2025, at approximately 9:45 A.M., and stayed on shift through Monday January 6, 2025, until approximately 7:00 A.M., for a total of approximately 21 hours and 15 minutes straight. Review of LPN A's electronic time card print out showed he/she clocked in on Saturday January 4, 2025, at approximately 6:00 A.M., and stayed on shift through Monday January 6, 2025, until approximately 7:00 A.M., for a total of approximately 49 hours straight. Review of CMT E's electronic time card print out showed he/she clocked in on Saturday January 4, 2025, at approximately 6:00 P.M., and clocked out on Sunday January 5, 2025 at approximately 7:00 A.M., for a total of approximately 13 hours. Review of CMT F's electronic time card print out showed: -He/She clocked in on Saturday January 4, 2025, at approximately 5:00 P.M., and clocked out on Sunday January 5, 2025 at approximately 6:00 A.M., for a total of approximately 13 hours. -He/She clocked in on Sunday January 5, 2025, at approximately 6:00 P.M., and stayed on shift through Monday January 6, 2025, until approximately 8:45 A.M., for a total of approximately 14 hours and 45 minutes. Review of CMT G's electronic time card print out showed: -He/She clocked in on Saturday January 4, 2025, at approximately 6:00 A.M., and clocked out at approximately 7:45 P.M., for a total of approximately 13 and a half hours. -He/She clocked in on Sunday January 5, 2025, at approximately 6:00 A.M., and stayed on shift through Monday January 6, 2025, until approximately 7:00 A.M., for a total of approximately 25 hours. Review of the electronic time cards showed: -Nurses and CNA's work 12-hour shifts -CMT's work 8-hour shifts. -Saturday 1/4/25 day shift showed: --RN A worked day shift. --LPN's A, B, and F worked day shift. --CNA's H, M, N, and P worked day shift. -Saturday 1/4/25 night shift showed: --LPN's A, B, and F worked night shift. --CMT's E and F worked night shift. --CNA's P, Q, R worked night shift. -Sunday 1/5/25 day shift showed: --LPN's A, B, and F worked day shift. --CMT G worked day shift. --CNA H worked day shift. -Sunday 1/5/25 night shift showed: --LPN's A, B, and F worked day shift. --CMT's F and G worked night shift. --CNA's H, L, Q, R, and S worked night shift. 9. During an interview on 1/27/25 at 1:03 P.M., CMT D said: -Did not work weekends. -Did not work on Saturday 1/4/25 or Sunday 1/5/25. -Did get a text message about coming in to work. -Could not get there. -Was able to make it into the facility on Monday 1/6/25. -Thought there were three LPNs, One CMT, and one CNA on Saturday night. -Did not know the schedule each of them worked on Sunday, but they were at the facility when he/she came to work on Monday 1/6/25. During an interview on 1/28/25 at 10:07 A.M., LPN A said: -Worked Tuesday, Wednesday and every other weekend 12-hour shifts. -A major storm started Saturday 1/4/25 in the afternoon. -Saturday 1/4/25 day shift 6:00 A.M., to 6:00 P.M., was staffed for both wings and included LPN B. -On Saturday 1/4/25 night shift 6:00 P.M., to 6:00 A.M., staff started calling off. -He/She stayed over since there were staff calling off. -On Saturday night there were a total of three nurses, two CMT's and two CNA's and that was manageable. -The nurses called the Assistant Director several times each shift and the Assistant Director kept saying he/she was working on it, but no other staff came in. -On Sunday morning 1/5/25 there were the same three nurses from Saturday morning and 1 CMT, and CNA H came in and stayed till Monday morning. -On Sunday night there were the same three nurses, a CMT, and two CNA's from Saturday morning. -He/She was one of the nurses that stayed from Saturday morning through Monday morning. -LPN B was the third nurse who worked and was an orientee and wasn't counted as staff when orienting but was a body to help with medications and tube feeding. -LPN B worked the A wing with LPN F and probably passed meds on the A wing. -He/She only gave residents their narcotic medications and insulin's and did accuchecks. -He/She did not give residents their regular medications on Sunday day and night shifts due to being too exhausted from working over 24 hours and did not feel safe in administering all the medications on the B wing. -It was his/her responsibility to pass medications. -He/She texted administrative staff about being exhausted because of working so many hours. --He/She did not receive responses to the texts sent. --He/She was told to sleep in rotation with the other staff to stay rested until other staff arrived to work. -He/She helped keep residents clean and dry. -He/she did give the 5:00 A.M., medications on Monday 1/6/25. -The Assistant Director was supposed to be working on getting staff in for Sunday. -One housekeeping staff and two kitchen staff made it in on Sunday morning and did breakfast and lunch. -A text message was sent out by the Assistant Director which read if a staff left their shift without being relieved it would be considered abandonment of the shift and would be fired. -The staff who were working were told to take turns and rest if staff were not able to make it in to work. -None of the staff went to an empty room to rest. --The staff didn't feel right going to an empty room to rest, so they didn't. -Two other kitchen staff came in Sunday afternoon and did dinner. -Nurses came in on Monday morning and the three that stayed from Saturday went home. -He/She worked a total of 49 hours for the weekend. During an interview on 1/28/25 at 10:30 A.M., LPN B said: -He/She worked Saturday January 4, 2025. -He/She and the other two nurses called other staff and administration to see if they would come in. -Administration staff would not answer their phone. -He/She had been at the facility for two days as orientation before the storm and should have still been on orientation. -He/She was a new graduate LPN. -On Saturday 1/4/25 he/she worked 16 hours from 6:00 A.M., to about 10:30 P.M. -He/She went home and rested and came back on Sunday 1/5/25 about 9:45 A.M., and stayed until about 7:00 A.M., on Monday 1/6/25 and worked about 21 hours. -All three nurses were so tired that they did not get all the medications passed. -The staff who were working were told to take turns and rest if staff were not able to make it in to work. -None of the staff went to an empty room to rest. --The staff didn't feel right going to an empty room to rest, so they didn't. -Residents got their insulin and medications that were needed. -He/She was afraid for the residents because there was no one else to work. During an interview on 1/28/25 at 12:39 P.M., the DON said: -He/She had heard alerts that there could be bad weather coming. -He/She didn't know if it was really coming on Friday 1/3/25. -He/She heard there might be bad weather on Sunday the 1/5/25. -He/She did not know if plans were made to be sure there would be enough staff coverage if there was a large storm. -The staffing coordinator would have been the one to see that there was enough staff if the weather was bad. -He/She started on Tuesday December 31, 2024, as the Interim DON. -He/She didn't know anything about the staffing at that time and still was not sure how the staffing was done. -He/She was not aware of what the staffing was during the weekend of the storm. -He/She was the night nurse and transitioning to the position of DON. -The Assistant Director asked him/her to come in on Friday morning due to being short staffed that morning. -Was not aware he/she should have been at the facility when there were staffing issues. -He/She never got a call to come in for the weekend from the Assistant Director. -He/She didn't call the facility to check if there was enough staff or call the Assistant Director to see if staffing was covered. -He/She thought if there was an issue that the Assistant Director would have called him/her. -Didn't know for sure who was responsible for making sure staffing was covered during bad weather. -He/she would assume all administration would be responsible. -He/She didn't know if there was an emergency plan for ensuring enough staff. -He/She didn't know what the plan was to get additional staff to the facility for emergencies. -The Assistant Director said there were rooms where staff could take naps. -He/She didn't know if agency staff was called. -He/She would expect administrative staff to come in and help. -There was a weekend RN but didn't know if he/she was here that weekend or not. -He/She would have also thought the Administrator would have called to check on staff or came in. -He/She was not sure if residents got medications or other cares. During an interview on 1/28/25 at 1:12 P.M., the Assistant Director said: -He/She did the staffing. -He/She had heard there was bad weather possibly coming, but didn't think it was going to be bad. -He/She did not watch the news or listen to weather reports. -He/She did not know the weather was bad until he/she got up on Saturday morning 1/4/25. -He/She got on the staffing phone and sent text messages out to everyone on the schedule. -He/She told staff they needed to try and come in early. -He/She put it on the facility's Paylocity time clock & communication board also, this was accessible to all staff via their phone. -He/She did not receive any responses back from staff as to whether they would or would not be at work. -He/She tried to get out of his/her street to come and check and did not make it in. -He/She sent a text out and put the text message on Paylocity communication board on 1/3/25 at 4:16 P.M., that said: --The corporation policy from handbook showing facility recognized that the weather conditions due to nature of work and caring for health and safety of resident's facility strongly encouraged employees to make every reasonable but safe attempt to get to work during severe weather conditions. Employees should notify department supervisor or Administrator as soon as possible when travel condition delayed or prevented getting to work. Employees who exhibited a pattern of missing or avoiding work because of threat or because of inclement weather would be in violation of the policy if other employees in area could get to work with reasonable effort during severe weather conditions. He/she understood there might be bad weather this weekend but staff still needed to try and get to work even if late just call facility and let know if will be late. Please remember at all times you can't leave the building unless your relief had accepted the hall, if you left without a relief it was and would be considered abandonment of your employment. ---The Paylocity communication board showed that 49 staff had reviewed it. -On Sunday 1/5/25 Former Executive Director put on the Paylocity communication board: Good morning he/she wanted to thank everyone who had come into work but unfortunately the ice that had accumulated had prevented others from coming in. For everyone's safety if you were stuck at work find an empty room and sleep in shifts until others were able to arrive. Meals could be provided. If you called in due to road conditions please continue to try to come in once your roads have been cleared. Others from night shift at the campus would like to go home. Unfortunately, some things were out of their control but first and foremost was our residents being cared for and your safety. --65 staff viewed this message. -He/She put on the Paylocity communication board on 1/6/25 at 9:05 A.M. Please if you were on the schedule for Monday and Tuesday and overnights please make provisions early to get to work. He/she was letting everyone know in plenty of time by Lift, Uber, or taxi to get to work. Everyone needs to make a good faith attempt to get to work on time or early as possible. Everyone wants to go home just like everyone else. Please to make a good faith attempt to get to work early or at least get there. Some staff who live in and around the area made it to work slowly but made it. Please make a good attempt to get to work tonight and Tuesday on days and nights. --65 staff viewed this message. -He/She was responsible for ensuring there was enough staff. -He/She was unable to find alternate transportation to come in on Saturday or Sunday. -He/She would have expected other administrative staff to have tried to make it in to the facility. -He/She sent a management group text to come in if they could safely make it. -Management did not clock in. -No management came in to work. -He/She did not have the new DON's phone number. -He/She would not expect them to do their responsibilities without rest. -In the text he/she had sent, staff were told to take turns and rest while at the facility. -The staff were told to sleep in shifts and alternate so meds could be administered safely, and cares done safely. -He/She would expect all residents medications to have been given per Physicians orders. -The Former Executive Director put out a staffing need to the staffing agency and no agency staff picked up any shifts. -The new DON was not officially the DON until 1/14/25 he/she had still been working night shift as the nurse. During an interview on 1/31/25 at 3:25 P.M., the DON, Assistant Director, and the Executive Director said: -The Assistant Director does the staffing. -Staffing sheets were done in advance and if there were empty positions he/she would try to find full time staff who would pick up the shift. -If full time staff didn't pick up a shift then he/she called the staffing agency. -If the agency couldn't fill the position, the facility offered incentives to staff such as a bonus for working an extra shift. -The process for staffing during inclement weather would be the same as above. -During inclement weather staff were notified of open positions by the facility paylocity communication board which staff can access by their phones and send text messages out to all staff. -Administrative staff including the DON should come in during inclement weather to see that things were being done and to offer help where there could. -The facility did not have a plan to get staff to the facility for inclement weather. -The facility should have a plan to be able to get staff to the facility during inclement weather. -The residents who did not receive their medications during the inclement weather was unacceptable. -The nursing staff that stayed during the inclement weather were instructed to rest in shifts to be sure there were no medication errors and be able to care for the residents. MO00247335 MO00247435 MO00247567 MO00247918

Based on observation and interview, the facility failed to post nurse staffing information, which included the facility census, the total number of each staff and actual hours worked by both licensed and unlicensed staff directly responsible for resident care, per shift on a daily basis and visible for residents, visitors, and staff to view at each nursing station. The facility census was 55 residents. A copy of the facility policy regarding posting of nursing staff type, hours worked by each discipline, and facility census was requested and not received at the time of exit. 1. Observation on 1/22/25 at 2:17 P.M., showed a staffing sheet was posted at the far right of the reception desk, but was not visible to residents or visitors who did not stop at the desk. During an interview on 1/22/25 at 2:17 P.M., the receptionist said: -The staffing sheets were posted every morning at the far right of the reception desk. -The staffing sheets showed the facility census, the number of staff and total hours worked for each nursing staff position. -The staffing sheets were not posted at each nursing station. During an interview on 1/22/25 at 2:21 P.M., Licensed Practical Nurse (LPN) D working the A wing said: -Staffing was posted at the front reception desk. -When residents or visitors wanted to know the number of staff or which staff were working, they needed to ask one of the staff who was working. -When an agency staff was working, that staff went to the front receptionist to find out. During an interview on 1/22/25 at 2:25 P.M., LPN A working the B wing said: -Staffing was posted at the front reception desk. -Residents or visitors could ask which staff were working. During an interview on 1/24/25 at 10:47 A.M., Certified Nursing Assistant (CNA) G said: -Staffing was posted at the front reception desk. -Today there were two CNA's, one Certified Medication Technician (CMT), one nurse, and one bath aide working the A wing. During an interview on 1/31/25 at 3:25 P.M., the Director of Nursing, Assistant Director and the Executive Director said: -The daily staffing information was posted daily. -The staffing sheets showed the facility daily census, the number of each nursing staff and the total hours of each position worked in 24 hours. -The staffing was posted at the front reception desk and at both nursing stations. -The staffing information should be posted in areas where it was easily accessible to all residents, visitors, and staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain hot meal items on room trays at or close to 120 ºF (degrees Fahrenheit) for five sampled residents (Resident #11, #159, #4, #19, and #109) out of 10 residents who received room trays. The facility census was 55 residents. Review of the facility policy titled The dining experience, staff roles dated 2020 showed: -The Dietary Services Manager or designee would be present in the dining room for all meals to ensure that the meals served: --Were palatable. --Were served at the appropriate temperatures. 1. Review of the resident council minutes, dated January 2025, showed the residents mentioned the food was cold and the food was not good. During an interview on 1/31/25 at 12:21 P.M., the Life Enrichment Coordinator said: -He/she made copies of the resident council minutes and gave them to each department to respond to the residents' concerns. -When each department head had developed a plan to address the resident's concerns, they were supposed to give that plan to the Social Service Designee (SSD). -The SSD was supposed to check with each department to see if the resident concerns has been resolved. 2. Review of Resident #11's quarterly Minimum Data Set (MDS--a federally mandated assessment tool completed by the facility for care planning), dated 11/29/24, showed the resident was cognitively intact. During an interview on 1/22/25 at 1:21 P. M.,the resident said: -He/she at in his/her room and had room trays. -The food was often cold. 3. Observation on 1/24/25 at 7:10 A.M., showed the temperature of the hot items in the kitchen at the steam table were as follows: -The omelet was 186 ºF. -The sausage patties were between 157 ºF to 160 ºF. During an interview on 1/24/25 at 7:31 A.M., Certified Nursing Assistant (CNA) G said: -He/she had not seen anyone from dietary come and check the temperatures of the food items on the trays. -He/she or the person delivering room trays, usually delivered the drinks and the food trays. Observation on 1/24/25 of the room tray delivery process showed: -At 7:33 A.M., CNA G started to deliver room trays. -At 7:38 A.M., CNA G delivered food to resident room [ROOM NUMBER] and had to awaken the resident before he/she was able to serve the resident his/her tray. -At 7:40 A.M., CNA G delivered food to resident room [ROOM NUMBER]. -At 7:46 A.M., CNA G delivered food to resident room [ROOM NUMBER]. -At 7:50 A.M., CNA G delivered food to resident room [ROOM NUMBER]. --That resident needed help to go to the restroom. -At 7:54 A.M., CNA G delivered food to resident room [ROOM NUMBER]. -At 7:57 P.M., CNA G delivered food to resident room [ROOM NUMBER]. -At 8:03 P.M., CNA G delivered food to resident room [ROOM NUMBER]. -At 8:07 A.M., CNA G delivered food to resident room [ROOM NUMBER]. --The resident needed ice water. ---CNA G went back to the kitchen to get ice water. 4. Observation on 1/24/25 at 8:14 A.M., showed the food delivered to Resident #159, had the following temperatures: -The egg omelet was 104 ºF. -The sausage link was 92.8 ºF. -The hot cereal was 112.1 ºF. During an interview on 1/24/25 at 8:18 A.M., the resident said: -He/she has breakfast in his/her room and typically by the time the food was delivered it was cold. -The breakfast meal was cold on most mornings. -This morning, he/she felt the food was cold and he/she turned the food away. --A new plate of food was not offered by the staff. 5. Review of Resident #4's admission MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 1/24/25 at 10:23 A.M., the resident said: -All three meals were delivered to him/her cold. -The breakfast that morning was lukewarm. 6. Review of Resident #19's quarterly MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 1/24/25 at 10:27 A.M., the resident said: -He/She received room trays every day for all meals. -His/her food was always cold. -The cold food negatively affected the amount of food that he/she consumed. -There were times, he/she did not get full. 7. Review of Resident #109's admission MDS, dated [DATE], showed the resident was cognitively intact. During an interview on 1/24/25 at 10:29 A.M., the resident said: -Almost every morning, the breakfast was cold. -At times, the vegetables served with is/her dinner were cold, because they stay out for a long time before being delivered. -He/she was at the end of the hall and usually was the last tray delivered. -The breakfast that morning was cold. 8. Review of the resident council minutes dated 10/24/24 showed: -There were 11 residents in attendance. -Dietary concerns were brought up during the meeting. -The food needs a little work (there was no further description of what was a concern). Review of the resident council minutes dated 12/19/24 showed: -There were eight residents in attendance. -Dietary concerns were brought up during the meeting. -The food was cold. -The food was not as good as it used to be. -The food was delivered late. 9. During an interview on 1/24/25 at 8:24 A.M., the Dietary Manager (DM) said: -He/she had not sent any dietary staff out to the floor to check temperatures of meals on room trays. -He/she had heard complaints from residents about the food being cold. During an interview on 1/31/25 at 10:41 A.M., the Registered Dietitian (RD) said: -He/she had not checked room tray temperatures in a while. -He/she went to the facility once a month. -He/she did not always check the rooms tray temperatures. During an interview on 1/31/25 at 3:30 P.M. the Director of Nursing said: -The Dietary Manager was in charge of the dietary department. -The Dietary Manager should have addressed any issues or concerns regarding the food.

Based on interview and record review, the facility failed to establish an Antibiotic Stewardship program and a system to monitor antibiotic usage. The facility census was 55 residents. Review of the facility's policy ,Infection Preventionist, dated September 2022 showed: -The Infection Preventionist was responsible for coordinating the implementation and updating of the infection prevention and control program; -The Infection Preventionist collects, analyzes and provides infection and antibiotic usage data and trends to nursing staff and health care practitioners; -The Infection Preventionist has obtained specialized training beyond initial professional training or education prior to assuming the role including antibiotic stewardship; -The Infection Preventionist was employed on site and at least part time. Review of the facility policy titled Antibiotic Stewardship-Order for Antibiotics dated December 2016 showed: -Antibiotics would be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing. -If an antibiotic was indicated, prescribers would provide complete antibiotic orders including the following elements: --Drug name. --Dose. --Frequency of administration. --Duration of treatment: ---Start and stop date. ---Number of days of therapy. --Route of administration. --Indication of use. -Appropriate indications for use of antibiotics included: --Criteria met for clinical definition of active infection or suspected sepsis. --Pathogen susceptibility, based on culture and sensitivity (or therapy begun while culture was pending). -When antibiotics were prescribed over the phone, the primary care practitioner would assess the resident within 72 hours of the telephone order. -When a culture and sensitivity was ordered, it would be completed. -As soon as clinically appropriate, the prescriber would be asked to review converting intravenous antibiotics to an oral formulation. 1. Review of the facility Antibiotic order list from Pharmacy dated November 2024, December 2024 and January 2025 showed: -In November 2024 there were seven residents who had been on antibiotics. -In December 2024 there were seven residents who had been on antibiotics. -In January 2025 there were 12 residents who were currently or had been on antibiotics. During an interview on 1/31/25 at 10:00 A.M. the Executive Director said: -There was currently no one in the role of the Infection Preventionist. -There should have been someone in the role or completing the tasks and responsibilities of the Infection Preventionist. -The Infection Preventionist would have been the person completing Antibiotic Stewardship. -There was no one performing the the tasks or taking the responsibility of maintaining Antibiotic Stewardship at this time. During an interview on 1/31/25 at 3:30 P.M. the Director of Nursing (DON) said: -He/She was not the Infection Preventionist. -The Infection Preventionist would be responsible for Antibiotic Stewardship. -He/She was not doing anything with Antibiotic Stewardship. -He/She did not know if anyone else was doing anything with Antibiotic Stewardship.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #2's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's immunizations form showed: -There was no documentation of the resident's pneumonia vaccine status. -The resident received the influenza vaccine on 11/16/23. -There was no documentation regarding the resident's influenza vaccine for 2024. 4. Review of Resident #9's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's immunizations form showed: -There was no documentation of the resident's pneumonia vaccine status. -The resident refused the flu vaccine. -There was not a date that the resident refused the flu vaccine and there was no documentation of any education provided for the risks and benefits of receiving the flu vaccine. 5. During an interview on 1/28/25 at 8:42 A.M., the Director of Nursing (DON) said they were looking into who was responsible for administering resident flu and pneumonia vaccines. During an interview on 1/29/25 at 10:15 A.M., Licensed Practical Nurse (LPN) A said: -The nurse on duty completed the new admission's assessments, including administering any requested or appropriate vaccines. -New residents were supposed to be offered the flu and pneumonia vaccine, if appropriate based on age and other factors, however residents were not offered either vaccine. -He/She had not completed any recent vaccines on newly admitted residents. -The DON reviewed the new admission chart within 72 hours of admission and should have seen if the vaccines were offered or completed. During an interview on 1/31/25 at 4:55 P.M., the DON said: -New residents were offered flu and pneumonia vaccines upon admission. -Current residents were offered the flu and pneumonia vaccines once a year. -The Social Services Designee (SSD) obtained consent from the residents. -Residents signed a form that stated if they consented or refused vaccines. -If refused the SSD provided risks and benefits of each vaccine. -The consent forms had been misplaced and were not able to be located. -He/She was unsure where the resident's vaccines would be documented. During an interview on 1/31/25 at 4:55 P.M., the Executive Director said: -The SSD was responsible for offering vaccines to residents and getting their consent or refusal. -The consent documentation he/she obtained was missing. -If the flu and pneumonia vaccines were not documented then they were not done. Based on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide pneumococcal (pneumonia-lung inflammation caused by bacterial or viral infection) and influenza (flu - an infection of the respiratory system: nose, throat and lungs) vaccines for four sampled residents (Resident #44, #109, #2, and #9) out of five residents sampled for immunizations. The facility census was 55 residents. Review of the facility's Influenza Vaccine policy, dated March 2022, showed: -All residents who have no medical contraindications to the vaccine were offered the flu vaccine annually. -The facility provided information about the significant risks and benefits of vaccines to residents. -Between October 1st and March 31st each year, the flu vaccine was offered to residents. -For those who received the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination was documented in the resident's medical record. Review of the facility's Pneumococcal Vaccine policy, dated March 2022, showed: -All residents were offered the pneumonia vaccine. -Assessments of the pneumonia vaccination status were conducted within five working days of the resident's admission. -Prior to receiving the vaccine, the resident or resident representative received information and education regarding the benefits and potential side effects of the vaccine. -Education was documented in the resident's medical record. -If the resident or resident representative refused the vaccine it was documented in the resident's medical record. -For each resident who received the vaccine, the date of vaccination, lot number, expiration dated, person administering, and the site of vaccination were documented in the resident's medical file. 1. Review of Resident #44's face sheet, undated, showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD- a condition that constricted the airways and caused difficulty or discomfort in breathing). -Diabetes (a disease that occurred when blood sugar was too high). -Heart disease. Review of the resident's care plan dated 10/11/24, showed: -The resident had an Activities of Daily Living (ADL) self-care performance deficit related to dementia. During an interview on 1/22/25 at 1:06 P.M., the resident's family member said: -They were unaware if the resident received any vaccines when admitted . -They thought the resident had a flu shot but could not be sure. Review of the resident's Physician Order Summary (POS) dated January 2025, showed no orders for the flu or pneumonia vaccines. Review of the resident's Immunizations Record, generated from the Electronic Health Record (EHR), dated 1/20/25, showed the resident had no flu or pneumonia vaccinations on file. 2. Review of Resident #109's face sheet, undated, showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Dependence on supplemental oxygen. -COPD. -Heart failure. Review of the resident's POS dated January 2025, showed the resident may receive the influenza vaccine. Review of the resident's Medication Administration Record (MAR)/Treatment Administration Record (TAR) dated December 2024 showed the flu and pneumonia vaccine were not given. Review of the resident's MAR/TAR dated January 2025 showed the flu and pneumonia vaccine were not given. Review of the resident's Immunizations Record, generated from the EHR, dated 1/20/25, showed: -The resident had no received flu or pneumonia vaccines on file. During an interview on 1/29/25 at 8:54 A.M., the resident said he/she did not remember if he/she received any vaccines when he/she was admitted to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide COVID-19 (a highly contagious respiratory disease caused by a new coronavirus that emerged in December 2019) vaccines for three sampled residents (Residents #2, #9, and #109) out of five residents sampled for immunizations. The facility census was 55 residents. Review of the facility policy titled Coronavirus Disease - Vaccination of Residents dated as revised June 2022 showed: -Residents who were eligible to receive the COVID-19 vaccine were strongly encouraged to do so. -The resident or resident representative could accept or refuse a COVID-19 vaccine and to change his/her decision. -COVID-19 vaccine education, documentation, and reporting were supposed to be overseen by the infection preventionist and coordinated by his/her designee. -The individual who coordinates the responsibilities in the facility was left blank. -The COVID-19 vaccine could be offered and provided directly by the facility or indirectly through an arrangement with a pharmacy partner or other appropriate health entity. -Before the COVID-19 vaccine was offered, the resident was to be provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. -Residents were to sign a vaccine consent form prior to receiving the vaccine. -Booster vaccine doses were provided in accordance with current Center for Disease Control guidance. -A vaccine administration record was to be provided to the resident and a copy is filed in the resident's record. -The resident's medical record included documentation that included the signed consent, and that the vaccine was administered to the resident. -If the resident did not receive the COVID-19 vaccine due to medical contraindications, prior to vaccination or refusal, appropriate documentation should be made in the resident's record. 1. Review of Resident #2's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's immunizations form showed: -The resident received the initial two COVID-19 vaccine doses on 2/10/21 and 3/10/21. -The resident received a COVID-19 booster on 10/27/21. -There was not a date that any additional boosters were offered to the resident. 2. Review of Resident #9's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's immunizations form showed there was no documentation regarding the resident's COVID-19 vaccine status. 3. Review of Resident #44's face sheet, undated, showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD- a condition that constricted the airways and caused difficulty or discomfort in breathing). -Diabetes (a disease that occurred when blood sugar was too high). -Heart disease. Review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/5/24 showed: -The resident was severely cognitively impaired. Review of the resident's Physician Order Summary, dated January 2025, showed no orders for the COVID-19 vaccine. Review of the resident's Immunizations Record dated 1/20/25 showed the resident had no immunizations on file. During an interview on 1/22/25 at 1:06 P.M., the resident's family member said they were unaware if the resident received any vaccines when admitted . 4. Review of Resident #109's face sheet, undated, showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Dependence on supplemental oxygen. -COPD. -Heart failure. Review of the resident's Physician Order Summary, dated January 2025, showed the resident may receive the COVID-19 vaccine. Review of the resident's Immunizations Record dated 1/20/25 showed the resident had no immunizations on file. During an interview on 1/29/25 at 8:54 A.M., the resident said he/she did not remember if he/she received any vaccines when he/she was admitted to the facility. 5. During an interview on 1/29/25 at 10:15 A.M., Licensed Practical Nurse (LPN) A said: -The nurse on duty completed the new admissions assessments, including administering any requested or appropriate vaccines. -New residents were supposed to be offered the COVID-19 vaccine, however residents were not offered that vaccine. -He/She had not completed any recent vaccines on newly admitted residents. -The Director of Nursing (DON) reviewed the new admission chart within 72 hours of admission and should have seen if the vaccines were offered or completed. During an interview on 1/31/25 at 4:55 P.M., the DON said: -New residents were supposed to be offered COVID-19 vaccines upon admission. -The Social Services Designee (SSD) obtained vaccine consent from the residents. -Residents signed a form that stated if they consented or refused. -If refused the SSD provided risks and benefits of each vaccine. -The consent forms had been misplaced and were not able to be located. -He/She was unsure where the residents COVID-19 vaccine would be documented. During an interview on 1/31/25 at 4:55 P.M., the Executive Director said: -The SSD was responsible for offering vaccines to residents. -The consent documentation he/she obtained was missing. -If the COVID-19 vaccine was not documented then it was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Automated External Defibrillator (AED a portable device that can be used to treat a person whose heart has suddenly stopped working by delivering an electrical shock) was in working condition. The facility census was 55 residents. Review of the facility's policy, Cardiopulmonary Resuscitation, dated February 2018 showed: -Early delivery of a shock with a defibrillator within three to five minutes of collapse can further increase chances of survival. -Maintain equipment and supplies necessary in the facility at all times. Review of the facility's policy, In House Maintenance for Defibrillators - AED dated [DATE] showed: -Maintenance should have been done monthly. -Verify electrodes (pad that delivers a shock) were connected to the AED and sealed in their package. -Replace if pads were expired. -Verify the green check light indicated ready for use. -Verify the batteries and pads were within expiration date. -Replace if expired. -Check for adequate supplies. Review of the HeartSine Samaritan PAD model SAM 300 manual dated 2011 showed it was recommended a spare Pad-Pak was kept with the AED machine. 1. Observation on [DATE] at 12:45 P.M. of the AED machine on hallway A showed: -The AED was not in the AED cabinet, it was in a bag on the crash cart. -The AED did not have a battery in the machine. -There were no pads in the bag with the AED machine. -The Crash cart Checklist did not include checking the AED machine. -The Crash cart checklist had not been done since [DATE]. Observation on [DATE] at 12:59 P.M. of the AED machine on hallway B showed: -The AED was in the AED cupboard. -The pads were stuck together indicating they had been used. -There were no new pads. -The Crash cart checklist for hallway B showed it had not been checked since [DATE]. -The Crash cart checklist did not include checking the AED machine. During an interview on [DATE] at 1:00 P.M. the Assistant Director said: -The pads on the AED machine on hallway B were open and stuck together indicating they had been used. -They did not have any extra pads with the AED machine on hallway B. -They did not have any extra batteries with the AED machine on hallway A. --The batteries could not be purchased locally, but needed to be ordered on the Internet. -The night shift charge nurse should have been checking the AED machine to ensure it worked and had the parts that it needed daily. -The AED machine should have been checked each night with the crash cart. -The crash cart check list did not include checking the AED. -He/She verified the crash cart check list on both hallways had not been done since mid December. -At least 30% of the 55 residents were a full code (lifesaving measures were to have been taken if their heart stopped). -The Director of Nursing (DON) was responsible to ensure the crash cart had all the essentials. During an interview and observation on [DATE] at 2:00 P.M. the Executive Director said: -There should have been pads and a battery in the AED pack. -They did not have any extras and would have to order them off of the Internet. -He/She was taking them out of service until he/she could talk to corporate to see what to do. -The crash cart checklist did not include checking the AED machines but it should have. -The crash cart checklist on both hallways had not been done since mid December. -The night shift charge nurse should have checked the crash cart and AED machines. -There should have been extra pads and batteries for each AED machine but they did not have them. During an interview on [DATE] at 3:30 P.M. the DON said: -They had two AED machines in the facility. -Maybe 25% to 30% of the residents were a full code. -The AED machines should have been evaluated monthly to ensure they had all the parts and it was in working order. -They did not have any pads or AED batteries at this time to replace the ones that had been used on both machines. -Checking the AED machine should have been part of the crash cart checklist.

