Based on interview and record review, facility staff failed to ensure one staff member (Registered Nurse (RN) A) had the required documentation to work in a long term care facility in Missouri. The facility census was 63. 1. Review of the facility policy's did not contain information to direct staff in regards to verification to be eligible to work in Missouri. Review of Registered Nurse A's employee file showed a hire date of 7/3/2014 as the Director of Nursing (DON). Review of RN A employee file did not contain documentation he/she was eligible to work at the facility. Review of RN A's earning statement, dated 4/27/25 through 5/10/25, showed RN A was paid for thirty two hours regular pay. During an interview on 6/6/25 at 8:31 A.M., the interim DON said he/she was asked to step in as interim DON because RN A needed some time off. He/She said multiple staff help do day to day tasks in RN A's absence and he/she does all mandatory meetings. During an interview on 6/6/25 at 8:39 P.M., the administrator said RN A is from another country and is on a school visa. He/She said RN A went to renew his/her nursing license on 4/30/25 and was unable to because there was an issue with his/her immigration paperwork. He/She said they immediately removed him/her from his/her position as the DON and got an interim DON. The administrator said RN A has helped with tasks like a science fair and reviewing referrals. RN A used his/her paid time off until he/she can get back in good standing. During an interview on 6/6/25 at 9:34 A.M., the human resources manager said RN A's license is inactive and he/she is taking PTO. He/She said RN A had a student visa and was unable to renew. He/She said he/she did not check RN A's Employment Eligibility Verification (a document required by the U.S. government to verify the identity and employment authorization of individuals hired for employment in the United States) to see if he/she could still be employed. He/She said Cross their mind they thought it would be handled quickly and just that RN A could not use his/her nursing license He/She said once it was brought to his/her attention RN A was no longer eligible to be employed, he/she terminated RN A. During an interview on 6/6/25 at 10:14 A.M., RN A said he/she came here from another country for school and had a renewable job permit. RN A said he/she sat out spring semester of 2024 and when he/she went to re-enroll in school for fall of 2024 he/she was told it was not renewable because he/she had lost his/her visa because he/she did not attend school in spring of 2024. He/She said he/she did not realize he/she was unable to legally work because his/her nursing license was still active. MO00254908

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to implement their grievance protocol for one resident (Resident #1) when he/she reported a missing cellular phone and staff did not document the results of the investigation for the missing cellular phone. The facility census was 59. 1. Review of the facility's Nursing Home Residents Rights policy, undated, showed staff were directed to provide prompt efforts to resolve grievances, and provide a written decision upon request. Review of the facility's Grievances Complaints, Recording and Investigating policy, undated, showed: -All grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievance(s); -The Grievance Officer/designee will record and maintain all grievance and complaints on the facility approved log; -Documentation of the investigation and actions taken in response will be maintained at the facility. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/11/24, showed staff documented the resident admitted to the facility on [DATE]. Review of the facilities investigation, dated 12/06/24, showed staff documented the resident's family member notified facility staff he/she attempted to contact the resident by cellular phone for several days and was unable to reach him/her via cell phone. The staff and the family member searched for the cellular phone and were not able to locate it. Review showed the facility did not have documentation a grievance form had been completed for the missing cell phone. During an interview on 12/18/24 at 9:43 A.M., the resident said he/she did have a phone, but it has been missing. He/She said he/she reported the missing phone to his/her family member, but not the staff. During an interview on 12/20/24 at 8:08 A.M., the administrator said the resident's family member reported the resident's cell phone was missing. He/She said he/she did not know if staff completed a grievance form for missing items or if one was given to the resident and/or the resident's representative. He/She said the facility did not have a designated grievance person, but they are looking at designating someone for the position. He/She said there was no paper trail when a resident reported a grievance. He/She said there was a potential a grievance could be overlooked, since there was no documentation of the reported grievance. He/She said staff verbally informed the resident and/or representative of the grievance resolutions. MO00246245

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to ensure the admission policy did not require the resident and/or responsible party to waive facility liability for loss or damage to personal belongings and failed to complete a Resident Inventory Listing for three residents (Resident #1, #2 and #3) out of three residents. The census was 59. 1. Review of the facility's Resident Personal Property policy, dated 11/2024, showe the resident is allowed to have personal belongings. Staff are directed to inventory and documented upon admission resident items and when replenished. Review of the facility's Resident Handbook policy, undated, showed the facility is not responsible for lost or missing items of any value. This includes, but is not limited to, personal effects such as jewelry, money, valuables, televisions, hearing aids, dentures, and eyeglasses. Review of the facility's Resident Inventory Listing form showed the form contained: -A list of types of belongings to be checked with blank areas for inventory not listed to be written in; -A signature and date line for the resident or legal representative upon admission and discharge; -A signature line and date line for the staff member completing the form upon admission and discharge. 2. Review of Resident #1's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/11/24, showed staff documented the resident was admitted to the facility on [DATE]. Review of the resident's medical record showed the Resident Handbook signed on 05/09/24, signed by the resident/responsible party and facility representative. The medical record did not contain documentation staff completed a Resident Inventory Listing form. 3. Review of Resident #2's Quarterly MDS, dated [DATE], showed staff documented the resident was admitted to the facility on [DATE]. Review of the resident's medical record showed a Resident Handbook signature page, dated 07/17/24, signed by the resident/responsible party and facility representative. The medical record did not contain documentation staff completed a Resident Inventory Listing form. 4. Review of Resident #3's Discharge MDS, dated [DATE], showed staff documented the resident was admitted to the facility on [DATE]. Review of the resident's medical record showed a Resident Handbook signature page, dated 10/14/24, signed by the resident/responsible party and facility representative. The medical record did not contain documentation staff completed a Resident Inventory Listing form. 5. During an interview on 12/18/24 at 9:55 A.M., Registered Nurse (RN) B said the nursing staff completed the inventory sheets upon admission. He/She said he/she did not know who was responsible to complete them for Resident #1, #2, or #3. During an interview on 12/20/24 at 8:08 A.M., the administrator said the nursing staff were responsible to complete the inventory sheets upon admission. He/She said he/she did not know who was responsible to complete the inventory sheets for Resident #1, #2 or #3 and could not locate the completed inventory sheets in the resident's medical records. He/She said there was no audit in place to ensure the inventory sheets were completed upon admission. He/She said the resident's or representative are provided with a resident handbook as part of the admission agreement. He/She said the resident and/or representative sign the Resident Handbook form, stating they have received a copy of the handbook, but he/she did not know if the resident and/or representative read through the entire pamphlet. He/She said the Resident Handbook did contain documentation the facility did not reimburse for missing or lost items. The administrator said he/she did not know it was a regulatory violation to not reimburse a resident for missing or lost items. During an interview on 12/20/24 at 8:09 A.M., the Director of Nursing (DON) said the nursing staff were responsible to complete the inventory sheets upon admission and the admission nurse would double check the sheets. The DON said he/she or the Assistant Director of Nursing (ADON) would be responsible to audit to ensure the process was completed. The DON said he/she did not know who was responsible to complete the inventory sheets for Resident #1, #2 and #3. The DON said he/she overlooked checking the resident's medical records to ensure staff had completed the inventory sheets. He/She said the resident's or representative are provided with a resident handbook as part of the admission agreement. He/She said the resident and/or representative do sign the Resident Handbook form, stating they have received a copy of the handbook, but he/she did not know if the resident and/or representative read through the entire pamphlet. He/She said the Resident Handbook did contain documentation the facility did not reimburse for missing or lost items. MO00246245

Based on observation, interviews, and record review facility staff failed to protect resident's private medical information by not closing the computers screens on two medication carts and one nurse desk. The facility census was 58. 1. Review of the facility's Resident Rights, dated 11/22/24, showed residents have the right to personal privacy and confidentiality of his or her personal and medical records. 2. Observation on 10/15/24 at 1:15 P.M., showed Licensed Practical Nurse (LPN) A left a medication cart on 200 hall unattended to administer medications. The computer screen on the medication cart open and visible to the public with residents medical information. During an interview on 10/15/24 at 1:30 P.M., LPN A said he/she should not have left the screen open on the computer. He/She staff are required to close the screen or lock it to protect resident's private medical information. 3. Observation on 10/16/24 at 10:41 A. M., showed a computer screen at the nurse's desk open and visible to the public with private resident medical information displayed. 4. Observation on 10/18/24 at 8:17 A.M., showed Registered Nurse (RN) D stepped away from a medication cart on 300 hall with the computer screen open and showed a medication for a resident. Observation showed four resident in proximity of the cart and a staff member walked by the cart. During an interview on 10/18/24 at 8:27 A.M., RN D said computer screens should be closed when stepping away from them to protect the residents information. He/She should have at least minimized it for resident privacy but was just going down the hall for a second. 5. During an interview on 10/18/24 at 9:18 A.M., the Director of Nursing (DON) said hall screens or medication cart screens should be closed or minimized to protect the privacy of residents medical information. Staff are educated monthly on privacy. During an interview on 10/18/24 at 9:42 A.M., the Administrator said computer screens should be closed if unattended. Doing so protects the residents private medical records. The DON is responsible to ensure staff are educated to protect the privacy of residents. I would not expect staff to leave the screens open.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, facility staff failed to maintain a professional standard of care when staff left medications at the dining room table and failed to ensure the resident took the medications for three residents (Resident #7, #19 and #26) of 17 residents. The facility census was 58. 1. Review of the facility's Medication Administration policy, undated, showed: -Medication will be administered by persons licensed or permitted by this state to prepare, administer and document the administration of medications; -Medications will be administered in accordance with the orders, including any required time frame; -Residents may self-administer their own medications only if the attending practitioner, in conjunction with the Interdisciplinary Care Planning team, has determined that they have the decision-making capacity to do so safely. Review of https://www.ncbi.nlm.nih.gov/book, Nursing Skills, Chapter 15: Oral Medication Administration, undated, showed Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) should remain with the patient until all medication has been swallowed before documenting to verify the medication has been administered. 2. Review of Resident #7's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 09/25/24, showed staff assessed the resident as cognitively intact. Observation on 10/16/24 at 7:58 A.M., showed the resident at the dining room table with a plastic medication cup in front of him/her with medication inside. The RN D walked away, passed medication to other residents and passed food trays. The RN did not remain with the resident whiled the resident took the medication. Observation on 10/17/24 at 8:18 A.M., showed the resident at the dining room table with a plastic medication cup in front of him/her with medication inside. The RN D walked away, passed other residents medication and food trays. The RN did not remain with the resident whiled the resident took the medication. Observation on 10/17/24 at 8:38 A.M., the resident poured the medication onto the table and took them one by one. Observation on 10/18/24 at 8:16 A.M., showed the resident at the dining room table with two other residents. Observation showed a plastic cup contained medication next to his/her breakfast. RN D sat in the dining room with his/her back to the resident whiel he/she assisted another resident. 3. Review of Resident #19's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively impaired. Observation on 10/16/24 at 7:58 A.M., showed the resident at the dining room table with a plastic medication cup in front of him/her with medication inside. The RN D walked away, passed medications to other residents and passed food trays. The RN did not remain with the resident whiled the resident took the medication. 4. Review of Resident #26's Annual MDS, dated [DATE], showed staff assessed the resident as cognitively impaired. Observation on 10/16/24 at 7:58 A.M., showed the resident in the dining with a plastic medication cup of medication in front of him/her and a brown container with eye drops inside. He/She sat at a table with three other residents while RN D passed medication to other residents, passed breakfast trays and assisted other residents. The RN did not remain with the resident whiled the resident took the medication. Observation on 10/16/24 at 8:41 A.M., showed the resident took the medication but did not administer the eye drops. Observation on 10/16/24 at 8:51 A.M., showed RN D took the resident to the medication cart and administered the eye drops to the resident. Observation on 10/17/24 at 8:17 A.M., showed the resident in the dining room with a plastic medication container with medication in front of him/her at the table and a eye drops. The resident sat with another resident and a visitor. RN D did not monitor the administration of the medication before leaving the resident. Observation on 10/18/24 at 8:16 A.M., showed the resident at the dining room table with a cup of medication on his/her breakfast tray and eye drops. The RN did not remain with the resident whiled the resident took the medication. 5. During an interview on 10/18/24 at 8:27 A.M., RN D said staff should not put medication in front of residents then walk away or someone else could take them. He/She said it is the person administering medication responsibility to ensure the resident takes the medication as ordered. He/She said he/she only puts the medications in front of the residents he/she feels will take them on their own. During an interview on 10/18/24 at 9:18 A.M., the Director of Nursing (DON) said staff should make sure the resident takes his/her medications before walking away from them to ensure the resident gets their medication, keep another resident from getting and taking it and/or monitor for any adverse effects of the administration and medication. During an interview on 10/18/24 at 09:41 A.M., the administrator said he/she expects the staff to remain with the resident during administration of medication to ensure the resident takes the medication and keep someone else from taking it.

