**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide trauma informed care (understanding a resident's life experiences to provide effective care) for one sampled resident (Resident #178) who had a diagnosis of Post Traumatic Stress Disorder (PTSD-a mental health condition caused by an extremely stressful or terrifying event) out of 12 sampled residents. The facility census was 38 residents. Review of the facility's Trauma Informed Care Policy, revised July 2024, showed: -It was the policy of the facility to provide care and services which, in addition to meeting professional standards, were delivered using approaches which were culturally competent, accounted for experiences and preferences, and addressed the needs of trauma survivors by minimizing triggers and/or re-traumatization. -The facility would use a multi-pronged approach to identify a resident's history of trauma, as well as his or her cultural preferences. This would include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others. -The facility would collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and other health care professionals (such as psychologist and mental health professionals) to develop and implement individualized care plan interventions. -The facility would identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions would identify ways to decrease the effect of the trigger on the resident and would be added to the resident's care plan. -Trauma specific care plans interventions would recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living), and anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Those interventions would also recognize the survivors need to be respected, informed, connected, and hopeful regarding their own recovery. -In situations where a trauma survivor is reluctant to share their history, the facility would still try to identify triggers which may re traumatize the resident and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident. Review of the facility's Comprehensive Care Plans Policy, revised July 2024, showed: -It was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the resident's comprehensive assessment. -Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. -The comprehensive care plan would describe, at a minimum, individualized interventions of trauma, as indicated. Trigger specific interventions would be used to identify ways to decrease the resident's exposure to triggers which re traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. -The comprehensive care plan would be prepared by an interdisciplinary team, that included, but was not limited to: The attending physician or non-physician practitioner designee involved in the resident's care, a registered nurse with responsibility to the resident, a nurse aide with responsibility to the resident, a member of the food and nutrition services staff, the resident and the resident's representative, to the extent practicable, and other appropriate staff or professionals in disciplines as determined by the resident's needs, such as: The social services director/social worker, licensed therapist, administration, mental health professionals, and chaplain. 1. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning), dated 1/18/25 showed: -The resident was admitted to the facility on [DATE]. -The resident had moderate cognitive impairment. -The resident had diagnoses which included: PTSD, Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others), and depression. Review of the resident's Care Plan (an individualized plan that summarizes a person's health conditions and current treatments for their care) dated 1/18/25, showed: -The resident had diagnoses which included: PTSD, schizophrenia, and Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Note: The resident's care plan did not have any focus, goals, or interventions to reflect the resident's diagnoses of: PTSD, schizophrenia, or major depressive disorder. Further the care plan did not identify potential triggers related to the resident's diagnosis of PTSD. Review of the resident's hospital Discharge summary, dated [DATE], showed: -The resident had the diagnoses of PTSD, schizophrenia, and depression. -The resident's psychiatric diagnoses could interfere with participation in therapies and limit the resident's functional progress. -A recommendation from the hospital physician was made to monitor the resident's mood. Review of the resident's Trauma Informed Care assessment dated [DATE], showed: -The resident had not experienced a traumatic event. -The probable PTSD interview questions were not completed. During an interview on 2/6/25 at 10:17 A.M., the resident said: -He/She had been a resident at the facility for a while. -He/She planned to discharge home after he/she completed physical therapy at the facility. -Note: The resident had aphasia (loss of ability to produce or comprehend language due to brain injury) due to a recent stroke and was having a difficult time communicating. He/She was unable to answer any questions when asked about his/her medical and mental health diagnoses. During an interview on 2/10/25 at 11:00 A.M., the Certified Nursing Assistant (CNA) A said: -He/She was aware of what PTSD was and how it was caused by trauma. -He/She was aware that the resident had PTSD due to another CNA reporting it to him/her. -He/She was not aware of the resident's triggers or how to prevent triggering the resident's past trauma. -He/She was not aware of how to access the resident's care plan in the electronic medical record. During an interview on 2/10/25 at 11:10 A.M., the agency Registered Nurse (RN) A said: -He/She was aware of what PTSD was and how it was caused by trauma. -He/She was not aware that the resident had a diagnosis of PTSD. -He/She was not aware that the resident had a diagnosis of schizophrenia or depression. -He/She was not aware of possible triggers for the resident's PTSD. -He/She was told by the staff to base his/her nursing care off the resident's care sheet. -Note: Review of the resident's care sheet, dated 2/10/25,did not show any of the resident's mental health diagnoses or triggers for the resident's PTSD diagnosis. During an interview on 2/10/25 at 11:15 A.M., the Interim Social Services Director said: -He/She was filling in for the permanent Social Services Director who was on maternity leave. -He/She was the Interim Social Services Director for approximately three months. -He/She was aware of what the medical diagnosis of PTSD was. -He/She knew that the resident had a diagnosis of PTSD and other mental health diagnoses. -The facility was in the process of coming up with plans to train him/her on adding the facility residents' mental health diagnoses to their care plans. -There were many residents in the facility that did not have their mental health diagnoses, including PTSD, on their care plans. -He/She knew that a resident's care plan should include the mental health diagnoses for PTSD, schizophrenia, and depression. -He/She would expect a resident who was diagnosed with PTSD to have a care plan that reflected goals, interventions, and triggers for the resident's trauma. -He/She knew the resident had triggers from working with the resident personally. -Other staff members were not aware of the resident's triggers. -He/She was the one responsible for care planning the resident's PTSD and triggers. During an interview on 2/10/25 at 11:25 A.M., the Nurse Practitioner (NP) said: -He/She would expect all mental health diagnoses to be on a resident's care plan. -He/She would expect PTSD triggers to be on a resident's care plan. During an interview on 2/10/25 at 4:46 P.M., the Director of Nursing (DON) said: -Social Services was responsible for ensuring that a resident's mental health diagnosis was care planned. -He/She would expect that a resident who was diagnosed with PTSD to have the diagnosis on their care plan as well as the triggers for the resident's past trauma. -He/She would expect the staff to be aware of the resident's PTSD triggers. -Social Services was responsible for completing the Trauma Informed Care Assessments when a resident is admitted to the facility. -The information for the Trauma Informed Care Assessments should come from a resident's admission medical documents when the resident had a cognitive impairment. -He/She would expect the Trauma Informed Care Assessment to accurately reflect a resident's PTSD diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure sufficient staff present to provide resident cares and to answer call lights in a timely manner for two sampled residents (Resident's #181 and #1)out of 12 sampled residents. The facility census was 38 residents. Review of the facility's Call Lights: Accessibility And Timely Response Policy, revised July 2024, showed: -Call lights would directly relay to a staff member or centralized location to ensure appropriate response. -All staff members who saw or heard an activated call light were responsible for responding. -The process to respond to call lights was to first turn off the signal light in the resident's room. **Note: the policy did not specify the expected time staff were expected to respond to call lights. 1. Review of Resident 181's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 2/6/25 showed: -The resident was admitted to the facility on [DATE]. -The resident was cognitively intact. Review of the resident's undated Care Plan, showed: -The resident had alterations in Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting). -The resident would be encouraged to use his/her call light when ADL assistance was needed. -The resident was partially blind. -The staff was encouraged to keep the resident's call light within reach at all times. During an interview on 2/7/25 at 12:22 P.M., the resident said: -The staff took a long time to answer his/her call light on many occasions. -The staff did not always explain to him/her where they placed the call light and he/she could not always find it. Observation on 2/7/25 at 12:22 P.M., showed: -The resident's call light was not within the resident's reach. -The resident had a hard time finding the call light as he/she is partially blind. Review of the resident's call light past event log dated 2/6/25-2/10/25, showed: -On 2/10/25 at 10:12 A.M., the resident's bed station call light was on for 23 minutes. -On 2/10/25 at 8:37 A.M., the resident's bathroom call light was on for 12 minutes. -On 2/8/25 at 9:35 A.M., the resident's bed station call light was on for 35 minutes. -On 2/8/25 at 4:00 A.M., the resident's bed station call light was on for 22 minutes. -On 2/7/25 at 9:07 P.M., the resident's bathroom call light was on for 33 minutes. -On 2/7/25 at 5:20 P.M., the resident's bed station call light was on for 20 minutes. -On 2/7/25 at 3:17 P.M., the resident's bed station call light was on for 31 minutes. -On 2/7/25 at 9:14 A.M., the resident's bed station call light was on for 21 minutes. 2. Review of Resident 1's admission MDS, dated [DATE] showed: -The resident was admitted to the facility on [DATE]. -The resident was cognitively intact. Review of the resident's undated Care Plan, showed: -The resident had alterations in ADL. -The resident would be encouraged to use his/her call light when ADL assistance was needed. During an interview on 2/6/25 at 3:01 P.M., the resident said: -Sometimes it takes a while for staff to answer his/her call light. -It does not seem to matter the time of day or night, he/she thinks it happens regardless if it is day shift staff or night shift staff. Review of the resident's call light past event log dated 2/6/25-2/10/25, showed: -On 2/10/25 at 7:10 A.M., the resident's bed station call light was on for 18 minutes. -On 2/8/25 at 2:18 P.M., the resident's bed station call light was on for 10 minutes. -On 2/8/25 at 11:21 A.M., the resident's bed station call light was on for 14 minutes. -On 2/8/25 at 7:19 A.M., the resident's bed station call light was on for 19 minutes. -On 2/7/25 at 3:44 P.M., the resident's bed station call light was on for 23 minutes. -On 2/7/25 at 1:21 P.M., the resident's bed station call light was on for 29 minutes. -On 2/6/25 at 4:16 P.M., the resident's bed station call light was on for 39 minutes. -On 2/6/25 at 7:54 A.M., the resident's bed station call light was on for 17 minutes. -On 2/6/25 at 6:05 A.M., the resident's bed station call light was on for 37 minutes. 3. During an interview on 2/10/25 at 11:25 A.M., the Administrator said: -He/She would expect the call lights to be answered in a timely manner. -He/She agreed that the call light response times on the report were substantial. -He/She needed to educate the staff on the importance of answering call lights in a timely manner. -The call light system notified staff through an application on the staff phones and through an electronic tablet in the hallway. During an interview on 2/10/25 at 1:53 P.M., the Certified Nursing Assistant (CNA) A said: -There was a tablet in the hallway that notified staff when a resident pushed their call light. -He/She had an application on his/her phone that notified him/her when a resident pushed their call light. -He/She was told during orientation to the facility that staff should answer call lights within 5 minutes. -He/She has had resident's and family members complain to him/her about call light response times. -All staff members were responsible for answering a resident's call light. During an interview on 2/10/25 at 1:58 P.M., the CNA B said: -There was a tablet in the hallway that notified staff when a resident pushed their call light. -He/She had an application on his/her phone that notified him/her when a resident pushed their call light. -Call lights should be answered within 5-15 minutes with emphasis given to bathroom call lights. -The bedside call light and the bathroom call light come across on the staff phones and the hallway tablets as different colors. -Residents and family members have complained to him/her about call light response times. During an interview on 2/10/25 at 2:03 P.M., the Licensed Practical Nurse (LPN) A said: -When a resident pushed their call light, the staff was notified by the tablet in the hallway and through the computer paging system at the nurse's station. -He/She would expect for a resident's call light to be answered within 3-5 minutes. -He/She had heard complaints from the CNA staff, residents, and resident's family members about call light response times. -He/She has reported the complaints to the administration staff. -He/She would never expect a call light response time to be 20-30 minutes. -Note: A computer monitor was observed at the nurse's station that notified staff of call light prompts. During an interview on 2/10/25 at 4:46 P.M., the Director of Nursing (DON) said: -When a resident pushed their call light it transmits to the computer at the nurse's station, the phone application on the staff phones, and the tablets in the hallways. -He/She would expect call light response times to be less than 15 minutes. -He/She has had some complaints from the residents and the residents' family members about call light response times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms) were used upon providing resident cares for three sampled residents (Resident #228, #3, and #229) out of 12 sampled residents. The facility census was 38 residents. Review of the facility's undated Transmission Based Precautions (Isolation Precautions) policy and procedure showed the facility will use standard approaches, as defined by the Centers of Disease Control (CDC) for transmission based airborne, contact and droplet precautions. The category of transmission based precautions will determine the type of personal protective equipment (PPE-gowns, gloves, face masks/shields) to be used. -All staff receive training on transmission-based precautions upon hire and at least annually. -An order for transmission-based precautions /isolation will be obtained for residents who are known or suspected to be infected or colonized with infectious agents that require additional controls to prevent transmission effectively. -The order for transmission-based precaution will specify the type of precaution and reason for transmission-based precautions. -Contact precautions is intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or resident environment. -Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. -Donning (to put on) PPE upon room entry and discarding before exiting the room is done to contain pathogens. -The policy did not specifically state EBP precaution guidelines. 1. Review of Resident #3's Face Sheet showed the resident was admitted on with diagnoses including a chronic ulcer (an open sore or wound that does not heal properly) of his/her left foot. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/23/25, showed the resident: -Was alert and oriented without confusion. -Had a venous/arterial wound (wounds that occur when there is poor blood flow to the arteries or veins) and received treatments and preventive services. Review of the resident's Physician's Order Sheet (POS) dated February 2025, showed physician's orders for wound care to the resident's anterior left foot. Orders showed: -Clean left anterior wound with saline. Apply lodosorb (a wound care product that treats wet wounds and ulcers) to the wound bed, cover with alginate pad and wrap with kerlix every day shift on Monday, Wednesday Friday and as needed (1/30/25). -There was no physician's order for enhanced barrier precautions. Observation on 2/6/25 at 10:15 A.M., showed there was a EBP sign on the resident's room door with a box containing PPE box outside of the door. The sign showed instructions staff should follow prior to entering the resident's room such as sanitizing hands and using gowns and gloves. Observation on 2/7/25 at 8:50 A.M., showed there was an EBP sign on the resident's room door. There was a box containing PPE right beside the resident's door. Certified Nursing Assistant (CNA) C sanitized his/her hands then entered the resident's room without donning PPE. He/She put on gloves and told the resident he/she was back to take the resident to get weighed. The resident was sitting up on the side of his/her bed with his/her tray table in front of him/her. CNA C assisted the resident to transfer to his/her wheelchair then brought the resident out of his/her room. CNA C was not wearing a gown. CNA C asked Certified Medication Technician (CMT) A (who was standing outside the resident's room) if the resident was to receive medications. CNA C then took the resident back into his/her room and told the resident he/she would be back after the resident received his/her medication. CNA C removed his/her gloves and sanitized his/her hands upon leaving the resident's room. During an interview on 2/7/25 at 8:59 A.M. CNA C said: -The resident was on EBP for wounds. -He/She was not sure when he/she needed to don PPE but he/she would find out. -When he/she went into the resident's room, he/she did not put on a gown prior to entering the room. -He/She did not pay attention to the sign on the resident's door, but now that he/she sees it, he/she will put on PPE every time he/she enters the resident's room. 2. Review of Resident #229's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including fracture of his/her right knee. Review of the MDS records showed the resident did not have an admission MDS completed to date. Review of the resident's POS dated February 2025, showed physician's orders for: -Remove the right leg immobilizer assess skin integrity and reapply every shift (1/23/25). -Apply surgical foam gel to right knee every shift on Tuesday, Thursday and Saturday and as needed if dislodged or soiled. Notify provider with any sign or symptom of infection (1/30/25). Observation on 2/6/25 at 11:08 A.M., showed there was a EBP sign on the resident's room door with a box containing PPE box outside of the door. The sign showed instructions staff should follow prior to entering the resident's room. The resident was sitting up in his/her recliner with his/her legs elevated. Licensed Practical Nurse (LPN) B did the following: -Sanitized his/her hands then entered the resident's room and said he/she was going to change the resident's bandage to the resident's wound. -Without donning a gown, LPN B removed the resident's leg brace, then gloved, removed the ace bandage, then removed and discarded the soiled bandage. -He/She discarded his/her gloves and sanitized his/her hands then left the room to get more supplies. -He/She sanitized his/her hands, re-entered the room without donning a gown, gloved, opened a clean bandage and placed it on the residents knee and dated it. -He/She then placed the ace bandage over the wound and put the resident's leg brace back on. LPN B then pulled the resident's pant leg back down, removed and discarded his/her gloves. LPN B pulled the trash and upon leaving, he/she sanitized his/her hands. 