**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents were treated in a dignified manner when staff failed to remove two hospital bracelets from one resident's wrist (Resident #306) until 12 days after discharging from the hospital. The facility census was 105. Review of the facility policy titled Federal Rights of Residents/Guests, dated 11/28/16, showed the following: -The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility; -The resident has the right to exercise his/her rights as a resident of the facility and as a citizen or resident of the United States; -The resident has a right to be treated with respect and dignity; -The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. 1. Review of Resident #306's face sheet (resident's information at a quick glance) showed the following: -admission date of 07/29/24 with readmission date of 05/01/25; -Diagnoses included dementia (brain disorder that causes a gradual decline in cognitive abilities, memory and behavior), heart disease (narrowing of the arteries), kidney disease (kidneys are damaged and can't filter blood as well as they should), anxiety disorder (excessive fear and worry), and transient ischemic attack (TIA - a temporary disruption of blood flow to the brain, leading to stroke like symptoms). Review of the resident's discharge assessment Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/28/25, showed the following: -Memory problems, moderately impaired cognition, and requires cues/supervision; -No behaviors; -Partial assistance with showers. Review of the resident's care plan, revised 05/02/25, showed the following: -Potential for falls. Resident sent to emergency room for acute process/evaluation on 04/28/25. -Offer to assist with restroom every two hours, remind resident to use call-light, physical and occupations therapy to evaluate and treat, and observe need for additional assistive devices; -Resident required assistance to complete daily activities of care safely; -Potential for elopement. Review of the resident's progress note dated 04/28/25, at 10:20 P.M., showed a registered nurse (RN) documented resident had an unwitnessed in resident's room resulting in head wound with active bleeding and hematoma (collection of blood outside of blood vessels) formation at occiput (back of the head). Resident complained of head, neck and upper back pain. Resident on Plavix (medication used to prevent blood clots) and aspirin. He/she was unable to recall what he/she was doing, just that he/she slipped and hit his/her head. Staff sent resident out to the emergency room. Review of the resident's progress note dated 05/01/25, at 5: 40 P.M., showed the resident returned with family from the hospital for readmission to the facility. Resident continued to require one staff for transfers. Observations on 05/12/25, at 4:45 P.M., showed the resident in the dining room listening to music. The resident had on two bracelets. One said fall risk and the other had personal information on it. During an observation and interview on 05/13/25, at 11:45 A.M., the resident sat at the dining room table. He/she had on the two bracelets. The resident said he/she did not know why they were on his/her wrist. The resident sat with other residents to eat his/her lunch. During an interview on 05/15/25, at 4:41 P.M., Licensed Practical Nurse (LPN) A said the following: -He/she noticed the resident had on the hospital bracelets either 05/12/25 or 05/13/25 and he/she cut them off; -He/she didn't realize the bracelets had been on the residents arm since the resident was discharged from the hospital on [DATE]. During an interview on 05/16/25, at 12:40 P.M., LPN B, said he/she didn't see hospital bracelets on the resident's wrists. Staff are supposed to remove them when a resident returns from the hospital. During an interview on 05/16/25, at 1:05 P.M., Certified Medication Technician (CMT) C said he/she didn't notice the resident having bracelet's on his/her wrists, but it wouldn't be appropriate to leave bracelets on after being hospitalized . During an interview on 05/20/25, at .12:34 P.M., the Director of Nursing (DON) and Regional Quality Assurance Nurse said the nurses or CNA's should remove the hospital bracelets as soon as possible, unless the resident doesn't want them removed. During and interview on 05/20/25, at 2:07 P.M., the Administrator said hospital bracelets should be removed.

Based on interview and record review, the facility failed to ensure all residents' drug regimes were free from unnecessary drugs when staff failed to specify a diagnosis for use of a psychotropic medication for one resident (Resident #37). A sample of eight residents was reviewed in a facility with a census of 105. Review of the facility's policy titled, Psychotropic Medication Use, dated 12/01/02, showed the following: -Psychotropic drug is any medication that affects brain activities associated with mental processes and behavior; -All medications used to treat behaviors must have a clinical indication. 1 Review of Resident 37#'s face sheet (resident's information at a quick glance) showed the following: -admission date of 08/26/24; -Diagnoses included major depressive disorder (persistent feelings of sadness), visual hallucinations (seeing things that are not actually present), and anxiety disorder (excessive fear and worry). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 04/10/25, showed the following: -No cognitive impairment; -No behaviors; -The resident took antianxiety and antidepressant medications; -Resident did not take an antipsychotic medication. Review of the resident's care plan, revised 04/10/25, showed the following: -Resident receives psychoactive medications related to depression and anxiety; -Attempt a gradual dose reduction as ordered by the provider and monitor drug for use, effectiveness and adverse consequences. Review of the the resident's May 2025 Physicians' Order Sheet (POS) showed an order, dated 12/13/24, to administer Abilify (antipsychotic) 5 milligrams (mg) daily at bedtime for delusions. The order did not indicate a diagnosis for administration of Ability, only the resident's symptom of delusions. Review of the resident's progress and nurses' notes showed staff did not document a diagnosis for the administration of Abilify. During an interview on 05/19/25, at 2:21 P.M., the MDS Coordinator said every medication should have an associated diagnosis. If the doctor wrote the diagnosis of delusions for prescribing Ability an antipsychotic, that should be fine. During an interview on 05/19/25, at 2:35 P.M., Licensed Practical Nurse (LPN) D said the following: -Each medication was prescribed for a diagnosis; -If a resident was receiving an antipsychotic, such as Ability, they would have a psychiatric diagnosis; -Delusions would not be a diagnosis, but a symptom. During an interview on 05/20/25, at 12:34 PM., the Director of Nursing (DON) and Regional Quality Assurance Nurse said a diagnosis must be appropriate for the use of medication. Signs and symptoms cannot be used instead of a diagnosis. During and interview on 05/20/25, at 2:07 P.M., the Administrator said a resident should have an appropriate diagnosis when taking an antipsychotic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow appropriate discharge procedures when staff failed to complete discharge and/or transfer documentation in the medical record for one resident (Resident #14). The census was 105. Review of the facility's policy entitled Transfer, Discharge and Therapeutic Leaves (including Against Medical Advice (AMA), dated 06/26/19, showed the following: -The resident had the right to refuse involuntary transfer out of or discharge from the facility under certain circumstances; -Transfer meant the moving of a resident from the facility to another legally responsible institutional setting. Discharge meant the moving of a resident to a non-institutional setting when the releasing facility ceases to be responsible for the resident; -According to federal regulations, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; -Emergency transfers should occur only for medical reasons, or for the immediate safety and welfare of a resident or other residents. Emergency transfer procedures should include obtaining physicians' order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis, and document information regarding the transfer in the medical record. 1. Review of the Resident #14's face sheet (a brief information sheet about the resident) showed admission date of 07/01/19. Review of the resident's Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), showed the following: -On 03/10/25, the resident was discharged with return anticipated; -On 03/13/25, the resident re-admitted to the facility. Review of the resident's entry MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with repositioning, upper body dressing, wheelchair mobility, and eating; -Required supervision or touching assistance with transfers, personal hygiene, lower body dressing, toilet transfer. Review of the resident's medical record, dated February 2025 and March 2025, showed staff documented the following: -On 02/28/25, at 7:46 A.M., the resident had an appointment on 02/27/25 and was being scheduled for surgery on 03/10/25. The doctor's office will call with pre-operative instructions by 03/06/25. Resident will need to stop taking metformin (medication primarily used to manage type 2 diabetes) and non-steroid anti-inflammatory drugs (NSAIDS - class of medications that reduce pain, inflammation, and fever) three days prior to surgery; -On 03/13/25, at 3:38 P.M., the resident arrived at 12:37 P.M., via ambulance transport. Report from the hospital states the resident had osteomyelitis of the left elbow, MRSA (methicillin-resistant Staphylococcus Aureus - a bacteria with antibiotic resistance) infection, and was on doxycycline (medication that fights bacterial infections by preventing the growth and spread of bacteria) oral tablet for 42 more days. (Staff did not document related to the resident being sent out to the hospital on [DATE].) During an interview on 05/16/25, at 10:45 A.M., the Regional Nurse Consultant said there was no discharge information available in the resident chart. There was no note related to the discharge from facility on 03/10/25. During an interview on 05/19/25, at 10:00 A.M., Registered Nurse (RN) E said nursing staff should document the appropriate information in the medical record any time a resident was transferred to the hospital. During an interview on 05/19/25, at 2:20 P.M., the MDS Coordinator said staff should chart a progress note with information of resident leaving the facility and doctor notification and orders as appropriate. During an interview on 05/20/25, at 12:34 P.M., DON said when a resident was sent to the hospital, she would expect the nursing staff to document in the medical record what happened and that the responsible party or family member and the physician were notified. During an interview on 05/20/25, at 2:07 P.M., Administrator said staff nursing staff should document why and when a resident was sent out of the facility and should document the family and physician were notified.

Based on record review and interviews, the facility failed to refer a Pre-admission Screening and Resident Review (PASARR) resident who had a negative Level I Preadmission Screen, who was later identified with a new mental disorder diagnosis, to the appropriate state designated authority for a Level II PASARR evaluation and determination for one resident (Resident #25) out of 8 sampled residents. The facility census was 105. Review showed the facility's policy titled Preadmission Screening Resident Review, revised on 06/2009, showed the following: -Preadmission screening of nursing home patients to establish a Level I Determination is a federal requirement; -The intent of a preadmission screening is to ensure that all individuals with a mental illness or mental retardation are appropriately placed in a nursing facility, have medical needs that outweigh their mental needs and receive appropriate services; -The nursing home is responsible for assessing a resident's status on an ongoing basis to identify any significant change. Those identified through the PASARR process as having an Mental illness diagnosis must have an updated Level I screening within 14 days of the significant change. 1. Review of Resident #25's face sheet (resident's information at a quick glance) showed the following: -admission date of 04/27/23; -Diagnosis included schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, and emotional responsiveness) and Parkinson's disease (progressive movement disorder that affects the nervous system). Review of the resident's admission assessment Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/04/23, showed the following: -Moderately impaired cognition; -Diagnoses did not include schizophrenia. Review of the resident's Level 1 PASARR, dated 04/27/23, showed the following information: -Resident did not show any signs of symptoms of major mental disorder; -Resident had diagnosis of major depressive disorder and anxiety disorder. Schizophrenia was not listed as a diagnosis; -Did not indicate a need for a level II screening. Review of the resident's medical records, dated 08/11/24 to 08/15/24, showed the following: -admission date of 08/11/24 to the hospital for complex medical condition requiring medication consultation; -Behavioral health was consulted due to altered mental status and history of schizophrenia; -Resident reported depression, anxiety, and post traumatic stress disorder; -discharged diagnosis of altered mental status and schizophrenia. Review of the resident's medical record showed staff did not document a new screening with the new diagnosis of schizophrenia. During interviews on 05/19/25, at 9:31 A.M., MDS Coordinator said the following: -He/she or the MDS Assistant does the level II if there has been a psych treatment stay in the past two years, any indication of danger to self or threats of or attempted suicide, or history of development disabilities; -If the resident has a new diagnosis from an inpatient hospital stay, they would need a level II screening; -The resident had been in and out of the hospital numerous times, and he/she knew the resident was evaluated mentally, but he/she didn't know if the resident had a psych stay. During an interview on 05/20/25, at .12:34 PM., the Director of Nursing (DON) and Regional Quality Assurance Nurse said the resident is sent out of a psych visit and new diagnosis of schizophrenia, and major mental change occurred there should be a referral packet on re-admission. Admissions gives it to the DON and MDS reviews and does the second part of the level for new submission. During and interview on 05/20/25, at 2:07 P.M., the Administrator said a new level one should be requested anytime before admission or changes in diagnosis would cause a trigger for a new level one.

Based on observation, interview, and record review, the facility failed to provide care in accordance with professional standards when staff failed to notify the physician and family of frequent refusal of medications for one resident (Resident #40) for review of medication regimen and failed to complete accu-checks (blood glucose level checks) as ordered when one resident (Resident #25). The facility census was 105. 1. Review of the facility titled General Dose Preparation and Medication Administration, dated January 2013, showed the following: -Facility staff should comply with facility policy, applicable law, and the State Operations Manual when administering medications; -After medication administration, facility staff should document necessary medication administration information. Review of the facility policy titled Resident Medication Rights, dated January 2013, showed the following: -Facility staff should document when a resident refuses a medication or treatment; -Facility staff should discuss the health and safety consequences of refused medication or treatments with the resident or representative as appropriate; -Facility staff should notify the physician of the resident's refusal of treatment; -Facility staff should notify the physician of a resident's refusal of medications for periods greater than twenty-four hours; - Facility staff should notify the physician immediately if the refused medication could affect the health or safety of the resident; -Facility staff should document the effect of refused medications in the resident's clinical record. Review of Resident #40's face sheet (a brief information sheet about the resident) showed the following: -admission date of 11/22/19; -Diagnoses included intellectual disabilities (intellectual functioning or intelligence, which include the ability to learn, reason, problem solve, and other skills needed for independent living and social functioning), chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), generalized anxiety disorder, dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) with agitation, cognitive communication deficit, hypothyroidism (condition in which the thyroid gland doesn't produce enough thyroid hormone - can disrupt such things as heart rate, body temperature, and all aspects of metabolism), gout (form of inflammatory arthritis caused by the buildup of uric acid crystals in joints, leading to pain, swelling, and redness), pain, and convulsions (uncontrolled, often sudden, and violent muscle contractions and relaxations, sometimes resulting in shaking or jerking movements). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 03/15/25, showed the following: -Severe cognitive impairment; -Resident was taking antibiotic, diuretic, opioid, and hypoglycemic. Review of the resident's care plan, last reviewed 03/26/25, showed the following: -Resident was on anti-anxiety medications; -Staff should administer medications as ordered; -Staff should assess effectiveness of ant-anxiety medication therapy; -Staff should assess for adverse effects, document, and report; -Resident had seizure disorder and was at risk for injury; -Staff should administer anticonvulsant medications as ordered; -Resident refuses care, including to take medication; -Staff should introduce self and express happy mood to encourage compliance. Review of the resident's physician order sheet (POS), current as of 05/20/25, showed the following: -An order, dated 11/23/19, for pain reliever ER (acetaminophen generic name) tablet 500 milligram (mg), administer one tablet three times per day for pain. Review of the resident's May 2025 Medication Administration Record (MAR) showed the following: -An order, dated 11/23/19, for pain reliever ER (acetaminophen) tablet 500 mg, administer one tablet three times per day for pain; -On 05/01/25, staff documented the morning dose was not administered due to the resident was asleep; - On 05/02/25, staff documented the morning dose was not administered due to the resident refused; - On 05/02/25, staff documented from evening dose through 05/05/25 evening dose the medication was not administered due to the resident refused; -On 05/06/25, staff documented evening dose was not administered due to the resident refused; -On 05/07/25, staff documented morning and evening doses not administered due to the resident refused; -On 05/09/25 morning dose through 05/14/25 evening doses, staff documented the medication was not administered due to the resident refused; -On 05/16/25 afternoon dose through 05/19/25 evening doses, staff documented the medication was not administered due to the resident refused. Review of the resident's medical record showed staff did not document physician notification of the refused doses of acetaminophen. Review of the resident's POS, current as of 05/20/25, showed an order, dated 01/22/24, for allopurinol 300 mg (can treat gout and kidney stones), give one tablet every day for diagnosis of gout. Review of the resident's May 2025 MAR, showed the following: - An order, dated 01/22/24, for allopurinol 300 mg, give one tablet every day for diagnosis of gout, administer time at 7:00 A.M.; -On 05/01/25, staff documented the medication was not administered due to the resident was asleep; -From 05/02/25 through 05/13/25, staff documented the medication as not administered due to the resident refused the medication; -On 05/14/25 and 05/15/25, staff documented the medication as not administered due to the resident was asleep; -On 05/16/25 through 05/20/25, staff documented the medication as not administered due to the resident refused the medication. Review of the resident's medical record showed staff did not document physician notification of the refused/missed doses of allopurinol. Review of the resident's POS, current as of 05/20/25, showed the following: -An order, dated 06/08/24, for levothyroxine (can treat hypothyroidism) tablet 75 microgram (mcg), take one-half tablet by mouth once daily for diagnosis of hypothyroidism. Review of the resident's May 2025 MAR showed the following: -An order, dated 06/08/24, for levothyroxine tablet 75 mcg, take one-half tablet by mouth once daily for diagnosis of hypothyroidism; -On 05/01/25, staff documented the medication was not administered due to the resident was asleep; -From 05/02/25 through 05/13/25, staff documented the medication was not administered due to the resident refused the medication; -On 05/14/25 and 05/15/25, staff documented the medication was not administered due to the resident was asleep; -On 05/16/25 through 05/20/25, staff documented the medication was not administered due to the resident refused the medication. Review of the resident's medical record showed staff did not document physician notification of the refused/missed doses of levothyroxine. Review of the resident's POS, current as of 05/20/25, showed the following: -An order, dated 11/08/24, for Depakote (can treat seizures) tablet, delayed release 250 mg, administer three tablets once a morning, to equal 750 mg, for diagnosis of cognitive communication deficit. Review of the resident's May 2025 MAR showed the following: -An order, dated 11/08/24, for Depakote tablet, delayed release, 250 mg, administer three tablets once a morning, to equal 750 mg, diagnosis of cognitive communication deficit; -On 05/01/25, staff documented the medication was not administered due to the resident was asleep; -From 05/02/25 through 05/13/25, staff documented the medication was not administered due to the resident refused the medication; -On 05/14/25 and 05/15/25, staff documented the medication was not administered due to the resident was asleep; -On 05/16/25 through 05/20/25, staff documented the medication was not administered due to the resident refused the medication. Review of the resident's medical record showed staff did not document physician notification of the refused/missed doses of Depakote. Review of the resident's POS, current as of 05/20/25, showed the following: - An order, dated 11/08/24, for Depakote (divalproex) tablet, delayed release, 500 mg, administer two tablets to equal 1000 mg at bedtime for diagnosis of cognitive communication deficit. Review of the resident's May 2025 MAR showed the following: -An order, dated 11/08/24, for Depakote tablet, delayed release, 500 mg, administer two tablets to equal 1000 mg at bedtime, fir diagnosis of cognitive communication deficit; -On 05/01/25 through 05/19/25, staff documented the medication was not administered due to the resident refused the medication. Review of the resident's medical record showed staff did not document physician notification of the refused/missed doses of Depakote. Review of the resident's POS, current as of 05/20/25, showed the following: -An order, dated 11/08/24, for Lasix (water pill that prevents the body from absorbing too much salt, causing it to be passed in the urine) 20 mg tablet, administer three tablets once a day, to equal 60 mg, for diagnosis of generalized edema (swelling). Review of the resident's May 2025 MAR showed the following: -An order, dated 11/08/24, for Lasix 20 mg tablet, administer three tablets once a day, to equal 60 mg, diagnosis of generalized edema; -On 05/01/25, staff documented the medication was not administered due to the resident was asleep; -From 05/02/25 through 05/13/25, staff documented the medication was not administered due to the resident refused the medication; -On 05/14/25 and 05/15/25, staff documented the medication was not administered due to the resident was asleep; -On 05/16/25 through 05/20/25, staff documented the medication was not administered due to the resident refused the medication. Review of the resident's medical record showed staff did not document physician notification of the refused/missed doses of Lasix. Review of the resident's POS, current as of 05/20/25, showed the following: -An order, dated 01/30/25, for Linzess (used to treat and relieve chronic constipation) capsule, 290 microgram (mcg), administer one capsule every day for irritable bowel syndrome (IBS). Review of the Resident's May 2025 MAR showed the following: -An order, dated 01/30/25, for Linzess capsule 290 mcg, administer one capsule every day for IBS; -On 05/01/25, staff documented the medication was not administered due to the resident was asleep; -From 05/02/25 through 05/13/25, staff documented the medication was not administered due to the resident refused the medication; -On 05/14/25 and 05/15/25, staff documented the medication was not administered due to the resident was asleep; -On 05/16/25 through 05/20/25, staff documented the medication was not administered due to the resident refused the medication. Review of the resident's medical record showed staff did not document physician notification of the refused/missed doses of Linzess. Review of the resident's POS, current as of 05/20/25, showed the following: -An order, dated 02/04/25, for ascorbic acid (vitamin C) tablet 500 mg, administer one tablet twice a day. Review of the resident's May 2025 MAR showed the following: -An order, dated 02/04/25, for ascorbic acid (vitamin C) 500 mg tablet. Staff to administer one tablet twice a day at 7:00 A.M. and 3:00 P.M.; -On 05/01/25, at 7:00 A.M., staff documented the medication was not administered due to the resident was asleep; -On 05/01/25 afternoon dose through 05/14/25 morning doses, staff documented the medication was not administered due to the resident refused the medication; -On 05/15/25 morning dose, staff documented the medication was not administered due to the resident was asleep; -On 05/16/25 morning dose through 05/20/25 morning doses, staff documented the medication was not administered due to the resident refused the medication. Review of the resident's medical record showed staff did not document physician notification of the refused/missed doses of ascorbic acid. Review of the resident's POS, current as of 05/20/25, showed the following: -An order, dated 02/14/25, for potassium chloride liquid 20 milliequivalent (meq)/15 milliliter(ml), administer 30 ml twice a day for supplement. Review of the resident's May 2025 MAR showed the following: -An order, dated 02/14/25, for potassium chloride liquid 20 meq/15 ml, administer 30 ml twice a day for supplement at 7:00 A.M. and 7:00 P.M.; -On 05/01/25, at 7:00 A.M., staff documented the medication was not administered due to the resident was asleep; -From 05/01/25 evening dose through 05/20/25 morning doses, staff documented the medication was not administered due to the resident refused the medication. Review of the resident's medical record showed staff did not document physician notification of the refused/missed doses of potassium chloride. Review of the resident's POS, current as of 05/20/25, showed the following: -An order, dated 04/14/25, Baclofen 10 mg tablet (used to help relax muscles in the body), administer one tablet every 12 hours for muscle spasm. Review of the resident's May 2025 MAR showed the following: -An order, dated 04/14/25, for Baclofen 10 mg tablet, administer one tablet every 12 hours for muscle spasm; -On 05/01/25, at 7:00 A.M., staff documented the medication was not administered due to the resident was asleep; -From 05/01/25 P.M. dose through 05/13/25 P.M. doses, staff documented the medication was not administered due to the resident refused the medication; -On 05/14/25 morning and evening dose and 05/15/25 morning dose, staff documented the medication was not administered due to the resident was asleep; -On 05/16/25 morning and evening dose through 05/20/25 morning dose, staff documented the medication was not administered due to the resident refused the medication. Review of the resident's medical record showed staff did not document physician notification of the refused/missed doses of Baclofen. Review of the resident's POS, current as of 05/20/25, showed the following: -An order, dated 05/06/25, for clotrimazole-betamethasone cream 1-0.05% (combination medication containing anti-fungal and steroid, used to treat fungal skin infections), administer topically twice daily, apply to both legs. Review of the resident's May 2025 MAR showed the following: -An order, dated 05/06/25, for clotrimazole-betamethasone cream 1-0.05%, administer topically twice daily, apply to both legs; -On 05/06/25 morning dose through 05/11/25 evening doses, staff documented the medication was not administered due to the resident refused the medication; -On 05/12/25 evening dose through 05/15/25 morning doses, staff documented the medication was not administered due to the resident refused the medication; -On 05/16/25 morning dose through 05/19/25 morning doses, staff documented the medication was not administered due to the resident refused the medication. Review of the resident's medical record showed staff did not document physician notification of the refused/missed doses of clotrimazole-betamethasone cream. During an interview on 05/15/25, at 2:35 P.M., Certified Medication Tech (CMT) C said when he/she administered medications, if a resident refused there was codes in the MAR to use for the reason the medication was not provided. He/she would notify the nurse that the resident refused medications. He/she said the resident refused his/her medications most of the time. He/she did not know if the doctor was aware of the resident refusing medications. During an interview on 05/15/25, at 4:00 P.M., Licensed Practical Nurse (LPN) A said the CMT staff should notify the charge nurse when a resident refused medications. The nurse could then try to administer the medications. The physician should be notified of medication refusal, especially if it was consistently refused. Staff should document and notify family as well. During an interview on 05/19/25, at 10:00 A.M., Registered Nurse (RN) E said if a resident refused a medication the CMT staff should let the charge nurse know. The nurse should let the physician know so that changes can be made if necessary. The nurse was not aware that the resident refused multiple medications. He/she said the physician should be notified. The resident's family should also be notified. During an interview on 05/19/25, at 3:45 P.M., CMT G said if a resident refused to take medications the staff should try multiple times before documenting as refused. He/she would notify the nurse when a resident refused medications. He/she did not know when or if the nurse told the doctor. He/she said the resident would refuse medications most of the time unless his/her family was in the room. He/she did not know if the nurse had told the physician. During an interview on 05/20/25, at 12:34 P.M., the Director of Nursing (DON) said if a resident refused medications the staff should document refused. If the resident consistently refused medications staff should notify the physician. Refusal of medications should be care planned and the staff should document in a progress notes. She was not aware of the resident specifically refusing medications. During an interview on 05/20/25, at 2:07 P.M., the Administrator said if a resident consistently refused to take medications, the staff should document and have conversation with the physician for further instructions or orders. 2. Review of the facility's policy titled, Blood Glucose Testing, dated 10/01/19, showed the physician's orders should specify the type of specimen to be obtained. Blood glucose levels for residents with diabetes vary depending on food intake, medication, and exercise. Review of Resident #25's face sheet showed the following: -admission date of 04/27/23; -Diagnoses included diabetes (body does not produce enough insulin). Review of the resident's discharge assessment Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 05/08/23, showed the resident had moderately impaired cognition and a diagnosis of diabetes. Review of the resident's care plan, revised on 05/12/25, showed staff to administer medications as ordered. (Staff did not care plan related blood sugar level checks. Review of the resident's March 2025 POS showed an order, dated 03/14/25, for check blood glucose twice daily at 7:00 A,M., and 7:00 P.M. Review of the resident's March 2025 Treatment Administration Record (TAR) showed the following: -On 03/16/25, staff noted glucose not completed with note that said other and comment of breakfast; -On 03/22/25, staff noted 8:14 A.M., late administration with no comments; -On 03/24/25, staff noted at 8:38 A.M., late administration with no comments; -On 03/26/25, staff noted at 10:31 P.M., late administration with no comments; -On 03/29/25, staff noted at 8:26 A.M., late administration - other with no comments. Review of the resident's April 2025 MAR showed the following: -An order, dated 03/14/25, to check blood glucose twice daily at 7:00 A.M. and 7:00 P.M. -On 04/02/25, staff noted at 10:04 P.M., late administration with no comments; -On 04/07/25, staff noted at 8:34 A.M., late administration with no comments; -On 04/11/25, staff noted at 8:33 A.M., late administration with no comments; -On 04/20/25, staff noted at 8:39 A.M., late administration with no comments; -On 04/22/25, staff noted at 8:22 A.M., late administration with no comments. Review of the resident's May 2025 MAR showed the following: -An order, dated 03/14/25, to check blood glucose twice daily at 7:00 A.M. and 7:00 P.M. -On 05/02/25, staff noted at 8:29 A.M., late administration with no comments; -On 05/13/25, staff noted at 8:00 A.M., late administration with no comments. During interviews on 05/13/25, at 12: 07 P.M. and 3:19 P.M., the resident said the following: -He/she has orders to get his/her blood sugar checked in the morning and night. Staff are not always checking his/her blood sugars and sometimes they're checked late. During an interview on 05/16/25, at 12:40 P.M., LPN B said the following: -Staff know when to complete blood sugar checks as there is an order and it pops up on the electronic MAR when it's due; -Staff should be completing the glucose checks as ordered; -The resident had an order for checks in the morning and evening. The CMT's are now completing the blood sugar checks for him/her; -He/she believed the blood sugar checks were being done for the resident as ordered. During interviews on 05/16/25, at 1:00 P.M., and on 05/19/25, at 12:41 P.M., Certified Medication Technician (CMT) H said the following: -Blood sugar checks show up on the electronic record, the MAR, as ordered; -The blood sugar checks should be completed as ordered; -CMTs now do blood sugar checks on those residents that have scheduled doses of insulin and long acting insulin; -If the blood glucose is checked late, the computer note will say late administration. If it's charted late, it will say charted late. During interviews on 05/16/25, at 1:05 P.M., CMT C said the following: -Blood glucose checks require an order; -He/she knew when to complete the orders as they pop up in the electronic medical record; -The resident had ordered blood glucose checks two times per day, in the morning and evening. During an interview on 05/19/25, at 12:55 P.M., CMT I said the following: -He/she knew when blood sugar checks were due because they pop up on the electronic MAR; -CMTs just began doing blood sugar checks on some residents that take long acting insulin and weekly blood sugar checks; -When the glucose is checked later, it will say late administration on the MAR; -He/she will often make a list and put them in the computer at one time so sometimes it says charted late. There should be a note if it's completed late. During an interview on 05/20/25, at 12:34 PM., the DON and Regional Quality Assurance Nurse said the following: -Nurses put in the orders and staff should be following the physician's orders; -The nurse should be completing the checks before breakfast and before bedtime; -The resident has refusals, then reports them not being done; -Staff should be documenting when the resident refuses and notifying the physician if there are frequent refusals.