Based on interview and record review, the facility failed to ensure the services of a Registered Nurse (RN) were utilized eight hours per day, seven days per week. This had the potential to affect all residents of the facility. The facility census was 55 residents. Review of the facility's Staffing, Sufficient and Competent Nursing policy, dated as revised August 2022, showed: -Licensed nurses and Certified Nursing Assistants (CNA) were available 24 hours a day, seven days a week to provide competent resident care services. -A RN provides services at least eight consecutive hours every 24 hours, seven days a week. -RNs may be scheduled more than eight hours depending on the acuity needs of the resident. 1. Review of the Facility Assessment, dated 1/16/25, showed: -The facility was licensed for 118 residents. -Current full-time staff was 41. -Part-time staff was 3. -As needed (PRN) staff was 4. Hours per resident days (HPRD) showed: -Day shift: --Two RNs. --Two Licensed Practical Nurses (LPNs). --Four CNA/Nurse Assistants (NA). -Night shift: --No RN. --Two LPNs. --Four CNA/NAs. Review of the facility staffing sheet, dated 1/4/25, showed: -RN A was scheduled to work the day shift on 1/4/25. Review of the facility staffing sheet, dated 1/5/25, showed: -RN A was not scheduled to work on 1/5/25. -There was no other RN scheduled to work. -The Director of Nursing (DON) did not come in to the building and work as the RN coverage. Review of the facility staffing sheet, dated 1/6/25, showed: -The DON was scheduled to be the RN in the building on 1/6/25. -There was no other RN scheduled to work. -The DON did not work on 1/6/25. Review of the facility's current staff list, dated 1/17/25, showed: -The DON as a RN. -RN A as the weekend and part time RN. -RN B as a full-time RN. During an interview on 1/28/25 at 12:39 P.M., the DON said: -He/She was a RN. -He/She had started on December 31, 2024, as the Interim DON. -The staffing coordinator was responsible to make sure there was enough staff for each position. -He/She didn't know anything about the staffing at that time and still was not sure how the staffing was done. -Was not aware the RN scheduled for 1/5/25 or 1/6/25 did not show. -He/She sometimes filled in as the RN and would work the floor if there was no other RN scheduled. -He/She was scheduled to work as the DON on 1/6/25, but was unable to come in. -He/She did not know there was no other RN working on 1/6/25. During an interview on 1/28/25 at 1:12 P.M., the Assistant Director said: -He/She did the staffing. -Staffing sheets were done in advance and if there were empty positions he/she tried to see if the full-time staff would pick up the shift. -If full time staff didn't pick up a shift then he/she called the staffing agency the facility contracts with. -If the staffing agency couldn't fill the position, the facility offered incentives to staff such as a bonus for working an extra shift. -The facility had a scheduled RN to work the weekends. -That RN worked Saturday 1/4/25. -Sunday 1/5/25 there was no RN scheduled to work. -The DON did not work on 1/5/25. -The DON was scheduled to work Monday 1/6/25 and would have been the RN, but he/she was unable to make it in. -There was no RN on duty on 1/5/25 and 1/6/25. During an interview on 1/31/25 at 3:25 P.M., the DON, Assistant Director, and the Executive Director said: -There should be RN coverage for at least eight hours in a 24-hour period. -There should have been a RN working on 1/5/25 and 1/6/25. -When a RN was not scheduled or if the RN called off, the DON was expected to cover the position. -Staffing sheets were done in advance and if a RN was needed, the Assistant Director would call the staffing agency to see if they could fill the spot. -The DON was not aware he/she was expected to cover shifts that did not have RN coverage.

Based on interview and record review, the facility failed to address areas of needed improvement by not developing and implementing Performance Improvement Plans (PIP - a process designed to help facilities address and fix deficiencies) which could affect all facility areas including residents quality of life. The facility census was 55 residents. Review of the facility's Quality Assurance and Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) Program - Governance and Leadership Policy, dated March 2020, showed: -The QAPI program was overseen and implemented by the QAPI committee and reported findings, actions and results to the administrator and governing body. -The Administrator was ultimately responsible for the QAPI program and for interpreting results, and findings to the governing body. -The QAPI committee was responsible for: --Coordinating, developing, implementing, monitoring and evaluation of performance improvement projects to achieve specific goals. --Establishing performance outcome indicators for quality of care and services delivered in the facility. --Choosing and implementing tools that best captured and measured dated about chose indicators. 1. During an interview on 1/31/25 at 9:18 A.M., the Assistant Director said: -There were no current PIPs the facility was working on. -The survey process identified several areas needing improvement: --Showers for residents. --Wound care. --General documentation. --Investigations in all areas. -He/She did not know what a PIP was until about two weeks ago. During an interview on 1/31/25 at 4:55 P.M. the Executive Director said: -He/She would have expected to see PIPs in place. -He/She expected areas of improvement to be identified in stand-up meetings (a daily meeting that involved the core team) every morning with department heads. -These areas of improvement would be carried over into a PIP.

Based on interview and record review, the facility failed to develop and implement written procedures for its Quality Assurance and Performance Improvement (QAPI - a data driven and proactive approach to quality improvement) Program which led to the inability to gather feedback for quality improvement. This practice had the ability to affect all residents. The facility census was 55 residents. Review of the facility's QAPI Program - Governance and Leadership policy, dated March 2020, showed: -The Administrator was ultimately responsible for the QAPI program. -The QAPI program was based on data, resident and staff input, and other information that measured performance. -The QAPI program focused on problems and opportunities that reflected processes, functions, and services provided by the residents. -The responsibilities of the QAPI committee were to: --Collect and analyze performance indicator data. --Identify, evaluate, monitor, and improve facility systems and processes. --Identify and resolve negative outcomes. --Establish benchmarks and goals. --Utilize root cause analysis to help identify problems. 1. Review of the facility's Quality Assurance (QA) Meetings agenda, dated 11/19/24, showed: -Number of staff breakdown by position, call-ins, and terminations. -Staff attended: --Medical Director. --Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) Coordinator. --Activities Director. --Human Resources Director. -NOTE: No other notes were available. Review of the facility's QA Meetings agenda, dated December 2024, showed: -Staff attended: --Medical Director. --MDS Coordinator. --Bookkeeper. --Dietary Manager. -COVID-19 status for residents was reviewed showing five residents. -NOTE: No other notes were available. Records for a January 2025 QA Meeting were requested and not provided. During an interview on 1/31/25 at 9:18 A.M., the Assistant Director said: -The QAPI committee met once a month, depending on the physicians schedule. -The Administrator, Director of Nursing (DON), MDS coordinator, Business Office Director (BOD), Maintenance Director, Dietary Manager, Activities Coordinator, Social Services Designee (SSD), Therapy and Human Resources (HR) attended the meetings. -The QAPI Committee only had a policy to go by. -There were no procedures or guidelines. -The committee did not meet in January 2025. -The committee had no current improvement projects. -During monthly QAPI meetings, all staff brought in packets with their concerns and information to report to the committee. -Those concerns were not tracked for improvement. During an interview on 1/31/25 at 4:55 P.M., the Executive Director said: -He/She requested copies of QAPI policies and procedures from the corporate office and was only provided the policy. -He/She expected staff to follow committee policies and procedures. -He/She was unaware the QAPI committee did not have procedures or guidelines to follow.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident #37's face sheet, undated, showed the resident had the following diagnoses: -Quadriplegia (a severe medical condition characterized by the partial or total loss of function in all four limbs and the torso) -The resident had a colostomy and a suprapubic catheter; -The resident had cystostomy (an opening into the urinary bladder by surgical incision). Review of the resident's TAR dated November 2024 showed: -The resident received colostomy care as ordered; -The resident received urinary catheter care as ordered. Review of the resident's December 2024 TAR, showed: -The resident received colostomy care as ordered; -The resident received urinary catheter care as ordered. Review of the resident's care plan dated 12/17/24, showed: -The resident had Clostridium Difficile (C-diff -a bacterium that caused an infection of the colon); --The resident was on contact isolation (gowns and masks should be worn when changing contaminated linens); --The resident remained free from discomfort, complications or signs and symptoms of gastro-intestinal alterations; -The resident had an indwelling suprapubic catheter; -The resident had a colostomy. Review of the resident's POS for all orders until 1/28/25, showed the resident had orders for: -Change colostomy bag every three days as needed; -Urinary catheter care every shift; -Change the urinary drainage bag every night shift on Sundays. During an interview on 1/27/25 at 12:54 P.M., CNA A said: -The resident had catheter care; -He/She used gloves when catheter care was provided; -No other PPE was used; -He/She did not remember a PPE cart being outside of the resident's door; -He/She was unaware of EBP. During an interview on 1/27/25 at 1:12 P.M., CNA B said: -He/She provided catheter care to the resident; -He/She was unaware of any issues with the residents catheter care; -He/She wore gloves as part of the residents catheter care; -He/She did not wear other PPE; -He/She was unaware that he/she was supposed to. During an interview on 1/28/25 at 9:30 A.M., LPN A said: -The resident had a catheter; -The resident received catheter and colostomy care from the CNA's; -He/She was familiar with and implemented EBP practices; -The other staff should have used EBP during catheter and colostomy cares, but he/she was unaware if other staff were; -There were no PPE carts outside of the resident's room; -He/She had PPE in the medication cart, in the clean utility closet and sometimes behind the nurses station desk. During an interview on 1/31/25 at 4:55 P.M. the Assistant Director said: -There were no EBPs put into place for this resident; -The resident should have been on EBP; -He/She received EBP training on 1/28/25; -The new DON was not aware of the EBP protocols; -The nurses were responsible for providing the care to the resident and should have used EBP; -They were not practicing EBP; -He/She was unaware if appropriate PPE was available for EBP; -He/She was unaware of the location of the PPE. 7. Observation on 1/22/25 at 2:00 P.M. showed: -There were no signs on Resident #3, #9, #30, #39, and #37's doors indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares on residents who should have been on EBP. Observation on 1/23/25 at 10:00 A.M. showed: -There were no signs on Resident #3, #9, #30, #39, and #37's doors indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares on residents who should have been on EBP. Observation on 1/24/25 at 9:36 A.M. showed: -There were no signs on Resident #3, #9, #30, #39, and #37's doors indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares on residents who should have been on EBP. Observation on 1/27/25 at 9:00 A.M. showed: -There were no signs on Resident #3, #9, #30, #39, and #37's doors indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares on residents who should have been on EBP. 8. Review of Resident #30's quarterly MDS dated [DATE] showed: -He/She was moderately cognitively impaired; -He/She was at risk for pressure sores; -He/She had an application of non surgical dressings to a place other than feet, dated 8/15/24; -He/She had an application of dressings to feet. Observation on 1/24/25 at 10:15 A.M. showed: -Two Certified Nursing Assistants (CNA)s entered the resident's room to do incontinent cares; -The two CNA's were not wearing PPE; -There was no sign on his/her door indicating he/she should have been on EBP; -There was no isolation cart with PPE in or by the room. Observation on 1/24/25 at 1:00 P.M. showed: -There were no signs on Resident #3, #9, #30, #39, and #37's doors indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares on residents who should have been on EBP. 9. Review of the facility's policy, Handwashing/Hand Hygiene, dated August 2019 showed: -All personnel should have been trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. -All personnel should have followed the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Use an alcohol-based hand rub or soap and water for the following situations: -Before and after direct contact with residents. -Before and after handling an invasive devise. -Before donning sterile gloves. -Before handling clean or soiled dressing. -Before moving from a contaminated body site to a clean body site during resident care. -After contact with a resident's intact skin. -After handling used dressings or contaminated equipment. -Before and after entering isolation precaution settings. -Hand hygiene was the final step after removing and disposing of PPE. Review of Resident 39's quarterly MDS dated [DATE] showed: -He/She was cognitively intact; -He/She was always incontinent of bowel and bladder; -He/She was at risk of developing skin ulcers; -He/She did not have an unhealed pressure ulcers. Review of the resident's skin monitoring/shower sheets dated December 2024 showed on 12/12/24 he/she had a spot on his/her buttock. Review of the resident's skin monitoring/shower sheets dated January 2025 showed: -On 1/13/25 he/she had an open sore on his/her buttock; -His/her peri area was very red; -On 1/20/25 he/she had a sore on his/her bottom; -His/her peri area was irritated. Review of the resident's Medication Administration Record (MAR) dated January 2025 showed: -Predisone Acetate Ophthalmic (medication used for inflammation or injury to the eyes) Suspension 1% to instill one drop in left eye one time a day dated 8/27/24; -Xalatan Ophthalmic solution (used to treat high pressure in the eye) 0.005% to instill one drop in each eye at bedtime for eye drops; -Cyclosporine emulsion (to treat dry eye) 0.005% to instill one drop in both eyes two times a day for dry eye; -Dorzolamide Hydrochloride solution 2% to instill one drop in let eye two times a day for dry eye; -Cleanse the buttocks wound with wound cleanser, gently pat dry, and cover with dressing daily and as needed, dated 12/27/24. The resident's care plan was requested and not provided by time of exit. Observation on 1/28/25 at 10:16 A.M. of wound care with Licensed Practical Nurse (LPN) B showed: -There was no EBP sign on the resident's door; -There was no isolation cart with PPE outside the resident's door; -CNA's E and F had moved the resident from his/her wheelchair to the bed; -CNA's E and F had assisted the nurse to reposition the resident in the bed and took off his/her pants to do wound care; -LPN B and CNA E and F had gloves on but no gown; -CNA's E and F removed the resident's paper brief; -LPN B wiped off the old cream on the resident's coccyx area; -The resident then urinated; -LPN B cleaned the urine off of the resident; -LPN B did not change gloves or wash hands before applying the cream.; -LPN B and CNA E and F took off their gloves but did not wash their hands when they left the room. During an interview on 1/28/25 at 10:40 A.M. LPN B said: -They should have washed their hands before they left the resident's room; -He/She did not know anything about EBP, the facility had not provided any education on EBP. During an interview on 1/28/25 at 10:45 A.M. CNA E and CNA F said: -They had never heard of EBP; -There had been no education on EBP at the facility; -They should have washed their hands after they took their gloves off before they left the room. Observation on 1/28/25 at 3:40 P.M. of pictures of the resident's buttock wounds showed: -There were three quarter sized stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. It may also present as an intact or open/ruptured blister) wounds on the residents coccyx area three weeks ago; -An area around the wounds that measured 10 centimeters (cm) by 6 cm was extremely reddened. During an interview on 1/30/25 at 4:00 P.M. the resident's family member said: -He/She came to to see the resident every night when he/she got off of work; -In the evening, staff were not wearing a gown or gloves when doing cares on the resident even though there has been a sign on the door and an isolation cart by the resident's door; -The Certified Medication Technician (CMT) C never wore gloves when he/she administered eye drops to the resident. 10. Review of Resident #3's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Gastrostomy status (a thin, flexible tube inserted through the abdominal wall and into the stomach to provide nutrition for those who can not eat); -Bladder neck obstruction (a condition in which the opening of the bladder is narrowed or blocked preventing urine from flowing freely); -Retention of urine (difficulty urinating and completely emptying the bladder). -Diarrhea (loose watery stools that occur frequently). Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact; -Having a catheter was not checked; -He/She was incontinent of bowel and bladder; -Had a feeding tube; -He/She did not have a pressure ulcer. Review of the resident's Skin monitoring/Shower sheet dated December 2024 showed on 12/18/24 the resident had a red area on his/her buttock and abdomen. Review of the resident's Skin monitoring/Shower sheet dated January 2025 showed on 1/27/25 his/her peri area and buttock were red. Review of the resident's POS dated January 2025 showed: -Give one and one half cartons of Jevity (a calorie dense therapeutic nutrition) 1.2 calorie three times a day; -Urinary catheter (a tube placed in the body to drain the urine) care every shift related to bladder-neck obstruction; -Nothing by mouth (NPO); -Apply protective house stock barrier cream/boarder foam to Stage I (skin that appears red but does not have a break in it) buttock area every morning and night for wound healing/infection prevention; -Cleanse lower abdominal rash/abrasion with wound cleanser cover with boarder gauze (a absorptive dressing that consists of three layers) one time a day for wound care relate to cellulitis (a potentially serious bacterial skin infection) of abdominal wall; -Cleanse coccyx wound area with wound cleanser, pat dry, apply Xeroform (a non adherent dressing that maintains a moist wound) or calcium alginate (absorbs wound fluid) and cover with wound dressing. Review of the resident's care plan dated 1/27/25 showed: -He/She had a peg tube for feeding daily; -He/She had an indwelling suprapubic catheter; -NOTE: The resident did not have a suprapubic catheter, the resident had an indwelling catheter; --Staff was to change indwelling catheter as indicated; -He/She had potential impairment to skin integrity related to decreased bed mobility. Lower abdominal rash/abrasion; --Staff was to cleanse wound with wound cleanser, barrier cream, foam dressing, border gauze; -He/She had a urinary tract infection on 8/25/24; --Staff should follow good hygiene practices; -He/She had a nutritional problem or potential nutritional problem related to being NPO and having a feeding tube for feeding; -Staff was to provide and serve diet as ordered; --NOTE: The resident was NPO and was not have anything by mouth; -Staff was to have snacks available between meals; --NOTE: The resident was NPO and was not have anything by mouth. Observation on 1/30/25 at 9:10 A.M. of the resident's wound care with LPN C and LPN C showed: -The resident's anal area was reddened and had stool on it; -LPN C cleaned the stool off the resident and then changed gloves without washing his/her hands; -LPN C wiped off the old ointment; -LPN C helped to change the residents position; -LPN C did not change gloves or wash his/her hands before applying the boarder gauze; -LPN C applied zinc oxide then took off gloves and washed his/her hands. During an interview on 1/30/25 at 9:30 A.M. CMT C said: -They were not doing EBP at the facility before this week; -Staff had not had education on EBP; -He/She did not know which residents should have been on EBP; -He/She did not know what was expected of staff other than what was now on the signs; -Staff should wash their hands every time gloves were changed; -When staff do resident cares hands should be washed before and after cares. During an interview on 1/30/25 at 9:40 A.M. LPN C said: -He/She should have washed his/her hands every time he/she changed gloves. -He/She forgot to do that. -He/She had not known what EBP was before this week. -They have not had education on EBP or told what was expected or who should have been on EBP. -The resident had an indwelling catheter, a feeding tube, and open areas on his/her skin. 11. During an interview on 1/31/25 at 3:30 P.M. the DON said: -No one was responsible to ensure staff were performing appropriate hand hygiene; -He/She had not heard of EBP and was not following it; -When doing wound care staff should have washed their hands before and after cares; -Staff were expected to wash hands and change gloves when going from dirty to clean during wound care; -Staff were expected to use gloves when administering eye drops; -He/She recently learned that any resident who had a catheter, feeding tube, or open areas should have been on EBP; -There should have been a sign on the door and an isolation cart also at the door; -Residents who were on EBP was something that should have been passed on during report. MO00247709 Based on observation, interview, and record review, the facility failed to ensure five sampled residents (Resident #3, #9, #30, #39, and #37) who should have been on Enhanced Barrier Precautions (EBP), a set of infection control measures that used personal protective equipment (PPE- specialized clothing or gear worn to protect the wearer from injury, infection, or illness) to reduce the spread of multidrug-resistant organism (MDRO - bacteria or microorganisms that have become resistant to multiple antibiotics) for residents who had wounds or indwelling medical devices. The facility also failed to educate staff about EBP, failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide Tuberculosis (TB-a communicable disease that affects the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for three sampled residents (Residents #2, #9, and #109); failed to ensure staff used hand hygiene during wound care for two sampled residents, (Resident #3 and #39); and failed to wear gloves when administering eye drops to one sampled resident (Resident #39) out of 14 sampled residents. The facility identified three residents as having pressure ulcers (any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s)) not present upon admission, one resident with tube feeding (a medical device used to provide nutrition to patients who cannot obtain nutrition by swallowing), one resident with a colostomy (an alternative exit from the colon created to divert waste through a hole in the colon and through the wall of the abdomen), and three residents with a catheter (a tube passed through the urethra into the bladder to drain urine) who should have had EBP in place. The facility census was 55 residents. Review of the facility's Tuberculosis, Screening Residents policy, dated August 2019, showed: -The facility screened all residents for TB. -Individuals identified with active TB would be isolated form other residents and staff. -The admitting nurse screened new residents prior to admission and readmission for information regarding exposure to the symptoms to TB, including: --Coughing for more than three weeks. --Loss of appetite. --Fatigue. --Weight loss. --Night sweats. --Bloody sputum (a blood-tinged thick mucus from the lung). --Hoarseness. --Fever and or chest pain. -If a potential resident was exposed to active TB or at increased risk of TB infection, he/she was screened for Latent Tuberculosis Infection (LTBI) using the TB skin tests (TST- a test to detect TB completed by injecting a small amount of TB protein under the top layer of skin on your inner forearm). -The facility conducted an annual risk assessment to determine risk of exposure. 1. Review of Resident #2's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's medical record showed there was no documentation of the resident's TB testing or screening. 2. Review of Resident #9's entry tracking form showed the resident admitted to the facility on [DATE]. Review of the resident's medical record showed there was no documentation of the resident's TB testing or screening. 3. Review of Resident #109's entry tracking from showed the resident admitted to the facility on [DATE]. Review of the resident's medical record showed there was no documentation of the resident's TB testing or screening. During an interview on 1/29/25 at 8:54 A.M., Resident #109 said he/she did not remember if he/she received a TST when he/she was admitted to the facility. 4. During an interview on 1/29/25 at 10:15 A.M., Licensed Practical Nurse (LPN) A said: -New residents were supposed to get the two step TST; -The nurse on duty completed the new admissions assessments, including administering the TST; -He/She had not completed any recent TST on the residents; -The DON reviewed the new admission chart within 72 hours of admission and should have seen if the TST was completed; -If the TST was completed it would be in the residents medical file. During an interview on 1/31/25 at 4:55 P.M., the Director Of Nursing (DON) said: -The facility did the TST on each resident within 24 hours of admission; -Each test was read in 48-72 hours; -The second step of the TST was done about two weeks later; -The admitting nurse was responsible for completing the TST; -There was a form the resident completed and signed giving permission or if the resident refused; -He/She was unsure what the protocol was if the resident refused; -The administering of the TST and results should be uploaded to the resident's medical file; -He/She was unaware if anyone was tracking them. During an interview on 1/31/25 at 4:55 P.M., the Executive Director said: -Nurses knew there was a physician's order for the TST and they were supposed to administer them; -TST's and results should be documented on the MAR/TAR, as well as on a progress note; -The Electronic Health Record system generated tasks when the tests were to be completed; -If there was no documentation of the TST being administered then it was not done. During an interview on 1/28/25 at 8:42 A.M., the DON said he/she was still looking into who was responsible for doing resident TB testing/screening. 5. Review of the facility's policy, Enhanced Barrier Precautions, dated August 2022 showed: -EBPs would be used as an infection prevention and control intervention to reduce the spread of MDROs to residents. -EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. -Gloves and gown would be applied prior to performing the high contact resident care activity. -Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: --Providing hygiene. --Changing briefs or assisting with toileting. --Device care or use (urinary catheter, feeding tube. --Wound care (any skin opening requiring a dressing). -Staff would be trained prior to caring for residents on EBPs. -Signs would be posted on the door or wall outside the resident's room indicating the type of precautions and PPE required. -PPE would be available outside the resident's room. Review of Resident #9's Physician's Order Sheet (POS), dated January 2025, showed: -Treatment orders for the resident's coccyx wound were to be completed daily; -Treatment orders for the resident's right cheek wound were to be completed every Monday, Wednesday and Friday and as needed for soiling. Observation on 1/22/25 at 10:15 A.M. showed: -Staff were inside the resident's room and responded doing cares when the door was knocked on; -There were no signs on the resident's door indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares. Observation on 1/22/25 at 11:10 A.M. showed: -An unidentified staff brought a mechanical lift into the resident's room and said he/she would be right back to get the resident up; -The unidentified staff went and got another unidentified staff person, they went into the resident's room and closed the door behind them, not wearing any PPE; -There were no signs on the resident's door indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares. Observation on 1/22/25 at 11:59 A.M. showed: -There were no signs on the resident's door indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares. Review of the resident's care plan showed: -The printed care plan dated 1/24/25 provided by the facility did not include any wounds; -The care plan in the EHR showed: --No care plan for the resident's wound on his/her cheek; --The problem identified updated on 1/24/25 was the resident had a venous/stasis ulcer (open lesion caused by poor blood flow) of the coccyx. Observation on 1/24/25 at 9:25 A.M. showed: -There were no signs on the resident's door indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares. Observation on 1/27/25 at 10:08 A.M. showed: -There were no signs on the resident's door indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares. Observation on 1/27/25 at 3:06 P.M. showed: -Agency Licensed Practical Nurse (LPN) E did not wear a gown during the resident's wound treatments; -There were no signs on the resident's door indicating EBP should have been used while doing cares on them; -There were no isolation carts that held PPE to have been worn while doing cares. During an interview on 1/28/25 at 10:40 A.M., LPN B said he/she did not know anything about EBP, and the facility had not provided any education on EBP. During an interview on 1/28/25 at 10:45 A.M. Certified Nursing Assistant (CNA) E and CNA F said: -They had never heard of EBP; -They were not doing EBP at the facility; -There had been no education on EBP at the facility. During an interview on 1/30/25 at 9:30 A.M. Certified Medication Technician (CMT) C said: -They were not doing EBP at the facility before this week; -Staff had not had education on EBP; -He/She did not know which residents should have been on EBP or what was expected of staff other than what was now on the signs. During an interview on 1/30/25 at 9:40 A.M. LPN C said: -He/She had not known what EBP was before this week; -They had not had education on EBP as to what was expected or who should have been on it. During an interview on 1/31/25 at 3:30 P.M. the DON said: -He/She had not heard of EBP before and were not following it; -There should have been an EBP sign on the resident's door and an isolation cart with PPE also at the door.