3. Review of Resident #228's Face Sheet showed the resident was admitted on [DATE], with diagnoses including urinary retention, and an arm fracture. Review of the MDS records showed the resident did not have an admission MDS completed to date. Review of the resident's POS dated February 2025, showed physician's orders for: -Wound Care-clean area to left heel with wound cleanser, apply a gauze dressing and cover every day shift and as needed for wound care (2/5/25). -Wound Care-clean areas to bilateral buttocks, apply calazime (a skin protectant that contains zinc oxide and menthol) every shift and as needed for wound care (2/5/25). -Enhanced Barrier Precautions related to wound care every shift (2/4/25). Observation and interview on 2/7/25 at 8:49 A.M., showed there was an EBP sign on the resident's door instructing staff to don PPE prior to entering the room. There was a hand sanitizer on the wall outside of the resident's room but the box containing PPE was across the hall from the resident's room. The resident was sitting up in his/her recliner with his/her legs elevated. At 8:50 A.M., CMT A went into the resident's to give his/her medications. CMT A sanitized his/her hands, but did not don a gown or gloves before entering his/her room. CMT A: -Sat the resident's medications on the tray table that was beside the resident and watched the resident take them. -He/She then said he/she was going to apply the resident's breathing treatment and put the resident's face mask on the resident, turned on the breathing treatment machine and then adjusted the resident's face mask. -CMT A then went to the bathroom and washed his/her hands prior to leaving the resident's room. -At 9:05 A.M., CMT A sanitized his/her hands, went into the resident's room without donning a gown or gloves, turned off the resident's breathing treatment and removed his/her face mask. He/She then went into the bathroom and washed his/her hands prior to leaving the room. CMT A said: -The resident received breathing treatments four times daily. -The resident is on EBP for wounds. -He/She usually washed or sanitized his/her hands before entering the resident's room, but he/she does not don a gown or gloves before giving medications. -He/She was told that PPE should only be used when providing direct care to a resident. -When giving a breathing treatment he/she still would not put on a gown or gloves, but he/she washes his/her hands prior to leaving the resident's room. 4. During an interview on 2/7/25 at 2:28 P.M., LPN B said: -EBP relates to anyone more susceptible to in infection, has an open wound, a catheter, etc. needs to wear extra PPE (gown) when giving cares to a resident. -Staff should wear PPE (gown and gloves) anytime wound care is done, peri care, or other cares where close proximately of the resident or cares completed and interaction with the insertion site (example catheters). -He/She was not told to use EBP for medication administration, glucose monitoring, or insulin administration. During an interview on 2/10/25 at 4:46 P.M., the Director of Nursing (DON) said: -The procedure for EBP is to wear gown and gloves to provide direct patient care such as transfers, providing toileting, and putting on creams. -The residents who have wounds, tubes such as gastronomy tube (a thin, flexible tube inserted through the abdominal wall into the stomach), foley catheter (a thin, flexible tube that is inserted into the body to drain or deliver fluids), intravenous site (IV-a medical procedure that involves inserting a needle or tube into a vein to deliver fluids, medications, or nutrients) or dialysis catheters (a thin, flexible tube inserted into a large vein to provide access to the bloodstream for hemodialysis treatment) should all be on EBP, have signs on their doors and a box containing PPE (gowns, gloves, face masks) by the door or in the hallway. -They have provided staff education on EBP. New hires get it in orientation and he/she tries to provide it every couple months. They also have signs on the doors that explain when they are to use it and what they are to wear. He/She said they should look at the signs on the doors. -If a resident has a sign on the door showing they are on EBP, he/she would expect the nursing staff to follow the signs based on the cares being provided. -With residents with a surgical wound or well-healing wounds they do not have to use EBP, but since he/she had a sign on his/her door, they are supposed to follow the precautions. -CNA C was from agency and he/she was aware that the CNA did not use gown and he/she should have. -It was a gray area with providing assistance with putting the resident's face mask on because they have been told that this was not really close contact and they have been told that they do not have to don PPE when giving medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document a comprehensive wound assessment and obtain physician's order for a pressure ulcer (a 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) upon admission for one sampled resident (Resident #10) out of seven sampled residents. The facility census was 36 residents. Review of the facility's Wound Management Policy dated revised 7/2024 showed: -To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. --Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. --In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 1. Review of Resident #10's Face Sheet showed the resident admitted to the facility on [DATE] with following diagnosis of: -Traumatic Hemorrhage of brain tissue (head injury cause bleeding between brain and skull). -End stage Renal disease (is when you have permanent kidney failure that requires a regular course of dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) or a kidney transplant). -Diabetic neuropathy (damage to the nerves resulting in sensory loss in the extremities). -Multiple rib fractures (is a painful crack or actual break in a rib). -Left femur fracture (long thigh bone). -He/she was admitted for skilled therapy services. Review of the resident's Nursing admission assessment dated [DATE] at 8:11 P.M. showed: -The resident admitted to the facility with a coccyx wound. -The skin section was check marked. -The resident had an area on his/her coccyx (tail bone) and buttocks. He/she had redness on buttocks. -There were no initial wound measurements or comprehensive assessment documented. Review of the resident's Physician Order Sheet (POS) dated 11/1/24 to 11/12/24 showed: -On 11/3/24 Registered Nurse (RN) A transcribed physician order for coccyx wound care to clean with wound cleanser, then pat dry and then apply Santyl, (an ointment used for the debridement of pressure ulcers) and calcium alginate (made from seaweed, they absorb fluids (exudate) from covered wounds and form a protective gel layer) to wound. Cover the wound with Optfoam (a thick pad dressing) dressing. Change wound dressing every day and as needed on day shift. Review of the resident's Treatment Administration Record (TAR) order dated 11/1/24 to 11/12/24 showed: -On 11/3/24: Coccyx wound care to clean with wound cleanser, then pat dry and then apply Santyl, and calcium alginate to wound. Cover the wound with Optifoam dressing. Change wound dressing every day and as needed on day shift. -Note: This order was obtained two days after admission. Review of the facility's Weekly Wound report dated 11/5/24 showed: -The resident had a coccyx wound upon admission on [DATE]. -The coccyx wound was an unstageable pressure injury. -Note: A comprehensive wound assessment was not documented until 4 days after admission. During an interview on 12/9/24 at 2:25 P.M., Wound Nurse said: -The admitting nurse was responsible for completing the resident's initial wound assessment. -He/she was onsite when the resident was admitted to the facility. -The resident was assessed by Licensed Practical Nurse (LPN) B and him/her. -The LPNs would been responsible for documenting the resident's initial skin assessment. -He/she would expect nursing staff to document more detail description of the resident's wounds upon admission. -The resident's wound was assessed upon admission but did not get documented in the medical record. -He/she would expect the nursing staff to obtain physician's orders for wound care when admitted . During an interview on 12/9/24 at 3:40 P.M. Director of Nursing (DON) said: -He/she would expect nursing staff to document detail wound assessment of to include the appearance or descriptive observation of the resident's coccyx wound. -The admitting nurse would be responsible for completing the initial admission assessment including any pressure wounds found. -The resident's coccyx wound was assessed upon admission by LPN B and the wound nurse, but they did not document a detail wound assessment to include general description and size of the resident's wound and obtaining treatment orders. -He/she would expect nursing staff document wound care and comprehensive wound assessment in the resident's progress notes and TAR upon admission. During an interview on 12/9/24 at 4:00 P.M., LPN B said: -He/she did assess the resident's coccyx wound on 11/1/24. -He/she did not document a comprehensive wound assessment but should have. -He/she only documented the resident had a coccyx wound and had redness. -He/she notified the wound nurse that the resident had a coccyx wound upon admission. -The wound nurse observed the resident coccyx wound on 11/1/24. -He/she was not aware if the wound nurse had document the resident initial wound assessment. -The corporation central intake office obtains and reviews the hospital physician orders and would transcribed the orders to the residents' POS and TAR. -He/she should have obtained physician's orders for wound care if they were not found on POS. During an interview on 12/11/14 at 8:38 A.M., RN A said: -On Saturday 11/2/24, an unknown Certified Nursing Assistant (CNA) informed him/her the resident dressing needed changed. -The resident had a wound to his/her coccyx area. -He/she called the physician and obtained orders for the resident's wound and treated the wound on 11/2/24. -He/she had forgot to transcribe the physician order and the treatment completed on 11/2/24 but update the information in the resident's medical record on 11/3/24. -The wound treatments was competed for the resident on 11/2/24. MO 00245262

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a controlled drug (medications that fall under the US Drug Enforcement Agency (DEA) of Schedules II through V, having a potential for abuse ranging from low to high and the potential to lead to physical or psychological dependence) card of 30 pills was accounted for and locked up and immediately reported as missing after documenting delivery of the medication from the pharmacy for one sampled resident (Resident #1) out of three sampled residents who received controlled medications. The facility census was 37 residents. On 12/26/23 the Administrator was notified of the past noncompliance which took place between 11/29/23 and ended on 12/2/23 when the facility discovered the resident's card of 30 oxycodone tablets, delivered by pharmacy on 11/29/23 were missing. On 12/2/23 one employee suspected of taking the resident's narcotic medication was suspended. Nurses were educated on 12/2/23 on expectations related to documentation and procedures related to controlled medications, ensuring medications were accounted for, and contacting the pharmacy to ensure residents had medications as ordered. The deficiency was corrected on 12/2/23. Review of the facility's Medication Storage policy, implemented 7/2021 and revised 6/2023 showed: Narcotics (opioids - opium, opium derivatives and semi-synthetic compounds resembling opium) and Controlled Substances will be stored under double lock and key, including: -Schedule II drugs (narcotics/opioids - drugs having a high potential for abuse which may lead to severe psychological or physical dependence). -Back up stock of: --Schedule IV medications (drugs having a low potential for abuse relative to substances in Schedule III medications). -Any discrepancies which cannot be resolved must be immediately reported as follows: --Notify the Director of Nursing (DON), charge nurse or designee and the pharmacy. --Complete an incident report detailing the discrepancy, steps taken to resolve it, and names of all licensed staff working when the discrepancy was noted. --The DON, charge nurse or designee must also report any loss of controlled substances where theft is suspected to appropriate authorities such as law enforcement, Department of Health and Senior Services (DHSS) and any other applicable agency. -Staff may not leave the area until discrepancies are reported as unresolved discrepancies. 1. Review of Resident #1's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 11/28/23 showed the resident was admitted to the facility on [DATE]. Review of the resident's Physician Order Report dated 11/28/23 through 12/2/23 showed the resident was prescribed: -Oxycodone (generic for OxyContin) - Schedule II oral tablet (a semi-synthetic narcotic/opioid used as an analgesic (pain reliever), 5 milligrams (mg). One to two tablets every four hours pro re nata (PRN - as needed) for pain starting 11/28/23. -Tramadol - Schedule IV oral tablet (an opioid/narcotic used as an analgesic), 50 mg. One tablet every six hours PRN for pain control starting 11/28/23. Review of the resident's Medication Administration Record (MAR), dated 11/28/23 through 12/2/23 showed: -Oxycodone - Schedule II oral tablet, 5 mg. One to two tablets every four hours PRN for pain starting 11/28/23. -The resident did not receive oxycodone PRN from 11/28/23 through 12/2/23. Review of the resident's progress notes from 11/28/23 through 12/2/23 showed: -A physician note, dated 11/29/23 showed a list of the resident's medications to include oxycodone 5 mg every four hours PRN. One to two tablets orally for pain starting 11/28/23. -A Nurse Practitioner (NP) note, dated 12/1/23 showed a list of the resident's medications to include oxycodone 5 mg every four hours PRN. One to two tablets orally for pain starting 11/28/23. -There were no other progress notes mentioning oxycodone and no progress notes showed oxycodone was not available at the facility as ordered for the resident during the 11/28/23 through 12/2/23 admission. Review of the resident's Discharge MDS, dated [DATE] showed the resident: -Was cognitively intact. -Had occasional pain and took pain medication(s). -Had not received opioid medications during the 11/28/23 through 12/2/23 stay. Review of the resident's Facility Investigation Report, dated 12/2/23 showed the following summary: -On 12/2/23 at 3:12 A.M. Licensed Practical Nurse (LPN) A texted the DON and reported a missing card of oxycodone 5 mg, quantity 30 for Resident #1. LPN A reported he/she looked in both medication carts and called the pharmacy. -The DON saw the text on 12/2/23 at 4:46 A.M. and called LPN A who reported that Pharmacy informed him/her the medication had been delivered at approximately 6:00 P.M. on 11/29/23 and the Unit Manager, a Registered Nurse (RN) signed off for the medication. The DON asked LPN B to send a copy of the Controlled Medication Card Inventory sheet which LPN B completed. -The DON noted the resident's oxycodone had not been added to the Controlled Medication Card Count sheet. -The DON reviewed camera footage from 11/29/23 which showed: --The Unit Manager signed in the narcotics from the pharmacy at 6:41 P.M. and was seen giving LPN B five narcotic cards. --At 6:42 P.M. LPN B took the medication cards to the medication cart. --At 6:42:47 P.M. LPN B opened the narcotic box and placed one card in the box. --At 6:43:25 P.M. LPN B put a second medication card in the box. --LPN B then grabbed the narcotic book, slid a narcotic card under the book and walked to the side of the medication cart. LPN B bent down out of camera view and appeared to pull the trash with the narcotic box open. --At 6:44:18 P.M. LPN B returned to the front of the medication cart. --At 6:44:29 P.M. LPN B added a narcotic medication card to the narcotic box and at 6:44:44 P.M. LPN B added another narcotic medication card for a total of four cards added to the narcotic drawer box. --At 6:45 P.M. LPN B and RN B counted the narcotic box drawer. After the two finished counting, they walked to the nurses' station where LPN B before exiting the building at 6:49 P.M. -On 12/2/23: --A call was placed at 5:41 A.M. to the Administrator, informing him/her of the missing oxycodone. --The DON arrived at the building at 5:45 A.M. to suspend LPN B pending investigation. --LPN B called the DON at 6:36 A.M. to inform the DON he/she would be late. The DON informed LPN B he/she was not to report to work as he/she was suspended pending investigation. --The DON called the local police department at 8:38 A.M. and filed a report. The on-call Nurse Practitioner (NP) was notified at 8:40 A.M. of the resident's missing narcotic. --At 9:08 A.M. the resident was notified of the missing narcotic and pharmacy was notified the medication needed to be refilled at facility cost. An authorization form was sent to the pharmacy and a replacement card of oxycodone arrived at the facility on 12/2/23 at 6:05 P.M. Review of supporting documentation in the facility investigation, dated 12/2/23 showed: -A Pharmacy Delivery Receipt, dated 11/29/23 which showed five controlled medications were delivered to the facility the evening of 11/29/23 and signed for by the Unit Manager. Two of the controlled drugs were for the resident and included a card of Oxycodone Immediate Release, 5 mg containing 30 tablets and a card of Tramadol HCL, 50 mg containing 20 tablets. -The Controlled Medication Card Inventory sheet with dates ranging from 11/25/23 through 11/30/23 showed LPN B's initial on 11/29/23 documenting he/she added + 4 to indicate four controlled medication cards had been added to the controlled medication box. The names of the medications added and the names of the residents whose cards were being added were not documented on the Controlled Medication Card Inventory sheet for the evening of 11/29/23 as they were on other dates. -The Controlled Medication Count for November, 2023 was signed by the off-going nurse, LPN B and on-coming agency nurse, RN A. -Documentation of authorization for replacement of the resident's Oxycodone Immediate Release 5 mg tablets, 30 count was signed 12/2/23. -Documentation of education by the DON with facility nurses on 12/2/23 related to procedures for identifying and reporting missing narcotics included who needed to be notified and when. -Documentation of education by the DON with facility nurses on 12/2/23 related to procedures for adding and subtracting controlled medication cards on the count sheet, including documenting the medication added or subtracted and the resident's name; procedures for totaling the controlled medications to ensure accuracy and clarity and what to do when there were discrepancies or errors. Observation on 12/21/23 of two video recordings showing the nursing station and medication cart from different angles on 11/28/23 between 6:40 P.M. and 6:45 P.M. showed: -RN A set five objects the size of medication cards one at a time in front of LPN B. -LPN B took the five medication cards or objects directly to the medication cart. -LPN B looked frequently in the direction of the Unit Manager and RN A while he/she was at the medication cart. The Unit Manager and RN A were not at the medication cart when LPN B put what appeared to be two medication cards in the narcotic box. -The objects LPN B placed in the narcotic box were the size of medication cards; however, due to the video being fuzzy no details such as the pill shapes or writing could be seen. The video was clear enough that staff members could be identified. -One object the size of a medication card was observed placed by LPN B under the narcotic count book and was taken out of camera sight to the side of the medication cart. When LPN B was back in front of the medication cart what looked like two additional cards were placed into the narcotic drawer for a total of four cards. LPN B did not put what looked like a fifth medication card into the controlled drug medication drawer. During interview on 12/21/23 at 12:15 P.M. LPN A said: -The resident had been at the facility a number of times. He/She knew from his/her first admission the resident liked to have his/her oxycodone at bedtime. He/She noticed the evening of 2/1/23 the resident did not have his/her oxycodone in the medication cart, but had a physician order for it. He/She thought the drug should have been at the facility from the pharmacy by then. -The resident's oxycodone did not come when pharmacy made their early morning delivery on 12/2/23 between 2:00 A.M. and 3:00 A.M. so he/she called the pharmacy and was told they had already delivered the resident's medication the evening of 11/29/23. -He/She had been off for a few days and thought the medication might have been misplaced. He/She looked on the medication cart for the other hall in case it had been placed there by mistake, but did not find it. -He/She texted the DON on 12/2/23 around 3:12 A.M. -The resident had an order for Tramadol PRN and had that medication available. -The evening of 2/1/23 he/she asked the resident if he/she wanted Tramadol and the