Based on observation, record review, and interview the facility failed to provide pharmaceutical services to meet the needs of each resident when staff failed to obtain and administer eye drop medications as ordered for one resident (Resident #1) Review of the facility policy titled Medication Shortages / Unavailable Medications, dated January 2013, showed the following: -This policy sets forth procedures relating to medication shortages and unavailable medications; -Upon discovery that facility has an inadequate supply of a medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from pharmacy; -If the medication shortage is discovered at the time of medication administration, facility staff should immediately take the action as follows: -If a medication shortage is discovered during normal pharmacy hours, the facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order or reorder for the next scheduled delivery. If the next available delivery causes delay or a missed dose in the resident's medication schedule, facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. If the medication is not available in the Emergency Medication Supply, facility staff should notify pharmacy and arrange for an emergency delivery; -If a medication shortage is discovered after normal pharmacy hours a licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply. If the ordered medication is not available in the Emergency Medication Supply, the licensed facility nurse should call pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include emergency delivery or use of an emergency (back-up) third party pharmacy; -If an emergency delivery is unavailable, facility nurse should contact the attending physician to obtain orders or directions; -If the medication is unavailable from pharmacy or a third-party pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate physician orders, as necessary; -If the medication is unavailable from pharmacy due to formulary coverage, contraindication, drug-drug interaction, drug-disease interaction, allergy or other clinical reason, facility should collaborate with pharmacy and physician to determine a suitable therapeutic alternative; -If facility nurse is unable to obtain a response from the attending physician in a timely manner, facility nurse should notify the nursing supervisor and contact facility's Medical Director for orders/direction, making sure to explain the circumstances of the medication shortage; -When a missed dose is unavoidable, facility nurse should document the missed dose and the explanation for such missed dose on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) and in the nurse's notes per facility policy. Such documentation should include a description of the circumstances of the medication shortage, a description of pharmacy's response upon notification, and action taken. Review of the facility policy titled Reordering, Changing, and Discontinuing Orders, dated October 2016, showed the following: -The policy sets forth procedures with respect to the facility's communication of any medication reorders, changes, or discontinuations to the pharmacy; -Facilities are encouraged to reorder medications electronically; -Facility staff should review the transmitted re-orders for status and potential issues and pharmacy response; - Facility staff should review the status of open orders for follow-up with pharmacy. 1. Review of Resident #1's face sheet (a brief information sheet about the resident), showed and admission date of 11/26/24. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 04/22/25, showed the resident had moderate cognitive impairment. Review of the resident's care plan, updated 05/12/25, showed staff should administered medications as ordered. Review of the resident's Physician's Orders Sheet (POS), current as of 05/20/25, showed the following: -An order, dated 01/09/25, for ketotifen fumarate (medication primarily used to relieve eye itching and other symptoms of allergic conjunctivitis (inflammation of the mucus membrane that covers the front of the eye and lines the inside of the eyelids)) drops 0.025 % (0.035 %), 1 drop both eyes every 12 hours; -An order, dated 04/07/25, for Pataday Once Daily Relief (an over-the-counter eye drop designed to relieve itching and redness caused by allergies) drops 0.7 %, administer one drop once per day to bilateral eyes due to seasonal allergies. Review of the resident's May 2025 MAR showed the following: -An order, dated 01/09/25, for ketotifen fumarate drops 0.025 % (0.035 %), one drop in both eyes every 12 Hours; -On 05/01/25, staff documented the morning dose as refused; -On 05/01/25, staff documented evening dose as administered; -On 05/11/25 to 05/12/25, staff documented for morning and evening the drops were unavailable; -On 05/13/25, staff documented for the morning dose the drops were unavailable; -On 05/13/25, staff documented the evening dose was administered; -On 05/14/25, staff documented the morning and evening dose were administered; -On 05/15/25, staff documented for the morning and evening dose the drops were unavailable; -On 05/16/25, staff documented for the morning and evening dose the drops were administered; -On 05/17/25, staff documented for the morning dose the drops were drug unavailable; -On 05/17/25, staff documented the evening dose was administered; -On 05/18/25, staff documented the morning dose was administered; -On 05/18/25, staff documented for the evening dose the drops were unavailable; -On 05/19/25, staff documented for the morning and evening dose the drops were unavailable. Review of the May 2025 MAR showed the following: -An order, dated 04/07/25, Pataday Once Daily Relief drops 0.7 %, administer one drop once per day to bilateral eyes due to seasonal allergies; -On 05/01/25, staff documented the resident refused the drops; -On 05/02/25 through 05/14/25, staff documented the drops were unavailable; -On 05/15/25 dose, staff documented the resident refused the drops. During an interview 05/13/25, at 9:48 A.M., the resident said he/she had been waiting three days for eye drops to be refilled. He/she said his/her eyes drip often. Review of the resident's May 2025 progress notes showed staff did not document notifying the physician related to unavailable medications. During an interview on 05/15/25, at 10:10 A.M., Certified Medication Tech (CMT) C said staff should notify the nurse when a medication was not available for administration. The nurse should notify the physician when a medication was delayed. He/she said the eye drops for the resident had not been delivered from the pharmacy. He/she did not know if the physician was aware. During an interview on 05/15/25, at 12:30 P.M., CMT H said when providing medications, if something was not available in the cart staff should go to the emergency kit in the medication room. If the medication was not available staff should notify the nurse. During an interview on 05/15/25, at 2:45 P.M., Licensed Practical Nurse (LPN) II said the CMT staff should notify the nurse if a medication was not available. The emergency kit had many medications always available. He/she was not aware of the resident not receiving his/her eye drops as ordered. During an interview on 05/15/25, at 3:00 P.M., Registered Nurse (RN) E said if a medication was not available, the staff should also let the charge nurse know and the nurse should contact the physician if wanted an alternative or okay to hold medication until it arrived from the pharmacy. The physician should be notified and he/she was not aware of the resident's eye drops not being administered. During an interview on 05/15/25, at 4:25 P.M., LPN A said when a medication was not available the CMT staff should go to the emergency kit. The staff should notify the nurse if not available. The nurse should notify the physician to check if need to provide an alternative or okay to wait until medication arrives. He/she was not aware of the resident's eye drops not being available. During an interview on 05/15/25, at 4:32 P.M., the Director of Nursing (DON) said if a medication was not available in the medication cart the staff should notify the nurse and check the emergency kit. The staff should check with the pharmacy for delivery schedule and if would be unavailable the same day the staff should notify the physician to see if alternative order. She was not aware of the resident's eye drops not being available. During an interview on 05/15/25, at 4:44 P.M., the Administrator said if medication was not available, the staff should notify the pharmacy. Most items can be available same day from multiple local pharmacies if needed. The physician should be notified if not available for multiple days. He was not aware of thy resident's eye drops not being available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure residents were free of any significant medication errors when staff failed to prime the insulin pens for two residents (Residents #156 and #100). The facility census was 105. Review of a facility policy titled General Dose Preparation and Medication Administration, revised 01/01/13, showed the following: -Facility staff should comply with facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications; -Verify each time a medication is administered that it is the correct medication, at the correct dose, route, rate, and time, for the correct resident; -Follow manufacturer medication administration guidelines. Review showed the facility did not provide a policy specific to the administration of insulin using pre-filled pens. Review of manufacturer guidelines for an insulin lispro KwikPen (rapid action insulin) showed the following: -Prime the pen by dialing the dose knob to two units, hold the pen upright, tap the cartridge to release any air bubbles and push the injection button until a drop of insulin appears at the needle tip; -Dial the dose knob to the prescribed number of units. 1. Review of Resident #156's face sheet (gives basic profile information at a glance) showed the following: -admission date of 05/09/25; -Diagnoses did not include a diabetes diagnosis. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 05/15/25, showed the following: -admission date of 05/09/25; -Mild cognitive impairment; -Diagnoses included diabetes mellitus; -Received insulin injections on six of six days since admission. Review of the resident's Physician Order Sheet (POS), dated 04/19/25 to 05/19/25, showed the following: -An order, dated 05/10/25, for insulin lispro pen 100 unit/milliliter (ml) subcutaneous (just below the skin) before meals at 7:30 A.M., 11:30 A.M., and 4:30 P.M. per the following sliding scale: -If blood sugar is less than 60 milligrams per deciliter (mg/dl), call physician; -If blood sugar is 60 mg/dl to 150 mg/dl, give 0 units; -If blood sugar is 151 mg/dl to 199 mg/dl, give 2 units; -If blood sugar is 200 mg/dl to 249 mg/dl, give 4 units; -If blood sugar is 250 mg/dl to 299 mg/dl, give 6 units; -If blood sugar is 300 mg/dl to 349 mg/dl, give 8 units; -If blood sugar is 350 mg/dl to 400 mg/dl, give 10 units; -If blood sugar is greater than 400 mg/dl, give 10 units; -If blood sugar is greater than 400 mg/dl, call physician. Review of the resident's care plan, dated 05/12/25, showed staff did not care plan related to the diabetes diagnosis or insulin use. Observation on 05/16/25, at 12:20 P.M., showed Registered Nurse (RN) QQ sanitized his/her hands, donned gloves, and performed an AccuCheck (blood test to determine glucose/sugar level) for the resident. The test result was 365 mg/dl. The RN reviewed the sliding scale for the ordered insulin lispro and said the resident required 10 units. RN QQ cleansed the insulin pen tip with an alcohol wipe, then placed the needle on the pen. Without first priming the pen, the RN set the pen dose meter to 10. RN QQ cleansed the resident's left upper arm with an alcohol swab, and administered the insulin. 2. Review of Resident #100's face sheet showed the following: -admission date of 04/03/25; -Diagnoses included type II diabetes mellitus with other skin ulcer and diabetic neuropathy (nerve damage), long-term use of insulin and oral anti-diabetic drugs. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognition intact; -Diagnoses included diabetes melliltus; -Received insulin on seven of the last seven days. Review of the resident's POS, dated 04/19/25 to 05/19/25, showed an order, dated 04/03/25, for insulin aspart insulin pen 100 units/ml, give 15 units subcutaneous before meals at 7:00 A.M., 11:30 A.M., and 4:30 P.M. Review of the resident's care plan, updated 05/05/25, showed the following: -Resident had diabetic foot ulcers and hyperglycemia (high blood glucose/sugar) related to diabetes mellitus; -Administer insulin and oral medications per orders; -Evaluate/record/report effectiveness/adverse side effects; -Monitor blood glucose per orders; -Monitor for signs of hyperglycemia (blood glucose >140 mg/dl, increase thirst, increased urination, increased appetite followed by a lack of appetite, or nausea/vomiting) or hypoglycemia (blood glucose <60 mg/dl, sweating, cold/clammy skin, numbness of fingers, toes, mouth, rapid heartbeat, nervousness, tremors, or faintness/dizziness). Observation on 05/16/25, at 12:34 P.M., showed RN QQ sanitized his/her hands, donned gloves, and performed an AccuCheck for the resident. The test result was 139 mg/dl. The RN reviewed the order for the insulin aspart and said the resident would receive 15 units. RN QQ cleansed the insulin pen tip with an alcohol wipe and placed the needle on the pen. Without first priming the pen, the RN set the pen dose meter to 15. RN QQ cleansed the resident's left upper arm with an alcohol swab, and administered the insulin. During an interview on 05/19/25, at 3:10 P.M., Licensed Practical Nurse (LPN) D said insulin pens should always be primed with at least 2 units until liquid is seen injected from the needle into the air. Then the ordered dose should be dialed in and administered. During an interview on 05/19/25, at 3:15 P.M., LPN O said insulin pens should be primed with two units before dialing in the required dose for administration. During an interview on 05/20/25, at 12:34 P.M., the Director of Nursing (DON) said staff should cleanse an insulin pen before securing the needle, prime the pen with at least two units, and then dial in the required dose to administer. During an interview on 05/20/25, at 2:08 P.M., the Administrator said he/she was not aware of the procedures for using an insulin pen. Staff should follow manufacturer guidelines.

Based on observation, interview, and record review, the facility failed to provide timely dental services for all residents when staff failed to identify the need for and obtain dental services for one resident (Resident #306) when his/her dentures were missing. The facility census was 105. Review of the facility's policy titled Dentures, Cleaning and Storing, dated 10/01/10, showed the following information: -Oral hygiene should be provided twice daily, unless documented by the physician as medically contraindicated, or the resident desires more frequent hygiene; -Clean dentures by brushing them with a denture cleaner or toothpaste; -Keep dentures in a cup in the bedside table until the resident is ready to replace them. 1. Review of Resident #306's face sheet (resident's information at a quick glance) showed an admission date of 07/29/24 and readmission date of 05/01/25. Diagnoses included transient ischemic attack (a temporary disruption of blood flow to the brain, leading to stroke like symptoms). Review of the resident's discharge assessment Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 04/28/25, showed the following information: -Resident was Independent with toileting hygiene, personal hygiene, and dressing; -Resident needed set up assistance with eating and oral hygiene. Review of the resident's care plan, revised on 05/02/25, showed staff to assist resident with brushing teeth and oral care. (Staff did not care plan related to denture use.) Observations on 05/13/25, at 11:45 A.M., showed the resident sat at the dining room table eating. The resident was not wearing dentures. Observation on 05/14/25, at 1:01 P.M., showed the resident eating in the dining room. He/she did not have dentures in his/her mouth. Observations and interview on 05/15/25, at 1:56 P.M., showed the resident was in his/her room eating. The resident said he/she had a partial and he/she doesn't wear it. During an interview on 05/13/25, at 3:20 P.M., the resident's family member said the following: -The resident's dentures went missing about three weeks ago. He/she told the Director of Environmental Services and he/she believed an aide and nurse were aware of them missing too; -He/she would like for the resident to have a dental appointment to get the dentures replace as they could not be found anywhere. During interviews on 05/15/25, at 10:15 A.M., and on 05/19/25, at 3:54 P.M., the Social Services Director (SSD) said the following: -He/she had not been told the resident was missing his/her dentures. He/she never knew if the resident had dentures; -When a resident had something come up missing, the facility staff searched the resident's room and looked in laundry; -If lost dentures were not located, he/she made an appointment with the dentist or affordable dentures to get them replaced. During an interview on 05/15/25, at 1:58 P.M., Certified Nurse Aide (CNA) J said the resident had dentures, but they got lost. He/she did not know when they were lost. The resident's family member came in about month ago and said they were missing. He/she told the nurse. They looked for them but were not able to locate them. She told laundry to see if they might be there, but they didn't locate them. They might have been thrown away as the resident has thrown things away in the past. He/she didn't believe the resident had gone to the dentist. During an interview on 05/15/25, at 2:30 P.M., CNA I said the resident got dentures recently. He/she remembered one time the resident lost the top plate and they found them. He/she didn't know if they were missing now. Staff do assist the resident with putting in the dentures as needed. During an interview on 05/15/25, at 4:41 P.M., Licensed Practical Nurse (LPN) A said he/she didn't remember seeing the resident wear dentures. He/she didn't know if the resident ever had dentures. During an interview on 05/16/25, at 12:40 P.M., LPN B said the resident got the dentures a few months ago. No one had reported them missing. The last time he/she spoke to the resident's family member the dentures were not fitting properly. When something is reported missing they look for them in the room and laundry. During an interview on 05/20/25, at .12:34 PM., the Director of Nursing (DON) and Regional Quality Assurance Nurse said when dentures come up missing, staff should look for them in the room, in the laundry, in the trash, and ask dietary. If not found they should notify family and notify the SSD to file a grievance. During and interview on 05/20/25, at 2:07 P.M., the Administrator said staff should look for missing dentures to see if they've been misplaced. If not found, staff should report the missing dentures so they can be replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promote and facilitate the right of self-determination for every resident when staff failed to honor reasonable shower preferences for four residents (Resident #76, #92, #29, and #74) . The facility census was 105. Review of the facility's policy titled Hygiene and Grooming, from the Nursing Guidelines Manual, dated October 2010, showed the following information: -Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity; -Services may be provided on a varying schedule when a physician's order or physician documentation of a medical contraindication exists or when the resident needs services more frequently; -Resident preferences for time of day, type of bath, and frequency of bath should be honored to the extent possible; -Family members or social service staff may be called upon to assist when the resident refuses appropriate hygiene or grooming measure by nursing staff; -Nail care is part of grooming. 1. Review of Resident #76's face sheet (brief information sheet about the resident) showed the following information: -admission date of 06/24/23; -Diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness one side of the body) following cerebral infarction (stroke - a condition where blood flow to the brain is interrupted, causing brain tissue to die) affecting left non-dominant side, chronic kidney disease (stroke, a condition where blood flow to the brain is interrupted, causing brain tissue to die) with heart failure (chronic condition in which the heart doesn't pump blood as well as it should), and major depressive disorder. Review of the resident's care plan, last reviewed 02/14/25, showed the following: -Resident required assistance to complete daily activities safely; -Staff should assist resident with brushing teeth, assist with hair, and assist with shaving; -Staff should bathe per schedule, twice weekly per preference; -Staff should provide assistance to gather items for bathing and assist to bathing area as needed. Review of the resident's quarterly, Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/26/25, showed the following: -Moderate cognitively impairment; -Required substantial to maximal assistance with tub or shower transfer and lower body dressing; -Required partial to moderate assistance with shower or bathing and upper body dressing. Review of the resident's shower sheet schedule, untitled, for the time period of April 2025 and May 2025, showed on 04/16/25, staff documented the resident received a shower. No other showers or baths were documented for the resident. Review of the resident's nursing notes, dated April 2025 and May 2025, showed staff did not document any additional showers or shower refusals by the resident. During an interview on 05/13/25, at 9:32 A.M., the resident said that his/her last shower was over one week ago. He/she received showers less than once per week and would prefer a shower every day but would at least like to have a shower twice per week. 2. Review of Resident #92's face sheet (brief information sheet about the resident) showed the following information: -admission date of 10/17/24; -Diagnoses included chronic ulcer (open sores that take a long time to heal, often due to underlying health conditions or injuries) of right heel and midfoot with necrosis of bone (condition where bone tissue dies due to a lack of blood supply), acute osteomyelitis (bone infection that typically develops quickly, often within a few weeks) right ankle and foot, and repeated falls. Review of the resident's significant change in condition MDS, dated [DATE], showed the following: -Cognitively intact; -Required substantial to maximal assistance of staff for bathing; -Required supervision or touching assistance of staff to dress; -Required set up assistance of staff for personal hygiene. Review of the resident's care plan, last reviewed 05/13/25, showed the following: -Resident required assistance to complete daily activities of care safely; -Staff will assist with hair as needed; -Staff will assist with setting up supplies for brushing teeth; -Staff will bath per schedule; -Make bathing process pleasant by ensuring a non-hurried atmosphere; -Resident required two staff transfer with mechanical lift due to weight bearing restrictions with foot wound. Review of the resident's shower sheet schedule titled Shower/Bath List, dated April 2025 and May 2025, showed the following: -On 04/08/25, the resident received a shower; -On 04/17/25, the resident received a shower (nine days after the last documented shower); -On 05/06/25, the resident received a bed bath (19 days after the last documented shower; Review of the resident's nursing notes, dated April 2025 and May 2025, showed staff did not document any additional showers or shower refusals by the resident. During an interview on 05/13/25, at 10:06 A.M., the resident said that he/she received a shower about every two weeks, and he/she would prefer a shower at least twice per week. He/she felt dirty and worried about body odor when only showered twice per month. He/she was okay with a bed bath as well. 3. Review of Resident #29's face sheet showed the following information: -admission date of 08/22/18; -Diagnoses included borderline personality disorder (mental health condition making it difficult to manage emotions, control impulses and maintain stable relationships), anxiety disorder (feelings of worry, nervousness and uneasiness), chronic pain, and major depressive disorder (severe feelings of sadness). Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required supervision with showers; -Independent with dressing and personal care. Review of the resident's care plan, reviewed 03/20/25, showed the following: -Resident had urinary incontinence; -Required occasional staff assistance with adult daily activities; -Staff will assist with bathing twice per week preference. Review of the resident's shower sheet schedule, untitled, for the time period of April 2025 and May 2025, showed the following: -Staff documented the resident received a shower on 04/03/25; -Staff documented the resident received a shower on 04/14/25 (11 days after the prior shower); -Staff documented the resident received a shower on 04/28/25 (14 days after the prior shower); -Staff documented the resident received a shower on 05/01/25; -Staff documented the resident received a shower on 05/07/25 (six days after the prior shower); -Staff documented the resident received a shower on 05/12/25. (Staff did not document any other showers for the resident.) Review of the resident's nursing notes, dated April 2025 and May 2025, showed staff did not document any additional showers or shower refusals by the resident. During observations and interviews on 05/12/25, at 11:48 A.M. and 1:17 P.M., the resident was walking down the rehabilitation hall and said he/she hasn't had a shower in over a week and his/her hair was somewhat unkept. The resident said he/she received a shower on 05/07/25, and he/she was supposed to get two showers per week. He/she asks every other day for a shower and the staff say they don't have time. 4. Review of Resident #74's face sheet showed the following information: -admission date of 03/22/24; -Diagnoses included heart disease (condition that affects the blood vessels in the heart), spinal stenosis (pressure on the spinal cord and nerve roots), osteoarthritis (weakened bones), and pressure ulcer of the sacral (triangle shaped bone at base of spine) region. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required substantial to maximal assistance with showers; -Required partial to moderate assistance with personal hygiene and dressing. Review of the resident's care plan, last reviewed 03/03/25, showed the following: -Resident had urinary incontinence; -Resident required assistance to complete daily activities safely; -Staff should assist resident with oral care, hair care, and bathe per schedule. Review of the resident's shower sheet schedule, untitled, for the time period of April 2025 and May 2025, showed the following: -Staff documented the resident received a shower on 04/03/25, 04/09/25, and 04/14/25; -Staff did not document shower dates for the resident in May 2025. Review of the resident's nursing notes, dated April 2025 and May 2025, showed staff did not document any additional showers or shower refusals by the resident. During an interview on 05/12/25, at 3:56 P.M., the resident said he/she had not received a shower since 04/14/25. He/she felt dirty. He/she would be glad to have a bed bath. 5. During an interview on 05/15/25, at 1:58 P.M., Certified Nurse Aide (CNA) J said the facility had one shower aide and he/she was on light duty. They want the aides working the halls to do showers. Several residents complain about not getting showers regularly. During an interview on 05/15/25, at 2:15 PM., CNA N said the facility used to have four shower aides and now they have one. The shower aide tries to get as many showers done as possible and the other aides help. Some residents complain about not getting showers often enough. During an interview on 05/15/25, at 2:30 P.M., CNA K said they have two shower aides, the other one quit. They now want the floor aides to give residents showers and they do not have time. In the evenings he/she was responsible for an entire hall and that doesn't leave time to give showers. During an interview on 05/15/25, at 4:32 P.M. CNA L said the following: -He/she was the only shower aide, there used to be three; -If there were two shower aides that would probably be enough, as the floor aides try to help with showers; -He/she does the first four rooms of each hall on Monday and Thursday, the next four rooms on Tuesday and Friday and the remaining rooms on Wednesday and Saturday; -He/she tried to give each resident two showers per week. During an interview on 05/19/25, at 3:29 P.M., CNA F said residents should have a shower or bed bath two times per week. He/she was not sure who made the schedule. He/she would notify the shower aide if a resident requested a shower. During an interview on 05/19/25, at 12:43 P.M., Certified Medication Tech (CMT) H said they have one shower aide and there used to be three. The Director of Nursing (DON) wants the floor aides to do showers. The aides are trying to do this and are doing better on days, but the evening staff are not offering showers. The residents are supposed to be offered two showers per week and upon request. During an interview on 05/19/25, at 12:55 P.M., CMT I said floor aides were supposed to be doing showers. Everyone has complained of not getting showers at some point. During an interview on 05/19/25, at 3:45 P.M., CMT G said the shower aide had a schedule and residents were scheduled for two times per week. During an interview on 05/16/25, at 12:40 P.M., Licensed Practical Nurse (LPN) B said they have one aide doing showers. They recently changed things and the floor aides are helping with the showers. There have been a lot of residents complaining about not getting showers. The shower aide does as many as he/she can, but he/she is only one person and the aides help as much as possible. During an interview on 05/19/25, at 10:00 A.M., Registered Nurse (RN) E said residents should receive showers per their scheduled days and per resident preference. During an interview on 05/20/25, at 12:34 P.M., with the DON and Corporate Compliance, the DON said there was a shower schedule that was on a rotation based on the resident room number. She said some residents preferred three showers per week. The residents were scheduled for twice per week unless they requested more and if time allowed. The residents should not have to wait 2 to 3 weeks for bed bath or showers. The aides should be documenting whether a resident was provided or refused a shower. The aide should tell the nurses if a resident refused and the nurses should be documenting that as well. During an interview on 05/20/25, at 2:07 P.M., the Administrator said residents should be offered and provided showers a minimum of twice per week. They can have more if preferred. Staff should be documenting in the electronic health record. Staff should be documenting if a resident refused and also talk to the nurse, so the nurse can see if they can get the resident to take the bath.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide a comfortable and homelike environment by failing to ensure the facility was in good repair, when staff failed to maintain a window screen for two residents (Resident #76 & #90), when staff failed to repair wall damage in one resident's (Resident #5) room, and when staff failed to maintain a clean shower on 200 hall. The facility census was 105. Review showed the facility did not provide a policy related to environment repairs. 1. Review of Resident #76's face sheet (a brief information sheet about the resident) showed an admission date of 06/24/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 03/26/25, showed the resident had moderate cognitive impairment. Review of Resident #90's face sheet showed an admission date of 09/27/24. Review of the resident's quarterly MDS, dated [DATE], showed the resident had severe cognitive impairment. During observation and interview on 05/12/25, at 10:15 A.M., Resident #76 and Resident #90 said they were unable to open their room window as there was not a screen on the window. They would like to open window at times to get fresh air when it was nice weather outside, but since there was not a screen flying pests would get into the room. They had told maintenance staff about the screen and were told he/she did not know when it could be replaced. The window had no screen on the exterior of the window. During an interview on 05/19/25, at 3:29 P.M., Certified Nurse Aide (CNA) F said if there were any environment concerns in the building or a resident told him/her of a problem he/she would report to maintenance through the computer system, in person, or by leaving a note on the maintenance door. He/she was not aware of any windows that residents wanted to open without a screen. During an interview on 05/19/25, at 3:45 P.M., Certified Medication Tech (CMT) G said he/she would notify maintenance or administration staff if he/she was aware of any needed repairs in resident rooms or other areas of the facility. During an interview on 05/19/25, at 10:00 A.M., Registered Nurse (RN) E said he/she would notify the maintenance department if he/she was aware of any damage to the building or needed repairs for resident rooms. He/she had not reported any needed repairs. During an interview on 05/19/25, at 4:10 P.M., the Maintenance Director said there were about 30 missing screens for the whole building. He/she was aware of the residents' room being without a screen. He/she said the previous maintenance supervisor had sent an email to corporate but there had not been a response. He/she had contacted the glass company and they do not work on screens. During an interview on 05/20/25, at 11:00 A.M., the Director of Environment said if there was any environment concerns, such as missing/damaged screens, staff should notify maintenance. During an interview on 05/20/25, at 12:34 P.M., with the Director of Nursing (DON) and Corporate Compliance, the DON said staff should notify maintenance through TELLS computer system or in person of any facility repairs or work to be done. The maintenance staff should then fix the problems. The maintenance staff checked the computer system multiple times per day for work orders placed. During an interview on 05/20/25, at 2:07 P.M., Administrator said staff should enter repair requests into the TELLS system. Any staff can log into the computer and enter the repair requests. Staff should notify maintenance of outside repairs including window screens. 2. Review of Resident #5's face sheet showed an admission date of 05/15/24. Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment. Observation on 05/12/25, at 11:24 A.M., showed the resident was lying in his/her bed. At the head of his/her bed was a hole in the wall that appeared to be about 1 and half inches horizontally and about 2 inches vertically. During an interview on 05/19/25, at 2:25 P.M., Licensed Practical Nurse (LPN) D said anytime he/she finds holes in a resident's walls, he/she reports it to maintenance and environmental services director. He/she has not been notified of any concerns. During an interview on 05/20/25, at 11:00 A.M., the Director of Environment said if there was any environment concerns, such as holes in the wall, staff should notify maintenance. He/she was not aware of any environment concerns at the time. During an interview on 05/20/25, at approximately 12:44 P.M., the DON and Regional Quality Assurance Nurse, said staff should notify maintenance if there are holes in the walls. During an interview on 05/20/25, at 2:07 P.M., the Administrator said maintenance staff staff should enter repairs into the TELLS system. Any staff can log in and enter the needs. 3. Observation on 05/19/25, at 10:40 A.M., of the 200 hall shower room showed to the left of the shower room, where the shower chair was located, there is a part that protrudes from the wall about a foot over and was about 2 feet tall. In between the tiles and in the corner there was grayish colored grime. The floors around the walls, one to two feet out, had gray dirty substance. During an interview on 05/19/25, at 2:25 P.M., LPN D said housekeeping is responsible for cleaning the shower rooms and the aides should also be cleaning it after giving resident's showers. During an interview on 05/20/25, at 11:00 A.M., the Director of Environment said that the housekeeping staff clean shower rooms daily and nursing staff should be disinfecting between each resident. If an area was not coming clean or required deep cleaning the housekeeping staff took care of that. If the area would not come clean, was stained, or broken staff should notify the maintenance staff. During an interview on 05/20/25, at approximately 12:44 P.M., the DON and Regional Quality Assurance Nurse said staff were to notify housekeeping when showers need cleaning and anyone can notify maintenance. During an interview on 05/20/25, at 2:07 P.M., the Administrator said shower rooms should be maintained and cleaned every day and between every resident. If something cannot be cleaned, it should be replaced or gotten rid of. Housekeeping and maintenance staff were responsible.