Based on interview and record review, the facility failed to have anyone in the position, or performing the tasks and responsibilities of the Infection Preventionist. The facility census was 55 residents. Review of the facility's policy ,Infection Preventionist, dated September 2022 showed: -The Infection Preventionist was responsible for coordinating the implementation and updating of the infection prevention and control program. -The Infection Preventionist collects, analyzes and provides infection and antibiotic usage data and trends to nursing staff and health care practitioners. -The Infection Preventionist has obtained specialized training beyond initial professional training or education prior to assuming the role including antibiotic stewardship. -The Infection Preventionist was employed on site and at least part time. 1. During an interview on 1/31/25 at 10:00 AM the Administrator said: -There was currently no one in the role of the Infection Preventionist. -They have not had an Infection Preventionist at the facility for years. -The Infection Preventionist would be responsible for monitoring, tracking infections, antibiotic usage, monitoring Transmission Based Precautions, and Enhanced Barrier Protection (a set of infection control measures that use personal protective equipment (PPE- specialized clothing or gear worn to protect the wearer from injury, infection, or illness) to reduce the spread of multidrug-resistant organism (MDRO - bacteria or microorganisms that have become resistant to multiple antibiotics) for residents who had wounds or indwelling medical devices) and education of staff and resident regarding infections, antibiotic usage, and the use of Transmission Based Precautions and Enhanced Barrier Protection. During an interview on 1/31/25 at 3:30 P.M. the Director of Nursing (DON) said: -There should have been an Infection Preventionist at the facility. -There was not anyone in the role of Infection Preventionist at this time. -No one was performing the tasks or responsibilities of the Infection Preventionist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to account for one sampled resident (Resident #1) funds within 30 days of the resident's death and to return the funds to the designated family members out of three sampled residents. The facility census was 55 residents. Review of the facility's Resident Trust Policy and Procedures dated 3/23 showed: -The following must be adhered to by the resident trust clerk upon the death of a resident who received aid or assistance from the Department of Social Services: -The operator shall submit in writing on form MO [PHONE NUMBER] a complete accounting of the resident remaining personal funds. This must be submitted within 30 days from the date of the resident's death; and also included on this form should be the name and address of the resident's guardian, conservator, legal representative or fiduciary of the resident's estate. -None of the resident's funds shall be distributed or spent until the operator has fully complied, except funeral expenses may be paid from a resident's personal funds held by the facility if no other funds are available to cover the cost. -The operator should provide the fiduciary of the resident's estate, at his/her request, all personal possessions and funds along with their complete accounting records. This must be submitted within 30 days of the resident's death, and included on this form should be the name and address of the resident's guardian, conservator, legal representative or fiduciary of the resident's estate. 1. Review of Resident #1's admission Record face sheet showed the resident was admitted to the facility on [DATE]. Review of Business Office Manager (BOM) A's written statement dated [DATE] showed: -Back in possibly [DATE] a refund was due for the resident of $7279.74. -He/She made the resident's Durable Power of Attorney (DPOA) aware of this. -The resident's DPOA wanted the money donated to the facility. -He/She explained the money would go to the whole company and not just that facility location. -He/She advised the DPOA he/she could always cash it and bring the cash in. -The DPOA allowed him/her to have the money as a donation because he/she had spent so much time with the resident. Review of the Administrator's investigation account of events dated [DATE] showed: -On [DATE] at approximately 1:00 P.M., BOM A came into his/her office and shut the door to speak to him/her. -BOM A said, I need to come clean about something. The resident passed away in February and had an overpayment on his/her account. The family wanted to donate the money, but since it would not go directly to this facility, the family member said for BOM A to keep it because he/she spent a lot of time with the resident and the resident family. BOM A wrote the check out to his/herself. During a telephone interview on [DATE] at 11:00 A.M., BOM A said: -He/She had an attorney who did not want him/her to talk to anyone. -He/she was unwilling to discuss his/her responsibilities and or expectations referencing his/her attorney had advised him/her to say no more. During an interview on [DATE] at 10:30 A.M., the Administrator said: -The resident died in February 2024. -The money was a refund, so it should have been sent to the family within 30 days per the facility policy. It was an overpayment. -BOM A's position was oversight of the residents' money. His/her direct supervisor was the Administrator-In-Training (AIT). -BOM A stated the family wanted him/her to have the money. -The resident's statement dated [DATE] showed the money was still owed to the family. During an interview on [DATE] at 11:55 A.M., the AIT said: -He/She was the Administrator with a temporary license from June until [DATE]. -Facilities were responsible for managing their own books. -He/She had never dealt with business office duties before. -BOM A was the business office manager at the time. -Every month the BOM was responsible to go through and audit accounts payable. When the audit was completed it was sent to the the corporate office. -The resident money had been in the account since February 2024. -He/she did not know why the money had not been noticed. -BOM A was supposed to send a request to the corporate office for a refund to be sent to the resident's family within 30 days after the resident's death and that was not done. -He/She did not know if anyone had contacted the family or not. -Families were not allowed to give staff money or gifts. During a telephone interview on [DATE] at 4:47 P.M., the DPOA said: -He/She got a phone call from BOM A on [DATE] telling him/her about the money. -He/She was not sure where the money came from at the time. -BOM A suggested the money be donated to the facility or given to him/her. -He/She never told BOM A either to donate the money to the facility or keep the money. When BOM A suggested it, he/she said nothing, because he/she was not sure what the laws and procedures would be for this. -The family had still not received their money or heard from the facility. During an interview on [DATE] at 10:53 A.M., the [NAME] President of Health Care Administration said: -The refund was due back to the family within 30 days after the resident's death. The money would have been in the operations account, not the resident trust account. -He/She did not oversee that facility until [DATE]. For the first 30 days he/she was trying to sort out the finances. He/She reported to the company Chief Financial Officer (CFO). -At the end of every month, the facilities were supposed to run their own financial's. -He/She would review the statements and the business software information to see if they matched. They had to do transactional analysis. Any discrepancies had to be accounted for. Everything had to have matching numbers. -He/She could not get deposit details from BOM A for several months. He/She asked numerous times and the Administrator was included on these conversations. -BOM A's direct supervisor would have been the Administrator. -Starting with the end of [DATE], he/she could not get answers from BOM A, so he/she spent 45 days teaching him/her what was needed, and even spent time with him/her at the facility to help him/her. -He/She did not know if BOM A had gotten any other resident's money, as he/she is still going back through resident's accounts. -Refunds were to be processed within 30 days. [NAME] was sent for pre-billing for the next month's room and board. The check would go into the operations account. -If a resident died, it took about 5 days to make sure they had all the charges and those got posted to the account. The BOM should send a copy of the statement, transaction report and check request for the refund and all the amounts should match. If there were no issues, it would be sent on the AP to send the refund. -Check requests should go through AP, but he/she did not know if the facility followed this. -If the process was not followed, he/she could not monitor the accounts. -When he/she tried to get account information from BOM A, he/she either did not take calls, constantly delayed or canceled meetings. MO00244744

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the misappropriation of one sampled resident's (Resident #1) monies when Business Office Manager (BOM) A wrote a check in the amount of $7279.74 to him/herself from the resident trust account out of three sampled residents. The facility census was 55 residents. Review of the facility's Check Signing and Management Policy dated 8/23 showed: -All checks and orders for the payment of money greater than $5000.00 must be signed by 2 approved signers as designated by board resolution. -In no case may one of the signatures be the same as the payee. Review of the facility's Resident Trust Policy and Procedures dated 3/23 showed: -The following must be adhered to by the resident trust clerk upon the death of a resident who received aid or assistance from the Department of Social Services: -The operator shall submit in writing on form MO [PHONE NUMBER] a complete accounting of the resident remaining personal funds. This must be submitted within 30 days from the date of the resident's death; and also included on this form should be the name and address of the resident's guardian, conservator, legal representative or fiduciary of the resident's estate. -None of the resident's funds shall be distributed or spent until the operator has fully complied, except funeral expenses may be paid from a resident's personal funds held by the facility if no other funds are available to cover the cost. -The operator should provide the fiduciary of the resident's estate, at his/her request, all personal possessions and funds along with their complete accounting records. This must be submitted within 30 days of the resident's death, and included on this form should be the name and address of the resident's guardian, conservator, legal representative or fiduciary of the resident's estate. 1. Review of Resident #1's admission Record face sheet showed the resident was admitted to the facility on [DATE]. Review of the [NAME] County Medical Examiner's Report of Death dated [DATE] showed he/she died on [DATE]. Review of facility check #2139 dated [DATE] in the amount of $7279.74 showed: -The check payee was originally made out to the resident's Designated Power of Attorney (DPOA) with the residents' name in the memo. -The check had white out and the payee name was changed to BOM A. -The check was endorsed on back by BOM A. Review of the facility's statement dated [DATE] showed: -The resident had a credit of $7279.74. -The resident was due a refund effective [DATE] for overpayment in the amount of $7,279.74. Review of the Police Report dated [DATE] showed: -The president of the facility contacted the police. -BOM A and had written a check to him/herself in the amount of $7,279.74 and cashed it. -The money was to have been paid to the family of the resident who had died the previous February. -The check had the signature of the retired vice president (VP) on it, who said he/she did not recall signing it and would not have, because it was made out to an employee. -BOM A was confronted with the theft and claimed the check was authorized via the deceased resident's family, and he/she would pay it back by Friday [DATE]. -The Administrator stated check #2139 was caught as an out of sequence check and was written to BOM A as the Director of Business and Accounts Receivable. BOM A was authorized to write checks, however was not authorized to write them to him/herself. BOM A admitted to having written and cashed the check. BOM A told the Administrator the resident's family wanted BOM A to have the money and authorized it. -The Administrator informed the officer of laws governing nursing homes and that BOM A was not allowed to accept monies from clients, and stated they wanted to prosecute for the theft. -The content of the check showed it to be dated [DATE] and made payable to BOM A. There was an authorizing signature from the VP on it. It was endorsed on the back by BOM A with a signature matching the signature on his/her driver's license. -In comparing the writing on the check for the vice president's signature with BOM A's signature on his/her driver's license, the writing appeared to match which would indicate BOM A forged the signature on the check. -BOM A's office was near the facility's main entrance. A facility staff person took the officer to BOM's office where he/she was supposed to be working. They unlocked the door and on the floor was a letter written by BOM A where BOM A admitted to receiving the monies as a donation because BOM A had spent so much time with the resident that had passed away. It also stated the family wanted the money donated to the business and allowed BOM A to keep it when BOM A explained the money would go to other locations if donated to the business. -BOM A had left the facility unexpectedly after the officers arrived on the scene. -BOM A's spouse also worked at the facility as the activities director. He/she contacted BOM A by telephone and convinced him/her to return to the facility. He/She claimed they had separate financial institutions and he/she was unaware of the theft. -BOM A returned to the facility and was taken into custody without incident and taken to detention and placed on a 24-hour hold. -The retired VP was contacted by telephone, and stated he/she had retired on [DATE] which was a Sunday. He/She would not have signed the check because he/she was out of town that day and not on-site. He/She also was positive he/she would not have signed the check because it was written out to an employee and that was a huge violation for them. A screen shot of the check was mailed to him/her and he/she confirmed it was not his/her signature. Review of BOM A's written statement dated [DATE] showed: -Back in [DATE] a refund was due for the resident of $7279.74. -He/She made the resident's DPOA aware of this and the resident's DPOA wanted the money donated to the facility. -He/She explained the money would go to the whole company and not just that facility location. -He/She advised the DPOA he/she could always cash it and bring the cash in. -The DPOA allowed him/her to have the money as a donation because he/she had spent so much time with the resident. -He/She took pride in watching over the resident. -The money would be returned to the facility on [DATE]. Review of the facility's Disciplinary Action Report dated [DATE] for BOM A showed he/she was terminated on that date for violation of the facility's gratuity gift policy, and he/she was expected to not accept gratuities from residents or families and not to embezzle funds from the corporation or residents. Review of the Administrator's investigation dated [DATE] showed: -On [DATE] at approximately 1:00 P.M., BOM A came into his/her office and shut the door to speak to him/her. -BOM A said, I need to come clean about something. A resident had passed away in February with an overpayment on his/her account. The family wanted to donate the money, but since it would not go directly to this facility, the family member said for him/her to keep it because he/she spent a lot of time with the resident and his/her family. He/she wrote the check out to him/herself and the VP signed the check after he/she explained the situation to him/her. -He/She questioned BOM A if he/she realized it was against policy to accept this from the family. -BOM A stated he/she did know it was against policy, which was why he/she decided to come clean about it that day. He/She said he/she could bring the money back in a few days. -He/She asked if the VP signed it without questioning it, and the VP was ok with the check made out to BOM A. -He/She called the president, which happened at the same time the corporate office found out about the situation. He/She explained the conversation and was sent a copy of the check so he/she could see who signed the check. He/She then pulled BOM A and his spouse's signatures from their driver's licenses. The signature was an exact match to BOM A's. -On [DATE] he/she received a call from the president and was asked to pull the Administrator-In-Training (AIT) to the call. Other corporate officers were on the call and advised the police had been called and would be to the facility shortly. The VP had stated he/she did not sign the check, so the situation had escalated. -He/She had accompanied the police officers to BOM A's office, which was locked. He/She go the master key and unlocked it, where they found a note, which he/she took for his/her personnel records and gave a copy to the police. During a telephone interview on [DATE] at 11:00 A.M., BOM A said: -He/She had an attorney who did not want him/her to talk to anyone. -He/She thought the bank took the money back and gave it to the facility the next day, so now he/she owed the money to his/her bank. During an interview on [DATE] at 10:30 A.M., the Administrator said: -The resident died in February 2024. -The money was a refund, so it should have been sent to the family. It was an overpayment. -BOM A's position was oversight of residents' money. His direct supervisor was the AIT. -He/She got a call from the corporate office that a check had cleared the bank that was made out to BOM A. -Accounts payable reached out to BOM A and this was when BOM A called back with his/her side of the story. -BOM A said he/she was going to fess up, he/she was bringing the money back and would give his/her two-week notice on [DATE]. -BOM A stated the family wanted him/her to have the money. BOM A told accounts payable he/she accidentally wrote BOM A's name on the check instead of the family's name. -This would have been cause for immediate termination, as he/she had been educated about not taking gifts. BOM A said he/she should not have taken the money, but the family insisted. -The check was created on [DATE], but not cashed until [DATE]. -Resident statement dated [DATE] showed the money was still owed to the family. -[DATE] it was found the VP signature on the check had been forged. -BOM A wrote out the resident's family member's name and put his/her own name on it. -The check was cashed with BOM A's name on it. -The police were contacted and arrested BOM A on Wednesday, [DATE]. -They did not get the money back and did not reach out to BOM A due to the police investigations. -The police were reaching out to the family and told him/her the facility should not do anything else. Nobody at the facility had talked to the family, since the police told them not to. BOM A was immediately terminated. During an interview on [DATE] at 11:55 A.M., the AIT said: -He/She was the Administrator, with a temporary license, from June until [DATE]. -Every month the business office manager should go through and audit accounts payable and then send the accounts payable to the corporate office. -The training he/she had was from the facility policy handbook and he/she had common sense. -BOM A also had the same training and would have had more intense training when he/she was hired. He/she also had a corporate person helping him/her in January. -The money sat in the account from February 2024 until [DATE]. -The accounts payable corporate officer discovered the check had been written and cashed. -The former administrator should have been responsible for oversight of BOM A. The auditing was done in the corporate office by the corporate business manager, this position was eliminated, until the [NAME] President of Health Care Administration became responsible in June. -BOM A was supposed to send a request to the corporate office for a refund to be sent to the resident's family within 30 days after the resident's death and that was not done. -He/She did not know if anyone had contacted the family or not. -Families were not allowed to give staff money or gifts. During a telephone interview on [DATE] at 4:47 P.M., the DPOA said: -He/She got a phone call from BOM A on [DATE] telling him/her about the money. -He/She was not sure where the money came from at the time. -BOM A suggested the money be donated to the facility or given to him/her. -He/She never told BOM A either to donate the money to the facility or keep the money. When BOM A suggested it, he/she said nothing, because he/she was not sure what the laws and procedures would be for this. -BOM A confessed to him/her that he/she had white out the name on the check and written it to him/herself. -The family had still not received the money or heard from the facility. During an interview on [DATE] at 10:53 A.M., the [NAME] President of Health Care Administration said: -The refund was due back to the family within 30 days after the resident's death. The money would have been in the operations account, not the resident trust account. -He/She did not oversee the facility until [DATE]. For the first 30 days he/she was trying to sort out the finances. He/She reported to the company Chief Financial Officer (CFO). -At the end of every month, the facilities were supposed to run financial's. -He/She would review the statements and the business software information to see if they matched. They had to do transactional analysis. Any discrepancies had to be accounted for. Everything had to have matching numbers. -He/She could not get deposit details from BOM A for several months. He/She asked numerous times and the administrator was included on the conversations. -BOM A's direct supervisor would have been the administrator. -At the end of [DATE], he/she could not get answers from BOM A, so he/she spent 45 days teaching BOM A what was needed, and even spent time with BOM A at the facility to help him/her. -Refunds were to be processed within 30 days. [NAME] was sent for pre-billing for the next month's room and board. The check would go into the operations account. -If a resident died, it took about 5 days to make sure they had all the charges and those got posted to the account. The BOM should send a copy of the statement, transaction report and check request for the refund and all the amounts should match. If there were no issues, it would be sent on the accounts payable to send the refund. -Check requests should go through accounts payable. -If the process was not followed, he/she could not monitor the accounts. -When he/she tried to get account information from BOM A, BOM A did not take calls, delayed or canceled meetings. MO00244744

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide care in a respectful and dignified manner when Certified Nursing Assistant A (CNA) forcefully pushed Resident #1 into his/her recliner out of three sampled residents. The facility census was 55 residents. On 4/22/24, the Administrator were notified of the past noncompliance (PNC) for an incident that occurred on 4/15/24. The facility administration had all staff in-serviced on abuse and neglect, customer services, resident rights and dignity. The deficiency was corrected on 4/15/24. Review of the facility policy titled Dignity, dated 2/2001 showed: -Residents are treated with dignity and respect at all times. -The facility culture supports dignity and respect for residents by honoring resident goals, choices preferences, values and beliefs. -Individual needs and preferences of the resident are identified through the assessment process. -When assisting with care, residents are supported in exercising their rights, such as: --Groomed as they wish to be groomed (hair styles, nails, facial hair, etc). --Encouraged to attend the activities of their choice, including religious, political, civic, recreational or social activities. --Allowed to choose when to sleep, eat and conduct activities of daily living (ADL's - those activities that people perform every day, such as eating, dressing and hygiene). --Staff do not handle or move a resident's personal belongings with the resident's permission. -Staff promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. -Demeaning practices and standards of care that compromise dignity are prohibited. -Staff are expected to promote dignity and assist residents; for example: -Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: --Addressing the underlying motives or root causes for behavior, and not challenging or contradicting the residents beliefs or statements. 1. Review of Resident #1's facility face sheet showed the resident admitted to the facility on [DATE] with the following diagnoses: -Congestive Heart Failure (a chronic condition in which the heart doesn't pump blood as well as it should). -Meniere's Disease (a disease of the inner ear that can cause a person to get dizzy and have trouble hearing). -Alzheimer's Dementia (a progressive disease that destroys memory and other important mental functions). -Pain. -Anxiety. -Age related Physical Debility. -Depression. -Mood Disturbance (a type of mental health condition where there is a disconnect between actual life circumstances and the persons state of mind or feeling). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool that facilities use for care planning) dated 2/13/24 showed: -The resident has severe cognitive impairment. -He/she requires assist of one staff for all activities of daily living. Review of the resident's care plan dated 2/28/19 showed: -The resident is dependent on staff for meeting emotional, intellectual, physical and social needs. -The resident has an Activity of Daily Living (ADL) self-care performance deficit related to Alzheimer's dementia, limited mobility and pain. -The resident has impaired cognitive function/dementia or impaired thought processes related to diagnoses. -The resident is high risk for falls related to deconditioning, incontinence, poor communication/comprehension, unaware of safety needs, leaves walker behind when ambulating. Review of the facility investigation dated 4/15/24 showed: -Persons involved in the incident were Resident #1 and CNA A. -Witnesses were the family via observation on video from video camera in the resident's room. -Family observed CNA A on video to be physically aggressive with the resident during cares. -CNA A rushed the resident into his/her recliner and appeared to push him/her into recliner with too much force. -The local police department was notified. During an interview on 4/17/24 at 10:00 A.M., Local Police Department said: -The CNA was assisting Resident #1 to his/her room and then the CNA backed up and shoved Resident #1 into his/her chair and closed the door and just left him/her in the room. -Resident #1 was turning around to sit down and was too slow and the CNA shoved him/her in the chair. -Family came to visit the resident, and resident was upset but couldn't vocalize the problem and the family watched the video and saw the incident. Observation of the video on 4/22/24 showed: -CNA A and Resident #1 entering the resident's room, with CNA A behind Resident #1, with his/her hand on the resident's back, while Resident #1 was walking with a walker. -CNA A was guiding the resident to the recliner in a rough manner, by pushing the resident forward. -When the resident reached the recliner, CNA A moved his/her hand to turn the resident around, while pushing the resident into the recliner. -The resident landed in the recliner with a hard landing. -The resident had a facial expression of confusion, while the CNA left the room. During an interview with Resident #1 on 4/22/24 at 11:45 A.M., he/she said: -He/she is fine, how are you? -Yes, everyone treats him/her very well here, thank you. -No, he/she doesn't think anyone was every rough with him/her. -He/she shakes head no, when asked if he/she remembers the incident with CNA A. During an interview with the Administrator on 4/22/24 at 12:05 P.M., he/she said: -He/she doesn't want CNA A working here with the residents. -He/she plans on terminating the CNA regardless of the outcome of State Agency (SA) investigation. -He/she watched the video that the family of Resident #1 sent him via email, and thought what if that was his/her mother? -He/she couldn't tolerate having residents treated in that manner. During an interview with CNA A on 4/22/24 at 1:30 P.M., he/she said: -He/she doesn't remember the incident really at all. -He/she wouldn't ever want to hurt anyone, or cause them to feel bad. -He/she may have just been in a hurry, but doesn't really remember at all. During an interview on 4/23/24 at 9:20 A.M., Resident #1's Durable Power of Attorney (DPOA) said: -If he/she didn't have the diagnoses of Alzheimer's dementia, and could remember things, he/she would have been furious at that CNA treated him/her. -He/she has no doubt in his/her mind that the resident would have been very mad and very hurt by how the CNA treated him/her. -The family did make the decision to not press charges against the CNA. MO00234815