Based on observations, interviews, and record review, the facility staff failed to properly secure potentially hazardous chemicals and objects in three facility rooms on 100 hall and properly secure the medicine cart on 300 hall, in a manner to prevent accidents. Facility staff failed to transfer one resident (Resident #17) of three sampled residents safely in the mechanical lift. The facility census was 58. 1. Review of the facility's policies showed staff did not provide a storage of hazardous items policy. 2. Observation on 10/15/24 1:47 P.M. showed the 100 hall spa door open and unsecured and unattended. The spa contained a wound cleanser, adhesive remover and one tube of zinc oxide maximum strength cream. Observation on 10/15/24 at 2:03 P.M., showed the 100 hall laundry door open and unsecured and unattended. The laundry room contained one container of premoistened wipes with an ethyl alcohol-based cleaning formula. Observation on 10/16/24 8:58 P.M. showed the 100 hall supply room door unsecured and unattended. The supply room counter and unlocked cabinet contained: -Odor eliminator bottle, -Eight bottles of perineal cleanser; -25 finger nail clippers; -70 disposable razors; During an interview on 10/18/24 9:08 A.M., Certified Medication Technician (CMT) E said all potentially hazardous chemicals should be locked up and out of reach of the residents. He/She said a confused resident could ingest them which may cause sickness or worse. He/she said sharp objects could cut someone. He/she said chemicals, razors, and nail clippers could be dangerous in the wrong hands. He/she said it was the responsibility of all staff to make sure potiential hazardous chemcals and objects were properly secured. During an interview on 10/18/24 8:56 A.M., Registered Nurse (RN) K said all potentially hazardous chemicals should be locked up and out of reach of the residents. He/she said that a confused resident could get chemicals in their eyes and/or ingest the chemicals, causing sickness or poisoning. He/she said sharp objects could injury a resident or employee. He/she said that any one could properly secure the hazardous objects from the residents. During an interview on 10/18/24 9:19 A.M., the Director of Nursing (DON) said hazardous chemicals and sharp objects should be locked up and out of the reach of residents. He/she said that the residents could injure or poison themselves. He/she said chemicals, objects such as razors and nail clippers could be dangerous in the wrong hands. During an interview on 10/18/24 9:45 A.M., the administrator said hazardous chemicals and objects should be locked in a room or secured inside the room. He/she said the this is to prevent harm to the residents or staff. He/she said all staff had the responsibility to make sure hazards were properly secured and ultimately is the responsiblity of nursing and the adminstrator. 3. Review of the facility's Medication Storage policy, undated, showed: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -The nursing staff shall be responsible for maintaining medication storage in a safe manner; -Compartments, including but not limited to carts, containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Review of the Medication Administration policy, undated, showed during administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide, clearly visible to the nurse administering medications, and all outward sides must be inaccessible to residents and others passing by. 4. Observation on 10/17/24 at 8:46 A.M., showed RN D step away from the 300-hall medication cart and passed through a door that lead down the stairs. He/She did not lock the cart or keep the cart in visible view. Observation showed multiple resident and staff walked past the medication cart. Observation on 10/18/24 at 8:17 A.M., showed RN D step away from the 300-hall medication cart by the dining room and did not lock the cart or keep the cart in visible view. Observation showed multiple resident and staff walked past the medication cart. During an interview on 10/18/24 at 8:22 A.M., RN D said the medication cart should be locked or someone could get into it and take something. He/She said typically he/she locks the cart, but was in a hurry and got busy. He/She said it is his/her responsibility to ensure the cart is kept locked since he/she is responsible for the medications. During an interview on 10/18/24 at 9:18 A.M., the DON said staff responsible for medication administration are expected to keep the medication cart locked when he/she steps away from it to keep the contents safe and residents or others free from getting into the cart. During an interview on 10/18/24 at 9:41 A.M., the administrator said he/she would expect nursing to keep the medication cart locked when out of sight or when stepping away from it to keep unauthorized individuals from accessing it for safety. 5. Review of the facility's Safe Lifting of Residents policy, undated, showed floor-based lifts require a minimum of two person assist. The policy did not contain direction on how to complete a transfer with the lift. 6. Review of Resident #17's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/08/23, showed staff assessed the resident as: -Cognitively impaired; -Dependent on staff for all transfers. Observation on 10/16/24 at 10:43 A.M., showed CNA F and CNA G provided transfer assistance to the resident using a mechanical lift from the bed to a reclining wheelchair. CNA G lifted the resident from the bed and left the resident suspended in the air without hands on the resident while CNA F positioned the reclining wheelchair. During an interview on 10/16/24 at 11:03 A.M., CNA G said two staff should perform mechanical lift transfers. One staff member to operate the lift and the second staff member to guide the resident. He/She said its not safe to leave the resident suspended without someone holding onto them while they are in the air and it could scare the resident. The CNA said that there isn't much room in the resident's room to position the chair and work the lift around so staff does the best they can. During an interview on 10/16/24 at 11:13 A.M., CNA F said he/she knew it was not ok to leave the resident suspended but needed to get the wheelchair in place. If you leave a resident suspended, they might fall and get hurt. During an interview on 10/18/24 at 8:27 A.M., RN D said staff should never leave a resident suspended in the mechanical lift without a staff member holding them for safety. The resident could slip out of the sling or the lift could tip over. He/She said that staff should be trained prior to using the lift. During an interview on 10/18/24 at 9:18 A.M., the DON said two staff should use the hoyer to ensure the resident remains safe. One staff is to guide the lift and the other staff is to keep hold of the resident to keep the resident from getting hurt. He/She said there are routine trainings regarding lift safety and would expect staff to follow the training. During an interview on 10/18/24 at 9:41 A.M., the Administrator said the nursing department is responsible to ensure resident lifts are done correctly and would expect staff to hold onto a resident while suspended in the air during a mechanical lift transfer for safety.

Based on interviews and record review, facility staff failed to notify one resident's (Resident #1) physician or representative in a timely manner of an unwitnessed fall and a room change for one resident (Resident #1). The facility census was 58. 1. Review of the facility's fall protocol policy and procedure, undated, showed facility staff are directed the physician or practitioner and the resident representative will be notified of the fall and any change of condition of the resident. Review of the facility's room change policy and procedure, undated, showed facility staff are directed to inform the resident and the resident representative with issuance of notice for a room or roommate change arrangements and will be documented in the resident's record. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 1/30/24, showed staff assessed the resident as: -Moderately cognitively impaired; -Fracture of the hip (a break in the thighbone (femur) of your hip joint), Dementia (the loss of cognitive functioning), -History of fall one month prior to admission with a fracture; -Anticuagulant use. Review of the facility's room change documentation, dated 2/12/24, showed the resident was moved rooms. Review of the resident's neurological checks, dated 2/17/24, showed staff documented they assessed the resident for an unwitnessed fall at 9:00 A.M. Review of the resident's nurses notes, dated 2/17/24 at 1:50 P.M., showed staff documented the resident's complained about his/her right eye pain at breakfast, eye noted to be slightly bloodshot. Resident ambulated back to his/her room with staff after breakfast without difficulty. On arriving in his/her room this nurse noted the lense from the resident's glasses was sitting on his/her bedside table. When resident was asked waht happened to hiis/her glasses, the resident stated he/she had fallen during the night and broke his/her glasses. No bruising noted at the time. The resident's representative came in to visit and resident reported to representative he/she had fallen. Glasses were found under the bed with frames bent. Resident very anxious after glasses were found with complaint of increased pain, noted that blood to right sclera had increased. Resident representative requested resident be evaluated in emergency room, sent by facility van for evaluation. During an interview on 2/27/24 at 10:59 A.M., the resident representative said he/she was not notified of the resident's room change, he/she and other family members went to visit the resident and had to ask where the resident had been moved too. He/She said he/she was not notified that the resident had a fall until he/she came to visit the resident and saw his/her eye was damaged and requested the resident be sent to the hospital due to increased pain. During an interview on 2/27/24 at 11:58 P.M., the administrator said the resident was moved on 2/12/24 to a private room because of Covid -19 (Coronavirus disease is an infectious respiratory disease caused by the SARS-CoV-2 virus.), he/she said if the resident is moved because of covid there would not be an official form like if there is a room change with a rate change but would expect to see the conversation in the nurses notes. He/She said the Social Services Director (SSD) is in charge of notifying resident's family and representatives of a room change. He/She said this might have not been done because the residents representative is in the building every day and there could have been a conversation about a room change. During an interview on 2/27/24 at 12:05 P.M., Registered Nurse (RN) A said the resident is very confused. He/She said around 7:00 A.M. on 2/17/24, the resident was at the breakfast table and his/her eye was blood shot, the resident said he/she fell last night on 2/16/24. He/She said that is when he/she contacted the physician for orders to send to the hospital and emergency medical services picked the resident up around 11:00 A.M. He/She said he/she had not contacted the resident representative prior to his/her arrival but would have. He/She said the nurse is in charge of contacting the physician and the resident representative after a fall. During an interview on 2/27/24 at 12:24 P.M., the SSD said he/she is often in charge of room change notifications but he/she is not here all the time and then the nurses are responsible for completing the room change notification. He/She said room change notifications should be documented in the nurses notes if they do not have an official form. He/She said room changes happen quickly and frequently on rehab because of covid, but he/she doubts the regulation is any different with notification of a room change because it is a rehab hall. During an interview on 2/27/24 at 1:20 P.M., the administrator said he/she expects both the physician and family to be notified once assessment is complete after a fall. MO00232017

Based on interview and record review, the facility staff failed to provide one resident (Resident #68) a 30-day prior written notice of a date of discharge from the facility with the resident's appeal rights, failed to find appropriate placement for the resident, and refused to readmit the resident after a hospital stay. The facility census was 53. 1. Review of the facility's Notice of Resident Transfer or Discharge Notice Form, undated, showed: -A fill-out line of the location for the transfer/discharge; -A fill-out line of the date of the transfer/discharge; -Checkboxes of the reason for the transfer/discharge; -A paragraph stating the physician was discussed and agreed upon by the physician, the right to appeal the decision and how to obtain assistance or appeal; -A signature line for the facility representative; and -A signature line for verification/receipt for Notice of Resident Transfer or Discharge for the resident or resident representative. 2. Review of the Resident's #68's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/12/23, showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use; -Required extensive assistance of one staff for locomotion; -Required supervision for personal hygiene; -Required set-up assistance to eat; -No limitations with balance or range-of-motion. -A wheelchair and a walker for mobility. Review of the resident's medical record showed the following: -Transferred to the hospital on 6/17/23; -Staff did not document they provided the resident and resident representative a discharge/transfer notice. During a telephone interview on 7/14/23, the ombudsman said the resident was in the hospital and the facility told the hospital social worker that he/she could not return to the facility due to lack of payment. The ombudsman said this resident did not get a 30-day notice or an alternative placement to accept the resident. During a telephone interview on 7/15/23 at 4:17 P.M., the Hospital Social Worker said the resident most likely had some significant cognitive issues that were not diagnosed. The social worker said essentially this resident was homeless, after being removed by the police and put up in a hotel until he/she became ill and was admitted to the hospital. The social worker said the facility was refusing to accept the resident back at this time, and the resident was refusing to accept any assistance to apply for funding of any kind, or to look into any funds that the resident may have. During an interview on 7/20/23 at 9:08 A.M., the Social Service Director and the Administrator said the resident had agreed to pay for his/her room at the facility after Medicare funding ended. They said the resident was unrealistic about returning home to his/her condemned property and refused to work with any social services, the ombudsman, the hospital staff or facility staff to arrange for payment or applications for assistance. The resident's family has been unwilling to assist with any discharge planning or with payments. The facility had arranged for the resident to transfer to an assisted living facility, and the resident had agreed to go, but at the last minute, the resident refused to leave. They said at this point no facility would accept the resident, and their facility is refusing to accept her back from the hospital. During an interview on 8/2/23 at 4:02 P.M., the Acting Administrator said the resident was not readmitted to the facility, and did not think a 30 day notice was issued, but would need to check with the administrator, who was out on leave of absence. During an interview on 8/3/23 at 8:48 A.M., hospital social worker said the resident remained at the hospital because no facility would accept the resident. He/She said the resident had not been issued a 30 day notice from the skilled nursing facility. During an interview on 8/3/23 at 8:56 A.M., the acting administrator said the resident's Medicaid application and been denied and as far as his/her understanding, the resident was getting assistance to re-apply. The acting administrator said a 30 day notice was not issued because, it would not do any good because our facility would have to keep the resident because no other place would take the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility staff failed to provide an ongoing program of activities designed to meet the residents' interest during the weekend for four residents (Resident #6, #23, #42 and #45). The facility census was 53. 