Based on interview and record review, the facility failed to ensure the completion of a necessary significant change Minimum Data Set (MDS, a federally mandated comprehensive assessment) for one resident with a hospice admission (Resident #161) out of 8 sampled residents. The facility census was 13. Review of a facility policy titled Minimum Data Set Assessments, dated 6/13/24, lacked information regarding triggering an MDS assessment and timing of assessments. Review of the MDS 3.0 Resident Assessment Instrument (RAI) Manual (a federally published guide for facility staff to complete and submit MDS assessments accurately and timely) instructed facilities to set a Significant Change Assessment Reference Date (ARD, the date of assessment initiation) no later than 14 days following the determination that a significant change had occurred. The RAI includes a hospice admission as a significant change and guides facilities to complete a Significant Change MDS assessment. 1. Review of Resident #161's Progress Note dated 4/10/24 at 1:13 P.M., showed the resident was admitted to Hospice A on 4/10/24. Review of the resident's Physician Order Sheet (POS) on 6/13/24 showed an order for admission to hospice placed on 5/1/24 to begin on 4/22/24. Note: the physician's orders did not get entered timely into the resident's medical record. Review of the resident's MDS assessments showed: -His/Her last assessment to be completed was a Quarterly Assessment, dated 12/11/23. -A Significant Change Assessment with the status of In Progress and an ARD of 5/24/24, 44 days from the hospice admission. During an interview on 6/12/24 at 11:48 A.M., Licensed Practical Nurse (LPN) A said: -He/she was recently hired by the facility in April and was responsible for completing MDS assessments. -He/she opened the Significant Change Assessment, but it was too late. -The Significant Change MDS Assessment should have been completed by now, but it has not. During an interview on 6/12/24 at 12:34 P.M., the Director of Nursing (DON) said: -LPN A was responsible for completing MDS assessments. -The Significant Change Assessment was the responsibility of the previous Assistant Director of Nursing (ADON), but he/she no longer worked at the facility. -Staff thought it was too late to complete the Significant Change Assessment, so it was not done. -MDS has been an ongoing problem for the facility. -The past ADON did not complete MDS assessments timely. -He/She expected MDS assessments to be completed within an acceptable timeframe per the RAI Manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #161's hospice facility admission orders, dated 4/10/24 and signed by a hospice Registered Nurse (RN), showed: -The resident was admitted to hospice services on 4/10/24. -An order for oxygen at 2 liters per minute as needed (PRN). -An order for Morphine (a narcotic pain medication) 5 milligrams (mg) every one hour as needed for pain or dyspnea (difficulty breathing). -An order for Lorazepam (a controlled medication used for anxiety) 0.5 mg every four hours as needed for anxiety. Review of the resident's POS on 6/13/24, showed orders for admission to hospice services and PRN oxygen. Review of the resident's undated Care Plan on 6/13/24 showed: -No information or direction for staff on the PRN oxygen order. -No information regarding indication, side effect monitoring or direction for staff on the Morphine or Lorazepam orders. -No indication the resident was admitted to hospice services, the date of service initiation, medication information, or what services the hospice agency would provide to the resident. 3. During an interview on 6/13/24 at 10:54 A.M., LPN C said: -The nurse usually will let the MDS Coordinator know when residents' care needs have changed, and the MDS Coordinator will update the resident's care plan. -The nurses will implement what the change in care is and write and implement new physician's orders (if there is a change in orders), but the nurses do not document any updates to the care plans. During an interview on 6/13/24 at 11:12 A.M., the Director of Nursing (DON) said: -Regarding the resident care plans, both the former and current MDS Coordinator did not keep up with updating care plans. -The care plans were already past due because the MDS's were past due. -The MDS Coordinator is not the only person who can update the care plan, but this is how it was done before now. -He/She has been assisting with updating the care plans as residents' care changes. -The nurses can update the care plans as the residents' care changes. -The quarterly updates to the care plans will be done with the MDS. Based on observation, interview and record review, the facility failed to ensure the care plans were updated as residents' care and needs changed for two sampled residents (Residents #59 and #161) out of 8 sampled residents. The facility census was 13 residents. 1. Review of Resident #59's Face Sheet showed the resident was admitted on [DATE], with diagnoses including Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), malnutrition, depression, high blood pressure, diabetes, low back pain and neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool to be completed by facility staff for care planning, dated 11/3/23, showed the resident: -Was alert and oriented with no confusion or behaviors. -Had no upper or lower extremity impairments and ambulated independently. -The resident had no significant weight loss or weight gain and did not have any chewing or swallowing problems. -The resident did not have another MDS completed or submitted since 11/3/23. Review of the resident's Nutrition Notes, dated 2/8/24, showed: -The resident's weight on 2/3/24 showed 160.5 pounds (Lbs.) down 8.7 percent in one month, down 16.3 percent in three months, and down 17.5 percent in six months. -The resident received a regular diet with chopped meat. -The resident's meal intake is usually between 75-100 percent. -The staff reports the resident eats well, was trying to lose weight, and eats less between meals. -The resident's skin was intact. -Notes showed the resident was happy with weight loss. His/Her intake met his/her nutritional needs. Continue plan of care and monitoring. Review of the resident's Care Plan dated 2/29/24, showed the resident had poor oral health which led to oral/dental health problems. The resident was able to perform oral care independently. The resident received a regular diet and did receive dental services from the facility dentist and has upper and lower dentures. Interventions showed staff would: -Serve the resident's diet as ordered and chop meats upon request. -Consult with the facility dentist as needed for oral management. -Consult with the Dietician if chewing and swallowing problems change. -Monitor the resident, report and document any signs/symptoms of oral/dental problems that need attention. -Assist the resident as needed with nutritional choices to achieve his/her weight loss goal. -Educate the resident regarding nutritional needs and requirements. -Encourage the resident to consume adequate protein to maintain stable blood sugars. -Encourage the resident to consume nutritious foods. Review of the resident's Weight Record showed the resident was on weekly weights for monitoring. The resident's monthly weights showed: -1/27/2024 =162.4 pounds (Lbs.) -2/24/2024 =164.8 Lbs -3/30/2024 =156.6 Lbs -4/27/2024 =151.8 Lbs -5/25/2024 =150.8 Lbs -6/8/2024 =145.8 Lbs -The documentation showed the resident's weight loss of 10.49 percent in 6 months, 6.45 percent in 3 months, and 2.68 percent in one month was not significant weight loss but his/her weight loss was gradual. Review of the resident's Physician's Order Sheet (POS), dated 6/2024, showed physician's orders for: -Regular modified diabetic diet with chopped meats (8/22/23). -Weekly weights on Saturday, notify the physician for weight gain or loss of more than 5 pounds (1/6/24). -Cholecalciferol Tablet 1000 UNIT Give 2 tablet by mouth one time a day related to protein calorie malnutrition (3/21/24). -Glucerna shake at breakfast (4/16/24). -Trulicity pen injection 0.75 milligrams (mg) inject 1.5 mg subcutaneously (beneath the skin) once daily for diabetes (5/30/24). Review of the resident's electronic record showed no additional notes showing the resident had any problems with weight loss or justification for weight loss interventions after 2/29/24. Documentation showed there was no problems with the resident's gums, however the documentation showed that the facility dentist made adjustments to the resident's dentures. There was no documentation showing this affected the resident's intake. Review of the resident's Care Plan dated 6/12/23, showed there was no update to the resident's nutritional status to show the resident had weight loss that was being monitored, had a weight loss goal, was placed on a health shake, was taking medication that directly affected his/her weight loss or if the resident had reached weight loss goals or what the current status nutritional status of the resident was. Observation and interview on 6/12/24 at 9:19 A.M., showed the resident was in his/her bed resting but was awake. The resident was not wearing dentures. The resident was alert and oriented and said: -The facility dentist came and got his/her dentures to readjust them because they didn't fit anymore due to him/her losing weight. -He/She currently had his/her dentures, but it has taken him/her time to get used to wearing them. -It really had not affected him/her being able to eat. -He/She was trying to lose weight, but he/she was also on Trulicity, which induced weight loss. -During the time he/she was without his/her dentures he/she wasn't eating as much, but he/she did not mind the weight loss. Once he/she got the new dentures, he/she continued to lose weight, but he/she thought his/her continued weight loss was due to the Trulicity. Observation on 6/12/24 at 12:01 P.M., showed the resident sitting in the dining room eating a regular diet of pork loin, sweet potato, cabbage with choice of beverage. He/She was not wearing his/her dentures and was eating independently without an assistive device or staff assistance. The resident was eating without choking, coughing or swallowing difficulty. He/She ate 75 percent of his/her meal and once he/she was done, he/she got up and ambulated out of the dining room. During an interview on 6/12/24 at 2:50 P.M., Licensed Practical Nurse (LPN) A said: -The resident had weight loss that was self-initiated by the resident. -The resident wanted to lose some weight and stopped eating as much. -The resident was also started on Trulicity for diabetes, which also has a side effect of weight loss and so some of her weight loss also came from the medication. -The resident had not had any issues eating and ate independently. -The resident usually ate without his/her dentures but does have and wear dentures. -He/She was not sure if the resident's continued weight loss was self induced. -She said the information regarding the resident's weight loss and interventions should be in the resident's care plan.