resident said yes. The resident never asked for his/her oxycodone the evening of 12/1/23 or morning of 12/2/23. During an interview on 12/21/23 at 12:57 P.M. the Unit Manager said: -He/She remembered signing for medications on 11/29/23 around 6:30 P.M. -LPN B came to the nurses' desk and he/she (the Unit Manager) separated the cards for the hall LPN B was working and gave them to LPN B. He/She gave the rest of the medication cards to the nurse working the other hall. -LPN B was staying over until Agency Nurse RN A could get there. -The DON called him/her in the middle of the night right after talking to LPN A and asked if he/she remembered signing in the resident's medications. He/She told the DON there had been a number of medication cards delivered and he/she didn't know if the resident's was one of them. He/She was told there was an oxycodone, 5 mg card of 30 tablets missing. The DON could pull up the facility's video surveillance on his/her phone. -He/She (the Unit Manager) also watched the video coverage himself/herself which showed he/she had a stack of medication cards. The footage showed he/she handed LPN B five medication cards. -In the video it showed LPN B opening his/her narcotic drawer and putting first one, then two medication cards in. -LPN B then picked up the narcotic count book with both hands and went to the side of his/her medication cart, disappearing from view and then messed with the trash bag from the treatment cart. Then LPN B put two more medication cards into the medication cart narcotic drawer, but he/she never put the fifth medication card in the narcotic drawer. -When LPN B documented +4 on the Controlled Medication Card Inventory sheet for the evening of 11/29/23, he/she never put the names of the residents who got newly delivered medication cards or the drugs that were delivered. He/She was supposed to write the resident's name, what drug was delivered, how many cards were delivered and also document if medication cards were being taken out of the narcotic drawer, what medication was taken out and for what resident. -Whatever medication cards are signed in as received from pharmacy and what is documented as being added to the Controlled Medication Card Inventory sheet should match. -The off-going and on-coming nurses count the number of medication cards together and do a narcotic count to make sure the correct number of pills are accounted for. During an interview on 12/21/23 at 1:30 P.M. the DON said: -The resident had three different admissions to the facility within the past few months. -The resident's oxycodone card was probably missed because the resident may not have asked for the medication. -The surveillance videos showed the Unit Manager counting the medication cards with the pharmacy employee. One video view showed the pharmacy employee leaving the nurses' station. -The Unit Manager could be seen giving LPN B five medication cards which he/she handed to LPN B one at a time. -LPN B brought the medication cards to the medication cart and flipped through the narcotic book. -First LPN B put one card in the narcotic drawer, then another. -LPN B grabbed a third card and slipped it under the narcotic book and then can be seen pulling trash while the narcotic drawer was still open. -LPN B then added a third and then a fourth medication card to the narcotic drawer. Only four cards were observed going into the medication cart, not five. -LPN B and agency RN A counted the narcotic cards, but since one was not placed in the narcotic drawer and LPN B only documented four added cards the number seemed to match up. -The Controlled Medication Card Inventory sheet did not match up with the pharmacy delivery documentation and they should have matched. During an interview on 12/21/23 at 3:09 P.M. LPN B said: -He/She counted medication cards with the Unit Manager before taking the cards to the medication cart. He/She couldn't remember how many he/she had been given, but thought it was two or three medication cards. -He/She put whatever was given to him/her by the Unit Manager into the narcotic drawer box. -He/She couldn't remember what number of medication cards he/she wrote down on the Controlled Medication Card Inventory sheet or the name of the residents who received the new medication cards. -The only time he/she was aware of he/she went out of camera view was when he/she changed out the medication cart trash bag. -He/She didn't think he/she would have touched the trash with the medication drawer open. -He/She couldn't remember whose medications he/she put in the narcotic medication drawer. -He/She didn't take any resident medication cards or any resident medication. -Whatever medication cards he/she was given by the Unit Manager would have been put into the narcotic medication drawer. If he/she had been given five cards, five cards would have gone into the drawer. During an interview on 12/21/23 at 3:30 P.M. with the Administrator and the DON, the DON said: -Off-going and on-coming staff were expected to count the medication cards and narcotic count sheets together. The Controlled Medication Card Inventory should match the pharmacy receipt description of medications delivered for incoming cards. Medications and resident names should be clearly documented on the forms. Staff were re-educated on 12/2/23 related to protocol. -If the resident had orders for a medication by 3:00 P.M. pharmacy should bring the medication by their early morning medication run. Medications should be delivered by pharmacy no later than within 24 hours of an order. -Staff have been educated to call the pharmacy and let the DON know if the medications are not at the facility within 24 hours. If a resident needs a medication before that time it can be taken from their automated medication dispensing system. MO00228231

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a recapitulation of stay was completed for two sampled residents (Resident's # 22 and #18) out of five sampled closed records. The facility census was 31 residents. Review of the facility's policy Discharge Summary and Plan revised 9/2012 showed the discharge summary would include a recapitulation of the resident's stay at the facility and a final summary of the resident's status upon discharge. 1. Review of Resident #22's admission record showed the resident was admitted to the facility on [DATE] with a primary diagnosis of displaced fracture (the bone is out of alignment) of shaft of right clavicle (middle portion of collarbone), subsequent encounter with routine healing. Review of the resident's Discharge and Transition Form dated 5/22/23 showed: -The resident was being discharged to a Skilled Nursing Facility (SNF). The name and address of the SNF was on the form. -He/she was being discharged with the Face Sheet/admission Record, active physician orders, and immunization record. -The resident's most recent weight, height, blood pressure, pulse, respiration, oxygen concentration levels and temperature were listed on the form. -Follow-up care and supportive services would be provided at the SNF (the form doesn't show what care or services were recommended or how the resident could be assisted when he/she goes to the SNF). -There was no recapitulation of the resident's stay showing the resident's primary or admitting diagnoses, course of treatment and rehabilitation, pertinent labs and consults, or a final summary of the resident's status. Review of the resident's electronic record showed there was no Discharge Summary with a recapitulation of the resident's stay. 2. Review of Resident #18's admission record showed he/she was admitted to the facility on [DATE]. Review of the resident's Physician's Order Recap Report for orders from 4/1/23 through 5/23/23 showed he/she received lavatory testing services, dialysis at an outside the facility clinic, daily weights, and rehabilitation services. Review of the resident's progress notes dated 5/18/23 through 5/23/23 showed no recapitulation of the resident's stay at the facility. Review of the resident's Discharge and Transition Form dated 5/23/23 showed: -He/she was discharged from the facility on 5/23/23. -There was no recapitulation of the residents stay showing a summary of the resident's stay, course of treatment and outcome of his/her treatment and rehabilitation services at the facility. 3. During an interview on 6/7/23 at 10:03 A.M. the Social Services Director (SSD) said: -Multiple staff were involved with the discharge summary. -Nursing was responsible for describing the medications and nursing care during the resident's stay, maintaining an inventory of the resident's belongings, and documenting where the resident's belongings went upon discharge. -The Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) Coordinator was responsible for writing about the resident's goals during their stay. -Therapy was responsible for the recapitulation of the resident's stay and their discharge plan. Therapy used a different medical documentation system than the facility and the facility did not have access to it. -The Discharge and Transition Form was the form the facility used for the discharge summary. During an interview on 6/7/23 at 12:17 P.M. the SSD said he/she just learned the Nurse Practitioner (NP) had been doing some of the residents' discharge summaries in a discharge summary note, but he/she couldn't find a discharge summary note for the resident. During an interview on 6/7/23 at 1:02 P.M. the Regional Nurse/Interim Director of Nursing (DON) said: -He/she did not know what a recapitulation of stay was or what it would include; he/she was not doing a recapitulation of stay at any of the facilities he/she had been at. -To his/her knowledge, the facility had not been doing recapitulations of residents stays at the facility. -The facility staff would have to be educated regarding completing recapitulations of resident stays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess one sampled resident (Resident #232) to ensure he/she could monitor and maintain his/her insulin pump (a device that regulates insulin mediation and blood sugar); and to ensure staff were educated on insulin pumps out of 12 sampled residents. The facility census was 31 residents. Review of the facility's policy Self-Administration of Medications revised 12/2012 showed: -Residents in the facility who wish to self-administer their medication may do so if it was determined they were capable of doing so. -As part of their overall evaluations, the staff and practitioner would assess each resident's physical and mental capabilities to determine whether they were capable of self-administering medications. 1. Review of Resident #232's admission record showed he/she: -Was admitted to the facility on [DATE] for skilled rehabilitation services. -Had a diagnosis of diabetes (a chronic, metabolic disease characterized by elevated levels of blood glucose). Review of the resident's Order Recap Summary showed the following physician's orders: -On 5/18/23: Insulin pump kit as directed and set up per resident. Before meals and at bedtime. -On 5/19/23: Insulin pump in place-check every shift for function and place every shift. -On 5/19/23: Glucose monitoring device(a continuous glucose monitoring system used to check blood sugar in people with diabetes): Inject one device subcutaneously (beneath the skin) one time every ten days on the back of the arm, abdomen or other area. Note this in progress notes. Perform calibrations per manufacturers recommendations. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff) dated 5/22/23 showed the resident: -Was cognitively intact. -Had a diagnosis of diabetes. -Was in the facility for skilled nursing rehabilitation stay after a hospitalization. Observation on 6/5/23 at 10:04 A.M. showed: -The resident had a continuous glucose monitoring device on the back of his/her right upper arm. -Had an insulin pump hanging from his/her neck. During an interview on 6/5/23 at 10:05 A.M. the resident said he/she maintained and monitored his/her own insulin pump. Review of the resident's care plan on 6/6/23 showed the resident: -Had a diagnosis of Diabetes Mellitus. -Had an insulin pump. -The care plan did not show how the resident was to monitored and maintained his/her own insulin pump. Review of the resident's electronic medical record on 6/6/23 showed no assessment completed to ensure the resident could maintain and monitor his/her own insulin pump or glucose monitoring device. Observation on 6/7/23 at 8:13 A.M. showed the resident: -The resident had a continuous glucose monitoring device on the back of his/her right upper arm. -Had an insulin pump hanging from his/her neck. -There was tubing that went from the insulin pump to his/her left lower abdomen. -The tubing connected to the inserted port into the abdomen where insulin was released. During an interview on 6/7/23 at 8:15 A.M. the resident said: -He/she changes the sensor on the back of his/her arm weekly along with the assistance of his/her family member. -He/she changed the insulin port himself/herself every three to four days. -His/her family member brings the insulin from home and he/she fills his/her insulin pump with Humalog insulin. -He/she had the device for three years. -The insulin pump automatically administers insulin based on his/her blood sugar level readings from the glucose monitoring device. -He/she had no low or high blood sugar levels or any issues with the devices. -He/she monitored the system and checked his/her blood sugar level frequently. -There have been no issues with the insulin pump or glucose monitoring device. During an interview on 6/7/23 at 9:11 A.M. Licensed Practical Nurse (LPN) B said: -He/she did not work with the resident. -He/she had not been trained on insulin pumps. -He/she was not very knowledgeable about insulin pumps. -He/she had only been working at the facility for a few months. During an interview on 6/7/23 at 10:24 A.M., LPN A said: -If a resident has an insulin pump upon admission they do not do a written assessment to ensure the resident can monitor and maintain the insulin pump. -The nurses do ask about the insulin pump on admission. -The resident was able to maintain and monitor his/her own insulin pump. -He/she was did not have knowledge of the insulin pump and how the device worked. -He/she was not sure what type of insulin the resident used. -He/she would ask the resident daily how his/her blood sugar levels were. -The resident did not have any issues related to the insulin pump or blood sugar levels since admission. During an interview on 6/7/23 at 1:03 P.M. the Regional Nurse/Interim Director of Nursing (DON) said: -If a resident had an insulin pump and blood glucose monitoring devices upon admission, the nurses were responsible for completing an assessment to ensure the resident could monitor and maintain the devices. -The DON was responsible for ensuring the staff were educated on how to care for the devices. -Education should have been provided to the nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure physician's orders for one sampled resident's (Resident #82) Continuous Positive Airway Pressure (CPAP - a machine that uses mild air pressure delivered by mask to keep breathing airways open during sleep) and oxygen use until five days after his/her facility readmission, and to ensure the cleansing and sanitary storage of the resident's CPAP nasal mask, machine and supplies, to assess and document the use of the resident's CPAP and ensure the resident's oxygen tubing was dated and properly stored when not in use and to ensure the resident's care plan addressed the use of CPAP and supplemental oxygen. The facility also failed to ensure one sampled resident's (Resident #81) oxygen tubing was dated, maintained off the floor, and properly stored when not in use, out of 12 sampled residents. The facility census was 31 residents. Review of the facility Oxygen Administration policy, revised October, 2010 showed: -Verify there is a physician's order for oxygen administration. -Document the date and time oxygen was administered. Review of the facility CPAP policy, revised March 2015. Showed: -Review the physician's order to determine the oxygen concentration and flow, and the pressure settings. -Specific cleaning instructions are obtained from the manufacturer/supplier of the CPAP device. -General guidelines for cleaning CPAP included: --Machine cleaning - wipe the machine with warm soapy water and rinse at least once a week and as needed. --Humidifier - use clean distilled water only in the humidifier chamber, clean the humidifier weekly and air dry, to disinfect place vinegar water solution (1:3 = one part vinegar, one part water) concentration) in humidifier chamber then soak for 30 minutes and rinse thoroughly. -Filter -rinse washable filter under running water once a week to remove dust and debris; replace the filter once a year; replace disposable filters monthly. -Masks, nasal pillows and tubing: Clean daily by placing in warm water and detergent as needed, allow to air dry. -Document: --The time CPAP was started and the duration. --Oxygen concentration and flow if used. --How the resident tolerated the procedure. 1. Review of Resident #82's admission record showed: -He/she was originally admitted to the facility on [DATE]. -His/her current admission date was on 6/1/23. -He/she had a diagnosis of obstructive sleep apnea (OSA - a condition in which breathing pauses during sleep because of narrowed or blocked airways), dated 4/25/23. Review of the resident's comprehensive care plan initiated on 4/27/23 and showing a current admission date of 6/1/23 showed: -No problem statement/focus area, goal or interventions/tasks related to the resident's CPAP. -No problem statement/focus area, goal or interventions/tasks related to the resident's oxygen use. Review of the resident's physician's orders, Medication Administration Administration Record (MAR) and Treatment Administration Record (TAR) dated 6/1/23 through 6/5/23 showed: -No physician's order for oxygen administration and no documentation of administration of oxygen prior to 6/5/23. -No physician's order for CPAP and no documentation record of administration of CPAP prior to 6/5/23. Review of the resident's licensed nurse's admission Assessment Note dated 6/1/23 showed: -He/she used CPAP. -He/she used oxygen. Review of the resident's Daily Skilled Nursing assessment dated [DATE] at 1:40 P.M. showed he/she had oxygen administration via CPAP. Review of the resident's Daily Skilled Nursing assessment dated [DATE] 11:02 A.M. showed he/she had oxygen administration via CPAP. Review of the resident's Daily Skilled Nursing assessment dated [DATE] 9:05 A.M. showed he/she had oxygen administration via CPAP. Observation on 6/5/23 at 9:18 A.M. showed the resident: -Was asleep in bed. -His/her nasal pillow mask was lying next to his/her pillow. -His/her CPAP machine was off. -His/her oxygen concentrator was in his/her toilet room. -The tubing for his/her oxygen was curled and draped over his/her oxygen concentrator, was not in a protective plastic bag and was not dated. Observation on 6/5/23 at 11:07 A.M. showed the resident: -He/she was asleep in bed. -His/her nasal pillow mask was lying next to his/her pillow. -His/her CPAP machine was off. -His/her oxygen concentrator was in his/her toilet room. -The tubing for his/her oxygen was curled and draped over his/her oxygen concentrator, was not in a protective plastic bag and was not dated. Review of the resident's Order Summary Report showed the following orders, dated 6/5/23 with start date of 6/6/23: CPAP: Apply supplemental oxygen (O2) supply at 2 liters per minute (2L/min) to CPAP device tubing two times a day. -CPAP: Check skin under/around CPAP ask daily for skin integrity, every day shift -CPAP: Clean CPAP filter and humidifier weekly with vinegar water (1:3), then with soap and water, and allow to air dry on clean surface one time a day every Sunday. -CPAP: CPAP with home setting 2 LPM bleed in (use of an oxygen bleed in adapter, usually placed between the CPAP outflow and the CPAP tubing); use CPAP while sleeping and at bedtime, remove in morning and when awake, every shift. -CPAP: Staff to assist resident apply mask as needed for proper fit and placement, two times a day. -CPAP: Wash mask daily with vinegar water (1:3), then soap and water, and allow to air dry on a clean surface, one time a day. -CPAP: Wash Tubing/Mask and supplies weekly with vinegar water (1:3), then soap, and water and allow to air dry on clean surface, every day shift Sunday. Observation on 6/6/23 at 8:39 A.M. showed: -The resident was awake and seated on his/her bed. -His/her nasal pillow mask was laying directly on the floor near the head of his/her bed. -His/her CPAP was off. -His/her oxygen concentrator was in his/her toilet room. -The tubing for his/her oxygen was curled and draped over his/her oxygen concentrator, was not in a protective plastic bag and was not date. During an interview on 6/6/23 at 8:29 A.M. the resident said: -He/she did his/her own CPAP care; the licensed nurses did not do anything regarding his/her CPAP. -He/she just puts it on at night and takes it off in the morning. -He/she did nothing with his/her pillow mask except put it on at night and take it off in the morning. Observation on 6/6/23 at 9:35 A.M. showed: -The resident was awake and seated in a wheelchair in his/her room. -His/her nasal pillow mask was laying directly on the floor near the head of his/her bed. -His/her CPAP was off. -His/her oxygen concentrator was in his/her toilet room. -The tubing for his/her oxygen was curled and draped over his/her oxygen concentrator, was not in a protective plastic bag and was not dated. Observation on 6/6/23 at 11:36 A.M. showed: -The resident was awake and seated in his/her bed. -His/her nasal pillow mask was laying directly on the floor near the head of his/her bed. -His/her CPAP was off. -His/her oxygen concentrator was in his/her toilet room. -The tubing for his/her oxygen was curled and draped over his/her oxygen concentrator, was not in a protective plastic bag and was not dated. During an interview on 6/6/23 at 11:36 A.M. the resident said: -He/she keeps his/her oxygen concentrator in his/her toilet room all the time because it makes a lot of noise; he/she used long oxygen tubing that reached from his/her toilet room to his/her night stand for connection to his/her CPAP machine at night. -The nurses did nothing with his/her oxygen, CPAP machine, CPAP mask. -He/she did not and the licensed nurses did not clean/wash his/her mask and did no other care for his/her CPAP machine. During an interview on 6/7/23 at 12:32 P.M. Certified Nursing Assistant (CNA) C said: -He/she had not yet been in the resident's room. -If he/she saw that the resident's CPAP mask was on the floor, he/she would tell the charge nurse because he/she did not know what should be done with a PAP mask. During an interview on 6/7/23 at 12:41 P.M. Licensed Practical Nurse (LPN) B said: -He/she had not yet been in the resident's room to assess him/her. -He/she was not familiar with the resident having a CPAP. -CPAP care included daily cleansing the mask in the morning with sterile water and vinegar, allowing it to air dry and storing it in a plastic bag. -There is an order in his/her EMR for CPAP, cleansing of his/her CPAP mask and equipment. -After looking in the resident's EMR, he/she stated that the resident had CPAP orders as of 6/5/23. The resident should have had the orders upon readmission on [DATE]. -He/she usually reviewed resident's physician's orders in the morning to familiarize himself/herself with the residents care needs; he/she had not had time to review residents' physician's orders because he/she was learning the new EMR documentation system. 