1. Review of the facility's Activities Program policy, undated, showed the following: Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Individualized and group activities are provided that: -Reflect the schedules, choices, and rights of the residents; -Are offered at hours convenient to the residents, including evenings, holidays, and weekends. Review of the facility's Activity Calendar, dated July 2023, showed the following: -Saturday, 7/1/23: Ask staff about activity cart; -Sunday, 7/2/23: Weekend activity cart, Community services worship; -Saturday, 7/8/23: Ask staff about activity cart -Sunday, 7/9/23: Weekend activity cart, Community services worship; -Saturday, 7/15/23: Ask staff about activity cart; -Sunday, 7/16/23: Weekend activity cart, Community services worship; -Saturday, 7/22/23: Ask staff about activity cart; -Sunday, 7/23/23: Weekend activity cart, Community services worship; -Saturday, 7/29/23: Ask staff about activity cart; -Sunday, 7/30/23: Weekend activity cart, Community services worship; 2. Review of Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/23/23, showed the resident thinks it is very important to do his/her favorite activities. During an interview on 7/20/23 at 8:35 A.M., the resident said he/she has not been told about the facility having weekend activities and did not think there were any available. He/She said he/she wished they had activities like movie nights or music on the weekends because there was not anything to do. He/She said puzzles and board games did not interest him/her. 3. Review of Resident #23's MDS, dated [DATE], showed the resident thinks it is very important to do his/her favorite activities. During an interview on 7/18/23 at 11:24 A.M., the resident said there was not much going on during the weekends, and the only thing to do on weekends was to watch television in his/her room. 4. Review of Resident #42's admission MDS, dated [DATE], showed the resident thinks it is very important to do his/her favorite activities. During an interview on 7/18/23 at 10:11 A.M., he/she said the facility does not have any activities on the weekends and he/she would like them, and said, bingo would be so fun. 5. Review of Resident #45's admission MDS, dated [DATE], showed the resident thinks it is very important to do his/her favorite activities. During an interview on 7/18/23 at 11:11 A.M., the resident said there were not any activities on weekends, or he/she did not really know there were any activities. The resident said the only activities on the weekend were to eat three meals a day, and that was it - which was not a whole lot. 6. During an interview on 7/20/23 at 8:30 A.M., Certified Nurse Aide (CNA) M said the activities director sometimes left out activities for staff to do with the residents on the weekends. He/She said when the activities director did not do that, it was up to the staff to come up with things for the residents to do. During an interview on 7/20/23 at 08:43 A.M., Certified medication technician (CMT)/CNA B said it just depended if residents had activities available to them on the weekends, maybe a movie or if time allowed a card game, but nothing like what the activities director did during the week. He/She said residents have complained in the past about not having activities on the weekends. During an interview on 7/20/23 at 9:01 A.M., CNA R said he/she used the calendar to assist residents in attending activities. He/She did not know about an activity cart for weekends. During an interview on 7/20/23 at 9:10 A.M., Registered Nurse (RN) O said he/she knew there were organized activities Monday through Friday. He/She said there were not consistent organized activities on the weekends. He/She said the only consistent organized activity was church services on Sundays and special occasions. He/She said it was the activities directors' responsibility to schedule the weekend activities and it was the nurses or aides responsibility to carry out those activities. During an interview on 7/20/23 at 9:41 A.M., RN D said on weekends, staff could access an activities cart and find activities such as word find and puzzles to give to residents. He/She said there were no structured activities. During an interview on 7/20/23 at 10:45 A.M., the Activity Director said he/she worked Monday through Friday, and on the weekends they left a cart for the staff to use for activities. The activity director said he/she had never had anyone to do weekend activities. He/She said on the weekends it was up to the staff to get the carts or get residents involved in an activity. The activity director said, I have heard some complaints from residents about being bored on the weekends. During an interview on 7/20/23 at 12:00 P.M., the Administrator and Director of Nursing (DON) said nursing staff were supposed to pick up on the weekends. The activity cart was left for the residents to have things to do when the activity director was not there. The administrator said the expectation for the weekends was the staff know the residents well enough to know what they would like to do or enjoy. Both the administrator and DON said on Sundays, some relatives will pick up residents and take them to church. They said there was not a known alternative for church on Sundays at the facility.

Based on interview and record review, the facility staff failed to properly screen six new employees out of ten employee files reviewed in accordance with their policy, prior to employment to determine if any had a Federal indicator with the Nurse Aide Registry (NAR), Employee Disqualification List (EDL), the Criminal Background Check (CBC) and/or the Family Care Safety Registry (FCSR). The facility census was 53. 1. Review of the facility's Residents rights to freedom from abuse, neglect, and exploitation policy and procedure, dated 2022, showed, it is the purpose of this facility to ensure that all of the facility residents are free from abuse, neglect, misappropriation of their property, and exploitation. This policy applies to any and all owners, directors, officers, clinical staff, employees, independent contractors, consultants, and others currently or potentially working for the facility. 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 state nurse aid registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or -Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. 2. Review of Registered Nurse (RN) F's employee file showed a hire date of 1/10/23. Further review showed the file did not contain: -NAR check until 5/15/23; -FCSR check until 5/15/23; -EDL check until 5/15/23. 3. Review of Dietary [NAME] G's employee file showed a hire date of 12/28/23. Further review showed the file did not contain: -NAR check; -FCSR check; -CBC check until 1/3/23; -EDL check until 3/10/23. 4. Review of Licensed Practical Nurse (LPN) H's employee file showed a hire date of 12/12/22. Further review showed the file did not contain: -NAR check; -FCSR check; -EDL check until 3/10/23. 5. Review of Certified Nursing Assistant (CNA) I's employee file showed a hire date of 12/5/22. Further review showed the file did not contain: -NAR check; -FCSR check; -EDL check until 3/10/23. 6. Review of Human Resources J's employee file showed a hire date of 12/6/22. Further review showed the file did not contain: -FCSR check; -NAR check; -EDL check until 3/10/23. 7. Review of Physical Therapy Assistant (PTA) K's employee file showed a hire date of 11/23/23. Further review showed the file did not contain a NAR. 8. During an interview on 07/20/23 at 12:13 P.M., the administrator said human resources was responsible for all pre-employment checks. There was an issue with the company they were contracting with to complete employment checks and realized they were not being conducted correctly. He/She was not aware of this issue until 48 hours ago. He/She said they only had to complete the NAR for nurse aides and CMTs. During an interview on 7/21/23 at 11:49 A.M., Human Resources L said when the facility was bought out the pre-employment checks were switched to the new company's contract. They did not realize they were not running the correct pre-employment checks. He/She said they got a new contract and began re-running all the required checks, including the NARs for everyone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to provide written notice to a resident (Resident #68) or the resident's representative regarding the resident's transfers to the hospital. In addition, the facility staff failed to provide the resident a 30-day prior written notice of a date of discharge from the facility with the resident's appeal rights, failed to find appropriate placement for the resident, and refused to readmit the resident after a hospital stay. Further, the facility staff failed to provide written notice to residents or the residents' representatives regarding resident transfers to the hospital for three additional residents (Resident #54, #69, and #70). The facility census was 53. 1. Review of the facility's Facility Initiated Transfer/Discharge Requirements Policy, undated, showed when sending a resident to the Emergency Department - the medical record should include demonstration that resident and/or resident representative was provided discharge notice that includes reason for transfer/discharge, date, and location that resident was sent to, and information where additional information can be found. Review of the facility's Notice of Resident Transfer or Discharge Notice Form, undated, showed: -A fill-out line of the location for the transfer/discharge; -A fill-out line of the date of the transfer/discharge; -Checkboxes of the reason for the transfer/discharge; -A paragraph stating the physician was discussed and agreed upon by the physician, the right to appeal the decision and how to obtain assistance or appeal; -A signature line for the facility representative; and -A signature line for verification/receipt for Notice of Resident Transfer or Discharge for the resident or resident representative. 2. Review of the Resident's #68's Significant Change Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 5/12/23, showed staff assessed the resident as follows: -Cognitively intact; -Required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use; -Required extensive assistance of one staff for locomotion; -Required supervision for personal hygiene; -Required set-up assistance to eat; -No limitations with balance or range-of-motion. -A wheelchair and a walker for mobility. Review of the resident's medical record showed the following: -admitted to the facility on [DATE]; -Transferred to the hospital on 3/25/23; -Returned to the facility on 4/7/23; -Transferred to the hospital on 6/17/23; -Staff did not document they provided the resident and resident representative a discharge/transfer notice. During a telephone interview on 7/14/23, the ombudsman said the resident was in the hospital and the facility told the hospital social worker that he/she could not return to the facility due to lack of payment. The ombudsman said this resident did not get a 30-day notice or an alternative placement to accept the resident. During a telephone interview on 7/15/23 at 4:17 P.M., the Hospital Social Worker said the resident most likely had some significant cognitive issues that were not diagnosed. The social worker said essentially this resident was homeless, after being removed by the police and put up in a hotel until he/she became ill and was admitted to the hospital. The social worker said the facility was refusing to accept the resident back at this time, and the resident was refusing to accept any assistance to apply for funding of any kind, or to look into any funds that the resident may have. During an interview on 7/20/23 at 9:08 A.M., the Social Service Director and the Administrator said the resident had agreed to pay for his/her room at the facility after Medicare funding ended. They said the resident was unrealistic about returning home to his/her condemned property and refused to work with any social services, the ombudsman, the hospital staff or facility staff to arrange for payment or applications for assistance. The resident's family has been unwilling to assist with any discharge planning or with payments. The facility had arranged for the resident to transfer to an assisted living facility, and the resident had agreed to go, but at the last minute, the resident refused to leave. They said at this point no facility would accept the resident, and their facility is refusing to accept her back from the hospital. During an interview on 8/2/23 at 4:02 P.M., the Acting Administrator said the resident was not readmitted to the facility, and did not think a 30 day notice was issued, but would need to check with the administrator, who was out on leave of absence. During an interview on 8/3/23 at 8:48 A.M., hospital social worker said the resident remained at the hospital because no facility would accept the resident. He/She said the resident had not been issued a 30 day notice from the skilled nursing facility. During an interview on 8/3/23 at 8:56 A.M., the acting administrator said the resident's Medicaid application and been denied and as far as his/her understanding, the resident was getting assistance to re-apply. The acting administrator said a 30 day notice was not issued because, it would not do any good because our facility would have to keep the resident because no other place would take the resident. 3. Review of Resident #54's medical record showed the following: -discharged from the facility on 7/1/23; -Returned to the facility on 7/5/23. -Staff did not document they provided the resident and resident representative a discharge/transfer notice. 4. Review of Resident #69's medical record showed the following: -Discharge from the facility on 6/14/23; -Did not readmit to the facility. -Staff did not document they provided the resident and resident representative a discharge/transfer notice. 