Based on interview and record review, the facility failed to transcribe medication orders accurately and periodically reconcile physician orders when an antipsychotic medication was added to a resident's medical record without an order for one resident (Resident #161) of 5 residents sampled for unnecessary medications. The facility census was 13. A policy for order transcription and medication reconciliation was requested on 6/13/24 but was not received prior to exit. 1. Review of #161's face sheet showed diagnoses including seizures, dementia without behavioral disturbances, adjustment disorder (excessive reactions to stress that involve negative thoughts, strong emotions, and changes in behavior), stroke, and insomnia (difficulty sleeping). Review of the resident's hospice facility admission orders, dated 4/10/24 and signed by a hospice Registered Nurse (RN), showed: -The resident was admitted to hospice services on 4/10/24. -A section of the orders titled Comfort Kit orders had standing orders and instructions to circle NO for all declined orders and draw a line through the order. -An order circled NO for Haloperidol (an antipsychotic drug used to treat certain types of severe mental disorders that can cause major, lasting side effects) 2 milligrams per milliliter (mg/ml), 1mg by mouth or sublingually (under the tongue) every four hours as needed for delirium, agitation, nausea and/or vomiting. -The order for Haldol had a line through the text and an X to the left of the order. Review of the residents Physician Order Sheet (POS) on 6/13/24, showed an order for Haloperidol 1mg sublingually, every four hours as needed for delirium, agitation, nausea and/or vomiting beginning on 4/10/24 with no end date. Review of the residents Medication Administration Record (MAR) since 4/10/24 showed the resident had not received any Haloperidol. During an interview on 6/12/24 at 12:05 P.M., Licensed Practical Nurse (LPN) A said he/she had not input any hospice admission orders yet but would think that a medication that was circled no with a line through the text would be a non-valid order and should not have been input into the resident's record. During an interview on 6/12/24 at 12:34 P.M., the Director of Nursing (DON) said: -The nurse would be responsible for transcribing hospice orders from the sheet and inputting them into the resident record. -The nurse on duty on 4/10/24 put the hospice orders in the computer and the DON verified the orders. -Medication orders should be reconciled once per month to ensure accuracy. -He/she had not reconciled medications in the previous two months. -The Haloperidol order should not have been input into the resident's medical record and should have at least been discontinued after 14 days per standard of practice for antipsychotic drugs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure initial and quarterly smoking assessments were completed to establish a resident's capacity for smoking and establish a baseline for the resident's ability to smoke, determine assistance as necessary, and ensure safe smoking habits were in place and continuing for two sampled residents (Residents #3 and #59) out of 9 residents who smoked in the facility. The resident sample was 8 residents. The facility census was 13 residents. Review of the facility Smoking policy and procedure, dated 9/25/23, showed the purpose was to establish a healthy environment for residents, visitors and employees. Additionally, the facility must comply with federal, state and local regulations regarding smoking in healthcare facilities. The policy showed: -Residents may smoke outside of the building in designated areas and away from the facility's exterior doors. -Employees are responsible for reminding residents, visitors and other employees of the smoking policy if they see someone violating the smoking policy. -Residents, family members and visitors will be notified -Smoking assessments will be completed upon admission, quarterly and with significant change of condition in conjunction with the Minimum Data Set (MDS), a federally mandated assessment tool to be completed by facility staff for care planning. -Generally, all residents will be supervised smoking upon admission and up to 72 hours after admission. -Residents who have been assessed as having the cognitive and functional ability to smoke independently may smoke in the designated areas independently as desired. These residents may keep their cigarettes and smoking materials. 1. Review of Resident #3's Face Sheet showed the resident was admitted on [DATE], with diagnoses including glaucoma (a disease that damages your eye's optic nerve that can cause blindness), high blood pressure, heart disease, paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), pain and edema (fluid in the tissues). 1. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment tool to be completed by facility staff for care planning, dated 1/26/23, showed the resident: -Was alert and oriented without confusion or behaviors. -Had bilateral lower extremity impairment and mobilized in a wheelchair. -Needed moderate to total assistance with transfers, bathing, dressing (lower body), and toileting. -The MDS did not show the resident used tobacco products. Review of the resident's Care Plan dated 5/2/24, showed: -The resident smoked cigarettes. -Interventions instructed staff to: --Instruct the resident about smoking risks and hazards and smoking cessation aids available. --Instruct the resident on the facility smoking policy. --Notify the charge nurse immediately if the resident violates the facility smoking policy. --Observe the resident for signs of cigarette burns on his/her skin and body. -Resident was educated on not throwing cigarette butts into the grass and not to smoke under the awning. --The resident was able to light his/her own cigarette and keep his/her own lighter. --The resident was able to smoke unsupervised. Review of the resident's electronic medical record showed there was no documentation showing the facility staff completed an initial smoking assessment, annual smoking assessment or any quarterly assessments thereafter on the resident. There was no documentation showing the resident's continued ability to safely smoke and abide by the facility smoking policy. Observation on 6/12/24 at 9:28 A.M., showed the resident was sitting in his/her wheelchair outside smoking. He/She was positioned upright without any noticed contracture or loss of upper body control. The resident was in the designated smoking area with other peers smoking safely. There was staff outside with the residents. 2. Review of Resident #59's Face Sheet showed the resident was admitted on [DATE], with diagnoses including high blood pressure, diabetes, low back pain and neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of the resident's most recent quarterly MDS dated [DATE], showed the resident: -Was alert and oriented with no confusion or behaviors. -Had no upper or lower extremity impairments and ambulated independently. -Was independent with bathing, dressing, toileting, transferring and eating. -The MDS did not show the resident used tobacco products. Review of the resident's Care Plan dated 3/2/23 showed: -The resident smoked cigarettes. -Interventions instructed staff to: --Instruct the resident about smoking risks and hazards and smoking cessation aids available. --Instruct the resident on the facility smoking policy. --Notify the charge nurse immediately if the resident violates the facility smoking policy. --Observe the resident for signs of cigarette burns on his/her skin and body. -The resident was educated on not throwing cigarette butts into the grass and not to smoke under the awning. --The resident was able to light his/her own cigarette and keep his/her own lighter. --The resident was able to smoke unsupervised. Review of the resident's electronic medical record showed there was no documentation showing the facility staff had completed an initial smoking assessment, annual smoking assessment or quarterly smoking assessments on the resident. There was no documentation showing the resident's continued ability to safely smoke and abide by the facility smoking policy. Observation on 6/11/24 at 2:00 P.M., showed the resident was sitting outside dressed for the weather smoking in the designated smoking area. He/She was smoking safely without assistance. When he/she was finished, he/she disposed of the smoking materials in the self-enclosed receptacle. 3. During an interview on 6/13/24 at 10:54 A.M., Licensed Practical Nurse (LPN) C said: -The nurses complete the initial smoking assessments, and they are in the resident's electronic medical record. -She said all smoking assessments are done in the facility electronic record system, not on paper. -The nurses should be completing quarterly smoking assessments, but he/she really had not seen any smoking assessments on residents that smoke. During an interview on 6/12/24 at 11:42 A.M., the Director of Nursing (DON) said: -He/She was not able to find the smoking assessments for the residents requested. -He/She did not realize that the smoking assessments had not been populating in the facility's electronic record system. -He/She was unable to find the handwritten smoking assessments except for one. -He/She completed the requested smoking assessments today and was auditing all of the files for the residents who smoke to ensure there are smoking assessments in their records. During an interview on 6/13/24 at 11:12 A.M., the DON said: -There were 9 residents who smoked in the facility and he/she was able to find smoking assessments on 5 residents. -He/She completed smoking assessments, in the electronic medical record, on everyone who smoked. -The residents should have an initial/annual smoking assessment and staff are supposed to complete quarterly assessments thereafter. -He/She did not find any quarterly assessments in the electronic records for the residents that smoked. -He/She discussed this in their team meeting and realized that the assessments were not being done appropriately and they are now going to ensure the assessments are going to be done with the quarterly MDS.

Based on observation, interview and record review, the facility failed to ensure medications were administered without significant errors when staff administered Lorazepam (a controlled medication given for anxiety) two times within one and one-half hours. This affected one resident (Resident #160) out of seven sampled residents for medication pass. The facility census was 13. A facility policy titled Medication Administration-General Guidelines, dated 9/1/2006, showed: -Medications were to be administered per physician orders. -Medications were to be administered within 60 minutes of the ordered time. -The individual who administered the medication was to document the administration directly after the medication was given. 1. Review of Resident #160's Physician Order Sheet (POS), obtained 6/13/24, showed: -An order for Carbidopa-Levodopa (a medication given for tremors) 25 milligrams (mg) Carbidopa/100 mg Levodopa, four times daily (9:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M.) -An order for Lorazepam (a controlled medication given for anxiety) 0.5 mg, three times daily (between 7:00 A.M.-10:00 A.M., between 11:00 A.M.-1:00 P.M., and between 7:00 P.M.-9:00 P.M.) During an interview on 6/13/24 at 7:20 A.M., Certified Medication Technician (CMT) A said: -The night nurse would often pass some day shift medications but would not document the medications as given. -He/She would have to look through the medication cart to see who had received medications and who had not. -The only way to tell if the medications had been given was to look at the timed/dated pill packs that some of the medications came from the pharmacy in to see if they were missing. -If the medication pack was missing, he/she would assume all the resident's morning medications had been given, even if they were not documented as given by the night shift nurse. During an observation of the medication pass on 6/13/24 at 7:30 A.M.: - Certified Medication Technician (CMT) A reviewed Resident #160's Medication Administration Record (MAR). -The MAR indicated the only medication due for the resident was Carbidopa-Levodopa. -CMT A said the night nurse gave many of the morning meds, and he/she was unsure which had been given. -After review of the resident's MAR, CMT A removed a Lorazepam 0.5 mg tablet from the locked narcotic box and signed the tablet out of the narcotic book. -CMT A administered the 0.5 mg Lorazepam tablet to the resident. -CMT A documented that Carbidopa-Levodopa was given in the MAR, but did not document Lorazepam in the MAR. Surveyor reconciliation of the medication administration on 6/13/24 at 8:14 A.M., showed Carbidopa-Levodopa had been signed out at 7:00 A.M. by Licensed Practical Nurse (LPN) B and again at 7:30 A.M. by CMT A. Further reconciliation revealed LPN B had documented the Lorazepam being given at 6:14 A.M. During an interview on 6/13/24 at 8:24 A.M., CMT A said he/she had given the resident only Lorazepam at the 7:30 A.M. administration. During an interview on 6/13/24 at 8:28 A.M., during review of the MAR, CMT A said he/she administered both Lorazepam and Carbidopa-Levodopa to the resident and he/she did not know why the MAR documentation had not shown the Lorazepam. CMT A verified the MAR showed Lorazepam was administered at 6:14 A.M., but that he/she gave it at 7:30 A.M. Review of the resident's MAR on 6/13/24, showed: -One documented administration of Lorazepam at 6:14 A.M. by LPN B. -A documented administration of Carbidopa-Levodopa at 7:32 A.M. by CMT A. During an interview on 6/13/24 at 8:30 A.M., the Director of nursing (DON) said: -Night shift may pick and choose some medications to administer for the day shift. -He/She expected any medications given by the night shift to be documented by the staff administering the medication. -He/She would not expect the day shift to have to guess who had received medications. -He/she expected staff to only document administration of medications they had administered themselves. -The Lorazepam appeared to be given to the resident twice within a one-hour timeframe.

Based on interview and record review, the facility failed to follow facility policies and procedures for checking the Nurse Aide Registry for federal indicators of abuse as part of the Criminal Background Check (CBC) and in accordance with state requirements for two of four employees sampled for the criminal background screening. The facility census was 13 residents. Review of the facility's revised Abuse and Neglect policy and procedure dated 1/1/2024, showed: -All potential employees will be screened and trained to ensure that individuals with a documented history of abuse or other inappropriate conduct are not hired, and that all employees are properly trained regarding abuse of residents. -All employees will be screened prior to contact with facility residents, and quarterly, as follows: Federal Indicator List. 1. Review of two employee records showed: -Licensed Practical Nurse (LPN) B was hired on 2/5/24, and there was no Nurse Aide Registry Check completed. -Cook A was hired on 4/8/24, and there was no Nurse Aide Registry Check completed. During an interview on 6/12/24 at 12:16 P.M., the Human Resource Manager said: -He/She was not aware that the nurse aide registry was supposed to be completed on all employees. -He/She was going to complete an audit on all employee records to ensure the nurse aide registry is completed and in all employee files. -He/she was responsible for completing background checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #160's Face Sheet showed the resident admitted [DATE] with diagnoses including urinary retention, anxiety, hemiplegia (paralysis of one side of the body following a stroke) of the right side, chronic pain, unspecified mood disorder, and a stage two pressure ulcer. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last annual assessment was completed 11/20/22 and was shown in the medical record as being 196 days overdue. -An annual assessment dated [DATE] was noted with a status of In Progress, but was incomplete and not submitted. 4. Review of Resident #4's Face Sheet showed the resident admitted [DATE] with diagnoses including cancer, depression, PTSD, and a personal history of other unspecified behavioral disorders. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last comprehensive assessment was the admission assessment, completed 4/13/23. -A comprehensive assessment was due 4/13/24, had not been completed, and was 46 days overdue. 5. Review of Resident #1's Face Sheet showed the resident admitted [DATE] with diagnoses including anxiety and depression. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last comprehensive assessment was a significant change assessment, completed 3/15/23. -A comprehensive assessment was due 3/15/24, had not been completed, and was 75 days overdue. 6. During an interview on 6/13/24 at 10:54 A.M., Licensed Practical Nurse (LPN) A said he/she does not complete the MDSs normally but as residents' care needs change, the nurse will let the MDS Coordinator know and the MDS Coordinator will update the residents' MDS assessments and care plans. During an interview on 6/13/24 at 11:12 A.M., the Director of Nursing (DON) said: -He/She expects for MDS to be completed and submitted timely. -Annual assessments should be completed according to the resident's MDS schedule yearly. -He/She was aware there were problems with the MDS submissions. -The former MDS Coordinator was not full time and the timeframe between when he/she left the position and when they found a new MDS Coordinator was when the submissions fell behind. -The current MDS Coordinator is in training and has not been able to get everything caught up yet but they are in the process of doing so. Based on interview and record review, the facility failed to ensure the annual comprehensive Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) were completed timely for four sampled residents (Residents #59, #57, #1, #4) out of 8 sampled residents and one supplemental resident (Resident #160). The facility census was 13 residents. 1. Review of Resident #59's Face Sheet showed the resident was admitted on [DATE], with diagnoses including Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), malnutrition, depression, high blood pressure, diabetes, low back pain and neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of the resident's MDS assessments showed: -The resident's last annual assessment was dated 5/3/23. -The resident's annual assessment was due on 5/3/24. The electronic medical record showed this assessment was 26 days overdue. -There was a quarterly assessment dated [DATE] that showed in progress but was not completed (this assessment should have been the annual assessment). 2. Review of Resident #57's Face Sheet showed the resident was admitted with diagnoses including stroke, high blood pressure, glaucoma (a disease that damages your eye's optic nerve that can cause blindness), and history of transient ischemic attack (TIA- stroke-like attack that, despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke). Review of the resident's MDS assessments showed: -The resident's last annual assessment was completed 5/3/24. -The resident's annual assessment was due on 5/3/24 and was shown in the electronic medical record as being 26 days overdue. -There was a quarterly assessment started on 6/21/24 and was shown in the electronic record as in progress but was not completed (this assessment should have been the Annual assessment).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #4's Face Sheet showed the resident admitted [DATE] with diagnoses including cancer, depression, PTSD, and a personal history of other unspecified behavioral disorders. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last quarterly assessment was completed 1/14/24. -A quarterly assessment was due 4/15/24, had not been completed, and was 44 days overdue. 6. Review of Resident #1's Face Sheet showed the resident admitted [DATE] with diagnoses including anxiety and depression. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last quarterly assessment was completed 12/16/23. -A quarterly assessment was due 3/17/24, had not been completed, and was 73 days overdue. 7. Review of Resident #2's Face Sheet showed the resident admitted [DATE] with diagnoses including high blood pressure and hemiplegia (partial or complete paralysis on one side of the body) on the right side. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last quarterly assessment was completed 12/19/23. -A quarterly assessment was due 3/20/24, had not been completed, and was 70 days overdue. 8. Review of Resident #161's Face Sheet showed the resident admitted [DATE] with diagnoses including seizures, dementia, hemiplegia, and insomnia. Review of the resident's MDS assessments on 6/13/24 showed: -The resident's last quarterly assessment was completed 12/11/23. -A quarterly assessment was due 3/12/24, had not been completed, and was 78 days overdue. 9. During an interview on 6/13/24 at 10:54 A.M., Licensed Practical Nurse (LPN) A said: -He/She said she does not complete the MDS but normally as residents' care needs change, the nurse will let the MDS Coordinator know and the MDS Coordinator will update the resident's MDS and care plan. During an interview on 6/13/24 at 11:12 A.M., the Director of Nursing (DON) said: -He/She expects for MDS to be completed and submitted timely. -Quarterly MDS should be completed every three months as scheduled. -He/She was aware there were problems with the MDS submissions. -The former MDS Coordinator was not full time and the timeframe between when he/she left the position and when they found a new MDS Coordinator was when the submissions fell behind. -The current MDS Coordinator is in training and has not been able to get everything caught up yet but they are in process of doing so. Based on record review and interview, the facility failed to ensure Minimum Data Sets (MDS, a federally mandated assessment tool to be completed by facility staff for care planning) were completed quarterly for 8 residents (Residents #3, #5, #59, #57, #4, #1, #2, and #161) out of 8 sampled residents. The facility census was 13 residents. 1. Review of Resident #3's Face Sheet showed the resident was admitted on [DATE], with diagnoses including urinary tract infection, diabetes, vitamin deficiency, glaucoma (a disease that damages your eye's optic nerve that can cause blindness), high blood pressure, heart disease, paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), pain and edema (fluid in the tissues). Review of the resident's MDS assessments showed: -The resident's last Annual assessment was completed on 6/25/2023. -The resident's Quarterly assessment was due on 3/27/24. It was not completed and showed in the electronic medical record as being 63 days overdue. 2. Review of Resident #5's Face Sheet showed the resident was admitted on [DATE], with diagnoses including a below the knee amputation. Review of the resident's MDS assessments showed: -The resident's admission assessment was completed on 11/29/23. -The resident's Quarterly assessment was due on 5/31/24. It was not completed and showed in the electronic medical record as being 2 days overdue. The electronic record showed the assessment was in process on 5/29/24. 3. Review of Resident #59's Face Sheet showed the resident was admitted on [DATE] with diagnoses including Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), malnutrition, depression, high blood pressure, diabetes, low back pain and neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of the resident's MDS assessments showed: -The resident's last annual assessment was dated 5/3/23. -The resident's quarterly assessment was due on 2/3/24. It was not completed and showed in the electronic medical record as being in process. This assessment was also shown as being 116 days overdue. 4. Review of Resident #57's Face Sheet showed the resident was admitted with diagnoses including stroke, high blood pressure, glaucoma, and history of transient ischemic attack (TIA-stroke-like attack that, despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke). Review of the resident's MDS assessments showed: -The resident's last Annual assessment was completed 5/3/24. -The resident's Quarterly assessment was due on 2/3/24. It was not completed and showed in the electronic medical record as being 116 days overdue.