2. Review of Resident #81's admission record showed: -He/she was admitted to the facility on [DATE]. -He/she had a diagnosis of saddle embolus (a large blood clot that sits atop the main pulmonary artery where it branches into the right and left lung) with cor pulmonale (a disorder of the lungs that causes dysfunction of the heart) and acute on chronic right heart failure (a condition that causes swelling and shortness of breath). Review of the resident's Order Summary Report showed: -Oxygen at 2 liters/min via nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside the nostrils for oxygen delivery as needed for dyspnea (difficulty breathing), dated 5/30/23. -Oxygen tubing to be changed and dated per facility protocol every night shift every Sunday, dated 6/5/23. Observation on 6/5/23 at 10:57 A.M. showed: -The resident was alert and in his/her bed. -The resident's oxygen tubing and nasal cannula were on the floor next to his/her bed. During an interview on 6/5/23 at 10:57 A.M. the resident said: -His/her oxygen came off during the night. -He/she did not want his/her oxygen on now. -Two staff had been in his/her room giving him/her medication and feeding him/her breakfast. Observation on 6/6/23 at 8:32 A.M. showed. -The resident was in bed. -His/her oxygen tubing and nasal cannula were on the floor next to the head of his/her bed. -A CNAs was seated next to his/her bed on the same side with his/her oxygen tubing and nasal cannula on his/her floor and was feeding the resident his/her breakfast. During an interview on 6/7/23 at 12:32 P.M. CNA C said: -He/she had not been in the resident's room that morning. -If he/she saw the resident's oxygen tubing on the floor, he/she would get new oxygen tubing for the resident. During an interview on 6/7/23 at 12:41 A.M. LPN B said: -When not in use oxygen tubing should be coiled in a plastic and placed on the resident's oxygen canister. -If a CNAs saw a resident's oxygen tubing and cannula on the floor on the floor, they should replace it with a new oxygen tubing. 3. During an interview on 6/7/23 at 1:03 P.M. the Regional Nurse/Interim Director of Nursing (DON) said: -Oxygen tubing should be changed and labeled with the date once weekly, usually on Saturday or Sunday during the night shift. -If staff saw a resident's oxygen tubing on the floor, it should be replaced with new tubing and labeled with the date at that time. -Oxygen tubing should be stored in a plastic bag when not in use. -If a CNA found oxygen tubing on the floor they can replace it. -If a CNA found a residents CPAP mask on the floor they should tell the charge nurse; he/she would not expect the CNAs would know what to do with the CPAP mask, so they should tell the charge nurse and the charge nurse should cleanse the CPAP, allow it to air dry and place it in a plastic bag. -For residents with CPAP, there should be a physician's order at the time of admission that included the settings for the CPAP and for the care of the CPAP equipment and supplies. -CPAP masks should be cleansed each morning, allowed to air dry and then be placed in a plastic bag. -All other supplies should be cleaned/replaced at specified time frames and per manufacture's recommendations or the facility policy. -The facility would need to establish the routine of what shift cares for which aspect of CPAP care, usually the night nurse would be responsible for changing tubing, filters and cleansing the surface of the machine and the day nurse would be responsible for cleansing and correct storage of the CPAP mask. -To his/her knowledge there was no established routine for licensed nursing care of CPAP masks, tubing, filters and other supplies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one resident's hemodialysis (a procedure involving diverting blood into an external machine, where it is filtered before being returned to the body to remove waste products and excess fluid from the blood when the kidneys stop working properly) access (the way the resident's blood is reached) was correctly identified in his/her physician's orders, treatment administration record and comprehensive care plan and was correctly assessed by facility licensed nurses, out of 12 sampled residents. The facility census was 31 residents. Review of the facility Hemodialysis Access Care policy, revised September 2010 showed: -Vascular access may be accomplished by three methods, including by central catheters (CVC - a long, soft tube placed into a large blood vessel in the neck, upper chest or groin). -Every shift the location of the catheter, the condition of the dressing and dressing interventions if needed, if dialysis was done during the shift, and observations post dialysis. 1. Review of Resident #7's admission record showed: -He/she was admitted to the facility on [DATE]. -He/she had a diagnosis of end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis). Review of the resident's physician's order recap showed: -Dialysis Monday, Tuesday, Thursday and Friday at 12:00 noon, including the name of the dialysis center, dated 5/19/22. -Monitor (assess the dialysis site arteriovenous (AV) fistula - hemodialysis access type that is created by surgically connecting an artery to a vein under the skin, usually in the upper or lower arm) bruit (the rumbling sound heard with a stethoscope placed on the skin above an AV fistula to assess that the fistula is functional) thrill (the vibration felt when touching the AV fistula with the fingers to assess that the fistula is functional). -Monitor for swelling, pain, redness, or drainage of the shunt every shift. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff) dated 5/22/23 showed the resident: -Was cognitively intact. -Received dialysis services while a resident at the facility. Review of the resident's medication administration record (MAR) dated 5/1/23 through 5/31/23 showed: -Monitor bruit and thrill each shift, dated 5/30/23. -Documentation that a bruit and thrill was assessed on the night shift on 5/30/23. --NOTE: The resident did not have an AV fistula, bruit and thrill cannot be assessed with a CVC dialysis access. -No further documentation of assessment of the resident's dialysis access (including AV access). --There was no documentation by the licensed nurses of the resident's correct CVC dialysis access for 27 out of 27 opportunities. Review of the resident's licensed nurse's notes dated 5/18/23 through 6/5/23 showed no assessment/ monitoring of the resident's central venous dialysis access. Review of the resident's comprehensive care plan dated 5/19/23 showed the following: interventions for an AV fistula and no identification or interventions for his/her CVC dialysis access. : -Interventions for an AV fistula. -Monitor bruit and thrill each shift and as needed. -Remove pressure dressing from fistula four hours post dialysis. -Monitor for swelling, pain, redness, or drainage of the shunt site each shift. -Monitor for swelling, pain, redness, or drainage of shunt site each shift. -No mention of or interventions for the resident's CVC dialysis access. The resident's June 2023 medication administration record was requested and not received. Observation on 6/5/23 at 9:14 A.M. showed: -The resident was lying in his/her bed and was alert and oriented. -He/she had no AV fistula. -He/she had a dressing over his/her right chest CV catheter site. During an interview on 6/5/23 at 9:14 A.M. the resident said: -He/she never had dialysis access in either of his/her arms. -He/she received his/her dialysis through a port in his/her right upper chest. -The nurses did not look at his/her right upper chest at all; at the facility therapy staff did but the nurses did not. -The dialysis center did the dressing changes for his/her dialysis access. During an interview on 6/7/23 at 12:41 A.M., Licensed Practical Nurse (LPN)B said: -He/she had previously worked on the resident's hall and had cared for the resident. -He/she had been aware the resident did not have an AV fistula. -He/she looked at the resident's CVC site every shift and documented that the CVC dressing was present and that there was no bleeding at the CVC site. -He had not yet been in to assess the resident that day. -The resident's had instructions on his/her in his/her electronic medical record (EMR) for nurses to assess his/her bruit and thrill each shift. During an interview on 6/7/23 at 1:03 P.M. the Regional Nurse/Interim Director of Nursing (DON) said: -He/she expected the resident's physician's order, care plan and nursing documentation, to correctly identify the resident's dialysis access. -He/she expected the nurse's assessments to be accurate as to the resident's dialysis access. -He/she expected the resident's dialysis access would be correct on his/her physician's orders, MAR/TAR and care plan -He/she expected that licensed nurses would ensure and correct the physician's orders, MAR/TAR and care plan to correctly identify the resident's CVC dialysis site. During an interview on 6/7/23 at 1:03 P.M. the MDS/Care Plan said: -He/she had assessed the resident during completion of the resident's admission MDS and was aware the resident did not have an AV fistula and did have CVC dialysis access. -He/she had incorrectly put in the resident's care plan to check his/her bruit and thrill. -He/she was aware at the time of completion of the resident's care plan that his/her dialysis access was a central venous catheter and that he/she did not have a dialysis fistula.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #283's admission record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. Review of the resident's admission MDS dated [DATE] showed the resident was cognitively intact. During an interview on 6/6/23 at 12:41 P.M., the resident said: -He/she already had an advance directive, but it was kept with his/her family. -No one from the facility had asked to have a copy of it brought in to the facility to put in his/her medical record. Review of the resident's electronic medical record on 6/6/23 showed no documentation related where staff had tried to obtain the residents advanced directives. 4. Review of Resident #284's admission record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. Review of the resident's admission MDS dated [DATE] showed the resident was mildly cognitively impaired. During an interview on 6/6/23 at 12:39 P.M. the resident said he/she was unsure about the advanced directive and his/her brother was in charge of that. Review of the resident's electronic medical record on 6/6/23 showed no documentation related where staff had tried to obtain the residents advanced directives or documentation where a nurse or any staff from the facility talked to the brother about an advanced directive. 5. During an interview on 6/7/23 at 8:22 A.M., Licensed Practical Nurse (LPN) B said: -A resident would be asked about a formulating an advance directive or if the resident had an advance directive upon admission. -When asked about advanced directives it would be charted in the Progress notes section the resident's electronic medical record. -When a resident had an advanced directive it would be requested to be brought in and charted that it was requested. -It would be documented in the assessments tab. -If a resident had one then someone would be contacted to bring it in. -When asked for a family to bring in the advance directive would be documented in the notes. -He/she was unable to show any documentation related to advanced directives for Resident's #283 and #284. During an interview on 6/7/23 at 8:23 A.M., Registered Nurse (RN) A said: -Residents were allowed to make an advance directives. -Upon admission the resident would be asked if they have an advance directive or would like to make a advanced directive. -Nursing would ask for a copy of the advance directive if a resident had one. -It would be documented in a progress note that it was asked for, and either if the resident wanted one or refused one, and who was going to bring it in. -He/she was unable to show any documentation related to advanced directives for Residents #283 and #284. Based on interview and record review, the facility failed to ensure five sampled residents (Resident #231, #232, #283, #284, and #3) were offered the right to formulate and/or obtain existing (advanced directives (legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) out of 12 sampled residents. The facility census was 31 residents. Review of the facility policy Advanced Directives revised 4/2013 showed: -Upon admission the Social Services Director (SSD) or designee would provide written information regarding medical care and the right to formulate advanced directives. -Prior to or upon admission, the SSD or designee would inquire about existing advance directives. 1. Review of Resident #231's admission record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. Review of the resident's admission Agreement dated 6/1/23 showed: -The resident had been given written materials about his/her right to formulate advanced directives. -The resident had the right to refuse medical treatments. -This was signed by the resident. Review of the resident's electronic medical record on 6/6/23 showed no documentation related to trying to obtain or formulate advanced directives. During an interview on 6/6/23 at 8:36 A.M. the resident said: -He/she did not have a Durable Power of Attorney (DPOA-an appointed person to make healthcare decisions if you becomes disabled or incapacitated) or a healthcare directive (a legal document explaining how you want medical decisions to be made when you are too ill to speak for yourself). -He/she did not receive any written documentation from facility staff about formulating advanced directives. -He/she thought the staff would be assisting him/her with a DPOA and healthcare directive. -Staff had not approached him/her to formulate and healthcare directive or DPOA. 2. Review of Resident #232's admission record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. Review of the resident's admission Agreement dated 5/18/23 showed: -The resident had been given written materials about his/her right to formulate advanced directives. -The resident had the right to refuse medical treatments. -This was signed by the resident. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 5/22/23 showed the resident was cognitively intact. During an interview on 6/5/23 at 2:55 P.M. the resident said: -He/she had a Living Will (A type of advance directive that states the specific types of medical care that a person wishes to receive if that person is no longer able to make medical decisions because of a terminal illness or being permanently unconscious) at home. -His/her spouse was the DPOA named in the Living Will. -He/she had not been asked to provide his/her Living Will to the facility. -This would be good to have on file at the facility in the event of a medical emergency. Review of the resident's electronic medical record on 6/6/23 showed no documentation related to trying to obtain or formulate advanced directives. 6. Review of Resident #3's admission record showed he/she was admitted to the facility on [DATE] with a primary diagnosis of displaced Intertrochanteric fracture of right femur (a hip fracture with the break at the top of the thigh bone), subsequent encounter with routine healing. Review of the resident's admission Agreement dated 5/10/23 showed: -The resident had been given written materials about his/her right to formulate advanced directives. -The resident had the right to refuse medical treatments. -This was initialed by the resident. Review of the resident's admission MDS dated [DATE] showed the resident was cognitively intact and was receiving rehabilitation services at the facility. Review of the resident's electronic medical record on 6/6/23 showed no documentation related to trying to obtain or formulate advanced directives. During an interview on 6/5/23 at 12:03 P.M. the resident said: -He/she couldn't remember being asked about Advanced Directives and formulating healthcare directives when he/she first came to the facility, but he/she had just had surgery a day or two prior to his/her admission and he/she was very out of it at the time. -He/she thought three of his/her family members might be his/her DPOA and they might have signed papers to speak on his/her behalf if he/she could not do so, but he/she wasn't certain about that. -He/she couldn't remember being asked if he/she had a DPOA or wanted to designate anyone as a DPOA. 7. During an interview on 6/7/23 at 9:23 A.M. the Admissions Coordinator said: -He/she was responsible for completing the admission agreement with the residents. -He/she let then resident/family know he/she had the right to formulate advanced directives. -He/she did not provide any written information about advanced directives to the resident or family. -He/she did not obtain any existing advanced directives from the resident or family. -The Social Services Director (SSD) was responsible for providing written information to the resident/family, obtaining advanced directives, or formulating advanced directives During an interview on 6/7/23 at 10:03 A.M. the Social Services Designee (SSD) said: -The Admissions Coordinator was responsible for asking and obtaining existing advanced directives upon admission. -He/she met with the resident after admission and would ask if the resident had any advanced directives. -This was not documented in the resident's medical record. -He/She did not provide written information to the resident/family about advanced directives. -He/She did not offer to formulate advanced directives for the resident. -Having a DPOA and healthcare directive on file at the facility would be important in case of a medical emergency. During an interview on 6/7/23 at 1:03 P.M. the Regional Nurse/Interim Director of Nursing (DON) said: -The Admissions Coordinator was responsible for obtaining existing advanced directives upon admission. -The SSD was responsible for helping the resident complete a healthcare directive and DPOA advanced directives. -The SSD should have been providing the written information regarding the right to formulate advanced directives as stated in admission agreement. -He/she expected the SSD to document in the residents' medical record about he/she tried to obtain or offered the right to formulate advanced directives. -The residents' should have advanced directives on file to guide care in the event of an emergency. -The process was not understood by the staff. -The advanced directive process was not being monitored.