5. Review of Resident #70's medical record showed the following: -Discharge from the facility on 2/13/23; -Did not readmit to the facility from this episode; -admitted to the facility for a new episode on 6/29/23; -discharged from the facility on 7/4/23; -Did not readmit to the facility. -Staff did not document they provided the resident and resident representative a discharge/transfer notices. 6. During an interview on 7/19/23 at 8:56 A.M., Registered Nurse (RN) A said when transferring a resident to the hospital, the resident was informed, as well as the resident representative, the physician, the Director of Nursing (DON) and the administrator. The charge nurse is responsible for preparing a face sheet, the current physician order sheet, and a summary of medical events leading up to the transfer. RN A said he/she was not sure what other paperwork was required, and any additional paperwork was the responsibility of social services, the business office manager, or the clinical liaison (acts as a mediator, who aids the communication between patients, family, and care professionals). During an interview on 7/19/23 at 2:28 P.M., Licensed Practical Nurse (LPN) C said the social worker is in charge of discharge paperwork for proper notifications. During an interview on 7/20/23 at 9:08 A.M., the Social Service Director and the Administrator said they did not realize there were required written notices for transfers to the hospital. During an interview on 7/20/23 at 9:41 A.M., RN D said charge nurses are responsible for some paperwork for emergency hospital transfers includes printing of the medication list, face sheet, and the transfer form called Interact which describes what has happened to the resident. RN D was not aware of additional required paperwork.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to properly store razors, an oxygen tank, personal care chemicals and alcoholic beverages. In addition, staff failed to properly propel three residents (Resident #11, #29, and #34) in wheelchairs in a manner to prevent accidents. The facility census was 53. 1. Review of the facility's policies showed the facility did not provide a policy for oxygen storage. The Occupational Safety and Health Administration (OSHA) requirement, CFR 1926.350(a)(1) 6-7 and 9, securing compressed gas cylinders , shows: (a) Transporting, moving, and storing compressed gas cylinders. -(6) Unless cylinders are firmly secured on a special carrier intended for this purpose, regulators shall be removed and valve protection caps put in place before cylinders are moved. -(7) A suitable cylinder truck, chain, or other steadying device shall be used to keep cylinders from being knocked over while in use. -(9) Compressed gas cylinders shall be secured in an upright position at all times except, if necessary, for short periods of time while cylinders are actually being hoisted or carried. Review of the facility's Storage and labeling of Personal Care Items, undated, showed personal care items and products that may be hazardous to others will be stored in a manner that will minimize access by other residents. Such items may include but are not limited to: -Products that are not ingestible (i.e., hair spray, deodorants); -Razors, scissors, nail files, or other items that may be sharp. 2. Observation on 7/17/23 at 11:02 A.M., showed the REACH Hall supply room unlocked and unattended with a portable oxygen tank standing on end without support, a countertop plastic drawer full of razors, and an unsecured drawer that contained hand sanitizer. In addition, the unlocked cabinet contained a supply of: -After Shave labeled: CAUTION: DO NOT SWALLOW, Use only as directed and WARNING: NOT FOR CONSUMPTION, KEEP OUT OF REACH OF CHILDREN; -Effervescent Denture Cleanser labeled: WARNING: Do not place tablets or denture cleaning solution in mouth. Do not use to clean natural teeth. Keep this product out of reach of children. This product contains persulfates, which are known allergens. In case of accidental ingestion, seek professional assistance or contact the Poison Control Center immediately; -Shaving Cream labeled: WARNING: Avoid spraying in eyes. Contents under pressure. Use only as directed. Keep out of reach of children; -Moisturizer labeled: CAUTION: For external use only. Avoid contact with eyes. Keep out of reach of children. Observation on 7/18/23 at 11:43 A.M., showed the REACH Hall supply room unlocked and unattended with a countertop plastic drawer full of razors and an unsecured drawer of hand sanitizers; In addition, the unlocked cabinet contained a supply of: -After Shave labeled: CAUTION: DO NOT SWALLOW, Use only as directed and WARNING: NOT FOR CONSUMPTION, KEEP OUT OF REACH OF CHILDREN; -Effervescent Denture Cleanser labeled: WARNING: Do not place tablets or denture cleaning solution in mouth. Do not use to clean natural teeth. Keep this product out of reach of children. This product contains persulfates, which are known allergens. In case of accidental ingestion, seek professional assistance or contact the Poison Control Center immediately; -Shaving Cream labeled: WARNING: Avoid spraying in eyes. Contents under pressure. Use only as directed. Keep out of reach of children; -Moisturizer labeled: CAUTION: For external use only. Avoid contact with eyes. Keep out of reach of children. Observation on 7/19/23 at 8:46 A.M., showed the REACH Hall supply room unlocked and unattended with a countertop plastic drawer full of razors; In addition, the unlocked cabinet contained a supply of: -After Shave labeled: CAUTION: DO NOT SWALLOW, Use only as directed and WARNING: NOT FOR CONSUMPTION, KEEP OUT OF REACH OF CHILDREN; -Effervescent Denture Cleanser labeled: WARNING: Do not place tablets or denture cleaning solution in mouth. Do not use to clean natural teeth. Keep this product out of reach of children. This product contains persulfates, which are known allergens. In case of accidental ingestion, seek professional assistance or contact the Poison Control Center immediately; -Shaving Cream labeled: WARNING: Avoid spraying in eyes. Contents under pressure. Use only as directed. Keep out of reach of children; -Moisturizer labeled: CAUTION: For external use only. Avoid contact with eyes. Keep out of reach of children. 3. During an interview on 7/20/23 at 9:01 A.M., Certified nurse aide (CNA) R said razors should be in a box out of sight, and toiletries like mouthwash should be shut away. He/She said oxygen tanks should be locked up in the oxygen room or in an oxygen tank trolley. During an interview on 7/20/23 at 9:30 A.M., CNA M said disposable razors should not be kept in resident rooms. He/She said disposable razors should be kept locked up in the storage room, shower rooms, or medication room. During an interview on 7/20/23 at 9:10 A.M., Registered Nurse (RN) O said he/she does not allow his/her residents to have disposable razors. He/She said it is the expectation that disposable razors should not be kept in resident rooms. He/She said they should be kept in a locked storage room or be put in the sharps box. During an interview on 7/20/23 at 9:41 A.M., RN D said all razors and toiletries should be put in a closed cabinet in the supply room. He/She said oxygen tanks must be kept secured to prevent the tanks from falling over. During an interview on 7/20/23 at 11:55 A.M., the Director of Nursing (DON) and administrator said razors should be locked in storage and discarded in a sharps container after they are used. They also said all toiletries such as lotion, mouthwash, and after shave should be in closed cabinets. Oxygen tanks are to be kept in the locked oxygen closet and secured in a rack, if outside the closet the oxygen should be in an oxygen trolley. 4. Review of the facility's policies showed the facility did not provide a policy that directed staff on the safe and proper handling and/or storage of alcoholic beverages. Observation on 7/17/23 at 11:24 A.M., showed the third floor kitchenette refrigerator was unlocked and unattended by staff. Observation showed the refrigerator contained a box of five glass bottles of 5.0% alcohol/volume beer. Observation on 7/18/23 at 10:45 A.M., showed the third floor kitchenette refrigerator was unlocked and unattended by staff. Observation showed the refrigerator contained a box of five glass bottles of 5.0% alcohol/volume beer. Observation on 7/19/23 at 9:04 A.M., showed the third floor kitchenette refrigerator was unlocked and unattended by staff. Observation showed the refrigerator contained a box of five glass bottles of 5.0% alcohol/volume beer. During an interview on 7/19/23 at 2:20 P.M., RN O said the box of beer has been in the 300 hall fridge for several months. He/She said he/she was not sure where it came from. He/She said any resident who drinks must have a physician order that states how much and how often they can have it. He/She said that any resident who is capable of getting to and opening the fridge, would have access to the beer. During an interview on 7/20/23 at 9:01 A.M., CNA R said he/she never heard of a beer in the resident refrigerator in the dining area. He/She said a resident's beer would be in the medication room. During an interview on 7/20/23 at 9:30 A.M., CNA M said he/she was not aware there was a box of beer in the 300 hall kitchenette refrigerator. He/She said residents should not have access to alcohol unless they have a physician order. During an interview on 7/20/23 at 9:41 A.M., RN D said a resident's beer should be kept in the kitchen, where residents would not have access. During an interview on 7/20/23 at 11:55 A.M., the Administrator and DON said they were not aware that beer was being stored in the refrigerator on the third floor. They said alcohol should be stored in the locked refrigerator in the medication room. They said staff are expected to track any alcohol that comes in from family and those residents should have a physician order for the alcohol. 5. Review of the facility's Wheelchair Safety Policy, undated, showed: -Clinical staff will be educated in care of residents who require the use of a wheelchair to promote resident safety during transfer to the wheelchair and while the resident is being transported by staff; -Footrests should be applied to the wheelchair and used to support the residents' feet/legs when the resident is unable or not using their feet to help propel the wheelchair. 6. Review of Resident #11's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 4/20/23 showed staff assessed the resident as: -Cognitively intact; -Diagnoses of fractures, multiple traumas, stroke, and hemiplegia; -Wheelchair use for locomotion. Observation on 07/20/23 at 09:19 A.M., showed CNA B propelled the resident in his/her wheelchair from the bathroom to his/her chair, without foot pedals. Further observation showed the resident's foot wear and wound boot skimmed the floor. 7. Review of Resident #29's quarterly MDS, dated [DATE], showed staff assessed the resident as: -Severely cognitively impaired; -Diagnoses of stroke and hemiplegia; -Wheelchair use for locomotion. Observation on 07/17/23 at 10:31 A.M., showed RN O propelled the resident in his/her wheelchair from the dining room to his/her bedroom, approximately 25 feet while the resident's left foot skimmed the floor. 8. Review of Resident #34's annual MDS, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Diagnoses of non-traumatic brain injury, arthritis, dementia, and Parkinson's; -Wheelchair use for locomotion. Observation on 07/19/23 at 06:48 A.M., showed Certified medication technician (CMT) P propelled the resident in his/her wheelchair to the bathroom, without foot pedals. Further observation showed the resident's socks skimmed the floor. 9. During an interview on 07/20/23 at 08:43 A.M., CMT/CNA B said a resident must have foot pedals on and keep hands and elbows in the ride at all times. It is never appropriate to propel a resident without pedals because they may not be able to keep their feet up and they could drag and it can get caught. He/She said staff would need to assist the resident if their feet are not staying on the pedals. During an interview on 7/20/23 at 9:01 A.M., CNA R said wheelchairs must have foot pedals so feet do not get run over. Without the pedals a resident could suffer breaks or bruises of the ankles, feet or toes. During an interview on 7/20/23 at 9:41 A.M., RN D said wheelchairs must have pedals for feet if staff is propelling the wheelchair. He/She said a resident could be flipped head over heels and get a concussion if their feet got caught. During an interview on 7/20/23 at 11:55 A.M., the DON and administrator said wheelchairs must be propelled with the pedals on, and there are signs to remind staff all over the building. Staff should assure the residents' feet are on the pedals, because all kinds of things could happen if they are not, such as fractures, falling out of the chair, or even death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to assess for risk of bed rail entrapment, or obtain informed consent for bed rails for four residents (Resident #23, #33, #45, and #60). In addition, facility staff failed to obtain bedrail orders for one Resident (Resident #23). The facility census was 53. 1. Review of the facility's Bed Rails policy, undated, showed: This organization will take measure to develop and implement a strategy to minimize the possibility of resident entrapment and or injury while using bed rails. This will include an evaluation of the residents who have a need for or desire to use bed rails and that may have characteristics that place them at special risk for entrapment. The evaluation will also include inspection of the bed, mattress, and bed rail for risk of entrapment. A. Evaluate Equipment -Use the FDA Guide to Bed Safety to evaluate any spaces or gaps created using bed rails or mattresses. As a part of the facility's routine maintenance program, resident beds, mattresses, and attached equipment (including bed rails) are assessed on an annual or as needed basis; -The director of Engineering/Maintenance, or designee, will maintain documentation of bed inspections. B. Assess the Resident -The bed rail evaluation, including the entrapment risk component, is completed: admission, readmission, quarterly, and at any time there is a significant change in resident condition; -If the resident's evaluation identifies him or her as appropriate for use of bedrail(s), the following procedures will be followed: -Educate the resident/resident representative on the risks and obtain consent for use; the resident and/or resident representative consent for use of the bed rails will be documented in the resident's medical record; -The physician/practitioner will be notified and a specific order for the use of bed rails (identify how many/type of rails, which side or sides of the bed, and when they are to be in place) will be obtained; -The reason for the bed rails and their proper use will be integrated into the comprehensive care plan and revised as necessary; -The use of rails will be documented in the medical record. 