Based on observation, interview and record review, the facility failed to ensure staff administered medications with a rate less than 5%. Facility staff made eight medication errors out of 29 attempts, resulting in a medication error rate of 27.59%. This affected three of seven sampled residents (Residents #2, #4, and #160) for medication pass. The facility census was 13. A facility policy titled Medication Administration-General Guidelines, dated 9/1/2006, showed: -Medications were to be administered per physician orders. -Medications were to be administered within 60 minutes of the ordered time. -The individual who administered the medication was to document the administration directly after the medication was given. 1. Resident #160's Physician Order Sheet (POS), obtained 6/13/24, showed: -An order for Carbidopa-Levodopa (a medication given for tremors) 25 milligrams (mg) Carbidopa/100 mg Levodopa, four times daily (9:00 A.M., 12:00 P.M., 5:00 P.M., and 9:00 P.M.) -An order for Lorazepam (a controlled medication given for anxiety) 0.5 mg, three times daily (between 7:00 A.M.-10:00 A.M., between 11:00 A.M.-1:00 P.M., and between 7:00 P.M.-9:00 P.M.) During an interview on 6/13/24 at 7:20 A.M., Certified Medication Technician (CMT) A said: -The night nurse would often pass some day shift medications but would not document the medications as given. -He/She would have to look through the medication cart to see who had received medications and who had not. -The only way to tell if the medications had been given was to look at the timed/dated pill packs that some of the medications came from the pharmacy in to see if they were missing. -If the medication pack was missing, he/she would assume all the resident's morning medications had been given, even if they were not documented as given by the night shift nurse. During an observation of the medication pass on 6/13/24 at 7:30 A.M.: -CMT A reviewed Resident #160's Medication Administration Record (MAR). -The MAR indicated the only medication due for the resident was Carbidopa-Levodopa. -CMT A said the night nurse gave many of the morning meds, and he/she was unsure which had been given. -After review of the resident MAR, CMT A removed a Lorazepam 0.5 mg tablet from the locked narcotic box and signed the tablet out of the narcotic book. -CMT A administered the 0.5 mg Lorazepam tablet to the resident. -CMT A documented in the MAR that he/she gave Carbidopa-Levodopa, but did not document that he/she gave Lorazepam. Surveyor reconciliation of the medication administration on 6/13/24 at 8:14 A.M., showed Carbidopa-Levodopa had been signed out at 7:00 A.M. by Licensed Practical Nurse (LPN) B and again at 7:30 A.M. by CMT A. Further reconciliation revealed LPN B had documented the Lorazepam being given at 6:14 A.M. During an interview on 6/13/24 at 8:24 A.M., CMT A said he/she had given the resident only Lorazepam at the 7:30 A.M. administration. During review of the MAR and an interview on 6/13/24 at 8:28 A.M., CMT A then said he/she administered both Lorazepam and Carbidopa-Levodopa to the resident and he/she did not know why the MAR documentation did not show he/she gave the Lorazepam. CMT A verified the MAR showed Lorazepam was administered at 6:14 A.M., but that he/she gave the resident a second dose at 7:30 A.M. Review of the resident's medication administration record (MAR) on 6/13/24, showed: -One documented administration of Lorazepam at 6:14 A.M. by LPN B. -A documented administration of Carbidopa-Levodopa at 7:32 A.M. by CMT A. -The CMT documented in error that he/she gave the Carbidopa-Levodopa, when he/she gave the resident a second dose of Lorazepam instead. During an interview on 6/13/24 at 8:30 A.M., the Director of nursing (DON) said: -He/she would not expect the Carbidopa-Levodopa to be documented if not given. -The Lorazepam appeared to be given to the resident twice within a one-hour timeframe. 2. Review of Resident #4's POS on 6/13/24 showed physician orders for: -Metoprolol (a drug given for high blood pressure and an elevated heart rate) 50mg tab to be given at 9:00 A.M. -Gabapentin (a drug given for nerve pain) 100 mg to be given at 9:00 A.M. -Cyclobenzaprine (a drug given for muscle spasms) 10mg to be given at 9:00 A.M. During an interview on 6/13/24 7:34 A.M., CMT A said Resident #4 had already had his/her medications administered because some had been documented on by night shift and the pill pack containing all of the medications was missing, so he/she would not be giving the resident any medications that morning. Review of the resident's MAR on 6/13/24 at 7:35 A.M., at that time, indicated Gabapentin, Metoprolol and Cyclobenzaprine had not been administered and were due at 9:00 A.M. During an interview on 6/13/24 at 7:36 A.M., CMT A stated again he/she would not be administering those medications, as they had already been given by the night shift and were not in the medication cart. Review of the MAR provided by the facility on 6/13/24 at 11:00 A.M., showed the doses of Gabapentin, Metoprolol, and Cyclobenzaprine had not been administered. 3. Review of Resident #2's POS showed physician orders for: -Acetaminophen (an over-the-counter pain medication) 500 mg, two tablets, at 8:00 A.M. -Metoprolol 50mg to be given at 9:00 A.M. -Tramadol (a narcotic pain medication) to be given at 9:00 A.M. -Linzess (a drug for maintaining healthy bowel movements) to be given at 9:00 A.M. During an observation on 6/13/24 at 8:01 A.M.: -CMT A took two Acetaminophen 500 mg tablets from the medication cart and attempted to administer them to the resident. -The resident declined and said he/she had already received all their medications that morning, including the Acetaminophen. -No medications were administered. -CMT A returned to the medication cart and documented Acetaminophen, Metoprolol, Tramadol and Linzess as administered at 8:08 A.M. Review of the resident's MAR provided by the facility on 6/13/24, showed the medications had been documented as administered at 8:08 A.M. 4. During an interview on 6/13/24 at 8:30 A.M., the Director of nursing (DON) said: -Night shift may pick and choose some medications to administer for the day shift. -He/She expected medications to be given no earlier than one hour before or no later than one hour after the time on the MAR. -He/She expected any medications given by the night shift to be documented by the staff administering the medication. -He/She would not expect the day shift to have to guess who had received medications. -He/she expected staff to only document administration of medications they had administered themselves. -He/she expected the medications to be documented as they were given, not hours later.