Based on record review and interview, the facility failed to ensure that staff notified the resident and/or the resident's representative in writing of a transfer to a hospital and failed to provide the bed hold policy at the time of transfer for six residents (Residents #41, #61, #78, #1, #306, and #25). The facility census was 105. Review of the facility's policy entitled Transfer, Discharge and Therapeutic Leaves (including Against Medical Advice (AMA)), dated 06/26/19, showed the following: -The resident has the right to refuse involuntary transfer out of or discharge from the facility under certain circumstances; -Transfer meant the moving of a resident from the facility to another legally responsible institutional setting. Discharge meant the moving of a resident to a non-institutional setting when the releasing facility ceases to be responsible for the resident; -According to federal regulations, the facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; -Emergency transfers should occur only for medical reasons, or for the immediate safety and welfare of a resident or other residents. Emergency transfer procedures should include the following obtain physicians' order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis; contact an ambulance service and provider hospital for transportation and admission arrangements; complete and send with the resident a Transfer Form which documents current diagnosis, reasons for transfer, date, time, physician, current medications, treatments, functional status, any special care needs, and care plan goals; and a copy of any advance directive, Durable Power of Attorney, Do Not Resuscitate (DNR) or Withholding or Withdrawing of Life-Sustaining Treatment forms should be sent with the resident. -The original copies of the transfer form and advance directives accompany the resident. Copies are retained in the medical record; -Document information regarding the transfer in the medical record; -A copy of resident bed hold and admission policies/transfer to hospital notice should be provided upon transfer by assigned nurse to resident and/or representative of resident. 1. Review of Resident #41's face sheet (gives basic profile information at a glance) showed an admission date of 07/11/23. Review of the resident's nurse progress notes showed the following: -On 04/11/25, staff documented the resident had weeping skin, lungs sounded coarse, and was currently on an antibiotic for pneumonia. The resident's family member was present in the facility and agreed to have the resident sent to the emergency department. -On 04/17/25, staff documented the resident returned to the facility with diagnoses of pneumonia, altered mental status, and pericardial effusion (fluid buildup in the membrane surrounding the heart). Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice or Bed Hold Policy given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 04/11/25. 2. Review of Resident #61's face sheet showed an admission date of 08/26/23. Review of the resident's nurses' progress notes showed the following: -On 02/25/25, staff documented the resident had flu-like symptoms, needed supplemental oxygen, and had a low blood pressure. Staff received orders for a urinalysis and intravenous (IV) fluids to be administered. Staff were unsuccessful with two attempts to start IV for fluid and two attempts to obtain specimen for urinalysis. Staff obtained new order to send resident to the hospital. Staff noted a Bed Hold Form sent with the resident and staff called spouse to inform; -On 03/08/25, staff documented the resident returned to the facility via ambulance. Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 02/25/25. 3. Review of Resident #78's face sheet showed an admission date of 11/24/23. Review of the resident's nurses' progress notes showed the following: -On 02/06/25, staff documented the resident was sent out to the hospital related to low pulse and reduced level of consciousness. Resident returned to the facility after hospital visit. Resident was seen for confusion and hallucinations. The hospital completed labs, CT (computed tomography) scan, chest x-ray, and physical examination. Recommended follow-up with primary care physician with no order changes. Review of the resident's medical records showed staff not have documentation regarding written transfer notice or Bed Hold Policy given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 02/06/25. Review of the resident's nurses' progress notes showed the following: -On 02/07/25, staff documented the resident's oxygen saturation rate was very low and resident became erratic. Staff called 911 and resident was sent out to the hospital (two copies of the face sheet and CCD were went out with the resident); -On 02/08/25, staff documented resident returned to the facility and staff clarified orders with house physician. Review of the resident's medical records showed staff did not have documentation regarding written transfer notice or Bed Hold Policy given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 02/07/25. Review of the resident's nurses' progress notes showed the following: -On 03/19/25, staff documented the resident fell in his/her room with no injuries noted on assessment. Staff notified all parties; -On 03/20/25, staff documented the resident was found lying next to his/her bed and was lethargic with hematoma (swollen bruise) on right rib moving into chest. Resident on monitoring noted to have blood pressure decreasing. Staff sent resident to the hospital for evaluation and treatment. Staff notified physician via fax and resident's responsible party via phone; -On 03/27/25, staff documented the resident returned to the facility post pacemaker placement with vital signs within normal limits. Review of the resident's medical records showed staff did not have documentation regarding written transfer notice or Bed Hold Policy given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 03/20/25. 4. Review of Resident #1's face sheet showed an admission date of 11/26/24. Review of the resident's census information in the medical records showed the following: -On 01/14/25, resident discharged with return expected; -On 01/15/25, resident was returned and was re-admitted to the facility. Review of the resident's progress notes showed the following: -On 01/15/25, at 6:01 A.M., the resident was noted with abnormal lab results. Staff notified physician and gave an order to send resident to hospital for evaluation and treatment. The resident was sent at 10:00 P.M. on 01/14/25. Staff called family but unsuccessful in reaching them. Staff notified management; -On 01/15/25, at 5:38 P.M., the resident came back to facility via private vehicle from hospital at 4:45 P.M. Staff notified physician. Review of the resident's medical records showed staff did not have documentation regarding a written transfer notice or Bed Hold Policy given and/or mailed to the resident and/or resident's representative pertaining to a hospital transfer on 01/14/25. 5. Review of Resident #306's face sheet showed an admission date of 07/29/24. Review of the resident's nurse progress notes showed the following: -On 04/28/25, at 10:20 P.M., the resident had an unwitnessed fall, resulting in a head wound with active bleeding and a hematoma formation at back of the head. Resident complaining of head, neck and upper back pain. Staff sent resident to the emergency room; -On 05/01/25, at 5:40 P.M., the resident returned with family from the hospital to the facility. Review of the resident's record showed staff did not have documentation indicating the family was notified in writing of the resident's transfer or bed hold. 6. Review of Resident #25's face sheet showed an admission date of 04/27/23. Review of the resident's nurse progress notes showed the following: -On 05/08/25, at 6:19 A.M., the resident complained of abdominal pain and cramping. The resident asked to be sent to the emergency room for evaluation and treatment. Resident picked up by ambulance at 9:00 P.M.; -On 05/11/25, at 11:11 A.M., resident returned from hospital at 11:00 A.M. Review of the resident's record showed staff did not have documentation indicating the family was notified in writing of the resident's transfer or bed hold. 7. During an interview on 05/15/25, at 3:50 P.M., the Director of Nursing (DON) said when a resident was sent out to the hospital, the nurse completes a Bed Hold Policy form. The resident signs the form if able, and a copy is mailed out to the responsible party by the business office. The nurse gives the resident and a family member a verbal explanation of the transfer, but the facility does not mail out a transfer letter. During an interview on 05/15/25, at 4:04 P.M., the Regional Nurse Consultant (RNC) showed the surveyors the Bed Hold Policy form and Transition of Care/Discharge Summary that are sent with the resident to the hospital. The RNC said a phone call is made to the resident's family notifying them of the need for the transfer. The RNC was not aware of the regulatory requirement to give the resident and/or responsible party a written transfer notice along with the Bed Hold Policy, which is mailed out by the business office. During an interview on 05/15/25 at 4:41 P.M., Licensed Practical Nurse (LPN) A said he/she sends a face sheet, orders, and code status with the ambulance when the resident is sent to the hospital. He/she doesn't give anything to the resident. He/she calls the representative, but doesn't mail anything to them. During an interview on 05/16/25, at 10:47 A.M., the RNC said the facility did not have evidence of written transfer letters or bed hold notices given pertaining to Residents #41, #61, #78, #1, #306, and #25. During an interview on 05/16/25, at 12:40 P.M., LPN B said they fill out a hospital transfer form along with the face sheet, order, and code status that's given to the paramedics for transfers. He/she does not give anything to the resident or mail it to the resident's representative. During an interview on 05/19/25, at 10:00 A.M., Registered Nurse (RN) E said that nursing staff should document the appropriate information in the medical record any time a resident has been transferred to the hospital. The bed hold notice should be sent with the resident. He/she did not know of a letter that was to be sent to the family related to hospital transfer. During an interview on 05/19/25, at 3:10 P.M., LPN D said the nurse prints out the resident's face sheet, Continuity of Care Document (CCD), and hospital transfer form, sets up an observation event in EMR, attaches a copy of the most recent vital signs, and nurse notes. The nurse fills in the Bed Hold form and has the resident sign it, if able. The form is sent with them to hospital. They should keep a copy of the form for the chart. LPN D did not know if a copy of the form or any other transfer letter was mailed out or given to the responsible party. During an interview on 05/19/25, at 3:25 P.M., RN M said when sending a resident out to the hospital the nurse should print out an ambulance transfer form, the Bed Hold policy (have the resident sign if able), face sheet, physician order sheet, and CCD. Staff should place a copy of all information in the front of the hard chart and document the resident's condition and transfer information in nursing progress notes. During an interview on 05/20/25, at 12:34 P.M., the DON said she expected staff to document in progress notes when a resident was sent to hospital, and the staff should send a bed hold notice with the resident. The staff should fill in information as to where the resident was being transferred and the reason on the letter, along with the bed hold notice. The written transfer notice and bed hold form should be signed by the resident if they are able to sign; otherwise staff should document that on the copy sent with the resident and make a copy to put in the resident's chart. On the next business day the information should be sent to the responsible party. The DON was not aware of the required information to be included on the transfer letter. The charge nurse will be sending it out at time with resident and Social services will send the letter by mail the next business day to the responsible party. During an interview on 05/20/25, at 2:07 P.M., Administrator said staff should send a bed hold policy with residents that transfer to the hospital and notify the family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure three residents (Residents #53, #92, and #25) and/or their representative were invited to participate in the resident's quarterly care plan meeting. The facility census was 105. Review of facility policy titled Person Centered Care Plans, dated August 2018, showed the following: -Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident; -The interdisciplinary plan of care committee may consist of nursing personnel having knowledge of the resident; Activities Director; Social Services Director; Dietary Manager/Registered Dietician or other members of Food & Nutrition Service; licensed therapists; attending physician; the resident; the resident family members and/or other representatives; -The Registered Nurse, or designee, should provide a list of the resident names, dates, and times for care plan meetings, two weeks in advance, to other team members. This list also includes information as to the type of care plan review for each resident: admission, quarterly, annual or significant change in status reviews; -The Social Service Director (SSD), or designee, should inform the resident and families of the scheduled meeting, by mailing Notice of Scheduled Plan of Care Conference to family members or legal representatives, as meeting notice. Family members and legal representatives should only be invited to attend, when permitted by the resident, or when the party is legally responsible for making health care decisions for the resident; -Family participation should be recorded in the medical record; -The resident participation should be recorded in the medical record; -When the family members or legal representatives are unable to attend the meeting, a review of the plan should be conducted by the care plan designee; -Contact with the family should be made by phone; -This communication should be recorded in the electronic medical record and entered as a telephone participant. The family member's comments may be documented on the Notice of Scheduled Plan of Care Conference. 1. Review of Resident #53's face sheet (a brief information sheet about the resident), showed an admission date of 05/11/21. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 04/07/25, showed the resident was cognitively intact. During an interview on 05/13/25, at 2:25 P.M., the resident said she asked for a care plan meeting with no response from staff. Review of the resident's medical record showed staff did not document regarding a care plan meeting invitation. Review of the resident's medical record showed a quarterly care plan meeting held on 04/22/25. The resident and/or the resident's representative were not listed as attendees. 2. Review of Resident #92's face sheet showed an admission date of 10/17/24. Review of the resident's quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment. During an interview on 05/13/25, at 10:15 A.M., the resident said he/she had not been asked to a care plan meeting, but would like to be included in that meeting. Review of the resident's medical record showed staff did not document regarding a care plan meeting invitation. Review of the resident's medical record showed a quarterly care plan meeting held on 04/22/25. The resident and/or the resident's representative were not listed as attendees. showed the following: 3. Review of Resident #25's face sheet showed an admission date of 04/27/23. Review of the resident's discharge assessment MDS, dated [DATE], showed the resident had moderately impaired cognition. During an interview on 05/13/25, at 9:40 A.M., the resident said he/she had never attended a care plan meeting and didn't recall being invited to one. Review of the resident's medical record showed staff did not document regarding a care plan meeting invitation. Review of the resident's medical record showed staff did not document when the last care plan meeting was held. 4. During an interview on 05/15/25, at 9:31 A.M., the MDS Coordinator said they hold care plan meeting quarterly or when there's a significant change. The resident, residents' family, or representative, and hospice are notified. The family receives a letter with the date and time and this is documented in the electronic record. The resident if verbally invited. All residents have quarterly care plan meetings. During interviews on 05/15/25, at 2:45 P.M., and on 05/16/25, at 11:00 A.M., the SSD said he/she mailed a care plan meeting invitation to the power of attorney, emergency contact family, and hospice. He/she mailed a letter to the family and he/she called hospice and verbally told the resident. The form is completed in the electronic record and he/she prints it off and mails it. He/she doesn't log anything or make any notes on the people he/she calls. Sometimes he/she forgets to mail out a invitation but he/she calls instead. He/she does not make a note in the resident's record when he/she called people to invite them to the care plan meeting. He/she did not make a note when he/she verbally invites the resident. During an interview on 05/20/25, at 12:34 P.M., the Director of Nursing (DON) said care plan meetings are generally held by social services and the MDS Coordinator gives the social worker a calendar of upcoming MDS assessments to help keep coordinated. The residents were invited directly by the social worker. The social worker should be sure any mailed item was received by placing a phone call to ensure aware of the meeting. The social worker should make notes of invitations in the chart. During an interview on 05/20/25, at 2:07 P.M., the Administrator said care plan meetings should have the resident and/or any responsible party invited. Care plan meetings should be attended by MDS, nurses, Social Services, and therapy department. The family should be contacted by letter and phone call. Staff should call one week from meeting to confirm attendance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents who were unable to carry out their own activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene when staff did not perform or address toenail care for three residents (Residents #84, #10, and #64) of eight residents reviewed for nail care. The facility census was 105. Review of the facility's policy entitled Hygiene and Grooming, dated 10/01/10, showed the following: -Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self-worth and dignity; -Guidelines for provision of hygiene and grooming services include shower, tub or complete bed bath, as needed; -Family members or social service staff may be called upon to assist when the resident refused appropriate hygiene/grooming measures by nursing staff; -Nail care is a part of grooming. 1. Review of Resident #84's face sheet showed the following information: -readmission date of 05/02/24; -Diagnoses included hemiplegia (muscle weakness or paralysis) affecting right dominant side, traumatic brain injury, presence of feeding tube, cognitive communication deficit, restlessness and agitation, history of blood clots, anxiety disorder, and insomnia. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 03/03/25, showed the following information: -Severely impaired cognition; -Rejection of care behavior not exhibited; -Dependent on others for shower/bathing and personal hygiene. Review of the resident's care plan, last updated 05/01/25, showed the following: -Required assistance to complete daily activities of care safely; -Provide nail care as needed. During an interview on 05/14/25, at 12:10 P.M., the resident's family member said the resident's toenails were in bad condition, but they were better because the family member had been working on them. He/she said staff had not corrected the condition. Observation on 05/15/25, at 9:36 A.M., showed the resident rested in bed and his/her feet were exposed. The resident's toenails appeared discolored (yellow, brown), very thick, and long. Some nails were as long as one inch and curved under. During an interview on 05/15/25, at 2:10 P.M., the Social Services Director (SSD) said the podiatrist comes to the facility every six to eight weeks. The resident was not seen previously, but was on the list to be seen with the next visit During an observation and interview on 05/19/25, at 2:55 P.M., the resident's toenails on both feet appeared discolored (yellow, brown), very thick, and long. Several nails curved under. Certified Nursing Assistant (CNA) F said the resident needed nail care. The CNA said the aides can provide residents' nail care unless the resident is diabetic or the nails are too thick or long. If the aide cannot perform nail care, they should report the status and need to the nurse. The nurse will do the nail care or request the resident be added to the list to be seen by the podiatrist on the next visit date. CNA F said the resident kicks, so most aides will not attempt toenail care. The nurse usually does the care. During an interview on 05/19/25, at 3:10 P.M., Licensed Practical Nurse (LPN) D said the resident had just changed rooms, back onto LPN D's hall. The LPN said he/she put the resident on the podiatrist list for the next visit. LPN D said the podiatrist comes to the facility every six to eight weeks and was just at the facility within the last two weeks. 2. Review of Resident #10's face sheet a showed the following information: -admission date of 01/18/18; -Diagnoses included Alzheimer's disease (gradual loss of memory), muscle weakness, dementia with other behavioral disturbances (causes problems with thinking), chronic pain, and cognitive communication deficit (impairment in the ability to receive, send, process and comprehend information). Review of the resident's quarterly assessment MDS, dated [DATE], , showed the following information: -Severely impaired cognition; -Rejection of care behavior not exhibited; -Dependent on others for shower/bathing and personal hygiene. Review of the resident's care plan, last updated 04/09/25, showed the following: -Required assistance to complete daily activities of care safely; -Provide nail care as needed. Review of the resident's skin assessments, dated May 2025, showed LPN A completed a skin assessment for the resident on 05/13/25 with no concerns noted. Observation on 05/12/25, at 11:26 A.M., showed the resident lying in bed. Both feet were visible. On the right foot, the big toenail was grown to the right, about ¾ of an inch. All the other toenails had grown over the ends of the toes. On the left foot, the big toenail was grown to the left about ¾ of an inch. The rest of the toenails [NAME] grown over the ends of each toe. During an interview on 05/15/25, at 11:05 A.M., the SSD said the podiatrist comes to the facility every third month. The podiatrist was in the building in February and May. The residents are put on the list by the nurse or the aide telling the SSD they need to see the podiatrist. He/she thought the resident was not on the list as receiving services for February or May. During an interview on 05/15/25, at 12:40 P.M., LPN B said aides do not trim the resident's nails. The social worker sets up appointments with the podiatrist that comes to the facility. He/she isn't sure how often the podiatrist comes to the facility. The resident's toenails were pretty bad. They've done his/her fingernails. The resident will only let certain people cut his/her nails and it has to be someone the resident likes. The resident does refuse cares sometimes. When he/she sees that a resident's toenails need to be cut, or are in a condition like the resident's he/she puts a note into the computer. He/she doesn't remember if he/she has told anyone about the resident's toenails. During an interview on 05/15/25, at 1:58 P.M., CNA J said the aides trim the resident's toenails unless they're diabetic, in which case the nurses do them. He/she has seen the resident's toenails and thought the nurses knew about them being long. He/she had not told a nurse about the resident's toenails being long. The resident does refuse showers. The aides should be charting if the resident is refusing showers or refusing to have the toenails trimmed. During an interview on 05/15/25, at 2:30 P.M., CNA K said he/she does know the resident's toenails are long and thick. He/she has told the nurses about the resident's nails, and he/she doesn't know if anything has been done about it. During an interview on 05/15/25, at 4:32 P.M., CNA L said the he/she was the shower aide. He/she does skin assessments and trims the resident's toenails and fingernails. If the resident is diabetic, he/she lets the nurse know and they trim the resident's nails. He/she has offered the resident a shower and he/she refuses. When the residents refuse, he/she tells the nurse. He/she has not seen the resident's toenails. During an interview on 05/15/25, at 4:41 P.M., LPN A said the shower aide trims the resident's nails unless they're diabetic. The nurse's trims the resident's nails if they have diabetes. Some resident's see a podiatrist that comes to the facility if there toenails are yellow, thick or have other issues. He/she didn't know if the resident saw the podiatrist. He/she has not seen the resident's toenails nor has he/she trimmed the resident's toenails. During an interview on 05/19/25, at 12:55 P.M., Certified Medication Technician (CMT) G said anyone can trim the resident's toenails unless the resident is diabetic or has thick toenails. In those cases the nurse or podiatrist do them. He/she has seen the resident's toenails and they're not good. The Activity Director did try to trim the resident's toenails, but he/she isn't sure how that went. 3. Review of Resident #64's face sheet showed the following information: -admission date of 08/26/24; -Diagnoses included osteoarthritis (joint disease causing breakdown of cartilage), depression (feelings of sadness), and diabetes (body doesn't produce enough insulin). Review of the resident's care plan, updated 02/26/25, showed the resident required assistance with ADL functions due to related medical issues and staff provided nail care as needed. Review of the resident's quarterly assessment MDS, dated [DATE], showed the following information: -No cognitive impairment; -Rejection of care behavior not exhibited; -Partial to moderate assistance with showers. Observations and interviews on 05/14/25, at 8:47 A.M., and on 05/15/25, at 10:55 A.M., showed the resident said his/her toenails needed to be cut. The podiatrist was at the facility the other day and the SSD was supposed to put him/her on the list to see the podiatrist and he/she was not on the list. The staff does cut his/her toenails in the shower sometimes, but they haven't in a while. He/she has thick, yellow toenails and athlete's foot. Observation of the resident's toenails showed them to be at least ¼ inch over the skin. The left pinkie toenail was long and part of it had broken off. There was some redness on the big toe on the left foot. The resident said he/she was having pain. During an interview on 05/15/25, at 11:05 A.M., the SSD said the podiatrist comes to the facility every third month. The podiatrist was in the building in February and May. The residents are put on the list by the nurse or the aide telling the SSD they need to see the podiatrist. If the resident doesn't have medical issues, the aides can cut the toenails. He/she believed the resident told him/her to put the resident on the list after the podiatrist left in May. He/she provided the list and the resident was not on the list as having been seen. During an interview on 05/15/25, at 4:41 P.M., LPN A said the shower aide trims the resident's nails unless they're diabetic. The nurse's trims the resident's nails if they have diabetes. Some resident's see a podiatrist that comes to the facility if there toenails are yellow, thick or have other issues. He/she doesn't know if the resident has long toenails since the resident has not complained to him/her. During an interview on 05/15/25, at 4:32 P.M., CNA L said the he/she was the shower aide. He/she does skin assessments and trims the resident's toenails and fingernails. If the resident is diabetic, he/she lets the nurse know and they trim the resident's nails. The resident is independent, but he/she will trim the resident's nails tomorrow. During an interview on 05/16/25, at 11:30 A.M., the resident said he/she got a shower on 05/15/25 and they did not trim his/her toenails. 4. During an interview on 05/15/25, at 2:15 P.M., CNA N said the aide doing the resident's shower is responsible for trimming the residents' toenails. If the resident is diabetic, the nurse will trim the toenails. If the resident has thick, yellow toenails the nurse's will put them on the list to be seen by the podiatrist. During an interview on 05/19/25, at 12:41 P.M., Certified Medication Tech (CMT) H said any staff can trim the resident's toenails. If they're diabetic or thick and hard, the nurse or podiatrist would do it. If they need to see the podiatrist, the nurse's put the resident on the list. It's not appropriate for the toenails to grow over the skin or around the toes. During an interview on 05/19/25, at 2:35 P.M., LPN D said the podiatrist trims the thick toenails. The nurses trim the residents' toenails that have diabetes. The nurses put the resident on the list to see the podiatrist. Any staff can trim other residents' toenails. It would not be appropriate for the toenails to be grown over the resident's skin. During an interview on 05/20/25, at 12:34 P.M., the Director of Nursing (DON) said the aides are responsible for doing toenail care for residents who are not diabetic. If the resident is diabetic, the wound care nurse or other floor nurse should do the nail care. The nurses can place the resident on the list for the podiatrist, who comes to the facility every six to eight weeks. A resident can be seen and billed every 60 days. During an interview on 05/20/25, at 2:07 P.M., the Administrator said the nursing staff was responsible for doing residents' nail care. If the staff were unable to do the toenail care, they should put the resident on the podiatrist' list for the next in-house visit.

Based on observation, interview, and record review, the facility failed to ensure an environment as free from possible accident hazards when staff failed to complete an assessment for, failed to monitor, and failed to care plan smokeless tobacco use for one resident (Resident #76). The facility census was 105. Review showed the facility did not provide a smokeless tobacco policy. 1. Review of Resident #76's face sheet (a brief information sheet about the resident) showed the following information: -admission date of 07/01/19; -Diagnosis included hemiplegia (paralysis on one side of the body) and hemiparalysis (weakness on one side of the body) following cerebral infarction (stroke, a condition where blood flow to the brain is interrupted, causing brain tissue to die) affecting left non-dominant side, memory deficit following cerebral infarction, anxiety disorder, and nicotine dependence. Review of the resident's care plan, updated 03/26/25, showed the following: -Resident had stroke resulting in left sided weakness in March 2023; -Staff should review activity of daily living (ADL) functioning as needed; -Assist with mobility needs and ADL's; -Staff should observe for change in mental function, speech, or motor function as needed. (Staff did not care plan related to use of smokeless tobacco.) During interview and observation on 05/13/25, at 9:38 A.M., the resident was seated in a wheelchair in his/her room with bedside table containing two cans of chew (tobacco) and a foam cup with used tobacco chew present. The resident said he/she used chew daily in his/her room. During observation on 05/15/25, at 12:42 P.M., the resident was in his/her room with two cans of tobacco chew and foam cup on bedside table. During observation on 05/19/25, at 9:50 A.M., the resident was in his/her wheelchair with his/her eyes closed. Three cans of tobacco chew and a foam cup for used chew was on the bedside table. Review of the resident's medical record showed no tobacco assessment or monitoring to assure resident safety to use the smokeless tobacco. During an interview on 05/19/25, at 10:00 A.M., the Registered Nurse (RN) E said residents that smoke or chew tobacco should have a tobacco assessment completed by facility staff. Chewing tobacco could be a choking hazard and he/she was unsure of facility policy for use of chew. Tobacco use should be care planned for residents that smoke or chew tobacco. During an interview on 05/19/25, at 3:29 P.M., Certified Nurse Aide (CNA) F said that he/she checked with new residents and if a smoker he/she would pass that information on during shift report. He/she said that generally a resident that smokes will tell staff when it was time for smoke break. If a resident had tobacco chew they could go outside or stay in their room. He/she did not know if the nurses complete an assessment for smoking or tobacco chew. During an interview on 05/20/25, at 12:34 P.M., the Director of Nursing (DON) said residents should have safe smoking assessments if they use any tobacco products. The facility did not have a smokeless tobacco policy. The resident should have tobacco use in their care plan. During an interview on 05/20/25, at 2:07 P.M., the Administrator said that residents should have tobacco use assessments and should be care planned for use of tobacco products.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, when staff did not obtain clarified orders for the use of supplemental oxygen for three residents (Residents #34, #65, and #41). The facility census was 105. Review of the facility's policy entitled Oxygen Administration, dated date, showed the following: -Purpose was to administer high purity oxygen for the treatment of certain diseases or conditions; -Oxygen should be administered under orders of the attending physician, except in the case of a emergency. In an emergency, oxygen may be administered without physician's order; however, the order should be obtained immediately after the crisis is under control; -Obtain physician's orders for the rate of flow and route of administration of oxygen (i.e., by tank, concentrator, nasal cannula (tubing), mask, etc.); -Explain the procedure to the resident. Assemble the oxygen unit and flow meter. Fill the humidifier container with distilled water and attach to oxygen unit. Attach the oxygen delivery device ordered by the physician to the oxygen mask/cannula and place the oxygen mask/cannula on the resident. Check oxygen flow meter for correct liter flow. Review of the facility's Medical Director's Standing Orders showed the following: -An standing order for dyspnea (difficulty breathing)/low oxygen blood saturation. If the oxygen leave is greater than 90%, apply oxygen at two liters per minute (L/min) via nasal cannula. Call physician if oxygen saturation drop has occurred and oxygen has been applied. A standing order for Duoneb MMTX (nebulized breathing treatment) three times per day x 5 days, then every 4 hours as needed. 1. Review of Resident #34's face sheet (gives basic profile information at a glance) showed the following: -admission date of 03/13/25; -Diagnoses included morbid obesity with alveolar hypoventilation (breathing disorder), chronic respiratory failure with low blood oxygen saturation, chronic obstructive pulmonary disease (COPD - breathing disorder), asthma (breathing disorder), and dependence on supplemental oxygen. Review of the resident's admission Minimum Data Set (MDS - a federally mandated comprehensive assessment tool completed by facility staff), dated 03/20/25, showed the following: -Cognitively intact; -Oxygen in use while a resident. Review of the resident's May 2025 Physician Order Sheet (POS) showed the following: -An standing order, dated 03/13/25, for oxygen per nasal cannula to maintain oxygen level less than 90%; -An order, dated 03/13/25, to replace oxygen tubing weekly, every Sunday on evening shift. The order was discontinued on 04/23/25. (Staff did not document physician orders for the current use of supplemental oxygen.) Review of the resident's care plan, last updated 03/27/25, showed the following: -Resident received oxygen therapy; -Administer oxygen therapy as ordered; -Change tubing per protocol; -Ensure that supply is available at all times' -Observe for changes that may indicate worsening respiratory status, notify provider of change, and provide with humidification. Observation on 05/12/25, at 12:40 P. M., showed the resident rested in bed. He/she used supplemental oxygen via nasal cannula at 2.5 L/PM provided through an oxygen concentrator. The humidification bottle (bubbler) was empty. The resident said he/she always used the oxygen and staff changed the tubing at least every week. Observation on 05/16/25, at 8:20 A.M., showed the resident resting in bed. Supplemental oxygen was used via nasal cannula at 2.5 L/PM and the bubbler was empty. During an interview on 05/19/25, at 3:10 P.M., Licensed Practical Nurse (LPN) D said the nurse should clarify any oxygen order that isn't documented per normal usage/orders. Upon review of the resident's POS, LPN D said the order wasn't right. Oxygen should be maintained greater than 90%, not less than as was documented in the order. There was was no indicated flow rate. 2. Review of Resident #65's face sheet showed the following: -admission date of 03/12/25; -Diagnoses included COPD, chronic respiratory failure with hypoxia (low blood oxygen level), high blood pressure affecting the lungs and heart, and dependence on supplemental oxygen. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognition intact; -Oxygen in use while a resident. Review of the resident's care plan, updated 04/30/25, showed the following: -Receiving oxygen therapy; -Head of bed elevated to facilitate breathing; -Administer oxygen therapy as ordered; -Change tubing per protocol, ensure that supply is available at all times, observe for changes in symptoms that may indicate worsening respiratory status, notify provider of change, and provide with humidification. Review of the resident's POS, dated 05/20/25, showed staff did not document orders pertaining to the use of supplemental oxygen. Observation on 05/12/25, at 12:42 P.M., showed the resident rested in bed. He/she used supplemental oxygen via nasal cannula at 3.5 L/PM. Observation and interview on 05/20/25, at 4:20 P.M., showed the resident rested in bed. Supplemental oxygen was in use via nasal cannula at 3.5 L/PM. The bubbler was empty. During the observation, the resident told the surveyor he/she needed the oxygen all the time and the flow rate should be set at 3.5 L/PM. He/she did not know if there was supposed to be water in the bubbler bottle. 3. Review of Resident #41's face sheet showed the following: -admission date of 07/11/23; -Diagnoses included pleural effusion (fluid buildup between the tissues that line the lungs and chest), pneumonia, emphysema, and asthma. Review of the resident's care plan, last updated 05/16/25, showed the following information: -alteration in cardiac function due to chronic congestive heart failure; monitor/report dizziness, evidence of circulatory problem, or shortness of breath, respiratory changes, and signs/symptoms of fluid overload (abnormal lung sounds, congestion, swelling). Review of the resident's annual (MDS), dated [DATE], showed the following information: -Mild cognitive impairment; -Supplemental oxygen utilized intermittently. Observation on 05/12/25, at 12:51 P.M., showed the resident resting in bed. He/she was using supplemental oxygen via nasal cannula. The flow meter indicated 2 L/PM. The resident's family member said the resident used the oxygen all the time. Observation on 05/13/25, at 12:45 P.M., showed the resident rested in bed. Supplemental oxygen was in use at 2 L/PM via nasal cannula. The cannula tubing was outside of his/her nostrils, but the resident said that was okay because it was hurting his/her nose. Review made on 05/13/25, at 1:33 P.M., of the resident's May 2025 POS showed staff did not have orders for the use of supplemental oxygen. Review made on 05/16/25, at 2:38 P.M., of the resident's May 2025 POS, showed staff did not have orders for the use of supplemental oxygen. During an interview on 05/19/25, at 3:10 P.M., LPN D said he/she thought the resident had been on continuous oxygen since returning from the hospital. Upon review, LPN D agreed there was no physician order for the oxygen use. 4. During an interview on 05/19/25, at 3:10 P.M., LPN D said the nurse should get an order for oxygen use. They can start by using the medical director's standing protocol orders, then get approval. The nurse should enter the orders into the electronic medical record (EMR) and all staff should follow the POS. The order should include the flow rate, route (such as nasal cannula or mask), and the frequency (either continuous or as needed) to maintain saturation level. During an interview on 05/19/25, at 3:15 P.M., LPN O said there should be orders for oxygen use. The nurse may start with following the medical director's protocol orders, and then get approval for the orders and enter them into the EMR. During an interview on 05/20/25, beginning at 12:34 P.M., the Director of Nursing (DON) said residents should have an order for oxygen use. If the nurse begins the oxygen administration based on the Medical Director's standing protocol orders, he/she should enter the order into the EMR and notify the physician. Oxygen use should be added to the care plan. An oxygen order should state to maintain the saturation greater than 90%, not less than. Protocol is to attach a humidifier to the oxygen concentrator, but some people do not like the humidifier, as it feels too wet in their nose. The humidifier is not part of the orders and is individualized per resident. During an interview on 05/20/25, at 2:08 P.M., the Administrator said the nurse should get an order for oxygen administration and enter the orders into the system. They can initiate oxygen based on the physician's standing protocol orders, but should then notify the physician for approval.