Based on interview and record review, the facility failed to ensure a background screening through the Certified Nurse Assistant (CNA) Registry was completed prior to hire to determine if there was a Federal Indicator (FI - a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) for four out of ten new employees whose files were sampled. This had the potential to affect any facility resident who received services from or whose medical records or belongings could have been accessed by one or more of the four employees. The facility census was 31 residents. Review of the facility's Abuse and Neglect policy, most recently reviewed May, 2022 showed: -The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment by a court of law; have had a finding entered into the Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or have a disciplinary action in effect against his/her professional license as a result of a finding of abuse, neglect, exploitation of residents or misappropriation of resident property. The facility will report to the State Nurse Aide Registry licensing authorities any knowledge it has of action by a court of law against an employee which would indicate unfitness for service as a nurse aide or other facility staff. -It is the responsibility of the Administrator and the Director of Nursing (DON) Services to ensure the screening of potential employees for a history of abuse, neglect, or mistreatment of residents. This includes attempting to obtain information from at least two former employers and/or current employers and checking with the appropriate licensing boards and registries. The Administrator and DON are responsible for ensuring the resident is protected from harm by conducting pre-employment reference checks on all facility employees and requiring documentation of such checks. Reference checks include a Criminal Background Check as prescribed by federal and state regulations, checking the state registry to verify licensure and to verify there are no disqualifications against the potential employee. 1. Review of Employee A's employee file showed: -The employee was hired on 9/8/22 as a Registered Nurse (RN). -The FI check was not completed. Review of Employee B's employee file showed: -The employee was hired on 6/29/22 as a Dietary Aide. -The FI check was not completed. Review of Employee E's employee file showed: -The employee was hired on 2/7/23 as a Housekeeper. -The FI check was not completed. Review of Employee J's employee file showed: -The employee was hired on 12/15/22 as a Licensed Practical Nurse (LPN). -The FI check was not completed. During an interview on 6/7/23 at 9:23 A.M. the Human Resources (HR)/Payroll Director said: -He/she was responsible for getting the background screening results for all employees prior to an offer of employment and making sure they were complete. -Background screenings included, but were not limited to, results of the Criminal Background Check, Employee Disqualification List (EDL), and reference checks from prior employers for all potential employees. Additionally, the Nurse Aide Registry screening results were obtained for all potential new CNAs prior to their date of hire. -He/she did not know it was required to do the Nurse Aide Registry screening for employees who were not going to be working as a CNA. During an interview on 6/7/23 at 1:03 P.M. the Interim DON said: -He/she had been working as the Interim DON only since 6/5/23. -As far as he/she knew, the DON was not responsible for verifying there were no disqualifications against potential or new employees. During an interview on 6/7/23 at 2:10 P.M. the Administrator said: -He/she was not aware background screenings were required through the Nurse Aide Registry for employees who would not be working as a CNA. -His/Her expectation was that all required background screenings be completed for all potential employees prior to an offer of employment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #21's admission record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 4/30/23 showed the resident was cognitively intact. Review of the resident's 48 Hour Baseline Care Plan showed: -At the top of the form: Review care plan with the resident and obtain his/her signature and date. Make a copy of the care plan and provide the copy to the resident. -The resident had been admitted to the facility on [DATE] after suffering a right calcaneus fracture (broken heel bone) and a left fibula fracture (broken lower leg). -The resident needed staff assistance with Activities of Daily Living (ADLs-activities related to personal care), used a wheelchair for mobility, needed set up help with meals and preferred to eat in the dining room. -The care plan was not signed by the resident. During an interview on 6/5/23 at 9:16 A.M. the resident said: -He/she did not remember going over his/her plan of care or signing the care plan around admission to the facility. -He/she wanted to go over his/her plan of care with the facility staff. 3. Review of Resident #231's admission record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. Review of the resident's 48 Hour Baseline Care Plan showed: -At the top of the form: Review care plan with the resident and obtain his/her signature and date. Make a copy of the care plan and provide the copy to the resident. -The resident had been admitted to the facility on [DATE] after having a pacemaker (a small device that's placed (implanted) in the chest to help control the heartbeat) placed. -The resident needed staff assistance with Activities of Daily Living (ADLs-activities related to personal care), used a wheelchair for mobility, needed set up help with meals, and preferred to eat in his/her room. -The care plan was not signed by the resident. During an interview on 6/6/23 at 8:36 A.M. the resident said: -He/she did not receive or sign a baseline care plan around admission to the facility. -He/she wanted to go over his/her plan of care. Based on interview and record review, the facility failed to provide the resident and/or their representative with a summary of a Baseline Care Plan (BCP) that was developed within the first 48 hours of admission for four sampled residents (Residents #132, #21, #231, and #82) out of 12 sampled residents. The facility census was 31 residents. Review of the facility's Preliminary Care Plan policy revised 8/2006 showed: -To assure the resident's immediate care needs are met and maintained, a preliminary care plan will be developed within 24 to 48 hours of the resident's admission. -The Interdisciplinary Team (IDT) will review the Attending Physician's order (e.g., dietary needs, medications, and routine treatments, etc.) and implement a nursing care plan to meet the resident's immediate care needs. -The preliminary care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary care plan. 1. Review of Resident #132's admission record showed he/she was admitted to the facility on [DATE] with: -A primary diagnoses of subluxation (spinal misalignment or joint gaps that cause pressure on the spinal nerves) of C4/C5 cervical vertebrae (mid-neck spinal bones). -A diagnosis of Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of the resident's Brief Interview for Mental Status (BIMS), dated 6/1/23 showed he/she was severely cognitively impaired. Review of the resident's baseline care plan, dated 6/1/23, showed: -He/she was cognitively impaired, had impaired decision-making, and was cooperative. -He/she required assistance of one person with walking using a walker, transfers, bed mobility, repositioning, grooming, and incontinence cares. Review of the resident's medical record on 6/6/22 showed there were no nurses' notes or social services notes that showed staff provided the baseline care plan to the resident and his/her family/responsible party. During an interview on 6/5/23 at 10:49 A.M. the resident's family member said: -No staff member discussed the resident's baseline plan of care with the resident and family. -The resident and family were not given a copy of the resident's BCP. 4. Review of Resident #82's admission record showed: -He/she was admitted to the facility on [DATE]. -He/she had a diagnosis of obstructive sleep apnea He/she had a diagnosis of obstructive sleep apnea (OSA - a condition in which breathing pauses during sleep because of narrowed or blocked airways), dated 4/25/23. Review of the resident's baseline 48 Hour Care Plan, dated 4/27/23 showed his/her Continuous Positive Airway Pressure (CPAP) and oxygen use was not addressed. During an interview on 6/6/23 at 8:39 A.M. the resident said: -He/she had used oxygen and CPAP at the time of his/her original facility admission in late April 2023. -He/she brought his/her CPAP to the facility at the time of his/her original facility admission. -He/she was given an initial care plan a couple of days after his/her admission in April 2023. -He/she did not recall what was in the initial care plan. 5. During an interview on 6/7/23 at 9:11 A.M. Licensed Practical Nurse (LPN) B said: -He/she gathered information and wrote the baseline care plan. -The nurses were responsible for completing the baseline care plans upon admission. -He/she put the baseline care plan in a file at the nurses' station. -He/she assumed the Social Services Director (SSD) went over the plan of care with the resident. -He/she had not been instructed to have the resident sign the baseline care plan, go over the care plan, or provide a copy to the resident or resident's representative. During an interview on 6/7/23 at 10:03 A.M. the Social Services Designee (SSD) said: -The nurses were responsible for completing the baseline care plans upon admission. -The admitting nurse would have the resident sign the baseline care plan, provide a copy to the resident and the residents' representative. -He/she did not go over the baseline care plans with the residents. During an interview on 6/7/23 at 10:24 A.M. LPN A said: -The nurses were responsible for completing the baseline care plans upon admission. -He/she filled out the information on the baseline care plan. -He/she did not have the resident sign the care plan or provide a copy to them or their representative. -The SSD would hold a care plan meeting and go over the plan of care. During an interview on 6/7/23 at 1:03 P.M. the Regional Nurse/Interim Director of Nursing (DON) said: -The baseline care plan was completed by the admitting nurse and reviewed with the resident and responsible party. -The residents were not given a copy, only if requested. -The nurses do have them sign off on the baseline plan of care to show it was reviewed with the resident. -The baseline care plan should have initial goals, treatments and services. -He/she was not sure where the staff documented when they go over the baseline care plan with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have a process in place to ensure Cardiopulmonary Resuscitation (CPR- an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who was in cardiac arrest) certified staff were available on all shifts. The facility census was 31 residents. Review of facility's policy Cardiopulmonary Resuscitation (CPR) dated 2001 revised 4/2016 showed: -Personnel have completed training on the initiation of CPR and basic life support (BLS) including defibrillation (shocking the heart), for victims of sudden cardiac arrest. -If an individual (resident, visitor, or staff member) was found unresponsive and not breathing normally, a licensed staff member who was certified in CPR/BLS would initiate CPR. -If the first responder was not CPR-certified, that person would call 911 and follow the 911 operator's instruction until a CPR-certified staff member arrived. 1. Review of the facility's list of CPR certified staff showed there were 11 CPR certified employed in the facility. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. Review of facility staffing sheets dated [DATE] showed there was no designation for employees that were CPR certified. During an interview on [DATE] at 8:09 A.M., Certified Nurse's Aide (CNA) A said: -He/she was CPR certified. -He/she did not know who in the facility was CPR certified. -There was nothing on the schedule that designated what staff were CPR certified. During an interview on [DATE] at 8:15 A.M., CNA B said: -He/she was CPR certified. -He/she was unsure if all the staff are CPR certified or was CPR certified. -There was nothing on the schedule that showed which staff were CPR certified. During an interview on [DATE] at 8:22 A.M., Licensed Practical Nurse (LPN) B said: -He/she was CPR certified. -He/she was unsure if all staff are CPR certified. -Staff who is CPR certified was not documented on the schedule. During an interview on [DATE] at 8:23 A.M., Registered Nurse (RN) A said: -He/she was CPR certified. -Not all the nurses, Certified Medication Technicians (CMT's), and CNA's were not certified for CPR. -Nothing on the schedule showed who was CPR certified. During an interview on [DATE] at 8:44 A.M., CMT A said: -He/she was not CPR certified. -There was nothing on the schedule that showed who was CPR certified in the building. -If a resident was found unresponsive and needed CPR, he/she would not know who to call except for the Assistant Director of Nursing because he/she was CPR certified. During an interview on [DATE] at 1:04 P.M., Regional Nurse Consultant Interim Director of Nursing (DON) said: -He/she had only been at the facility for three days. -It was his/her expectation that all nursing staff be CPR certified. -He/She had discovered that not all staff were CPR certified. -It was his/her expectation that there would be a list of which staff were CPR certified in the building per shift at the nurse's station. -The DON or the DON designee would be responsible for this list and having it placed at the nurses station. -It was the DON's responsibility to audit staff and to make sure that staff were current on CPR certification. -He/she said that currently there was no list of CPR certified staff at the nurses station, and which staff were CPR certified was no designated on the schedule there was no way for a non CPR certified staff member to know who was CPR certified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three sampled residents (Resident #21, #231, and #232) signed arbitration agreements (a private process where disputing parties agree that one or several individuals can make decisions about the dispute after receiving evidence and hearing arguments) after this was explained in a manner they understood; and also to ensure the agreement contained arbitration was not required to be signed as a condition of admission and the resident had the right to communicate with state officials out of 12 sampled residents. The census was 31 residents. A policy on arbitration was requested from the facility but not received. 1. Review of Resident #21's admission Record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning dated 4/30/23 showed the resident was cognitively intact. Review of the resident's arbitration agreement 4/26/23 showed: -The resident signed to allow arbitration. -The arbitration agreement did not include signing for arbitration was not a condition of admission and the resident was allowed to communicate issues with state officials. During an interview on 6/7/23 at 8:41 A.M. the resident said: -He/she did not remember signing and agreeing to arbitration. -He/she was not sure if the arbitration process was explained to him/her. 2. Review of Resident #231's admission Record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. Review of the resident's arbitration agreement 6/1/23 showed: -The resident signed to allow arbitration. -The arbitration agreement did not include signing for arbitration was not a condition of admission and the resident was allowed to communicate issues with state officials. During an interview on 6/7/23 at 8:35 A.M. the resident said: -He/she signed his/her arbitration agreement. -He/she thought arbitration meant he/she had to follow the rules at the facility. -Arbitration was not explained to him/her during the admission process. 3. Review of Resident #232's admission Record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. Review of the resident's arbitration agreement 5/18/23 showed: -The resident signed to allow arbitration. -The arbitration agreement did not include signing for arbitration was not a condition of admission and the resident was allowed to communicate issues with state officials. Review of the resident's admission MDS dated [DATE] showed the resident was cognitively intact. During an interview on 6/7/23 at 8:26 A.M. the resident said: -He/she did sign the arbitration agreement. -The arbitration process was not explained to him/her upon signing the agreement. 4. During an interview on 6/7/23 at 9:23 A.M. the Admissions Coordinator said: -He/she was responsible for completing the arbitration agreements upon admission which included the arbitration agreement. -He/she thought arbitration was when a residents' insurance disputed the charges the facility would assist with helping the resident. -He/she explained this information to the residents and had the residents' sign the agreement. -He/she was not aware of what the meaning of arbitration was. -Arbitration was not explained to the residents in a meaning that was understood. -He/she was not sure what the agreement should contain. During an interview on 6/7/23 at 1:51 P.M. the Administrator said: -The arbitration agreement was part of the admission agreement. -The Admissions Coordinator was responsible for explaining arbitration in a clear manner that was understood by the residents. -The arbitration agreement did not contain that the residents did not have to sign to accept arbitration as a condition upon admission or the residents had the right to communicate with state officials.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three sampled residents (Resident #21, #231, and #232) signed arbitration agreements (a private process where disputing parties agree that one or several individuals can make decisions about the dispute after receiving evidence and hearing arguments) that contained a neutral arbitrator and a venue to hold the arbitration meeting agreed upon by both parties (resident and facility) out of 12 sampled residents. The census was 31 residents. A policy on arbitration was requested from the facility but not received. 1. Review of Resident #21's admission record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning dated 4/30/23 showed the resident was cognitively intact. Review of the resident's arbitration agreement 4/26/23 showed: -The resident signed to allow arbitration. -The arbitration agreement did not contained a neutral arbitrator and a venue to hold the arbitration meeting agreed upon by both parties. 2. Review of Resident #231's admission record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. Review of the resident's arbitration agreement 6/1/23 showed: -The resident signed to allow arbitration. -The arbitration agreement did not contained a neutral arbitrator and a venue to hold the arbitration meeting agreed upon by both parties. 3. Review of Resident #232's admission record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation services. Review of the resident's arbitration agreement 5/18/23 showed: -The resident signed to allow arbitration. -The arbitration agreement did not contained a neutral arbitrator and a venue to hold the arbitration meeting agreed upon by both parties. Review of the resident's admission MDS dated [DATE] showed the resident was cognitively intact. 4. During an interview on 6/7/23 at 9:23 A.M. the Admissions Coordinator said: -He/she was responsible for completing the arbitration agreements upon admission which included the arbitration agreement. -He/she was not sure what the agreement should contain. -The agreement did not contain a neutral arbitrator and a venue to hold the arbitration meeting agreed upon by both parties. During an interview on 6/7/23 at 1:51 P.M. the Administrator said: -The arbitration agreement was part of the admission agreement. -The arbitration agreement did not contain a neutral arbitrator and a venue to hold the arbitration meeting agreed upon by both parties. -These requirements should be in the arbitration agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of weight gain for one sampled resident (Resident #37) who was being treated for edema (swelling caused by excess fluid trapped in your body's tissues) out of 12 sampled residents. The facility census was 37 residents. Record review of the facility's policy titled Change in a Resident's Condition or Status dated 11/17/21 showed the facility would promptly notify the resident's physician of medical or status changes. 1. Record review of Resident # 37's admission Record showed he/she was admitted to the facility on [DATE] for Medicare Part A skilled services and a diagnosis of Congestive Heart Failure (CHF-disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). Record review of the resident's Order Summary Report showed the following physician's orders dated 8/31/21: -Weekly weight: please check current weight against historical weights to assess for error. -Furosemide (Lasix (diuretic) used to decrease swelling or to decrease blood pressure) 80 milligrams (mg); give one tablet by mouth one time per day for fluid retention. Record review of the resident's Care Plan dated 9/1/21 showed he/she was being monitored for adverse reactions related to being on a diuretic (a type of drug that causes the kidneys to make more urine) medication. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning) dated 9/3/21 showed the resident had CHF. Record review of the resident's weight log showed: -On 9/3/21 the resident weighed 294.7 pounds. -On 9/5/21 the resident weighed 299.2 pounds. --This was an increase of 4.5 pounds in two days. -On 9/19/21 the resident weighed 298.6 pounds. -On 9/26/21 the resident weighed 309.0 pounds. --This was an increase of 10.4 pounds in one week. Record review of the resident's electronic medical record (EMR) on 9/27/21 showed there was no documentation the physician had been notified of the resident's weight gain. During an interview on 9/28/21 at 11:45 A.M. Certified Nurses Assistant (CNA) A said: -He/she would weigh the residents' but did not look at previous weights. -He/she gave the weights to the charge nurse to enter in the residents' electronic medical record. -He/she only weighed the residents' but did not look for weight discrepancies. -The nurse was responsible for reviewing the residents' weights for increases. During an interview on 9/28/21 at 11:55 A.M. Registered Nurse (RN) C said: -The CNA's were responsible for weighing the residents. -The nurses made a list of weights that needed to be obtained that day and would help out as needed with weighing the residents. -The nurses were responsible for documenting the weights in the residents' EMR. -When documented, the nurse was responsible for looking at weight changes. -He/she would look for normal baseline of weight. -He/she would have the resident re-weighed if weight change was significant. -The normal protocol was not in a physician's order but the nurse was responsible for notifying the physician of a weight gain of two pounds in one day or five pounds in one week. -The weights needed to be watched closely if the resident had edema. During an interview on 9/28/21 at 12:04 P.M. RN B (Unit Manager) said: -The charge nurse gave a list of residents' who needed to be weighed that day to the CNA. -The nurse was responsible for looking at weight changes especially in residents' with edema. -The nurse was responsible for notifying the physician for weight gains that were more significant. -The nurse was responsible for notifying the physician of a weight gain of two pounds in one day or five pounds in one week. During an interview on 9/29/21 at 12:08 P.M. the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said: -CNA's completed weekly weights on Sundays and daily weights throughout the week. -Nurses were responsible for entering the weights into the residents' electronic medical record. -The CNA would not know if there were weight discrepancies. -The nurse should review for weight discrepancies. -If there was a two pound weight gain in 24 hours or five pounds in one week the nurse should notify the physician. -The nurse should notify the physician of the weight gain especially if the resident had edema. -If there was a big weight discrepancy the nurse should have the resident re-weighed to ensure there was no issue when weighing the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent the diversion (the unauthorized removal) of Lorazepam (a controlled medications used to treat anxiety that had a higher potential of dependence and abuse) from one sampled resident (Resident #41) to two sampled residents (Residents #16 and #149) out of 12 sampled residents and 10 closed records. The facility census was 37 residents. Record review of the facility's policy on Abuse and Neglect revised 5/2018 showed: -Residents have the right to be free from theft and/or, misappropriation of property. -The resident was to be free from abuse and neglect, and that swift and immediate action would be taken to investigate and adjudicate alleged instances of resident abuse and neglect. -Misappropriation of resident property was defined as the patterned or deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. -It was the responsibility of the Administrator and the Director of Nursing Services to ensure employees are trained. -The training covered what constituted misappropriation of resident property. -It was the responsibility of the Administrator and Director of Nursing Services to identify events that constituted abuse and determined the direction of the investigation. -Staff, at any level and in any position, are expected to report any allegations of any type of abuse. -The Administrator and/or the Director of Nursing Services are responsible to initiate the investigation immediately upon notification of the alleged event. -The facility documented investigation findings, included witness statements, corrective actions, and the conclusion in the administrative file. -It was the responsibility of every employee of the facility to report misappropriation of property. -Alleged violations of misappropriation of resident's property are reported immediately but no later than two hours after the allegation is made. -After the facility submitted an immediate report of an alleged violation, the facility conducted a thorough investigation; prevented other incidents from occurring throughout the course of the investigation and reported the results of the investigation to the state agency within five working days. -Any employee of the facility, who is suspected to disregard any of the resident's rights would be suspended from all duties and from the facility pending an investigation. -If the investigation validated that resident's rights were disregarded, appropriate and immediate disciplinary action would be conducted regarding the employee up to and included termination of employment. Record review of the facility policy for Controlled Substances dated 2001 revised 2012 showed: -Only authorized licensed nursing and/or pharmacy personnel shall have access to Scheduled II controlled drugs maintained on the premises. -The Director of Nursing Services identified staff members who are authorized to handle controlled substances. -Controlled Substances are stored in the medication room in a locked container, separated from containers for any non-controlled medications. The container must remain locked at all times, except when accessed to obtain medications for residents. -All Schedule II narcotics were to be double locked at all times. -The Charge Nurse on duty was to maintain the narcotic keys at all times. -The Director of Nursing (DON) was to maintain a set of back-up keys for all drug storage areas including the keys to the narcotics storage containers. -The facility nursing staff were to count narcotics at the end of each shift. -The nurse coming on duty and the nurse going off duty were to count the narcotics together. -The DON was to investigate all discrepancies in the narcotics reconciliation to determine the cause and identify any responsibility parties, and shall give the Administrator a written report of such findings. 1. Record review of Resident #41's admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Aftercare following joint replacement surgery. -Presence of left artificial knee joint. -Osteoarthritis (a degenerative disease of the bones and joints), left knee. -Anemia (condition in which a person quickly loses a large volume of circulating hemoglobin). -Hyperlipemia (high levels of lipids in the blood). -Difficulty in walking, not elsewhere classified. Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool used by facilities for care planning), dated 7/27/21 showed: -A Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. -He/she required extensive assistance and oversight for all Activities of Daily Living (ADL's - basic tasks of daily life that most people are used to doing without assistance, such as eating, bathing, toileting, walking, transferring). Record review of the resident's Order Summary Report dated 8/13/21 showed Lorazepam tablet give 0.5 milligram (mg) tablet by mouth every 8 hours as needed for Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). 2. Record review of Resident #149's facility admission Record showed he/she was admitted on [DATE] with diagnoses that included: -Encephalopathy (any abnormal condition of the structure or function of brain tissues, especially chronic, destructive, or degenerative conditions). -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) without behavioral disturbances. -Anxiety disorder, unspecified. -Mild cognitive impairment (an early stage of memory loss or other cognitive ability loss (such as language or visual/spatial perception) in individuals who maintain the ability to independently perform most activities of daily living), so stated. Record review of the resident's admission MDS dated [DATE] showed: -A BIMS score of 11, which indicated the resident had moderate cognitive impairment. -He/she required extensive assistance with all ADL's. Record review of the resident's Order Summary Report dated 8/31/21 showed Lorazepam give 0.5 mg tablet by mouth two times a day for Anxiety. 3. Record review of Resident #16's facility admission Record showed he/she admitted to the facility on [DATE] with diagnoses that included: -Major Depressive Disorder (also referred to as clinical depression, is a significant medical condition that can affect many areas of your life. It impacts mood and behavior as well as various physical functions, such as appetite and sleep), recurrent, unspecified. -Anxiety Disorder, unspecified. Record review of the resident's admission MDS dated [DATE] showed: -A BIMS score of 11, which indicated the resident had moderate cognitive impairment. -He/she required extensive assistance with all ADL's. Record review of the resident's Medication Administration Report (MAR) dated 8/25/21 showed Lorazepam give 1 mg tablet by mouth three times a day for Anxiety. 4. Record review of the facility Investigation Report dated 8/14/21 showed: -The narcotic count sheet for Resident #41 had five tablets of Lorazepam 0.5 mg signed out on 8/9/21 at 8:00 A.M. by Registered Nurse (RN) A and RN B. -RN A signed out 5 tablets of Lorazepam from Resident #41 for Resident #16 and Resident #149 on the 200 hall as the Cubex (automated medication dispensing system for medication management) was empty. -RN A gave the 5 tablets of Lorazepam to RN B. -Resident #149 and Resident #16 had orders for Lorazepam. -RN B thought the Cubex was empty. -RN B called the pharmacy on 8/13/21 and the pharmacy said the Lorazepam was available in the Cubex. -RN B thought the Cubex would not let him/her pull them because he/she requested too many pills at one time. -It was determined by investigation that RN A did not use the Lorazepam for his/her own use, but used it for Resident #16 and Resident #149 who needed the medication immediately. -RN A was educated that even though he/she was meeting the needs of the residents, borrowing other resident's narcotics was not an acceptable practice. Record review of the Employee Disciplinary Form dated 8/17/21 showed RN A was suspended from 8/14/21 to 8/17/21. During an interview on 9/22/21 at 2:27 P.M. RN A said: -He/she was the Charge Nurse on the 100 Hall. -RN B was the Charge Nurse on the 200 Hall. -RN B had two new admissions. -The Ativan for the new admissions had not arrived yet. -RN B reported the Cubex was empty when they both tried it. -RN A and RN B called the pharmacy and the pharmacy said that a written prescription was needed. -Resident's #16 and #149 had an order for Lorazepam. -Resident #41 had discharged and did not take his/her Lorazepam home. -RN A signed out 5 Lorazepam 0.5 mg tablets and RN B cosigned for the medication from Resident #41. -RN B took the medication and administered it to Resident #16 and Resident #149 whose medication had not been delivered. -All the Lorazepam was given at that time, and not stored for later use. During an interview on 9/23/21 at 6:14 A.M. Licensed Practical Nurse (LPN) A said: -Borrowing medications from one resident and giving it to another resident was not correct. -Staff could lose their job. -This was misappropriation. During an interview on 9/23/21 at 6:14 A.M. LPN C said: -Borrowing medications from one resident and giving it to another resident was not correct. -Staff could lose their job. -This was misappropriation. During an interview on 9/24/21 at 9:01 A.M. RN B said: -He/she was the Chare Nurse on 200 Hall. -Resident #16 was very anxious and distraught and his/her Lorazepam was due. -Resident #149's Lorazepam was also due. -Neither resident had had the medication delivered. -RN B went to the Cubex to pull the medication and was unsure what happened but thought the Cubex was out of Lorazepam. -He/she walked out of the medication room and said I he/she needed Lorazepam, and the Cubex was empty. -RN A heard RN B's comment and told RN B he/she had some in his/her medication cart. -RN A removed the doses of Lorazepam for Resident #16 and Resident #149 from Resident #41's card of Lorazepam. -RN B signed Resident #41's narcotics sheet with RN A. -RN B gave the medication to Resident #16 and Resident #149. -RN B called the pharmacy and the pharmacy said the Lorazepam was in the Cubex. -RN B went back to the Cubex and the Lorazepam was in the Cubex. -RN B realized that taking medication from one resident and giving to other residents was wrong. -RN B said he/she would not do that again. During an interview on 9/27/21 at 3:26 P.M. the Administrator said: -He/she was out of town when he/she was notified of the issue on 8/14/21. -He/she notified the Clinical Director immediately who was covering for him/her. -The Clinical Director was going to start the investigation immediately. -The Clinical Director had determined in the investigation that it was borrowing medication and not misappropriation. -Had it been determined to be misappropriation it would have to be reported immediately to the state. During an interview on 9/28/21 at 11:17 A.M. the Clinical Director said: -He/she was notified by the Administrator of a text message from an employee saying medication was taken from one resident and given to two other residents. -He/she called the staff member who had texted the Administrator and interviewed him/her. -The facility utilized a Cubex. -He/she called and spoke to RN A. -RN A said that five Lorazepam tablets had been taken from Resident #41's medication card and was given to Residents #16 and Resident #149. -He/she suspended RN A pending the results of the investigation. -He/she called RN B and took a statement as to what happened. -RN B said the Lorazepam had been taken and used for two residents who had not received their medication from the pharmacy. -RN B tried to get the medication from the Cubex, but the Cubex would not allow it. -RN B went to RN A and explained that the Cubex was not allowing him/her to remove Lorazepam and two residents needed it. -RN A borrowed the medication from a resident that was discharged and gave it to RN B to give to the residents. -All the medication had been used at one time and none was stored for later use. -In hindsight this was misappropriation and should have been reported to the state. During an interview on 9/29/21 at 2:38 P.M. the Director of Nursing (DON) said: -Nurses cannot borrow medication from one resident and given to another resident. -It would be misappropriation if you borrowed medication from a resident. -The misappropriation would be reported to the state immediately. MO00190875

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #16's admission Record face sheet dated 8/6/21 showed he/she was admitted with the following diagnoses: -Displaced comminuted fracture (a break when the bone is not in proper alignment) of shaft of humerus (a bone between the shoulder and elbow), left arm. -Unspecified fracture of left acetabulum (a concave surface of the pelvis). -Unspecified fracture of sacrum (a bone at the bottom of the spine). -Unspecified fracture of right pubis (the most forward facing bone of the pelvis). -Primary osteoarthritis (wearing down of protective tissue at the ends of bone), right shoulder. -Fall on stairs and steps. -Anxiety (intense, excessive and persistent worry and fear about everyday situations) disorder. Record review of the resident's Resident Grievance/Complaint Investigation Report Form dated 8/13/21 showed: -Incident description: CNA F pushed the resident's right arm (the non-broken one) and ran out of the room. When asked if CNA F was trying to reposition him/her, he/she said CNA F was not. -The resident was not injured. -Both the resident and CNA F were interviewed. -CNA F provided a written statement. -No other staff were interviewed or gave statements. -Four other residents were interviewed. -All the residents interviewed said they felt safe at the facility and had not been provided with rough cares. -The grievance/complaint was resolved to the satisfaction of all concerned, and signed off by the corporate nurse. Record review of the resident's progress notes from 8/13/21 to 8/17/21 showed no documentation that the resident had alleged abuse or rough treatment, and no mention of any type of investigation or outcome. During an interview on 9/21/21 at 11:22 A.M., the resident said: -CNA F hit him/her. -He/she didn't remember the date, but said it was toward the beginning of his/her stay at the facility. -He/she said CNA F punched him/her on the right shoulder as hard as he/she could, on an area where he/she had a previous surgery. -He/she did not know if there was any bruising or injury to the area. -The alleged incident was investigated by the corporate nurse. -The corporate nurse apologized to him/her for the alleged incident happening. -CNA F was no longer allowed in his/her room. During an interview on 9/22/21 at 1:46 P.M., CNA F said: -The alleged abuse incident happened on Sunday, 8/15/21, in the evening between 7:00 P.M. and 7:30 P.M. -He/she worked the night shift. -This was the first time he/she worked with the resident. -The resident asked him/her to put a pillow under his/her left broken arm. -He/she tried to move the left arm as gently as possible, but the resident screamed and said he/she was beating him/her. -He/she left the room and went back to his/her work. -The resident put on his/her call light and RN B answered the light. -The resident told RN B that CNA F had beat him/her. -RN B told him/her not to go in the resident's room again. -CNA G took over care of that resident. -The resident told CNA G that CNA F had beat him/her all night. -He/she was off work on 8/16/21 and 8/17/21. -The corporate nurse contacted him/her on 8/17/21 to come to the facility and make a statement. -He/she believed RN B wrote the incident up. -He/she had been trained by the facility on resident abuse and neglect. -They had training at least once a year. During an interview on 9/22/21 at 2:07 P.M., RN B said: -He/she didn't remember what the resident told him/her CNA F did. It had something to do with putting a pillow under his/her arm. -He/she thought the alleged incident had already been reported. -If he/she had thought it was a new incident of alleged abuse, he/she would have made sure the resident and CNA were separated and immediately notified the DON and Administrator. -He/she had been trained on abuse and neglect policies During an interview on 9/22/21 at 2:41 P.M., the Corporate Nurse said: -He/she was at the facility on 8/16/21 because both the administrator and DON were out that day. -RN C, the day shift charge nurse, approached him/her and reported that the resident wanted to speak to him/her regarding CNA F going in his/her room. -RN B, the night charge nurse, did not file an incident report. -RN B did not think it was an abuse situation because the resident had pain with all movement, -He/she didn't think the resident made the complaint about being pushed until the day shift. -The resident never made any statement about being punched. -The investigation was started on 8/16/21. -He/she interviewed CNA F on 8/17/21 about the incident. -Due to the resident's complaint, he/she asked the social worker to interview other residents. -He/she had RN C do a head to toe assessment of the resident. -The resident had no new bruising or injuries. -His/her conclusion was that the resident was not pushed on the right arm, and the left arm was diagnosis related pain. -CNA F was not suspended because the facility investigation was concluded before he/she was due to work again. -The administrator and DON returned to work on 8/17/21 and they were informed of the incident. -He/she thought an incident report was not written sooner because the allegation was being handled and it was not abuse. -The date on the Grievance/Incident report of 8/13/21 was because the resident could not remember the date for certain. -The facility had abuse and neglect training every year for all staff. During an interview on 9/28/21 at 11:07 A.M., Certified Medications Technician (CMT) A said: -The resident told him/her CNA F was mean to him/her. -From what he/she remembered, the facility did an investigation of the alleged incident. -This was the first time the resident had said anything about any staff. -If a resident reported physical abuse, the process would be to notify the charge nurse and DON immediately. -He/she had been trained on abuse and neglect of residents. During an interview on 9/28/21 at 11:25 A.M., RN C said: -On 8/16/21, the resident told him/her that CNA F had been rough with him/her the night before. -The resident said they were rolling him/her in the bed and shoved his/her arm, and he/she was in excruciating pain. -He/she reported it to the supervisor that day. -The corporate nurse and RN A were both there and looked into it. During an interview on 9/28/21 at 11:52 A.M., the SSD said: -He/she did the resident interviews. -He/she also reviewed everything that was done with the resident and completed a grievance form. -The grievance was about rough handling. -The resident never said he/she was abused. -The interviews with other residents were part of the investigation of potential abuse. -He/she had been trained at the facility on resident abuse and neglect. During an interview on 9/29/21 at 9:54 A.M., the Administrator said: -An investigation of abuse or neglect would require staff interviews, resident interviews and written statements from the staff. -The investigation report would have a conclusion summary. -He/she thought the investigation was done for the resident's allegations. -The corporate nurse handled it while he/she was out of town. During an interview on 9/29/21 at 12:09 P.M., the DON said: -CNA F should have been suspended and the DON notified. -He/she preferred to error on the side of caution and an investigation should be done. -The administrator should be notified. -With a suspicion of abuse, the state should be notified immediately. -This was in their policy for abuse and neglect. During a telephone interview on 9/29/21 at 4:35 P.M., CNA G said: -He/she did not feel that any abuse had taken place. -Nobody told him/her about any investigation of the alleged incident. -Nobody said a report was going to be made. MO00190875 Based on interview and record review, the facility failed to fully investigate an allegation of abuse and injuries of unknown origin for one closed record sampled resident (Resident #10) and one sampled resident (Resident #16) out of 12 sampled residents and 10 closed record sampled residents. The facility census was 37 residents. Record review of the facility's Abuse and Neglect Policy last reviewed 4/2021 showed: -It was the responsibility of every employee of the facility to report the following types of alleged violations: -In the event an employee witnessed or had knowledge of any abuse situation occurring in the facility, that employee was to immediately notify the Supervisor who would notify the Administrator and the Director of Nursing Services (DON). -Any allegation of abuse, where it was substantiated or not, reported by the resident, staff or responsible party. -Alleged included occurrences between staff/resident, resident/resident, family, visitor, volunteer, responsible party/resident. -All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were to be reported immediately, but not later than 2 hours after the allegation is made. -The facility would take actions to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in progress. 1. Record review of Resident #10's admission Record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation therapy and had the following diagnoses: -Cognitive emotional or social deficits following a stroke. -Senile degeneration of the brain (A decrease in cognitive abilities or mental decline. This may include the person's inability to concentrate, to recall information, and to properly judge a situation). -Falls. Record review of the resident's admission Assessment Note dated 7/29/21 showed he/she was alert to himself/herself only. Record review of the resident's admission Nursing assessment dated [DATE] showed the resident: -Had a right elbow skin tear. -Had an incision on his/her chest from previous open heart surgery. -Had a large faded bruise on his/her middle back. -Had many scattered bruises to his/her arms in various stages of healing. -Had a dry scab to his/her left calf. -Had multiple dry scabs to the left forearm. Record review of the resident's Baseline Care Plan dated 7/29/21 showed the resident: -Was alert to himself/herself only. -Had impaired decision making and was confused. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 8/4/21 showed the resident: -Was moderately cognitively impaired. -Needed the extensive assistance of two staff members for bed mobility and transfers. -Did not ambulate. Record review of the resident's Incident Report dated 8/9/21 at 7:00 A.M. completed by Registered Nurse (RN) B (also the Unit Manager) showed: Incident description: A Certified Nurses Aide (CNA) reported the resident had a new bruise. Upon assessment the resident was found to have a large purple bruise to the right chest, torso, and flank (the side of a person's body between the ribs and the hip). The resident was unable to say when or how the bruise occurred. -The physician and family were notified. -A witness statement completed by Licensed Practical Nurse (LPN) D dated 8/9/21 showed: The resident was asleep in bed and remained asleep throughout the night. He/she checked on the resident throughout the night because the resident was a high fall risk. The only time he/she entered the resident's room was to turn down the television. -A typed note by the Social Services Director (SSD) dated 8/10/21 showed: The resident said to nursing that someone hit him/her during the night. The resident was interviewed and said sometimes I forget I am not there referring to his/her military war service. He/she recanted his/her statement that someone hit him/her and thought he/she was back there. The family reiterated the resident had flashbacks, Post Traumatic Stress Disorder (PTSD-a set of reactions that can occur after someone has been through a traumatic event) and flashbacks which were worse at night. The resident was severely cognitively impaired. -A typed note completed by RN A (also the former Director of Nursing) dated 8/16/21 showed: On 8/11/21, it was reported by LPN E (no longer employed at the facility) the resident had a new skin impairment to his/her right scalp. RN A went to assess the resident and noted a small, bright red abrasion to his/her right scalp. The patient was severely cognitively impaired. The resident was unable to provide a description of what occurred. The resident was known to self-transfer in his/her room. The resident was on anti-coagulant (blood thinning) medications which put the resident at high risk for bruising and bleeding. -Four residents were interviewed on 8/10/21 by the SSD who said they felt safe at the facility and no one had provided rough cares. -There was no further information showing staff on all shifts were interviewed regarding the residents chest bruising and no additional follow up investigation for the residents head laceration. No summary or conclusions were in the report. Record review of the resident's Nurses Notes late entry note dated 8/10/21 at 10:48 A.M. completed by RN A showed: -On this day, this RN contacted family regarding new bruise to resident's chest. -Resident alleged that someone hit him in the middle of the night. -The resident was alert to person, place, and time with periods of confusion and hallucinations. -The resident had a diagnosis of cognitive social or emotional deficit following other cerebrovascular disease (stroke), other symptoms and signs involving cognitive functions following other cerebrovascular disease, senile degeneration of brain, and other cerebrovascular disease. -The resident was unable to provide a description of the alleged person, unable to recall the situation, just said they were there and BAM. -The resident had been witnessed reverting back to his/her time in the military. -The resident's family member said the resident had some dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), hallucinations, and PTSD. The family member said there have been times when the resident was at the gas station, and thought those around him/her were against him/her and not on his side. At home, the resident has had an occasion where he/she was certain someone broke into his/her house, but no one actually broke into his/her house. -The family member also said the resident suffered from Sundowners and his/her behaviors seemed to be worse after dusk. -The family member said the resident was on an anticoagulant medication and bruised very easily. He/she also obtained frequent skin impairments due to fragile/thin skin. -This RN updated the resident's physician and the resident was started on medication to help with hallucinations and PTSD. Record review of the resident's Social Services Note dated 8/10/21 at 11:08 A.M. showed during the social services assessment the resident said that he/she forgets he/she was not still there regarding his/her military war time. Record review of the resident's Incident Report dated 8/10/21 at 3:21 P.M. completed by LPN E showed: -Incident Report: The resident had an area to the top of his/her hand and left middle finger and an open area to the left lower leg shin with a scant amount of blood. The resident was alert and oriented but this fluctuated to periods of confusion. -The family and physician were notified. -There was no information showing staff on all shifts were interviewed regarding the residents hand and leg injuries. No summary or conclusions were in the report. Record review of the resident's Nurses Note dated 8/10/21 at 6:54 P.M. completed by LPN E showed: -It was reported to this nurse the resident had a large bruise to the middle chest area and an open area to his/her middle index knuckle area, and an open area to the left lower leg. -The physician and family were notified. -Treatment orders were obtained from the resident's physician related to the resident's wounds. Record review of the resident's Nurses Notes dated 8/11/21 at 6:30 A.M. completed by LPN E showed: -The CNA called this nurse to the resident's room reporting blood on his/her pillow and head. -The resident had an open area to the right side of his/her forehead. -The resident did not know what happened and denied falling. -The resident was assessed for injuries. -The resident's family was notified. -The resident was alert and oriented and did not have any hallucinations this shift. -There was no Incident Report completed for the open area to the head, no investigation, no witness statements, no description or the size of the open area to the head, and no summary or conclusion. Record review of the resident's Nurses Notes dated 8/11/21 at 6:44 A.M. completed by LPN E showed: -The CNA reported a bloody open area to the scalp and blood on the pillow. -The family and physician were notified. -The area was cleansed and bandaged and the area had dried blood. During an interview on 9/28/21 at 11:00 A.M. CNA B said: -He/she was not aware of any head lacerations, chest bruising and/or finger or leg lacerations on this resident. -He/she would report any new skin issues or injuries to the nurse. -If a resident said they had been hit by staff, he/she would report this immediately to the charge nurse and the DON. -The administrator, SSD, and the DON would be responsible for completing the investigation. -If nothing was done, he/she would go straight to the Administrator and report the incident. During an interview on 9/28/21 at 12:20 P.M. LPN A said: -He/she was not aware of this resident having any head lacerations, chest bruising and/or finger and leg injuries. -If a resident alleged abuse he/she would call the DON immediately even on the weekend. -The nurse was responsible for completing the incident reports. -The DON and the Administrator were responsible for completing an investigation. During an interview on 9/28/21 at 12:30 P.M. the SSD said: -He/she only knew about the resident potentially being hit by a staff member. -The nurse was responsible for completing an incident report. -The DON was responsible for completing the whole investigation. -He/she was responsible for helping with the investigation. -After speaking with the resident and resident's family member, this was PTSD and the resident was sun downing. -He/she also interviewed other residents related to rough cares and there were no concerns. -He/she was not aware if all staff were interviewed for that shift. -The two abuse coordinators were the DON and Administrator. -RN A was the DON at the time of this allegation. -The DON was responsible for monitoring all incident reports. -The Interdisciplinary Team (IDT) met weekly to go over all incident reports. During an interview on 9/29/21 at 2:57 P.M. MDS Coordinator A said: -He/she met along with the IDT to go over all incidents with the SSD, DON, Assistant Director of Nursing (ADON) and Administrator. -The nurse that discovered the bruising or injury was responsible for completing an incident report. -The resident was known to crawl on his/her mattress and self-transfer. -He/she did not assist with the investigation and was unaware of all of the resident's injuries. -He/she was responsible for ensuring incident reports were completed. During an interview on 9/29/21 at 8:54 A.M. RN B (Unit Manager) said: -The staff had reported a bruise on the resident's chest. -The resident was unable to say how the bruise occurred. -RN A was the charge nurse on the resident's hall that day. -RN A said the bruise that was on the resident's chest was there upon the resident's admission to the facility. -The next day, he/she was told by LPN E the resident had a bruise on his/her chest and the resident had said he/she had been punched in the chest. -The next thing he/she knew was the admission skin assessment was not looked at correctly and the resident did not have a bruise to his/her chest on the form. -The resident was confused sometimes, was not alert and oriented and was a fall risk. -He/she had not been aware of any other injuries on the resident. -If a resident had any injury an incident report was completed by the charge nurse. -The DON was responsible for completing an investigation to determine if abuse had occurred. During an interview on 9/29/21 at 9:11 A.M. RN A (former DON): -He/she was the DON in August 2021. -The resident's chest bruising was initially reported to him/her on a Monday. -He/she had reviewed the resident's admission skin assessment and read the report wrong. -The admission skin assessment showed bruising on the resident's back and not the chest. -The resident had thought someone had hit him/her. -He/she talked to the resident and determined he/she was hallucinating and was self-transferring. -It was likely the resident fell. -He/she spoke with the resident's family member who said the resident was having flashbacks and abuse was ruled out quickly. -He/she had gone back and initiated the incident report but it should have been done the day before. -He/she at first told LPN E to complete an incident report but he/she was uncomfortable with this so RN B completed the incident report. -The nurses were responsible for completing the incident reports and he/she had instructed LPN E to complete one for the resident's head injury but LPN E did not complete the incident report. -He/she did interview other staff but did not collect witness statements. -Other residents were interviewed regarding rough cares. -The Administrator was made aware of the allegation of abuse. -A complete investigation was not done because abuse was ruled out early. During an interview on 9/29/21 at 9:54 A.M. the Administrator said: -He/she was the Abuse Coordinator along with the DON. -All investigations of abuse and injuries of unknown origin should contain staff interviews and written statements, resident interviews and a conclusion summary. -The DON was responsible for completing the investigation. -A complete investigation was not done. During an interview on 9/29/21 at 12:08 P.M. the DON said: -The nurse was responsible for completing an incident report. -He/she was responsible for completing the investigation. -The SSD was involved and would help with the investigation. -The investigation should contain all staff interviews on each shift including written witness statements and resident interviews. -Interviews of other residents would also be conducted to look for a pattern or witnessed by anyone. -The investigation should contain a summary and outcome of investigation. -The nurse that assessed the resident should have a clear description of the injury, measurements to determine if abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to withhold basic life support, including cardiopulmonary resuscitation (CPR- an emergency procedure that is performed when a person's heartbeat or breathing has stopped) per the resident's choice for one sampled resident (Resident #150) out of 12 sampled residents and 10 closed record residents. The facility census was 37 residents. Record review of the facility's policy titled Emergency Procedure-CPR revised 4/2016 showed: -If an individual was found unresponsive and not breathing normally, a licensed staff member should initiate CPR unless: --The individual was a Do Not Resuscitate (DNR-instructs health care providers not to do CPR if a patient's breathing stops or if the patient's heart stops beating) code status. --The individual showed obvious signs of irreversible death. 1. Record review of Resident #150's admission Record showed he/she was admitted to the facility on [DATE] for Medicare Part A skilled services and had the following diagnoses: -Hypertension (HTN-high blood pressure). -Bradycardia (slower than normal heart rate). -Dependence on supplemental oxygen. Record review of the resident's Care Plan dated [DATE] showed he/she was a DNR code status. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated [DATE] showed he/she was severely cognitively impaired. Record review of the resident's Order Summary Report (OSR) showed a physician's order for a DNR dated [DATE]. Record review of the resident's Outside the Hospital DNR Order (OHDNR) form kept in the Code Status book dated [DATE] showed: -CPR should be withheld in the event his/her heart stopped or breathing stopped. -The DNR order form was signed by the resident's responsible party and physician. Record review of the resident's Nurses Notes dated [DATE] at 3:03 A.M. by Licensed Practical Nurse (LPN) B showed: -The Certified Nurses Assistant (CNA) was performing rounds at 2:15 A.M. -The CNA noticed something was wrong with resident. -The CNA went to check on the resident and noticed that he/she was unresponsive. -The CNA came and notified this writer about what he/she found. -This nurse assessed the resident and resident was unresponsive. -This writer felt for a pulse and checked for respirations. -The pulse was weak and no respirations were present. -This writer started CPR at 2:20 A.M. -This nurse told the CNA to get the crash cart. -This writer contacted 911, while performing CPR. -The CNA brought in the crash cart. -This writer took the AED machine (a portable, life-saving devices designed to treat people experiencing sudden cardiac arrest) and connected it to the resident. -He/she continued to perform CPR until assistance arrived. -Emergency Medical Services (EMS) came first and took over CPR. -The other nurse returned from lunch and started assisting. -When assistance arrived, the other nurse contacted the resident's physician, Director of Nursing (DON), Administrator and family. -EMS pronounced the resident deceased at 2:48 A.M. During an interview on [DATE] at 6:50 P.M. LPN D said: -He/she had used an AED machine but the resident was not shocked. -He/she did chest compressions until EMS arrived and they took over. -The resident did not have any responses of movement or grimacing as a result of the CPR. -The resident was not mottled (when the heart is no longer able to pump blood effectively. The blood pressure slowly drops and blood flow throughout the body slows, causing one's extremities to begin to feel cold to the touch. Mottled skin before death presents as a red or purple marbled appearance) and his/her extremities were not cyanotic (bluish color of the skin). -The CNA's do not have access to check the resident's code status. -The resident had been checked on approximately one hour before this event. During an interview on [DATE] at 12:08 P.M. the Assistant Director of Nursing (ADON) and DON said: -He/she expected the nurse to look at code status if a resident was in cardiac arrest. -If the resident was a full code, the nurse should perform CPR. -If the resident was a DNR, he/she expected the nurse not to perform CPR. -He/she expected the nurse to assess the resident and check the residents' code status. -CNA's have access to check the resident's code status in e-chart. -The resident's code states was also in a binder book that has OHDNR forms that were kept at the nurses station. -If the resident did not have an OHDNR form in the binder then the resident was a full code status. MO00190875

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #41's admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Aftercare following joint replacement surgery. -Presence of left artificial knee joint. -Osteoarthritis (a degenerative disease of the bones and joints), left knee. -Acute Posthermorrhagic Anemia (condition in which a person quickly loses a large volume of circulating hemoglobin). -Hyperlipemia (high levels of lipids in the blood). -Difficulty in walking, not elsewhere classified. Record review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool used by facilities for care planning), dated 7/27/21 showed he/she: -Had a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. -Required extensive assistance and oversight for all Activities of Daily Living (ADL's - basic tasks of daily life that most people are used to doing without assistance, such as eating, bathing, toileting, walking, transferring). Record review of the resident's Order Summary Report dated 8/13/21 showed Lorazepam (Ativan a medication used to treat anxiety, the anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus) tablet give 0.5 milligram (mg) tablet by mouth every 8 hours as needed 4. Record review of Resident #149's facility admission Record showed he/she was admitted on [DATE] with diagnoses that included: -Encephalopathy (any abnormal condition of the structure or function of brain tissues, especially chronic, destructive, or degenerative conditions). -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) without behavioral disturbances. -Anxiety disorder, unspecified. -Mild cognitive impairment (an early stage of memory loss or other cognitive ability loss (such as language or visual/spatial perception) in individuals who maintain the ability to independently perform most activities of daily living), so stated. Record review of the resident's admission MDS dated [DATE] showed he/she: -Had a BIMS score of 11, which indicated the resident had moderate cognitive impairment. -Required extensive assistance for all ADL's. Record review of the resident's Order Summary Report dated 8/31/21 showed Lorazepam tablet 0.5 mg give 0.5 mg tablet by mouth two times a day for Anxiety. 5. Record review of Resident #16's facility admission Record showed he/she admitted to the facility on [DATE] with diagnoses that included: -Major Depressive Disorder (also referred to as clinical depression, is a significant medical condition that can affect many areas of your life. It impacts mood and behavior as well as various physical functions, such as appetite and sleep), recurrent, unspecified. -Anxiety Disorder, unspecified Record review of the resident's admission MDS dated [DATE] showed: -BIMS score of 11, which indicated the resident had moderate cognitive impairment. -Required extensive assistance for all ADL's. Record review of the resident's Medication Administration Report (MAR) dated 8/25/21 showed Lorazepam tablet 1 mg give 1 mg tablet by mouth three times a day for Anxiety. 6. During an interview on 9/22/21 at 2:27 P.M. Registered Nurse (RN) A said: -He/she was the Charge Nurse on the 100 Hall. -RN B was the Charge Nurse on the 200 Hall and he/she had two new admissions. -The Lorazepam for the new admissions had not arrived yet. -RN B reported the Cubex (automated medication dispensing system for medication management) was empty when RN A and RN B tried it. -RN A and RN B called the pharmacy and the pharmacy said that a written prescription was needed. -Both Resident #16 and Resident #149 had an order for Lorazepam. -Resident #41 had discharged and did not take his/her Lorazepam home. -RN A signed out 5 Lorazepam 0.5 mg tablets and RN B cosigned for the medication from Resident #41. -RN B took the Lorazepam and administered it to Resident #16 and Resident #149 whose medication had not been delivered. -All the Lorazepam was given at that time, and not stored for later use. During an interview on 9/23/21 at 6:14 A.M. Licensed Practical Nurse (LPN) A said: -Borrowing medications from one resident and giving it to another resident was not correct. -Staff could lose their job. -This was considered misappropriation. During an interview on 9/23/21 at 6:14 A.M. LPN C said: -Borrowing medications from one resident and giving it to another resident was not correct. -Staff could lose their job. -This was considered misappropriation. During an interview on 9/24/21 at 9:01 A.M. RN B said: -He/she was the Chare Nurse on 200 Hall. -Resident #16 was very anxious and distraught and required the ordered Lorazepam. -Resident #149 was also due for his/her scheduled Lorazepam. -Neither resident had had the medication delivered. -He/she went to the Cubex to pull the medication and was unsure what happened but thought the Cubex was out of Lorazepam. -He/she walked out of the medication room and said he/she needed Lorazepam, and the Cubex was empty. -RN A heard this and said he/she had some in his/her medication cart. -RN A removed the doses of Lorazepam for Resident #16 and Resident #149 from Resident #41's medication card on 8/9/21. -He/she signed the narcotics sheet with RN A. -He/she gave the medication to the Resident's #16 and #149. -He/she called the pharmacy and the pharmacy said the medication was in the Cubex. -He/she went back to the Cubex and the Lorazepam was in the Cubex. -He/she realized now that taking medication from one resident and giving it to other residents was wrong. -He/she would not do that now. During an interview on 9/27/21 at 3:26 P.M. the Administrator said: -He/she was out of town when notified of the issue 8/14/21 and notified the Clinical Director immediately who was covering for him/her. -The Clinical Director was going to start the investigation immediately. -In the investigation it was determined by the Clinical Director and the Administrator that medication was borrowed and was not misappropriation. -Had it been determined misappropriation it would have to be reported immediately to the state. During an interview on 9/28/21 at 11:17 A.M. the Clinical Director said: -The Administrator had received a text message from an employee saying medication was taken from one resident and given to two other residents. -He/she said that staff had texted the Administrator and interviewed him/her. -The facility utilized a Cubex. -RN A said that 5 Lorazepam tablets had been taken from one resident's medication card and was given to two other residents. -He/she called and spoke to RN A and suspended him/her pending the results of the investigation. -Then he/she