Based on observation and interview, the facility failed to retain operable thermometers in all refrigerators and/or freezers to confirm adequate temperature ranges; failed to maintain plastic cutting boards in good condition to avoid food safety hazards (cross-contamination); and failed to separate damaged foodstuffs, in accordance with State of Missouri rules and regulations, established national guidelines, and professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who ate food from the kitchen. The facility's census was 13 residents with a licensed capacity for 16 residents at the time of the survey. 1. Observations on 6/11/24 at 10:53 A.M., during the facility basement inspection, showed there was no thermometer in the freezer in the Food Storage room. Observations on 6/11/24 at 11:16 A.M., showed there was a 7 pound (lb.) 3 ounce (oz.) can of baked beans that was dented on one side and stored on a shelf with other various undented cans. Observations on 6/12/24 at 9:18 A.M., during the follow-up kitchen inspection showed a yellow cutting board on the food preparation table next to the 3-tub sink was heavily scored to the point that plastic bits were flaking off. During an interview on 6/12/24 at 1:31 P.M., the Dietary Manager (DM) said: -After separating damaged foodstuffs from the regular, they send them back to the food vendor for a refund. -He/She would expect food to be free of foreign substances. -Damaged food preparation items are thrown away when found, especially cutting boards. -All refrigerators and freezers should have thermometers in them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of Legionella (a [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis, all illnesses caused by Legionella, including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak with accepted response protocols, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility census was 13 residents with a licensed capacity for 16 residents at the time of the survey. 1. Observations on 6/11/24 at 11:17 A.M., during the initial kitchen Life Safety Code (LSC) inspection with the Dietary Manager (DM) present, showed a three-sink area, a chemical and high heat dish-washing machine, and a hand-washing sink. Observations on 6/12/24 between 9:33 A.M. and 3:57 P.M., during the initial facility LSC room-to-room inspections with the Maintenance Manager (MM), showed the following: -There was a facility-wide fire sprinkler system. -On the lower level there was a laundry room with clothes washers, two restrooms, and the Maintenance Office where the sprinkler risers (Fire sprinkler risers are, in a sense, where the plumbing outside a building ends and a fire sprinkler system begins. Each riser taps into a permanent source of water, such as a pipe connected to the city water system, a water tank, or reservoir.) were located. -On the main level there were at least 12 resident rooms with sinks and bathrooms, two bathhouses, a Main Dining Room with an ice machine, and a janitor's closet with a mop hopper sink. Review of the facility's water-borne pathogen prevention program in a binder entitled, Water Management Program, last reviewed on 7/14/23 and provided by the MM, showed the following: -There was no facility-specific risk management plan assessment that considered all elements of the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188. -There was no completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -There was no facility-specific infection prevention and control program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. -There was a diagram on page 6 showing possible stagnation locations throughout the facility, but no assessments of each location's individual potential risk level. -At Appendix B2: Example Log Sheets and Checklists, there were 12 blank pages of various charts, checklists, and spreadsheets to be used by the facility including, but not limited to a Program Strategy, Potable Water Services Monitoring, At-Risk Water System Monitoring, Bacterial Indicator Test, and a Program Action Log, but none were completed or used as templates. -There was no documentation of any site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned. -The 4-page report from the water lab company, dated 6/1/23, showed no test methods listed under that same heading on pages 2 through 4. During an interview on 6/12/24 at 2:47 P.M., the MM said the following: -The blank sheets in the binder are not used. -The company that created the program was sending someone out to periodically test the water for Legionella, but they said the facility was at low risk so testing was really only needed once a year. -He/She did occasional flushings, but they were not documented anywhere. During an interview on 6/13/24 at 12:16 P.M., the Administrator said the following: -Their water-borne pathogen program was based on the regulations and created by the MM and the previous Administrator. -He/She would expect that whoever created the Legionella program would know all the requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Ombudsman (a network of ombudsmen volunteers serving residents of nursing homes and residential care facilities to provide support and assistance with their problems or complaints) for one sampled resident's (Resident #1) discharge to the hospital out of nine sampled residents. The facility census was 14 residents. Record review of the facility's undated Bed Hold policy and procedure showed: -Documentation related to the resident's bed hold rights and financial responsibilities and the responsibilities of the facility regarding bed holds. -The document did not show that part of the policy was to notify the Ombudsman of all discharges/transfers from the facility and it did not show that notification should be completed at least monthly. 1. Record review of Resident #1's Face Sheet showed the resident was admitted on [DATE], with diagnoses including human immunodeficiency virus (HIV- a virus that attacks the body's immune system, preventing the body from fighting infection), diabetes, blindness, and depression. Record review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) assessments showed: -A discharge MDS assessment dated [DATE], showed the resident was discharged on 9/13/22. The document showed the resident's discharge was unplanned, to the hospital with return anticipated. -An entry MDS assessment dated [DATE], showed the resident returned to the facility from the hospital. Record review of the resident's Nursing Notes showed: -9/14/22 the writer called and spoke with the hospital nurse who said the resident had a small bowel obstruction and was not having any pain at this time. Would continue follow up as needed. -9/18/22 the Charge nurse received a call from the Social Worker at the hospital and stated the resident was doing better and would be returning to the facility tomorrow. He/she would be on an antibiotic for urinary tract infection and fluids were encouraged. -9/20/22 the resident returned to the facility at 3:25 P.M., and was alert and pleasant after his/her hospitalization for ileus (a condition in which the bowel does not work correctly, but there is no structural problem causing it). The resident denied pain. The nurse completed a full body assessment without any concerns. The resident had a large bowel movement and the physician was notified of the resident's return to the facility. -9/22/22 The nurse documented hospital follow up note stating the resident was discharged from the hospital on 9/20/22 in the afternoon. He/she denied pain and had a good appetite. No concerns were noted. Record review of the resident's Physician's Notes dated 9/20/22, showed: -The resident's was being seen after his/her recent hospitalization for ileus. -The physician completed an examination of the resident and the resident acknowledged having a bowel movement and had no complaints at that time. The physician was going to continue to monitor the resident. During an interview on 1/26/23 at 10:32 A.M., the Social Service Director (SSD) said: -He/she completed an initial bed hold agreement with every resident upon the resident's admission. -He/ she was unaware about needing to notify the Ombudsman of all transfers/discharges monthly. -He/she would be responsible for that task but, he/she was not given instruction to send the Ombudsman a monthly discharge/transfer list and had never done that. -The Ombudsman was in the facility last month and discussed the services they provided, but he/she did not say anything about sending out a list of discharges to him/her monthly. -He/She would begin providing this information. During and interview on 1/27/23 at 12:26 P.M., the Director of Nursing (DON) said: -He/she was aware that the Ombudsman should be provided a monthly report of the discharges on an ongoing bases. -He/she did not know that it was not being provided monthly. -He/she thought the SSD was responsible for providing this information to the Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the bed hold notice was provided to one sampled resident (Resident #1) or his/her responsible party when he/she was sent to the hospital, out of nine sampled residents. The facility census was 14 residents. Record review of the facility's undated Bed Hold policy and procedure showed: -A resident's bed will be held without charge for up to three days for each hospitalization. Thereafter, a resident will be charged the then current normal daily room rate for each day. -Residents who have a reserved bed during their hospitalization will be re-admitted to the facility immediately upon discharge from the hospital if the facility can continue to meet the needs of the resident and if payment of the then current daily rate for each day of hospitalization has been made. -Residents who do not have a reserved bed will be assessed upon discharge from the hospital if the facility can continue to meet the needs of the resident. If no bed is available the resident will be re-admitted on ce a bed becomes available and if the facility can meet the needs of the resident. -The document showed options for the resident/responsible party to choose from: I wish to hold my bed pursuant to the policy, or I do not wish to hold my bed pursuant to the policy and I understand that re-admission may or may not be possible. 1. Record review of Resident #1's Face Sheet showed he/she was admitted on [DATE], with diagnoses including human immunodeficiency virus (HIV- a virus that attacks the body's immune system, preventing the body from fighting infection), diabetes, blindness, and depression. Record review of the resident's Bed Hold document dated 5/23/22 showed the resident signed the facility Bed Hold policy and agreement. There were no indications that the resident had a hospitalization at the time of the completion of the form (5/23/18). Record review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 7/4/2022 showed: -The resident was alert and oriented with no confusion. -The resident had some incontinence and needed assistance of one for toileting. Record review of the resident's MDS Assessments showed: -A discharge MDS assessment dated [DATE], showed the resident was discharged on 9/13/22. The document showed the resident's discharge was unplanned, to the hospital with return anticipated. -An entry MDS assessment dated [DATE], showed the resident returned to the facility from the hospital. Record review of the resident's Nursing Notes showed: -9/14/22 the writer called and spoke with the hospital nurse who said the resident had a small bowel obstruction and was not having any pain at this time. Would continue follow up as needed. -9/22/22 The nurse documented hospital follow up note stating the resident was discharged from the hospital on 9/20/22 in the afternoon. He denied pain and had a good appetite. No concerns were noted. Record review of the resident's Physician's Notes dated 9/20/22, showed: -The resident's was being seen after his/her recent hospitalization for ileus (a condition in which the bowel does not work correctly, but there is no structural problem causing it). -The physician completed an examination of the resident and the resident acknowledged having a bowel movement and had no complaints at this time. The physician was going to continue to monitor the resident. Record review of the resident's medical record showed there was no documentation showing the resident was provided with bed hold documentation for the hospitalization from 9/14/22 to 9/20/22. Observation and interview on 1/26/23 at 9:14 A.M., showed the resident was in his/her room laying on his/her bed. The resident was alert and oriented and did not wish to be interviewed. During an interview on 1/26/23 at 10:26 A.M. the Director of Nursing (DON) said: -The Social Service Director (SSD) was responsible for ensuring the Bed Hold form was discussed and signed by the resident or the resident's responsible party upon admission. -He/she did not know if residents were provided with the bed hold document prior to hospitalization because he/she was not in the facility at the time the resident was sent out. During an interview on 1/26/23 at 10:32 A.M., the SSD said: -He/she completed an initial bed hold agreement with every resident upon the residents admission. -He/she had not given the resident a bed hold upon his/her hospitalization or after he/she was hospitalized . -He/she did not know whether he/she or the nursing staff was supposed to complete and provide a bed hold agreement to the resident each time a resident was admitted to the hospital. -He/she had never been instructed to provide this information to the resident at the time of hospitalization and did not know they were supposed to do so. -He/she had checked the resident's medical record and he/she did not find a bed hold during the resident's hospitalization (9/14/22 to 9/20/22). During and interview on 1/27/23 at 12:26 P.M., the DON said nursing staff should complete the bed hold and provide it to the resident or responsible party upon discharge of a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) was completed and submitted timely for one sampled resident (Resident #214) out of nine sampled residents. The facility census was 14 residents. Record review of the facility's policy titled Resident Assessments, dated November 2019, showed MDS assessments were to be conducted at time of admission, quarterly, and with any change in condition. 1. Record review of Resident #214's Face Sheet showed he/she was admitted to the facility on [DATE]. Record review of the resident's Centers for Medicare and Medicaid (CMS) MDS database submissions showed: -An Annual MDS assessment with an Assessment Reference Date (ARD) of 1/14/22. -A Quarterly MDS assessment with an ARD of 4/15/22. -NOTE: No MDS assessments of any type had been completed for the resident since April 2022. Record review of the resident's facility electronic medical record showed: -The last Annual MDS assessment was submitted on 1/31/22. -The last quarterly MDS assessment was submitted on 4/28/22. -NOTE: No MDS assessments of any type had been completed and submitted since 4/28/22. During an interview on 1/26/23 at 10:22 A.M., the Assistant Director of Nursing (ADON) said: -He/she had received very little training on MDS assessments. -He/she used the electronic calendar scheduling tool in the MDS program. -He/she checked the calendar weekly. -The resident's Quarterly MDS, which was due 7/15/22, was missed which made the calendar not populate. -He/she was not responsible for MDS assessments in July 2022 and therefore did not know why the assessment had been missed. -The Quarterly MDS assessment showed as 180 days overdue. During an interview on 1/27/22 at 10:24 A.M., the Administrator said: -The MDS assessments were used by staff for care planning and therefore it was important to have MDS's completed on time and accurately. -He/she was aware the facility was required to submit MDS data. During an interview on 1/27/22 at 12:20 P.M., the Director of Nursing (DON) said: -The ADON was responsible for completing and submitting MDS's. -He/she expected the MDSs to be accurate and completed on time. -He/she did not know why this was not done. -He/she assumed the prior MDS Coordinator did something wrong and it effected the way the calendar populated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a comprehensive-care-plan was reassessed and updated to indicate adequate and appropriate interventions to meet the resident's medical, mental, and psychosocial needs specifically for the consumption of alcohol and the subsequent behaviors exhibited for two sampled residents (Resident #4 and #10) out of nine sampled residents. The facility census was 14 residents. 