2. Review of Resident #23's admission Minimum Date Set (MDS), a federally mandated assessment, dated 7/5/23 showed staff assessed the resident as: -Cognitively Intact; -Required extensive assistance of one staff for bed mobility; -Required limited assistance of one staff for transfers; -Used bed rails. Review of the resident's medical record showed the record did not contain documentation staff completed an entrapment assessment, a signed consent, or obtained a physician's order for the use of side rails. Observation 7/17/23 at 11:32 A.M., showed bed rails raised on both sides of the resident's bed. During an interview on 7/18/23 at 11:24 A.M., the resident said he/she used the bedrails for mobility. 3. Review of Resident #33's admission MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Active diagnoses: pneumonia, depression and respiratory failure; -Bedrails used daily. Review of the resident's medical record showed the record did not contain documentation staff completed an entrapment assessment or a signed consent. Observation on 07/18/23 at 10:09 A.M., showed the resident in bed watching TV with bilateral rails in the upright position 4. Review of Resident #45's admission MDS, dated [DATE], showed staff assessed the resident as: -Cognitively Intact; -Required extensive assistance of two staff for bed mobility and transfers; -Used bed rails. Review of the resident's medical record showed the record did not contain documentation staff completed an entrapment assessment or a signed consent. Observation 7/18/23 at 11:11 A.M., the resident in bed with the bed rails raised on both sides of the bed. During an interview on 7/18/23 at 11:11 A.M., the resident said he/she used the bedrails for mobility. 5. Review Resident #60's medical record showed the record did not contain documentation staff completed an entrapment assessment or a a signed consent. Observation on 7/17/23 at 11:40 A.M., showed bed rails raised on both sides of the resident's bed. During an interview on 7/18/23 at 10:04 A.M., the resident said he/she used the bedrails for mobility. 6. During an interview on 07/19/23 at 12:10 P.M., the assistant director of nursing (ADON) said their new system does not have a place for residents or resident representatives to sign a consent. During an interview on 07/19/23 at 12:12 P.M., the maintenance director said bed measurements are left up to the nurses upon admission and it is only required to be done again if a change occurs. During an interview on 07/19/23 at 02:28 P.M., Licensed practical nurse (LPN) C said the facility does not have bedrails, only half bars for mobility and positioning. He/she said he/she thinks maintenance does the entrapment assessments for the rails that is not something the nurses do. During an interview on 07/20/23 at 08:43 A.M., Certified Nurse aide (CNA) B said he/she is not aware of who does the assessments for bed rails and if the nursing staff were supposed to, he/she has never been taught that. During an interview on 7/20/23 at 9:10 A.M., Registered Nurse (RN) O said side rails are assessed on admission and reassessment reminders periodically pop up for nurses to complete. He/She said maintenance is responsible for maintaining, and measuring the rails. He/She said nurses are not responsible for measuring the side rails. He/She said he/she has never measured the side rails. During an interview on 7/20/23 at 10:35 A.M., CNA M said side rails are used to help residents in and out of bed and to help prevent from falling out of bed. He/She said it is important for staff to make sure the rails are in working order to prevent residents from falls, getting hung up in the rails, fingers from getting smashed, and getting arms caught. During an interview on 7/20/23 at 10:29 A.M., RN A said when a resident is admitted , assessments for resident use of bed rails are completed, and orders are entered for bed rail use. RN A said consents are obtained verbally, but no written consent with a signature is required. During an interview on 7/20/23 at 10:46 A.M., the ADON said residents have a bedrail assessment upon admission and quarterly. The ADON said consents for use of bedrails are verbal and in the baseline care plan. He/She said maintenance does measurements of the beds with bed rails to make sure the beds are standardized. During an interview on 7/20/23 at 11:55 A.M., the Director of Nursing (DON) and administrator said facility staff completes a bed rail assessment to make sure the resident is cognitively aware and can safely use the bed rails. They said the maintenance department does a check to assure the bed rails are up to code to prevent entrapments, but the measurements are not done while the resident is in bed. In addition, staff do obtain order for bed rails and the assessments, but do not have the resident sign a consent for bedrail use. Currently the staff uses the signature on the baseline care plan to indicate consent bedrails, but this is something the administrator and the DON want to fix.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility staff failed to communicate pharmacy recommendations to the physicians for six residents (Resident #2, #6, #13, #29, #34, and #41) to prevent or minimize adverse consequences related to medication therapy to the extent possible. The facility census is 53. 1. Review of the facility's Monthly Medication Regimen Review policy, not dated, showed: -The primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent and minimize adverse consequences related to medication therapy to the extent possible; -The Consultant Pharmacist will perform a Medication Regimen Review (MMR) for every resident in the facility; -Routine reviews will be done monthly; -The pharmacist will report any irregularities to the attending physician and the facility's medical director, director of nursing (DON), and these reports must be acted upon; -The attending physician or medical director will document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. 2. Review of Resident #2's quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/21/23 showed staff assessed the resident as follows: -Diagnoses of anxiety depression chronic lower back pain, and chronic kidney disease; -Use of antidepressants, opioids and diuretics on seven of seven days during the look back period (seven day period before the assessment is completed to capture the status of a resident). Review of the resident's MMR note showed 12/31/2022 MMR completed - see MMR report. Review of the resident's medical record showed the following: -Did not contain documentation of the pharmacist's report or physician's response; -Did not contain MMRs past December 2022. 3. Review of Resident #6 quarterly MDS, dated [DATE] showed staff assessed the resident as follows: -Diagnoses of cancer, coronary artery disease (coronary arteries build up with plaque and narrow, limiting blood flow to the heart), heart failure, hypertension (high blood pressure), kidney failure, urinary tract infection, diabetes mellitus (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), anxiety, and respiratory failure; -Use of antidepressant, opioid, insulin, and diuretic seven of seven days in the look back period; -Use of antibiotics three of seven days in the look back period. Review of the resident's medical record showed the record did not contain documentation of the pharmacist's MMR. 4. Review of Resident #13's quarterly MDS, dated [DATE] showed staff assessed the resident as follows: -Diagnoses of Anxiety, Seizure disorder or Epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures); -Use of antidepressants seven of seven days during the look back period, and antipsychotic three of seven days in the look back period. Review of the resident's medical record showed the record did not contain documentation of the pharmacist's MMR. 5. Review of Resident #29 Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severely cognitively impaired; -Diagnoses of diabetes, coronary artery disease, epilepsy and depression; -Use of antidepressant and anticoagulant seven of seven days in the look back period; -Use of opioid one of seven days in the look back period. Review of the resident's MMR note showed 12/31/2022 MMR completed - see MMR report. Review of the resident's medical record showed the following: -Did not contain documentation of the pharmacist's report or physician's response; -Did not contain MMR's past December 2022. 6. Review of Resident #34's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnoses of arthritis (inflammation of one or more joints, causing pain and stiffness that can worsen with age), dementia(a group of thinking and social symptoms that interferes with daily functioning), Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), and depression; -Use of antipsychotic, antianxiety and antidepressant seven of seven days in the look back period. Review of the resident's MMR note showed 12/31/2022 MMR completed - see MMR report. Review of the resident's medical record showed the following: -Did not contain documentation of the pharmacist's report or physician's response; -Did not contain MMRs past December 2022. 7. Review of Resident #41's annual MDS, dated [DATE], showed staff assessed the resident as follows: - Diagnosis of hypertension, anxiety, and depression; - Use of antianxiety and antidepressants seven of seven days in the look back period (seven day period before the assessment is completed to capture the status of a resident). Review of the resident's MMR note showed:-12/31/2022 MMR completed - see MMR report. Review of the resident's medical record showed the following: -Did not contain documentation of the pharmacist's report or physician's response; -Did not contain MMRs past December 2022. 8. During an interview on 7/20/23 at 9:10 A.M., Registered Nurse (RN) M said he/she worked day shift and had not seen pharmacy review resident medications. He/She said they may do them off site because he/she had occasionally seen notes on residents. He/She said the Assistant Director of nursing (ADON) was responsible for obtaining the recommendations and the physician responses. During an interview on 7/20/23 at 11:30 A.M., the ADON said pharmacy comes once a month to review medications, look at the medication carts and storage room. He/She said the pharmacist emails the recommendations to the facility and it is a combined effort before between the DON and herself to ensure they are completed, scanned, and have physician responses. During an interview on 7/20/23 at 11:55 A.M., the Administrator said it is a team effort between the ADON, DON, and himself/herself to ensure MMR's are getting done. He/She said pharmacy reviews resident medications monthly and then faxes or emails the recommendations to the office. Once the recommendations come in he/she said the physician is notified. He/She said physician notifications are expected to be done within seven days of receiving the pharmacy recommendations. He/She said MMRs and physician responses should then be scanned into the resident medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, facility staff failed to perform Gradual Dose Reductions (GDRs) on psychotropic medications for three residents (Resident #18, #34, and #41). The facility census was 53. 1. Review of the facility's Gradual Dose Reduction policy, undated showed the following: -After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. All medications shall be considered for possible tapering. Tapering that is applicable to antipsychotic medications shall be referred to as gradual dose reduction. Residents who use psychoactive drugs will receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. -Resident who use psychoactive drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. -Within the first year after a resident is admitted on an antipsychotic medication or after the resident has been started on an antipsychotic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated. 2. Review of Resident #18's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 6/30/23, showed staff assessed the resident as follows: -Cognitively intact; -Diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities). -Received antipsychotic and antidepressant medications seven out of seven days in the look back period (seven day period of time before the assessment is completed to capture the status of a resident). Review of the resident's Physician Order Sheets (POS), dated July 2023, showed on order on 12/15/22 for Buspirone HCI (antianxiety medication) 10 mg (milligrams) BID (twice a day). Review of the resident's medical record showed the record did not contain documentation to show an attempt for a GDR for the resident's psychotropic medications or a clinical rationale by the physician to continue the medication without a GDR. 3. Review of Resident #34's Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnoses of dementia, Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors)and depression; -Use of antipsychotic, antianxiety and antidepressant seven of seven days in the look back period; Review of the resident's POS, dated July 2023 showed an order for Mirtazapine (to treat depression) 7.5 mg. Review of the resident's medical record showed the pharmacist recommended a GDR on 6/18/23. Further review showed the physician did not receive the GDR requests until 7/19/23. Further review of the resident's POS, dated July 2023 showed an order for Hydroxyzine (to treat anxiety) 50 mg. Review of the resident's medical records showed the pharmacist recommended a GDR on 5/14/23. Further review showed the physician did not recieve the GDR reguests until 7/19/23 and recommended a decrease to 25 mg. 4. Review of Resident #41's annual MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Diagnoses of anxiety and depression; -Use of antianxiety and antidepressant seven of seven days in the look back period. Review of the resident's POS, dated July 2023, showed an order on 12/19/22 for the following medications: -Lorazepam (sedative) 0.5 mg tablet daily for anxiety; -Sertraline HCL (antidepressant) 25 mg tablet daily for major depressive disorder and anxiety. Review of the resident's medical record showed the record did not contain an attempt for a GDR for the resident's psychotropic medications or a clinical rationale by the physician to continue the medication without a GDR. 5. During an interview on 7/20/23 at 9:15 A.M., LPN C said the ADON is responsible for bringing medication changes, and GDRs to the charge nurse after it is signed by the doctor. The charge nurse updates it in the system. LPN C said the night shift nurse does a medication audit weekly but is unsure what that consists of. During an interview on 7/20/23 at 11:30 A.M., the Assistant Director of nursing (ADON) said he/she believes GDRs have not been completed timely because the medication start dates changed when the facility switched pharmacies. During an interview on 7/20/23 at 12:01 P.M., the Director of Nursing (DON) said the expectation is to get GDR recommendations and signatures from the physician and then passed on to the nurses to make the changes within a week. He/She said recently they have had difficulty getting them back timely. During an interview on 7/20/23 at 12:00 P.M., the administrator said this process is a team effort currently, ever since the building was taken over in October, and they are working on it. The administrator said the Director of Nursing and Assistant Director of Nursing will take over the audit and monitoring of the process. After the GDRs are received they are will be given it to the charge nurse on the floor to update in the resident's chart.