Based on observation, interview, and record review, the facility failed to have sufficient staff to meet the needs of the residents resulting in staff failing to answer call lights in a timely fashion for three residents (Resident #14, #39, and #61). The facility census was 105. Review showed the facility did not provide a policy related to call light response. 1. Observations on 05/14/25, at 8:23 P.M., showed the following: -Two call lights alarming on the 100 hall and Resident #14, Resident #39, and Resident #61 call lights alarming on the 500 hall; -Resident #41 yelling out on the 500 hall; -Resident #31 yelling for staff to help Resident #41 on the 500 hall; -Registered Nurse (RN) JJ passed medications to Resident #50 on 500 hall; -At 8:27 P.M., RN JJ entered Resident #41 room gave resident reassurance; -At 8:32 P.M., Resident #41 continued crying out; -At 8:34 P.M., Nurse Aide (NA) KK overhead paged from the nursing station for Certified Nurse Aide (CNA) F to come to the nursing station; -At 8:35 P.M., NA KK walked down 500 hall looking for another aide. He/she did not look into the three rooms with call lights alarming; -At 8:38 P.M., RN JJ walked down 500 hall and did not look into the rooms with call lights alarming and walked to the commons area near nursing desk with resident medications; -At 8:39 P.M., the Regional Nurse Consultant enter the building and answered call lights down the 100 hall; -At 8:41 P.M., the Regional Nurse Consultant answered the call light for Resident #14. He/she requested a pain pill. The Regional Nurse Consultant advised he/she would notify the nurse; -At 8: 41 P.M., two aides, CNA LL and CNA MM, exited Resident #9's room pushing the hoyer lift (mechanical lift) out of the room with trash; -At 8:42 P.M., Regional Nurse Consultant answered Resident #61 call light. The resident said he/she had to go to the bathroom but no longer had to go to the bathroom; -At 8:43 P.M., Regional Nurse Consultant answered Resident #39's call light and advised staff would be in to assist; -At 8:47 P.M., Resident #61 turned call light back on; -At 8:48 P.M., Regional Nurse Consultant sent a nurse aide to Resident #61 room; -At 8:51 P.M., the Regional Quality Assurance walked down halls checking call lights. During an interview on 05/12/25, at 11:15 A.M., Resident #39 and his/her roommate said that were times they had to wait for a long time for staff to respond to the call light. Sometimes they waited for pain medications, toileting assistance, or even had waited thirty minutes to get someone to help back to bed. During an interview on 05/12/25, at 4:10 P.M., Resident #92 said that it often took thirty or more minutes to get assistance with toileting hygiene. He/she said the staff would tell him/her there was not enough staff to get help sooner. During an interview on 05/14/25, at 9:28 P.M., RN NN said usually call lights were answered well. Staff work together well. Staff should not walk by a call light without notifying resident someone will return and time frame. During an interview on 05/14/25, at 9:32 P.M., CNA N said he/she said he/she tried to answer call lights as quickly as possible on assigned hall. During an interview on 05/19/25, at 10:00 A.M., RN E said staff should not walk by call lights even if not assigned to the hall. They should at least check in and tell resident time frame and ensure the resident's safety, that is why the residents have call lights. During an interview on 05/19/25, at 3:29 P.M., CNA F said the aides help each other out with call lights. He/she said they all check other halls when lights going off. He/she would not expect call lights to be alarming for over 20 minutes. He/she said generally someone would stop and check with the resident and will let the aide of the hall know what was done or needed done. During an interview on 05/20/25, at 12:34 P.M., the Director of Nursing (DON) said everyone should answer call lights and the expectation was that staff answer the call light within five minutes. The nursing staff and aides should not be by-passing call lights. During an interview on 05/20/25, at 2:07 P.M., the Administrator said anyone can answer call lights. They should be answered as soon as possible. He said if a time limit was put on the call light response, staff would try to ride out the time limit. He said that twenty minutes was not acceptable and that staff should not bypass the call lights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility policy entitled Tuberculosis Screening, dated 11/14/16, showed the following: -Purpose was to prevent the spread of tuberculosis through early detection of the disease in residents/guests and employees; -Upon admission, residents should receive the PPD (purified protein derivative) two-step screening. If screening was done by the transferring hospital, it must have occurred within 30 days prior to nursing home admission; -Any resident with positive active TB, or suspicious symptoms, should be discharged to a hospital. The county health department should be notified within twenty-four hours; -Method one includes apply first test; read results in 7 days, and if result is negative (0-9 millimeter (mm) induration) apply second test the same day. Read results in 72 hours and use the second test as the baseline. -Method two includes -apply first test; read results in 72 hours; if result is negative apply second test 1 to 3 weeks later and read results of second test in 72 hours. Use the second test as the baseline. -Results of all PPD tests should be documented in the medical record. Review of a facility policy entitled Tuberculosis Control and Prevention, dated 09/01/17, showed the following: -Purpose was to prevent the spread of tuberculosis in residents and employees; -TB screening is conducted prior to or at the time of admission to the facility for all residents. Employees are screened for TB at the time of employment; -The Infection Preventionist/designee is designated to monitor and coordinate compliance with tuberculosis screening and management per state/regional/community data/recommendations per applicable Federal and State Laws. The facility did not provide a policy specific to the TB testing for employees. 6. Review of Resident #91's face sheet shows the following information: -admission date of 04/02/25; -Diagnoses included non-traumatic brain bleed, right dominant side weakness and/or paralysis following stroke, high blood pressure, gout (form of arthritis that causes severe pain, swelling, redness, and tenderness in joints), urinary retention, and cellulitis (bacterial skin infection) of left toe. Review of the resident's electronic medical record (EMR) and paper chart showed staff did not document regarding a two-step TB test process at or since admission. During an interview on 05/20/25, at 10:45 A.M., the Director of Nursing (DON) said he/she was unable to find documentation that TB testing was done for the resident. During an interview on 05/20/25, at 12:34 P.M. the DON said the DON or designee should administer a TB test to all residents on admission or re-admission from the hospital, with a second test done in about 10 days. During an interview on 05/20/25, at 2:07 P.M., the Administrator said TB testing should be completed for all residents on admission or re-admission from the hospital and annually. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program when staff failed to follow Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities) and failed to complete urinary catheter (a thin, flexible tube used to drain fluids from the body) care during incontinence care for one resident (Resident #92). The staff also failed to perform appropriate hand hygiene during incontinence care for two residents (Resident #92 and #10). The facility also failed to follow contact precautions for one resident (Resident #46). The facility also failed to complete and monitor two-step TB (tuberculosis - bacterial lung disease) testing for one resident (Resident #91). The facility census was 105. Review of the Centers for Disease Control and Prevention (CDC)'s Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 04/02/24, showed the following: -MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs; -EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO; -Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care; -Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization; -Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care (use of central line, urinary catheter, feeding tube, tracheostomy/ventilator), and wound care (any skin opening requiring a dressing). -When implementing contact precautions or EBP, it was critical to ensure that staff have awareness of the facility's expectations about hand hygiene and gown/glove use; -Post clear signage on the door or wall outside of the resident room indicating the type of precautions and required PPE (e.g., gown and gloves); -For EBP signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves; -Make PPE, including gowns and gloves, available immediately outside of the resident room. Review of the facility provide policy titled Enhanced Barrier Precautions, dated April 2024, showed the following: -EBP are an approach to the use of personal protective equipment (PPE) as a strategy to decrease transmission MDRO when contact precautions do not apply; -The precautions are to be used during specific high-contact resident activities associated with MDRO transmission and do not involve room restrictions -EBP is used in conjunction with standard precautions; -Upon admission and/or readmission or when a current resident meets the indications for EBP, these should be implemented, and the resident, representative, and staff should be informed; -The Infection Preventionist and/or Director of Nursing (DON) should maintain a list of all residents that have been determined to require EBP and if it is questionable whether or not a resident should have these implemented, the DON or Infection Preventionist will review and make the final determination; -A sign indicating the EBP should be placed on the resident's door and if it is a semi-private room, it should be labeled for which bed; -PPE and alcohol-based hand rub should be readily accessible at all times, preferably near or inside and/or outside of resident rooms, shower rooms, and therapy gyms; -EBP requires donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing; -EBP is indicated for resident with infection or colonization with a MDRO when contact precautions do not otherwise apply and wounds and or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO); -Examples of chronic wounds include but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers; -Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies; -EBP is employed while performing high-contact resident care activities that included dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting; during device care; and during wound care. Review of the facility policy titled Perineal Care, dated October 2010, showed the following: -Good perineal care helps prevent infection, irritation, and skin breakdown; -Residents who are incontinent of urine or feces should receive perineal care as needed. Residents should receive perineal care during routine baths or showers; -Remove any fecal matter or urine wiping with tissue from front to back; -Pre-moistened disposable wipes or washcloth should be used. Review of the facility policy titled Urinary Catheter Care, dated November 2014, showed the following: -Urinary catheter care helps to prevent urinary tract infection; -Catheter care should be provided each time perinea! care is provided, and at least daily; -Wash hands thoroughly before and after providing catheter care and wear gloves; -Wash perineal area per policy; -Cleanse area of catheter insertion well using soap and water and being careful not to pull on catheter or advance it further; -Wash the catheter itself by holding on to the catheter at the insertion site and wash with one stroke downward approximately 3 inches from the meatus (passage or opening leading to the interior of the body) while holding the catheter to prevent pulling. Repeat as necessary; -Rinse perineal area well and rinse the catheter by holding on to the insertion site and rinse with one stroke downward approximately 3 inches from the meatus while holding the catheter to prevent pulling. Repeat as necessary; -Towel dry the perineal area. 1. Review of Resident #92's face sheet (a brief information sheet about the resident), showed the following: -admission date of 10/17/24; -Diagnoses included chronic ulcer (open sores that take a long time to heal, often due to underlying health conditions or injuries) of right heel and midfoot with necrosis of bone (condition where bone tissue dies due to a lack of blood supply), acute osteomyelitis (bone infection that typically develops quickly, often within a few weeks) of right ankle and foot, and type 2 diabetes mellitus (chronic condition that affects the way the body processes blood sugar (glucose)). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment completed by facility staff), dated 04/09/25, showed the following: -Moderate cognitive impairment; -Set up assistance of staff for oral hygiene and personal hygiene; -Dependent of staff for toileting hygiene, transfers, and mobility. Review of the resident's care plan, reviewed 05/13/25, showed the following: -Resident required assistance to complete daily activities of care safely; -Resident had a urinary catheter; -Staff should use EBP: -Staff must wear gloves and gown when providing personal cares. Observation on 05/13/25, at 10:35 A.M., showed the following: -Certified Nurse Aide (CNA) Q and CNA R prepared supplies and entered the resident's room. An EBP sign was on the resident's door. The staff did not apply gowns. -Without completing hand hygiene the staff applied gloves and opened the incontinent brief. The resident rolled to his/her left side. CNA Q wiped the resident's buttock with wet wipes. The resident had a small bowel movement (BM). The aide tucked the soiled brief under the resident. The aide picked up a clean incontinent brief with the same gloved hands. He/she applied the clean brief to the bed. The resident rolled to his/her right side and CNA Q touched the resident's outer thigh to assist the resident with positioning with the same gloved hands. -CNA R pulled the soiled incontinent brief through and disposed of in the trash. The aide pulled the clean brief into place and the resident rolled onto his/her back. The staff closed the brief. -The staff did not clean catheter tube after the bowel movement. -The staff pulled the resident up in the bed with the draw sheet with the same gloved hands. CNA Q lifted the resident's feet with same gloved hands and CNA R placed pillows under the resident legs and feet. CNA Q then adjusted the resident pillowcases on the pillows with same gloved hands and positioned the pillows under resident head. -CNA Q removed gloves, took trash, and left the room without completing hand hygiene. -CNA R drained the catheter collection bag into a urinal, disposed of the urine in the bathroom, removed his/her gloves, and left room without completing hand hygiene. -CNA R entered another resident room without completing hand hygiene. Observation on 05/14/25, at 9:00 A.M., showed the following: -Licensed Practical Nurse (LPN) O prepared wound care supplies at the nursing cart and then entered the resident's room. There was an EBP sign on the resident's door. The nurse cleared the bedside table of drinks and wiped the table with disinfecting bleach wipe for 3 minutes. The nurse washed his/her hands at the sink and applied gloves. -NA T entered the room, washed his/her hands at the sink, and then applied gloves. The nurse brought the prepared supplies on a clean foam plate and placed on the clean bedside table. The nurse washed his/her hands and applied gloves. The nurse and the NA did not wear a gown. -The NA held the resident's leg up for the nurse and the nurse removed the wound dressing and then removed his/her gloves and washed hands at the sink. The resident had wounds on the bottom of his/her foot, a clean suture line on the top of foot, and a wound on the outside of the foot below the small toe. The nurse applied gloves and washed the wounds with gauze and wound cleanser, he/she removed the gloves and washed hands at sink. He/she applied gloves, applied kerlix wrap (gauze bandage roll used for wound care to secure dressings, protect wounds, and provide support), and adjusted the resident in bed. The aide and the nurse removed gloves and washed hands at sink. Observation on 05/15/25, at 12:00 P.M., showed the following: -Nurse Aide (NA) M entered the resident's room with the hoyer lift (mechanical device with a sling attached to lift and transfer a non-ambulatory resident). An EBP sign was on the resident door. The aide applied gloves without completing hand hygiene. The aide did not apply a gown. The aide drained the catheter bag into urinal with about 600 cubic centimeters (cc) of clear yellow urine. He/she then disposed of the urine into toilet and rinsed the urinal. -He/she picked up a clean incontinent pull up brief with the same gloved hands and put the catheter bag and tube through the leg of pull up. -The aide unhooked the residents brief and the resident rolled to his/her left side. The aide took a wet wipe and wiped large BM using wet wipes. The aide wiped the resident's buttock thoroughly using multiple wipes. The resident rolled to his/her back side and the aide cleaned front private and the anchored the catheter tubing at private area with his/her left hand and wiped the catheter tubing with his/her right hand. The aide removed his/her gloves and said he/she had to put on new gloves due to BM got on the gloves. The aide did not complete hand washing or use hand sanitizer. The aide applied clean gloves. -The aide put the resident's left leg through incontinent pull up, then put the right leg through incontinent pull up. The aide then put the resident legs through pants. The resident rolled to his/her left side, the aide pulled pants up, and the resident rolled to his/her right side and the aide pulled the pants up. The resident sat up and the aide removed the hospital type gown and pulled a clean shirt over the resident's head and pulled resident's hair through the shirt. The aide straightened the resident's hair with his/her gloved hands. The aide placed the hoyer pad on the bed and the resident rolled left and the aide tucked the lift pad under the resident. -CNA S entered the room and applied gloves. He/she did not apply a gown or complete hand hygiene prior to gloves. The resident rolled to his/her right side and the staff pulled the hoyer pad under the resident. NA M moved the hoyer lift and the aides hooked up lift pad to lift. The staff transferred the resident to the wheelchair. The staff adjusted the resident's clothing and hoyer pad with the same gloved hands. The staff did not complete hand hygiene. -NA M handed the resident his/her purse, cell phone, and water cup. CNA S left the room with the resident. NA M removed his/her gloves and began to straighten resident bedding without completing hand hygiene. 2. Review of Resident #46's face sheet showed the following: -admission date of 03/22/24; -Diagnoses included resistance to vancomycin, VRE urine (bacteria that have become resistant to the antibiotic vancomycin), acute cystitis without hematuria (bladder infection, typically a bacterial infection, that causes inflammation of the bladder, resulting in symptoms like pain or burning during urination, frequent urination, and a strong urge to urinate), and person history of traumatic brain injury (injury to the brain caused by an external force, such as a blow to the head or other blunt force trauma). Review of the resident's care plan, last reviewed 05/13/25, showed the following: -Isolation related to VRE in urine; -Isolation will be discontinued when clinically indicated; -Staff should observe for changes in condition. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Independent with toileting hygiene, personal hygiene, mobility, and transfers. Observation on 05/14/25, at 2:00 P.M., showed Housekeeping U in the resident's room mopping the bathroom and bedroom floor. A sign on the door noted resident was on contact isolation and noted that anyone that entered the room was required to wear gown and gloves in the room. The Housekeeper was no wearing any gown or gloves. During an interview on 05/19/25, at 4:15 P.M., Housekeeping U said that resident rooms that have signs related to precautions for illness, staff should follow the signage and should wear gown and gloves when cleaning room. He/she did not remember the resident's room having an isolation sign. 3. Review of Resident #10's face sheet showed the following: -admission date of 01/18/18; -Diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), cognitive communication deficit, and anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Severe cognitive impairment; -Dependent on staff for toileting hygiene, personal hygiene, mobility, and transfers. Review of the resident's care plan, reviewed 04/09/25, showed the following: -Required staff assistance with all activities of daily living; -Resident was incontinent of bladder and bowel; -Staff should complete peri-care after each incontinent episode. Observation on 05/16/25, at 9:35 A.M., showed the following: -NA P and CNA J entered the resident's room. The staff washed their hands at the sink and applied gloves. The staff prepared supplies to include an incontinent brief and wet wipes. The staff pulled the residents covers back. -NA P opened the residents brief and wiped the peri area. The aides rolled the resident to his/her left side and CNA J wiped large BM with multiple wipes and BM got on the aides gloves. He/she wiped with his/her gloves with a wet wipe. The aide then picked up a clean brief and applied under resident. -The aide pulled the residents shirt down with the same gloved hands. The staff rolled the resident to his/her right side and pulled the brief into place. The staff pulled the resident's shirt down. The staff rolled the resident to his/her back side and pulled the brief through the resident legs and secured in place. -CNA J wiped interior of resident legs with wet wipe and the wiped his/her gloves with a wet wipe. The staff disposed of wet wipes and incontinent brief into the trash can. The aides pulled the resident up in bed with the draw sheet and adjusted the pillows with the same gloved hands. The staff pulled the covers up and adjusted the bed with the controls. -CNA J removed his/her gloves, removed trash, and washed hands at sink and left the room. -NA P removed and disposed of gloves. NA P pushed the bedside table in place and picked up the resident's cup from the bedside table and left room to get a drink in the cup. He/she used hand sanitizer at the end of the hall with the cup in his/her hands. 4. During an interview on 05/15/25, at 12:25 P.M., NA M said the following: -The EBP sign on door means one of the residents in the room has c-diff (refers to a bacterium called Clostridioides difficile, which can cause infections, primarily in the digestive system), but neither Resident #92 or the roommate had c-diff. She thought someone did not take the sign down. Staff was to wear a gown and gloves when completing resident care if there was sign on the door, but the nurses did not wear gowns when working with the resident, so he/she assumed that he/she did not need to wear a gown either. -Hand hygiene should be done before resident care and after resident care. Staff should change gloves between dirty and clean task and should change gloves after wiping BM and apply clean gloves. Staff should clean hands if soiled. During an interview on 05/19/25, at 3:29 P.M., CNA F said the following: -If a resident had an EBP sign outside their door, depending on what the resident had depended on what PPE wear. -Residents with contact isolation signs mean that staff should put PPE on before entering the room and will have a biohazard box in the room. -If the resident had an open wound staff should wear gloves and a mask to complete cares. -If the resident had a catheter staff should wear gloves for cares. Staff did not need to wear gowns for resident cares with catheters. -Residents that had tube feeding the aides only wear gloves for cares because the aides did not do any work with the tube feeding, the nurse was responsible for tube feeding care. During an interview on 05/15/25, at 12:30 P.M., Certified Medication Technician (CMT) H said the following: -The EBP signs on doors for residents that have a wound, catheter, or central line. The staff should wear gown and gloves to protect the resident from staff during direct care. The staff should wear a gown when emptying a catheter bag. -When completing incontinent care, staff should wash their hands when they enter the room, again during care, and whenever changing gloves. If gloves get dirty during care staff should change gloves. -Staff should follow signage on doors including contact isolation. During an interview on 05/19/25, at 3:45 P.M., CMT G said the following: -EBP meant that staff should wear a gown and gloves when performing direct personal care for any resident with catheter or tube feed. -Staff should use hand sanitizer or wash hands before and after any resident cares. During an interview on 05/15/25, at 12:40 P.M., LPN A said the following: -EBP signs mean the resident had catheter, feeding tube, or an indwelling medical device. Staff should wear a gown and gloves with direct resident cares, including wound care. -Staff should complete hand hygiene before entering a resident room, and when leaving the room. Staff should change gloves during any dirty to clean process. Staff should complete hand hygiene when hands are soiled. During an interview on 05/19/25, at 10:00 A.M., Registered Nurse (RN) E said the following: -When a resident had EBP signage on their door, the staff should wear gown and gloves for direct care with any residents that have indwelling devices, peg tube, catheter, or wounds. There should be a sign on the resident door and PPE supplies behind the door. Staff should not complete direct care without the gown and gloves in the resident room. -When a resident room had contact isolation signage there would be PPE outside the door and biohazard box in the room and all staff should follow the signage. -Hand hygiene should be done multiple times throughout one procedure. Staff should wash hands before entering resident room and complete hand hygiene between glove changes. Staff should not clean gloves with wet wipes if soiled during care. If hands become soiled with feces staff should remove gloves and use soap and water. During an interview on 05/20/25, at 12:34 P.M., the DON said the following: -EBP required staff to wear gown and gloves with the direct cares for residents with anything that included a break in the skin, catheters, tube feeding, and major wounds. PPE was hanging on the doors in some rooms or in the resident closet. EBP was required for all direct personal cares. -Hand hygiene should be done before, during, and after personal care. Staff should complete hand hygiene between change of gloves. Hands should be cleaned between dirty to clean process. Staff should not wipe off gloves with wet wipes. Staff should change gloves and complete hand hygiene. -All staff should follow signage on resident door if under contact isolation. During an interview on 05/20/25, at 2:07 P.M., the Administrator said staff should wear gown and gloves with catheter care, according to the EBP policy. Staff should be changing gloves during cares. Once done with dirty process, staff should change gloves and clean hands before touching anything clean. It was not okay to use wet wipe to clean gloves that were soiled. Staff should follow signage on door if resident in contact isolation.

Based on observation, interview, and record review, the facility failed to ensure six nurse aides (Nurse Aide (NA) A, NA AA, NA V, NA W, NA X, NA Y, NA Z) of sixteen sampled NAs, completed a certified nurse aide (CNA) training program within four months of employment in the facility as a nurse aide. The facility census was 105. Review showed the facility did not provide a policy regarding nurse aide certification or training. Review of the facility provided list of current NA staff showed sixteen staff on the list. Six NA staff had been employed greater than 120 days. 1. Review of NA AA's personnel file showed the following: -Date of hire of 10/02/24 (seven months and eighteen days since date of hire); -Staff did not have documentation NA AA had completed the nurse aide training program. Review of the state agency CNA registry, on 05/21/25, showed NA AA not listed with an active certificate. 2. Review of NA V's personnel file showed the following: -Date of hire of 10/15/24 (seven months and five days since date of hire); -Staff did not have documentation NA V had completed the nurse aide training program. Review of the state agency CNA registry, on 05/21/25, showed NA V not listed with an active certificate. 3. Review of NA W's personnel file showed the following: -Date of hire of 11/15/24 (six months and five days since date of hire); -Staff did not have documentation NA W had completed the nurse aide training program. Review of the state agency CNA registry, on 05/21/25, showed the NA W not listed with an active certificate. Observations on 05/16/25, at 10:05 A.M., showed NA W working, providing direct care to residents in the facility. Review of the facility's daily staff schedules, dated 05/11/25 through 05/20/25, showed NA W worked on the day shift on 05/16/25. 4. Review of NA X's personnel file showed the following: -Date of hire of 01/06/25 (four months and fourteen days since date of hire); -Staff did not have documentation NA X had completed the nurse aide training program. Review of the state agency CNA registry, on 05/21/25, showed the NA X not listed with an active certificate. Review of the facility's daily staff schedules, dated 05/11/25 through 05/20/25, showed NA X worked on the day shift on 05/14/25. 5. Record review of NA Y's personnel file showed the following: -Date of hire of 01/09/25 (four months and eleven days since date of hire); -Staff did not have documentation NA Y had completed the nurse aide training program. Review of the state agency CNA registry, on 05/21/25, showed the NA Y not listed with an active certificate. Review of the facility's daily staff schedules, dated 05/11/25 through 05/20/25, showed NA Y worked on the evening shift on 05/16/25. 6. Record review of NA Z's personnel file showed the following: -Date of hire of 01/12/25 (four months and eight days since date of hire); -Staff did not have documentation NA Z had completed the nurse aide training program. Review of the state agency CNA registry, on 05/21/25, showed NA Z not listed with an active certificate. Review of the facility's provided daily staff schedules, dated 05/11/25 through 05/20/25, showed NA Z worked on the day shift on 05/11/25. Review of the state agency CNA registry, on 05/21/25, showed the Nurse Aides not listed with an active certificate. 7. During an interview on 05/19/25, at 10:00 A.M., Registered Nurse (RN) E said NA's should be certified within 120 days of hire. He/she said there were several NAs that had been at the facility longer than 120 days. During an interview on 05/19/25, at 4:55 P.M., with the Director of Nursing (DON) and Corporate Compliance, the DON said NA's that were over the 120 days of hire should only pass ice, answer call lights, and perform hospitality aide duties. NA V and NA AA were still working to get practice. During an interview on 05/20/25, on 12:34 P.M., DON said when a NA was hired they were started in classes as soon as possible. There had been backlog when she started at the facility. The NA should be fully educated within 4 months. Until the NA was certified they were assigned with a second staff member. During an interview on 05/20/25, on 2:07 P.M., Administrator said NA's should be certified within four months of hire.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep food safe from potential contamination at all times when staff failed to air dry dishes, failed to ensure the ice machine had a proper air gap, and failed to keep kitchen surfaces clean and free of food debris. The facility census was 105. 1. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed dishes were to be allowed to air dry. Observations on 05/12/25, at approximately 10:55 A.M., of the kitchen area showed the following dishes were wet and placed in a manner that trapped water preventing air movement and trapping moisture: -Twenty-two plastic trays; -Sixty-one ceramic plates; -Seventy-two plastic bowls; -Ninety medium clear plastic cups. Observations on 05/13/25, at approximately 10:50 A.M., of the kitchen area showed the following dishes were wet and placed in a manner that trapped water preventing air movement and trapping moisture: -Six clear bowls -Eleven small clear cups; -Fourteen juice cups -Twenty-one coffee cups; -Twenty-five plastic bowls. Observations on 05/15/25, at approximately 8:20 A.M., of the kitchen area showed the following dishes were wet and placed in a manner that trapped water preventing air movement and trapping moisture: -Two metal steam table pans; -Eighteen clear cups; -Twenty-seven coffee cups; -Fifty-seven plastic bowls. During an interview on 05/15/25, at approximately 2:00 P.M., Dietary Aide (DA) BB said he/she did not know the dishes had to be fully dried prior to being stored away. During an interview on 05/15/25, at approximately 2:10 P.M., DA CC said he/she knew dishes cannot be put away while they are still wet or there could be bacteria growth During an interview on 05/15/25, at approximately 2:25 P.M., [NAME] DD said he/she did not realize that some dishes were being put away while still wet. During an interview on 05/16/25, at approximately 1:15 P.M., the Dietary Manager said the dishes have to be completely dried before they can be put away Bacteria can start growing in a very short amount of time. During an interview on 05/16/25, at approximately 1:35 P.M., the Regional Dietary Manager said he/she has let staff know dishes must be air dried when they are removed from the dishwasher. During an interview on 05/20/25, at approximately 1:45 P.M., the Facility Corporate Nurse said he/she would expect the dietary staff to know that dishes are being fully dried, prior to being stored away. During an interview on 05/20/25, at approximately 2:25 P.M., the Administrator said he/she expected staff to put the dishes up after they have fully air dried. 2. Review of the facility policy titled Ice Chest and Ice Machines, dated 11/14/16 showed staff to install proper air gaps where the condensate lines meet the waste lines. Observation on 11/12/25, at approximately 11:30 A.M., of the ice machine showed the pipe coming out of the ice machine laying directly on the floor drain. There was no air gap between the pipe and floor drain. During an interview on 05/19/25, at approximately 2:55 P.M., the Maintenance Director said maintenance was responsible for making sure there was an air gap of at least two inches. During an interview on 05/20/25, at approximately 1:50 P.M., the Director of Nursing (DON) said there must be an air gap of 2 inches. During an interview on 05/20/25, at approximately 2:25 P.M., the Administrator said he/she was not aware of the ice machine not having an air gap. He/she was unsure how much of an air gap was required. 3. Review of the Food and Drug Administration (FDA) 2022 Food Code showed the following: -The objective of cleaning focuses on the need to remove organic matter from food contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. -The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed the following: -Carts for food delivery and utility are to be cleaned daily by wiping with a clean cloth soaked in sanitizing solution, after each meal; -Carts for food delivery and utility are to be cleaned weekly by emptying the cart, wash (giving attention to the tray slides), rinse, sanitize, and air dry; -Dish carts and dollies are to be cleaned weekly by removing dishes, clean the cart, rinse, sanitize and air dry; -The range and grill are to be cleaned daily and the cook on each shift is responsible for keeping the stove as clean as possible during the preparation of the meal. Take out burner grids and wash in the pot and pan sink, rinse, and sanitize. Brush the burners and check for clogs by lighting burners. Remove grease tray and trap door clean; -Can openers should be cleaned after each use. Remove from base, wash blade and other moving parts, rinse, sanitize, and air dry. Review of the facility cleaning schedule showed the daily cleaning checklist, weekly cleaning checklist, and monthly cleaning checklist were blank. Observation on 05/12/25, at approximately 10:55 A.M., of the kitchen showed the following: -The wall behind the steam table had grease and food splatter present. A metal shelf on the same wall had a film of grease covering the surface; -The plate warmer, next to the steam table, was had food crumbs present and a film of grease covering the surface; -The tea maker has a film of grease covering the surface; -The wall behind the counter and cabinets had a film of grease covering the surface; -The metal prep table bottom shelf was rusty and has a moldy like substance in the corners at the legs; -The metal rolling cart was covered in food splatters and crumbs; -The teeth on the can opener had a thick, greasy substance present; -The toaster oven was covered in a layer of food crumbs; -The seal-a-meal on the counter top was covered in grease and discolored; -The convection oven had a build-up of grime and had a film of grease covering the surface; -The muffin pans and cake forms, sitting on top of the convection oven, were covered in a grease film; -The range and hood pipes going into ceiling [NAME] a mixture of grease and lint present; -The front of stove and behind the knobs had a film of grease covering the surface. During an interview on 05/15/25, at approximately 2:00 P.M., DA BB said the following: -He/she had never been asked to clean the area where he/she was stationed; -He/she had thought about cleaning the wall, but did not want to mess with anything plugged into the wall and worried it could not get wet; -He/she has never seen a cleaning schedule posted. During an interview on 05/15/25, at approximately 2:10 P.M., DA CC said the following: -He/she had never seen a cleaning schedule; -He/she cleaned up in the area, where he/she was stationed; -He/she had not had the time to do extra cleaning. During an interview on 05/15/25, at approximately 2:25 P.M., [NAME] DD said the following: -There was a cleaning schedule up on the wall, at one time, but has not seen one in a long time; -He/she usually wiped down the prep tables and areas where he/she worked; -He/she will clean the steam table and change the well water. During an interview on 05/16/25, at approximately 1:20 P.M., the Dietary Manager said he/she had already started a new cleaning schedule and a check list that will be for each area. During an interview on 05/20/25, at approximately 2:25 P.M., the Administrator said the following: -All surfaces are to be cleaned daily in areas where each staff is working, then specific areas, also weekly and monthly; -He/she expected the dietary staff to keep the kitchen clean.