1. Record review of Resident #4's undated face sheet showed he/she was admitted to the facility with the following diagnoses: -Other Recurrent Depressive Disorders (a mental health disorder characterized by a feeling of profound and persistent sadness or disrepair and is frequently accompanied by a loss of interest in things that were once pleasurable). -Other Psychoactive Substance Abuse, Uncomplicated (A drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). Record review of the resident's social service note dated 11/8/22 showed: -The resident had been consuming an extreme amount of alcohol several times a week. -The resident could get very uncontrollable and aggressive from drinking. -The Administrator and the Social Service's Director (SSD) had made several attempts to redirect the resident's behaviors. -The resident said that he/she was going to drink because he/she was a grownup and denied having any behaviors. Record review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 11/27/22 showed: -The resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated he/she was cognitively intact. -The resident did not have any physically aggressive behaviors towards others. -The resident did have verbally aggressive behaviors towards others. -The verbal behavior occurred 1-3 times during that look back period. Record review of the resident's care plan dated 12/31/22 showed: -The problems identified: --The resident had a psychosocial well-being problem actually related to ineffective coping due to alcohol consumption. --The resident had the potential to be verbally aggressive related to ineffective coping skills and alcohol consumption. --The resident is/has potential to be physically aggressive related to poor impulse control. -Interventions included: --Monitor/document resident's usual response to problems: Internal- how the individual makes own changes. External- expects others to control problems or leaves to fate, or luck, updated on 10/14/22. --The resident was an elopement risk related to leaving facility leaving the facility without notifying staff or signing out, updated on 12/2/22. --Resident has a history of making false accusations about physical harm while intoxicated. Look for signs and symptoms of physical harm and call administrator immediately, updated on 12/7/22. --Psychiatric/Psychogeriatric consult has indicated, updated on 12/31/22. --Consult with Pastoral care, Social services, and Psychiatric services, updated on 2/22/22. -NOTE: There were no new interventions put into place following the instances the resident was impaired as a result of his/her drinking. -NOTE: There was no problem identified or interventions put into place regarding the resident potentially being in a relationship with another resident (Resident #10). 2. Record review of Resident #10's undated face sheet showed he/she was admitted to the facility with a diagnosis of Alcohol Abuse with Intoxication, Unspecified (a habitual misuse of alcohol). Record review of the resident's MDS dated [DATE] showed: -The resident had a BIMS score of 14 out of 15, which indicated he/she was cognitively intact. -The resident had not exhibited any verbal or aggressive behaviors towards others. Record review of the resident's care plan dated 12/2/22 showed: -The problem identified: --The resident had the potential to be physically aggressive related to alcohol consumption. --The resident was an elopement risk/wanderer related to having a history of attempts to leave the facility without notifying staff. -The interventions included: --Staff were to intervene before agitation escalated. --Staff were to guide the resident away from source of distress. --Engage calmly in conversation. --If the resident's response was aggressive, staff were to walk calmly away, and approach later. -NOTE: There were no new interventions regarding the resident making attempts or actually leaving the facility without notifying staff. -NOTE: There was no problem identified or interventions in place regarding the resident potentially being in a relationship with another resident (Resident #4). 3. During an interview on 1/25/23 at 1:28 P.M. Licensed Practical Nurse (LPN) A said: -If a resident exhibited a new behavior or had an incident the resident's care plan would need to be updated with new interventions specific to the behavior or the incident. -The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were responsible for updating care plans. During an interview on 1/26/23 at 10:58 A.M. Registered Nurse (RN) A said: -The ADON and the DON were responsible for updating care plans. -The nurses could tell the ADON and DON what needed to be updated on the care plans. During an interview on 1/26/23 at 1:40 P.M. the Administrator said nurses were responsible for developing care plan interventions. During an interview on 1/26/23 at 2:04 P.M. the Administrator said: -He/she did not think the care plans for Resident #4 and Resident #10 needed to be updated after the incident from 12/1/22. -He/she thought the care plans had mentioned the relationship status of Resident #4 and Resident #10. -If the care plan did not include the relationship then it needed to be updated. During an interview on 1/26/23 at 2:40 P.M. the DON said he/she thought that the relationship between Resident #4 and Resident #10 should be included in the care plan, but was unsure how to include it in the care plans. During an interview on 1/27/23 at 12:26 P.M. the DON said he/she would expect all interventions that the facility had attempted with Resident #4 to be documented in his/her care plan. MO00210625 MO00211932

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to acknowledge, assess and provide supportive services for one sampled resident (Resident #1), who informed staff of past trauma, and to develop a care plan that showed interventions the facility staff would take to try to protect the resident and prevent trauma from recurring, out of nine sampled residents. The facility census was 14 residents. The facility did not have a behavior management policy/procedure. 1. Record review of Resident #1's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including depression. There was no documentation showing the resident had a diagnosis of post traumatic stress disorder (PTSD- a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event. Symptoms may include nightmares or unwanted memories of the trauma, avoidance of situations that bring back memories of the trauma, heightened reactions, anxiety, or depressed mood). Record review of the resident's Nursing Notes dated 4/21/22 to 7/27/22, showed: -The resident exhibited no behaviors. -There was no documentation showing the resident expressed any prior trauma, substance or alcohol use/abuse, fear, anxiety or depressive symptoms. Record review of the resident's Care Plan dated 4/25/22, showed: -No area related to depression and no goals to maintain the resident's psychosocial and mental health. -There were no interventions showing the resident had depression, received medication for depression or had any depression symptoms. -There was no documentation showing the resident had past trauma, physical or verbal abuse, substance or alcohol abuse or any triggers that would cause the resident trauma. -There were no interventions that showed any preventive interventions, how the facility would address these behaviors if they occurred and how the facility would provide support to the resident. Record review of the resident's undated Social Service Assessment showed: -The resident had no documented diagnoses of depression, PTSD, substance/alcohol abuse, psychosis or trauma. -The section titled, Significant Life Experiences, showed the resident had several marriages and divorces and was widowed from his/her last marriage. -Had a history of substance abuse addiction that resulted in loss of custody of two children, which he/she was able to regain. -It was noted the resident did not want to continue the interview at that time. -The section titled, Significant Medical and Psychiatric History, showed the resident wanted to resolve issues related to diabetes and insulin management and dental concerns. -There was no documentation showing the resident had ever had any counseling/therapy or treatment for depression or substance abuse or was receiving therapy or treatment at the time the assessment was completed. -The assessment did not address alcoholism or any physical or verbal abuse. Record review of the resident's quarterly Social Service Notes showed: -On 5/5/22 the report showed the resident had been homeless and a substance abuser that could no longer take care of himself/herself and needed assistance and was ready to get his/her life cleaned up and back on track. --The note did not show how the facility was supporting him/her or whether the resident had any current supports. -On 7/13/22 the report showed the resident seemed to be doing better, enjoyed living at the facility and visits with family. The note showed the resident sat outside and drank liquor while listening to music. It did not show if the resident had any behaviors associated with drinking alcohol. --The notes did not show the facility offered or were providing any supportive services to the resident to address depression or substance abuse. There was no indication the resident had indicated past trauma that needed to be addressed at this time. Record review of the resident's Nursing Notes showed: -On 7/27/22 the resident approached the nurse and reported that his/her roommate, on the previous evening, was belligerent and drunk from drinking alcohol. -The resident reported that his/her roommate was being really loud cursing and singing. -The resident said that his/her roommate threw a plate at the wall and it broke. -He/she said he/she had PTSD from living with a former partner who consumed a lot of alcohol and was verbally and physically abusive. -The resident said he/she did not wish to continue to be roommates. -The nurse spoke with management and it was collectively decided to move the resident into another room. The resident was notified and his/her move was completed. -From 7/27/22 to 12/30/22 there were no notes showing the facility provided a psychiatric/psychological evaluation on the resident to address his/her trauma and did not show that any counseling or supportive services were provided to the resident. Record review of the resident's undated Care Plan showed: -There were no updates after 4/25/22, to the resident's care plan that addressed the resident's statements of having a history of physical and verbal abuse from a former partner. -There was no documentation of the triggering event/behavior that occurred that caused the resident to voice concerns. -There was no documentation of any acute short term interventions to mitigate the resident's trauma (moving the resident out of the room) or any long term interventions to try to prevent future trauma or support services offered to try to assist the resident in coping with said trauma. Record review of the resident's quarterly Social Service Notes showed: -There were no notes showing the Social Work Director had been informed that the resident had voiced prior trauma related to his/her past history of physical and verbal abuse from a former partner who also abused alcohol, on 7/27/22. -There were no notes showing the resident discussed or was being assisted with depression symptoms or coping skills. -There were no notes showing any supportive services were offered to the resident for assessment of his/her psychological/psychiatric health and coping skills to assist the resident. Record review of the resident's Nursing notes from 7/24/22 to 8/1/22 showed there was no documentation showing the resident had any behaviors, depressive symptoms, concerns regarding triggering events/occurrences or mental health concerns. There was no documentation showing any support services were offered to the resident to assist in managing his/her depression, past trauma/abuse or coping skills. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 8/1/22, showed the resident: -Was alert and oriented with no confusion. -Had no psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality), hallucinations (an experience involving the apparent perception of something not present) or delusions (a false belief or judgment about external reality, held despite incontrovertible evidence to the contrary, occurring especially in mental conditions). -Had a diagnosis of depression and had depressive symptoms-feeling bad about self, hopeless, depressed, little interest in doing things and trouble concentrating on things during the look back period. -Received anti-depressant medication, and did not receive any anti-psychotic medications. -Did not show the resident had any substance or alcohol abuse and did not show the resident had any mood or behaviors related to physical or verbal abuse, or was physically or verbally abusive towards self/others. Record review of the resident's Nursing notes from 8/1/22 to 10/10/22 showed there was no documentation showing the resident had any behaviors, depressive symptoms, concerns regarding triggering events/occurrences or mental health concerns. There was no documentation showing any support services were offered to the resident to assist in managing his/her depression, past trauma/abuse or coping skills. Record review of the resident's quarterly Social Service assessment dated [DATE] showed: -During the past quarter the resident had no significant medical or psychosocial issues. -The resident had been becoming more comfortable in the facility and was getting along with his/her roommate and staff. -The resident continued to receive visits from family. Record review of the resident's Mood Interview/assessment dated [DATE] showed a score of 0.0, meaning the resident had no complaints related to mood, depression or trauma. Record review of the resident's Nursing notes from 10/24/22 to 12/30/22 showed there was no documentation showing the resident had any behaviors, depressive symptoms, concerns regarding triggering events/occurrences or mental health concerns. There was no documentation showing any support services were offered to the resident to assist in managing his/her depression, past trauma/abuse or coping skills. Record review of the resident's Behavior Notes showed: -On 12/30/22 The resident was outside when another resident (former roommate) hit him/her. They both began to fight each other, falling to the ground, punching each other in the face and pulling each other's hair. Staff attempted to separate the residents but were unsuccessful. Police had to be called along with the ambulance. The resident's physician, Administrator and Social Services Director were also notified. Documentation showed the emergency services completed a full body assessment of the resident and found no reason to transport him/her for further services/hospitalization. The note showed the resident was not transported to the police station. The notes did not show any immediate behavioral interventions the facility initiated or any long-term interventions implemented. Record review of the resident's Physician's Order Sheet (POS) dated 1/2023 showed the resident had a diagnosis of depression and there were physician's orders for: -Amitriptyline 10 milligrams (mg) daily for depression. Monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. Observation and interview on 1/25/23 at 1:28 P.M., showed the resident was in his/her room laying down fully dressed with his/her glasses on. He/she said: -When he/she was younger, he/she had abused substances and had gone through substance abuse recovery and had not abused any drugs in years. -He/she had been homeless and was with a partner who also had alcohol abuse and substance abuse and was physically and verbally abusive to him/her regularly. -He/she also had depression related to abuse trauma and his/her diagnosis of HIV. -The reason he/she no longer had a roommate was because his/her former roommate drank alcohol frequently and would become volatile after becoming intoxicated. One night his/her roommate became angry, threw a plate against the wall and broke it. -He/she requested to be moved out of the room because it reminded him/her of the trauma he/she experienced with his/her former partner when he/she became drunk. -He/she told staff about his/her past trauma and domestic violence and substance abuse. -He/she had not had a psychological/psychiatric evaluation and had not been offered any therapy, counseling or substance abuse treatment since he/she was admitted . -He/she did feel safe in the facility now that he/she was in a room by himself/herself and was not subjected to his/her former roommate's behaviors when drunk. -He/she told nursing staff he/she wanted therapy for depression related to his/her own traumas and coping with it. -He/she said when he/she had concerns or issues he/she felt comfortable talking to the staff here, usually the Social Service Director (SSD) and he/she thought staff took his/her concerns seriously. -He/she spoke with the Social Worker about starting therapy. He/she requested it because he/she had been receiving counseling before he/she was admitted to the facility, and it was supposed to start sometime in February. -He/she did not have a diagnosis of alcohol abuse, but he/she would have an after dinner cocktail or beer. He/she said he/she did not drink in excess. During an interview on 1/26/23 at 2:38 P.M., Certified Nursing Assistant (CNA) D said: -The resident was usually very calm and did not have any behaviors. -He/she drank alcohol occasionally and did not get out of control, he/she did not have any behaviors. -He/she was not aware that the resident had any trauma related to physical/verbal abuse by a partner or had a substance abuse history. During an interview on 1/26/23 at 3:02 P.M., Registered Nurse (RN) A said: -He/she was not aware that the resident had a prior