called RN B and took a statement as to what happened. -The Lorazepam had been taken and used for two resident who had not received their medication. -RN B had tried to get the medication from the Cubex, but the Cubex would not allow it. -RN B went to RN A and explained that the Cubex was not allowing him/her to remove the medication, and Resident's #16 and #149 needed it. -RN A took the medication from Resident #41 that had discharged , and gave it to RN B to give to Resident #16 and Resident #149. -All the medication had been used at one time and none was stored for later use. -In hindsight this should have been determined to be misappropriation and should have been reported to the state. During an interview on 9/29/21 at 2:38 P.M. the Director of Nursing (DON) said: -Nurses cannot borrow medication from one resident and it be given to another resident. -It would be misappropriation if you borrowed medication from a resident. -Misappropriation would be reported to the state immediately. MO00190875 2. Record review of Resident #16's admission Record face sheet dated 8/6/21 showed he/she was admitted with the following diagnoses: -Displaced comminuted fracture (a break when the bone is not in proper alignment) of shaft of humerus (a bone between the shoulder and elbow), left arm. -Unspecified fracture of left acetabulum (a concave surface of the pelvis). -Unspecified fracture of sacrum (a bone at the bottom of the spine). -Unspecified fracture of right pubis (the most forward facing bone of the pelvis). -Primary osteoarthritis (wearing down of protective tissue at the ends of bone), right shoulder. -Fall on stairs and steps. -Anxiety (intense, excessive and persistent worry and fear about everyday situations) disorder. Record review of the resident's Resident Grievance/Complaint Investigation Report Form dated 8/13/21 showed: -Incident description: Resident reported that CNA F pushed his/her right arm (the non-broken arm) and ran out of the room. -The resident said CNA F was not trying to reposition him/her. -The resident was not injured. -Both the resident and CNA F were interviewed. -CNA F provided a written statement regarding the alleged incident. -Four other residents were interviewed. -All the residents interviewed said they felt safe at the facility and had not been provided with rough cares. -The grievance/complaint was resolved to the satisfaction of the resident. Record review of the resident's skin assessment dated [DATE] showed no bruising or other injury noted after the incident. Observation on 9/21/21 at 11:22 A.M. showed the resident: -Was lying in bed with a sling on his/her left arm. -There was no indication of injury to his/her right arm. During an interview on 9/21/21 at 11:22 A.M., the resident said: -CNA F hit him/her. -He/she didn't remember the date, but said it was toward the beginning of his/her stay at the facility. -He/she said CNA F punched him/her on the right shoulder as hard as he/she could, on an area where he/she had a previous surgery. -He/she did not know if there was any bruising or injury to the area. -The alleged incident was investigated by the corporate nurse. -The corporate nurse apologized to him/her for the alleged incident happening. -CNA F was no longer allowed in his/her room. During an interview on 9/22/21 at 1:46 P.M., CNA F said: -The alleged incident happened on Sunday, 8/15/21, in the evening at approximately 7:00 P.M. to 7:30 P.M. -He/she worked the night shift. -This was the first time he/she worked with the resident. -The resident asked him/her to put a pillow under his/her broken arm. -He/she tried to move the arm as gently as possible, but the resident screamed and said he/she was beating him/her. -He/she left the room and went back to his/her work. -The resident put on his/her call light and Registered Nurse (RN) B answered the light. -The resident told RN B that CNA F had beat him/her. -RN B told him/her not to go in that room again. -CNA G took over care of that resident. -The resident told CNA G that CNA F had beat him/her all night. -He/she was off work on 8/16/21 and 8/17/21. -The corporate nurse contacted him/her on 8/17/21 to come to the facility and make a statement. -He/she believed RN B wrote the incident up. -He/she had been trained by the facility on resident abuse and neglect. -They had training at least once a year. During an interview on 9/22/21 at 2:07 P.M., RN B said: -He/she didn't remember what the resident told him/her CNA F did. It had something to do with putting a pillow under his/her arm. -He/she had never previously heard of any complaints against CNA F. -He/she thought the incident had already been reported. -If he/she had thought it was a new incident of alleged abuse, he/she would have made sure the resident and CNA were separated and immediately notified the DON and Administrator. -He/she had been trained on abuse and neglect policies. During an interview on 9/22/21 at 2:41 P.M., the Corporate Nurse said: -He/she was at the facility on 8/16/21 because both the Administrator and DON were out that day. -RN C, the day shift charge nurse, approached him/her and reported that the resident wanted to speak to him/her regarding CNA F going in his/her room. -RN B, the night charge nurse, did not file an incident report. -RN B did not think it was an abuse situation because the resident had pain with all movement. -The resident said he/she did not want CNA F in his/her room because he/she had asked for a pillow under his/her left arm and it hurt when CNA F placed it. He/she then said CNA F ran around the bed and pushed hard on his/her right arm. -He/she asked the resident if CNA F could have been repositioning him/her and the resident said CNA F was not. -He/she didn't think the resident made the complaint about being pushed until the day shift. -The resident never made any statement about being punched. -The investigation was started on 8/16/21. -He/she interviewed CNA F on 8/17/21 about the incident. -Due to the resident's complaint, he/she asked the social worker to interview other residents. -He/she had RN C do a head to toe assessment of the resident. -The resident had no new bruising or injuries. -His/her conclusion was that the resident was not pushed on the right arm, and the left arm was diagnosis related pain. -CNA F was not suspended because the facility investigation was concluded before he/she was due to work again. -The Administrator and DON returned to work on 8/17/21 and they were informed of the incident. -He/she thought an incident report was not written sooner because the allegation was being handled and it was not abuse. -The date on the Grievance/Incident report of 8/13/21 was because the resident could not remember the date for certain. -The facility had abuse and neglect training every year for all staff. During an interview on 9/28/21 at 11:07 A.M., Certified Medication Technician (CMT) A said: -The resident told him/her CNA F was mean to him/her. -From what he/she remembered, the facility did an investigation of the alleged incident. -This was the first time the resident had said anything about any staff. -If a resident reported physical abuse, the process would be to notify the charge nurse and DON immediately. -He/she had been trained on abuse and neglect of residents. During an interview on 9/28/21 at 11:18 A.M., CNA D said: -He/she was not working at the time of the incident. -The resident told him/her that CNA F was mean to him/her, and really rough with him/her. -The process for reporting abuse was to go to the charge nurse, who would go to the DON and administrator. -He/she had been trained on abuse and neglect of residents. During an interview on 9/28/21 at 11:25 A.M., RN C said: -On 8/16/21, the resident told him/her that CNA F had been rough with him/her the night before. -The resident said they were rolling him/her in the bed and shoved his/her arm, and he/she was in excruciating pain. -He/she reported it to the supervisor that day. -The corporate nurse and RN A were both there and looked into it. -CNA F was no longer allowed in that room. -The resident had certain staff he/she liked and disliked. -The resident's spouse never said anything about the alleged incident. -Protocol for reporting abuse was to notify the manager or DON that day and it would be reported to the administrator. -He/she didn't remember if he/she had been trained on abuse and neglect at the facility. During an interview on 9/28/21 at 11:52 A.M., the Social Worker (SW) said: -He/she did the resident interviews. -He/she also reviewed everything that was done with the resident and completed a grievance form. -The grievance was about rough handling. -The resident never said he/she was abused. -The interviews with other residents were part of the investigation of potential abuse. -He/she had been trained at the facility on resident abuse and neglect. During an interview on 9/29/21 at 9:54 A.M., the Administrator said: -He/she was not sure if the alleged incident was reported to the state. -The corporate nurse did the investigation. During an interview on 9/29/21 at 12:09 P.M., the DON said: -CNA F should have been suspended and the DON notified. -He/she preferred to error on the side of caution and an investigation should be done. -The Administrator should be notified. -With a suspicion of abuse, the state should be notified immediately. -This was in their policy for abuse and neglect. During a telephone interview on 9/29/21 at 4:35 P.M., CNA G said: -He/she was told by the charge nurse to assume care for the resident on the night of the alleged incident. -He/she was never in the room when CNA F was giving care. -He/she did not feel that any abuse had taken place. -Nobody told him/her about any investigation of the alleged incident. -Nobody said a report was going to be made. Based on observation, interview and record review, the facility failed to report allegations of abuse and injuries of unknown origin to the State Agency (SA) for one closed record sampled resident (Resident #10) and one sampled resident (Resident #16); and to report misappropriation of a controlled substance when the medications were taken from one sampled resident (Resident #41) and administered to two sampled residents (Resident #16 and #149) out of 12 sampled residents and 10 closed record sampled residents. The facility census was 37 residents. Record review of the facility's Abuse and Neglect Policy last reviewed 4/2021 showed: -After the facility submitted an immediate report of an alleged violation, the facility must conduct a thorough investigation; prevent other incidents from occurring during the course of the investigation and report the results of the investigation to the SA within five working days or as designated by state law. Record review of the facility's policy on Abuse and Neglect revised 5/2018 showed: -Residents have the right to be free from theft and/or, misappropriation of property. -The resident was to be free from abuse and neglect, and that swift and immediate action would be taken to investigate and adjudicate alleged instances of resident abuse and neglect. -Misappropriation of resident property was defined as the patterned or deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. -It was the responsibility of the Administrator and the Director of Nursing Services to ensure employees are trained. -The training covered what constituted misappropriation of resident property. -It was the responsibility of the Administrator and Director of Nursing Services to identify events that constituted abuse and determined the direction of the investigation. -Staff, at any level and in any position, are expected to report any allegations of any type of abuse. -The Administrator and/or the Director of Nursing Services are responsible to initiate the investigation immediately upon notification of the alleged event. -The facility documented investigation findings, included witness statements, corrective actions, and the conclusion in the administrative file. -It was the responsibility of every employee of the facility to report misappropriation of property. -Alleged violations of misappropriation of resident's property are reported immediately but no later than two hours after the allegation is made. -After the facility submitted an immediate report of an alleged violation, the facility conducted a thorough investigation; prevented other incidents from occurring throughout the course of the investigation and reported the results of the investigation to the state agency within five working days. -Any employee of the facility, who is suspected to disregard any of the resident's rights would be suspended from all duties and from the facility pending an investigation. -If the investigation validated that resident's rights were disregarded, appropriate and immediate disciplinary action would be conducted regarding the employee up to and included termination of employment. 1. Record review of Resident #10's admission Record showed he/she was admitted to the facility on [DATE] for skilled rehabilitation therapy and had the following diagnoses: -Cognitive emotional or social deficits following a stroke. -Senile degeneration of the brain (A decrease in cognitive abilities or mental decline. This may include the person's inability to concentrate, to recall information, and to properly judge a situation). Record review of the resident's admission Assessment Note dated 7/29/21 showed the resident was alert to himself/herself only. Record review of the resident's Baseline Care Plan dated 7/29/21 showed the resident: -Was alert to himself/herself only. -Had impaired decision making and was confused. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by facility staff for care planning) dated 8/4/21 showed the resident: -Was moderately cognitively impaired. -Needed the extensive assistance of two staff members for bed mobility and transfers. -Did not ambulate. Record review of the resident's Incident Report dated 8/9/21 at 7:00 A.M. completed by Registered Nurse (RN) B (also the Unit Manager) showed: -Incident description: A Certified Nurses Aide (CNA) reported the resident had a new bruise. Upon assessment the resident was found to have a large purple bruise to the right chest, torso, and flank (the side of a person's body between the ribs and the hip). The resident was unable to say when or how the bruise occurred. -The physician and family were notified. -A witness statement completed by Licensed Practical Nurse (LPN) D dated 8/9/21 showed: The resident was asleep in bed and remained asleep throughout the night. He/she checked on the resident throughout the night because the resident was a high fall risk. The only time he/she entered the resident's room was to turn down the television. -A typed note by the Social Services Director (SSD) dated 8/10/21 showed: The resident said to nursing that someone hit him/her during the night. The resident was interviewed and said sometimes I forget I am not there referring to his/her military war service. He/she recanted his/her statement that someone hit him/her and thought he/she was back there. The family reiterated the resident had flashbacks, Post Traumatic Stress Disorder (PTSD-a set of reactions that can occur after someone has been through a traumatic event) and flashbacks which were worse at night. The resident was severely cognitively impaired. -A typed note completed by Registered Nurse (RN) A (also the former Director of Nursing) dated 8/16/21 showed: On 8/11/21, it was reported by LPN E (no longer employed at the facility) that the resident had a new skin impairment to his/her right scalp. RN A went to assess the resident and noted a small, bright red abrasion to his/her right scalp. The resident was severely cognitively impaired. The resident was unable to provide a description of what occurred. Resident was known to self-transfer in his/her room. The resident was on anti-coagulant (blood thinning) medications which put the resident at high risk for bruising and bleeding. -Four residents were interviewed on 8/10/21 by the SSD who stated they felt safe at the facility and no one had provide rough cares. -There was no further information showing staff reported this allegation of abuse to the SA. Record review of the resident's Incident Report dated 8/10/21 at 3:21 P.M. completed by LPN E showed: -Incident Report: The resident had an area to the top of his/her hand and left middle finger and an open area to the left lower leg shin with a scant amount of blood. The resident was alert and oriented but this fluctuated to periods of confusion. -The family and physician were notified. -There was no further information showing staff reported this allegation of abuse to the SA. Record review of the resident's Nurses Notes dated 8/11/21 at 6:30 A.M. completed by LPN E showed: -The CNA called this nurse to the resident's room reporting blood on his/her pillow and head. -The resident had an open area to the right side of his/her forehead. -The resident did not know what happened and denied falling. -The resident was assessed for injuries. -The resident's family was notified. -The resident was alert and oriented and did not have any hallucinations this shift. --There was no further information showing staff reported this allegation of abuse to the SA. During an interview on 9/28/21 at 11:00 A.M. CNA B said: -He/she would report any new skin issues or injuries to the nurse. -If a resident said they had been hit by staff, he/she would report this immediately to the charge nurse and the DON. -The Administrator and DON were responsible for reporting all allegations of abuse to the SA. During an interview on 9/28/21 at 12:20 P.M. LPN A said the DON and Administrator were responsible for reporting any allegations of abuse and injuries of unknown origin to the SA. During an interview on 9/28/21 at 12:30 P.M. the SSD said: -He/she was not aware if this was reported to the SA. -The two Abuse Coordinators were the DON and Administrator. During an interview on 9/29/21 at 8:54 A.M. RN B (Unit Manager) said the Administrator and DON were responsible for reporting allegations of abuse and injuries of unknown origin the SA. During an interview on 9/29/21 at 9:11 A.M. RN A (former DON) said: -He/she or the Administrator were responsible for reporting allegations of abuse to the SA. -These injuries were not reported to the SA. During an interview on 9/29/21 at 9:54 A.M. the Administrator said: -All allegations of abuse were to be reported to the SA. -He/she was responsible for reporting to the SA. During an interview on 9/29/21 at 12:08 P.M. the DON said: -The administrator was responsible for reporting to the SA. -The allegations of abuse should be reported to the SA immediately.

Based on interview and record review, the facility failed to ensure Certified Nurse Assistants (CNA's) received twelve hours of training based on their performance reviews. The facility census was 37 residents. Record review of the facility's policy titled Staff Development Program dated 11/17/17 showed: -CNA's were required to complete no less than twelve hours of in-service training that was sufficient to ensure continued competency. -The training should address any specific areas of weakness identified in performance evaluations. 1. Record review of the facility's training in the past year showed the following training had been completed: -On 6/24/21, Abuse and Neglect training. -On 7/22/21 Activities of Daily Living (ADL's-transfers, cares, bathing, hygiene), Abuse and Neglect, and Abuse Coordinator training. -On 8/26/21, Novel Coronavirus disease (COVID-19, a new disease, caused by a novel or new Coronavirus) and vaccinations, dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses) dying, and fall prevention training. --There was no documentation that showed the length of the in-services. During an interview on 9/29/21 at 8:20 A.M. the Director of Nursing (DON) said: -He/she started at the facility approximately two weeks ago. -He/she was not aware of how the training was conducted. -The previous DON was responsible for ensuring training was completed. -He/she was now responsible for staff training. -The requirement of twelve hours of training was not met this past year. During an interview on 9/29/21 at 8:28 A.M. the Corporate Nurse said: -The facility had their first COVID 19 outbreak in 8/20. -Staff were given handouts of information but no monthly in-services were completed. -The annual in-services had not been completed. During an interview on 9/29/21 at 9:31 A.M. Registered Nurse (RN) B said: -He/she was the former DON. -He/she had been responsible for completing the in-services and training but this was not completed due to COVID 19. -He/she had started providing some of the in-services but was no longer the DON.

Based on interview and record review, the facility failed to ensure the shift change narcotic count was completed and signed by both the on-coming and off-going nursing staff. The facility census was 37 residents. Record review of the facility's Controlled Substances policy dated 2001 and revised on 12/12 showed: -Nursing staff must count controlled medications at the end of each shift. -The nurse coming on duty and the nurse going off duty must make the count together. -They must document and report any discrepancies to the Director of Nursing (DON). 1. Record review of the facility's Controlled/Narcotic Count Sheet dated July 2021 for the 100 hall medication cart showed: -12 out of 124 opportunities were not signed by oncoming staff. -14 out of 124 opportunities were not signed by the off going staff. Record review of the facility's Controlled/Narcotic Count Sheet dated August 2021 for the 100 hall medication cart showed: -17 out of 124 opportunities were not signed by the oncoming staff. -12 out of 124 opportunities were not signed by the off going staff. -Two out of 124 opportunities were not signed by both the oncoming or off going staff. Record review of the facility's Controlled/Narcotic Count Sheet dated September 2021 for the 100 hall medication cart showed: -12 out of 85 opportunities were not signed by the oncoming staff. -Eight out of 85 opportunities were not signed by the off going staff. -One out of 85 opportunities were not signed by both the oncoming or off going staff. During an interview on 9/23/21 at 3:56 A.M. Licensed Practical Nurse (LPN) C said: -The narcotics are counted at the beginning and end of each shift with the oncoming nurse/ Certified Medication Technician (CMT) and off going nurse/CMT. -Both nurses and/or CMT sign the count sheet when the count has been completed and verified the count is correct. During an interview on 9/23/21 at 8:34 A.M. CMT A said: -The narcotics are counted at the beginning and end of each shift with the oncoming nurse/CMT and off going nurse/CMT. -Both nurses and/or CMT sign the count sheet when the count has been completed. During an interview on 9/28/21 11:05 A.M. LPN A said: - The narcotics are counted at the beginning and end of each shift with the oncoming nurse/CMT and off going nurse/CMT. -Both nurses and/or CMT sign the count sheet when the count has been done. During an interview on 9/29/21 12:38 P.M. DON said: -The expectation was narcotics would be counted at shift change by the off going nurse/CMT and oncoming nurse/CMT. -That the nurse/CMT would sign the narcotic sheet when the count was done. -The count would be done each shift.