Based on record review and interview, the facility failed to ensure the facility's quarterly Quality Assurance Performance Improvement (QAPI) Committee meetings occurred at least quarterly and included the required staff. The facility census was 105. Review of the facility policy entitled Quality Assurance/QAPI, dated 11/28/19, showed the following: -The program monitors data, analyzes and improves its performance to improve resident outcomes. It recognizes that value in healthcare is the appropriate balance between good measures, excellent care, services and cost; -QAPI Committee will meet quarterly and the facility QAPI team will meet at a minimum monthly. Performance Improvement Project (PIP) committees will meet weekly and report to QAPI Committee concerns. At a minimum, one PIP will be charted per year; -Input is obtained from facility staff on a monthly basis through the QAPI committees. The committees are responsible for talking to their employees before reporting findings to QAPI. Residents/Families have input through resident/family council and satisfaction surveys; -The Administrator will be the Quality Management Coordinator and responsible for QAPI process; -Monthly committee membership is interdisciplinary with at lease two non licensed staff members and one resident council member. The QAPI Monthly Committee meets monthly and maintains minutes of all activity. 1. Review of facility's QAPI Committee documentation, dated 01/23/25, showed attendance by signature which included the Administrator, Medical Director, Housekeeping Supervisor, Activities Director, two MDS (Minimum Data Set - a federally mandated comprehensive assessment tool completed by facility staff) Coordinators, Social Service Director, and Regional Quality Assurance Nurse. (The meeting did not include a designated Director of Nursing (DON) and Infection Preventionist.) Review of facility's QAPI Committee documentation, dated 04/09/25, showed attendance by signature included the Administrator, DON, and the Medical Director. (The meeting did not include the two additional required members and the Infection Preventionist.) Review showed the facility did not provide any additional QAPI Committee documentaiton for the prior 12 months. During an interview on 05/19/25, at 4:19 P.M., the Administrator said he held a QAPI meeting shortly after starting in his position with the facility around 04/01/25. Only the three attendees were available at the time. Monthly attendance should include the Administrator, DON, ADON, Medical Director, all department heads, and the pharmacist when available. The Administrator was told the previous administrator had some QAPI notes, but he was only able to locate notes for one monthly meeting.

Based on interviews and record review, the facility failed to prevent misappropriation of resident property for all residents when one resident's (Resident #1) money was stolen from the lockbox kept in the resident's dresser in the facility. The facility census was 104. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown source, Exploitation, dated 02/08/18, showed the following: -All residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident/guest property; -The facility's policy strictly prohibits the abuse, neglect, exploitation and involuntary seclusion of residents. The policy also prohibits the misappropriation of resident's property. This policy against abuse, neglect, exploitation and misappropriation of resident property includes abuse by any other person; -Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. Acts that may constitute the misappropriation of resident property include, but are not limited to the theft or attempted theft of a resident money or personal property of any value or type, theft of a resident's medication regardless of amount, or the use of resident's funds including credit cards or checks and identity theft. 1. Review of Resident #1's face sheet (a snapshot of resident information) showed an admission date of 09/27/24. Review of the resident's care plan, dated 12/08/24 to 01/07/25, showed the following: -Resident chooses to keep personal funds, cash, financial cards in her room; -Facility staff to assist with the replacement of missing items; -Staff will educate resident on the risks of having money financial cards of things of value in his/her room; -Staff provided resident with a lock box for his/her room/drawer. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 12/13/24, showed the following: -Resident was cognitively intact; -Resident required moderate assistance for transfers and mobility. Review of the facility's Grievance/Complaint form, dated 01/07/25, showed the following: -The resident believed he/she was missing 185 dollars cash from his/her lockbox. He/she went to the bank on 11/22/24 to pull out money. He/she took out 200 dollars and spent 15 dollars of it; -On or around 01/07/25, he/she realized it was not in the lock box. His/her debit cards were not missing and were in the box as well; -On 01/07/25, the Business Office Manager (BOM) and the resident called his/her bank to cancel his/her cards and requested new debit cards; -On 01/08/25, the Administrator contacted the resident family and discussed the resident not keeping cash on hand and setting up a resident trust fund account; -The form was signed as completed by the Administrator on 01/08/25. Review of the facility's investigation, dated 01/07/25, showed the following: -On 01/07/2025, the resident requested manager to take resident to room following lunch to assist with paying his/her phone bill that was due. The Housekeeping Manager took the resident to the resident's room. They looked at his/her phone bill and when he/she went to get his/her debit card in the lock on the lockbox was broken. The resident reported he/she had an envelope with initially 200 dollars cash and used 15 dollars cash for a birth certificate leaving his/her with 185 dollars cash missing. His/her debit cards were still in lock box; -On 01/07/25, the Director of Nursing (DON) and Administrator spoke with resident. The resident verified he/she drew out 200 dollars from the bank. He/She spent 15 dollars at the Health Department. He/She said his/her family member comes to visit, however is out of town for work. He/She said the key was up under the lid of the top drawer. He/she said the Housekeeping Manager and Business Office Manager (BOM) knew where the key was. The resident denied going on outings or making purchases for friends. He/she confirmed he/she was out of his/her room for meals and for therapy; -On 01/08/25, a second interview was completed in person by the Administrator who spoke to resident regarding report of missing envelope with items in it. The resident verified he/she asked the Housekeeping Supervisor to take him/her to his/her room to help him/her to make a phone payment when the lock box lock was found broken, and his/her envelope of money was missing. The resident said he/she had gone to the bank to get money out to get cards as gifts, but he/she had not done this yet and kept his/her money in the lockbox. The Administrator informed the resident that the internal investigation was in place and would follow back up with him/her with results and action plan. The Administrator contacted the resident's family member with the resident's permission to see if he/she had been on any outings and he/she said not that he/she was aware. The family member noted the lock box intact was when he/she visited on 12/19/24; - On 01/07/25, the lock box lock was broken and envelope of 185 dollars was missing. The Housekeeping Manager and SSD were granted permission by resident to search room for missing envelope. A grievance was filed. On 01/08/25, the resident asked the Administrator, are you going to find who took the money. The police department was notified. The detective visited the Administrator and the resident on 01/15/25. The Administrator followed up with the resident's family member with resident's permission to check to see if he/she knew of an envelope of missing money and if resident had been on any outings which he/she was aware of. The facility provided a new lock box with pad lock. During an interview on 01/09/25, at 11:58 A.M., the resident said the following: -The Housekeeping Supervisor took him/her to the bank and got out two hundred dollars. He/she then used 15 dollars to get a new birth certificate; -He/She had 185 dollars left. The Housekeeping Supervisor put the envelope of 185 dollars into the lockbox that was provided by the facility in the top dresser drawer per his/her request. It was locked and he/she hid the key; -He/she was not sure what day it was, but thought it was around Thanksgiving; -He/she asked the Housekeeping Supervisor to get one of his/her cards out of the lock box so he/she could pay a bill; -The lock on the lockbox had been busted and there were pieces in the drawer; -The envelope of 185 dollars was gone. There were also cards in the lockbox, but they had not been touched. However, he/she had to get new cards due to whoever broke into the lockbox having access to his/her card numbers; -He/she was not sure if any other staff were aware of money he/she had in the lockbox; -He/she suspected it was taken when he/she was gone to therapy or meals; -He/she had not left the facility and has not had any visitors recently except for a family member on 12/28/24, but the family member was never left in the room alone. During an interview on 01/09/25, at 12:21 P.M., the Housekeeping Supervisor said the following: -He/she took the resident to the bank and he saw him/her withdraw 200 dollars and it was put in a bank envelope. He/she saw the resident use 15 dollars of the 200 dollars; -When they returned to the facility, the resident asked him/her to put the envelope in the lockbox and he/she did; -He believed he/she last saw the envelope of money in the lockbox on 12/31/24 when he/she helped the resident pay a bill using one of his/her cards. The lockbox was locked with the envelope of 185 dollars was in it; -The resident also had debit/credit cards in the lockbox; -A few days ago, the resident asked him/her to help him/her get a debit card out of the lockbox to pay a bill; -He/she opened the drawer and noticed the lock was broken and in pieces. The lock box was no longer locked and when he/she opened the bank envelope with the money was gone; -He/she thought other staff were aware of the resident having the lockbox. Review of the Police Report dated 01/08/25, at 3:14 P.M., showed the following: -Offense: Larceny/ Stealing; - On 01/08/25, the officer contacted the Administrator who advised the resident had 185 dollars taken from a lockbox in his/her room. The Administrator said the money was placed into the lockbox by the resident with the assistance of the Housekeeping Supervisor on 11/22/24. The resident asked the Housekeeping Supervisor to help him/her remove the cash from the lock box on 01/07/25. The Housekeeping Supervisor found the lock damaged and the money missing. The Housekeeping Supervisor reported the theft to the Administrator. The Administrator said only three people knew of the money in the lockbox, herself, the Housekeeping Supervisor, and the BOM. It was possible other staff members could have learned of the existence of the money in the box from the resident. The Administrator said there are no cameras that overlooked the hallway to determine who had access to the resident's room. -The resident said he/she had placed the money and his/her debit cards in the box with the Housekeeping Supervisor. He/she did not remember the date that occurred. He/She had asked the Housekeeping Supervisor to take the money out on 01/07/25. He/She did not remember any other time of asking anyone to access the lockbox. The resident believed the lock had been pried open with a screwdriver. The resident wished to pursue charges if a suspect could be identified. -The Officer contacted the resident's family member. He/she said he/she was the only family member that visited the resident. The family member last checked the lockbox on 12/28/24 and it was undamaged. The family member had told the resident several times not to keep cash in the box as it was not a secure place to keep it. He/she denied taking the money and did not know of any suspects who would have taken it; -On 01/13/25, the detective came to the facility and spoke with the Director of Nursing (DON) and then the Administrator regarding this incident. The DON said approximately 100 employees had access to the resident's room. It was possible people who visit the facility had access to the resident's room as well. The Administrator explained that the resident can decide to have money and credit cards in his/her room. It has been suggested to the resident that he/she can utilize the facilities trust to keep her money and cards safe. During an interview on 12/31/24, at 12:43 P.M., CNA E said staff should not take any belongings from residents. He/she reports to the DON or Administrator if a resident is missing any items or believe they had something stolen. The residents should be able to feel their belongings are safe at the facility. During an interview on 01/09/25, at 11:35 A.M., Registered Nurse (RN) A said the following: -It was not appropriate for staff to take any of the resident's belongings to help keep their items safe. The residents are encouraged to put money in the resident trust, or a lock box can be requested; -He/she reported any missing stolen items to the DON or Administrator. During an interview on 01/09/25, at 12:16 P.M., the Maintenance Supervisor said the following: -He/she installed the lockbox for the resident. He/she screwed the lockbox to the drawer. He/she was not aware of what the resident put in the lockbox; -He/she was made aware on 01/07/25 that the lock box lock was broken. It looked like someone had used a tool like a screwdriver to force the lock open. The lock was in pieces; -It was not appropriate to take resident belongings. During an interview on 01/09/25, at 12:33 P.M., the Business Office Manager (BOM) said the following: -On 01/07/25, the housekeeping supervisor came to his/her office and showed him/her the broken pieces of the lock box from the resident's room. The Housekeeping Supervisor said the resident had asked him to help him/her get his/her debit cards out of the lock box and he/she found it broken; -He/she reported the possible misappropriation to the Administrator. The resident said he/she had 185 dollars in an envelope inside the lock box; -The debit cards were still in the lock box, but he/she helped the resident cancel them and get new ones due to them possibly being compromised; -The bank records showed that the resident had pulled 200 dollars cash on 11/22/24. The resident said he/she used 15 dollars; -He/she was not aware of the resident leaving the facility recently; -He/she believed the resident would remember if he/she gave money to someone or used any money. During an interview on 01/09/25 at 4:23 P.M., the Assistant Director of Nursing (ADON) said the following: -It is not appropriate or staff to take any money or belongings from residents and it would be considered misappropriation; -The residents are encouraged to put money in a resident trust and to use a lock box provided by the facility to keep their items safe. During an interview and observation on 01/09/25, at 11:14 A.M., the Administrator said the following: -The police were called, and they have started interviewing staff regarding the broken lock box and missing money; -The lock box was last seen intact on 12/31/24. -He/she has no suspicions of who could have taken the money at this time. He/she will be trying to interview all staff that worked during that time period to get more information. MO00247711

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Please refer to event ID XMKY12, exit date 11/21/24. MO00245443, MO00244807 Based on interviews and record review, the facility failed to protect all residents from misappropriation of resident property when belongings for one resident (Resident #1), including purse, wallet, debit cards, ID cards, and money, went missing while the resident resided at the facility. The facility census was 106. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown source, Exploitation, dated 10/15/22, showed the following: -All of our resident have the right to be free from abuse, neglect, exploitation, and misappropriation of resident/guest property; -The facility's policy prohibits the misappropriation of resident's property; -This policy against abuse, neglect, exploitation and misappropriation of resident property includes abuse by any other person; - Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the residents consent. Acts that may constitute the misappropriation of resident property include, but are not limited to the theft or attempted theft of a resident money or personal property of any value or type, theft of a residents medication regardless of amount, or the use of residents funds including credit cards or checks and identity theft. 1. Review of Resident #1's face sheet (a snap shot of resident information) showed the following: -admission date of 09/27/24; -Diagnoses included spinal stenosis (a chronic condition that occurs when the spinal canal narrows, putting pressure on the spinal cord and nerves), chronic pain syndrome, hypo-osmolality (condition where there are low levels of electrolytes, proteins, and nutrients) and hyponatremia (a condition where there are low levels of sodium in the blood). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/02/24, showed the following: -Moderate cognitive impairment; -Required moderate assistance for transfers and mobility. Review of the facility's Grievance/Complaint Form, dated 11/07/24, showed the following: -The resident discovered his/her purse was missing. He/She said it had items in it including a wallet and cash. The cash was in the amount of 140.00 dollars in 20 dollar bills and stack of [NAME] and ones of unknown amount; -The action taken to resolve the concern was replacing the missing money, purse, and wallet. The facility will take the resident to replace his/her photo ID. They will also take him/her to the bank to cancel out debit cards and get new ones. A lock box was placed and bolted in a drawer in the resident's room; -The grievance was resolved; -A request was made for a check to replace 140 dollars and for 20 dollars to replace the purse and wallet; -The resident was notified with a one-on-one discussion; -The form was completed on 11/21/24 by the Administrator. Review of the facility's investigation, dated 11/07/24, showed the following: -On 11/07/24, the resident found that his/her purse was missing with items in it including his/her, purse, wallet, and cash. He/She discovered it was missing after lunch when taken to the room by the housekeeping supervisor and assisting him/her to look for his/her purse to make a payment to the facility. His/Her purse was described to be a black clutch purse with two zippers on the outside, kept inside was his/her checkbook and cash with one check left, ID card, debit cards, and wallet. The resident said he/she had, 140 dollars in 20's and stack of dollar bills and five dollar bills,. He/She was uncertain how much; -On 11/07/24, the Administrator spoke to resident, with Housekeeping supervisor present, regarding report of missing purse with items in it. The resident verified he/she was going to make a payment to the facility and his/her purse with ID card, two debit cards, one check, insurance cards, and wallet were not in his/her room. The resident said he/she would hide it under his/her mattress at times and the Administrator checked with no purse found. The Administrator contacted the resident's family, to see if he/she took it home and he/she said he/she did not. Resident said he/she recalled having, 140 dollars in twenties and and one dollar bills in a stack with an unknown amount of the stack. Resident said the purse was approximately twenty dollars in value; -On 11/07/24, the resident's purse was discovered missing by the resident. The Housekeeping Supervisor assisted the resident in looking for his/her purse to make a payment to the facility, the purse was found to be missing, The Housekeeping Supervisor reported this to the Unit Coordinator/Registered Nurse (RN) on the resident's hall. The Unit Coordinator/RN and the Housekeeping Supervisor reported this to Financial Specialist. The Unit Coordinator and the Financial Specialist entered resident's room to talk with resident and with permission searched his/her room. The purse was not found. The Administrator was notified at 1:00 P.M., and he/she spoke to resident. The police department was notified. Social services was notified and a grievance was filed. The Administrator followed up with family with resident's permission to check to see if the family had taken the resident's items home. The Financial Specialist, with resident's permission, called the resident's bank to stop active debit cards and check statements to make sure there was no recent activity. The bank confirmed there had been no recent activity. The last check payment was made on 10/23/24. The resident had his/her purse at that time. On 11/07/24, transportation was provided through the facility for resident to go to the bank to pick up new debit cards. The resident was encouraged to have them locked up and wanted the Financial Specialist, to lock them up in the front office. The resident had a date set next week with transportation from the facility to go to the driver's license bureau to get a new id. A plan was set to provide the resident a new purse of comparable cost. Financial Specialist was getting the resident new insurance cards. Facility will provide a lock box for resident to keep his/her valuable items. Resident was encouraged to keep money locked up. Review of the Police Report, dated 11/07/24, showed the following: -On 11/07/24, the officer responded to the facility in reference to a possible larceny. Information gathered and report completed; -The resident said that he/she went to get his/her purse today to write a check and he/she could not find it. The resident said he/she kept the purse in a drawer next to his/her bed and he/she last saw/used it on 10/23/24. The resident and multiple staff members have searched through his/her room and was unable to find his/her purse. The resident described his/her purse to be a black clutch bag that contained 140 dollars in cash or slightly more, two debit cards, driver's license (ID card), vehicle insurance cards, and a check book with one check left in it (unknown check number). The resident valued his/her purse at seven dollars. The resident wished to pursue charges if his/her purse was in fact stolen. The resident had since canceled the remaining check and the two debit cards. There were no security cameras around the facility. -On 11/08/24, the officer contacted the resident by phone. The resident confirmed he/she had notified his/her bank and canceled the debit cards/check. The resident was not aware of any other thefts within the facility. -The resident was asked to contact the police department if his/her bank notified his/hr that his/her debit card got used/declined as well as the stolen check. There were currently no leads or suspects. During an interview on 11/21/24, at 9:19 A.M., the resident said the following: -He/she asked the admission Coordinator to help her get the purse out of his/her drawer so he/she could pay his/her bill to the facility about a week and a half ago; -The purse was not in the drawer -He/she had no idea who would want to take the purse. He/she wishes they would have just taken the money and left the purse; -The purse was a small black purse with a zipper. His/her wallet, including two debit cards, insurance and ID cards, and 140 dollars in 20-dollar bills were gone. She also had some [NAME] and dollar bills but was unsure of exact amount were gone. She also had a check book in the purse; -He/she kept it in the top drawer. He/she believed he/she last saw the purse when he/she paid the facility in October; -The facility looked for the purse everywhere, but were unable to find it; -The facility took him/her to the bank to cancel the cards and get new cards. The cards had not been used. The insurance company is supposed to be sending new cards. -Staff was aware he/she had the purse because she kept it under the mattress at one point and they helped get it out of the drawer so she could pay bills. During an interview on 11/21/24, at 9:40 A.M., the Financial Specialist said the following: -He/she had seen the resident's purse at the facility in his/her room when he/she paid her last check to the facility on [DATE]; -It was a small black purse. He/she also saw that the resident had checks and a wallet in the purse. He/she was not sure of the contents of the wallet; -On 11/07/24, he/she was informed by the Housekeeping Supervisor and Unit Coordinator that the resident was missing his/her purse. The staff searched for the purse and could not find it; -The resident's family said he/she did not take the purse; -The facility helped the resident replace the cards and will be replacing the money; -He/she is not aware of anyone taking any items During an interview on 11/21/24, at 9:50 A.M., the Admissions Coordinator said the following: -He/she was not aware that the resident had a purse or money at the facility. He/she encouraged all residents to not keep valuables or money in their room; -On 11/07/24, he/she went to the resident's room to collect money owed to the facility. The resident asked him/her to get his/her purse out of the drawer in his/her nightstand. When he/she opened he drawer it was not there; -He/she assisted the resident in looking around the room, but the purse was not found; -The resident said he/she was going to talk to his/her family and make sure he/she did not take it home; -The resident later reported that his/her family did not have the purse and it was indeed missing. During an interview on 11/21/24, at 10:00 A.M., the Housekeeping Supervisor said the following: -On 11/07/24, he/she went to take the resident to lunch and he/she was upset because his/her purse was missing; -He/she had seen the purse before. The last time was a few weeks prior. The resident had hid it under the mattress. It was a small black purse; -He/she was aware of her having 140 dollars in the purse because he/she had helped him/her to count the money. He/she also saw that he/she had debit cards, checks, and insurance cards in the purse; -He/she had no idea what happened to the purse; -He/she had been trained to report misappropriation. It is not appropriate for staff or residents to take items from residents. During an interview on 11/21/24, at 10:09 A.M., Unit Coordinator/RN said the following: -He/she was informed that the resident's purse was missing and he/she helped to search the room; -It is not appropriate for anyone to take a resident's belongings; -The staff is to report any stolen items to the Director of Nursing (DON) or Assistant Director of Nursing (ADON). During an interview on 11/21/24, at 3:09 P.M., the DON said the following: -An inventory sheet was not completed for the resident; -The resident did not go out to any appointments between 10/23/24 and 11/07/24. During an interview on 11/21/24, at 3:50 P.M., the DON and the Administrator said the following: -When a resident admits to the facility, the admission team should make sure an inventory sheet is completed of the resident's belongings; -The residents should be encouraged to lock up valuable items or to have them taken home; -It is not appropriate for any staff or residents to take a resident's belongings; -The resident's belongings were not found. The facility is helping to replace all items; -Staff should not be counting the resident's money.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect all residents from misappropriation of resident property when belongings for one resident (Resident #1), including purse, wallet, debit cards, ID cards, and money, went missing while the resident resided at the facility. The facility census was 106. Review of the facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown source, Exploitation, dated 10/15/22, showed the following: -All of our resident have the right to be free from abuse, neglect, exploitation, and misappropriation of resident/guest property; -The facility's policy prohibits the misappropriation of resident's property; -This policy against abuse, neglect, exploitation and misappropriation of resident property includes abuse by any other person; - Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the residents consent. Acts that may constitute the misappropriation of resident property include, but are not limited to the theft or attempted theft of a resident money or personal property of any value or type, theft of a residents medication regardless of amount, or the use of residents funds including credit cards or checks and identity theft. 1. Review of Resident #1's face sheet (a snap shot of resident information) showed the following: -admission date of 09/27/24; -Diagnoses included spinal stenosis (a chronic condition that occurs when the spinal canal narrows, putting pressure on the spinal cord and nerves), chronic pain syndrome, hypo-osmolality (condition where there are low levels of electrolytes, proteins, and nutrients) and hyponatremia (a condition where there are low levels of sodium in the blood). Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 10/02/24, showed the following: -Moderate cognitive impairment; -Required moderate assistance for transfers and mobility. Review of the facility's Grievance/Complaint Form, dated 11/07/24, showed the following: -The resident discovered his/her purse was missing. He/She said it had items in it including a wallet and cash. The cash was in the amount of 140.00 dollars in 20 dollar bills and stack of [NAME] and ones of unknown amount; -The action taken to resolve the concern was replacing the missing money, purse, and wallet. The facility will take the resident to replace his/her photo ID. They will also take him/her to the bank to cancel out debit cards and get new ones. A lock box was placed and bolted in a drawer in the resident's room; -The grievance was resolved; -A request was made for a check to replace 140 dollars and for 20 dollars to replace the purse and wallet; -The resident was notified with a one-on-one discussion; -The form was completed on 11/21/24 by the Administrator. Review of the facility's investigation, dated 11/07/24, showed the following: -On 11/07/24, the resident found that his/her purse was missing with items in it including his/her, purse, wallet, and cash. He/She discovered it was missing after lunch when taken to the room by the housekeeping supervisor and assisting him/her to look for his/her purse to make a payment to the facility. His/Her purse was described to be a black clutch purse with two zippers on the outside, kept inside was his/her checkbook and cash with one check left, ID card, debit cards, and wallet. The resident said he/she had, 140 dollars in 20's and stack of dollar bills and five dollar bills,. He/She was uncertain how much; -On 11/07/24, the Administrator spoke to resident, with Housekeeping supervisor present, regarding report of missing purse with items in it. The resident verified he/she was going to make a payment to the facility and his/her purse with ID card, two debit cards, one check, insurance cards, and wallet were not in his/her room. The resident said he/she would hide it under his/her mattress at times and the Administrator checked with no purse found. The Administrator contacted the resident's family, to see if he/she took it home and he/she said he/she did not. Resident said he/she recalled having, 140 dollars in twenties and and one dollar bills in a stack with an unknown amount of the stack. Resident said the purse was approximately twenty dollars in value; -On 11/07/24, the resident's purse was discovered missing by the resident. The Housekeeping Supervisor assisted the resident in looking for his/her purse to make a payment to the facility, the purse was found to be missing, The Housekeeping Supervisor reported this to the Unit Coordinator/Registered Nurse (RN) on the resident's hall. The Unit Coordinator/RN and the Housekeeping Supervisor reported this to Financial Specialist. The Unit Coordinator and the Financial Specialist entered resident's room to talk with resident and with permission searched his/her room. The purse was not found. The Administrator was notified at 1:00 P.M., and he/she spoke to resident. The police department was notified. Social services was notified and a grievance was filed. The Administrator followed up with family with resident's permission to check to see if the family had taken the resident's items home. The Financial Specialist, with resident's permission, called the resident's bank to stop active debit cards and check statements to make sure there was no recent activity. The bank confirmed there had been no recent activity. The last check payment was made on 10/23/24. The resident had his/her purse at that time. On 11/07/24, transportation was provided through the facility for resident to go to the bank to pick up new debit cards. The resident was encouraged to have them locked up and wanted the Financial Specialist, to lock them up in the front office. The resident had a date set next week with transportation from the facility to go to the driver's license bureau to get a new id. A plan was set to provide the resident a new purse of comparable cost. Financial Specialist was getting the resident new insurance cards. Facility will provide a lock box for resident to keep his/her valuable items. Resident was encouraged to keep money locked up. Review of the Police Report, dated 11/07/24, showed the following: -On 11/07/24, the officer responded to the facility in reference to a possible larceny. Information gathered and report completed; -The resident said that he/she went to get his/her purse today to write a check and he/she could not find it. The resident said he/she kept the purse in a drawer next to his/her bed and he/she last saw/used it on 10/23/24. The resident and multiple staff members have searched through his/her room and was unable to find his/her purse. The resident described his/her purse to be a black clutch bag that contained 140 dollars in cash or slightly more, two debit cards, driver's license (ID card), vehicle insurance cards, and a check book with one check left in it (unknown check number). The resident valued his/her purse at seven dollars. The resident wished to pursue charges if his/her purse was in fact stolen. The resident had since canceled the remaining check and the two debit cards. There were no security cameras around the facility. -On 11/08/24, the officer contacted the resident by phone. The resident confirmed he/she had notified his/her bank and canceled the debit cards/check. The resident was not aware of any other thefts within the facility. -The resident was asked to contact the police department if his/her bank notified his/hr that his/her debit card got used/declined as well as the stolen check. There were currently no leads or suspects. During an interview on 11/21/24, at 9:19 A.M., the resident said the following: -He/she asked the admission Coordinator to help her get the purse out of his/her drawer so he/she could pay his/her bill to the facility about a week and a half ago; -The purse was not in the drawer -He/she had no idea who would want to take the purse. He/she wishes they would have just taken the money and left the purse; -The purse was a small black purse with a zipper. His/her wallet, including two debit cards, insurance and ID cards, and 140 dollars in 20-dollar bills were gone. She also had some [NAME] and dollar bills but was unsure of exact amount were gone. She also had a check book in the purse; -He/she kept it in the top drawer. He/she believed he/she last saw the purse when he/she paid the facility in October; -The facility looked for the purse everywhere, but were unable to find it; -The facility took him/her to the bank to cancel the cards and get new cards. The cards had not been used. The insurance company is supposed to be sending new cards. -Staff was aware he/she had the purse because she kept it under the mattress at one point and they helped get it out of the drawer so she could pay bills. During an interview on 11/21/24, at 9:40 A.M., the Financial Specialist said the following: -He/she had seen the resident's purse at the facility in his/her room when he/she paid her last check to the facility on [DATE]; -It was a small black purse. He/she also saw that the resident had checks and a wallet in the purse. He/she was not sure of the contents of the wallet; -On 11/07/24, he/she was informed by the Housekeeping Supervisor and Unit Coordinator that the resident was missing his/her purse. The staff searched for the purse and could not find it; -The resident's family said he/she did not take the purse; -The facility helped the resident replace the cards and will be replacing the money; -He/she is not aware of anyone taking any items During an interview on 11/21/24, at 9:50 A.M., the Admissions Coordinator said the following: -He/she was not aware that the resident had a purse or money at the facility. He/she encouraged all residents to not keep valuables or money in their room; -On 11/07/24, he/she went to the resident's room to collect money owed to the facility. The resident asked him/her to get his/her purse out of the drawer in his/her nightstand. When he/she opened he drawer it was not there; -He/she assisted the resident in looking around the room, but the purse was not found; -The resident said he/she was going to talk to his/her family and make sure he/she did not take it home; -The resident later reported that his/her family did not have the purse and it was indeed missing. During an interview on 11/21/24, at 10:00 A.M., the Housekeeping Supervisor said the following: -On 11/07/24, he/she went to take the resident to lunch and he/she was upset because his/her purse was missing; -He/she had seen the purse before. The last time was a few weeks prior. The resident had hid it under the mattress. It was a small black purse; -He/she was aware of her having 140 dollars in the purse because he/she had helped him/her to count the money. He/she also saw that he/she had debit cards, checks, and insurance cards in the purse; -He/she had no idea what happened to the purse; -He/she had been trained to report misappropriation. It is not appropriate for staff or residents to take items from residents. During an interview on 11/21/24, at 10:09 A.M., Unit Coordinator/RN said the following: -He/she was informed that the resident's purse was missing and he/she helped to search the room; -It is not appropriate for anyone to take a resident's belongings; -The staff is to report any stolen items to the Director of Nursing (DON) or Assistant Director of Nursing (ADON). During an interview on 11/21/24, at 3:09 P.M., the DON said the following: -An inventory sheet was not completed for the resident; -The resident did not go out to any appointments between 10/23/24 and 11/07/24. During an interview on 11/21/24, at 3:50 P.M., the DON and the Administrator said the following: -When a resident admits to the facility, the admission team should make sure an inventory sheet is completed of the resident's belongings; -The residents should be encouraged to lock up valuable items or to have them taken home; -It is not appropriate for any staff or residents to take a resident's belongings; -The resident's belongings were not found. The facility is helping to replace all items; -Staff should not be counting the resident's money. MO00245443, MO00244807