history of domestic violence or verbal and physical abuse by a former partner. -The resident had a roommate when he/she was first admitted but his/her former roommate drank alcohol at night and would be very loud and the resident did not like it. -The resident requested a room change and was moved into another room by himself/herself. -The resident did not have a diagnosis of substance or alcohol abuse. -He/she was not aware of the resident having any trauma related to physical abuse or verbal abuse from a former partner who abused alcohol. -Recently the resident requested counseling and they set up an evaluation for him/her with the Psychiatrist on March 13, 2023 at 3:00 PM. -He/she had not asked the resident why he/she wanted counseling. -Anything that was pertinent to the resident's clinical care should be shared with the Assistant Director of Nursing (ADON), Director of Nursing (DON) and physician. -Any interventions that they implemented that were related to past trauma or past or recent behaviors should be in the resident's care plan. -If the resident told them that he/she had a past trauma related to physical and verbal abuse or domestic violence, it should be in his/her care plan and they should develop interventions to try to protect the resident from any future trauma related to this. -The ADON and DON develop the care plans. During an interview on 1/27/23 at 9:47 A.M. the SSD said: -The resident had not had any behaviors in the facility until 12/31/22 during an incident with his/her former roommate. -The resident drank alcoholic beverages at times in the evening with peers. -He/ she had not heard from other staff or residents that the resident became drunk, obnoxious, or became verbally or physically aggressive after he/she had been drinking alcohol. -The resident had a prior substance abuse history, but they did not and had not put any interventions in place for the resident regarding him/her drinking alcohol or for substance abuse. -He/she was not aware of the resident having a prior trauma from a physically and verbally abusive partner before admitting to the facility. -If he/she was aware of the resident having prior trauma (domestic violence), he/she would expect to have been notified. -They would have developed interventions to protect the resident from future trauma and try to put supportive services in place for coping. -He/she had known the resident since his/her admission. -He/she was aware that the resident and his/her former roommate did not get along, but he/she was not in on the decision making regarding them separating their living arrangement. -If the resident told the nursing staff that he/she had experienced trauma from a former partner, the nursing staff should have notified him/her so he/she could have spoken with the resident and the Administrator about it so they could offer the resident counseling and supportive services. -He/she would also have asked the resident if he/she felt safe in the facility. -He/she was not aware of the resident having a diagnosis of PTSD, only depression. During an interview on 1/27/23 at 10:46 A.M., Licensed Practical Nurse (LPN) B said: -He/she was familiar with the resident and worked both day and night shift. -The resident was diagnosed with depression but he/she did not have a diagnosis of PTSD that he/she was aware of. -He/she was not aware of the resident having a history of trauma-physical or verbal abuse, substance abuse or alcohol abuse. -He/she had been instructed to monitor the resident's behaviors for aggression/impulsivity, nausea, drowsiness, and slurred speech, due to his/her medications. -They chart daily for behaviors in the computer system where they document if any behaviors occurred. -The resident normally did not have any behaviors. -If the resident had expressed past trauma to include abuse, the nurse would document it in the nursing notes, inform the physician, DON, Social Service Director, and the resident's responsible party and try to get the resident a psychological or psychiatric evaluation or follow up to ensure they were providing for his/her safety and mental health. -It should also be documented in the resident's care plan. During an interview on 1/27/23 at 11:01 A.M., the ADON said: -He/she was aware that in the resident's past, his/her partner was abusive to him/her and the resident had been attending counseling before admitting to the facility. -The resident currently had requested and received outpatient psychological services and he/she also attended bible study during the week and attended church on Sunday. -They had not set up any supportive services for the resident after notification that he/she had past trauma and domestic violence related to alcoholism. -They could have developed interventions to address his/her trauma but they had not developed a care plan to include it. -They had not developed interventions related to the resident's depression, substance abuse or use of alcohol. -All incidents should be communicated to the SSD, but often times when things occur, they are not notified of it unless a resident tells them. -The communication at the facility needed improvement. During an interview on 1/27/23 at 12:26 P.M., the DON said: -He/she personally had not offered any support services to the resident and did not know if any support services had ever been offered to the resident. -He/she was aware that the resident had been homeless, had substance abuse issues and he/she had been in an abusive relationship before coming to the facility. That's why (he/she) came here. -He/she had not provided the resident with any psychosocial support services to prevent future trauma upon admission, and he/she was not aware if the resident had received any counseling or supportive services related to his/her trauma. -He/she would expect all information about the resident's history to be in the resident's medical record. -If the resident expressed that he/she had experienced abuse or trauma history to nursing staff, he/she would expect the nurse to inform him/her of the resident's statement, share this information with SSD and would expect it to be documented in the resident's nursing notes and care plan. -He/she would expect for the physician to be informed and he/she would expect the interdisciplinary team (IDT) to be informed and to discuss it to develop a plan of care for the resident. MO00211932

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain physician's order for the use of two half side rails; and to complete a comprehensive side rail safety assessment to determine if the two half side rails were a restrainting device for one sampled resident (Resident #8) who had impaired bed mobility out of nine sampled residents. The facility census was 14 residents. Record review of the Facility Physical Restraint policy dated 10/14/19 showed: -Required to have a physician's order for use of any restraints to include when the restraints are to be used, type of restraints and medical symptoms for use and the purpose of the resident restraints. An example would be use of side rails (metal or plastic bars positioned along the side of a bed, also commonly known as side rails) to increase bed mobility (is the moving to and from a lying position, turning from side-to-side and positioning the body while in bed). -The interdisciplinary team (IDT) will document evidence in the resident's medical record that the resident or his/her responsible party had made an informed choice for the use of restraints and that the risk, benefits and alternatives have been explained to them. -A consent from the resident's responsible party will be documented in the resident medical record. 1. Record review of Resident #8's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnosis of paraplegia (is the loss of movement of both legs and generally the lower trunk). Record review on the resident's Activities of Daily Living (ADL's) care plan revised on 4/7/22 showed: -The problem identified: --He/she had a self-care performance deficit related to paraplegia. -Interventions dated 4/7/22 included: --The resident used an overhead trapeze (a triangle-shaped metal bar) and two half side rails for assisting with bed mobility. --The resident was able to move his/her upper body and aid in repositioning and mobility. -NOTE: There was no documentation that indicated the two half side rails were or were not a restraint. Record review of the resident's restraint care plan revised on 4/14/22 showed: -The problem identified: --The resident required the use of side rails to aid in positioning and mobility. -The desired outcome: -He/she would remain free of complications related to restraint use through review date of 2/16/23. -Interventions included: --The facility staff were to discuss and record with the resident, family and caregivers, the risks and benefits for the use of a restraint and when the restraint should or would be applied, care routines while restrained and any concerns or issues regarding restraint use. --Ensure the facility had a valid consent in the resident's medical record prior to the initiation of the restraint. --The resident used two half side rails for assisting in positioning and mobility while in bed. Record review of the resident's quarterly nursing skilled evaluation to include use of a safety assistive device dated 10/1/22 showed: -The resident had required the use of half side rails. -NOTE: There was no documentation that indicated the two half side rails were or were not a restraint. Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 12/25/22, showed: -He/she was cognitively intact and his/her Brief Interview Mental Status (BIMS) score was 15 out of 15. -He/she was able to understand others and was able to make his/her needs known. -He/she required extensive assistance of one staff member for bed mobility. -Functional limitation in range of motion was marked as impairment on both sides in his/her lower extremities. -Restraints was marked and he/she required the use of bed rails daily. Record review of the resident's medical record showed the resident: -Did not have a physician's order for the use of two half side rails. -Did not have a comprehensive side rail safety assessment. --NOTE: With no comprehensive side rails safety assessment there was no determination made if the side rails were or were not a restraint. ---Did not have a signed consent documented for the use of two half side rails. Record review of the resident's Physician Order Sheet (POS) dated 1/1/23 to 1/25/23 showed the resident did not have physician's order for the use of two half side rails to include the reason of use. Record review of the resident's Treatment Administration Record (TAR) dated 1/1/23 to 1/25/23 showed: -He/she did not have physician's order for the use of the two half side rails. -He/she did not have any documentation of monitoring the resident for safety with the use of the two half side rails. Observation on 1/24/23 at 2:17 P.M. showed the resident: -Had two half side rails towards the head of his/her bed that were raised while he/she was in bed. -Had an overhead trapeze at the head of his/her bed. During an interview on 1/24/23 at 2:17 P.M. the resident said: -He/she required assistance from staff for his/her bed mobility and cares. -He/she used the two half side rails and overhead trapeze for repositioning himself/herself while in bed. Observation on 1/25/23 at 1:10 P.M., of the resident's personal cares and transfer showed: -Licensed Practical Nurse (LPN) A and Certified Nursing Assistant (CNA) B assisted the resident to bed and with personal cares. -The resident had two half side rails and an overhead trapeze that he/she used to assist with positioning while in bed. -The resident used the right side rail to turn himself/herself to his/her right side. -The resident used the overhead trapeze to lift and move his/her upper body while in bed. -CNA B had lowered the left side rail during cares. -CNA B raised the left side rail after cares had been completed. -LPN A and CNA B said the resident had requested the use side rail for positioning. During an interview on 1/25/23 at 3:27 P.M., CNA B said: -The resident had requested the use of side rails. -The resident used the side rails to assist with his/her positioning and rolling to his/her side for cares. During an interview on 1/26/23 at 10:53 A.M., the resident said: -He/she requested the use of the two half side rails for bed mobility. -He/she had never been trapped between the side rails and mattress. -He/she was not able to lower the two half side rails without assistance by facility staff. -Facility nursing staff did assess the resident for use of side rails at one time, but he/she did not remember when. -He/she never signed a consent for the use of the side rails. -He/she did not know if the two half side rails were considered a restraint. During an interview on 1/26/23 at 11:16 A.M., CNA A said: -The resident used his/her side rails for assistance with repositioning while in bed and turning with cares. -The resident was not able to lower the side rails by himself/herself. -He/she required the assistance of facility staff to lower the side rails. -He/she would report any changes in the resident or concern with side rails to the charge nurse and DON. -He/she did not know if the two half side rails were considered a restraint. During an interview on 1/27/23 at 9:45 A.M., LPN B said: -He/she had only been at the facility a few times. -Nursing staff should have obtained a physician's order for the use of side rails for bed mobility and positioning. -Nursing staff or therapy staff should have completed a safety assessment for the use of side rails. -He/she did not find a physician's order or a nursing safety assessment for the residents use of the two half side rails. During an interview on 1/27/23 at 10:28 A.M., the Assistant Director of Nursing (ADON) said: -Any nursing staff would be responsible for completing a side rail assessment. -If the side rails were a restraint a consent should have been obtained. -He/she was not aware of a policy related to obtaining a written consent for the use of side rails if they were not a restraint. During an interview on 1/27/23 at 10:28 A.M., the Director of Nursing (DON) said: -The resident's side rails on his/her bed were not considered a restraint. -The resident had requested the use of the side rails for positioning. -He/she was not aware of a policy related to obtaining a written consent for the use of side rails if they were not a restraint. During an interview on 1/27/23 at 12:23 P.M., DON said: -He/she would expect to have a physician's order for side rails and it should include a diagnosis and the reason for use, such as for bed mobility. -He/she would expect nursing staff to have completed a comprehensive side rail assessment and staff to document continued use and ongoing monitoring of the assistive devises at least quarterly. -Maintenance would be responsible for checking for the function and safety of the side rails. During an interview on 1/27/23 at 1:00 P.M., the Administrator said: -The facility did not have a policy for use of side rails for bed mobility or for other non-restraint use. -Side rail safety assessments would be in the facility nursing policies. -He/she would have expected the DON to ensure the facility had a nursing policy for use of side rails.