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective infection control program that included tracking and trending of facility resident infections and to use proper hand hygiene between glove changes; to ensure perineal care was completed per facility policy to prevent Urinary Tract Infections(UTI) and placed soiled linen directly on floor for one sampled resident (Resident #7) out of three sampled residents. The facility census was 59 residents. 1. Review of the facilities policy Surveillance for Infections revised 9/2017 showed: -The Infection Preventionist (IP) will conduct ongoing surveillance for healthcare-associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. -The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and prevent future infections. Review of the facility infection surveillance dated 2/1/23 - 2/1/24 showed: -The facility had no information regarding or record of analysis of infection data including no trends/patterns in location /types/rates of infection and no comparison of previous months/years infection data. Review of the facility policy Perineal (area between the thighs that marks the boundary of the pelvis and is occupied by the urinary and genital ducts and rectum) Care for Incontinent Residents not dated showed: -Collect your equipment. -Wash hands and put on a clean pair of gloves. -Put your patient on their back or side. -Place clean towel under their hips. -Use a sheet to cover your patient for modesty. -Expose their perineal area. -Start with patients inner thighs to gently cleanse the area. -Clean outer and work inwards. -Use front to back technique. -Use a clean area of the washcloth for each stroke. -Use a clean towel to gently pat dry the areas that you cleaned. -Remove towel. -Remove and dispose of your equipment. -Take off your gloves and wash your hands. -Assist patient into a comfortable position. Review of the facility policy Linen Disposed of Properly not dated showed: -Always follow proper hand washing procedure. -Always wear reusable rubber gloves before handling soiled linen. -Never carry soiled linen against body. Always place it in the designated container. -Never place soiled linen on the floor. -Carefully roll up soiled linen to prevent contamination of the air, surfaces, and cleaning staff. Do not shake linen. -If there is any solid excrement on the linen, such as feces or vomit, scrape it off with a flat, firm object and put it in the commode or designated toilet/latrine before putting linen in the designated container. -Place soiled linen into a clearly labeled, leak-proof container (e.g. bag, bucket) in the patient care area. Do not transport soiled linen by hand outside the specific patient care area from where it was removed. -Reprocess (i.e., clean and disinfect) the designated container for soiled linen after each use. 1. Review of Resident #7's face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Need for assistance with personal care. -Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that block airflow and make it difficult to breath). -Communication deficit Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool completed by the facility staff for care planning), dated 1/30/24 showed: -He/She was cognitively impaired. -He/She needed set-up or clean up assistance with toileting. -He/She was frequently incontinent of bladder. -He/She was occasionally incontinent of bowel. During an interview 2/13/24 at 9:30 A.M., Licensed Practical Nurse (LPN) A said: -He/She had worked at the facility since 8/2023. -He/She had no recent perineal care training. -He/She believed urinary tract infections had increased. Observation on 2/13/24 at 10:52 A.M., of the resident's perineal care by Certified Nursing Assistant (CNA) A showed: -He/She used one perineal cleansing wipe when wiping front to back five swipes without using a new surface or replacing the perineal cleansing wipe. -He/She had removed gloves and had not washed his/her hands, touched the resident door handle to go and retrieve clean linen from the clean linen closet. -He/She had put soiled linen directly on the resident floor without a barrier. During an interview 2/13/24 at 11:15 A.M., the CNA A said: -He/She has worked for facility since 10/2023. -He/She had perineal care training upon hire to the facility. -He/She should had used a clean part of the wipe with each wipe. -He/She should had wash hands every time his/her soiled gloves are removed and prior to leaving the resident room. -He/She should have not place soiled linen directly on the floor. During an interview 2/13/24 at 11:30 A.M., the Director of Nursing (DON) said: -He/She was new DON at the facility since 12/2023. -He/She was not aware that infection monitoring had not been tracked for past year and it would be his/her responsibility to ensure it was completed. -He/She was not aware the facility percentage of urinary tract infections was above average. -He/She had not given recent perineal care training to nursing staff. -He/She would expect soiled linen to placed in a bag and not directly on the floor. -He/She would expect staff to wash hands prior to leaving a resident room and after removing soiled gloves. MO 00231711

Based on interview and record review, the facility failed to have an antibiotic stewardship program that addressed antibiotic use protocols and a system to monitor antibiotic use. The facility census was 59 residents. Review of the facility's policy Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcomes revised 12/2016 showed: -Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. -As part of the facility antibiotic stewardship program, all clinical infections treated with antibiotic will undergo, review by the Infection Preventionist (IP), or designee. -The IP or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. 1. Review of the facility's 2/1/23-2/1/24 Antibiotic Stewardship Program (ASP) showed no documentation the facility was utilizing an ASP. During an interview on 2/13/24 at 11:30 A.M., the Director of Nursing (DON) said: -He/She was hired 12/2023 and a new DON. -He/She was not aware that the facility needed an ASP and thought pharmacy had kept tract of antibiotics related to infections. -He/She would be getting his/her IP certification and was not sure who was doing the IP tasks currently. -He/She would be responsible to audit that ASP is being done per facility policy. During an interview on 2/13/24 at 11:45 A.M., the Administrator said: -He/She was unable to locate ASP documentation. -The former Minimum Data Set (MDS- a federally mandated assessment tool completed by facility staff for care planning) Coordinator whose last day was 2/12/24 was the facility IP and responsible for the ASP. -The Corporate Nurse will start 2/14/24 as facility IP and MDS Coordinator and would be responsible for the ASP. MO 00231711

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have an authorization form signed by the Public Administrator (PA- a court appointed Personal Representative guardians and/or conservators for individuals who are unable to care for themselves or their property and in cases when there is no one else available to serve) for one sampled resident (Resident #2) and to have a legible authorization form for one sampled resident (Resident #1) out of four residents who were sampled for the purposes of reviewing the resident fund procedures at the facility. The facility census was 55 residents. 1. Review of Resident #2's resident fund paperwork showed: - Court Documents dated 2/8/16, from the local county circuit court, which stated the resident was appointed the Public Administrator as the guardian for the resident. - The above named guardian and conservator is authorized and empowered to perform the duties of guardian and to perform the duties of conservator as provided by law, under the supervision of the court having the care and custody of the person and estate of the above-named incapacitated and disabled person. - The absence of an authorization form for the facility to manage his/her funds, signed by the Public Administrator. During an interview on 6/2/23 at 1:40 P.M., the Business Office Manager (BOM) said the resident's authorization from the PA's office could not be found. During an interview on 6/5/23 at 9:13 A.M., the BOM said: - The resident has been at facility since 2005. - He/she and the Corporate BOM spent 5 hours on 6/2/23, by looking in the resident's overflow files and found no authorization forms signed by the Resident's PA. 2. Review of Resident #1's resident fund paperwork showed: - An undated document entitled Patient Financial record which showed the resident was admitted on [DATE] the resident's date of birth and a bar code (an image of lines (bars) and spaces that is affixed to retail store items, identification cards and postal mail to identify a particular product number, person or location). - The absence of a signed authorization by the resident. During an interview on 6/2/23 at 1:46 P.M., the Corporate BOM said the authorization form for the resident did not show pertinent information such as signatures. During an interview on 6/5/23 at 9:07 A.M., the BOM said they were using the scan technology at that time (circa 2014) for the authorizations. Currently the facility did not have the technology to read the scan code on the resident's authorization from back in 2014.

Based on interview and record review, the facility failed to list transactions for May 2023 on the ledger sheet of one sampled resident (Resident #1) out of four residents sampled for the purposes of reviewing the resident fund procedures at the facility. The facility census was 55 residents. 1. Review of the Resident #1's ledger sheet printed on 6/2/23 showed: -He/she had a balance of $6,890.67 on 5/4/23. - No transactions for the month of May 2023 were listed on the ledger sheet. During an interview on 6/5/23 at 9:04 A.M., the Business Office Manager (BOM) said he/she missed entering in the resident's transactions for 5/23, by failing to take out the payment for 5/3/23 and he/she took out two payments for 5/23 and 6/23, on 6/2/23.

Based on interview and record review, the facility failed to notify one sampled resident (Resident #1) and/or the resident's responsible parties, of the resident's resident fund balances remaining above $5,101.85 (the limit which should trigger a notification) for the months of 2/23, 3/23, 4/23 and 5/23. Four residents were sampled for the purposes of reviewing the resident fund procedures at the facility. The facility census was 55 residents. 1. Review of Resident #1's ledger sheet printed on 6/2/23 showed the following balances for the following months: - On 2/28/23, the resident's fund balance was $5,153.76. - On 3/7/23, the resident's fund balance was $5,399.76. - On 4/17/23, the resident's fund balance was $5,533.97. - On 5/4/23, the resident's fund balance was $6,890.67. Further review, showed the absence of notifications that the resident was within $200 of over the limit. During an interview on 6/5/23 at 8:47 A.M., the Business Office Manager (BOM) said he/she: - Did not know what the amount of the balance a resident had to have in order for notification to that resident or the responsible parties to take place. - Did not find out the limit which would cause a notification to the resident and/or responsible parties, to be issued, until 6/2/23. - Has skimmed through some regulations but was not was really familiar with the regulations which pertained to resident funds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate assessment and monitoring for one sampled resident (Resident #42) who utilized a seatbelt when sitting in his/her wheelchair out of 16 sampled residents. The facility census was 55 residents. Review of the facility's policy titled Identifying Involuntary Seclusion and Unauthorized Restraint: dated September 2022 showed: -Physical restraint is defined is defined as any manual method, physical, or mechanical device, equipment, or material that meets all of the following criteria: --Is attached or adjacent to a resident's body. --Cannot be easily removed by the resident (in the same manner as it was applied by the staff). --Restricts the resident's freedom of movement or normal access to his/her body. 1. Review of Resident #42's undated face sheet showed he/she admitted to the facility with the following diagnoses: -Other non-traumatic intracerebral hemorrhage (a subtype of stroke in which a hematoma is formed within the brain). -Quadriplegia, unspecified (paralysis of all four limbs). Review of the resident's Motorized Wheelchair assessment dated [DATE] showed: -The resident was deemed safe to use his/her motorized wheelchair. -The resident had muscular spasms at times that would cause involuntary movement or of the wheelchair, must wear seat belt. Review of the resident's Motorized Wheelchair assessment dated [DATE] showed: -The resident was deemed safe to use his/her motorized wheelchair. -The resident had muscular spasms at times that would cause involuntary movement of his/her wheelchair. Review of the resident's quarterly Minimum Data Set (MDS- a federally required assessment tool completed by facility staff for care planning) dated 11/17/22 showed: -The resident was cognitively intact. -The assessment was marked no for the use of any restraint. Review of the resident's quarterly MDS dated [DATE] showed the assessment was marked no for the use of any restraint. Review of the resident's Motorized Wheelchair assessment dated [DATE] showed: -The resident was deemed safe to use his/her motorized wheelchair. -The resident had muscular spasms at times that would cause involuntary movement or of the wheelchair, must wear seat belt. Review of the resident's care plan dated 3/14/23 showed: -No specific care area related to the use of his/her seatbelt. -The resident had a care area related to falls with an intervention for the use of the seatbelt related to fall from 11/26/22. -The resident had a care area related to Activities of Daily Living (ADLs) care with an intervention for the resident to use his/her seatbelt when in his/her motorized wheelchair. Review of the resident's Physician Order Sheet (POS) dated May 2023 showed no order for the use of a seatbelt. Continuous observation started on 6/1/23 at 12:12 P.M. showed the resident was in the dining room with his/her seatbelt on. During an interview on 6/1/23 at 12:13 P.M. the resident said he/she was not able to remove the seatbelt by his/herself. During an interview in the resident's room on 6/1/23 at 1:14 P.M. the resident said: -He/she used the seatbelt so he/she did not fall out of his/her wheelchair. -Due to his/her quadriplegia he/she had muscle spasms and the seatbelt kept him/her safe. -He/she felt the staff checked on him/her frequently enough to release him/her from the seatbelt. Observation on 6/1/23 at 2:14 P.M. of the resident showed: -The seatbelt had not been released from the resident since he/she had come back to his/her room from lunch. -No staff had checked on him after returning to his/her room from lunch. Observation on 6/1/23 at 3:03 P.M. of the resident showed two staff members greeted the resident, but did not enter the resident's room or physically check on the resident. Observation on 6/1/23 at 3:14 P.M. showed no one had released the resident from the seatbelt. During an interview on 6/5/23 at 11:07 A.M. Certified Nursing Assistant (CNA) B said: -The resident wears a seatbelt for his/her safety because he/she had fallen out of his/her wheelchair. -He/she would check on him frequently to prevent the resident from falling. -He/she had only released him/her from the seatbelt when the resident was getting put into bed. -The resident had not indicated to him/her that he/she was uncomfortable, but the resident was capable of telling him/her of the resident needs. -He/she was unsure if the seatbelt was in the resident's care plan, but had did not really look at resident care plans. -The resident's spouse was the person who was adamant about the use of the seatbelt and that should be mentioned in the resident's chart somewhere. During an interview on 6/5/23 at 11:32 A.M. Licensed Practical Nurse (LPN) A said: -The resident wear a seatbelt for safety. -He/she checked on him every two hours to release the resident from the seatbelt. -He/she reminded the CNA's to release the resident from the seatbelt. -There should be an order in place for the use of the seatbelt if it is a restraint. -The use of a restraint should also be in the resident's care plan. -The resident's spouse preferences should also be in the resident's care plan. -He/she knew a restraint assessment was needed in order for the resident to have the continued use of the restraint. -He/she thought the restraint assessment should be done quarterly. -If he/she thought the restraint was no longer needed or a new assessment was needed he/she would notify the MDS nurse. During an interview on 6/5/23 at 12:52 P.M. the Director of Nursing (DON) said: -Any resident with a restraint should have an order for it. -An assessment should be completed to ensure the resident still needed to restraint. -He/she thought restraint assessments needed to be completed quarterly. -The resident should be checked on every two hours and the restraint needed to be released. -The use of a restraint should be in the resident's care plan and thought it was on the resident's care plan. -The use of restraints should be included in the resident's MDS. -He/she would be the person responsible for ensuring all restraint documentation was in place and completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a thorough investigation of a resident's bruise of unknown origin and a left arm fracture to rule out abuse and neglect for one sampled resident (Resident #1) out of 16 sampled residents. The facility census was 55 residents. Review of the facility's policy, dated July 2017, titled Accidents and Incidents-Investigating and Reporting showed the following information was to be included in the investigation report: -The date and time the incident took place. -The nature of the injury. -The circumstances surrounding the accident or injury. -Where the accident or incident took place. -The names of witness and their account of the accident or injury. -The condition of the injured person, including their vitals (essential body functions, including heartbeat, breathing rate, temperature, and blood pressure). -Any corrective action taken. -Follow-up information. -Other pertinent data as necessary or required. 1. Review of Resident #1's face sheet showed he/she was admitted on [DATE] with muscle weakness and reduced mobility. Review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 3/2/23, showed the resident was totally dependent on staff for transfers. Review of the resident's Progress Notes, dated 5/29/23, showed: -Agency Licensed Practical Nurse (LPN) A documented at 7:45 P.M. that an unnamed Certified Nursing Assistant (CNA) had reported the resident had a skin tear to his/her right forearm and bruising on is/her left arm; the LPN notified the physician, Director of Nursing (DON), and family. -The MDS Coordinator documented at 9:26 P.M. that an unnamed night time CNA had put the resident to bed and saw a large bruise on the resident's left arm and a skin tear on the resident's right forearm which had dried blood present; he/she educated staff on abuse reporting and neglect; and the charge nurse had interviewed staff and residents with no additional findings. Review of the resident's X-Ray report, dated 5/29/23, showed: -The physician determined the resident had suffered an acute (sudden onset) impacted (tightly wedged) humeral surgical neck (the humerus neck is at the top of the humerus (upper arm) bone) fracture (a break in the bone). Review of the facility's Resident Abuse Investigation Report Form, dated 5/30/23, showed: -The facility documented staff members had provided written statements. -The facility documented staff attempted to interview the resident and the resident was unable to communicate how he/she was injured. -The Administrator, physician, family, and state agency had been notified of the incident. -The facility's Summary of Findings indicated the resident was frail, had osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), and used a Hoyer (brand of mechanical lift) for transfers. -The facility was unable to determine how the injury occurred. -The facility had provided an in-service to staff on the mechanical lift. -Attached in-service for mechanical lift was dated 11/9/22 (prior to incident) and did not indicate whether training was verbal, a demonstration, or if a return demonstration had been performed. -Attached statements included two staff not present when injury was found and one staff member (CNA C) who was working when the injury was found. -Attached statement from CNA C showed he/she found a bruise on the resident's left arm and a skin tear on the resident's right arm. Observation on 5/30/23 at 11:57 A.M. showed the resident: -Had a purple bruise approximately eight inches long and six inches wide on his/her upper left arm. -Had a dressing on his/her right lower arm. During an interview on 5/30/23 at 11:57 A.M., the resident's family member said: -He/she was unsure what had happened to the resident. -He/she wanted more information about the injury. During an interview on 6/1/23 at 1:14 P.M., LPN A said: -The resident had fractured bone in his/her upper left arm. -He/she had seen the resident before leaving for the day on 5/29/23 and he/she had not seen any bruising or skin tears. -He/she was notified on 5/30/23 that the resident had complained of pain in the left arm and x-rays had been ordered. -He/she was aware the resident complained of pain when his/her left arm was touched. -He/she believed the injury could have resulted from a mechanical lift transfer but was unsure. During an interview on 6/1/23 at 1:31 P.M., CNA D said: -He/she had received an in-service on abuse recently. -He/she was not aware of any mechanical lift in-service. During an interview on 6/1/23 at 2:39 P.M., CNA C said: -He/she had transferred the resident from his/her wheelchair to the bed on the night the injuries were found. -He/she found the bruise once the resident was in bed. -He/she did not have any trouble during the mechanical lift transfer. -A second CNA had assisted with the transfer. During an interview on 6/1/23 at 3:13 P.M., the MDS Coordinator said he/she: -Had been notified by the staff on 5/29/23 that the resident had an injury of unknown origin. -Went to the facility to assess the resident. -Got statements from two staff members then delegated collecting statements from the rest of the staff and residents to the charge nurse on duty. -Never received the statements from the rest of the staff or any residents. -Was unsure how an investigation could be completed without reviewing the rest of the staff and resident statements. -Believed the injuries were a result of a mechanical lift transfer. -Knew the resident frequently complained of left arm pain but did not know why. -Had provided staff with abuse and neglect education but had not educated on the mechanical lift. During an interview on 6/1/23 at 3:16 P.M., the DON said he/she: -Believed the injury was a result of a mechanical lift transfer. -Did not believe staff were in-serviced on the mechanical lift after the injury was found. During an interview on 6/2/23 at 11:02 A.M., CNA A said: -He/she had never been trained on the proper use of the mechanical lift. -He/she was not aware the resident had a broken bone in his/her arm. -He/she had cared for the resident during the day of the incident and there was no bruising or skin tear when he/she left at approximately 6 P.M. -No one had asked him/her for a statement regarding the incident. During an interview on 6/2/23 at 12:01 P.M., LPN A said he/she did not know if any residents had been asked for statements regarding the incident or surrounding factors. During an interview on 6/5/23 at 8:55 A.M., the DON said: -The investigation was complete. -He/she had determined the root cause of the incident was an improper Hoyer transfer. -He/she had not reviewed any resident statements because he/she hadn't found any of them. -No resident came to the staff and said there was a problem. -He/she could determine what happened without statements because of the location and type of injury. -He/she did not believe the resident had fallen. -If he/she had contacted all staff, no one would have admitted the resident fell so there was no reason to collect statements. -He/she felt residents occasionally get stuck in the lift and staff didn't know there was a problem until much later. -It was his/her job to document the root cause. -He/she was unsure if the root cause had been documented. During an interview on 6/5/23 at 12:52 P.M., the DON said: -He/she expected every incident report to be thoroughly investigated. -He/she expected the root cause, once determined, to be documented on the incident report. -Staff training was to include an in-service on any equipment they would use, a demonstration based on the manufacturer's instructions, and a return demonstration to show competency. -The in-service sheet should specify what type of competency was shown, whether through return demonstration or verbally. -He/she was not aware of any staff performing a return demonstration of proper mechanical lifts. -He/she did not believe any new interventions specific to the resident were necessary. MO00219140