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care per standards of practice when facility staff failed to update orders and continue medications upon one resident's (Resident #1) return to the facility from the hospital, resulting in the resident not receiving any medication for one day. The facility census was 114. Review of the facility policy titled, admission of a Resident, effective October 2010, showed the following: -The admission process was intended to obtain all the information as possible about the resident for the development of comprehensive plans of care and to assist the resident in becoming comfortable in the facility; -To obtain a complete document of the physician's plan of care at the time of admission the resident's medical record should include treatments and medications; -The admitting licensed nurse should transcribe all physicians' orders from the transfer sheet (if transferred from another health care institution), or from the physician directly (if admitted from home) and double check for accuracy when transcribing orders onto the facility admission's order sheet; -If the transfer sheet or orders are not signed by the attending physician, a telephone order should be executed to verify the physician's approval. Add any verbal orders for changes in medications or treatments to the admission order sheet. All orders should be signed by the licensed nurse with the full name, acronym, date, and time of day; -Notify appropriate personnel and departments of admission. Notify pharmacy of new admission, medication and treatment orders, and any allergies. Review of the facility policy titled, General Dose Preparation and Medication Administration, effective December 12/01/07, showed the following: -This policy set forth the procedures relating to general dose preparation and medication administration; -Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and the State Operations Manual when administering medications. 1. Review of Resident #1's face sheet showed the following: -admission date of 08/06/24; -readmission date of 09/04/24; -Diagnoses included Parkinson's disease and dyskinesia with fluctuations (a chronic brain disorder that causes movement problems, mental health issues, and other health concerns), metabolic encephalopathy (a series of neurological disorders not caused by primary structural abnormalities), unspecified protein-calorie malnutrition, and dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, memory, and reasoning, that interferes with daily life). Review of the resident's hospital after visit summary, dated 08/29/24, showed the resident was hospitalized from [DATE], at 12:30 P.M., to 09/04/24, at 10:45 P.M. The resident's medication at discharge included the following: -Ondansetron (used to treat nausea) 4 milligrams (mg), take one tablet by mouth every 8 hours as needed for nausea/emesis. Dissolve tablet on top of tongue and then swallow with saliva; -Apixaban (anticoagulant) 2.5 mg tablet, take one tablet by mouth two times daily; -Bisacodyl 10 mg suppository (stool softener), insert one suppository by rectum daily; -Dronabinol 5 mg capsule (used to treat nausea and vomiting caused by cancer chemotherapy), take 1 capsule by mouth two times daily with meals; -Acetaminophen (pain reliever) 325 mg tablet, take 2 tablets by mouth every six hours as needed; -Amlodipine (treats high blood pressure and chest pain) 5 mg tablet, take five mg by mouth daily; -Ascorbic acid (vitamin C) 500 mg tablet, take 1 tablet by mouth 2 times daily; -Buspirone HCL (used to treat anxiety) 5 mg tablet, take three times daily orally; -Carbidopa-levodopa (used to treat Parkinson's disease) 25-100 mg, take one tablet by mouth four times daily; -Cyanocobalamin (vitamin B-12), take one 1,000 microgram (mcg) tablet by mouth daily; -Famotidine (acid reducer) 20 mg tablet two times daily; -Folic acid, five mg tablet one time per day; -Mirtazapine (treats depression) 15 mg tablet, rapid dissolve, place inside cheek daily at bedtime; -Rivastigmine tartrate (treats Parkinson's disease) 1.5 mg capsule, take one capsule by mouth two times daily with meals; -Sucralfate (used to treat ulcers) 100 mg/milliliter (ml) oral every six hours. Review of the resident's progress note dated 09/05/24, at 2:31 A.M., showed Licensed Practical Nurse (LPN) A noted the following: -The resident arrived from the hospital on a stretcher with no paperwork or orders. The resident was alert and oriented to self only. The resident's speech was unclear and he/she found it hard to verbalize needs in an understanding manner. The resident was incontinent of bowel and bladder and will require to be checked and changed. The resident was diagnosed with failure to thrive. The resident was on a regular mechanical soft diet and thin liquids. The resident refused a mechanical soft diet while at the hospital. Bilateral sacral (triangular bone located at the base of the spine) spine deep tissue pressure injury (Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) and unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured) wound on heel. Resident had no signs of pain or discomfort currently. Staff placed call light and cell phone within reach. Review of the resident's September 2024 Physician Order Sheet showed staff did not document any new medication orders, as listed on the hospital discharge summary, for 09/04/24 or 09/05/24. Review of the resident's September 2024 Medication Administration Record (MAR) showed staff did not document administering medications on 09/04/24, 09/05/24, or 09/06/24. Review of the resident's progress note dated 09/06/24, at 4:25 A.M., showed the following: -The resident was sent out to the hospital at approximately 12:42 A.M. in an ambulance. The resident's vitals were stable and there were no signs of acute distress at the time he/she was sent out. The resident's family visited the resident and said that he/she was different than he/she had been at the hospital. The nurse told them that the resident's condition had not changed since admission the night before. The resident's family requested he/she be sent to hospital. The on-call physician notified and order received to send out to hospital. During an interview on 10/03/24, at 2:20 P.M., LPN A said the following: -He/she was working on the over night shift when the resident returned to the facility; -The hospital did not call to give report and he/she did not call the hospital to get report. The resident came from the hospital with no orders or discharge paperwork; -He/she did not know what the policy was and did not know if there was a procedure for admitting a new resident if they did not have orders; -He/she did not know who was responsible for putting in new orders when a resident is readmitted ; -He/She did not call the physician, on-call manager, or the hospital to attempt to get orders; -He/she thought maybe he/she should have called the physician or the Director of Nursing (DON). but the resident was not in distress; -He/She said he/she let a nurse know in the morning, but he/she did not remember who that was; -He/she did not administer any medications to the resident. During an interview on 10/03/24, at 2:33 P.M., LPN B said the following: -He/she worked at the facility on 09/05/24. He/she remembered caring for the resident. He/she was not aware that the resident did not have any medication orders entered; -If he/she would have been made aware, he/she would have called the hospital or physician to get orders. He/she would have entered them, requested them STAT from the pharmacy, and gotten any available medication out of the emergency kit if needed; -The admitting nurse was responsible for entering medication orders and contacting the physician if there was an issue; -He/she sent the resident to the hospital later that evening. During an interview on 10/03/24, at 2:10 P.M., Certified Medication Technician (CMT) D said the following: -He/she remembered working on 09/05/24. They did not have medication orders for the resident after he/she had returned from the hospital; -He/she let the nurse know that he/she could not administer any medications to the resident due to there not being orders; -He/she could not remember who the nurse was; -He/she believes that the hospital did not send discharge orders with the resident when he/she readmitted to the facility: -He/she did not know if the physician was called, but he/she would assume they would be contacted; -He/she believed the nurse can also pull medications from there emergency kit if they do not have them on hand; -The resident may not get their first dose of their medication, or it may be delayed but they should not go all day without getting their medications after they readmit. During an interview on 10/03/24, at 1:25 P.M., Registered Nurse (RN) C said the following: -If a resident was admitted /readmitted , the admitting nurse puts in the orders. If there are no orders, then the physician or hospital should be contacted to get orders. If they still cannot get orders, then the Director of Nursing (DON) should be contacted; -A resident should not go a day without medication. Staff can order important medication stat from the pharmacy. If there is a delay in getting the medication from the pharmacy, they can pull medication from the e-kit or contact the physician for an alternative; -He/she remembered the resident readmitting to the facility, but was not sure why the orders were not put in. During an interview on 10/03/24, at 2:45 P.M. the DON said the following: -The admitting nurse was responsible for making sure they have medication orders and entering the orders into the computer; -The admitting nurse should contact the hospital or physician if the resident does not have orders. He/she would expect the nurse to call and get report on a new admit/readmitted resident; -It is not appropriate for a resident to go a day without any medication if the medications were necessary. The physician should be notified if this occurs. The computer system gives the nurse the option to reactivate orders if it is a readmission; -He/she was made aware of the incident, but it was after it had happened; -The facility had an emergency supply of many medications if they don't have them on hand. During an interview on 10/03/24, at 3:41 P.M., the Administrator said the following: -The admitting nurse was responsible for entering medication orders for the resident; -If a resident arrives to the facility from the hospital without orders that should be communicated and the hospital should be contacted or staff should contact their provider as soon as possible; -It is not appropriate for a resident to go all day without medication; MO00243037

2. Review of the facility's policy Urinary Catheter Care, effective 11/10/14, showed drainage bag covers can be used when the resident leaves the room to promote dignity if a big leaf urinary drain bag is not being used. Review of Resident #311's face sheet showed the following: -admission date of 08/31/23; -Diagnoses included chronic kidney disease (damaged kidneys that can no longer filter blood the way they should). Observation on 09/11/23, at 3:45 P.M., showed the resident walked down the hall with a physical therapist. The resident was using standard walker to assist him/her with walking. The resident's catheter bag was hanging on walker in sight of anyone in the area. The catheter bag was not in a dignity bag. During an interview on 09/11/2023, at 5:13 P.M., the Administrator said the following: -The facility catheter bags have a dignity leaf on them; -If a resident comes from the hospital with a catheter bag, staff should change the bag as soon as possible to a bag with a dignity leaf. -The Administrator was not aware that the resident did not have a dignity catheter bag and stated that the resident should have had his/her catheter bag changed up on admission. Based on observation, interview, and record review, the facility failed to ensure all residents' a dignified existence when staff treated one resident (Resident #164) in an undignified and disrespectful manner and when staff did not utilize a dignity cover for one resident's (Resident #311) catheter (a flexible tube inserted in the bladder) bag while he/she ambulated in the hallway. The facility census was 107. Review of a facility policy entitled Federal Rights of Residents/Guest(s), dated 11/28/16 showed the following: -The resident has a right to a dignified existence; -The resident has the right to be treated with respect and dignity; -The facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality. 1. Review of the Resident #164's face sheet (gives basic profile information) showed the following: -admission date of 09/03/23; -Diagnoses included orthopedic aftercare following surgical amputation, acquired absence of right leg above knee, heart failure, chronic obstructive pulmonary disease (COPD - breathing disorder), acute respiratory failure, encephalopathy (brain disease caused by infection or stroke), peripheral vascular disease (disrupts blood flow to extremities), depression, and sleep disorder. Observation on 09/08/23, at 8:25 A.M., showed Certified Nursing Assistant (CNA) D speaking very loudly to the resident his/her room. The CNA's voice was audible from within another resident's room located across the hall and one door down. CNA D said forcefully, You need to wake up right now! Do we need to put a cold cloth on your face to make you wake up and eat?! Because that is what's going to happen next, and we'll send you to the hospital! Is that what you want? The CNA then exited the room, turned back into the room, loudly saying, Now your light is on again! What is it you want now? I'm not going to keep doing this in and out of the room thing! During an interview on 09/11/23, at 2:55 P.M., CNA D staff should speak to residents like they would speak to a family member and respectfully. If a resident is sleepy at mealtime, staff should try to get them awake enough to eat by using touch, placing food with aromas in front of them, or just talk to them. Staff should answer call lights as soon as possible, and shouldn't speak in a hostile or angry manner. Staff shouldn't say that they were just in there. During an interview on 09/11/23, at 2:05 P.M., CNA E said the facility does education and in-services regarding communicating with dignity/respect. All staff should speak to residents respectfully and in a manner that is not threatening or demanding. Staff should answer call lights respectfully, even if the resident repeatedly uses the call light. During an interview on 09/11/23, at 2:14 P.M., CNA F said staff should speak to residents in a tone of voice that doesn't sound threatening or demanding. Staff should speak in a normal voice at an appropriate volume. Staff should answer call lights nicely. If a CNA notes a resident to be more lethargic than their baseline, they should immediately tell the charge nurse so an assessment can be made. During an interview on 09/11/23, at 2:20 P.M., Licenses Practical Nurse (LPN) G said staff should greet the resident upon entering a room, check with them nicely to assess their needs, and notify the charge nurse if the resident exhibits a change of condition or is lethargic. Staff should never use a tone of voice that might sound threatening or intimidating. During an interview on 09/11/23, at 2:25 P.M., the Director of Nursing (DON) said staff should speak to residents in a calm manner that is not intimidating or demeaning. Staff should answer call lights respectfully to assess for needs. During an interview on 09/11/23, at 4:55 P.M.,with the Administrator, DON, Regional Administrator, and Regional QA Nurse, the facility Administrator said staff should be polite and courteous to all residents. She said it would not be acceptable to answer a call light by saying, What do you want now? I don't want to keep coming in and out of your room. If a resident were sleepy at mealtime, a staff member could gently touch the resident's shoulder or arm and speak to them calmly. An aide should never tell a resident they were going to be sent to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #60's face sheet showed the following: -admission date of 07/11/23; -Diagnoses included urinary tract infection (infection in part in the urinary system including the kidneys, ureters, bladder or urethra), fibromyalgia (chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia), restlessness and agitation, and open wound on left foot. Review of the resident's care plan, last reviewed 07/12/23, showed the following information: -Resident required assistance to complete daily activities of care safely; -Staff should assist with dressing; -Staff should assist with bathing per schedule; -Staff should assist with brushing teeth and oral care; -Staff should assist with hair. Record review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Required limited assistance of one staff for bed mobility, personal hygiene, and dressing;; -Resident able to help in part of the bathing activity with one staff physical assistance. Review of the resident's medical and shower records showed staff documented the resident received a bath on the following dates for July 2023 through September 2023: -Staff documented the resident received a bath/shower on 07/13/23 and 07/14/23; -Staff documented the resident received a bath/shower on 07/25/23 (11 days after the last documented bath/shower): -Staff did not document any baths/showers provided in them month of August 2023; -Staff documented the resident received a bath/shower on 09/5/23. During observation and interview on 09/06/23, at 11:55 A.M., the resident was seated in a chair with his/her spouse. The resident's hair appeared un-brushed and oily. The resident's shirt had several areas of food colored stains down the front. The resident was unable to tell when he/she had a shower last. 2. During an interview on 090/8/23, at 1:15 P.M., Shower Aide R said the following: -Residents are not getting showers as they are scheduled; -He/she said it is because they don't have enough staff working; -He/she usually gives several showers a day, but lately, has been pulled from showers to do other duties. 3. During an interview on 09/08/23, at 1:25 P.M., Nurse Aide (NA) S said the following -It is really hard to get showers in; -When it's about time to give one, it's possible someone will say to forget the showers and go help in another area instead. 4. During an interview on 9/8/23, at 1:35 P.M., NA T said the he/she feels bad about the showers as he/she knows some residents have gone a while without getting one. ) 5. During an interview on 09/11/23, at 4:54 P.M., with the Administrator and the Director of Nursing (DON, the DON said that the facility expectation is that residents receive showers twice per week. She said there are some residents that will absolutely refuse, but maybe once per week. Staff should document if a resident refuses and the preference should be in the care plan. There are three full time shower aides for the long term care side and one for the rehab side. There are times that the facility has had to pull aides from showers to help on the nursing floor or the kitchen due to staffing. If a shower gets missed one day, staff would normally have a make-up shower day. There is a schedule of Monday/Thursday and Tuesday/Friday showers and Wednesday is a make-up day. A resident can have more than two showers per week if that is their preference. If a resident told the DON or the Administrator that they have not had a shower and they would find someone and tell them to get the resident in the shower. MO00223563, MO00224650 Based on observation, interview, and record review, the facility to provide services to maintain good personal hygiene for all dependent residents when staff failed to provide sufficient bathing opportunities to two dependent residents (Resident #22 and #60) which resulted in the resident being noticeably dirty. The facility census was 107. #60 Review of the facility policy titled Hygiene and Grooming, dated 10/01/10, showed the following: -Guidelines for the provision of hygiene and grooming services are shower, tub, or complete bed bath, as needed; -Resident preferences for time of day, type of bath, and frequency of bath should be honored, to the extent possible; -Family members or social service staff may be called upon to assist when the residents refuse appropriate hygiene/grooming measures by nursing staff; -Residents should be encouraged to groom themselves whenever possible. 1. Review of the Resident #22's face sheet (quick summary of the resident's medical information) showed the following information: -admission date of 05/23/23; -Medical diagnoses included adult failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, impaired immune function, and low cholesterol), spina bifida (a congenital defect of the spine in which part of the spinal cord and its meninges (the three membranes that line the skull and vertebral canal and the brain and spinal cord) are exposed through a gap in the backbone, often causing paralysis of the lower limbs) and type II diabetes mellitus (a disease that occurs when blood glucose, also called blood sugar, is too high). Review of the resident's care plan, dated 05/23/23, showed the following information: -Resident required staff assistance for bathing; -Resident required staff assistance for transferring. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated comprehensive assessment instrument completed by facility staff), dated 06/07/23, showed the following information: -The resident requires limited assistance for bathing; -The resident has limited range of motion; -The resident is occasionally incontinent of urine. Observations and interviews during the Resident Council Meeting held on 09/7/23, at 2:00 P.M., showed the resident had a strong body odor. The resident said aides may be assigned to showers, but then they are needed somewhere else and then showers are not being given. Review of the resident's shower sheets showed the following information: -Staff did not shower/bathing records for May 2023 or June, 2023; -Staff documented showers provided on 07/03/23, 07/05/23 and 07/06/23; -Staff documented a shower provided on 07/13/23 (seven days after the prior documented shower); -Staff documented showers provided on 07/14/23 and 07/19/23; -Staff documented a shower provided on 07/29/23 (ten days after the prior documented shower); -Staff documented a shower provided on 08/09/23 (11 days after the prior documented shower); -Staff documented showers provided on 08/14/23; -Staff documented a shower provided on 08/20/23 (six days after the prior documented shower); -Staff documented a shower provided on 08/31/23 (11 days after the prior documented shower); -Staff documented a shower provided on 09/06/23 (six days after the prior documented shower). During an interview on 9/6/23, the resident said the following: -He/she feels like he/she is going several days in between showers; -He/she is not sure of the exact amount of time but knows he/she must wait a long time for the next one to come around; -He/she would like to have showers more so they do not have an odor; -He/she knows there is an odor at times, because he/she has smelled it before; -He/she thinks it takes too long to get showers and it's making him/her uncomfortable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all staff were trained on where to find a resident's choice of code status (whether or not the wish to receive cardiopulmonary resuscitation (CPR - hands-on emergency intervention used to restore heartbeats and breathing) if a person's heart stops or he/she stops breathing), failed to obtain a physician's order for DNR code status for one resident (Resident #92), and failed to ensure one resident's (Resident #62) code status matched throughout the medical record. A sample of 14 residents were reviewed in a facility with a census of 107. Review of the facility policy, titled Advanced Directives and Refusal of Treatment, dated [DATE], showed the following: -The purpose of the policy for Do Not Resuscitate Orders (DNR - resident does not wish to receive CPR) to clearly enunciate the circumstances under which a physician may enter a DNR order into a resident medical record and the practice to be followed when a physician issues such an order; -When a DNR order is decided upon, the DNR order must be entered in the resident's medical record; -DNR orders should be reviewed at least once every thirty days during a resident's first ninety days of admission, then every 60 days thereafter, or as often as appropriate; -Only when the resident's medical status and the resident's or family's wishes indicate, can DNR forms be completed. This could be at any point in the resident's care; -The forms should be placed in the front of the medical record housed in a plastic sheath; -Orders should be written in the physician orders section of the medical record; -In Missouri, an Out of Hospital DNR form should be completed by the resident or legal representative and signed by the attending physician. The form should be printed on purple card stock. 1. Review of Resident #92's face sheet (brief information sheet about the resident) showed the following: -admission date of [DATE]; Diagnoses included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function), and metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), dated [DATE], showed the resident had severe cognitive impairment. Review of the resident's care plan, last updated [DATE], showed no information related to code status. Review of the resident's electronic medical record (EMR) showed a physician order sheet, current as of [DATE], with no orders regarding code status. Review of the resident's paper medical record showed a purple sheet of paper for an Outside the Hospital DNR order that was signed and dated [DATE]. 2. Review of Resident #62's face sheet (resident's information at a quick glance) showed the following: -admission date of [DATE]; -Diagnoses included Alzheimer's disease, insomnia (decreased ability to fall asleep and/or stay asleep), and chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems). Review of the resident's quarterly MDS, dated [DATE], showed the resident had a severe cognitive impairment. Review of the resident's care plan, dated [DATE], showed the following: -The resident is a DNR code status; -Respect the resident's decisions and assure that the resident may change his/her mind at any time concerning terms of living will/DNR. Review of resident's [DATE] Physician Order Summary Report showed the following: -An order, dated of [DATE], for DNR code status. Review of the resident's EMR showed the resident wished to receive CPR. Review of the resident's paper medical record showed a purple sheet of paper for an Outside the Hospital DNR order that was signed and dated [DATE]. 3. During an interview on [DATE], at 11:21 A.M., Certified Nurse Aide (CNA) O said he/she sees a resident's DNR code status when charting. He/she does not know where to find if a resident is full code. 4. During an interview on [DATE], at 2:15 P.M., CNA J said that a resident's code status can be found at the top of the electronic medical record nursing aide charting in a red box. 5. During an interview on [DATE], at 2:35 P.M., CNA C said that a resident's code status is on the aide charting electronic chart in a bold line at the top. 6. During an interview on [DATE], at 10:08 A.M., Licensed Practical Nurse (LPN) I said that a resident's code status can be found in the EMR under the physician's orders and there should be a purple sheet DNR order form in the resident's paper chart. 7. During an interview on [DATE], at 2:45 P.M., LPN M said a resident's DNR code status is found in the electronic chart under physicians' orders. DNR status (purple paper) is found in resident's the hard chart. 8. During an interview on [DATE], at 11:14 A.M., Registered Nurse (RN) L said code status for a resident is found in physician orders in the electric chart and the purple paper in the hard chart. 9. During an interview on [DATE], at 12:35 P.M., the MDS assistant said code status is discussed/reassessed during care plan meetings with either the resident or their representative. 10. During an interview on [DATE], at 4:54 P.M., with the Administrator and Director of Nursing (DON), the DON said that the facility does not enter any information into a resident's chart if they elect to be full code. If a resident elects DNR status an order is obtained and put in the physician's orders and a purple sheet DNR order is in the paper chart. The code status should match throughout the record. The facility policy is for staff to only go by physician's orders for code status. The facility does not use the electronic portion of the face sheet that has code status. There is no way to deactivate the information from the electronic system. It was felt there are too many locations that code status would cause too much room for error. The staff are to only use the physician orders for resident code status.

Based on observation, interview, and record review the facility failed to document assessment and monitoring of a pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one resident (Resident #327) of three sampled residents. The facility census was 107. Review of a facility policy entitled Protocol for Certified Nuse Aide (CNA) and Licensed Nurse Skin Inspections - Guidelines, revised 11/1/22, showed the following: -Intent is to identify any skin concerns in residents immediately and implement early intervention; -CNAs will conduct body inspections of residents at risk for pressure sores on a daily basis. Any skin concern identified by the CNA will be reported to assigned Licensed Nurse immediately; -Licensed Nurses will conduct body inspection of residents at risk for pressure sores on a weekly basis; -Nurse identifying concern should evaluate wound and notify physician for initial treatment orders; -Any skin concerns identified will be presented at the morning meeting; -Weekly results will be reviewed at the Quality Assurance (QA) Skin Sub-Committee meeting. 1. Review of Resident #327's face sheet (gives basic profile information) showed the following: -admission date of 08/22/23; -Diagnoses included orthopedic aftercare following surgical amputation, acquired absence of right leg above knee, sepsis (infection in the blood), atrial fibrillation (irregular heart rhythm), diabetes mellitus, and irritant contact dermatitis due to friction or contact with body fluid. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 08/28/23, showed the following information: -Mild cognitive impairment; -Required extensive assistance of two persons for bed mobility and transfers; -Required extensive assistance of one person for dressing, personal hygiene, toileting, and bathing; -Impairment to one lower extremity; -At risk for pressure ulcers; -No unhealed pressure ulcers; -Presents with moisture associated skin damage (MASD); -Pressure relieving device to chair and bed. Review of the resident's care plan, started on 08/23/23, showed the following: -Goal to be free of skin breakdown for the next 90 days; -Turn and reposition per resident's individual turning schedule; -Provide incontinent care after each episode; -Assess skin daily with routine care. Review of the resident's Physician Order Sheet (POS) showed an order, dated 08/31/23, for change dressing to Stage 2 (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) pressure injury (ulcer) to sacrum (a triangular bone in the lower back) every Monday and Thursday, and as needed. Staff to cleanse with normal saline, apply skin prep (barrier cream) to periwound, apply Xeroform (non-adherent Vaseline infused pad) to wound bed and cover with dry dressing. Review of the resident's nurses' notes on 09/05/23 and 09/06/23 showed staff did not document identification of a new skin issue the order was received for on 08/31/23. Review of the resident's New Skin Audit Report Roster showed the following entries: -On 09/06/23, at 7:46 P.M. (evening shift), CNA D documented Any new skin problems: No; -On 09/06/23, at 3:12 A.M. (night shift,) Nurse Aide (NA) E documented Any new skin problems: No. Review of the resident's nurses' notes on 09/07/23, at 8:51 A.M., Registered Nurse (RN) A documented Stage 2 pressure injury to sacrum resolved. During an interview on 09/07/23, at 8:55 A.M., RN A said he/she had completed the resident's wound treatment for the day shift. The buttock wound was resolved and no longer open. Observation and interview on 09/07/23, at 9:05 A.M., showed the following: -RN A washed his/her hands and donned a gown and gloves per facility protocol; -RN A assisted the resident to turn onto his/her left side and folded back the sheet away from the resident's buttocks and right thigh. RN indicated a skin area and said the resident's coccyx/sacral wound was resolved, and he/she demonstrated that the skin was blanchable (blood flow quickly returns when skin is slightly depressed with a finger); -The surveyor questioned the skin to the left buttock, which showed the skin peeled with an open area approximately 1/2 pea sized; -RN A said he/she had not seen the new wound during the morning's treatment and assessment, but would proceed with physician notification and initiating treatment orders. During an interview on 09/11/23, at 6:05 P.M., CNA B said the aides should check residents' skin with all incontinent care/bathing. They can apply cream, but must tell the charge nurse so they can assess the wound and get treatment orders. During an interview on 09/11/23, at 6:08 P.M., CNA C said the aides should check a resident's skin during any personal care, and they should tell the charge nurse if an open area is noted. The nurse will assess the wound, call the physician, and get treatment orders. During an interview on 09/11/23, at 4:55 P.M., with the Administrator, Director of Nursing (DON), Regional Administrator, and Regional QA Nurse, the Administrator and DON said CNAs should chart information about each resident every shift, including new skin issues. They should notify the charge nurse as soon as possible if a new issue is noted. The charge nurse should obtain physician orders and initiate treatment. If the Wound Care Nurse finds the new wound, he/she should enter the formulary treatment orders into the electronic record, start the treatment, and notify the physician.

Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to prevent possible urinary tract infection (UTI - (infection in any part of the urinary system, the kidneys, bladder) when staff failed to ensure the catheter drainage bag (bag collect urine from tube attach to a catheter (tube) that is inside the bladder) of one resident (Resident #68), with a prior history of UTIs, did not set or drag on the floor under the wheelchair or in the resident's room. Three residents were sampled in a facility with a census of 107. Review of the facility policy titled Urinary Catheter Care, dated 07/12/11, showed catheter tubing and drainage bags are kept off the floor to prevent contamination. 1. Review of Resident #68's face sheet (brief information sheet about the resident) showed the following: -admission date of 03/16/23; -Diagnosis included hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (stroke) affecting the left non-dominant side, urinary tract infection, neuromuscular dysfunction of the bladder (the nerves and muscles don't work together very well and the bladder may not fill or empty correctly), severe dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change) with anxiety, and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). Review of the resident's care plan, last reviewed 04/03/23, showed the following: -Resident had a Foley catheter (flexible tube that passes through the urethra and into the bladder to drain urine) due to diagnosis of neurogenic bladder; -Staff may use leg strap to secure catheter tubing; -Staff should observe for signs and symptoms of infections. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility), dated 08/17/23, showed the following: -Severe cognitive impairment; -Required extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Required total dependence on staff for locomotion; -Used a wheelchair; -Had an indwelling catheter. Review of the resident's physician orders, current as of 09/11/23, showed the following: -An order, dated 08/12/23, for indwelling Foley catheter with routine catheter care every shift. -An order, dated 08/12/23, for Foley catheter, may use leg band. Catheter size of #16 French/10 cc bulb to closed urinary drainage bag. Staff to change catheter and leg band monthly and as needed for obstruction. Observations of the resident showed the following: -On 09/05/23, at 12:30 P.M., the resident was in his/her wheelchair in the dining room waiting for lunch meal. The resident's catheter bag was located under the wheelchair and the bottom of the bag was setting on the dining room floor; -On 09/06/23, at 9:38 A.M., the resident was in his/her wheelchair. A staff member pushed the resident in the hallway from the dining room. The resident's catheter bag was under the wheelchair and the bottom of the bag was being dragged on the floor; -On 09/06/23, at 5:30 P.M., the resident was pushed in his/her wheelchair towards the dining room. The catheter bag was under the wheelchair and dragging on the floor. The bag contained approximately 300 milliliters of urine; -On 09/07/23, at 12:51 P.M., the resident was pushed in hallway by staff to the dining room. The bottom of catheter bag dragged on the floor under the wheelchair; -On 09/08/23, at 08:30 A.M., the resident was resting in bed with his/her eyes closed. The catheter bag was at the bottom of the bed rail and was setting on the floor. During an interview on 09/11/23, at 2:15 P.M., Certified Nurse Aide (CNA) F said that catheter bags should be placed under the wheelchair where the bars cross. The bag should not be touching or dragging on the floor. During an interview on 09/11/23, at 2:25 P.M., CNA H said catheters bags should be placed on the side of the wheelchair or under the wheelchair. They should not be touching or dragging on the floor. He/she said if he/she saw one the floor he/she would pick it up and ensure it was correctly placed. During an interview on 09/11/23, at 2:35 P.M., CNA C said that catheter bags should be placed on the bed rail towards the foot of the bed and should be tucked under the wheelchair when out of bed. The bag should not be touching the ground or dragging on the ground, which would be contamination. He/she would get a clean catheter bag and notify the nurse. During an interview on 9/11/23, at 2:55 P.M., Licensed Practical Nurse (LPN) I said that catheter bags should be in a dignity cover and should be placed below the bladder, the bag should not be touching the floor and should not be dragging on the floor under a wheelchair. He/she would fix it immediately if that was observed. During an interview on 09/11/23, at 3:05 P.M., Certified Medication Technician (CMT) K said that catheter bags should be under the wheelchair and not touching the floor. There should be a dignity bag on the bag and the bag should be adjusted so the bag does not touch the floor. During an interview on 09/11/23, at 4:54 P.M., with the Administrator and Director of Nursing (DON), the DON said that catheter bags should always be below the bladder. The facility catheters bag have the dignity leaf, the bag and dignity leaf should not be on the floor or dragging on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #92's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission date of 12/10/22; -Diagnoses included neurocognitive disorder with Lewy bodies ( type of progressive dementia that leads to a decline in thinking, reasoning and independent function), and myoclonus (sudden, brief involuntary twitching or jerking of a muscle or group of muscles). Review of the resident's care plan, last reviewed 06/05/23, showed the following information: -Resident requires assistance to complete daily activities of care safely; -Staff should assist the resident with hair; -Staff will assist with bathing face and upper body; -Staff will assist with brushing teeth, oral care; -Staff will assist with bath per schedule. (Staff did not care plan regarding the resident's shower/bath preference.) Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 06/08/23, showed the following: -Severe cognitive impairment; -Limited assistance of one staff for bed mobility, transfer, and personal hygiene; -Extensive assistance of one staff for dressing and toilet use; -Resident able to help in part of the bathing activity with one staff physical assistance. Review of the resident's medical/shower records showed staff documented the resident received a bath on the following dates for August 2023 and September 2023: -Staff documented the resident received a bath/shower on 08/17/23; -Staff documented the resident received a bath/shower on 08/29/23 (12 days after the last documented bath/shower); -Staff documented the resident received a bath/shower on 09/07/23 (nine days after the last documented bath/shower). During an interview on 09/06/23, at 1:20 P.M., the resident was seated in a wheelchair in the dining room with a family member present. The resident's family member said that the resident was not getting showers very often and has to ask for a shower. 3. Review of Resident #88's face sheet showed the following: -admission date of 05/19/22; -Diagnoses included age-related osteoporosis (condition that causes the bones to become weak and brittle) and insomnia (persistent problems falling and staying asleep). Review of the resident's care plan, last reviewed 06/05/23, showed the following information: -Resident required assistance to complete daily activities of care safely; -Resident required supervision and verbal cues to complete activities of daily living due to dementia; -Staff should assist with bath per schedule; -Staff should assist with hair; -Staff should assist with brushing teeth and oral care. (Staff did not care plan regarding the resident's shower/bath preference.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -Resident able to help in part of the bathing activity with one staff physical assistance. Review of the resident's medical/shower records showed staff documented the resident received a bath on the following dates for July 2023 and August 2023: -Staff documented a bath/shower on 07/04/23; -Staff documented a bath/shower on 07/13/23 (nine days after the last documented shower/bath); -Staff documented a bath/shower on 07/24/23 (11 days after the last documented shower/bath); -Staff documented a bath/shower on 08/02/23 (nine days after the last documented shower/bath). 4. Review of Resident #96's face sheet showed the following: -admission date of 05/18/23; -Diagnoses included acquired absence (amputation) of right leg above the knee, personal history of transient ischemic accident (TIA -temporary period of symptoms similar to those of a stroke), and cerebral infarction (stroke) without residual deficit. Review of the resident's care plan, last reviewed 05/22/23, showed the following information: -Resident has actual skin breakdown; -Resident required assistance to complete daily activities of care safely; -Staff should complete bath per schedule; -Staff should assist with shaving; -Staff should assist with brushing teeth, oral care; -Staff should assist with hair. (Staff did not care plan regarding the resident's shower/bath preference.) Review of the resident's quarterly MDS, dated [DATE], showed the following: -Cognitively intact; -Required extensive assistance of two staff for bed mobility, transfers, toilet use; -Requires extensive assistance of one staff for dressing and personal hygiene; -Resident able to help in part of the bathing activity with one staff physical assistance. Review of the resident's medical/bathing records showed staff documented the resident received a bath on the following dates for July 2023 through September 2023: -Staff documented a bath/shower on 07/05/23; -Staff documented a bath/shower on, 07/14/23 (11 days after the last documented shower/bath); -Staff documented a bath/shower on 07/20/23 and 07/26/23; -Staff documented a bath/shower on 08/11/23 (16 days after the last documented shower/bath); -Staff did not document any baths/showers in September 2023. During an interview on 09/06/23, at 10:09 A.M., the resident said he/she would love to have a shower. The resident said that he/she felt dirty and felt like he/she probably had body odor. 5. During an interview on 09/08/23, at 1:15 P.M., Shower Aide R said the following: -Residents are not getting showers as they are scheduled; -He/she said it is because they don't have enough staff working; -He/she usually gives several showers a day, but lately, has been pulled from showers to do other duties. 6. During an interview on 09/08/23, at 1:25 P.M., Nurse Aide (NA) S , said the following: -It is really hard to get showers in; -When it's about time to give one, it's possible someone will say to forget the showers and go help in another area, instead. 7. During an interview on 09/08/23, at 1:35 P.M., NA T said he/she feels bad about the showers as he/she knows some have gone a while without getting one. 8. During an interview on 09/11/23, at 4:54 P.M., with the Administrator and the Director of Nursing (DON), the DON said that the facility expectation is that resident receive showers twice per week. She said there are some residents that will absolutely refuse, but maybe once per week. Staff should document if a resident refuses and the preference should be in the care plan. There are three full time shower aides for the long term care side and one for the rehab side. There are times that they have had to pull aides from showers to help on the nursing floor or the kitchen due to staffing. If a shower gets missed one day, they would normally have a make-up shower day. There is a schedule of Monday/Thursday and Tuesday/Friday showers with Wednesday as a make-up day. A resident can have more than two showers per week if that is their preference. If a resident told the DON or the administrator that they have not had a shower and they would find someone and tell them to get the resident in the shower. MO00223563, MO00224650 Based on interview and record review, the facility failed to provide showers/baths per resident preferences and failed to care plan shower/bathing preferences for three residents (Resident #92, #88, and #96). The facility census was 107. Review of the facility policy titled Hygiene and Grooming, dated 10/01/10, showed the following: -Guidelines for the provision of hygiene and grooming services are shower, tub, or complete bed bath, as needed; -Resident preferences for time of day, type of bath, and frequency of bath should be honored, to the extent possible; -Family members or social service staff may be called upon to assist when the residents refuse appropriate hygiene/grooming measures by nursing staff; -Residents should be encouraged to groom themselves whenever possible. 1. Interviews during the Resident Council Meeting held on 09/07/23, at 2:00 P.M., showed the following: -Resident #42 said it was hard to get one shower a week, so two is about impossible; -Resident #82 said he/she has gone two weeks without a shower and he/she will sometimes have to give him/herself a sponge bath; -Resident #16 said he/she has gone more than two weeks without a shower and he/she cannot take one on their own; -Resident #73 said he/she needed help with showering, but does not get very often.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge and failed to provide the ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of the transfer and discharge notification for four residents (Residents #75, #60, #68, and #43), of four sampled residents. The facility census was 107. Review of the facility policy,titled Transfer, Discharge and Therapeutic Leaves (including AMA (against medical advice)), dated 06/26/19, showed the following: -The resident has the right to refuse involuntary transfer out of a or discharge from the facility under certain circumstances; -Emergency discharges should occur only for medical reasons, or for the immediately safety and welfare of a resident or other resident; -Emergency transfer procedures should include the following: -Obtain physician's order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis; -Complete and send with the resident a transfer form which documents current diagnosis, reasons for transfer, date, time, physician, current medications, treatments, functional status, any special needs, and care plan goals; -A copy of any advance directive (written statement of a person's wishes regarding medical treatment), Durable Power of Attorney (written instrument where a person appoint one or more persons to act on their behalf), DNR forms (do-not-resuscitate order, is a medical order indicating that a person should not receive cardiopulmonary resuscitation if that person's heart stops beating) should be sent with the resident; -The original copies of transfer form and advance directives accompany the resident. Copies are retained in the medical record; -Document information regarding the transfer in the medical record; -A copy transfer to hospital notice should be provided upon discharge by the nurse to the resident or resident representative 1. Review of Resident #75's face sheet (brief information sheet about the resident) showed the an admission date of 05/11/21. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/13/23, showed resident was cognitively intact. Review of the resident's nursing progress notes showed the following: -On 06/26/23, at 5:07 A.M., staff documented the resident was experiencing seizure like activity when staff entered the room. The nurse checked on the resident and timed seizure at approximately two minutes. The resident was coherent and talking throughout the seizure. The resident stated this was the second one this morning and are usually due to pain. The resident complained of severe pain in his/her pelvic area. Staff contacted the physician on-call and received an order to send resident to the emergency room for evaluation. Staff prepared paperwork and the ambulance was contacted. Record review of the resident's medical record showed the staff did not have a copy of a written notice provided to the resident, or resident's representative, regarding the hospital transfer on 06/26/23. During an interview on 09/07/23, at 11:19 A.M., the resident said if he/she was given any information regarding transfer, it was likely in the business office. He/she said that he/she was not provided with any paperwork and was his/her own responsible party. 2. Review of Resident #60's face sheet showed an admission date of 07/11/23. Review of the resident's admission MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's nursing progress notes showed the following: -On 07/15/23, at 11:17 P.M., staff documented the nurse went to administer intravenous (IV - by vein) antibiotics at 8:25 P.M. The resident was crying inconsolably, throwing his/her ice water at staff. After hooking up the IV antibiotic staff left the room. The nurse noticed the resident laying in bed naked and the resident had pulled out the PICC line at 8:35 P.M. The resident refused to let staff wrap arm and refused to let staff check vitals. Nurse called on-call physician at 8:40 P.M. the physician called back at 10:10 P.M. and gave a telephone order to send the resident to the hospital due to abnormal mentation (mental activity), possible sepsis (blood infection), and peripherally inserted central catheter (PICC) line needed for IV medicine. The ambulance arrived at 10:55 P.M. and resident transferred by extensive assistance of two emergency medical service (EMS) and three staff members. Resident left facility at 11:00 P.M. Review of the resident's medical record showed the staff did not have a copy of a written notice provided to the resident, or resident's representative ,regarding the hospital transfer on 07/15/23. Review of the resident's nursing progress notes showed the following: -On 07/18/23, at 9:01 P.M., staff observed altered level on consciousness in resident that deviated from his/her baseline. Staff notified on-call provider who ordered the resident transferred to the hospital. At approximately 8:34 P.M., ambulance arrived. Review of the resident's medical record showed the staff did not have a copy of a written notice provided to the resident or resident's representative regarding the hospital transfer on 07/18/23. Review of the resident's nursing progress notes showed the following: -On 07/26/23, at 9:40 A.M., staff documented the nurse was called to the resident room at 7:46 A.M., where resident was found to be unresponsive and having what appeared to be seizure like activity that last for 10 minutes. At 8:03 A.M., more seizure type activity started lasting three minutes. Staff called 911 at 8:03 A.M. and arrived at 8:08 A.M. Once the resident was on the gurney another seizure began. Resident left the facility by ambulance at 8:10 A.M. Review of the resident's medical record showed the staff did not have a copy of a written notice provided to the resident, or resident's representative, regarding the hospital transfer on 07/26/23. Review of the resident's nursing progress notes showed the following: -On 08/07/23, at 5:23 A.M., staff documented at about 12:45 A.M., the nurse observed the resident leaning over the bed and talking to the floor. The nurse assessed the resident and performed vital signs. At 1:45 A.M. the nurse observed the resident again leaning over the bed and talking to the floor and there was not anyone in the room with the resident. The nurse performed vital signs and contacted the on-call physician and advised of deteriorating condition. The physician ordered resident sent to the emergency room. Ambulance left with the resident at 2:12 A.M. Review of the resident's medical record showed the staff did not have a copy of a written notice provided to the resident, or resident's representative, regarding the hospital transfer on 08/07/23. 3. Review of Resident #68's face sheet showed an admission date of 03/16/23. Review of the resident's quarterly MDS, dated [DATE], showed the resident had severe cognitive deficit. Review of the resident's nurses' progress notes showed the following information: -On 08/15/23, at 6:41 A.M., staff documented the resident was found face down on the fall mat with cervical collar on at 5:55 A.M. The nurse assessed the resident. The nurse and the certified nurse aide (CNA) assisted the resident from the floor mat back to bed. Staff notified the clinical supervisor notified of the fall and resident representative was notified of the fall. The nurse reached out to physician on-call and advised of situation. On-call physician gave an order to send the resident to the hospital. Ambulance arrived at 6:20 A.M. Staff notified clinic supervisor of order to send out to hospital. Face sheet, physician orders, and bed hold policy send with the resident to the hospital. Review of the resident's medical record showed no documentation regarding or a copy of a written notice provided to the resident or resident's representative regarding the hospital transfer on 08/15/23. 4. Review of Resident #43's face sheet showed admission date of 10/18/22. Review of the resident's annual MDS, dated [DATE], showed the resident had moderately impaired cognition. Review of the resident's nurses' progress notes showed staff documented the following entries: -On 1/21/23, at 11:16 P.M., staff documented nurse assessed resident at 4:30 P.M. Resident noted to be drinking milk and coughing with productive cough, but difficulty swallowing. Resident stated he/she didn't feel well and declined evening smoke breaks. Staff received radiology report via fax at 10:00 P.M. with chest x-ray results. Resident's right lower lobe with atelectasis (collapse) and heart with mild cardiomegaly (enlargement). Nurse assessed resident at 10:10 P.M. an noted labored breathing with right upper lobe wheeze, right lower lobe crackles, and left lower lobe coarse rub. Resident noted to have declining oxygen saturation rate of 82% and continued to drop. Staff administered breathing treatment per orders and noted it ineffective. Staff switched resident to non-rebreather face mask and increased oxygen to 15 liters pre minute (LPM). Resident's oxygen saturation rate was 87%. Staff contacted physician and received order to send the resident to the hospital at 10:20 P.M. Staff sent face sheet, physician orders, and bed hold policy with resident. Staff notified responsible party. Review of the resident's medical record showed no documentation regarding or a copy of a written notice provided to the resident, or resident's representative, pertaining to the hospital transfers on 01/21/23. Review of the resident's nurses' progress notes showed staff documented the following entries: -On 01/27/23, at 12:40 P.M., nurse practitioner (NP) assessed the resident while aide was in the room checking vital signs. Resident's oxygen saturation was 86% on 5 LPM. NP gave order to send resident to the hospital. Staff contacted wife at 12:40 P.M. Review of the resident's medical record showed no documentation regarding or a copy of a written notice provided to the resident, or resident's representative, pertaining to the hospital transfers on 01/27/23. 5. During an interview on 09/11/23, at 2:55 P.M., Licensed Practical Nurse (LPN) I said that he/she sends a face sheet, bed hold notice, and discharge summary with the resident when transferred to the hospital. He/she calls the family to notify of the transfer. 6. During an interview 09/11/23, at 3:10 P.M., the Social Services Director (SSD) said he/she did not know if any information was sent to the resident's family about transfers to the hospital. He/she did not know if any information was sent to the ombudsman about residents' discharge or transfers. 7. During an interview on 09/11/23, at 6:09 P.M., the front office Financial Specialist said he/she was unable to locate an ombudsman notification log, but believed that the previous SSD had been sending transfer and discharge information to the ombudsman every month. 8. During an interview on 09/11/23, at 4:54 P.M., with the Administrator and Director of Nursing (DON), the DON said that staff should send a hospital transfer form, bed hold policy, face sheet and physician orders with the resident to the hospital and should call the family of the resident transfer to the hospital. She was not aware if a copy of the transfer form was being sent to the ombudsman or if a copy was kept in the resident's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written information to the resident, or resident representative ,regarding the facility bed hold policy at the time of transfer to the hospital for three residents (Residents #75, #60, and #43) of four sampled residents. The facility census was 107. Review of the facility policy,titled Transfer, Discharge and Therapeutic Leaves (including AMA (against medical advice)), dated 06/26/19, showed the following: -The resident has the right to refuse involuntary transfer out of a or discharge from the facility under certain circumstances; -Emergency discharges should occur only for medical reasons, or for the immediately safety and welfare of a resident or other resident; -Emergency transfer procedures should include the following: -Obtain physician's order for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis; -Complete and send with the resident a transfer form which documents current diagnosis, reasons for transfer, date, time, physician, current medications, treatments, functional status, any special needs, and care plan goals; -A copy of any advance directive (written statement of a person's wishes regarding medical treatment), Durable Power of Attorney (written instrument where a person appoint one or more persons to act on their behalf), DNR forms (do-not-resuscitate order, is a medical order indicating that a person should not receive cardiopulmonary resuscitation if that person's heart stops beating) should be sent with the resident; -The original copies of transfer form and advance directives accompany the resident. Copies are retained in the medical record; -Document information regarding the transfer in the medical record; -A copy bed hold policy should be provided upon discharge by the nurse to the resident or resident representative. 1. Review of Resident #75's face sheet (brief information sheet about the resident) showed the an admission date of 05/11/21. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff), dated 07/13/23, showed resident was cognitively intact. Review of the resident's nursing progress notes showed the following: -On 06/26/23, at 5:07 A.M., staff documented the resident was experiencing seizure like activity when staff entered the room. The nurse checked on the resident and timed seizure at approximately two minutes. The resident was coherent and talking throughout the seizure. The resident stated this was the second one this morning and are usually due to pain. The resident complained of severe pain in his/her pelvic area. Staff contacted the physician on-call and received an order to send resident to the emergency room for evaluation. Staff prepared paperwork and the ambulance was contacted. Record review of the resident's medical record showed staff did not document information related to the bed hold policy being to the resident, or resident's representative. During an interview on 09/07/23, at 11:19 A.M., the resident said if he/she was given any information regarding bed hold, it was likely in the business office. He/she said that he/she was not provided with any paperwork and was his/her own responsible party. 2. Review of Resident #60's face sheet showed an admission date of 07/11/23. Review of the resident's admission MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's nursing progress notes showed the following: -On 07/15/23, at 11:17 P.M., staff documented the nurse went to administer intravenous (IV - by vein) antibiotics at 8:25 P.M. The resident was crying inconsolably, throwing his/her ice water at staff. After hooking up the IV antibiotic staff left the room. The nurse noticed the resident laying in bed naked and the resident had pulled out the PICC line at 8:35 P.M. The resident refused to let staff wrap arm and refused to let staff check vitals. Nurse called on-call physician at 8:40 P.M. the physician called back at 10:10 P.M. and gave a telephone order to send the resident to the hospital due to abnormal mentation (mental activity), possible sepsis (blood infection), and peripherally inserted central catheter (PICC) line needed for IV medicine. The ambulance arrived at 10:55 P.M. and resident transferred by extensive assistance of two emergency medical service (EMS) and three staff members. Resident left facility at 11:00 P.M. Record review of the resident's medical record showed staff did not document information related to the bed hold policy being to the resident, or resident's representative. Review of the resident's nursing progress notes showed the following: -On 07/18/23, at 9:01 P.M., staff observed altered level on consciousness in resident that deviated from his/her baseline. Staff notified on-call provider who ordered the resident transferred to the hospital. At approximately 8:34 P.M., ambulance arrived. Record review of the resident's medical record showed staff did not document information related to the bed hold policy being to the resident, or resident's representative. Review of the resident's nursing progress notes showed the following: -On 07/26/23, at 9:40 A.M., staff documented the nurse was called to the resident room at 7:46 A.M., where resident was found to be unresponsive and having what appeared to be seizure like activity that last for 10 minutes. At 8:03 A.M., more seizure type activity started lasting three minutes. Staff called 911 at 8:03 A.M. and arrived at 8:08 A.M. Once the resident was on the gurney another seizure began. Resident left the facility by ambulance at 8:10 A.M. Record review of the resident's medical record showed staff did not document information related to the bed hold policy being to the resident, or resident's representative. Review of the resident's nursing progress notes showed the following: -On 08/07/23, at 5:23 A.M., staff documented at about 12:45 A.M., the nurse observed the resident leaning over the bed and talking to the floor. The nurse assessed the resident and performed vital signs. At 1:45 A.M. the nurse observed the resident again leaning over the bed and talking to the floor and there was not anyone in the room with the resident. The nurse performed vital signs and contacted the on-call physician and advised of deteriorating condition. The physician ordered resident sent to the emergency room. Ambulance left with the resident at 2:12 A.M. Record review of the resident's medical record showed staff did not document information related to the bed hold policy being to the resident, or resident's representative. 3. Review of Resident #43's face sheet showed admission date of 10/18/22. Review of the resident's annual MDS, dated [DATE], showed the resident had moderately impaired cognition. Review of the resident's nurses' progress notes showed staff documented the following entries: -On 01/27/23, at 12:40 P.M., nurse practitioner (NP) assessed the resident while aide was in the room checking vital signs. Resident's oxygen saturation was 86% on 5 liters per minute (LPM). NP gave order to send resident to the hospital. Staff contacted wife at 12:40 P.M. Record review of the resident's medical record showed staff did not document information related to the bed hold policy being to the resident, or resident's representative. 4. During an interview on 09/11/23, at 2:55 P.M., Licensed Practical Nurse (LPN) I said that he/she sends a face sheet, bed hold notice, and discharge summary with the resident when transferred to the hospital. On the bed hold notice the staff fill out the resident's name and the resident can fill out the form while at the hospital and have the hospital fax it back to the facility. 5. During an interview 09/11/23, at 3:10 P.M., the Social Services Director (SSD) said he/she did not know if any information was sent to the resident's family about the bed hold policy. 6. During an interview on 09/11/23, at 4:54 P.M., with the Administrator and the Director of Nursing (DON), the DON said staff should send a bed hold policy with the resident to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain informed consent for the use of side rails (bed rails) prior to installation for three residents (Resident #96, Resident #317, and Resident #311 and failed to obtain physician's orders for side use and failed to care plan side rail use for two residents (Resident #96 and #317). The facility's census was 107. Review of the facility's policy titled Bed Rail Use, effective 10/26/22, showed the following: -Bed rails are used to enable a resident to become more functionally independent and when the medical condition of the resident requires the use of a bed rail; -Bed rails could be considered a form of physical restraint; therefore, the need for bed rails should be identified in the resident assessment, and the plan of care, per guidelines and regulatory requirements; -Bed rails may be used to help a resident position or turn him/herself. Provide instructions to the resident as needed. The interdisciplinary team should determine if the clinical benefits outweighs the risk of a device/bed rail; -Possible hazards and clinical benefits of the bed rail use should be explained to the resident/guest and his/her family/representative, during the admission process and upon initial implementation; -Continued use of bed rails requires documentation of the presence of a medical symptom which would necessitate the use of bed rails, or that the bed rails assist the resident with mobility and transfer abilities and that clinical benefits still outweigh the risks of use; -Complete the Enabler/Assistive Device/Side Rail Review and side rail evaluation upon admission/readmission, upon initially implementing side rail, with a significant change, and with assessments. Side rails should be addressed in the care plan; -The resident and the resident representative should give informed consent to the use of the device prior to use. 1. Review of Resident #96's face sheet showed the following information: -admission date of 05/18/23; -Diagnoses included acquired absence (amputation) of right leg above the knee, history of transient ischemic accident (TIA- temporary period of symptoms similar to those of a stroke) and cerebral infarction (stroke) without residual deficit. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 08/15/23, showed the following: -Cognitively intact; -Required extensive assistance of two staff for bed mobility and transfers. During observation and interview on 09/04/23, at 4:02 P.M., the resident was resting in bed with bilateral one quarter size grab bars on the resident's bed. The resident said he/she used the bars to assist with bed mobility. Review of the resident's medical record on 09/04/23 showed no order for side rails, no care plan information for side rails or grab bar, and no signed consent noted. 2. Review of Resident #317's face sheet showed the following: -admission date of 08/29/23; -Diagnoses included age-related physical debility. Review of the resident's admission MDS, dated [DATE],showed the following information: -Moderate cognitive impairment; -Required limited assistance with transfers; -The resident had a fall one month prior to admission. Observation on 09/05/23, at 11:17 A.M., showed the resident had bilateral (both sides, quarter side rails on his/her bed. During an interview on 09/11/23, at 3:13 P.M., the resident said the following: -The side rails on his/her bed are for his/her protection and give him/her stability to pull up in bed; -The staff did not talk to him/her prior to installing side rails. Review of the resident's medical record showed prior to 09/06/23 the resident's records did not have signed informed consent specific to side rail usage, a side rail evaluation, side rails ordered, or physician's orders for use of side rails. 3. Review of Resident #311's face sheet showed the following: -admission date of 08/31/23; -Diagnoses included chronic kidney disease (damaged kidneys that can no longer filter blood the way they should), heart failure and diabetes. Observation on 09/05/23, at 11:21 A.M., showed the resident #ad bilateral quarter side rails on his/her bed. During an interview on 09/06/23, at 1:20 P.M., the resident said he/she uses the side rails to assist him/her in sitting up in bed. Review of the resident's September 2023 Physician Order Summary report showed an order, dated of 9/1/23, for bilateral quarter rails on bed to promote independence with bed mobility. Review of the resident's care plan, dated 09/01/23, showed the following: -Required enabler, bilateral quarter rails on bed to promote independence with bed mobility; -Inform resident/responsible party of risk of using enabler. Review of the resident's medical record showed prior to 09/06/23 the resident's records did not have signed informed consent specific to side rail usage or a side rail evaluation. 4. During an interview on 09/11/23, at 2:45 P.M., Licensed Practical Nurse (LPN) M said the following: -If a resident requests side rails, LPN M notifies the MDS coordinator; -Maintenance or housekeeping usually installs the side rails. 5. During an interview on 09/11/23, at 3:20 P.M., LPN N said the following: -If a resident requests side rails, LPN N tells the MDS coordinator; -LPN N was not aware of the requirements for resident's to obtain side rails. 6. During an interview on 09/11/23, at 11:14 A.M., Registered Nurse (RN) L said the following; -If a resident requests side rails, RN L alerts therapy services and the MDS coordinator; -Therapy services evaluates for the use of side rails; -The MDS coordinator documents the use of side rails on the residents care plan. 7. During an interview on 09/11/23, at 12:35 P.M., the MDS coordinator said that following: -He/she receives side rail request for therapy services or nursing staff; -The resident is educated on the use/risk of side rails and signs a release/consent for side rails upon admission. 8. During an interview on 09/11/23, at 5:13 P.M., the Administrator said the following: -The resident has to request side rails; -When a resident requests side rails, the MDS coordinator evaluates resident for safe use and takes measurements; -Review of resident's side rail use is completed quarterly and with significant change; -Staff educate residents about the use of side rails upon admission, during evaluation, and when side rails are installed; -Residents sign the restraint information page at admission for any potential side rail use; -No form regarding informed consent for side rail use/education for residents to sign upon installation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to employ a qualified dietary manager for food and nutrition services with accredited education in food service management. The facility census was 107. Review of the facility's job description titled Dietary Manager, dated 06/30/03, showed the following: -The Dietary Manager is to assist in planning, organizing, developing and directing the overall operation of the dietary department in accordance with current federal, state, and local standards governing the facility and as may be directed by the administrator and/or dietary consultant; -The Dietary Manager is to ensure that qualify nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe and sanitary manner; -The Dietary Manager must be a Certified Dietary Manager in good standing or in training to satisfactorily complete the requirements to become a Certified Dietary Manager; -The Dietary Manager must comply with all Quality Assurance and regulatory requirements; -The Dietary Manager must be at least [AGE] years old and previous experience in a supervisory capacity is preferred. 1. During an interview on 09/06/23, at 11:30 A.M., Head [NAME] P said the following: -There is no Dietary Manager and has not been one for quite some time; -The Dietary Manager from a sister facility does come over about once a week to ensure everything is going fine; -There is a Regional Manager who has also came to the facility to ensure everything is going fine until a new manager is hired. During an interview on 09/06/23, at 11:40 A.M., the dietary manager of the sister facility said the following: -He/she has been coming over to this facility to help out wherever needed; -He/she is unsure how long the facility has gone without a Dietary Manager. During an interview on 09/07/23, at 1:40 P.M., the Regional Dietician, said the following: -When here, he/she will stay to make sure the residents are getting meals in a timely manner; -He/she does not remember when the last Dietary Manager left the facility. During an interview on 09/07/23, at 1:55 P.M., the Dietary Manager said the following: -He/she is just now starting the position of Dietary Manager; -He/she is going to start training for being certified as a Dietary Manager. He/she is not currently enrolled. During an interview on 09/11/23, at 5:30 P.M., the Administrator said the following: -They and other staff have been stepping into the kitchen to assist in getting the meals out in a timely manner for the residents; -The last Dietary Manager walked out on 8/11/23; -They thought as long as the Regional Manager and the other Dietary Manager were coming in, that it was sufficient in coverage until a new Dietary Manager was hired.