Based on observation, interview, and record review facility staff failed to ensure medications were stored in a safe and effective manner for two out of three medication carts, and for one resident (Resident #18). The facility census was 53. 1. Review of the facility's Storage of Drugs and Biologicals, undated, showed staff were directed as follows: -The facility shall store all drugs and biologicals in a safe, secure, and orderly manner; -Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. Observation on 7/17/23 at 11:56 A.M., showed the medication cart for the 300 hall, contained the following loose pills: -One small oval blue pill stamped with RDYL493; -One small oval white pill stamped with G4; -One small oval red pill; -One small round white pill; -One small round white pill stamped with 15; -One small round white pill stamped with C; -One small square tan pill stamped with 59; -One large round white pill. 4. Observation on 07/18/23 at 10:03 A.M., showed the medication cart for 200 hall, contained the following loose pills: -Two loose white pills stamped with L and G; -One loose yellow pill stamped with U; -Five red square gummies in clear zip lock bag, not labeled or dated. 5. Review of Resident #18's quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 6/30/23 showed staff assessed the resident as: -Cognitively intact; -Diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), and depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities). Observation of the medication cart on 200 hallway on 7/19/23 at 3:00 P.M., showed four red square gummies in clear zip lock bag, not labeled or dated with the resident's name printed on it. Review of the resident's Physician Order Sheet (POS), dated July 2023 showed an order dated 2/20/23 for CBD (Cannabidiol) gummy, up to 3 times a day as needed every 8 hrs for anxiety. During an interview on 7/19/23 at 3:01 P.M., LPN C said the gummies are CBD, which the resident's family brings in for him/her. The family member brings in a package and leaves a certain amount for the resident, then takes the rest home. The staff keep the gummies in a plastic bag so they are easier to count. The LPN said he/she is unsure of the dosage per gummy or if they have an expiration date. During an interview on 7/20/23 at 12:00 P.M., the Administrator and Director of Nursing (DON), the DON said I knew the gummies were up there, and that there was an order for them, however wasn't real sure the process for it. The DON did not know if there was a milligram amount on CBD. The administrator said, I thought it was just like an over the counter. The Administrator and DON both said they did not know or realize what the expectation was pertaining to CBD. 6. During an interview on 7/17/23 at 11:58 A.M., Registered Nurse (RN) M said he/she cleaned out the medication room and carts on Sunday 7/18/23. He/She said he/she tried to clean out the carts every day if he/she had a chance, but for sure once a week. He/She said when he/she found loose pills in his/her cart or needed to dispose of resident medications, he/she used a special solution that was kept in the medication storage room. He/She said there was not a place to document when loose pills were found. During an interview on 07/19/23 at 02:28 P.M., Licensed Practical Nurse (LPN) C said Certified medication technicians (CMT)s and nurses should be in charge of getting loose pills from the cart but there was no set schedule to clean it. During an interview on 7/20/23 at 11:55 A.M., the Administrator and Director of nursing (DON) said it was their expectation that medication carts and rooms were checked monthly by pharmacy, daily by charge nurses, and weekly by the DON. If loose pills were found it was their expectation that they were discarded in the medication destroyer. They said it was also their expectation that the charge nurse investigated why the loose pills occurred in order to prevent the issue from reoccurring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants during perineal care, when staff failed to perform appropriate hand hygiene, and glove changes for one resident (Resident #11), failed to perform appropriate incontinent care by wiping multiple times with the same area of the wipe for one resident (Resident #28), and when staff failed change and/or store oxygen tubing in a manner to prevent the spread of bacteria for three residents (Resident #7, #55 and #63). Additionally, the facility failed to ensure the two-step purified protein derivative (PPD) (skin test for TB) was completed in accordance with their policy and on file for five employees (Dietary cook G, Certified nurse aide (CNA) M, Licensed practical nurse (LPN) H, CNA I, MDS Coordinator N) out of ten employee files reviewed. The facility census was 53. 1. Review of the facility's Hand Hygiene Policy, undated, showed the following: -The facility promotes hand hygiene as a simple and effective method for preventing the spread of infections. Glove use is not a substitute for hand hygiene. All staff are to perform hand hygiene during all care activities and while working in all locations within the facility. -All staff are responsible for hand hygiene procedures: i. Before and after having direct contact with a resident's intact skin (taking pulse or blood pressure, performing physical examinations, lifting the patient in bed); ii. After contact with blood, bodily fluids or excretions, mucus membranes, non-intact skin, or wound dressings; iii. When hands move from a contaminated-body site to a clean body site during resident care; iv. Before and after wearing gloves. Review of the facility's Perineal Care procedure, undated, showed the following: -Wash and dry hands thoroughly; -Put on gloves; -Wash perineal area, wiping from front to back; -Continue to wash the perineum moving from inside outward to thighs. Rinse perineum thoroughly in the same direction, using fresh water and a clean washcloth; -Discard disposable items into designated containers; -Removed gloves; -Wash and dry hands thoroughly. 2. Review of the Resident #11's Quarterly Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 4/20/23, showed staff assessed the resident as: -Cognitively intact; -Active diagnoses of hemiplegia (one-sided muscle paralysis or weakness); -Required assistance of two or more for toileting; -Continent of bowel and bladder. Observation on 07/20/23 at 09:19 A.M., showed Certified medication technician (CMT)/ CNA B did not wash or sanitize his/her hands in between a soiled glove change during perineal care for the resident. 3. Review of Resident #28's quarterly MDS, dated [DATE] showed staff assessed the resident as: -Cognitively intact; -Required extensive assistance of two staff for bed mobility; -Totally dependent on two staff for toileting; -Always incontinent of bowel; -Frequent incontinent of bladder; -Active diagnoses of neurological bladder (lacking bladder control due to a brain, spinal cord or nerve problem). Observation on 7/18/23 at 12:48 P.M., showed CNA M and CNA Q entered the resident's room to provide perineal care. CNA M and CNA Q did not wash or sanitize their hands before they put on gloves. CNA M wiped the resident's back side three different times with the same portion of the wipe before he/she discarded it into the trash. CNA M used the same portion on the wipe when he/she wiped both sides of the resident's groin and then up the center. Further observation showed CNA M and CNA Q did not wash or sanitize their hands between soiled glove changes or before they left the resident's room. During an interview on 7/20/23 at 10:35 A.M., CNA M said staff are expected to wash hands before providing care, between providing care, with glove changes, and after providing perineal care. He/She said when providing perineal care staff should always wipe front to back and discard wipes after each wipe. During an interview on 7/20/23 at 10:32 A.M., Registered Nurse (RN) O said it was his/her expectation that staff wash their hands when entering the room, before and after care, with glove changes and before leaving the resident's room. He/She said staff should wipe the residents front to back and should throw away the wipes after each swipe. During an interview on 7/20/23 at 11:55 A.M., the Administrator and Director of nursing (DON) said they expected their staff to perform hand hygiene before providing perineal care, between glove changes, when gloves become soiled, after care and before leaving the residents room. He/She said it is their expectation that staff wipe resident's front to back and that wipes are discarded after each swipe. 4. Review of the facility's policies showed the facility did not provide a policy for changing or dating oxygen tubing. 5. Review of Resident #7's Quarterly MDS dated [DATE], showed staff assessed the resident as follows: -Utilized oxygen therapy; -Totally dependent on staff for toileting; -Required extensive one person physical assistince with transfers; -Uses a walker and wheelchair for mobility. Observation on 7/17/23 at 10:30 A.M., showed the resident sat in his/her recliner with oxygen on and the oxygen tubing lay across his/her bed and on the floor next to the resident's bed. Further observation showed oxygen tubing was not dated. Observation on 7/18/23 at 1:00 P.M., showed the resident sat in his/her recliner with oxygen on and the oxygen tubing lay across his/her bed and on the floor next to the resident's bed. Further observation showed oxygen tubing was not dated. Observation on 7/19/23 at 9:00 A.M., showed the resident sat in his/her recliner with oxygen on and the oxygen tubing lay across his/her bed and on the floor next to the resident's bed. Further observation showed oxygen tubing was not dated. 6. Review of Resident #55's admission MDS, dated [DATE], showed staff assessed the resident did not utilize oxygen therapy. Review of the resident's medical record showed the record did not contain an order for oxygen therapy. Review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed the record did not contain scheduled oxygen tubing changes. Observation on 7/17/23 at 10:42 A.M., showed the resident sat in bed with a portable oxygen canister in the room. The tubing attached and stored coiled around the canister was not dated. Observation on 7/18/at 10:09 A.M., showed the resident stood by the bed with a portable oxygen canister in the room. The tubing attached and stored coiled around the canister was not dated. 7. Review of Resident # 63's medical record showed an order for oxygen therapy. Review of the resident's MAR and TAR showed the record did not contain scheduled oxygen tubing changes. Observation on 7/17/23 at 11:08 A.M., showed the resident sat in the recliner with an oxygen concentrator with tubing coiled and stored on the machine. The tubing attached to the concentrator was not dated. Observation on 7/18/23 at 10:11 A.M., showed the resident in bed with a nasal cannula on and attached to the concentrator. The oxygen tubing was not dated. 8. During an interview on 7/19/23 at 8:56 A.M., RN A said physician orders for oxygen did not come from the physician with orders for tubing changes. RN A said nursing staff administer treatments as indicated on the TAR. During an interview on 7/20/23 at 9:41 A.M., RN D said treatments are administered as ordered on the TAR. RN D said oxygen tubing changes would occur if in the orders on the TAR. During an interview on 7/20/23 at 11:55 A.M., the DON and administrator said oxygen tubing should be labeled and dated, and have zip-lock bag so when not being used the tubing doesn't hit the ground. They said oxygen tubing should be changed monthly, with an order for the changes and the order should be scheduled in the TAR. 9. Review of the facility's Pre-employment Medical Examination, undated, showed a physical examination within 30 days including a Mantoux test is required following an offer of employment. The Mantoux test results must be read prior to the first day of work. If there is no documented history of a negative Mantoux in the last 12 months the two-step method will be used. 10. Review of Dietary [NAME] G's employee file showed: -Hire date of 12/28/23; -First step PPD administered on 1/4/23, the file did not contain the results; -Second step PPD administered on 1/27/23 and read on 1/29/23. 11. Review of CNA M's employee file showed: -Hire date of 04/19/23; -First step PPD administered on 4/17/23 and read on 4/19/23; -The file did not contain documentation a second PPD dose was administered. 12. Review of LPN H's employee file showed: -Hire date of 12/12/22; -First step PPD administered on 12/12/22, the file did not contain the results; -The file did not contain documentation a second PPD was administered. 13. Review of CNA I's employee file showed: -Hire date of 12/5/22; -First step PPD administered on 12/7/22 and read on 12/9/22; -The file did not contain documentation a second PPD was administered. 14. Review of MDS Coordinator N's employee file showed: -Hire date of 4/24/23; -First step PPD administered on 4/22/23 and read on 4/24/23; -Second step PPD administered on 5/9/23, the file did not contain the results. 15. During an interview on 7/20/23 at 12:13 P.M., the Administrator said Human Resources (HR) administered the employees' first step before orientation, department heads are to get with their employees to read first step, administer second step and read results. HR goes behind and audits if the TB steps were completed or not. During an interview on 7/20/23 at 12:13 P.M., the DON said if a reading is missed on a first step, the facility must start over, same on the second step. He/She said TBs may not be getting done because of multiple competing priorities.