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident and/or responsible party were informed of and signed a bed hold for one sampled resident (Resident #28) out of 16 sampled residents. The facility census was 55 residents. A copy of the facility's Bed Hold policy was requested but not provided. 1. Review of Resident #28's Face sheet showed he/she was admitted on [DATE], with diagnoses including cognitive deficit, stroke, muscle wasting, urine retention, and pressure sores. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/18/22, showed the resident: -Had cognitive incapacitation and significant memory loss. -Needed extensive to total assistance with bed mobility, transfers, bathing, dressing and incontinence care and did not walk. -Had two unhealed pressure sores that were present upon admission. Review of the resident's discharge MDS dated [DATE], showed the resident was discharged to the hospital. Review of the resident's Nursing Notes showed on 12/24/22 nursing staff sent the resident to the hospital for suspicion of a wound infection due to foul odor and increased drainage. Review of the resident's Bed Hold notification dated 12/24/22, showed the resident's responsible party was who the letter was directed to however, the document had no signatures to show the responsible party acknowledged that the facility informed him/her of the bed hold policy and procedure or the date that the facility notified the responsible party of the bed hold. During an interview on 6/02/23 at 12:20 P.M., the Social Service Designee said: -The nursing staff was responsible for completing the bed hold form and explaining the bed hold to the resident and/or responsible party when the resident is being discharged to the hospital. -Nursing staff were supposed to ensure the bed hold form is signed by the resident or responsible party. -Nursing staff was supposed to make a copy of the bed hold form and send the original with the resident to the hospital. -They were supposed to give a copy of the form to him/her and he/she uploaded the form into the resident's electronic record. -If the resident is not their own responsible party, he/she will mail a copy of the bed hold to the responsible party. -He/She faxes the list of discharged residents to the Ombudsman on the 5th of every month and also keeps a copy of it in a file. During an interview on 6/5/23 at 10:34 A.M., Licensed Practical Nurse (LPN) A said: -Nurses are responsible for completing the bed hold form. -When a resident goes to the hospital, he/she calls the family and lets them know about the resident's hospitalization and what hospital the resident is going to. -He/she will then fill out the bed hold form and sign it and get another nurse to witness it, then he/she will copy the bed hold form and send the original with the resident and give the copy to the social worker. -He/she said she also explains the bed hold policy to the resident and responsible party, and if they are able to sign the form, he/she will get them to sign it. -If the responsible party is not available to sign, he/she has sent the bed hold form to the family, but he/she has not documented on the form the date or time he/she spoke with the responsible party on the bed hold form to show they acknowledged it. -He/she will always send a copy of the bed hold form with the resident. During an interview on 6/05/23 at 12:49 P.M., the Director of Nursing (DON) said: -The Charge Nurse or the nurse who is sending the resident out to the hospital, is responsible for completing the bed hold form and explaining the bed hold policy to the resident. -The nurse will get the form and fill it out and if the resident is able to sign, they should sign it. -If the resident cannot sign, they should notify the responsible party and explain the bed hold policy to them. -The nurse makes a copy of the bed hold and sends the original with the resident. -The Social Service Designee will send the bed hold policy it to the family. -Nursing staff should document that notification to the responsible party was completed on the form or in the nursing notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete a significant change Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) assessment when the resident had a change in condition and was admitted to hospice services (a type of health care for end of life care) for two sampled residents (Resident #19 and Resident #6) out of 16 sampled residents. The facility census was 55 residents. Review of the facility's policy, dated March 2022, titled Comprehensive Assessments showed: -Staff were to complete a comprehensive assessment in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) User Manual. -Staff were to complete a Significant Change in Status Assessment when it was determined that the resident met the significant change guidelines for major decline. 1. Review of Resident #19's face sheet showed he/she was readmitted to the facility on [DATE]. Review of the resident's MDS submissions showed: -A quarterly MDS was completed on 2/17/23. The resident was not on hospice services and did not have a condition or chronic disease that may result in a life expectancy of less than six months. -A discharge MDS was completed on 4/11/23. -An entry MDS was completed on 4/21/23. -A significant change in status MDS was started on 5/4/23 but had not been submitted as of 5/31/23. Review of the resident's Physician Order Report, dated 6/1/23, showed the physician ordered hospice services on 4/21/23. 2. Review of Resident #6's face sheet showed he/she was readmitted to the facility on [DATE]. Review of the resident's MDS submission showed: -A significant change in status MDS was completed 1/18/23. The resident was not on hospice services and did not have a condition or chronic disease that may result in a life expectancy of less than six months. -A discharge MDS was completed on 1/26/23. -An entry MDS was completed on 1/31/23. -A significant change in status MDS was completed on 4/20/23. Hospice was not listed as a treatment for the resident. -No further MDS submissions found. Review of the resident's Physician Order Report, dated 6/1/23, showed: -The physician ordered hospice to evaluate the resident on 5/4/23. -The physician ordered hospice services on 5/5/23. 3. During an interview on 6/2/23 at 11:47 A.M., the MDS Coordinator said: -Staff are required to complete a significant change in status MDS when a resident is started on hospice services. -A significant change in status MDS was to be started within five days of the change in condition, and completed within 14 days. -He/she was new to the MDS position and the facility and was unsure how to sign and submit the MDSs. -He/she was responsible for all resident MDS assessments. During an interview on 6/5/23 at 12:52 P.M., the Director of Nursing (DON) said: -Staff are required to submit a significant change in status MDS for a resident when were started on hospice services. -He/she expected the MDS submissions to be completed by the time frame set by the Centers for Medicare and Medicaid Services (CMS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed for one sampled resident (Resident #9) out of 16 sampled residents. The facility census was 55 residents. A policy related to PASARR was requested and not received at the time of exit. 1. Review of Resident #9's face sheet showed he/she was admitted to the facility on [DATE] with the diagnosis of Down syndrome (a genetic disorder caused when abnormal cell division results in extra genetic material from chromosome 21). Review of the resident's Electronic Medical Record (EMR) a PASARR or DA-124 could not be found. A copy of the PASARR was requested on 5/31/23 from the Social Services Director (SSD). During an interview on 6/1/23 at 9:23 A.M. the Business Office Manager (BOM) said: -Upon admission to the facility a PASARR was not requested for the resident. -The only paperwork that was requested at the time was Pension Award letter. During an interview on 6/1/23 at 10:25 A.M. the SSD said: -He/she had filled out the PASARR paperwork on 5/31/23 and sent it to the doctor to sign. -He/she was not aware that a PASARR needed to be completed for this resident. During an interview on 6/5/23 at 12:52 P.M. the Director of Nursing (DON) said: -All residents should have completed PASARR prior to or on admission. -The resident should have had one completed before 5/31/23. -He/she thought the SSD was responsible for the completion of PASARRs. -The SSD had been made aware of the new PASARR rule updated on 5/11/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #9's face sheet showed he/she was admitted to the facility on [DATE] with the diagnosis of Down syndrome (a genetic disorder caused when abnormal cell division results in extra genetic material from chromosome 21). Review of an event report from the resident's Electronic Medical Record (EMR) dated 3/24/23 at 10:42 A.M. showed: -The resident had fallen in the shower. -The resident had an abrasion and knot to his/her head from the fall. -Neurological checks were initiated. -There was no evaluation from the fall on the report and showed Event still open. Review of the resident's admission MDS dated [DATE] showed: -There is no documentation showing the resident had a history of falls prior to admitting to the facility. -The resident was severely impaired cognitively. -The resident was only able to respond to simple, direct communication. Review of an event report from the resident's EMR dated 4/1/23 at 8:00 P.M. showed: -The resident had a witnessed fall. -The resident had been walking in the hall and attempted to turn with his/her walker and could not hold his/her balance and slowly went to the floor. -There was no evaluation from the fall on the report and showed Event still open. Review of an event report from resident's EMR dated 4/7/23 at 10:28 A.M. showed: -The resident had an unwitnessed fall. -The resident was found in his/her room by a Certified Medication Technician (CMT). -The resident was positioned sitting on the floor on his/her buttocks by his/her walker. -The resident was assisted into a standing position and brought to a chair by the nurse ' s station. -Neurological checks were initiated. -The resident was unable to explain what happened. -There was no evaluation from the fall on the report and showed Event still open. Review of an event report from the resident's EMR dated 4/16/23 at 9:15 P.M. showed: -The resident had an unwitnessed fall. -Neurological checks were initiated. -The resident was found in the chapel by a CMT. -The resident was positioned on his/her buttocks sitting on the floor. -There was no evaluation from the fall on the report and showed Event still open. Review of the resident's care plan dated 4/18/23 showed: -The resident was at risk for falls related to impaired balance, weakness, and impaired cognition. -The resident had multiple falls since admission and the staff needed to continue to be watchful of the resident. -Assess the resident for injury with any fall and document post fall assessments for at least 72 hours. -Observe frequently and place in supervised area when out of bed. -Resident needs assistance of one staff with supervision for transfers. -The resident used his/her walker for locomotion in room and hallways. -The care plan did not mention any behavioral symptoms or patterns indicating the resident was purposefully placing him/herself on the floor. Review of an event report from the resident's EMR dated 4/25/23 at 4:50 P.M. showed: -The resident had an unwitnessed fall with no injury. -Neurological checks were initiated. -The resident was found in the family room by a CMT. -The resident was positioned flat on his/her back on the floor. -The resident was placed in a chair with two staff assistance. -The resident was then able get up and ambulate with his/her walker without difficulty. -The evaluation noted therapy had been working with the resident with his/her walker use. -The Interdisciplinary Team (IDT) determined the resident's cognitive level was preventing him/her to use a walker safely. Review of a progress note from 5/7/23 at 2:02 P.M. showed: -The resident had been found by a CNA sitting on the floor in the hallway. -A physical assessment was completed with no sign of injury or pain. -NOTE: An event report was not received at time of exit. Review of a progress note from 5/11/23 at 12:08 P.M. showed: -The resident had sat on the floor in the rehabilitation gym. -A Physical Therapist (PT) had been working with the resident and started to try and sit on the floor so the resident was lowered to the ground. -An assessment had been completed with no apparent injury or pain. -The resident was unable to explain what happened. -NOTE: An event report was not received at the time of exit. During an interview on 6/5/23 at 11:28 A.M. CNA B said: -He/she was unaware of any fall interventions in place for the resident. -He/she was unaware that the resident was at risk for falls. -He/she knew the resident had used a walker in the past. -He/she was able to look at resident care plans to see what type of care a resident needs. -If he/she saw a resident on the floor, he/she would make sure the resident stayed in their current position and would get a nurse. -After a fall occurred he/she would check on that resident more frequently. -He/she would also ask the resident about pain throughout the shift. -If a resident was at risk for falls then it should be included in the care plan. During an interview on 6/5/23 at 11:38 A.M. LPN A said: -He/she knew the resident was not able to continue the use of a walker, so the resident had been placed in a wheelchair for mobility. -He/she was unsure if the resident had the multiple falls due to weakness or as a behavior. -When a resident falls he/she was responsible for: --Making sure the resident is safe. --Assessing the resident. --If able assist the resident to a comfortable position. --If needed call for an ambulance for an abnormalities in the assessment. --An event report needed to be written. --If the fall was unwitnessed then Neurological checks needed to be initiated. --Notifying the DON, doctor, and family. -The DON was responsible for completing the fall investigation. -He/She only assisted in fall investigations if the DON had questions for him/her. -When a resident is found on the floor it always counted as a fall. -If the resident had a change of plane it always counted as a fall. -Only charting a progress note was not appropriate documentation if a resident fell. -Falls should be included in the resident's care plan. 3. During an interview on 6/5/23 at 12:39 P.M. LPN A said: -Neurological checks are only charted on paper. -Only current Neurological Checks are kept at the nurse's station and the completed ones were sent to medical records to get uploaded into the resident's Electronic Medical Record (EMR). During an interview on 6/5/23 at 12:52 P.M. The DON said: -He/she would expect nurses to complete an Event Report if a resident fell during their shift. -He/she would also expect nurses to document a detailed progress note about the fall. -Only charting a progress report was not the correct documentation for falls. -Any unwitnessed fall should have neurological checks initiated and completed, but was unsure of where that documentation was kept. -There was a risk meeting every week that went over all of the falls from the previous week and any new interventions that were in place. -Any new interventions in place from falls needed to be added to the care plan. -The MDS nurse was responsible for updating care plans. -During the risk meeting a root cause analysis from a fall would be completed. -The DON could document the root cause in the event report and close out the event. -All event reports should have a root cause analysis attached to them. -Any time a resident is found on the floor or is lowered to the floor it counted as a fall. -Therapy had worked with the resident with the use of his/her walker. -The resident was able to mobilize him/herself with a wheelchair and needed assistance of one staff if the resident were to use his/her walker. -There should be documentation in the resident's EMR with his new mobility status. -The fall interventions in place for the resident were: --Therapy involvement. --Educating the resident. -Having the resident use a wheelchair instead of a walker. -Assist the resident with any bathroom use. Based on observation, interview and record review, the facility failed to complete thorough fall investigations per facility policy for two sampled residents (Resident #9 and #27) who had multiple falls out of 16 sampled residents. The facility census was 55 residents. Review of the facility's Fall and Fall Risk, Managing policy and procedure dated March 2018, showed: -The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. -If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). -Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etcetera. -If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. -If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. -The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. 1. Review of Resident #27's Face Sheet showed he/she was admitted on [DATE] with diagnosis including heart failure, high blood pressure, and pain. Review of the resident's Comprehensive Care Plan dated 1/5/23, showed fall risk due to impaired balance, occasional incontinence and mild cognitive impairment. Interventions showed staff should assess and treat the resident for low blood pressure, increase staff supervision, complete pharmacy medication reviews to assess for medications that increase fall risk. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 3/12/23 showed the resident: -Was cognitively intact with minimal memory loss. -Needed limited assistance with bed mobility and transfers. -Was not steady in surface to surface transfers and needed staff assistance. -Used a wheelchair for mobility. -Had one injury fall since admission or during the lookback period. Review of the resident's Fall assessment dated [DATE] showed a fall risk score of 18 which was determined to be high risk for falls. Review of the resident's Nursing Notes showed: -On 4/7/23 staff heard the resident yelling help, help. The nurse went to resident's room and observed resident sitting on the floor, propped up on his/her elbows. -The resident stated he/she was picking up a piece of paper off of the floor and fell face first to the floor. -He/she had a small, red knot above his/her left eye with no additional injuries noted and he/she was able to move all extremities without problem. -Two staff assisted the resident back into his/her wheelchair. -Nursing staff initiated neurological checks (neurological checkpoints to monitor: level of consciousness, ability to move extremities, eye responses and change in pupils) that were within normal limits. -The nurse notified the resident's physician and responsible party/family. Review of the resident's Fall Investigation dated 4/7/23, showed: -The resident had an unwitnessed fall in his/her room and staff found the resident on the floor sitting on the floor, propped up on his/her elbows. -The resident said he/she was trying to pick up a piece of paper on the floor and fell forward, face first onto the floor, sustaining a small, raised red knot over his/her left eye, with no additional injuries. The resident complained of mild pain at the site. -Staff assisted the resident into his/her wheelchair and the resident was able to move all of his/her extremities without problem. -The nurse started neurological checks and vital signs (temperature, respirations, blood pressure and pulse) and all were within normal limits. Nursing staff notified the resident's family and physician. The physician gave no new orders for treatment or evaluation. -The resident remained on follow up charting with bruising noted at his/her forehead and arm appearing on the resident. The resident had no pain and the physician provided no new orders for evaluation or treatment. -The report did not show any interventions that were already in place to prevent falls. -The report showed the event was still open. The document did not have a summary showing a summary of the root cause of the resident's fall and any new interventions that were implemented to try to prevent further falls once this fall occurred. Review of the resident's Care Plan showed the facility did not update any fall interventions since 1/5/23, that showed the resident fell forward onto the floor on 4/7/23 and sustained an injury to his/her left eye. There were no interventions that showed what the staff implemented for the resident to prevent further falls. Observation and interview on 5/31/23 at 9:30 A.M., showed the resident was sitting in his/her wheelchair in his/her room with his/her glasses on. The resident had no black eye, redness or bruising to either eye. There was a reacher device (a device that enables individuals to easily reach things in high places or pick up things off the ground without having to bend or stoop) on his/her bed. He/she said: -He/she has had falls at the facility and that was why he/she has a reacher now. -He/she fell out of bed and onto the floor while reaching to pick up something on the floor and he/she hit his/her eye on the floor and it gave him/her a black eye. -He/she yelled for help and the nursing staff came to check on him/her and attended to his/her eye. -Nursing staff also notified his/her spouse and physician. -At the time, there was no indication that his/her eye was black but they provided ice for it. -He/she did not need to go to the hospital. -The fall occurred a few weeks ago and he/she was not injured outside of having the black eye. -Nursing staff told him/her to use his/her call light to request assistance and they also provided a reacher for him to use when trying to reach things on the floor or that are out of reach. -The resident used the reacher to pick up a piece of paper towel he/she dropped. -He/she had not had any falls since last month. During an interview on 6/2/23 at 1:24 P.M., agency Certified Nursing Assistant (CNA) A said: -When a resident falls, the CNA was supposed to let the nurse know so they can evaluate the resident and let them know if they can get the resident up. -The CNA and nurse both complete vital signs (pulse, blood pressure, respirations and temperature) on the resident. -The nurse reports the fall to the physician and family and there should be an incident report showing what was observed or how the fall occurred. -He/she usually will write a statement stating how the resident fell or what he/she saw if the resident's fall was unwitnessed. -The nurse writes the incident report and any nursing notes and follow up monitoring. -They will implement new interventions for the resident, but the nurse will write the interventions on the fall report and care plan. During an interview on 6/5/23 at 10:40 A.M., Licensed Practical Nurse (LPN) A said: -When a resident falls the nurse was supposed to assess the resident for injury, complete vital signs and neurological checks and notify the physician and family. -They will follow the physician's orders for any additional care needed or hospitalization if needed. -The nurses were supposed to start an event/incident report, document the incident and start the investigation of the fall. -Documentation should be detailed and show what he/she observed or what the staff and resident say occurred. -They notify the resident's responsible party and physician and follow any physician's orders for the resident. -They try to implement an immediate intervention to try to prevent further falls. -The nurse provided the fall event/incident report and investigation to the Director of Nursing (DON) once it is completed. -The facility has risk management meetings weekly where the risk team will discuss resident falls and determine interventions for each resident to try to prevent further falls. -He/She did not participate in the risk meetings but the nurses are informed of any new fall interventions by the MDS Coordinator. -The MDS Coordinator was responsible for documenting the fall interventions on the resident's Care Plan and any updated interventions that were developed after a fall. During an interview on 6/5/23 at 12:49 P.M., the DON said: -When a resident falls the nurse that responds to the fall is to assess the resident, notify the physician family, DON and Administrator and they also let therapy know as needed. -The nurse was to complete an event/investigation report. -He/she was ultimately responsible to audit to ensure investigation reports were completed. -He/she expected the report to be a detailed account of how the fall occurred or what the staff witnessed/found the resident. -The nurse should complete vital signs and neurological checks and follow up monitoring documentation in the nursing notes for 72 hours after the fall. -They have a risk meeting every week on Tuesdays that is attended by the DON, rehabilitation staff, MDS Coordinator, Restorative Aide and sometimes the Social Service Designee. -In the risk meeting they discuss week to week falls, why the fall occurred and possible interventions. -The MDS Coordinator usually places all new interventions on the resident's care plan. -Nursing staff can also update the care plan to show any acute interventions that were implemented after a fall. -They try to determine the root cause at the time of the resident's fall but they will discuss it at the risk meeting. -The root cause should be documented by the DON on the incident investigation report and the care plan interventions should be updated on the resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection control practices were maintained during the placement of indwelling Foley catheter (a urinary bladder catheter inserted through urethra) drainage bag (catheter bag, a bag that hold drained urine) with bed in lowest position and placement under wheelchair for two sampled residents (Resident #2 and Resident #30) who was at risk for Urinary Tract Infections (UTI - an infection of one or more structures in the urinary system), failed to obtain an physician orders for indwelling catheter for one sampled resident (Resident #30) out of 16 sampled residents. The facility census was 55 residents. Review of the facility Indwelling Catheter Care Policy and Procedure dated 1/1/23 showed: -Keep the resident catheter bag of the floor at all times and in a dignity bag. -When bed lowered to lowest position, place a bath basin below the catheter bag to ensure not touching the floor. -While in a wheelchair, the drainage bag should be placed on a non-moving part, and below the bladder with excess tubing in a dignity bag. -If the drainage bag does touch the floor, should be wipe down and if visibly soiled, it should be changed by appropriate staff. 1. Review of Resident #2's admission Face Sheet showed a diagnosis of: -Hydronephrosis (is usually caused by a blockage in the urinary tract or something disrupting the normal workings of the urinary tract) with Urteropelvic junction (is blockage in the renal pelvis of the kidney). -Bladder neck obstruction (is a blockage that slows or stops urine flow out of the bladder). -History of UTI. Review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 2/25/23, showed he/she: -Was severely cognitively impaired and had short-term and long-term memory problems. -He/she was able to understand others and make his/her needs known. -Required total assistance from staff for all cares and transfer. -admitted with indwelling catheter. Review of the resident's Care Plan dated 11/28/22 and revised on 4/13/23 showed: -The resident at risk for UTI related to / history of UTI's, he/she had a Foley catheter and was incontinent of bowel and bladder. -Interventions included facility staff to provide proper catheter care every shift and as needed. -Did not have a specific plan of care for the resident's Foley catheter and placement of drainage bag. -On 4/13/23 the resident had been on an antibiotic for UTI. Review of the resident's Physician Order Sheet (POS) dated 5/2023 showed: -Indwelling Catheter size of a 16 French (Fr) 10 milliliter (ml) balloon. Indwelling Catheter Indication for diagnosis of Bladder-neck obstruction (Ordered on 10/7/21). -Indwelling Catheter Care and Monitor every shift and as needed (Ordered 10/7/21). -Change Indwelling catheter monthly on the 20th of the month (Ordered 1/25/22). Review of the resident's nursing note dated 5/20/23 at 5:43 P.M., showed: -The resident's catheter had been changed roughly around 2:30 P.M. -At about 4:00 P.M., the catheter drainage bag noted to be empty and had a scant amount of blood noted on resident's meatus (a passage or opening leading to the interior of the body). -A new catheter was inserted and drained around 200 ml of blood-tinged urine. -Information were to be passed on to the on-coming nurse for continued monitoring. -Did not have documentation of any further follow-up nursing note related to monitoring of the resident catheter site. Observation on 5/30/23 at 9:39 A.M., of the resident showed: -An unidentified nurse had just exited the resident room. -The resident's bed was in the lowest position, within inches from the floor. -The resident's catheter drainage bag was attached to the bed frame and the bottom of the bag was lying on the ground without a barrier. Observation on 6/1/23 at 8:50 A.M., of the resident showed; -The resident was in bed, the bed was in the lowest position to the ground. -The catheter drainage bag was touching the ground without a barrier. Observation and interview on 6/5/23 at 8:37 A.M., of the resident showed: -The catheter drainage bag was not hooked onto the bed rail or bed frame. -The catheter drainage bag and tubing laid on the floor by his/her bed without a barrier. -Licensed Practical Nurse (LPN) B said the Certified Nursing Assistants (CNAs) had already provided catheter care for the resident that morning. Observation on 6/5/23 at 9:50 A.M., of the resident showed: -The catheter drainage bag, which was in a dignity bag and tubing lying on floor by the bed without a barrier. -The catheter drainage bag was not hung on bed rail or bed frame. Observation and interview on 6/5/23 at 10:28 A.M., of the resident's catheter care showed: -CNA K and CNA L provided catheter care. -CNA K noted the resident catheter drainage bag and tubing laid flat on the ground. -He/she sent CNA L to obtain a bath basin to use as barrier. -CNA K said he/she had changed the resident's privacy bag and cleaned the tubing. -CNA L said the catheter bag should be left in a dignity bag and not to be laid on the ground any time without a barrier of some kind. 2. Review of Resident #30's admission Face Sheet showed a diagnosis of Chronic Kidney Disease stage 3 (is when kidneys have mild to moderate damage, and they are less able to filter waste and fluid out of your blood). Review of the resident's admission Nursing Note dated 4/18/23 showed the resident admitted to facility and had brought doxycycline 100 milligrams (mg) (antibiotic) to be given twice a day for seven days for UTI. The resident had two and half days left on treatment. Review of the resident's admission MDS dated [DATE], showed he/she: -Was mildly cognitively impaired and had short-term and long-term memory problems. -He/she was able to understand others and make his/her needs known. -Required total assistance from staff for all cares and transfer. -admitted with indwelling catheter. Review of the resident's POS dated 5/1/23 to 6/1/23 showed the resident did not have a physician orders for indwelling catheter, monitoring, and care. Review of the resident's Active of Daily Living (ADL's) care plan dated 5/2/23 showed: -The resident interventions were to monitor the resident for signs and symptoms of a UTI due to his/her Indwelling catheter. -The resident did not have a comprehensive Care plan for an indwelling catheter to include, type, size, catheter care and monitoring for proper placement of his/her catheter drainage bag and tubing. Observation on 5/30/23 at 10:05 A.M. showed: -The resident was sitting in a wheelchair in his/her bedroom. -The resident catheter drainage bag was placed in a dignity bag located under wheelchair. -The catheter tubing was dragging on the ground. -The catheter tubing had a thick cloudy substance draining in the tube. Observation on 5/30/23 at 10:55 A.M. showed: -The resident propelling himself/herself down the hallway, with the catheter tubing dragging on the ground. During an interview on 6/5/23 at 11:28 A.M. CNA B said he/she was able to look at resident care plans to see what type of care a resident needs. During an interview on 6/6/23 at 12:01 P.M., Licensed Practical Nurse (LPN) A said: -Review the resident POS showed the resident did not have a physician order for a indwelling catheter. -He/she would expect the resident should have a detail physician order to include the type and size of catheter and care of catheter. -Catheter monitoring and care should be documented in the resident Treatment Administration Record (TAR). -Care plans should include oxygen therapy and dementia care along with any interventions that were needed to give the resident appropriate care. -The MDS nurse was the person who updated care plans. 3. During an interview on 6/2/23 11:02 A.M., CNA A said: -Catheter drainage bags should be placed in a dignity bag under the wheelchair. -When the resident is in bed, the catheter bag should be placed on the side bed frame and not to be touching the floor. -He/she would place the tubing over the resident's leg so it doesn't get kinked. During an interview on 6/2/23 at 11:05 A.M., MDS Coordinator said: -Resident #2 and Resident #30 did not have a detailed comprehensive plan of care for Foley catheters. -The MDS Coordinator or nursing staff can initiate a care plan. During an interview on 6/2/23 at 11:47 A.M., the MDS Coordinator said: -He/she was responsible for completing care plans. -Any resident that used Hospice services should have hospice listed on their care plan. -He/she did not know why Resident #19 and Resident #6 did not have hospice on their care plans. -Care plans were to reflect the resident's current health status. During an interview on 6/2/23 at 11:14 A.M., CNA F said: -If a resident has a catheter, the drainage bag should be placed in a dignity bag and hung on the bed frame, not touching the ground. -If the resident is sitting in a wheelchair, the catheter drainage bag should be in a dignity bag hooked under the wheelchair and should not be touching the floor. -Catheter drainage bag and tubing should not be laid on the floor or be dragging on the floor at any time. During an interview on 6/2/23 at 11:02 A.M., CNA A said: -Catheter bags should be placed in a dignity bag under the wheelchair, when in bed on the side of the bed, always below the bladder. -I know res specific needs by asking the nurse, looking at the care plan, some residents you can ask. -Care plans are in the medical records charting, he/she would always check with the nurse after reviewing the care plan to ensure had correct plan. During an interview on 6/2/23 at 12:01 P.M., LPN A said: -The resident catheter drainage bag should be placed in a dignity bag. -The catheter drainage bag and tubing should never touch the floor. During an interview on 6/5/23 at 10:28 A.M., CNA K and CNA L said: -CNA K said the catheter drainage bag should be placed in a bath basin when the resident's bed is in the lowest position. -If the catheter bag is found on the ground, staff should change the dignity bag and clean the tubing. -For a resident in a wheelchair, the Foley catheter drainage bag should clipped under the chair. --Would ensure the catheter drainage bag and tubing were not touching or dragging on the ground. -All care staff were responsible for monitoring for proper placement of the residents' catheter drainage bags and tubing. During an interview on 6/5/23 at 10:51 A.M., LPN B said: -The resident's catheter drainage bag should be placed in a dignity bag and should be placed where it is not touching the ground. -If the catheter bag is found on the ground, he/she would get a new dignity bag and clean the tubing as needed. -CNA staff or nursing staff were responsible for ongoing monitoring for proper catheter drainage bag placement. During an interview on 6/5/23 at 11:11 A.M., the DON said: -The resident's catheter bag and tubing should never touch the ground. -Would expect facility care staff to ensure to have some type barrier when the resident's bed is in the lowest position and attached properly underneath the resident's wheelchair so the catheter bag and tubing were not touching the ground. -Facility care staff were to monitor catheter bag and tubing placement during rounds by any staff, CNA or nursing staff. -Any resident with an indwelling catheter, the drainage bag and tubing should be kept in a dignity bag and tubing placed not touching the ground. -Would expect facility care staff to change the catheter bag systems (which includes drainage bag and tubing) when found on the ground or to use disinfect wipes to clean the catheter drainage bag and tubing. -Would expect care staff to ensure Resident #2's catheter drainage bag was attached to the bed frame (not on any moving part of bed) and ensure the resident's catheter drainage bag and tubing were placed in a barrier such as a bath basin when his/her bed was in the lowest position to the ground. -Would expect Resident #30's catheter drainage bag to be clipped under the resident's wheelchair to ensure the catheter tubing and drainage bag were not dragging or touching the ground. -CNA's would be responsible for documenting cares in paper form for the monitoring of placement of resident's catheter drainage bag and any Foley catheter care provided. -Nursing staff would document in the resident's nursing progress notes or the Treatment Administration Record (TAR) any catheter care provided. -He/she would expect to have a comprehensive indwelling catheter care plan to include instruction on proper placement and care of the resident catheter, drainage bag and tubing. During an interview on 6/5/23 at 12:52 P.M., the DON said: -Care plans were the responsibility of the MDS Coordinator. -Care plans were to be comprehensive and reflect the resident's current health status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #12's face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Neurogenic disorder with Lewy bodies (also known as Lewy Body Dementia (LBD) a disease with abnormal deposits of Lewy bodies that affect the chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life. -Hallucinations (an experience involving the apparent perception of something not present). Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 1/29/23 showed: -The resident received anti-psychotic medication. -The resident received anti-depressant medication. Review of the resident 's MRRs from November 2022 to May 2023 showed: -No documentation of a review for November 2022. -No documentation of a review for December 2022. -No documentation of a review for March 2023. -No documentation of a review for April 2023. -No documentation of a review for May 2023. Review of the resident's Physician Order Sheet (POS) dated May 2023 showed: -An order for Sertraline (an anti-depressant). -An order for Wellbutrin (an anti-depressant). -An order for Olanzapine (an anti-psychotic that can treat mental disorders). 4. Review of Resident #13's face sheet showed he/she admitted to the facility with the following diagnoses: -Schizoaffective Disorder (A mental health condition including schizophrenia and mood disorder symptoms). -MDD. Review of the resident's quarterly MDS dated [DATE] showed: -The resident received an anti-psychotic. -The resident received an anti-depressant. Review of the resident's MRRs from June 2022 to May 2023 showed: -No documentation of a review for June 2022. -No documentation of a review for July 2022. -No documentation of a review for September 2022. -No documentation of a review for November 2022. -No documentation of a review for December 2022. -No documentation of a review for February 2023. -No documentation of a review for March 2023. -No documentation of a review for April 2023. -No documentation of a review for May 2023. Review of the resident's POS dated May 2023 showed: -An order for Olanzapine. -An order for Duloxetine (an anti-depressant). -Mirtazapine (an anti-depressant). 5. During an interview on 6/1/23 at 9:48 A.M., the Director of Nursing (DON) said: -He/she received the pharmacist's recommendations, faxed them to the physician, and when the physician returned them, he/she would update the orders and have the signed physician's order uploaded into each resident's chart. -He/she did not get a list of residents that did not have recommendations, he/she only received a list of recommendations. -He/she would not know if all residents' medications had been reviewed as he/she only received documents on resident with recommendations. During an interview on 6/5/23 at 11:49 A.M. Licensed Practical Nurse (LPN) A said: -The DON was responsible for completed the MRRs. -He/she helped with them occasionally by answering questions and putting in any new orders. During an interview on 6/5/23 at 12:52 P.M. the DON said: -Each resident should have a medication review monthly and documentation was to be kept to verify they were reviewed. -He/she was responsible for ensuring the pharmacist reviewed each residents' medication monthly. -As he/she had not received a list of residents that did not have recommendations, he/she wouldn't know if the pharmacist had reviewed each residents' medication. -The typical process for completing MRRs was: --The pharmacy would fax or bring the reports to the facility. --He/she would then scan and send the reports to the doctor. --Once the doctor reviewed and signed the reports they would be given back to him/her. --He/She would then place any new orders in the resident's POS and write a progress note. --Once completed, he/she would also send them back to the pharmacy. --The reports were also scanned into the resident's medical record. -He/she was not aware that the MRRs were not getting completed. -All residents should have a documented monthly progress note related to the MRRs. -He/she was unsure if the pharmacy sent out reports indicating a resident was reviewed and no recommendations were needed at that time. Based on interview and record review, the facility failed to ensure resident monthly pharmacy drug regimen reviews were completed for four sampled residents (Resident's #6, #3, #12, and #13) out of 16 sampled residents. The facility census was 55 residents. A copy of the facility's Monthly Medication Review policy was requested and not received at time of exit. 1. Review of Resident #6's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Pain. -Unspecified heart failure. -History of Urinary Tract Infection (UTI). -Major depressive disorder. -Other anxiety disorder. Record review of the monthly MMR from 6/2022 through 6/2023 showed: -No documentation of a review for July 2022. -No documentation of a review for August 2022. -No documentation of a review for September 2022. -No documentation of a review for November 2022. -No documentation of a review for December 2022. -No documentation of a review for April 2023. 2. Review of Resident #3's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). -UTI. -Unspecified dementia. -Major depressive disorder. Record review of the monthly MMR from 6/2022 through 6/2023 showed: -No documentation of a review for July 2022. -No documentation of a review for August 2022. -No documentation of a review for September 2022. -No documentation of a review for December 2022. -No documentation of a review for January 2023. -No documentation of a review for March 2023. -No documentation of a review for April 2023.