Based on interview, observation, and record review, the facility failed to ensure food was protected from possible contamination, and in accordance with professional standard of practice, while stored, prepared, and served when staff stacked wet dishes, failed to seal and date open food items, and failed to keep all of the kitchen areas clean and free of debris. The facility census was 107. 1. Review of the Food and Drug Administration (FDA) 2013 Food Code showed the following information: -Clean equipment and utensil shall be stored in a self-draining position that allows air drying; -Items must be allowed to drain and to air-dry before being stacked or stored; -Stacking wet items prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of the facility's policy titled, Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed water pitchers should be air dried. Observation on 09/05/23, at 10:49 A.M., showed the following dishes were wet and stacked upside down, on top of each other, trapping water inside (allowing for potential to grow bacteria): -28 clear plastic glasses; -50 plastic bowls; -24 coffee cups; -12 plastic water pitchers. During an interview on 09/06/23, at 11:30 A.M., Head [NAME] P said the following: -Dishes have to be air dried; -He/she did not realize the dishes were being put away wet. During an interview on 09/06/23, at 10:25 A.M., Dishwasher Q said he/she had not realized that the glasses could not be stacked. During an interview on 09/06/23, at 10:40 A.M., the sister facility Dietary Manager said he/she was unaware dishes were not being air dried before being put away, or he/she would have said something; During an interview on 09/07/23, at 1:40 P.M., the Regional Dietician said the following: -The dishes, especially anything like cups and glasses, should always be air dried and never stacked; -If he/she were aware that the dishes were being stacked before being dried. He/she would have pointed this out and said something. During an interview on 09/07/23, at 1:55 P.M., the Dietary Manager (DM) said he/she is aware that there is potential for bacterial growth if glasses are stacked together wet. During an interview on 09/11/23, at 5:30 P.M., the Administrator, said the following: -All dishes should be air dried before being put away; -Dishes should not be stacked together while drying and prevent nesting (when dishes are stacked in a pile, which may keep them from drying properly); -He/she was not aware that dishes were not being air dried before being put away. 2. Review of the FDA 2013 Food Code showed the following information: -Food held for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded; -Ensure the food is labeled with the product name. Review of the facility policy titled Leftover Food Storage and Use, dated 09/12/19, showed the following information: -Leftovers should be refrigerated promptly, in approved storage containers of appropriate size and depth, to allow prompt cooling; -Leftover foods should be covered, labeled, and dated. Observation on 09/05/23, at 11:12 A.M., of the three-door refrigerator showed the following items were open, exposed to air, and undated/unlabeled: -Large bag of chopped ham; -Plastic container holding chopped tomatoes; -Large bag of lettuce. Observation on 09/05/23, at 11:22 A.M., of the walk-in freezer showed the following items open, exposed to air, and undated/unlabeled: -One large bag of pre-cooked chicken; -One large bag of french fries; -24 cups with a scoop of vanilla ice cream. During an interview on 09/05/23, at 11:30 A.M., Head [NAME] P said the following: -All food put away for later must be dated; -Items in the refrigerator should not be kept longer than three days; -He/she said the ice cream was dished out the night before so that it would be ready for today's lunch. During an interview on 09/07/23, at 1:40 P.M., the Regional Dietician said anything that has been opened is to be labeled and dated before being put back on a shelf. During an interview on 09/11/23, at 5:30 P.M., the Administrator said all items should be labeled and dated so staff knows when the item is good to be used. 3. Review of the 2013 Missouri Food Code showed physical facilities shall be cleaned as often as necessary to keep them in sanitary condition. Record review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed the following information: -Walls and ceilings should be cleaned as needed; --Walls and ceilings should be washed thoroughly at least twice each year. Observation on 09/05/23, at 10:55 A.M., of the kitchen showed the following: -Thick cobwebs covering the window above the sink; -Light film of greasy-lint mixture covering the air conditioner; -The ceiling, around the vents, and above the oven had a film of grease and lint; -The gas pipe going from the stove up into the ceiling was covered with the greasy/lint mixture. (The grease/lint could fall from these areas and contaminate food.) During an interview on 09/07/23, at 1:40 P.M., the Regional Dietician said the the staff have been been so busy and short-staffed, that cleaning has taken a back seat. During an interview on 09/11/23, at 5:30 P.M., the Administrator said they are aware of these areas that are in need of improvement. 4. Review of the 2013 Missouri Food Code showed physical facilities shall be cleaned as often as necessary to keep them in sanitary condition. Record review of the facility policy titled Cleaning of Miscellaneous Equipment and Utensils, dated 09/03/19, showed staff to wash inside and outside of walk-in refrigerator thoroughly. Observation on 09/05/23, at 10:55 A.M., of the walk-in refrigerator showed the following: -On the fan, attached to the ceiling, there was a built up greasy substance clinging to the fan grate covering (protector from the blade). (The build-up could fall and contaminate food.) During an interview on 09/06/23, at 11:40 A.M., the sister facility Dietary Manager said he/she was not aware of anything on the fan covering in the walk-in. During an interview on 09/11/23, at 5:30 P.M., the Administrator said they are aware of these areas that are in need of improvement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to keep the kitchen area clean and free of debris that could potentially come in contact with food being served. This has the potential to harm all residents. The facility census was 107. Record review of the facility policy titled, Cleaning Schedules, dated 8/11/2018, showed the following information: -The purpose of a cleaning schedule is to prevent the spread of bacteria that may cause food borne illnesses; -The cleaning schedule should include the frequency of cleaning for each person responsible. 1. Observation on 9/5/23, at 10:55 A.M., of the kitchen showed the following: - Thick cobwebs were found covering the window, above the sink window; -There is a light film of greasy-lint mixture, covering the air conditioner; -The ceiling, ceiling, especially around the vents and above the oven, are dirty with the same greasy mixture; -The gas pipe going from the stove up into the ceiling, is also covered with the greasy/lint mixture. During an interview on 9/6/23, at 11:30 A.M., Head [NAME] P, said the following: -He/she only noticed the dirty areas after the dietary manager from Carthage, pointed out that the areas were covered in a greasy/lint debris or in cobwebs; -He/she has been so busy trying to just cook that these things have gone unnoticed. During an interview on 9/6/23, at 11:40 A.M., the Dietary Manager (assisting from another facility) said the following: -He/she comes over to make sure things are okay and has started cleaning in some of the areas where they know are obvious issues; -He/she cleaned the area on the ceiling, above the oven and said he/she cannot believe the difference it is with being so much cleaner. During an interview on 9/7/23, at 1:40 P.M., the Regional Dietician, said the following: -He/she said there was no excuse for the kitchen to have this much dirt and grime, except they've been so busy and short-staffed, that cleaning has taken a back step; -He/she said it will be resolved soon and very clean. Record review of the facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, dated 9/3/2019, showed the following information: -Refrigerator (walk-in type); -Wash inside and outside thoroughly; -Wash walls and baseboards; -Rinse and sanitize; -Mop floor; -Clean the drain; -Shelves should be washed weekly. Walls and Ceilings (as needed): -Walls and ceilings should be free of chipped and /or peeling paint; -Walls and ceilings should be washed thoroughly at least twice each year; -Painted walls and ceilings should be washed with a mild detergent solution, rinsed using a clean cloth and dried to eliminate streaking. Observation on 9/5/23, at 10:55 A.M., of the [NAME] walk-in refrigerator showed the following: -On the fan, attached to the ceiling, has a greasy substance that is built up and clinging to the fan grate covering (protector from the blade); -When touched, the item smears and is thick and hard to remove. During an interview on 9/6/23, at 11:40 A.M., the Dietary Manager (from another facility) said the following: -He/she was not aware of anything on the fan covering, in the walk-in. During an interview on 9/7/23, at 1:40 P.M., the Regional Dietician, said the following: -He/she said they actually just noticed the substance on the fan, earlier this very day; -He/she is trying to figure out what it actually is, but said it will be taken care of; -He/she will have maintenance shut the unit off so they can clean it out, really well. During an interview on 9/7/23, at 1:55 P.M., Dietary Manager, said the following: -He/she is aware that cleaning has not been the most important issue but that this will be changing; -He/she is going to do some in-services and everyone will clearly understand their duties. During an interview on 9/11/23, at 5:30 P.M., the administrator, said the following: -He/she said they are aware of these areas that are in need of improvement and he/she is confident the new kitchen manager will implement all necessary changes from here on out.

Based on interview, observation, and record review, the facility failed to ensure staff were aware of the emergency water policy and that a minimum amount of water was kept on hand at all times in case of emergency. The facility census was 107. Review of the facility's policy titled Water Service Interruption, undated, showed the following information: -Purpose to ensure water is available to the facility for both consumption by residents and staff, and for use in residents care, such as bathing; -As part of disaster planning, the facility should prepare a contingency plan, in the event of the loss of normal water supply, for each department; -The Administrator is to notify the appropriate state agency regarding interruption of water supplies to the facility; -All staff, residents, and visitors should be notified; -Disaster plans for the provision of emergency water supplies should be implemented. 1. Review of the facility's policy worksheet, provided in which the Regional Dietary Manager (RDM), showed the amount of required needed was based on 110 residents. The following calculations showed water needed per day: -Bedside fluids - 83 gallons; -Medications - 18 gallons; -Tube feeding fluids - 3 gallons; -Hand washing/resident hygiene - 220 gallons; -Water with meals - 42 gallons; -Three compartment sink - 75 gallons; -Cooking - 40 gallons; -Clean up - 30 gallons; -Laundry/Housekeeping - 688 gallons; -Floors - 150 gallons; -Toilets - 1000 gallons; -Total water needed daily of 2377 gallons. Observation on 09/05/23, at 11:35 A.M., of the kitchen showed there was no large supply of water being stored that could be used it there was an emergency. During an interview on 09/06/23, at 11:45 A.M., Head [NAME] P said the following: -He/she was not aware of any water being stored near or in the kitchen; -He/she was not aware of any water being stored in any other location of the building that could be used in case of an emergency -He/she was not aware that the facility if the facility had a supply of extra water to be used if there was an emergency. During an interview on 09/07/23, at 11:40 A.M., the sister facility Dietary Manager said the following: -He/she was not aware if the facility has an emergency supply of water; -He/she has not seen any stored water. During an interview on 09/07/23, at 2:45 P.M., the RDM, said the following: -He/she said the facility did have a contract with a supplier to provide emergency water and to keep it supplied; -He/she was not sure what happened to that contract, but thinks it has probably been discontinued. During an interview on 09/07/23, at 3:10 P.M., the Dietary Manager said he/she was not aware until today, about keeping water on-site, for emergency purposes. During an interview on 09/11/23, at 5:30 P.M., the Administrator, said the following: -He/she said they have just decided they can't hold the larger bottles like anticipated, so they are going to go with a different provider who will provide smaller containers; -They will make sure to keep up with the contract to ensure there is always water on-site, in case of any kind of emergency.

Based on interview and record review the facility failed to treat one resident (Resident #250) with dignity and respect. A sample of 23 residents was selected for review in a facility with a census of 114. Record review of facility's policy titled Resident/Guest Rights, dated November 2016, showed the following: -The resident/guest has the right to a dignified existence; -A facility must treat each resident/guest with respect and dignity and care for each resident/guest in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident/guest(s) individuality. 1. Record review of the Resident #250's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 7/1/19; -Diagnoses including Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors), major depressive disorder, and anxiety disorder. Record review of the resident's quarterly Minimum Data Set (MDS), federally mandated assessment instrument completed by facility staff, dated 12/23/19, showed the following: -Cognitively intact; -Independent with eating, bed mobility, transfers, and toileting; -Limited staff assistance required for dressing and walking; -Staff supervision required for hygiene. Record review of the resident's care plan, review date 1/17/20, showed a focus area of potential for altered mood state/psychosocial well-being due to depression. The interventions showed direction for the following: -Provide support and reassurance as needed; -Encourage/allow the resident to voice feelings and concerns; -Address complaints/concerns timely. During interviews on 01/30/20, at 10:00 A.M., and on 02/04/20, at 1:44 P.M., the resident said the following: -The Director of Nursing (DON) made a comment about the resident playing an air guitar due to his/her involuntary arm movement; -Another staff member knew by his/her face that he/she was upset. The staff member apologized for the DON; -He/She was embarrassed and upset by it; -He/She lays on his/her arm to keep it from shaking; -Staff help him/her with smallest tasks, such as brushing his/her teeth; -The DON apologized and nothing has happened like that again; -Staff normally are kind to him/her. During an interview on 01/31/20, at 1:44 P.M., the Housekeeping Supervisor said the following: -Staff receive training during orientation, as well as on-going training, on resident rights; -Training covers dignity and respect and include the facility is the residents' home; -He would immediately report any observation of a resident not being treated with respect. During an interview on 02/04/20, at 11:22 A.M., Certified Medication Technician (CMT) D said the following: -Residents should be treated with respect; -Staff receive training on resident rights, especially if an incident occurs; -He/she would report any dignity/respect concerns to charge nurse; -He/she has not observed any incident of a resident being treated disrespectfully. During an interview on 02/04/20, at 11:52 A.M., Licensed Practical Nurse (LPN) C said the following: -Staff receive training on treating residents with dignity and respect; -He/she treats the residents like family as this is their home; -Staff should speak kindly and not disrespectfully to the residents; -He/She would tell a staff member to stop if he had any concerns regarding dignity/respect and he would immediately report it to management; -He/she recently observed an incident with a staff member telling a resident, who has severe tremors, that he/she had mastered the air guitar. The resident shakes severely and becomes upset, anxious and depressed about his lack of independence. The resident walked off after the comment from the DON. LPN C apologized to resident. The resident said his/her feelings were hurt; -Staff have to assist the resident with many tasks. During an interview on 02/04/20, at 2:34 P.M., the Administrator said the following: -Employee on-line training classes continually cover resident rights; -Staff receive training at orientation on respect and dignity for the residents; -She expects staff to treat residents with respect and dignity; -She tells the new employees to treat residents like family; -If staff observe another staff member not treating residents with respect, she would expect staff to report it to management; -An incident occurred which involved DON and a comment to a resident; -The DON wrote out a statement and apologized to the resident and said he did not mean the comment in a derogatory way. During an interview on 2/4/20, at 2:53 P.M., the DON said the following: -He received training on resident rights at orientation; -Staff receive on-going training's on abuse and neglect, as well as resident rights; -He expects staff to immediately report any observation of residents not being treated with respect and dignity. MO00166017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff administered medications with an error rate of less than 5.0 percent when staff made two errors out of 29 opportunities, resulting in an error rate of 6.8 percent. This affected two residents (Resident #202 and Resident #46). The facility census was 114. Record review of the Tresiba (a long-acting insulin) website guidance, dated 9/2015, showed the following: -Prime (referred to as an air shot) the flex pen before each injection; -Turn the dose selector to select two units; -Press and hold the dose button; -Make sure a drop appears; -Priming the flex pens removes the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly; -Failure to prime the flex pen before each injection may result in administering an incorrect dose of insulin. Record review of the Levemir (a long-acting insulin) website guidance, dated 2/2015, showed direction to avoid injecting air and ensure proper dosing, prime the flex pen before each injection to release air that may collect in the cartridge during normal use. Failure to prime the pen may result in too much or too little insulin administered. 1. Record review of Resident #202's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 1/15/20; -Diagnosis of diabetes mellitus (DM - chronic condition that affects the way the body processes blood sugar (glucose)). Record review of the resident's physician order, dated 1/17/20, showed direction for staff to administer Tresiba insulin 20 units (U) per FlexTouch pen (a prefilled insulin pen) subcutaneously (SQ - under the skin) daily for diabetes. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/22/20, showed the following: -Moderately impaired cognition; -Insulin injections five out the previous seven days. Record review of the resident's care plan, dated 1/28/20, showed staff identified the resident at risk for complications related to diabetes and intervention included administer medications as ordered for diabetes. Observations on 1/30/20, at 7:56 A.M., showed Registered Nurse (RN) A placed a needle on the resident's Tresiba FlexPen and dialed the pen to 20 units. RN A administered the resident's insulin. The RN did not prime the FlexPen prior to administering the insulin. 2. Record review of Resident #46's face sheet showed the following: -admission dated 11/21/19; -Diagnosis of DM with long-term use of insulin. Record review of the resident's care plan, dated 11/22/19, showed staff identified the resident at risk for complications related to diabetes and intervention included administer medications as ordered for diabetes. Record review of the resident's admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Insulin injections seven out the previous seven days. Record review of the resident's PO, dated 1/20/20, showed direction for staff to administer Levemir insulin 12 units per FlexTouch pen SQ two times a day for diabetes. Observations on 1/30/20, at 8:05 A.M., showed RN A opened the residents new, sealed Levemir FlexPen. He/She dialed the FlexPen to 12 units. The RN administered the resident's insulin. The RN did not prime the FlexPen prior to administering the insulin. 3. During an interview on 2/4/20, at 11:30 A.M., RN B said new Flex Pens should be primed before use but opened FlexPens are not primed before each use. 4. During an interview on 2/4/20, at 11:45 A.M., the Director of Nursing (DON) said he expected staff to prime insulin FlexPens prior to each use. Staff should dial the pen to two units and press the dose button to perform an air shot to expel air out of the cartridge and needle prior to selecting the ordered dose of insulin. 5. During an interview on 2/4/20, at 12:10 P.M., the Administrator said the facility does not have a policy for insulin FlexPen's. Staff should follow the manufacturer's recommendations and guidelines. Staff should always prime the FlexPen's prior to administering insulin injections. Failure to prime the pens puts the resident at risk for receiving the wrong dose of insulin. Staff had been educated on administering insulin with the FlexPens.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure all residents were free from significant medication errors when staff administered insulin (medication used to help control blood sugar levels) without priming the insulin pens prior to administration per manufacture recommendations and standards of practice for two (Resident #202 and Resident #46). The facility census was 114. Record review of the Tresiba (a long-acting insulin) website guidance, dated 9/2015, showed the following: -Prime (referred to as an air shot) the flex pen before each injection; -Turn the dose selector to select two units; -Press and hold the dose button; -Make sure a drop appears; -Priming the flex pens removes the air from the needle and cartridge that may collect during normal use and ensures the pen is working correctly; -Failure to prime the flex pen before each injection may result in administering an incorrect dose of insulin. Record review of the Levemir (a long-acting insulin) website guidance, dated 2/2015, showed direction to avoid injecting air and ensure proper dosing, prime the flex pen before each injection to release air that may collect in the cartridge during normal use. Failure to prime the pen may result in too much or too little insulin administered. 1. Record review of Resident #202's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 1/15/20; -Diagnosis of diabetes mellitus (DM - chronic condition that affects the way the body processes blood sugar (glucose)). Record review of the resident's physician order, dated 1/17/20, showed direction for staff to administer Tresiba insulin 20 units (U) per FlexTouch pen (a prefilled insulin pen) subcutaneously (SQ - under the skin) daily for diabetes. Record review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 1/22/20, showed the following: -Moderately impaired cognition; -Insulin injections five out the previous seven days. Record review of the resident's care plan, dated 1/28/20, showed staff identified the resident at risk for complications related to diabetes and intervention included administer medications as ordered for diabetes. Observations on 1/30/20, at 7:56 A.M., showed Registered Nurse (RN) A placed a needle on the resident's Tresiba FlexPen and dialed the pen to 20 units. RN A administered the resident's insulin. The RN did not prime the FlexPen prior to administering the insulin. 2. Record review of Resident #46's face sheet showed the following: -admission dated 11/21/19; -Diagnosis of DM with long-term use of insulin. Record review of the resident's care plan, dated 11/22/19, showed staff identified the resident at risk for complications related to diabetes and intervention included administer medications as ordered for diabetes. Record review of the resident's admission MDS, dated [DATE], showed the following: -Moderately impaired cognition; -Insulin injections seven out the previous seven days. Record review of the resident's PO, dated 1/20/20, showed direction for staff to administer Levemir insulin 12 units per FlexTouch pen SQ two times a day for diabetes. Observations on 1/30/20, at 8:05 A.M., showed RN A opened the residents new, sealed Levemir FlexPen. He/She dialed the FlexPen to 12 units. The RN administered the resident's insulin. The RN did not prime the FlexPen prior to administering the insulin. 3. During an interview on 2/4/20, at 11:30 A.M., RN B said new Flex Pens should be primed before use but opened FlexPens are not primed before each use. 4. During an interview on 2/4/20, at 11:45 A.M., the Director of Nursing (DON) said he expected staff to prime insulin FlexPens prior to each use. Staff should dial the pen to two units and press the dose button to perform an air shot to expel air out of the cartridge and needle prior to selecting the ordered dose of insulin. 5. During an interview on 2/4/20, at 12:10 P.M., the Administrator said the facility does not have a policy for insulin FlexPen's. Staff should follow the manufacturer's recommendations and guidelines. Staff should always prime the FlexPen's prior to administering insulin injections. Failure to prime the pens puts the resident at risk for receiving the wrong dose of insulin. Staff had been educated on administering insulin with the FlexPens.

Based on interview and record review, the facility failed to ensure the required two-step tuberculosis (TB - a potentially serious airborne bacterial infection affecting the lungs that spreads through the air when a person with TB coughs, sneezes, or talks) test was completed and documented completely for two residents (Resident #55 and #79). A sample of 23 residents was selected for review out of a census of 114. General requirements for Tuberculosis testing for residents in Long Term Care Facilities, 19 CSR 20-20.100, reads as follows: -Long-term care facilities shall screen their residents for tuberculosis using the Mantoux method purified protein derivative (PPD) five tuberculin unit test. Each facility shall be responsible for ensuring all test results are completed and documentation is maintained for all residents. -Within one month prior to or one week after admission, all residents new to long-term care are required to have the initial test of a Mantoux PPD (tuberculin sensitivity test) two-step tuberculin test. If the initial test is negative, the second test can be given after admission and should be given one to three weeks later; -All skin test results are to be documented in millimeters (mm) of induration. -All long-term care facility residents shall have a documented annual evaluation to rule out signs and symptoms of tuberculosis disease. Record review of the facility's policy titled Tuberculosis Screening, dated 11/2016 showed the following: -Residents will receive a TB test on admission; -Read results in 72 hours; -If result of the first test is negative (0-9 mm induration) administer a second test one to three weeks later. 1. Record review of Resident #55's face face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 9/6/19; -Diagnoses included heart disease, shortness of breath, nicotine dependence and a history of upper respiratory infection. Record review of the resident's physicians order, dated 9/6/19, showed direction for staff to administer Tubersol 0.1 milliliters (ml) intradermal (a shallow or superficial injection of a substance) and to read and record the results in millimeters (mm). Record review of the resident's medication administration record (MAR) showed the following: -On 9/6/19, staff administered an intradermal TB test; -On 9/9/19, staff documented no adverse reactions; -Staff did not document the result of the TB test in millimeters; -Staff did not document the resident received the second of the two-step TB test. 2. Record review of Resident #79's face sheet showed the following: -admission dated 6/27/19; -Diagnoses included end stage renal disease (last stage of chronic kidney disease (longstanding disease of the kidneys leading to kidney failure)), chronic obstructive pulmonary disease (COPD - a lung disease that blocks airflow and makes it difficult to breathe). Record review of the resident's POS showed the following: -Dated 12/04/19, an order directed staff to administer Tubersol 0.1 ml, intradermally and to read and record the results in 72 hours; -Dated 12/18/19, an order directed staff to administer Tubersol 0.1 ml, intradermally and to read and record results in 72 hours. Record review of the resident's MAR dated December 2019 showed the following: -On 12/4/19, staff documented administering Tubersol 0.1 ml. Staff did not document the results of the TB test; -On 12/18/19, staff documented administering Tubersol 0.1 ml, the second step of the two-step TB test without results of the first step. Staff documented the results on 12/21/19. 3. During an interview on 2/4/20 at 11:30 A.M., Registered Nurse (RN) B said the following: -A charge nurse administers a resident's TB skin test on admission; -The TB test should be read in 72 hours and the results documented in the resident's medical record; -All resident will have a two-step TB test completed. 4. During an interview on 2/4/20 at 11:45 A.M., the Director of Nursing (DON) said staff should administer a TB test on the date of a resident's admission. The test should be read in 72 hours and the results documented in millimeters in the resident's medical record. A second step TB test is scheduled 10 days after the first TB test is done. If staff fail to read the TB test within the 72 hour time frame, the two step process should be repeated. 5. During an interview on 2/4/20 at 11:54 A.M., the Administrator said all residents should receive the two-step TB testing on admission. She expects the tests to be read within 72 hours and documented in the resident's record. Resident #55 did not receive the second TB test. The two-step TB testing should have been repeated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pneumococcal vaccines (vaccines used to prevent some cases of pneumonia, meningitis (swelling of brain and spinal cord membranes, typically caused by an infection), and sepsis (potentially life-threatening complication of an infection)) to two residents (Resident #55 and #250) following the residents' admission to the facility. The facility census was 114. According to the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults, dated 11/30/15, showed the following: -Two pneumococcal vaccines are recommended for adults; -CDC recommends vaccinations with the pneumococcal conjugate vaccine (PCV13 or Prevnar 13) for all adults 65 years or older and people 19 through 64 years with certain medical conditions, including chronic (ongoing) conditions; -CDC recommends vaccination with the pneumococcal polysaccharide vaccine (PPSV23 or Pneumovax23) for all adults 65 years or older regardless of previous history of vaccinations with pneumococcal vaccines, and people 19 to [AGE] years old with certain medical conditions including chronic medical condition. Record review of the facility's policy titled Inoculations, dated September 2006, showed the following: -Upon admission, residents will be offered the pneumonia vaccines in accordance with CDC recommendations; -Before receiving the pneumococcal vaccinations, the resident or the legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccines; -Provision of offered vaccinations and education shall be documented in the resident's medical record. 1. Record review of Resident #55's face sheet (a document that gives a resident's information at a quick glance) showed the following: -admission dated 9/6/19; -Diagnoses included heart disease, shortness of breath, nicotine dependence and history of upper respiratory infection. Record review of a pneumococcal vaccine consent form dated 9/20/19 showed the resident's responsible party requested the PCV13 and the PPSV23 for the resident. Record review of the resident's medical record showed staff did not document administering the PCV13 or the PPSV23 to the resident. 2. Record review of Resident #250's face sheet showed the following: -admission dated 7/1/19: -Diagnoses included diabetes, Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors) and coronary artery disease. Record review of a pneumococcal vaccine consent form dated 10/12/19 showed the resident requested the PCV13 and the PPSV23. Record review of the resident's medical record showed staff did not document administering the PCV13 or the PPSV23 to the resident. 3. During an interview on 2/4/20 at 11:30 A.M., Registered Nurse (RN) B said he/she was unaware of the process for providing the pneumococcal vaccines. He/She said the charge nurses do not routinely give the vaccines. 4. During an interview on 2/4/20 at 11:45 A.M., the Director of Nursing (DON) said the following: -The facility follows CDC guideline for recommendations for pneumonia vaccines; -The pneumonia vaccines will be offered on admission to the resident or the resident's responsible party. If consent if obtained, the charge will administer the vaccine as indicated. 5. During an interview on 2/4/20 at 11:54 A.M., the Administrator said she expects staff to follow the CDC guidelines for pneumonia vaccines. The facility offers both the PCV13 and the PPSV23 vaccines. All vaccines should be documented on the resident's medication administration record when administered. Residents #55 and #250 had signed consents requesting the pneumonia vaccines. Staff failed to administer the pneumonia vaccines.