Based on observation, interviews, and record reviews, the facility staff failed to maintain the kitchen in a clean and sanitary manner, to cover kitchen trash cans when not in use, to utilize hair restraints appropriately, and to properly store open food to prevent cross contamination and outdated usage. This failure had the potential to affect all residents. The census was 53. 1. Review of the facility's daily Kitchen Cleaning List, undated, showed: - Sweep under all storage racks in dry storage; - Clean and organize freezer; - Clean seals around walk-in cooler; - Clean both ovens including the racks and doors; - Sweep under all tables and coolers; - Wipe under slicer and the shelf under slicer. Review of the facility's End of Shift Cleaning Checklist, undated, showed: - Sweep and mop kitchenette; - Wipe steam table and lids; - Wipe off all countertops; - Wipe out microwave, even if you did not use it; - Sanitize all surfaces. Ex: Refrigerator door and handles. Review of the facility's daily Kitchen and Bakery Cleaning Chart, effective 4/12/21, showed staff are directed to wipe, clean, and sanitize all surfaces. Review of the facility's Weekly Cleaning policy, undated, showed: - On Sunday, the A.M. cook clean and organize seasoning shelf, the P.M. cook clean and organize under prep tables, the baker clean and organize shelves in the bakery; - On Wednesday, the P.M. cook wash can openers; - On Friday, the A.M. cook wipe, clean, and sanitize walls in the kitchen area; the P.M. cook wipe, clean, and sanitize walls in the hallway; the baker wipe, clean, and sanitize walls in the bakery area. Review of the facility's Monthly Cleaning policy, effective 4/12/21, showed: - By the 10th of the month, deep clean stove, take shelves and racks apart to clean, clean out prep table drawers; - By the 20th of the month, deep clean stove; - By the last day of the month; deep clean rational, take apart can opener from prep tables and send through the dishwasher. Observation on 7/18/23 at 1:40 P.M., of the main kitchen, showed: - Metal food preparation table with crumbs on second and third shelves. Further observation showed serving containers and cake pans stored inverted in the crumbs; - A metal table, with steamer, visibly dirty with white spots, crumbs, and brown buildup; - Can opener visibly dirty with crumbs and brown buildup; - Spice cabinet, located over a slicer and food preparation table, visibly dirty with fingerprints and smudges; - Double door refrigerator, located near the food preparation table, visibly dirty with crumbs in handles, orange chunks, and drips; - Metal food preparation table, located near the convection oven, visibly dirty with crumbs on bottom shelf. Further observation showed bulk food container sat on the shelf in the crumbs. Observation also the bulk food container, unlabeled, visibly dirty with crumbs and sticky to touch; - Column located between two food preparation tables visibly dirty with spots and drips; - Convection oven visibly dirty with crumbs and brown buildup; - Column, located between the stove and the convection oven, visibly dirty with spots, spatters, and dust buildup on top of outlets and light switch; - [NAME] table visibly dirty with brown substance, red spots, red chunks, and crumbs. Further observation showed muffin tin sat uncovered on the green table; - Ice machine visibly dirty with crumbs, drips, and white substance on the lid and front; - Food preparation sink cabinet, located near the ice machine, with hole in the bottom shelf, red and brown substance and crumbs present. Further observation showed the shelf not smooth and washable, the hole in the bottom shelf measure 8 3/4 inch by 8 3/4 inch and the space under the cabinet visible and accessible. Observation also showed the handles to the cabinet sticky with a brown substance present. Observation on 7/18/23 at 3:01 P.M., of the second floor kitchenette, showed: - Food service refrigerator visibly dirty with spots and splatters on handles and doors on outside and visibly dirty with red spots and crumbs on the inside; - Cabinets, located under the oven and over the counters, visibly dirty with chunks; - Light switch over counter visibly dirty with brown and yellow substance; - Counter around sink with black substance; - Coffee pot visibly dirty with white substance at water reservoir; - Resident refrigerator visibly dirty with white drips and spots on the outside, ice dispenser with brown substance present, and visibly dirty with brown and red spots, chunks, and drips on the inside. Observation on 7/18/23 at 3:23 P.M., of the third floor kitchenette, showed: - Cabinet drawers, located near the stove, visibly dirty with brown chunks; - Microwave with food debris on top and sides. Observation on 7/19/23 at 11:15 A.M., of the main kitchen, showed: - Metal food preparation table with crumbs on second and third shelves. Further observation showed serving containers and cake pans stored inverted in the crumbs; - A metal table, with steamer, visibly dirty with white spots, crumbs, and brown buildup; - Can opener visibly dirty with crumbs and brown buildup; - Spice cabinet, located over a slicer and food preparation table, visibly dirty with fingerprints and smudges; - Double door refrigerator, located near the food preparation table, visibly dirty with crumbs in handles, orange chunks, and drips; - Metal food preparation table, located near the convection oven, visibly dirty with crumbs on bottom shelf. Further observation showed bulk food container sat on the shelf in the crumbs. Observation also the bulk food container, unlabeled, visibly dirty with crumbs and sticky to touch; - Column located between two food preparation tables visibly dirty with spots and drips; - Convection oven visibly dirty with crumbs and brown buildup; - Column, located between the stove and the convection oven, visibly dirty with spots, spatters, and dust buildup on top of outlets and light switch; - [NAME] table visibly dirty with brown substance, red spots, red chunks, and crumbs. Further observation showed muffin tin sat uncovered on the green table; - Ice machine visibly dirty with crumbs, drips, and white substance on lid and front; - Food preparation sink cabinet, located near the ice machine, with hole in the bottom shelf, red and brown substance and crumbs present. Further observation showed the shelf not smooth and washable, the hole in the bottom shelf measure 8 3/4 inch by 8 3/4 inch and the space under the cabinet visible and accessible. Observation also showed the handles to the cabinet sticky with a brown substance present. Observation on 7/19/23 at 11:24 A.M., of the second floor kitchenette, showed: - Food service refrigerator visibly dirty with spots and splatters on handles and doors on outside and visibly dirty with red spots and crumbs on the inside; - Cabinets, located under the oven and over the counters, visibly dirty with chunks; - Light switch over counter visibly dirty with brown and yellow substance; - Counter around sink with black substance; - Microwave with food debris present on the inside top and sides; - Coffee pot visibly dirty with white substance at water reservoir; - Resident refrigerator visibly dirty with white drips and spots on the outside, ice dispenser with brown substance present, and visibly dirty with brown and red spots, chunks, and drips on the inside; - Toaster visibly dirty with crumbs. Observation on 7/19/23 at 11:30 A.M., of the third floor kitchenette, showed: - Cabinet drawers, located near the stove, visibly dirty with brown chunks; - Resident refrigerator visibly dirty on ice dispenser with brown substance; - Microwave with food debris on top and sides. During an interview on 7/19/23 at 1:15 P.M., the dietary manager (DM) and the dietary director (DD) said they are responsible to ensure the kitchen is maintained in a clean and sanitary manner. The facility has a policy for cleaning the kitchen, and the dietary staff are trained on the policy. The DM and DD said they try to use a cleaning schedule to maintain the cleanliness of the kitchen. The DM conducts audits on Monday through Fridays, but he/she does not document the audits. The DD also conducts audits, and he/she makes a list of his/her observations and files it. The DM and the DD said they discuss the audits with each other, but they do not conduct in-services with the dietary staff regarding their observations. They said they verbally mention their observations with the dietary staff. The DM and DD said it is expected the staff would clean the work stations and the kitchenettes after their shift and as needed. During an interview on 7/19/23 at 2:03 P.M., the administrator said the DD or their designee is responsible to ensure the kitchen is maintained in a clean and sanitary manner. She said the facility has a policy regarding cleaning the kitchen, and the DD is trained on the policy. The administrator said the kitchen should have a cleaning schedule, and it is expected staff would keep the kitchen clean. 2. Review of the facility's Dispose of Garbage and Refuse policy, dated 8/2017, showed: - Appropriate lids are provided for all containers; - The policy did not address utilization of trash can lids. Observation on 7/18/23 at 1:50 P.M., showed a trash can located near the cooking appliances, uncovered and not in use. Observation on 7/18/23 at 2:25 P.M., showed a trash can located near the dishwashing area, uncovered and not in use. Observation on 7/18/23 at 3:38 P.M., showed a trash can located near the dishwashing area, uncovered and not in use. Observation on 7/19/23 at 11:15 A.M., of the main kitchen, showed a trash located near the dishwashing area uncovered and not in use. Observation also showed a trash can located near the cooking appliances uncovered and not in use. During an interview on 7/19/23 at 1:15 P.M., the DM and the DD said the trash cans should have lids on them when they are not in use. The DM said trash cans should be covered at the end of the day when staff are no longer using the trash cans. The DM and the DD said they were not aware the trash cans should be covered throughout the day when staff are not actively using the trash cans. During an interview on 7/19/23 at 2:03 P.M., the administrator said the DD is responsible to ensure trash cans are maintained according to regulations. She said the facility has a policy, and the staff are trained on the policy. The administrator said it is expected the trash cans would be covered. 3. Review of the facility's Staff Attire policy, dated 9/2017, showed all staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Observation on 7/18/23 at 2:56 P.M., showed [NAME] T prepared the residents' dinner meal. Further observation showed the cook had a goatee which measured greater than 3/4 inch long and did not wear a beard guard. Observation on 7/19/12 11:30 A.M., showed dietary aide U placed the residents' lunch meal on the steam table, uncovered the containers, and took food temperatures. Further observation showed the dietary aid had a goatee which measured greater than 1/4 inch long and did not wear a beard guard. Observation also showed the dietary aid wore a hair net, but the hair net did not cover three inches of hair on the left side and neck area of the dietary aide's head. During an interview on 7/19/23 at 1:15 P.M., the DM and the DD said staff should wear hairnets and beard guards anytime they are in the kitchen, kitchenettes, and dining rooms. They said the all the staff's hair should be contained in the hairnet or beard guard. The DM and the DD said the facility has a policy regarding the use of hairnets and beard guards, and the dietary staff have been trained on the policy. During an interview on 7/19/23 at 2:03 P.M., the administrator said the DD or their designee is responsible to ensure the dietary staff utilize hairnets and beard guards appropriately. She said the facility has a policy on hairnets, and the staff is trained on the policy. The administrator said if staff have hair on their head or face then they should wear a hairnet or beard guard to ensure all the hair is covered. 4. Review of the facility's Food Storage: Dry Goods policy, dated 9/2017, showed: - All packaged and canned food items will be properly sealed; - Storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of the facility's Food Storage: Cold Foods policy, dated 4/2018, showed all foods will be stored wrapped or in covered containers, labeled, and dated, and arranged in a manner to prevent cross contamination. Review of the facility's daily kitchen and bakery cleaning chart, effective 4/12/21, showed staff directed to date, label, and rotate stock. Observation on 7/18/23 at 2:10 P.M., of the double door refrigerator showed a Ziploc bag with opened feta cheese undated. Observation on 7/18/23 at 2:15 P.M., of the food preparation table, showed a bulk container of a white substance unlabeled. Observation on 7/18/23 at 2:33 P.M., of the walk-in refrigerator, showed an open bag of Hawaiian rolls undated. Observation on 7/18/23 at 3:18 P.M., of the second floor resident refrigerator, showed: - An open container of ice cream with scoop unlabeled and undated; - An open bag of red raspberries undated. Observation on 7/18/23 at 3:23 P.M., of the third floor resident refrigerator, showed: - Breaded food item unlabeled and undated; - Pint of ice cream unlabeled and undated; - Bowl of yellow and brown food unlabeled and undated. Observation on 7/19/23 at 11:15 A.M., of the double door refrigerator showed a Ziploc bag with opened feta cheese undated. Observation on 7/19/23 at 11:17 A.M., of the food preparation table, showed a bulk container of a white substance unlabeled. Observation on 7/18/23 at 11:24 A.M., of the second floor resident refrigerator, showed: - An open container of ice cream with scoop unlabeled and undated; - An open bag of red raspberries undated. Observation on 7/19/23 at 11:30 A.M., of the third floor resident refrigerator, showed: - Breaded food item unlabeled and undated; - Pint of ice cream unlabeled and undated; - Bowl of yellow and brown food unlabeled and undated. During an interview on 7/19/23 at 1:15 P.M., the DM and the DD said they are responsible to ensure food is stored correctly in the kitchen. They said the facility has a policy on food storage, and staff are trained on the policy. The DM and the DD said all food should be protected, labeled, and dated when placed in storage. It is expected staff would correct any items they saw stored incorrectly. The DM and the DD said resident food is not stored separately from the facility food supplies. They said resident's food should have the resident's name, room number, and the date on each item. During an interview on 7/19/23 at 2:03 P.M., the administrator said the DD or their designee is responsible to ensure food is stored according to policy. She said the facility has a policy on food storage, and the staff is trained on the policy. The administrator said all food should be protected, labeled, and dated. She said resident food should be stored in a separate refrigerator from the facility's food. The administrator said the resident's food should be labeled with the resident's name.

Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical abuse when Licensed Practical Nurse (LPN) A pushed the resident down in bed multiple times by his/her shoulders and held the resident's right arm down to the nurse's station desk to keep the resident from moving. The facility census was 56. 1. Review of the facility's Resident's Right to Freedom Form Abuse, Neglect, and Exploitation Policy, dated 2022, showed residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in the policy. Associates must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion against any resident. 2. Review of Resident #1's admission Minimum Data Set, a federally mandated assessment tool, dated 2/17/23, showed staff assessed the resident as: -Cognitively intact; -Diagnoses of acute respiratory failure, chronic obstructive pulmonary disease (COPD) (condition involving constriction of the airways and difficulty or discomfort in breathing), and atrial fibrillation (irregular and often very rapid heart rhythm); -Rejected care and wandering behaviors 1-3 days per week. Review of the resident's plan of care, dated 2/10/23, showed staff assessed the resident did show behaviors. The plan of care did not list any interventions to address the resident's behaviors. Review of the facility's abuse investigation, dated 2/16/23, showed the administrator immediately made aware LPN A raised his/her voice to the resident, pushed the resident down by his/her shoulders to the bed, and held the resident's right arm down on the nurses station. Review showed staff suspended LPN A pending the investigation. Review showed staff assessed the resident, interviewed staff and residents, and notified necessary parties. Review showed staff terminated the LPN A on 2/20/23. During an interview on 3/1/23 at 11:21 A.M., the resident's Primary Care Physician (PCP) said he/she heard LPN A tell the resident multiple times he/she had to go to bed and instructed the staff to take the resident to bed even though the resident said he/she did not want to go to bed. He/She said the staff brought the resident back to the nurses station after he/she refused to lay down to call his/her spouse. He/She said the resident picked a phone up off of the nurses station and LPN A reached across the nurses station, grabbed the resident's right arm, and held it down to the desk so the resident could not move. He/She said LPN A yelled at the resident Give it back and Registered Nurse (RN) C told LPN A let go of the resident. He/She said Certified Nurse Aide (CNA) D asked the resident for the phone, the resident handed CNA D the phone, and he/she handed it to LPN A. He/She said he/she immediately reported the incident to the administrator. He/She said the resident was not being combative towards any of the staff. During an interview on 3/1/23 at 12:12 P.M., the administrator said he/she was contacted by the resident's PCP and informed of an allegation of abuse. He/She said he/she instructed the staff be pulled from the floor and contacted the Director of Nursing (DON). He/She said when he/she arrived to the facility he/she assessed the resident who did not recall the incident. He/She said he/she interviewed staff and LPN A said he/she did hold the resident's arm down on the desk so he/she would not hit him/her. He/She said he/she suspended LPN A and reported the incident to the state. He/She said the resident did not remember the incident, they notified the resident's family of the incident who did not want to press charges, and the facility staff terminate LPN A on 2/20/23. During an interview on 3/1/23 at 12:20 P.M., the DON said when he/she arrived, LPN A was not on the floor, assessed the resident and found him/her without injury. He/She said RN C assessed the resident directly following the incident. He/She said the resident has sundowning tendencies (a term referring to a state of confusion occurring in the late afternoon and lasting into the night) and he/she likes to sit in the dining room in the evenings. He/She said staff are expected to respect the resident's rights and report abuse and neglect allegations immediately to the charge nurse or next in the chain of command. During an interview on 3/1/23 at 3:00 P.M., LPN A said he/she went to assist the resident to bed because he/she refused for CNA D and CNA E. He/She said both CNA D and CNA E went to the resident's room with him/her. He/She said when he/she transferred the resident to bed, the resident became combative and tore his/her nametag off and tried to rip his/her scrub pocket off. He/She said he/she did not push the resident down in bed by his/her shoulders. He/She said once it was determined the resident would not lay down, CNA D got the resident up and propelled him/her to the nurses station to call his/her spouse. He/She said the resident grabbed his/her phone off the desk and he/she held the resident's right arm to the the desk so the resident could not hit him/her. During an interview on 3/1/23 at 3:22 P.M., CNA D said he/she was told to take the resident to bed. When he/she and CNA E took the resident to his/her room, the resident voiced he/she did not want to go to bed. He/She said he/she told LPN A the resident did not want to be put to bed and LPN A told him/her he/she would do it. He/She said LPN A propelled the resident to his/her room, transferred him/her to bed, and pushed the resident down by his/her shoulders to the mattress multiple times. He/She said the resident did grab LPN A's name badge and scrub pocket as he/she pushed the resident down to his/her mattress by his/her shoulders. He/she said the resident was trying to sit up and was not combative towards LPN A. He/She said after LPN A decided the resident was not going to bed, he/she got the resident up and propelled the resident to the nurses station to talk to his/her spouse. He/She said the resident grabbed the first phone in sight. He/She said when LPN A saw it was his/her phone, LPN A reached across the nurses station, grabbed the resident's right arm and held it down to the desk so he/she could not move. He/She said LPN A yelled at the resident Give me my phone, don't break my stuff and asked him/her to get his/her phone from the resident. He/She said he/she asked the resident for the cell phone and the resident gave it to him/her without any issues. He/She said the resident never tried to hit LPN A. During an interview on 3/1/23 at 3:48 P.M., RN C said he/she could hear LPN A in the resident's room from the nurses station, but could not hear what he/she said. He/She said CNA D propelled the resident to the nurses station to talk to his/her spouse because it helped calm the resident down. He/She said the resident grabbed a cell phone off the front of the nurses station and LPN A immediately reached over the desk and grabbed the resident's right arm and held it down to the desk. He/She said LPN A yelled at the resident to Give it to me. He/She said he/she told LPN A to let go of him/her, and then LPN A let go of the resident's arm. He/She said the PCP was there at the time and notified the administrator of the incident while he/she assisted the resident to contact his/her spouse and assessed the resident for injury. He/She said the resident did not try to hit LPN A. During an interview on 3/1/23 at 4:34 P.M., CNA E said he/she was instructed to assist the resident to bed with CNA D. He/She the resident did not want to go to bed, so he/she and CNA D took the resident back up to the dining area. He/She said LPN A told them he/she would put the resident to bed. He/She said LPN A propelled the resident to his/her room and assisted him/her to bed. He/She said LPN A pushed the resident by his/her shoulders down in bed multiple times. He/She said the resident did grab at LPN A because he/she was trying to get up, but LPN A kept pushing him/her down in the bed. He/She said the resident did not try to hit LPN A. He/She said when LPN A could not get the resident to lay down, he/she had CNA D get him/her up so he/she could talk to his/her spouse to help him/her calm down. He/She said CNA D propelled the resident to the nurses station. He/She said he/she did not witness the incident at the nurses station. MO00214185

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to revise the care plan for one resident (Resident #12) when the resident's code status (type of emergent treatment a person would or would not receive if their heart or breathing were to stop) changed from a Full Code (full support which includes cardiopulmonary resuscitation (CPR), if the the heart or breathing stops) to a DNR (CPR would not be initiated if the heart or breathing stops), failed to revise the plan of care for one resident (Resident #24) with weight loss, and failed to revise the plan of care for four residents (Resident #7, #8, #14, and #45) who required assistance from staff for personal hygiene and grooming. The facility census was 46. 1. Review of the facility's Care Plans- Comprehensive Person-Centered Policy, dated [DATE], showed: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident; -In addition to the formal care plan document, the resident's individualized plan of care, as determined through the care planning process, will also be reflected in and communicated to the team via, but not limited to, the following tools; current physician orders, current medication record, current treatment record, current rehab therapy plan and goals, CNA touchscreen and community or neighborhood specific tools designed by the team to facilitate communication of resident care needs; -The interdisciplinary team (IDT), in conjunction with the resident, or representative, develops and implements a comprehensive, person-centered care plan for each resident; -The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment utilizing information gathered from and including, but not limited to, the resident, their representative, and direct care staff from all shifts; - The care planning process will incorporate the resident's personal and cultural preferences in developing the goals of care; - The comprehensive, person-centered care plan will include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, incorporate identified problem areas, incorporate identified problem areas, aid in preventing or reducing decline in the resident's functional status and/or functional levels, and reflect currently recognized standards of practice for problem areas and conditions; - Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process; - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change; - The Interdisciplinary Team must review and update the care plan when there has been a significant change in the resident's condition, the desired outcome is not met and at least quarterly, in conjunction with the required quarterly MDS assessment. 2. Review of the facility's Advanced Directives policy, dated [DATE], showed: -Advanced directives will be respected in accordance with state law and community policy; -Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record; -The plan of care for each resident will be consistent with their documented treatment preferences and/or advanced directives; -A nurse will notify the physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care; -Inquiries concerning advance directives should be referred to Social Services. 3. Review of Resident #12's admission Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated [DATE], showed staff assessed the resident as cognitively impaired. Review of the resident's Physicians Orders, dated [DATE], showed a DNR order, indicating the resident would not want CPR performed. Review of the Outside the Hospital Do-Not-Resuscitate (OHDNR) order, dated [DATE], showed it was signed by the resident and physician, which indicated the resident chose a DNR code status. Review of the care plan, dated [DATE], showed: -Full Code, indicating CPR, would be performed; Staff failed to revise the resident's care plan to include his/her advanced directives. 4. Review of Resident #24's Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive two person assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. -Required limited one person assistance for eating; -Had no weight loss of 10% or more in the past six months. Review of the resident's medical record, dated [DATE] through [DATE], showed the resident had a weight loss of 13.96 %. Review of the care plan, dated [DATE], showed it did not contain direction for staff in regards to the resident's weight loss. 5. Review of Resident #7's, Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive one person assistance for personal hygiene. Review of the resident's care plan, dated [DATE], showed it did not contain direction for staff in regards to the resident's facial hair preference. Observations from [DATE] at 11:00 A.M. through [DATE] at 1:45 P.M., showed the resident had long hairs on his/her chin. 6. Review of Resident #8's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive one person assistance for bed mobility, transfers, dressing and personal hygiene; Observations from [DATE] at 11:00 A.M. through [DATE] at 1:45 P.M., showed the resident had long hairs on his/her chin. Review of the resident's care plan, dated [DATE], showed it did not contain direction for staff in regards to the resident's facial hair preference. 7. Review of Resident #14's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required extensive one person assistance with personal hygiene; Review of the resident's care plan, dated [DATE], showed it did not contain direction for staff in regards to the resident's facial hair preference. Observations from [DATE] at 11:00 A.M. through [DATE] at 1:45 P.M., showed the resident had long hairs on his/her upper lip and chin. During an interview on [DATE] at 2:30 P.M., the resident said staff assisted him/her with shaving his/her upper lip and chin. He/She did not want to talk about it further. 8. Review of Resident #45, Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required limited one person assistance with transfers and personal hygiene; Review of the resident's care plan, dated [DATE], showed it did not contain direction for staff in regards to the resident's facial hair preference. Observations from [DATE] at 11:00 A.M. through [DATE] at 1:45 P.M., showed the resident had long hairs on his/her upper lip and chin. During an interview on [DATE] at 2:06 P.M., the resident said he/she did not want hair on his/her upper lip or chin. He/She said the staff does not assist him/her with facial hair removal. 9. During an interview on [DATE] at 9:47 A.M., Licensed Practical Nurse (LPN) B said nursing staff provide resident updates to the MDS Coordinator, who is responsible for updating the care plans. He/She said he/she would expect to see the resident's facial hair preference, weight loss, and code status addressed in the care plan. During an interview on [DATE] at 10:14 A.M., Certified Nurse Aide (CNA) C said he/she was unsure where to find the information for preferences, but could ask a nurse. He/She said he/she would not expect facial hair in the care plan, but the care plan listed the code status. He/She said he/she did not know who updated care plans. During an interview on [DATE] at 10:21 A.M., LPN D said facial hair preference would be listed in the care plan. He/She said the code status should be in the care plan and the resident's chart, as well as, weight loss interventions. He/She said the care plan is updated by the MDS Coordinator or nursing staff. During an interview on [DATE] at 10:31 A.M., the MDS Coordinator said he/she is responsible for updating the care plans, as well as, the Director of Nursing (DON), and other nursing staff. He/She said weight loss, facial hair preference, and code status should be listed in the care plan. During an interview on [DATE] at 10:40 A.M., the DON said he/she would expect to see the resident's facial hair preference, weight loss, and code status, which should match the physician orders, listed in the care plan. He/She said the care plans were updated by the DON, nursing staff and the social worker. He/She said the CNA's have limited access to the information in the care plan. During an interview on [DATE] at 12:54 P.M., the Administrator said the care plan is updated by the charge nurse, DON, the IDT team, and social services as needed. He/She said care plans are discussed and updated during IDT meetings. He/She said he/she would expect the care plan to address rejection of care that negatively affected the residents' quality of life, weight loss and the code status, which should match the physician orders. He/She said residents with impaired cognition, should have their facial hair preferences documented on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to ensure four residents (Residents #7, #8, #14 and #45), that were unable to complete their own activities of daily living (ADLs), received the necessary care and services to maintain good personal hygiene. The facility census was 46. 1. Review of the facility's ADL Supporting policy, dated 5/26/21, showed: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs; -Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Review of Resident #7's, Annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive one person assistance for personal hygiene. Review of the resident's care plan, dated 12/4/18, showed it did not contain direction for staff in regards to the resident's facial hair preference. Observations from 4/18/22 at 11:00 A.M. through 4/21/22 at 1:45 P.M., showed the resident had long hairs on his/her chin. 3. Review of Resident #8's admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Required extensive one person assistance for bed mobility, transfers, dressing and personal hygiene; Observations from 4/18/22 at 11:00 A.M. through 4/21/22 at 1:45 P.M., showed the resident had long hairs on his/her chin. Review of the resident's care plan, dated 7/2/22, showed it did not contain direction for staff in regards to the resident's facial hair preference. 4. Review of Resident #14's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/14/22, showed staff assessed the resident as follows: -Cognitively intact; -Required extensive one person assistance with personal hygiene. Review of the resident's care plan, dated 3/12/21, showed it did not contain direction for staff in regards to the resident's facial hair preference. Observations from 4/18/22 at 11:00 A.M. through 4/21/22 at 1:45 P.M., showed the resident had long hairs on his/her upper lip and chin. During an interview on 4/19/22 at 2:30 P.M., the resident said staff assisted him/her with his/her hair to upper lip and chin. He/She said staff helped him/her that morning. 5. Review of Resident #45, Quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required limited one person assistance with transfers and personal hygiene. Review of the resident's care plan, dated 7/7/21, showed it did not contain direction for staff in regards to the resident's facial hair preference. Observations from 4/18/22 at 11:00 A.M. through 4/21/22 at 1:45 P.M., showed the resident had long hairs on his/her upper lip and chin. During an interview on 4/18/22 at 2:06 P.M., the resident said he/she did not want hair on his/her upper lip or chin. He/She said the staff does not assist him/her with facial hair removal. 6. During an interview on 4/21/22 at 9:42 A.M., Certified Nurse Aide (CNA) A said the residents were shaved daily, if needed, or when showered, which was twice a week. During an interview on 4/21/22 at 9:47 A.M., Licensed Practical Nurse (LPN) B said residents were shaved as needed, or when they received showers, which was twice a week unless a different preference was requested. He/She was not sure how often all residents were shaved. He/She said he/she did not notice facial hair on Residents #7, #8, #14 or #45. During an interview on 4/21/22 at 10:14 A.M., CNA C said residents were showered twice and week and shaved on those days, or when needed, by the CNAs. During an interview on 4/21/22 at 10:21 A.M., LPN D said residents were shaved on showered days by the shower aides. He/She said residents were shaved when they ask, but he/she was not sure of the process if the resident was not cognitive. During the interview on 4/21/22 at 10:40 A.M., the Director of Nursing (DON) said the residents are shaved based on personal preference, but usually the residents were shaved on shower days, when requested, or based on behaviors. He/She said staff were expected to document any refusal of care in the residents chart, including refusing to groom facial hair. He/She said he/she was aware of several residents who had facial hair. During an interview on 4/21/22 at 12:54 P.M., the Administrator said the CNAs and the nursing staff were responsible for shaving the residents when needed, but there was no scheduled times. He/She said he/she would expect staff to update the progress notes if a resident refused care. He/She said he/she was aware there were certain residents who had facial hair.