Based on observation, interview and record review, the facility failed to ensure resident's controlled substance medication that had been prescribed by a physician were dated when they were opened and failed to ensure safe secure safe storage controlled substance medication and other resident medication which were in an unlocked and open door of one medication room out two and the medication refrigerator were left unlocked with Schedule Controlled substance medication in side. The facility census was 55 residents. Review of the product insert for Ativan (an antianxiety medication) revised June 2016 showed to discard opened bottle after 90 days. Review of the Facility Policy and Procedures for Medication Administration revised on 4/2019, showed when opening a multi-dose medication container, the date opened were to be recorded on the container. Review of the Facility Policy and Procedures for Medication Storage revised on 11/2022, showed: -All drug are stored in a locked secure compartment (storage area) under proper temperatures. -Nursing staff were responsible for ensuring safe and secure storage of the medication. -Compartments such as a medication room or medication cart are to be secure and locked when not use. -Medication requiring refrigeration are stored in refrigerator in a medication room behind the nursing station or other secure locations. -Schedule Controlled II-V medication (medication substances in these schedule level have a high potential for abuse) were to be stored in a separately locked, permanently fixed compartment from non-controlled medication. 1. Observation on 6/5/23 at 7:20 A.M. to 7:49 A.M., of the medication room showed: -Behind the nursing station was the medication room. -The medication room door was propped open with a trash can. -The medication room and the medication refrigerator were not securely locked. -Facility staff were not at or around nursing station or in the hallways at that time. Observation on 6/5/23 at 7:55 A.M. to 8:00 A.M., showed: -A facility staff member was behind the nursing station. -Licensed Practical Nurse (LPN) A was in front of the nursing station and then walked away. -The medication room door was left propped open with a trash can. Observation on 6/5/23 at 8:06 A.M. to 8:12 A.M., showed: -LPN A had walked by the nursing station and had glanced toward the medication room. -He/she did not shut the medication room door. -The medication room door remained propped open with a trash can. Observation on 6/5/23 at 8:14 A.M. to 8:19 A.M., showed: -The medication room door remained propped opened by a trash can. -LPN A went and sat behind the nursing desk. -At 8:19 A.M., LPN A had left the nursing station and medication room door remained propped open. Observation on 6/5/23 at 8:42 A.M., showed: -Certified Nursing Assistant (CNA) B and LPN A were behind nursing station and the medication room door remained propped open with trash can. -CNA B and LPN A, then walked away leaving the medication room unsecured with door propped open. Observation on 6/5/23 at 8:56 A.M. of the medication room with LPN A showed: -The medication room not secured or locked, the door was propped open with a trash can. -Medication refrigerator door padlock was unlocked. -The refrigerator had controlled medications that were not securely double locked, which had multi-vial bottles of Ativan. -Three bottles of Ativan were opened without a date when the bottle was opened. 2. During an interview on 6/5/23 at 9:00 A.M., LPN A said: -The medication room door should be securely locked and not left propped open any time. -Medication refrigerator should be securely pad locked at all times when not in use. -Nursing staff and the Certified Medication Technician (CMT) both have keys to medication room. -The medication room including medication refrigerator should be monitored daily to ensure safe storage of the medication. -CMT staff do not have keys to medication refrigerator pad lock. -Medications, including controlled substances, should be dated with date opened. During an interview on 6/5/23 at 9:15 A.M., CMT A said: -Medication room doors should always be securely locked and never be left propped open. -The resident's medication should be dated with the date opened. -Nursing staff would be responsible for monitoring medication room and medication refrigerator to ensure locked at all times. During an interview on 6/5/23 at 10:51 A.M., LPN B said: -Medication rooms door should always securely locked and never propped open. -The residents' medications should have the date they were opened written on them. During an interview on 6/5/23 at 11:11 A.M., Director of Nursing (DON) said: -The medication room should be closed and securely locked at all times. -Nursing staff and CMT should never to leave the medication room unsecured and left propped opened any time. -He/she would expect medications to be dated when opened. -Medication refrigerator should be secured with pad locked at all times when not in use. -Refrigerated control substance medication should be stored with double lock system, which would be the medication room door locked and the pad lock on the refrigerator door. -Medication room should be monitored by charge nurse and include safe secure storage of medication by the charge nurse and CMT.

Based on observation, interview and record review, the facility failed to ensure there was an air gap (a vertical space usually one inch or more between the end of a drainage pipe which creates a separation between the drainage pipe and the drainage hole in the ground) between a drainage pipe from the automated dishwasher and the drainage hole in the floor of the kitchen and to ensure the gasket (a material such as rubber or a part used to make the area between two pieces of a material resist the flow of fluid such as air or water) of one refrigerator was in good repair. The facility census was 55 residents. Review of the 2015 Uniform Plumbing Code Chapter 801.2 Air Gap or Air Break Required, showed: Indirect waste piping shall discharge into the building drainage system through an air gap or air break as set forth in this code. Where a drainage air gap is required by this code, the minimum vertical distance as measured from the lowest point of the indirect waste pipe or the fixture outlet to the flood-level rim of the receptor shall be not less than 1 inch in. 1. Observation on 5/30/23 at 9:19 A.M. and on 6/1/23 at 9:26 A.M., showed the absence of an air gap between the drainage pipe from the automated dishwasher and the drainage hole on the floor. During an interview on 5/31/23 at 10:19 A.M., the Maintenance Director acknowledged that the drainage pipe from the automated dishwasher needed to be raised to create an air gap. During an interview on 6/1/23 at 1:23 P.M., the Dietary Manager (DM) said he/she has made the Maintenance Person aware of the lack of the air gap from the automated dishwasher. 2. Observation on 6/1/23 at 10:58 A.M., showed an area of gasket on a reach-in refrigerator that was torn for 1 foot (ft.) 7 in.). During an interview on 6/1/23 at 1:23 P.M., the DM said he/she was aware of the torn gasket of that reach-in refrigerator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #12's face sheet showed he/she admitted to the facility with the following diagnoses: -Neurogenic disorder with Lewy bodies (also known as Lewy Body Dementia (LBD) a disease with abnormal deposits of Lewy bodies that affect the chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behavior, and mood). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life. -Hallucinations (an experience involving the apparent perception of something not present). -Dyspnea (difficult or labored breathing). -Congestive Heart Failure (a weakness of the heart that leads to a build-up of fluid in the lungs and surrounding body tissues). Review of the resident's care plan dated 2/2/23 showed: -The care plan did not include a care area related to oxygen therapy. -The care plan did not include a care area related to dementia care. 4. During an interview on 6/2/23 at 11:47 A.M., the MDS Coordinator said: -He/she was responsible for completing care plans. -Any resident that used hospice services should have hospice listed on their care plan. -He/she did not know why Resident #19 and Resident #6 did not have hospice on their care plans. -Care plans were to reflect the resident's current health status. During an interview on 6/5/23 at 11:13 A.M., Certified Nursing Assistant (CNA) B said care plans should include dementia care, any behaviors related to the dementia care, and oxygen therapy. During an interview on 6/5/23 at 11:28 A.M., CNA B said he/she was able to look at resident care plans to see what type of care a resident needs. During an interview on 6/5/23 at 11:46 A.M., Licensed Practical Nurse (LPN) A said: -Care plans should include oxygen therapy and dementia care along with any interventions that were needed to give the resident appropriate care. -The MDS nurse was the person who updated care plans. During an interview on 6/5/23 at 12:52 P.M. the Director of Nursing (DON) said: -All care plans should be comprehensive and reflect the resident's current medical status. -He/she would expect Oxygen therapy and Dementia Care to be addressed in the resident's care plan. -He/she was responsible for ensuring all care plans were comprehensive. -Care plans were the responsibility of the MDS Coordinator. -Care plans were to be comprehensive and reflect the resident's current health status. Based on interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for three sampled residents (Resident #19, Resident#6, and Resident #12) out of 16 sampled residents. The facility census was 55 residents. Review of the facility's policy, dated March 2022, titled Care Plans-Comprehensive Person-Centered showed: -A comprehensive care plan was to be developed within seven days of the completion of a significant change in status Minimum Data Set (MDS-a federally mandated tool used for care planning). -The comprehensive, person-centered care plan: --Includes measurable objectives and timeframes. --Describes he services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. --Includes the resident's stated goals upon admission and desired outcomes. --Builds on the resident's strength. --Reflects currently recognized standards of practice for problem area and conditions. -Assessments of residents are ongoing and care plans are revised as information about the residents and the resident ' s condition change. -The interdisciplinary team reviews and updates the care plan: --When there has been a significant change in the resident's condition. --When desired outcome is not met. --When the resident has been readmitted to the facility from a hospital stay. --At least quarterly, in conjunction with the required quarterly MDS assessment. 1. Review of Resident #19's face sheet showed he/she was readmitted to the facility on [DATE]. During an interview on 5/30/23 at 3:17 P.M., the resident's family member said: -The resident had been on hospice (a type of healthcare for end of life care) since April 2023. -Hospice staff communicated any changes with the resident to him/her. -He/she spoke with the hospice staff approximately twice a week. Review of the resident's Physician Order Report, dated 6/1/23, showed the physician ordered hospice services on 4/21/23. Review of the resident's care plan showed: -Staff had last updated the care plan on 11/28/22. -Hospice services were not listed. 2. Review of Resident #6's face sheet showed he/she was readmitted to the facility on [DATE]. During an interview on 5/30/23 at 11:05 A.M., the resident's family member said: -The resident was recently started on hospice services. -Hospice staff had attended the resident's most recent care plan meeting. Review of the resident's Physician Order Report, dated 6/1/23, showed: -The physician ordered hospice to evaluate the resident on 5/4/23. -The physician ordered hospice services on 5/5/23. Review of the resident's care plan showed: -Staff had last updated the care plan on 4/6/23. -Hospice services were not listed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure bathing was completed per the resident's preference for three sampled residents (Resident #3 and #27) and one supplemental resident (Resident #36) who needed assistance or were dependent on staff for bathing, out of 16 sampled residents and eight supplemental residents. The facility census was 55 residents. Review of the facility's policy, dated 1/1/23, titled Safe Bathing and Showering Policy showed staff were to: -Offer each resident a shower at least twice a week. -Complete a bath sheet on every resident. 1. Review of Resident #3's face sheet showed he/she was admitted with the following diagnoses: -Major depressive disorder. -Pain. -Urinary Tract Infection (UTI). Review of the resident's care plan, last updated 11/28/22, showed: -One to two staff were required to assist the resident with activities of daily living. -Staff were to give the resident a bed bath if he/she refused a shower as it was traumatizing for him/her. -Staff were to offer showers two times a week and more often as needed. Review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 2/12/23, showed: -Staff documented the resident did not refuse cares. -Staff documented the resident was totally dependent on cares. -One to two staff were required to assist the resident with transfers. -The resident was totally dependent for bathing. Review of the resident's bath sheets showed the resident was bathed: -5/11/23. -5/18/23. -5/22/23. --NOTE: The records indicated the resident was bathed once a week. Observation on 5/30/23 at 9:11 A.M. showed the resident was in his/her bed, his/her face was shiny, and there was a strong odor of feces in the room. Observation on 5/31/232 at 9:04 A.M. showed the resident was in his/her bed, his/her face was shiny, and his/her hair was slick and was not brushed. During an interview on 5/31/23 at 2:16 P.M., the Director of Nursing (DON) said the bath sheets he/she provided were all the facility had. Observation on 6/1/23 at 9:17 A.M. showed the resident was in his/her bed, hair was not brushed and he/she was wearing a hospital gown. 2. Review of Resident #27's Face Sheet showed he/she was admitted on [DATE] with diagnosis including heart failure, high blood pressure, and pain. Review of the resident's Comprehensive Care Plan dated 1/5/23, showed staff should offer a shower to the resident twice weekly and as needed, provide assistance of one with bathing and allow the resident to bathe body parts that he/she was able to bathe himself/herself. Review of the resident's quarterly MDS dated [DATE] showed the resident: -Was cognitively intact with minimal memory loss. -Needed limited assistance with bed mobility and transfers. -Required one staff to physically assist with bathing. -Was not steady in surface to surface transfers and needed staff assistance. -Used a wheelchair for mobility. Review of the resident's Hospice Communication Book showed the resident: -Plan of care showed the resident received a bath aide twice weekly for bathing assistance. -Bath aide documentation showed the resident received bathing on 4/8, 4/12, 4/14, 4/19, 4/21, 4/26, 4/28, 5/1, 5/3, and 5/22. On 5/17 resident refused shower and shave, but nail care was provided. Review of the resident's bath sheets from April and May 2023, showed the facility gave the resident a bath on 5/17/23. No additional bath sheets were located. Observation and interview on 5/31/23 at 9:30 A.M., showed the resident was sitting up in his/her wheelchair in his/her room. He/she was dressed for the weather and was not odorous. The resident said: -He/she was usually bathed twice weekly by the Hospice bath aide, but he/she had not had a bath this week. -The nursing staff at the facility had given him/her a bath before but they usually did not provide bathing to him/her regularly. Observation and interview on 6/2/23 at 10:59 A.M., showed the resident was sitting up in his/her wheelchair in his/her room. At 11:00 A.M., the hospice nurse was in his/her room speaking with the resident. At 11:38 A.M., the resident was sitting in his/her room and said hospice did not give him/her a bath today because it was not the bath aide that visited, it was the nurse. He/she said staff at the facility had also not given him/her a bath today. Observation on 6/5/23 at 10:01 A.M., showed the resident was sitting in his/her wheelchair in his/her room reading the newspaper. He/she said: -The hospice bath aide did not come in over the weekend to give him/her a bath and the facility staff had not given him/her a bath either. -He/she did not receive a bath from the facility staff last week. -The hospice bath aide was supposed to come today and he/she should get a bath today. -The facility staff do not normally bathe him/her, only hospice staff. During an interview on 6/5/23 at 10:08 A.M., Certified Nursing Assistant (CNA) B said: -The residents are bathed by the bath aides who complete all of the baths. -Sometimes when the bath aide does not come in or if a resident needs a bath and they are informed, the CNA's will give the resident's bath. -The facility has two bath aides. -He/she thought the residents were supposed to get baths/showers at least twice per week. -If a resident was on hospice, usually the hospice bath aide gave the resident bats/showers twice weekly. -If hospice did not come in to give the resident's bath, the CNA or bath aide should provide the resident's bath/shower. -He/she gave Resident #27 a shower on 5/27/22 and he/she was not aware that the resident had not had a shower since then or that hospice had not given him/her a shower last week. -He/she usually completed the resident's bath sheet and turned it into the nurse when bath sheet forms are available. -Sometimes the bath sheet forms are not available because there haven't been copies made of the form. -When there are no forms available, he/she does not document the bath, but he/she will inform the nurse that he/she gave the resident a bath. He/she did not remember documenting Resident #27's bath on the bath sheet when he/she gave his/her bath. 3. Review of Resident #36's Face Sheet showed he/she was admitted on [DATE] with diagnoses including heart disease, urinary tract infection, left artificial knee joint, stroke, arthritis, and muscle weakness. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented with no memory problems. -Needed supervision with transfers, mobility, toileting and dressing. -Needed partial bathing assistance of one person. Review of the resident's Care Plan dated 2/15/23 showed the resident needed assistance with activities of daily living and transfers due to weakness at times. Interventions showed: -Staff needed to provide showers to the resident twice weekly and as needed, provide assistance with bathing and to allow the resident to bathe areas that he/she could do himself/herself. Review of the resident's bath sheets from April and May 2023 showed the resident received no bathing in April 2023 and one bath/shower on 5/8/23. During an interview on 6/5/23 at 10:08 A.M., CNA B said: -The resident told him/her on Thursday that he/she has not had a shower in almost a month and he/she asked the bath aide for a bath. -He/she informed night shift during report that the resident stated he/she had not been bathed in a month and they acknowledged it. -Today when he/she asked the resident if he/she had received his/her bath and the resident said no, but he/she was supposed to receive one today at 10:00 A.M. -A resident should never wait this long to receive a shower, but he/she was unaware that the resident had not had a shower until last Thursday right before dinner. -At the time he/she found out, he/she was getting off of work so he/she informed the night shift on Thursday. -When he/she gives a bath, he/she has to fill out the bath sheet and if a resident refused the bath, he/she has to write it on the bath sheet (that the resident refused) and if the resident can sign it they have the resident sign the form. -They were supposed to turn the form in to the nurse and the nurse signs off on the form. 4. During an interview on 6/2/23 at 11:02 A.M., CNA A said: -Staff were to bathe residents two to three times a week. -Baths were performed by the bath aides, but CNAs were to complete the task if no bath aide was available. -Staff were to complete a bath sheet, even if the resident refused, and write 'refused' on the sheet and have the resident sign the sheet. If the resident was unable, he/she would request another staff member to sign the refusal. -If a resident refused a shower, he/she expected a bed bath to be offered. -He/she was not aware of the resident ever refusing baths. -The resident was occasionally anxious when he/she was having his/her brief changed but bathing had never been an issue. During an interview on 6/2/23 at 11:14 A.M., CNA F said: -Staff were to bathe residents every two days or more often if requested. -Refusals were to be documented on the bath sheet and the charge nurse was to be notified. -He/she expected a resident to be offered a bath three times before writing refused on the bath sheet. -He/she would have the resident sign the bath sheet that says refused so it is clear it was the resident's choice. During an interview on 6/2/23 at 12:01 P.M., Licensed Practical Nurse (LPN) A said: -Staff were to offer each resident a bath every two days or more if needed. -Refusals were to be documented in the nurse's notes and on the bath sheet which the resident should also have signed. -He/she knew the resident didn't like baths but had never known him/her to refuse one. During an interview on 6/2/23 at 1:24 P.M., CNA A said: -Residents are bathed at least twice weekly. -They have two bath aides who give baths during the week and on weekends they have a rotation where the CNA's give resident baths. -He/she has assisted with giving showers, but usually, the bath aides were responsible for giving showers. -When they give showers they complete the bath sheet and then they place them at the nursing station because the nurse has to check it and sign it. During an interview on 6/5/23 at 10:40 A.M., LPN A said: -There are two bath aides and residents are supposed to get baths twice weekly or as needed. -On occasion the CNA staff will give a bath if the bath aide calls in or if a resident needs a bath due to soiling themselves or if the bath aides are behind schedule. -Residents with hospice services have a hospice bath aide that gives their baths, but the facility staff should also give baths to those residents unless the resident refuses. -If baths are not given by the bath aide, the CNA staff should bathe the resident and residents should not go a week or more without getting a bath. During an interview on 6/5/23 at 12:52 P.M., the DON said: -Staff were to document all baths on the bath sheets. -The nursing staff, once they complete a resident's bath, are supposed to fill out the bath sheets and give them to the charge nurse who gives them to the DON. -Every resident was to be bathed twice a week. -If a resident refused a bath, he/she expected staff to notify the charge nurse, the charge nurse to reassign the bath and reassess the resident to see why they refused and document it in the resident's progress note; he/she was aware staff had not been doing that. -He/she also expected any refusals for bathing to be documented on a bath sheet. -All residents should get bathed twice weekly by the bath aides, they have two. -Anyone in nursing can give bath. -They used to have a bath book they kept all of the bathing sheets in, but when the new DON came, he/she got rid of the bath book and so they have no single location for the bath sheets and they have been found in various places in his/her office. -Some of the bath sheets, they were unable to find. -For residents on hospice, the facility is still primarily responsible for bathing the residents even though they get baths through hospice. The facility staff should still offer two baths per week to hospice residents. -If the bath aide is unable to give a bath, the bath aide should notify the charge nurse so he/she can reassign the bath or reassess the resident for a bath. -If a resident refused a bath, it should be in the resident's progress note and the refusal should be documented on the bath sheet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the low air loss mattress (an air mattress covered with tiny holes that are designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) remained inflated and in working order for one sampled resident (Resident #28), who had pressure ulcers (damage to an area of the skin caused by constant pressure on the area) and to ensure the mattress settings were documented in the resident's medical record out of 16 sampled residents. The facility census was 55 residents. Review of the undated facility Low Air Loss Mattress policy and procedure showed: -A low air loss mattress will be provided for residents as ordered by the physician or indicated on the care plan. -Check low air loss mattress every 2 hours while doing care by placing hand under the resident's thighs. If the air mattress is deflated, increase the pressure of the pump. Report any pump malfunctions to the nursing supervisor. 1. Review of Resident #28's Face sheet showed he/she was admitted on [DATE], with diagnoses including cognitive deficit, stroke, muscle wasting, urine retention, and pressure ulcers. Review of the resident's Care Plan dated 2/7/23, showed the resident required assistance with bed mobility, had pressure ulcers on his/her buttocks and had a low air loss mattress to alleviate pressure on the resident. There were no interventions instructing staff to checking to ensure the mattress remained inflated, at what frequency they should be checking the mattress or what settings the mattress should be set on to ensure the mattress was working properly and providing the best benefit to the resident. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 4/29/23, showed the resident: -Had cognitive incapacitation and significant memory loss. -Needed extensive to total assistance with bed mobility, transfers, bathing, dressing and incontinence care and did not walk. -Had two unhealed pressure ulcers that were present upon admission. -Had interventions including a pressure relief device for his/her bed, application of ointments and dressings and pressure ulcer care to address and prevent further deterioration of the resident's skin. Review of the resident's Physician's Order Sheet (POS) dated 5/23, showed there were physician's orders for pressure ulcer treatments, but there were no physician's orders showing the resident had a low air loss mattress, what settings the mattress should be kept on for the resident or the frequency that staff should be checking to ensure it was inflated and on the correct setting. The POS showed the resident received Hospice (end of life) Services. Observation on 6/1/23 at 10:23 A.M., showed the resident was laying in bed on his/her right side with his/her eyes closed, on a low air loss mattress with bolsters on both sides of the mattress. There were anti-slip mats on the ground next to his/her bed. The mattress was set to 350 firm, but the mattress was not inflated. it showed that the mattress was in the on position, but the light was not on. The resident's mattress was not plugged into the wall. At 10:25 A.M., Certified Nursing Assistant (CNA) B walked past the resident's room and looked in on the resident, but did not enter the resident's room or notice that the resident's mattress was deflated. At 10:47 A.M., CNA J and the hospice Nurse Practitioner went into the resident's room, but did not seem to notice that the resident's mattress was deflated and did not check on the resident. They both left the resident's room. At 10:49 A.M., the laundry staff went into the resident's room to put away some of the resident's clothes then left the room without noticing the resident or that the mattress was not inflated. During an interview on 6/1/23 at 10:58 A.M., CNA J said he/she was new to the facility and was not very familiar with the residents or how things were done in the facility and was still learning. He/she said he/she did not notice that the resident's low air loss mattress was not inflated when he/she went into the resident's room. During an observation and interview on 6/1/23 at 11:21 A.M., Licensed Practical Nurse (LPN) B went into the resident's room and checked on the resident. The resident was still laying on his/her right side and was awake but not verbalizing. LPN B said he/she did not know that the resident's low air loss mattress had deflated. LPN B then checked the resident's mattress (felt it) and said it was deflated and though the controls showed it was on, it was not inflated. LPN B began checking to see if there was an issue with the controls on the mattress or the cord on the mattress. He/she then saw that the mattress was unplugged from the wall and plugged it up. The resident's bed immediately came on, the control lit to a green color and the mattress immediately began to inflate. LPN B said: -Any staff that goes into the resident's room should be checking to ensure the low air loss mattress is inflated. -The resident cannot move himself/herself in bed, and though he/she was offloaded from his/her wound, laying on a deflated mattress could cause the resident's skin to breakdown (in areas that did not have wounds) or if the resident had been laying on his/her back, the pressure sores on his/her bottom could worsen. -He/she had just checked on the resident to cover him/her up with a blanket and did not notice the resident's mattress was deflated. -When he/she completed the resident's wound care earlier this morning, the resident's mattress was inflated. -The resident was not strong enough to unplug the mattress from the wall and did not know how it became unplugged. Observation on 6/1/23 at 11:30 A.M., CNA B and CNA J came into the resident's room and said they were going to get the resident up for lunch. LPN B informed them that the resident's low air loss mattress was deflated and the cord had been unplugged from the wall. CNA B said he/she and CNA J went to lay the resident down after breakfast before 10:30 A.M., and the resident's mattress was inflated at that time. Neither said they had unplugged the resident's mattress. LPN B asked CNA B and CNA J to get the resident up so that his/her mattress could inflate. During an interview on 6/1/23 at 1:25 P.M., LPN B said: -Hospice provided the resident's bed and mattress and they probably initially set up the resident's bed and mattress. -He/she was going to notify the physician to see if he/she could write an order to include this information on the resident's POS. -The resident's mattress was usually set to the resident's weight. -He/she did not see any documentation instructing the staff to check the resident's mattress in the resident's care plan or medical record. During an observation and interview on 6/2/23 at 10:58 A.M., the resident was laying in his/her bed on his/her left side. The resident was laying on a different low air loss mattress that was set to firm (with no correlating numbers), alternating with bolsters. The mattress was inflated. The resident's eyes were closed and resting comfortably. LPN B said: -He/she spoke with the Hospice Nurse Practitioner about the resident's mattress and he/she said he/she had been in the resident's room on 6/1/23, and did not notice the resident's mattress had deflated. -The Hospice nurse ordered a new air loss mattress and they came and placed the mattress on the resident's bed. -The Hospice Nurse Practitioner ordered a new air loss mattress for the resident for precaution and they brought the resident's mattress n this morning and set it up. -The Hospice Nurse Practitioner said he/she did not notice the resident had any skin damage to his/her hips, side or bony prominences on his/her right side that resulted from the mattress. -He/she did not notice any skin damage that would have resulted from laying on his/her right side on the deflated mattress. -The resident's mattress was set to firm and he/she reminded the nursing staff to check the resident's mattress during the day to ensure it was inflated. During an interview on 6/5/23 at 12:49 P.M., the Director of Nursing (DON) said: -Anytime the nursing staff go into the resident's room they should be checking the resident's mattress to ensure it is inflated and is at the correct setting. -They would know what the setting should be for the mattress based on the resident's weight. -The setting for the resident's mattress should be documented in the resident's care plan. -He/she did not know exactly how long the mattress could be deflated before it could cause injury to the resident, but it would not take long for the resident's skin to show signs of breaking down. -Nursing staff notified hospice once the resident's mattress was found to be deflated and hospice came in and brought another mattress for the resident on the same day. -The resident's mattress should be set to firm and they will make sure this information is in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #12's face sheet showed he/she admitted to the facility with the following diagnoses: -Dyspnea (difficult or labored breathing). -Congestive Heart Failure (a weakness of the heart that leads to a build-up of fluid in the lungs and surrounding body tissues). -Chronic Kidney Disease (a long standing kidney disease based on kidney damage or decreased kidney function for three or more months). Review of the resident's admission MDS dated [DATE] showed: -The resident used oxygen therapy. -The resident was cognitively intact. Review of the resident's POS dated May 2023 showed an orders for: -Continuous oxygen at 2 Liters (L) via nasal cannula at night. -Ipratropium-Albuterol solution for nebulization (a form of respiratory care in which the medication is directly inhaled into the lungs) 0.5 milligrams (mg) - 3 mg (one vial) four times a day. Observation on 5/30/23 at 9:37 A.M. showed: -The resident had an oxygen concentrator and nebulizer equipment in his/her room. -The oxygen tubing was dated 4/9/23. -The nebulizer equipment was not stored in a bag, laying on a bedside table, and there was no bag in the room to store the equipment. -The oxygen tubing was hanging off the resident's bed. During an interview on 5/30/23 at 9:37 A.M. the resident said: -He/she wore oxygen when he/she remembered. -He/she could not remember the last time his/her oxygen tubing was changed. Observation on 5/31/23 at 9:58 A.M. of the resident's room showed: -The oxygen tubing was still labeled 4/9/23. -The nebulizer equipment was still on the bedside table, not stored in a bag, and no bag was seen in the room for storage. Observation on 6/1/23 at 11:15 A.M. of the resident's room showed: -The oxygen tubing was on the floor. -The tubing was still labeled 4/9/23. -The nebulizer equipment remained on the bed side table, uncovered, with no bag for storage. 3. Review of Resident #1's face sheet showed he/she was admitted following a history of COVID-19 (a new disease caused by a novel (new) coronavirus). Review of the resident's Significant Change MDS, dated [DATE], showed the resident: -Was severely cognitively impaired. -Suffered from delusions. -Was totally dependent on staff for personal hygiene needs. Review of the resident's Physician Order Report, dated 5/30/23, showed the physician ordered ipratropium-albuterol 0.5 mg-3 mg/3 ml to be given via a nebulizer. Review of the resident's Medication Administration Record (MAR), dated 5/31/23, showed the staff administered the ipratropium-albuterol via a nebulizer four times a day from 5/1/23-5/30/23. Observations on 5/30/23 at 9:11 A.M. and on 5/31/23 at 9:25 A.M. showed: -The nebulizer mouthpiece was lying on the machine undated and uncovered. Observation on 6/1/23 at 1:02 P.M. showed the resident was in his/her room and receiving a breathing treatment via the nebulizer. Observation on 6/1/23 at 1:13 P.M. showed the nebulizer mask had been removed and was sitting on the resident's tray table without a barrier or cover. Observation on 6/5/23 at 8:09 A.M. showed the nebulizer mask was on the resident's tray table with the inner portion of the mask (which touches the face) in direct contact with a remote control and papers. 4. Review of Resident #25's face sheet showed he/she was admitted with a diagnoses of Chronic Obstructive Pulmonary Disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Review of the resident's quarterly MDS, dated [DATE] showed: -The resident received oxygen therapy. -The resident was severely cognitively impaired. -The resident required significant assistance with personal hygiene. Review of the resident's Physician Order Sheet, dated 6/1/23, showed the physician had ordered continuous oxygen via nasal cannula due to COPD. Observation on 5/30/23 at 9:26 A.M. showed: -Two oxygen concentrators (A machine that concentrates the oxygen from a gas supply by selectively removing nitrogen to supply an oxygen-enriched product gas stream. They are used industrially and as medical devices for oxygen therapy) in his/her room, one with an undated humidifier and one with a nasal cannula attached and resting in the handle of the machine uncovered. Observation on 6/1/23 at 2:56 P.M. showed: -Certified Nursing Assistant (CNA) D was moving the resident in his/her wheelchair, the oxygen tubing fell from the resident's wheelchair, CNA D stepped on the tubing near the nose piece, picked up the tubing, and placed the tubing around the portable tank of oxygen on the resident's wheelchair. Observation on 6/1/23 at 3:13 P.M. showed an oxygen concentrator in his/her room had a nasal cannula attached, undated and uncovered, lying on the resident's bed. Observation on 6/5/23 at 11:58 A.M. showed: -The resident was not in the room. -The oxygen concentrator had a nasal cannula attached, which was lying on the resident's bed uncovered and without a barrier. 5. Review of Resident #53's face sheet showed he/she was admitted with a diagnosis of dependence on supplemental oxygen, shortness of breath, and dependence on the use of a bi-pap while sleeping. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident was moderately cognitively intact. -The resident required extensive assistance from staff for personal hygiene. -The resident required oxygen therapy. Review of the resident's MAR, dated 5/31/23, showed the resident received ipratropium-albuterol via nebulizer at least once per day. Review of the resident's Treatment Administration Record (TAR), dated 5/31/23, showed the resident: -Received oxygen every day during the month of May 2023. -Had his/her Bi-pap applied and removed every day during the month of May 2023. Observation on 5/30/23 at 9:26 A.M. showed: -The resident was resting in bed. -The resident's wheelchair had an oxygen tank with a nasal cannula attached. -The nasal cannula was wrapped around the tank, uncovered and undated. -The resident's bi-pap mask was hung on a hook on the wall, uncovered. -The resident's nebulizer mouthpiece was stuck in the handle of the nebulizer, undated and uncovered. Observation on 5/31/23 at 9:19 A.M. showed: -The resident's bi-pap mask was hung on a hook on the wall, uncovered. -The nasal cannula attached to the resident's oxygen tank on his/her wheelchair was wrapped around the wheelchair handles without a barrier. Review of the resident's Physician's Order Sheet, dated 6/1/23, showed the physician ordered: -Ipratropium-albuterol 0.5 mg-3 mg/3 ml to be given via a nebulizer. -Oxygen to be given continuously via nasal cannula for COPD. -Bi-pap machine to be used at bedtime and removed in the morning. Observation on 6/1/23 at 9:14 A.M. showed: -The resident's bi-pap mask was hung on a hook on the wall, uncovered. -The resident's nebulizer mouthpiece was lying on his/her bedside table without a barrier and uncovered. Observation on 6/2/23 at 11:00 A.M. showed the resident was receiving a nebulizer treatment. Observation on 6/5/23 at 8:08 A.M. showed the resident's bi-pap mask was hung on a hook on the wall, uncovered. 6. During an interview on 6/2/23 at 11:02 A.M., CNA A said: -All respiratory equipment was to be bagged when not in use. -If he/she found respiratory equipment on the floor, he/she would dispose of it and replace with a new one. -If he/she stepped on oxygen tubing, he/she would replace it immediately. -All staff were responsible for ensuring oxygen tubing was bagged. -Any staff that found respiratory equipment uncovered were responsible for disposing of it and replacing with a new one. During an interview on 6/2/23 at 11:14 A.M., CNA F said: -All respiratory equipment was to be stored in a bag. -If he/she found respiratory equipment on the floor, he/she would throw it away and notify the nurse. -Bi-pap masks should not be touching the wall because they would then be dirty. During an interview on 6/2/23 at 12:01 P.M., Licensed Practical Nurse (LPN) A said: -All respiratory equipment, including bi-pap mask, nebulizers, and nasal cannulas, were to be stored in a plastic bag when not in use. -All nursing staff were responsible for ensuring respiratory equipment was bagged. -He/she expected staff to replace any respiratory equipment found on the floor or not bagged. During an interview on 6/2/23 at 1:24 P.M., CNA A said: -All face masks, mouthpieces and oxygen equipment was supposed to be kept in a bag when not in use. -He/she usually tries to check for this as he/she goes to check on the residents he/she is assigned to. -He/she was not sure who changed out the hoses, tubing, face masks and mouthpieces, and he/she has not had to do this yet, but he/she thought they were changes weekly and as needed. During an interview on 6/5/23 at 10:40 A.M., LPN A said: -All oxygen supplies should be changed every Sunday. -Nasal cannulas, face masks, and mouthpieces should be covered and placed in a bag when not in use. -The plastic bags are in the supply room and all staff are able to gain access to get bags whenever they need them. -Nursing staff should be checking when they go into the resident's room to ensure the oxygen supplies are covered. During an interview on 6/5/23 11:14 A.M., CNA B said: -Throughout his/her shift he/she would monitor oxygen tanks and concentrators to ensure they are on and to see if the tanks needed to be changed out. -Oxygen and nebulizer equipment should be stored in a bag when not in use. -If he/she found oxygen tubing on the floor or if it was dated from more than a week prior he/she would get new oxygen tubing. -He/She did not think the facility had a process for when oxygen tubing, masks, or other oxygen equipment should be changed out on a routine basis. -If he/she found nebulizer equipment uncovered he/she would ask the nurse for a storage bag. -Storage bags for oxygen equipment should be dated. During an interview on 6/5/23 at 12:52 P.M., the Director of Nursing (DON) said: -He/she expected all nasal cannulas, face masks, nebulizer mouthpieces, to be stored in a dated bag and hung on the concentrator or placed on the bedside table when not in use. -He/she expected every staff member to verify all respiratory equipment was properly bagged each time they entered a resident room. -There are baggies in the storage room and all staff have access to it, or they can ask the charge nurse for the bags. -Every Sunday, nursing staff is supposed to replace the oxygen supplies and provide new storage bags for all respiratory equipment and place them in the resident's rooms. -If the oxygen tubing/equipment was stored in a clean space in the resident's room he/she would expect the care staff to go to the supply to grab a storage bag or ask the nurse where the storage bags could be found. -If the oxygen tubing/equipment was found in a dirty space like the floor or resident's bedside table he/she would expect care staff to get new tubing/equipment. -Oxygen storage bags should be labeled. -Oxygen tubing should be labeled. -Oxygen tubing dated 4/9/23 should have been replaced. Based on observation, interview and record review, the facility failed to ensure the facemask for a Continuous Positive Airway Pressure (CPAP)/Bilevel Positive Airway Pressure (BiPAP) (a machine that provides air at a consistent pressure level at all times (CPAP) or provides air at two different pressure levels, one for breathing in and one for breathing out (BiPap) and the mouthpiece for a nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) machine were kept covered when not in use for three sampled residents (Resident #27, #12, and #1) and two supplemental residents (Resident #25 and #53); and to update respiratory care interventions in the care plan for one sampled resident (Resident #27) out of 16 sampled residents. The facility census was 55 residents. Review of the facility's policy, dated 6/8/23, titled Oxygen Administration showed: -Staff were to replace nasal cannulas (a device used to deliver supplemental oxygen), oxygen tubing, and oxygen masks weekly. -Staff were to date oxygen tubing, cannulas, and masks, when they were placed. -Staff were to place tubing in a bag when not in use. -Staff were required to date the bag used for storing the oxygen tubing, cannulas, or masks. -Staff were required to store all oxygen tubing, cannulas, and masks in a dated bag when not in use. 1. Review of Resident #27's Face Sheet showed he/she was admitted on [DATE] with diagnosis including heart failure, high blood pressure, cough and pain. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/10/22 and quarterly MDS dated [DATE], showed the resident was cognitively intact with minimal memory loss. It also showed the resident did not receive oxygen therapy or nebulizer treatments. Review of the resident's Care Plan initiated on 1/5/23 and updated on 4/5/23 showed the resident used a CPAP/BiPAP machine. Interventions showed staff was to: -Place the face mask on the resident when he/she was in bed. -Change out the face mask every three months. -Wash the reservoir weekly and replace it every six months or if it becomes discolored or cracked. -The care plan did not show the resident received nebulizer treatments and there were no interventions for use of a nebulizer. Review of the resident's Nursing Notes dated 4/21/23, showed the resident's hospice (end of life) nurse visited and there was a new medication order for the resident to receive Albuterol (medication used to increase the movement of air in the lungs) via nebulizer machine twice daily. Review of the resident's Physician's Order Sheet (POS) dated 5/2023 showed physician's orders for: -Albuterol solution for nebulization, 3 milliliters (ml)/1 vial inhalation twice daily as needed for cough (ordered from 4/21/23 to 6/1/23). -Apply CPAP/BiPAP machine at bedtime (ordered 11/30/22). Review of the resident's Care Plan showed the most recent update was on 4/5/21 and there was no update to the resident's care plan after this date showing the resident was now using a nebulizer machine (as of 4/21/23) and there were no interventions documented for it's use, treatment or care. Observation and interview on 5/31/23 at 9:08 A.M., showed the resident was sitting in his/her wheelchair dressed for the weather with glasses on. The resident was not wearing oxygen and seemed to be breathing without distress. Beside the resident's bed, on his/her tray table, was a CPAP machine and the facemask was laying next to the machine, uncovered. There was no bag or covering seen in the resident's room. At the foot of his/her bed, on the dresser was a breathing treatment machine (nebulizer) and the mouthpiece was laying next to the machine uncovered. The resident said: -The nurse comes in to give him/her his/her treatments daily as he/she needs it and it helps him/her to clear his/her lungs when he/she is congested. -He/she wore his/her CPAP machine nightly or whenever he/she was in bed for snoring. -At 9:20 A.M., nursing staff entered the resident's room to provide water, but did not change or cover the resident's face mask or mouthpiece. -At 9:27 A.M. the nurse came into the resident room to provide wound care, but he/she did not check to see that the face mask and mouthpiece were uncovered and did not cover them before leaving the resident's room. Observation on 6/1/23 at 10:35 A.M., showed the resident was in his/her room sitting up in his/her wheelchair. The resident's nebulizer machine was sitting on the dresser at the foot of his/her bed and the mouthpiece was laying on the dresser uncovered. The resident's CPAP/BiPAP machine was sitting on the tray table beside his/her bed and the face mask was uncovered. Observation on 6/2/23 at 10:59 A.M., showed the resident was sitting up in his/her wheelchair reading. The resident's nebulizer machine was sitting on the dresser at the foot of his/her bed and the mouthpiece was laying on the dresser uncovered. The resident's CPAP/BiPAP machine was sitting on the tray table beside his/her bed and the face mask was uncovered. There was no covering or bags available in the room to cover the respiratory equipment. During an interview on 6/02/23 at 11:50 A.M., the interim MDS Coordinator said: -The MDS Coordinator is responsible for care plans and the nursing staff sometimes will also enter information. -If the care plan is inaccurate, staff would have to communicate the resident's needs to the nursing staff. -The care plans are on the computer, but he/she did not know for sure where the physical copies were kept. -The care plan should reflect the residents health status and be updated. -Interventions for all respiratory equipment use and cleaning/changing should be documented on the care plan. -He/she had noticed that the care plans were not all complete and updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a cold food (cucumber tomato salad) at or below a temperature of 41 ºF (degrees Fahrenheit) throughout the lunch meal service on 6/1/23 and to ensure the hot meal (a meatball sandwich) was served at a temperature of or close to 120 ºF when the meal was served to two sampled residents (Residents #16 and #39) who chose to eat in their rooms on 6/1/23. This practice potentially affected 54 residents who ate food from the kitchen. The facility census was 55 residents. 1. Observations on 6/1/23, showed: - At 10:01 A.M. Dietary Aide (DA) A finished slicing the cucumbers and tomatoes for the cucumber tomato salad. - At 10:05 A.M. the large bowl of cucumber/tomato salad was placed into a reach-in refrigerator. - At 11:06 A.M. a large bowl of the cucumber tomato salad was placed in a tub of ice outside of the refrigerator. - From 11:07 A.M. through 12:01 P.M. none of the Dietary Cooks nor the Dietary Aide checked the temperature of the cucumber/tomato salad. - At 12:06 P.M., the temperature of the cucumber/tomato salad was 50.2 ºF. - At 12:16 P.M. eight room trays were prepared for delivery. - At 12:29 P.M. the temperature cucumber/tomato salad was checked on one tray that was for a resident who was out of the facility at that time and the temperature was 66 ºF. - At 12:31 P.M. the temperature of the cucumber/tomato salad was checked for a second tray and the salad was 55.5 ºF - At 12:35 P.M. the temperature of the tomato/cucumber salad was 51.9 ºF. During an interview on 6/1/23 at 12:57 P.M., Dietary [NAME] (DC) A said there was not enough dietary staff to check the temperatures of the food. 2. Observation on 6/1/23 showed the following: - At 11:04 A.M. the meatballs that were to be used for the meatball sandwich on the steam table was 198.5 ºF. - At 11:06 A.M. the sandwich buns were also out on the steam table and kept at room temperature. - At 12:16 P.M. eight room trays were prepared for delivery. - At 12:29 P.M. the temperature of the meatball sandwich on one tray that was for a resident who was out of the facility at that time and the temperature was 105 ºF. - At 12:31 P.M. the temperature of the meatball sandwich was checked, and the temperature was 115.5 ºF. 3. Record review of Resident #16's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 2/18/23, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status, which helped to determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) score of 15 of 15. During an interview on 6/1/23 at 1:04 P.M., the resident said: - His/her food was just OK. - His/her hot food was not hot - Sometimes he/she did not receive what was on the dietary ticket. - The food was cold and late. 4. Record review of Resident #39's quarterly MDS dated [DATE], showed the resident was cognitively intact with a BIMS score of 15 of 15. During an interview on 6/1/23 at 1:07 P.M., the resident said: - The taste of the food was OK. - Just about all the time his/her food was cold. - In the past, he/she has spoken to the previous Administrator about the cold food. - The salad was not real cold. 5. During an interview on 6/1/23 at 1:15 P.M., Certified Nurse's Aide (CNA) D said he/she delivered room trays regularly and has not seen dietary staff check temperatures of room trays or test trays on carts that were delivered to rooms. During an interview on 6/1/23 at 1:33 P.M., the Dietary Manager (DM) said: - The practice has been to check the temperature of the food before it is placed on the delivery cart. - It has not been a practice to check the food when it gets to the residents. During an interview on 6/5/23 at 11:59 A.M., the DM said: - Dietary staff should check temperatures prior to service after it comes out of the oven. - Dietary staff should check the temperatures, right when they serve it. - Dietary staff should check the temperatures of the food every 15 minutes after the food comes out of oven and every 15 minutes. - Within 10 minutes of the actual serving time for the facility. - For the cold food, the dietary staff has used the 6 inch deep pans. - In the past, he/she has told them to transition to the 2 inch (in.) deep pans to store the food in the fridge until that tray is ready to be used. During an interview on 6/5/23 at 12:14 P.M. DC B said: - He/she has not been taught to check the temp of food during the meal service. - The dietary staff should have checked the temperature of the cucumber/tomato salad to make sure that it was still under 41 ºF.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that nursing staff had the appropriate competencies and skills sets to use a mechanical lift prior to use for two sampled residents (Resident #6 and #1) out of 16 sampled residents. This had the potential to effect any resident that required the use of a mechanical lift for transferring. The facility census was 55 residents. A copy of the facility's policy on staff training was requested and not received at time of exit. A copy of the facility's mechanical lift policy and procedure, as well as staff training policy, was requested but not received at time of exit. Review of the Food and Drug Administration's undated article titled Patient Lifts Safety Guide showed: -Staff were to receive training and practice before operating a lift. -Staff were to ensure all movable items were locked and stable before beginning to lift a resident. 1. Review of Resident #6's Care Plan, dated 4/6/23, showed he/she required two staff and the use of a mechanical lift for transfers. Review of the resident's Significant Change Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 4/20/23, showed he/she was totally dependent on staff for transfers. Observation on 5/30/23 at 9:13 A.M. showed: -Certified Nursing Assistant (CNA) G and CNA H transferred the resident from a wheelchair to the bed using a mechanical lift. -Staff did not lock the wheels on the resident's wheelchair or mechanical lift prior to lifting the resident. -As CNA G began lifting the resident from the wheelchair, the wheelchair began to move and CNA H placed his/her foot behind one wheel. During an interview on 5/30/23 at 9:13 A.M., CNA G said there was nothing he/she would have done differently. 2. Review of Resident #1's Care Plan, dated 11/28/22, showed he/she required two staff and the use of a mechanical lift for transfers. Review of the resident's Significant Change MDS, dated [DATE], showed the resident was totally dependent on staff for transfers. Observation on 6/1/23 at 1:31 P.M. showed: -CNA D and CNA E transferred the resident from a wheelchair to the bed using a mechanical lift. -Staff did not lock the wheels on the wheelchair or Hoyer (a mechanical lift) prior to attaching the sling and lifting the resident. 3. During an interview on 6/1/23 at 1:31 P.M., CNA D said he/she was not aware of any mechanical lift in-service and had not attended any such in-service. During an interview on 6/1/23 at 3:16 P.M., the Director of Nursing (DON) said he/she: -Didn't like the facility's mechanical lift as it not only moved up and down but also back and forth. -Had previously pinched an unspecified resident's hand in the lift because the lift was so difficult to use. During an interview on 6/2/23 at 11:02 A.M., CNA A said he/she had never been trained on the proper use of the mechanical lift. During an interview on 6/2/23 at 11:14 A.M., CNA F said he/she: -Had been shown once how to use the lift by an unnamed bath aide. -Had not been asked to demonstrate proper use of the lift. During an interview on 6/5/23 at 11:06 A.M., Agency CNA A said he/she: -Had not been educated on Hoyer lifts. -Had never demonstrated competency to use the Hoyer lift. During an interview on 6/5/23 at 8:55 A.M., the DON said: -Staff were to lock the wheels on the wheelchair and mechanical lift before raising or lowering a resident. -The MDS Coordinator had done an in-service previously but had not documented it, he/she believed it was a verbal in-service only with no demonstrations. During an interview on 6/5/23 at 12:52 P.M., the DON said: -Staff training was to include an in-service on any equipment they would use, prior to use, a demonstration based on the manufacturer's instructions, and a return demonstration to show competency. -The in-service sheet should specify what type of competency was shown, whether through return demonstration or verbally. -He/she was not aware of any staff performing a return demonstration of proper mechanical lifts. MO00219140

Based on interview and record review, the facility failed to submit the Payroll Based Journal data (PBJ- a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for the last three quarters which had the potential to affect all residents. The facility census was 55 residents. Review of the facility's policy, dated October 2017, titled Reporting Direct-Care Staffing Information (PBJ) showed: -As of 7/1/16, the facility was to electronically report direct care staffing and census information to the Centers for Medicare and Medicaid (CMS) through the PBJ system. -Staffing information was to be collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. 1. Review of the facility's PBJ Quarter Three (2022) from 4/1/22-6/30/22 showed no data submitted for the quarter. Review of the facility's PBJ Quarter Four (2022) from 7/1/22-9/30/22 showed no data submitted for the quarter. Review of the facility's PBJ Quarter One (2023) from 10/1/22-12/31/22 showed no data submitted for the quarter. During an interview on 6/1/23 at 2:13 P.M., the Human Resources Director said the Business Office Manager was responsible for submitting the PBJ reports. During an interview on 6/1/23 at 2:15 P.M., the Business Office Manager said: -He/she was responsible for submitting the PBJ information. -The facility's former Director of Nursing (DON) was supposed to submit the data for the PBJ report but did not know how to do it. -He/she was submitting the reports moving forward. -He/she expected all regulations to be followed. -He/she was aware the reports were required to be submitted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedure for a COVID-19 breakout by having two supplemental residents (Resident #4 and #40) share a bathroom out of seven supplemental residents; by not performing COVID-19 tests correctly for one sampled resident (Resident #19) and two supplemental residents (Resident #33 and #8) out if 16 sampled residents and seven supplemental residents; by placing used Personal Protective Equipment (PPE) outside of COVID-19 positive resident rooms which had the potential to affect all residents; and not notifying the families of two sampled COVID-19 positive residents (Resident #30 and #12); and failed to ensure handwashing was completed to prevent cross-contamination during wound care for one sampled resident (Resident #27) out of 16 sampled residents. The facility census was 55 residents. Review of the facility's policy titled Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures dated September 2022 showed: -The infection prevention and control measures that are implemented to address the SARS-CoV-2 (COVID) pandemic are incorporated into the facility infection prevention and control program include: --Identifying and managing ill residents and staff. --Implementing source control measures. --Implementing universal use of PPE for staff. --Responding to SARS-CoV-2 exposures. --Implementing outbreak investigations when indicated. Review of the facility's policy titled Infection Prevention and Control Program Policy and Procedure dated 10/27/22 showed: -The purpose of the policy was to prevent, recognize, and control the onset and spread of COVID-19 to the extent possible. -Inform residents, their representatives, and families of those residing in the facility by 5:00 P.M. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new on-onset of COVID-19 infection occurring within 72 hours of each other. Review of an in-service completed 1/25/23 showed: -The type of PPE used will vary based on the level of precautions required, such as standard and contact, droplet, or airborne infection isolation precautions. (The in-service also included an audit tool and instructions on how to [NAME] and Doff PPE) Review of the facility's policy titled Handwashing/Hand Hygiene dated August 2019 showed: -All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: --Before and after direct contact with residents. --After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. -The use of gloves does not replace hand washing/hand hygiene. -Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 1. Review of Resident #4's face sheet showed he/she admitted to the facility with the following diagnoses: -Acute embolism (an obstruction in an artery) and thrombosis (the clotting of the blood within the circulatory system) of other specified deep vein of the left lower extremity. -Essential (primary) hypertension (HTN-high blood pressure). Review of the facility's facility wide COVID-19 testing on 5/28/23 showed the resident tested positive for COVID-19. Review of Resident #40's face sheet showed the resident admitted to the facility with the following diagnoses: -Spinal Stenosis (an abnormal narrowing of the spinal canal), lumbar region (lower back) without neurogenic claudication (leg pain, heaviness, and/or weakness with walking that arises from the nervous system). -HTN. Abdominal aortic aneurysm (an enlargement of the aorta (the main blood vessel that delivers blood to the body) at the level of the abdomen) without rupture. NOTE: The resident did not test positive for COVID-19 at time of exit. Review of the facility's facility-wide COVID-19 testing on 5/28/23, 5/31/23, and 6/3/23 showed the resident tested negative for COVID-19. Review of Resident #40's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by the facility staff for care planning) dated 4/17/23 showed: -The resident had severe impairment of cognition. -The resident was frequently incontinent of bladder and bowel. Observation on 5/30/23 at 10:15 A.M. showed Resident #4 did not have a commode in his/her room. Observation on 5/31/23 at 2:50 P.M. showed Resident #40: -Did not have a commode in his/her room. -Did not have signage on the bathroom door indicating the resident could not use the restroom. During an interview on 5/31/23 at 2:50 P.M., Certified Nursing Assistant (CNA) B said: -Resident #4 and Resident #40 shared a bathroom. -Resident #4 and Resident #40 were the only ones in his/her care section that shared a bathroom. -He/she had told Resident #40 not to use his/her bathroom due to Resident #4 being COVID-19 positive on 5/28/23. -He/she then asked the resident how many times he/she had used the shared bathroom in between 5/28/23 and the time of the interview and Resident #40 said two times. -He/she reminded the resident to continue to not use the shared bathroom. During an interview on 6/5/23 at 8:56 A.M., Agency CNA A said: -A COVID-19 positive resident should not share a bathroom with a COVID-19 negative resident. -He/she would offer the COVID-19 positive resident a commode to use during the period of isolation. -Another solution is to keep the bathroom continually sanitized, specifically the toilet. -If he/she came upon a room in which a COVID-19 positive resident and COVID-19 negative resident shared a bathroom he should would go ask the nurse for that hall what the appropriate action should be. During an interview on 6/5/23 at 8:58 A.M. CNA B said: -He/she could have put signage up to remind Resident #40 to not use the shared bathroom. -Resident #40 was usually incontinent and wore a brief. -He/she did not offer the resident a commode at the time the shared bathroom could no longer be used by Resident #40. -He/she did not think a commode was offered to Resident #40 throughout the time the resident could not use the shared bathroom. -The reason he/she did not offer a commode to Resident #40 was because he/she did not like to use commodes due to the smell. During an interview on 6/5/23 at 9:03 A.M. Licensed Practical Nurse (LPN) A said: -When a COVID-19 positive resident and COVID-19 negative resident share a bathroom the bathroom needed to be sanitized after each use of the bathroom by the COVID-19 positive resident. -A commode could have been offered to Resident #4 so that both Resident #4 and Resident #40 did not have to share a bathroom. -To his/her knowledge a commode was never offered to Resident #4 or Resident #40 during the time Resident #4 was in isolation. -He/she would educate CNA's, Certified Medication Technicians (CMTs) and housekeeping on offering commodes and sanitizing the bathroom if he/she knew a COVID-19 positive resident and COVID-19 negative resident were sharing a bathroom. -He/she had only been in Resident #4's room to perform treatments or give medications, but never assisted the resident in the bathroom. -He/she did not think there had been any issues with Resident #40 using the bathroom in the hall while Resident #40 could not use his/her bathroom. -Resident #40 is incontinent the majority of the time and had been frequently checked throughout the week. During an interview on 6/5/23 at 9:45 A.M. the Director of Nursing (DON) said: -Resident #4 and Resident #40 should not have shared a bathroom while Resident #4 was in isolation due to his/her COVID-19 status. -He/she would have expected staff to move either resident to a different room so the bathroom could not be used by both residents. -The facility did have the capability at that time to move either resident. -He/She would have expected staff to offer a commode to the COVID-19 positive resident if moving either resident was not possible. -To his/her knowledge Resident #40 was only provided education to remind Resident #40 to not use the shared bathroom. -An additional intervention would have been to use plastic to cover the door or put signage up as additional reminders to Resident #40 to not use the shared bathroom. -The staff were incorrect in their actions to prevent Resident #4 and Resident #40 of sharing a bathroom during the time of Resident #4's isolation. 2. Review of Resident #8's face sheet showed he/she was admitted to the facility with the following diagnoses: -Encephalopathy (a broad term for any brain disease that alters brain function or structure). -Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation). Observation on 5/31/23 at 2:30 P.M. of COVID-19 testing on Resident #8 performed by the Human Resources Director (HRD) showed: -He/she had already prepped the test before sanitizing his/her hands or using gloves. -He/she sanitized his/her hands and put on gloves. -He/she then knocked on Resident #8's door, walked into the room, explained the testing procedure, and performed the COVID-19 test. -He/she then came of the resident's room, placed the nasal swab into the test, and touched other testing equipment with the same gloved hands including the pen and fluid droplet used for testing. -He/she then removed his/her gloves, sanitized his/her hands, and put on new gloves before moving on to the next resident. 3. Review of Resident #33's face sheet showed he/she was admitted to the facility with the following diagnoses: -HTN. -Anemia (a condition in which there is a deficiency of red blood cells or of hemoglobin in the blood). Observation on 5/31/23 at 2:32 P.M. of COVID-19 testing on Resident #33 performed by the HRD showed: -He/she knocked on the Resident #33's door with gloved hands, walked into the room, and explained the procedure to the resident. -He/she came out of the resident's room, opened a new test, put the drops into the test, grabbed the pen to write the resident's name on the test, and grabbed a swab for the bag. -He/she then walked back into the resident's room, tested the resident, and exited the resident's room. -He/she put the swab into the test, closed the resident's door, removed his/her gloves and sanitized his/her hands. 4. Review of Resident #19's face sheet showed he/she admitted to the facility with the following diagnoses: -Cerebral Infarction (disrupted blood flow to the brain) due to unspecified occlusion (blockage) or stenosis (an abnormal narrowing) of the basilar artery (the artery that branches to establish the right and left posterior (back) cerebral (head) arteries. -Coronary Artery Disease (CAD- a condition which affects the arteries that supply the heart with blood) without angina pectoris (chest pain). Observation on 5/31/23 at 2:39 of COVID-19 testing on Resident #19 performed by the HRD showed: -He/she sanitized his/her hands and put gloves on. -He/she then knocked on Resident #19's door, went into the room, explained the procedure to the resident, and touched the resident on the back for reassurance. -He/she then exited the resident's room grabbed a test, opened the test, and wrote the resident's name on the test without taking off his/her gloves or washing/sanitizing his/her hands. -He/she continued to prepare for the test, grabbed a swab out of the bag, unpackaged the swab, and went into the resident's room to perform the test. -After exiting the room, he/she grabbed the liquid bottle and put in the drops before inserting the swab into the test and grabbed the same pen to write the time on the test. -He/she then put the lid back onto the bottle of testing liquid, removed his/her gloves and sanitized his/her hands. During an interview on 5/31/23 at 2:45 P.M. the HRD said: -He/she performed the tests the best way he/she knew how to do it, but was unsure of his/her performance. -He/she would not have done anything differently through the testing process. -He/she kept his/her gloves on going in and out of resident rooms because he/she did not think he/she needed to put in new gloves or wash sanitize his/her hands even after touching a resident. -Was unsure if using the same gloves after completing each test and touching other testing equipment was appropriate or not. -He/she had never done testing at this facility before and at his/her previous facility the same gloves were used throughout the whole process. During an interview on 5/31/23 around 3:00 P.M. the DON said: -The HRD had not performed the COVID-19 testing per facility protocol. -He/she would have expected the HRD to sanitize his/her hands every time he/she entered and exited a resident's room. -He/she would have expected the HRD to remove his/her gloves and sanitize his/her hands after testing the resident and before touching other testing material. -He/she would need to educate the HRD on how testing should be performed. -He/she then pulled the HRD from continuing COVID resident testing. 5. Observation on 5/30/23 at 9:15 A.M. showed used gowns hanging outside of each COVID-19 positive resident room. Observation on 5/31/23 at 12:11 P.M. showed used gowns hanging outside of each COVID-19 positive resident room. Observation on 6/1/23 at 9:05 P.M. showed used gowns hanging outside of each COVID-19 positive resident room. During an interview on 6/1/23 at 9:52 A.M., the DON said: -He/she was unaware that hanging the used gowns outside of the COVID-19 positive resident rooms was not appropriate practice. -He/she then realized that it was inappropriate due to not having a designated COVID-19 unit in the facility. -He/she then left to take down all of the used gowns and dispose of them. During an interview on 6/5/23 at 11:50 A.M., LPN A said: -He/she kept all of her COVID-19 gowns inside of resident rooms. -Keeping used gowns outside of COVID-19 positive resident rooms was an inappropriate practice due to the facility not having a designated COVID-19 unit. -He/She and other nurses were responsible for notifying the families of COVID-19 positive residents of their COVID-19 status. 6. Review of Resident #30's face sheet showed he/she admitted to the facility on [DATE]. Review of the Resident COVID-19 testing log showed the resident was positive for COVID-19 on 5/31/23. Review of the Resident #30's most recent progress notes indicated family was not notified of the resident's positive COVID-19 status as of 6/5/23. 7. Review of Resident 12's undated face sheet showed he/she admitted to the facility on [DATE]. Review of the Resident COVID-19 testing log showed the resident was positive for COVID-19 on 5/31/23. Review of Resident #12's most recent progress notes indicated family was not notified of the resident's positive COVID-19 status as on 6/5/23. During an interview on 6/5/23 at 9:45 A.M., the DON said: -He/she thought all families of COVID-19 positive residents were notified on 5/28/23. -The nurses were expected to notify the families and put a progress note once completed. -He/she was responsible for ensuring all families were notified. -He/she could not provide any documentation of notification to families after 5/28/23 for the newly COVID-19 positive residents. During an interview on 6/5/23 at 11:50 A.M., LPN A said: -He/she was responsible for notifying the families of COVID-19 positive residents of their COVID-19 status. -He/she notified a family of a COVID-19 status then he/she would document that in a progress note. Complaint MO00219381 8. Review of Resident #27's Face Sheet showed he/she was admitted on [DATE] with diagnosis including heart failure, high blood pressure, and pain. Review of the resident's Comprehensive Care Plan dated 1/5/23, showed the resident needed assistance with activities of daily living and transfers due to weakness. Intervention showed staff would assist the resident with transfers, dressing, bed mobility, assess the resident's skin for signs and symptoms of skin breakdown and monitor the resident for pain. The care plan also showed the resident was at fall risk due to impaired balance, occasional incontinence and mild cognitive impairment. Review of the resident's quarterly MDS dated [DATE] showed the resident: -Was cognitively intact with minimal memory loss. -Needed limited assistance with bed mobility and transfers. -Was not steady in surface to surface transfers and needed staff assistance. -Used a wheelchair for mobility. Observation and interview on 5/31/23 at 9:08 A.M., showed the resident was sitting in his/her wheelchair, dressed in shorts with glasses on. His/her call light was within reach. The resident had small scabs that were the size of the top of a pencil eraser and smaller on both his/her knees. On the resident's left knee there was a scab that looked to have come off and the skin underneath was actively bleeding. The resident said: -He/she had bumped his/her knee while coming out of the bathroom, but he/she did not realize that it was bleeding. -The nursing aide was just in his/her room and his/her knee was not bleeding at the time. He/she requested a paper towel and began to clean the blood that was on his/her left leg. -The call light was turned on at 9:12 A.M. and CNA B came into the resident's room and told the resident to use the paper towel to put pressure on the area and the nurse was on the way. -CNA B then without washing or sanitizing his/her hands, put on gloves, took the bloody paper towel from the resident and began patting the wound to absorb the blood. He/she wiped the skin around the wound then put a sterile band aid on it and told the resident this was just until the nurse came in. -CNA B then picked up a cleansing wipe and wiped dried blood that was on the resident's leg and discarded the wipe then removed and discarded his/her gloves. -Without washing or sanitizing his/her hands, CNA B left the resident's room and informed the resident the nurse would be in shortly. During an observation on 5/31/23 at 9:27 A.M., LPN C entered the resident's room and without washing or sanitizing his/her hands, he/she put on gloves and peeled back the band aid that was covering the resident's wound. -The resident said he/she bumped his/her knee and LPN C said it looked as though the scab came off of the resident's sore. -He/she told the resident he/she was going to get supplies to clean the area and put a larger bandage on it. LPN C then discarded his/her gloves, washed his/her hands and left the resident's room. - At 9:37 A.M., LPN C came back into the resident's room with supplies to clean and cover the resident's wound. Without sanitizing or washing his/her hands, LPN C put on gloves, removed the band aid on the resident's left knee and discarded it. -LPN C then discarded his/her gloves then without washing or sanitizing his/her hands, put on new gloves, cleaned the resident's knee with wound cleanser using a 4 by 4 gauze pad. -LPN C then removed his/her gloves, discarded them and washed his/her hands using a paper towel to dry them. LPN C then took the sterile bandage out of the package, washed his/her hands again and dried them turning off the faucet with a paper towel. -He/She dated the bandage and placed it on the resident's wound. LPN C discarded the paper from the bandage into the trash can then washed his/her hands, turning off the water with a paper towel. During an interview on 6/5/23 at 10:08 A.M., CNA B said: -The nursing staff were supposed to wash or sanitize their hands before going into a resident's room and before they leave their room. -He/she should have washed his/her hands before he/she went into the resident's room and again after he/she removed his/her gloves once he/she cleaned the blood off of the resident's leg. -He/she should have also washed his/her hands before he/she left the resident's room. -He/she knew that he/she had not washed her hands upon entering the room and after cleaning the blood on the resident and then placing the bandage on his/her leg. -He/she thought about it afterward and recognized his/her mistake, but he/she should have washed her hands upon entering the room, after cleaning up the blood and after putting the band aid on the resident's leg before leaving the resident's room. During an interview on 6/5/23 at 10:40 A.M., LPN A said: -All nursing staff should wash their hands before entering the resident's room, before exiting the resident's room and during care if/when needed. -If nursing staff is cleaning blood or bodily fluid, they should put on gloves and clean the bodily fluid and then discard their gloves and wash their hands after they clean it up. -Nursing staff should then complete the clean process, placing the bandage on the resident, and then wash their hands again before they leave the resident's room. During an interview on 6/5/23 at 12:49 P.M., the Director of Nursing (DON) said: -The nursing staff is supposed to sanitize or wash their hands before they enter the resident's room (sanitizing station in the hall) or upon entering the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff kept urinary catheter tubing (a sterile tube inserted into the urinary bladder to drain urine), drainage bag (a bag that is attached to the urinary catheter tubing) and privacy bag off (a cover to conceal the urine drainage from view) off the floor which has the potential to cause infection for two sampled residents (Resident #9 and #13) out of 13 sampled residents. The facility census was 30 residents. Catheter Care (Indwelling) guidelines dated March 2015 did not list any guidance for keeping the urinary drainage bag whether in or out of a privacy bag off of the floor. 1. Record review of Resident #9's admission Record showed he/she admitted to the facility on [DATE] with following diagnoses: -Neuromuscular dysfunction of bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). -Quadriplegia (paralysis of all four extremities and usually the trunk). Record review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 5/17/21 showed: -His/Her cognition was intact. -He/She was totally dependent on staff for all aspects of his/her care. -He/She had an indwelling catheter. -He/She had no Urinary Tract Infections (UTI-an infection in any part of the urinary system-kidneys, ureters, bladder and urethra). Record review of the resident's Care Plan dated 5/10/21 showed the resident requires an indwelling urinary catheter related to Neurogenic Bladder and quadriplegia. During an observation of a mechanical lift transfer (a device used to lift and transfer a person from one surface to another surface) on 8/5/21 at 8:43 A.M., showed: -Certified Nursing Assistant (CNA) A and CNA B moved the resident from his/her wheelchair to the bed. -Two empty privacy bags were attached to the resident's bed frame. -CNA A placed the resident's urinary drainage bag on the floor without a barrier. 2. Record review of Resident #13's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 5/28/21 showed: -Obstructive Uropathy (a condition in which the flow of urine is blocked from leaving the bladder). -His/Her cognition was severely impaired. -He/She had a UTI within the last 30 days of this MDS. During an observation on 8/9/21 at 8:30 A.M., showed: -The resident in bed asleep. -The resident's bed was in the lowest position with a fall mat next to the bed. -The resident's Foley catheter bag was in a privacy bag on the fall mat. -There was no barrier between the privacy bag and the fall mat. During an observation on 8/9/21 at 1:32 P.M., showed: -The resident awake sitting up in bed. -The resident's bed was in the lowest position with a fall mat next to the bed. -The resident's Foley catheter bag in a privacy bag on the fall mat. -There was no barrier between the privacy bag and the fall mat. 3. During an interview on 8/5/21 at 9:00 A.M., CNA B said: -The Foley Catheter bag gets placed in the privacy bag on the side of the bed or on the wheelchair after a transfer. -The Foley Catheter bag should not be placed on the floor. During an interview on 8/9/21 at 4:12 P.M., the Director of Nursing (DON) said: -When the resident is in bed the catheter bag should be in a privacy bag hung on the bed frame. -At no time should the catheter bag, in or out of a privacy bag, be on the floor. -If a resident with a catheter bag, in or out of a privacy bag, needs his/her bed in the lowest position there should be a barrier like a towel or a wash basin under the bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pharmacy Medication Regimen Reviews with the pharmacist's recommendation notes were in the resident's medical record monthly for two sampled residents (Resident #1 and #20) out of 13 sampled residents. The facility census was 30 residents. Record review of the facility's undated Medication Regimen Reviews (MRR) Policy showed: -The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. -The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. -The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors, and other irregularities. -Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity and includes: the resident's name; the name of the medication; the identified irregularity; the pharmacist's recommendation. -An irregularity refers to the use of medication that: is inconsistent with accepted pharmaceutical services standards of practice; is not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of the pharmaceutical services. --It may also include the use of medication: without indication; without adequate monitoring; in excessive doses; and/or in the presence of adverse consequences. -If the Physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been taken: he/she contacts the Medical Director. -If the Medical Director is the physician of record he/she contacts the Administrator. -The attending Physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it. -The Consultant Pharmacist provides the Director of Nursing Services and Medical Director with a written, signed and dated copy of all medication regimen reports. -Copies of MRR reports, including Physician responses are maintained as part of the permanent medical record. --The Consultant Pharmacist submits a quarterly report that includes a summary of key findings from the MRR's. 1. Record review of Resident #1's admission Record showed he/she was admitted on [DATE] with a diagnosis of Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of the resident's Care Plan (written out plan for the care of the resident) dated as last reviewed 6/28/21 showed he/she was at risk for adverse consequences related to receiving antidepressant medication (Remeron) for treatment of depression. Record review of the resident's Physicians Order Summary (POS) dated August 2021 showed Mirtazapine (Remeron) (an antidepressant, treats depressive disorders) 7.5 milligram (mg) by mouth (PO) at bedtime for a diagnosis of Major Depressive Disorder. Start 06/08/2020 renewed 06/20/2021. Record review of the resident's pharmacist monthly MRR and Gradual Dose Reduction (GDR) from January 2021 to July 2021 showed: -Pharmacist notes stating see notes recommendations dated 3/9/21. -Pharmacist notes stating see notes recommendations dated 6/22/21. --No documentation could be located by the facility regarding the pharmacist recommendation or the physician response in the resident's medical records. Record review of the resident's medical record showed no documentation of the resident's Pharmacist Consultation Report or recommendations from 3/9/21 and from 6/22/21. 2. Record review of Resident 20's admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Frontotemporal Dementia (a type of Dementia [a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning] that causes problems with behavior and language). -Generalized Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Major Depressive Disorder. Record review of the resident's POS dated August 2021 showed: -Ativan (a Benzodiazepine, acts on the brain and nerves to produce a calming effect) 0.5 mg PO three times a day (TID) for diagnosis of Generalized Anxiety Disorder. Start date 3/17/21. -Haloperidol (Haldol) (an antipsychotic, for treatment of Psychosis, and also for some Dementias) 1 mg PO twice a day (BID) for diagnosis of Frontotemporal Dementia. Start date 6/28/21. -Remeron (mirtazapine) 15 mg PO bedtime for diagnosis of Major Depressive Disorder. Start date 4/29/21. -Trazodone (an Antidepressant) 50 mg PO bedtime for diagnosis of Insomnia. Start date 3/17/21. -Zoloft (sertraline) (a Selective Serotonin Reuptake Inhibitor, slows the process by which Serotonin is reused by nerve cells that make it) 100 mg PO bedtime give along with Zoloft 25 mg to equal 125 mg for diagnosis of Major Depressive Disorder. Start date 4/22/21. -Zoloft (sertraline) 25 mg PO bedtime give along with Zoloft 100 mg to equal 125 mg for diagnosis of Major Depressive Disorder. Start date 4/22/21. Record review of the Pharmacist monthly MRR and GDR from January 2021 to July 2021 showed: -Pharmacist notes stating see notes recommendations for January 18, 2021. -Pharmacist notes stating see notes recommendations for March 9, 2021. -Pharmacist notes stating see notes recommendations for March 18, 2021. -Pharmacist notes stating see notes recommendations for June 22, 2021. --No documentation could be located by the facility regarding the pharmacist recommendation or the physician response in the resident's medical records. Record review of the resident's medical record showed no documentation of the resident's Pharmacist Consultation Report or recommendations from 1/18/21 and from 6/22/21. 3. During an interview on 8/9/21 at 8:35 A.M., the Director of Nursing (DON) said: -He/she looked for the missing Pharmacist notes to the Physician in both of the resident's medical records. -He/she was unable to locate the missing ones. -With the previous owners two staff members kept records of Pharmacist notes. -Administration is having a meeting to decide who will keep tract of different records instead of several staff assigned to keep the same type of records. During an interview on 8/9/21 at 4:12 P.M., the DON said: -He/She expects the Pharmacist to do a monthly medication review on each resident. -The Pharmacist fills out the recommend form and emails it to the facility. -The Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) Coordinator has been putting the Pharmacist recommendations in the physician's facility mailbox. -The Physician should be checking his/her facility mailbox weekly. -The Physician makes the choices of what he/she wants. -The Physician usually gives the form to a nurse who puts in the orders. -The DON is taking over this responsibility from the MDS Coordinator and will be checking to be sure the physician sees the recommendations and any order updates are completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff completed the annual tuberculosis (TB - a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) screening for one sampled resident (Resident #19) and three supplemental residents (Residents #10, #22, and #24) out of five residents sampled for tuberculosis screening. The facility census was 30 residents. Review of the undated facility Screening Residents for Tuberculosis policy showed: -The facility will screen all residents for TB infection and disease. -Individuals identified with active TB disease shall be isolated from other residents and ancillary staff and transported to an appropriate care facility as soon as possible. -Screening New Admissions or Readmissions: --The admitting nurse will screen referrals for admission and readmission for information regarding exposure to or symptoms of TB. --If a potential resident has been exposed to active TB or is at increased risk of TB infection he/she will be screened for latent tuberculosis infection using tuberculin skin tests (TST) or interferon gamma release assay (IGRA). --If the IGRA or TST or TST is positive, the nursing staff will contact the physician to obtain orders for a chest X-ray (CXR) and the physician will access the resident prior to admission for possible active TB. -Screening of new admissions and readmissions for TB infection and disease is in compliance with State regulations. 1. Review of Resident #19's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Stroke. -COVID (a new disease caused by a novel (new) coronavirus). Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 6/21/21, showed: -The resident's most recent admission date to the facility was 6/30/20. -He/She was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 10 out of 15. Review of the resident's medical records showed no documentation a TB screening had been completed for the resident. It could not be determined if/when the last TB screening had been completed for the resident. 2. Review of Supplemental Resident #10's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Hemiplegia/Hemiparesis (partial loss of movement or feeling) following stroke. -Abnormal weight loss. -Diabetes. Review of the resident's quarterly MDS, dated [DATE], showed: -His/Her most recent admission date to the facility was 12/28/20. -He/She was severely cognitively impaired. Review of the resident's medical records showed no documentation a TB screening had been completed for the resident. It could not be determined if/when the last TB screening had been completed for the resident. 3. Review of Supplemental Resident #22's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Bladder cancer. -COVID. -Skin cancer. -Prostate cancer. Review of the resident's annual MDS, dated [DATE], showed: -His/Her most recent admission date to the facility was 9/9/19. -He/She had a BIMS of 10 out of 15 indicating he/she was moderately cognitively impaired. Review of the resident's medical records showed no documentation a TB screening had been completed for the resident. It could not be determined if/when the last TB screening had been completed for the resident. 4. Review of Supplemental Resident #24's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -COVID. -Asthma (a respiratory disorder characterized by recurring episodes of shortness of breath, wheezing on expiration and/or inspiration caused by constriction of the bronchi, coughing, and thick secretions). Review of the resident's annual MDS, dated [DATE], showed: -His/Her most recent admission date to the facility was 3/5/21. -He/She had a BIMS of 15 out of 15 indicating he/she was cognitively intact. Review of the resident's medical records showed no documentation a TB screening had been completed for the resident. It could not be determined if/when the last TB screening had been completed for the resident. 5. During an interview on 8/13/21 at 12:08 P.M., the Director of Nursing (DON) said: -He/She could not locate documentation of TB testing or signs and symptoms of TB screenings for Residents #10, #19, #22, or #24. -He/She expected the nursing staff to have completed annual screening on all residents and to have placed the screening in the resident's medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain the two Automatic External Defibrillator (AED) machines (a portable electronic device that automatically diagnoses the life-threatening heart rhythms) by not ensuring the AEDs were checked monthly, by not ensuring the battery/pads pack were not expired, by not ensuring the battery/pads pack had not been opened, and by not ensuring the staff knew where the AEDs were located, for two out of two sampled AED machines. The facility census was 30 residents. Record review of the facility's undated policy, AED - Care and Use of the Automatic External Defibrillator, showed: -During a sudden cardiac arrest event (the abrupt loss of heart function, breathing and consciousness), follow guidelines outlined in the procedure for Cardiopulmonary Resuscitation (CPR a lifesaving technique) and Basic Life support -The automatic external defibrillator would be used to try to restore normal cardiac rhythm when arrhythmia (an irregular or abnormal heart rhythm) was strongly suspected. -If an individual was found unconscious and Sudden Cardiac Arrest was suspected, they were to begin the AED protocol. -Begin CPR until the AED was available. -Remove the device from it's case. -Check the adhesive on the pads to make sure they were sticky, if not replace the pads. -Follow the prompts (the AED machine would tell you what to do) until emergency medical service arrives. -Replace used accessories, including the pads. -Clean and inspect the device. -Follow the manufacturer's guidelines for proper storage. Record review of the undated SAM 300P (AED) User's Manual showed: -The user was to check the expiry date on the label. -The user was not to open the Pad-Pak tray or defibrillation protective packaging until they were required in an emergency. -Inform any possible users of the location of the SAM 300P. -The manufacturer recommended that a spare Pad-Pak was kept with the SAM 300P. -The manufacturer recommended the users perform regular maintenance checks. -The users were to check the status indicator. -If the status indicator was not flashing or was flashing red a problem had been detected, refer to the troubleshooting section of the manual. -Check the expiration date of the Pad-Pak currently inserted. -If the Pad-Pak had exceeded its use by date, remove it and replace with a new Pad-Pak. -Check supplies, accessories and spares for damage or expiration. -Replace any accessories for any damaged or that have exceeded their expiration date. -Check the exterior of the SAM 300P for cracks or other signs of damage. -Check that trained responders were aware of the SAM 300P's location. 1. Observation of the AED at Nurses' Station A on [DATE] at 12:00 P.M. with the Restorative Aid (RA) showed: -The foil container with the battery/pads (Pad-Pak) in it had been opened. -The expiration date on the Pad-Pak was 1/20. -There was no sheet at the nurses station to show anyone had checked the machine. 2. Observation of the AED at Nurses' Station B on [DATE] at 12:15 P.M. with the RA showed: -The foil container with the Pad-Pak in it, had expired 1/20. -There was no sheet at the nurses station to show anyone had checked the machine. During an interview on [DATE] at 12:20 P.M. the RA said: -The Director of Nursing (DON) was responsible for checking the AED machine monthly. -He/she did not know if there was a maintenance log or where it was kept. -There had been a resident living in the facility that had coded (cardiac arrest)the week before. -The staff had brought the AED machine and opened the foil package with the pads. -The AED was not used but the foil container was put back in the AED pack. -He/she did not know if you could use the pads once the foil package had been opened. -He/she did not know if there were any spare pads or batteries for the AED. -The pad-pak should not have been used if it had expired. During an interview on [DATE] at 12:30 P.M. the Administrator said: -The DON was responsible for checking the AED machine. -It was to be checked every month. -There should have been documentation it had been checked. During an interview on [DATE] at 12:45 P.M. the DON said: -He/she had not been told it was part of his/her duties to check the AED machine. -He/she had not checked the AED. -He/she did not know where the maintenance log would have been kept. -The AED should have been checked monthly and recorded on a maintenance log. -He/she did not know if the facility had a spare pad-pak or batteries. -He/she did no know where the pad-pak or batteries would have been kept. During an interview on [DATE] at 8:15 A.M. Certified Nursing Assistant (CNA) C said: -He/she had worked at the facility for almost 15 years. -He/she did not know if the facility had an AED machine. During an interview on [DATE] at 8:50 A.M. CNA D said: -He/she has worked at the facility for two years. -There were two AED machines. -One was located at each nurse's station. -It was used recently on a resident who had coded. -He/she did not know who was responsible for maintaining it. During an interview on [DATE] at 10:00 A.M. the DON said: -He/she was not able to provide any paperwork to show the AED had been maintained during the last year. -There were no extra battery/pad packs in the facility. -A new battery/pad pack has been ordered. -The pad-pak was not something that could have been purchased at a local store. -An expired pack should not have been used. -A pad-pack would not be reused if the foil container had been opened as the pads could have dried out. -Going forward he/she would be responsible for ensuring the AED is checked monthly with a clipboard and sign in sheet nearby. -There were residents in the facility that were a full code (CPR and AED would be used until EMS arrived) and would possibly need to use the AED on them if they went into cardiac arrest. -The staff should have known where the AED's were kept. -This would need be added to the staff's education.