Based on interview and record review, the facility failed to ensure appropriate and adequate social service assistance specifically for psychiatric and alcohol abuse treatment was provided for one sampled resident (Resident #4) out of nine sampled residents. The facility census was 14 residents. 1. Record review of Resident #4's undated face sheet showed the resident admitted to the facility with the following diagnoses: -Other Recurrent Depressive Disorders (a mental health disorder characterized by a feeling of profound and persistent sadness or disrepair and is frequently accompanied by a loss of interest in things that were once pleasurable). -Other Psychoactive Substance Abuse, Uncomplicated (A drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). Record review of the resident's progress note dated 10/15/22 showed the resident was very inebriated. (effected by alcohol or drugs especially to the point where physical and mental control is markedly diminished). Record review of the resident's progress note dated 10/18/22 showed the resident was inebriated and was placed wheelchair for his/her safety. Record review of the resident's administration note dated 10/20/22 showed the resident was inebriated, in a wheelchair, very drunk. Record review of the resident's administration note dated 10/23/22 showed the resident had appeared to be intoxicated and a Certified Nursing Assistant (CNA) was keeping an eye on the resident. Record review of the resident's administration note dated 10/25/22 showed the resident was drinking excessively. Record review of the resident's administration note dated 10/27/22 showed the resident was drinking excessively. Record review of the resident's administration note dated 10/29/22 showed the resident was drinking too excessively. Record review of the resident's administration note dated 10/30/22 showed the resident had been drinking and was inebriated. Record review of the resident's behavior note dated 11/5/22 showed the resident: -Had left the facility without signing out and did not notify the nurse. -Returned to the facility and was educated. --NOTE: There were no specifics documented as to the condition the resident was in when he/she returned. --NOTE: There were no specifics documented as to what the resident was educated on. Record review of the resident's social service's note dated 11/8/22 showed: -The resident had been consuming an extreme amount of alcohol several times a week. -The resident could get very uncontrollable and aggressive from drinking. -The Administrator and the Social Services Director (SSD) had made several attempts to redirect the resident's behaviors. -The resident had stated that he/she was going to drink because he/she was a grown up and denied having any behaviors. Record review of the resident's Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 11/27/22 showed: -The resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated he/she was cognitively intact. -The resident did not have any physically aggressive behaviors towards others. -The resident did have verbally aggressive behaviors towards others. -The behavior occurred 1-3 times during that look back period. Record review of an incident report dated 12/1/22 showed the resident had come back to the facility intoxicated. Record review of the resident's administration note dated 12/2/22 showed the resident had been arguing with a different resident and needed to be separated. Record review of the resident's administration note dated 12/11/22 showed the resident had been drinking excessively and was placed in a wheelchair for his/her safety. Record review of the resident's administration note dated 12/20/22 showed the resident had been drinking and was loudly cussing at a peer. Record review of the resident's administration note dated 12/24/22 showed the resident had been very drunk and was placed in a wheelchair for his/her safety. Record review of the resident's administration note dated 12/25/22 showed the resident had been drunk that day. Record review of the resident's behavior note dated 12/30/22 showed: -The resident had been drinking and approached another resident. -The resident had punched the other resident who was also intoxicated. -There were no injuries noted after the altercation. Record review of the resident's care plan dated 12/31/22 showed: -The problem identified: --The resident had a psychosocial well-being problem related to ineffective coping due to alcohol consumption. --The resident had the potential to be verbally aggressive related to ineffective coping skills and alcohol consumption. --The resident was an elopement risk related to leaving the facility without notifying staff or signing out. --The resident had the potential to be physically aggressive related to poor impulse control. -Interventions included: --Consult with Pastoral care, Social services, and Psychiatric services, dated 2/22/22. ---There was no documentation that indicated those services were provided. --Monitor/document resident's usual response to problems: Internal- how the individual makes own changes. External- expects others to control problems or leaves to fate, or luck, dated 10/14/22. --The resident had a history of making false accusations about physical harm while intoxicated. Look for signs and symptoms of physical harm and call Administrator immediately, dated 12/7/22. --Psychiatric/Psychogeriatric consult has indicated, dated 12/31/22. -NOTE: There were no interventions noted that addressed the resident being an elopement risk. -NOTE: There were no interventions documented following each episode of the resident being intoxicated and aggressive towards other residents. Record review of the resident's administration note dated 1/1/23 showed the resident was intoxicated, slurring his/her speech, and unsteady. Record review of the resident's social service's note dated 1/3/23 showed: -The Administrator and SSD had asked the resident if he/she wanted to get help regarding his/her drinking. -The resident agreed to go to an inpatient facility. -During the intake process with the inpatient facility the resident changed his/her mind about going inpatient. -The SSD would continue to follow the resident on a weekly basis. Record review of the resident's administration note dated 1/5/23 showed the resident had been drinking excessively and was drunk. Record review of the resident's administration note dated 1/7/23 showed the resident had been drinking excessively. Record review of the resident's administration note dated 1/8/23 showed the resident had been drinking and had walked to the liquor store twice that day. Record review of the resident's administration note dated 1/17/23 showed the resident had been inebriated. During an interview on 1/17/23 at 10:00 A.M. the Administrator said the resident exhibited behaviors when drinking. During an interview on 1/25/23 at 1:19 P.M. CNA B said: -He/she was unsure what kind of services or therapies the resident had been receiving related to alcohol consumption. -He/she did know that the Administrator, Director of Nursing (DON), and SSD had talked with the resident about his/her behaviors. During an interview on 1/25/23 at 1:28 P.M. Licensed Practical Nurse (LPN) A said he/she was not sure if the resident was receiving any services or therapies related to alcohol consumption. During an interview on 1/25/23 at 2:44 P.M. the SSD said: -He/she had previously developed a contract with the resident regarding his/her alcohol consumption and behaviors. -He/she had made multiple attempts to find different placement for the resident, but no other facility had accepted the resident to date. -After the altercation on 12/30/22 there were no attempts made for the resident to go to Alcoholics Anonymous (AA). -There were no attempts made to request anyone from AA to come to the facility. -There were interventions in place for when the residents are intoxicated, but not to keep the residents from consuming alcohol. During an interview on 1/25/23 at 2:57 P.M. CNA D said he/she was not sure if the resident was receiving any services or therapies related to alcohol consumption. During an interview on 1/26/23 at 6:03 A.M. LPN C said he/ she was not sure what services or therapies the resident was receiving related to alcohol consumption. During an interview on 1/26/23 at 10:58 A.M. Registered Nurse (RN) A said: -The resident was not receiving any services or therapy at that time related to alcohol consumption -The resident had declined services and therapy in the past. -If he/she had asked the resident about receiving services or therapy he/she would document the offer and acceptance/refusal. During an interview on 1/26/23 at 11:17 A.M. the SSD said: -The resident was not accepted into inpatient rehabilitation because the resident would be returning back to the facility. -He/she did not document all of the offers and refusals because he/she had done it so often. -He/she was unsure if he/she needed to document the offers and refusals. During an interview on 1/26/23 at 12:12 P.M. the Assistant Director of Nursing (ADON) said: -The Covid-19 (an acute disease in humans caused by the coronavirus which is characterized by fever and coughing) pandemic caused issues with getting services into the facility related to alcohol consumption. -He/she had not attempted to offer services or therapies to the resident since the pandemic. -When the resident refused services in the past it was hard to continue to offer services. -He/she thought the resident would benefit from a psychiatric evaluation and therapy, but no one had offered the resident those services. -Social Services would need to get involved and follow-up with residents regarding the behavior. During an interview on 1/26/23 at 12:15 P.M. the resident said: -The facility had offered him/her therapy services in the past related to alcohol consumption and he/she had not accepted the offer. -The facility offered AA the following day after the altercation on 12/30/22. -He/she did not want any treatment. -The facility had never sent him/her out for a psychiatric/psychological evaluation and he/she never had one completed. -He/she was open to having someone come into the facility to talk about how to better manage his/her alcohol. During an interview on 1/26/23 at 2:04 P.M. the Administrator said: -There had been attempts made for the resident to receive services. -There had been issues in the past with the resident refusing services and inpatient settings not having beds. -The SSD was available to come up and help with behavioral issues with the residents and he/she was always available by phone call to help alleviate altercations. -He/she had tried to stop the resident from leaving the facility to drink in the past, but had not documented it. During an interview on 1/26/23 at 2:40 P.M. the DON said: -The resident was not currently receiving services for alcohol abuse. -The resident had usually refused services. -There had been multiple attempts made to offer services to the resident that had not been documented. -He/she expected all staff to document when offering a service and the response from the resident. During an interview on 1/27/23 at 12:26 P.M. the DON said: -He/she had provided a resource for counseling services with telehealth options to the Administrator, but was not sure what happened after that. -He/she would expect all interventions that the facility had attempted with the resident to be documented in the resident's care plan. MO00210625

Based on observation, interview and record review, the facility failed to ensure there were recipes available for dietary staff to process recipes for the pureed (cooked food that has been ground pressed, blended or sieved to the consistency of a creamy paste or liquid) items of the meal and to follow the menu for the following meals due to the ingredients not being available: the lunch meal on 1/23/23, the supper meal on 1/24/23, and the lunch meal on 1/25/23. The facility census was 14 residents. 1. Observation on 1/24/23 at 11:55 A.M., showed: -The Dietary Manager (DM) placed one serving of taco meat (with no other liquid or ingredients) into the food processor and pureed the taco meat. - There was open recipe book for pureed food. - During a taste test with the DM, the texture of the taco meat was not a smooth texture, and was still gritty as confirmed with the DM. During an interview on 1/24/23 at 12:23 P.M., the DM said he/she may not have a recipe book for the pureed version of today's meal. He/she looked but did not find a recipe for the pureed items of that meal. 2. Record review of the week at a glance menu dated 2022-2023 for the third week of January 2023, showed the absence of a taco meal as the lunch meal day 10 of the menu, which included taco meat, taco shells (soft and crunchy), rice, refried beans and taco salad. During an interview on 1/24/34 at 12:29 P.M., the DM said: - The facility has new menus as of 1/19/23. - The meal on 1/24/23 was a switch, because the beef cubed steak, buttered corn, stewed tomatoes, and ingredients for the bread pudding, which were ingredients for the dinner meal on 1/24/23, did not come in with the last food order. - Ingredients were ordered from old menu and the food delivery truck came to the facility on 1/19/23. During an interview on 1/25/23 at 10:06 A.M., the DM said: - The facility switched food supply companies from Food Supply Company A to Food supply Company B after Christmas 2022. - The menus did not come until the week of 1/16/23. - The menus were supposed to arrive before the switch. - On 1/25/23, meatloaf was served for lunch, because there was not anything else on the menu that he/she had ingredients to make. - He/she was still using foods from Food Supply Company A. - He/she had to switch the lunch meal to it being the dinner meal on 1/25/23, because the dinner meal according to the new menu was supposed to be resident's choice on 1/25/23, instead of what they had ingredients for the resident's choice, on 1/26/23 according to the old menu. - The menus came in late. - On 1/23/23, he/he did not have ingredients for the egg salad sandwich, which was a lunch meal. During a phone interview on 1/30/23 at 11:42 A.M., the Consultant Dietitian said: - He/she did not know the facility changed food vendors. - He/she expected the facility to have recipes for pureed items if the facility had a resident who was on a pureed diet. - They should have had the pureed recipe. - He/she had not had a chance to look at the new menus as yet. - The last time she was at the facility as a consultant was 11/16/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the wall mounted fans in resident rooms 10, 11, 8, 12, 7, 4 and 2 free of a heavy buildup of dust and to maintain a stand-up lift used to transfer one sampled resident (Resident #6) free from a crack in the base out of nine sampled residents. The facility census was 14 residents. 1. Observations with the Maintenance Director (MD) on 1/26/23 between 11:10 A.M. to 12:29 P.M., showed resident's rooms 10, 11, 9, 12, 8, 7, 4 and 2 had wall mounted fans and all had a heavy build up of dust on the fan blades and plastic grate. Record review of Resident #214's, quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 4/15/22, showed he/she was cognitively intact with a Brief Interview for Mental Status (BIMS - an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident ' s attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) of 15 out of 15 indicating he/she was cognitively intact. During an interview on 1/26/23 at 12:01 P.M., the resident said it had been a while since he/she saw housekeeping clean the fan. During an interview on 1/26/23 at 2:30 P.M., the housekeeping Supervisor said: - The wall mounted fans should be cleaned weekly. - He/she was without housekeeping help since April of 2022. - He/she saw several fans in resident rooms which were real dusty. 2. Observation with the MD on 1/26/23 at 12:21 P.M., showed a three inch (in.) crack on the base of a stand-up lift in resident room [ROOM NUMBER] that was occupied by Resident #6 During an interview on 1/26/23 at 12:22 P.M., the MD said the stand-up lift was not cracked at the beginning of 1/23. During an interview on 1/26/23 at 12:24 P.M., Certified Nurse's Assistant (CNA) A said: - He/she assisted Resident #6 with a transfer that morning. - He/she inspects the wheels of the stand-up lift, ensure that the brakes of the stand-up lift, and he/she inspected the sling (a device designed to be suspended from and attached to the patient lift boom and swivel bar of a mechanical lift). - He/she did not necessarily check the base where the resident stood. -This was the only resident who used the stand-up lift on. During a phone interview on 1/30/23 at 12:01 P.M., the Director of Nursing (DON) said the CNAs should be looking at the lifts and he/she absolutely expected them to inspect the lift every time before they use it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper behavioral health management was implemented and support services were offered to assist in promoting healthy psychosocial functioning and failed to initiate interventions that would prevent negative interactions/incidents between two sampled residents (Resident #4 and #10) who were in a relationship, and two sampled residents (Resident #4 and Resident #12), who had a physical altercation out of nine sampled residents. The facility census was 14 residents. 1. Record review of Resident #4's undated face sheet showed he/she was admitted to the facility with the following diagnoses: -Other Recurrent Depressive Disorders (a mental health disorder characterized by a feeling of profound and persistent sadness or disrepair and is frequently accompanied by a loss of interest in things that were once pleasurable). -Other Psychoactive Substance Abuse, Uncomplicated (A drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior). Record review of the resident's progress note dated 10/15/22 showed he/she was very inebriated (effected by alcohol or drugs especially to the point where physical and mental control is markedly diminished). Record review of the resident's behavior note dated 10/16/22 showed: -He/she was arguing with another resident (Resident #10) in his/her room. -Both residents had been drinking. Record review of the resident's progress note dated 10/18/22 showed he/she was inebriated and was placed in a wheelchair for his/her safety. Record review of the resident's administration note dated 10/20/22 showed: -He/she was inebriated. -He/she was placed in a wheelchair for his/her safety. Record review of the resident's administration note dated 10/20/22 showed: -He/she was inebriated. -He/she was placed in a wheelchair for his/her safety. Record review of the resident's administration note dated 10/23/22 showed he/she appeared to be intoxicated. Record review of the resident's administration note dated 10/25/22 showed he/she was drinking excessively. Record review of the resident's administration note dated 10/27/22 showed he/she was drinking excessively. Record review of the resident's administration note dated 10/29/22 showed the resident: -Was drinking too excessively. -Had requested a wheelchair to sit in. -Had not been exhibiting any inappropriate behavior. Record review of the resident's administration note dated 10/30/22 showed the resident: -Had been drinking and was inebriated. -Had declined using a wheelchair. Record review of the resident's behavior note dated 11/5/22 showed he/she had left the facility without signing out and did not notify the nurse. Record review of the resident's social service note dated 11/8/22 showed: -The resident had been consuming an extreme amount of alcohol several times a week. -The resident could get very uncontrollable and aggressive as a result of drinking. -The Administrator and the Social Service Director (SSD) had made several attempts to redirect the resident's behaviors. -The resident said he/she was going to drink because he/she was a grown up and denied having any behaviors. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 11/27/22 showed: -The resident had a Brief Interview for mental Status (BIMS) score of 14 out of 15 which indicated he/she was cognitively intact. -The resident did not have any physically aggressive behaviors towards others. -The resident did have verbally aggressive behaviors towards others. -The verbal behaviors occurred 1-3 times during the look back period. Record review of the resident's administration note dated 12/2/22 showed he/she had been arguing with another resident and needed to be separated. Record review of the resident's administration note dated 12/11/22 showed: -He/she had been drinking excessively. -He/she was placed in a wheelchair for his/her safety. Record review of the resident's administration note dated 12/20/22 showed: -He/she had been drinking. -He/she was loudly cussing at a peer. Record review of the resident's administration note dated 12/24/22 showed: -He/she was very drunk. -He/she was placed in a wheelchair for his/her safety. Record review of the resident's administration note dated 12/25/22 showed he/she had been drunk that day. Record review of the resident's care plan dated 12/31/22 showed: -The problem identified: --The resident has a psychosocial well-being problem related to ineffective coping skills due to alcohol consumption. --The resident is/has potential to be verbally aggressive related to ineffective coping skills and alcohol consumption. --The resident is/has potential to be physically aggressive related to poor impulse control. --The resident is an elopement risk related to leaving facility leaving the facility without notifying staff or signing out. -Interventions included: --Consult with Pastoral care, Social services, and Psychiatric services. --Monitor/document the resident's usual response to problems/ ---How the resident makes his/her own changes. ---How the resident expects others to control his/her problems. --Resident had a history of making false accusations about physical harm while intoxicated. --- Monitor for signs and symptoms of physical harm and call the Administrator immediately. --Psychiatric/Psychogeriatric consult as indicated. -NOTE: There were no new interventions put into place following the instances the resident was impaired as a result of his/her drinking. -NOTE: There were no new interventions put into place that addressed being an elopement risk. -NOTE: There was no problem identified or interventions in place that addressed the resident having a potential relationship with another resident (Resident #10). Record review of the resident's behavior note dated 12/31/22 showed the resident left the facility and refused to return to the facility even though facility staff tried to redirect the resident. Record review of the resident's administration note dated 1/1/23 showed he/she was intoxicated, slurring his/her speech, and was unsteady. Record review of the resident's social service note dated 1/3/23 showed: -The resident had an altercation with another resident on 12/30/22. -The Administrator and SSD asked the resident if he/she wanted to get help regarding his/her drinking. -The resident agreed to go to an inpatient treatment facility. -During the intake process of the inpatient treatment facility the resident changed his/her mind about going inpatient. -The SSD would continue to follow the resident on a weekly basis. Record review of the resident's administration note dated 1/5/23 showed he/she had been drinking excessively and was drunk. Record review of the resident's administration note dated 1/7/23 showed he/she had been drinking excessively. Record review of the resident's administration note dated 1/8/23 showed: -He/she had been drinking. -He/she walked to the liquor store twice that day. Record review of the resident's administration note dated 1/17/23 showed he/she was inebriated. During an interview on 1/24/23 at 2:05 P.M. the resident said I have already talked with a lot of people about the situation and I do not want to answer any more questions. There is nothing more that can be done. During an interview on 1/26/23 at 12:15 P.M. the resident said: -The facility had offered him/her therapy services in the past and he/she had not accepted the offer. -The facility offered Alcoholics Anonymous (AA) the following day after the altercation on 12/20/22. -The facility had told him/her that he/she was going to a different facility to get help, but the facility told him/her that there were no beds available. -He/she did not want any treatment. -The facility had never sent him/her out for a psychiatric/psychological evaluation and he/she never had one completed. -He/she was not an alcoholic and did not have a drinking problem. -He/she only had problems when he/she was drinking. -He/she would go back to his/her room after drinking and sometimes would curse and yell. -I drink too much sometimes. -I need to watch how much I drink. -When he/she was drinking that he/she needed to go to his/her room when he/she was angry. -He/she did not remember having a contract about his/her behaviors and drinking. -He/she was open to having someone come into the facility to talk about how to better manage his/her alcohol. 2. Record review of Resident #10's undated face sheet showed the resident admitted to the facility with a diagnosis of Alcohol Abuse with Intoxication, Unspecified (a habitual misuse of alcohol). Record review of the resident's nurse's note dated 10/03/22 showed: -The resident had been following another resident (Resident #4) continuously throughout the day. -Licensed Practical Nurse (LPN) A saw the resident and the other resident (Resident #4) arguing three times throughout the day. -LPN A also saw the resident drinking. Record review of the resident's social service note dated 10/10/22 showed: -When the resident drank alcohol he/she could become rude and aggressive towards other residents. -The resident denied having any behaviors while drinking. -The Administrator had spoken to the resident about his/her behavior with another resident. Record review of the resident's annual MDS dated [DATE] showed: -The resident had a BIMS score of 14 out of 15, which indicated he/she was cognitively intact. -The resident had not exhibited any verbal or aggressive behaviors towards others. Record review of the resident's care plan dated 12/2/22 showed: -The problem identified: --The resident had the potential to be physically aggressive related to alcohol consumption. --The resident was an elopement risk/wanderer related to history of attempts to leave the facility without notifying staff. -Interventions included: --When the resident becomes agitated, intervene before agitation escalates. --Guide the resident away from the source of distress. --Engage the resident calmly in conversation. ---If the resident response was aggressive, staff were to walk calmly away, and approach later. -NOTE: There were no interventions put into place that addressed the residents being an elopement risk. -NOTE: There was no problem identified or interventions put into place that addressed the resident having a potential relationship with another resident (Resident #4). During an interview on 1/17/23 at 11:10 A.M. the resident said: -On 12/1/22, the other resident (Resident #4) fell pretty hard and he/she could not pick up the other resident (Resident #4). -The neighbors had come to help pick up the other resident (Resident #4). -The other resident (Resident #4) could get belligerent when drinking hard liquor. -He/she had not been drinking the night of 12/1/22. During an interview on 1/24/23 at 12:19 A.M. the resident said he/she liked Resident #4 but was not in a relationship with Resident #4. 3. Record review of the incident report dated 12/1/22 showed: -Resident #4 and Resident #10 were in a relationship. -Resident #4 and Resident #10 left the facility without signing out after dinner. -Resident #4 and Resident #10 came back to the facility intoxicated. -Resident #4 asked Certified Nurses Aide (CNA) C if there was a scratch on his/her face. -CNA C saw what looked like a scratch and showed the scratch to Registered Nurse (RN) A. -Resident #4 said Resident #10 scratched his/her face. -Resident #4 was placed on a one-to-one observation due to his/her intoxication. -Resident #10 said when they were out, Resident #4 tripped and fell. -Resident #10 said a neighbor helped Resident #4 up from the ground. -Resident #10 said he/she did not physically hurt Resident #4. -Resident #4 was intoxicated and could not remember all of the events. -Resident #4 said he/she remembered that he/she fell and people helped him/her up. -Resident #4 said he/she was mad at Resident #10 and lied about Resident #10 scratching his/her face. 4. During an interview on 1/17/23 at 10:00 A.M. the Administrator said: -Resident #4 and Resident #10 were in a relationship. -When both residents drank the relationship was not good. -Resident #4 exhibited behaviors when drinking. -Resident #10 could get aggressive towards Resident #4 when drinking. During an interview on 1/17/23 at 11:24 A.M. Resident #4 said he/she fell at the park and Resident #10 did not scratch him/her. During an interview on 1/25/23 at 1:19 P.M. CNA B said: -He/she would consider Resident #4 and Resident #10 in a relationship. -When Resident #4 was not drinking he/she did not exhibit any behaviors. -When Resident #4 was drinking was when he/she started to exhibit behaviors such as cussing. -There had been incidents in the past with Resident #4 and Resident #10. -Most of the incidents between the two residents happened during the night time. -He/She was unsure what kind of services or therapies Resident #4 had been receiving. -He/She knew that the Administrator, Director of Nursing (DON), and SSD had talked with Resident #4 about his/her behaviors. -When Resident #4 and Resident #10 were exhibiting behaviors and/or drinking he/she was to separate the residents. -He/she would tell the charge nurse if a resident was exhibiting any behaviors and the charge nurse would call the Administrator or DON if the behaviors were escalating. During an interview on 1/25/23 at 1:28 P.M. LPN A said: -He/she would not consider Resident #4 and Resident #10 in a relationship. -When Resident #4 was not drinking he/she could be mellow. -Resident #4 did not exhibit behaviors towards Resident #10 when sober, he/she only argued with the resident. -Was not sure if Resident #4 and Resident #10 had any altercations prior to the incident on 12/1/22. -Was not sure if Resident #4 was receiving any services or therapies. -He/she would document any behaviors in a behavioral note or progress note. -When charting a behavior he/she would chart the behavior, any triggers that caused the behavior, and any interventions that were done. During an interview on 1/25/23 at 2:44 P.M. the SSD said: -He/she had previously developed a contract with Resident #4 regarding his/her alcohol consumption and behaviors. -After the altercation on 12/30/22 there were no attempts made for Resident #4 to go to AA or request anyone from AA to come to the facility. -There were interventions in place for when the residents were intoxicated, but not to keep the residents from consuming alcohol. During an interview on 1/25/23 at 2:57 P.M. CNA D said: -He/she thought that Resident #4 and Resident #10 were in a relationship. -When Resident #4 was sober, he/she did not exhibit any behaviors. -When Resident #4 was drinking he/she could get really loud and verbally aggressive towards staff and Resident #10. -Did not know if there were any previous incidents between Resident #4 and Resident #10. -Was not sure if Resident #4 was receiving any services or therapies. -When Resident #4 was intoxicated he/she would place the resident in a wheelchair and would assist in monitoring the resident. -When a resident was exhibiting behaviors he/she would tell the charge nurse and intervene if able. -He/she would intervene by redirection. During an interview on 1/26/23 at 6:03 A.M. LPN C said: -Resident #4 and Resident #10 were in a relationship. -Resident #4 and Resident#10 had no issues when sober. -Resident #4 did exhibit behaviors towards Resident #10 when Resident #4 was drinking. -Both residents could exhibit behaviors towards each other, mainly arguing. -Resident #4 could get really loud, cuss, and be generally verbally aggressive towards others. -Could not think of any altercations between the residents prior to the incident on 12/1/22. -Was not sure what services or therapies Resident #4 was receiving. During an interview on 1/26/23 at 10:58 A.M. Registered Nurse (RN) A said: -He/she charted behaviors with a behavioral note. -Some residents have behavioral monitoring as an order and would have to get charted on every shift. -When documenting behavior notes the behavior and the interventions needed to be documented. -When Resident #4 and Resident #10 were drinking his/her responsibility was to monitor the residents and if a conflict had occurred they would intervene and separate the residents. -Resident #4 was not receiving any services or therapy at that time. -Resident #4 had declined services and therapy in the past. -If he/she had asked Resident #4 about receiving services or therapy he/she would document the offer and acceptance/refusal. -If a resident was exhibiting a behavior the staff need to be knowledgeable of the behavior and monitor for the behavior throughout the shift. -He/she would delegate tasks to the CNA's to assist with monitoring. -He/she had talked with Resident #4 about the consequences of drinking alcohol. -He/she tried to document those conversations with Resident #4, but shifts could get busy. During an interview on 1/26/23 at 11:17 A.M. the SSD said: -The resident had a contract in the past, it was a blanket statement that Resident #4 signed then disregarded it. -Could not provide documentation of the contract. -Resident #4 did not get drunk while he/she was at the facility. -If Resident #4 was drinking during the day, Resident #4 was re-directable. -It was hard to document each incident that Resident #4 or Resident#10 had because the residents do not remember what happened and neither do the staff. -He/she was not present during the time of the altercation on 12/1/22. -He/She thought the Administrator was responsible for writing a note of the altercation in his/her absence. -Resident #4 was not accepted into inpatient rehabilitation because Resident #4 would be returning back to the facility. -He/she did not document all of the offers and refusals because he/she had done it so often. -Resident #4 could tell anyone how much the SSD offered services. -He/she was unsure if he/she needed to document the offers and refusals. During an interview on 12/26/23 at 12:12 P.M. the ADON said: -The Administrator and DON were responsible for the initial investigation of the incident from 12/1/22. -The facility provided oversight and protection with monitoring for residents, but when management would leave in the evening that was when most events and incidents would happen. -Resident #4 and Resident #10 have done activities together and had no issues. -When alcohol became involved that was when Resident #4 and Resident #10 would start exhibiting behaviors. -Resident #4 would be verbally aggressive and would curse at Resident #10 and staff while intoxicated. -He/she would stay late and that would refrain Resident #4 and Resident #10 from drinking. -A follow-up should have been done after the incident from 12/1/22. -The Covid-19 pandemic caused issues with getting services into the facility. -He/she had not attempted to offer services or therapies to Resident #4 since the pandemic. -When Resident #4 refused services in the past it was hard to continue to offer services. -Thought Resident #4 would benefit from a psychiatric evaluation and therapy, but no one had offered Resident #4 those services. -Behaviors needed to be documented and should be documented with the behavior and the follow-up that was done. -Social Service would need to get involved and follow-up with residents regarding the behavior. -The doctor should also be involved and notified of resident behaviors and get orders as needed for the residents. During an interview on 1/26/23 at 1:21 P.M. CNA B said: -When Resident #4 was intoxicated he/she would be the instigator towards Resident #10. -Resident #10 would then exhibit behaviors in response to Resident #4's instigation. -Resident #4's behaviors would then become worse. During an interview on 1/26/23 at 1:22 P.M. the ADON said: -Resident #10 received behavioral health services. -Resident #10 had recently been assigned a Guardian. -Resident #10 was not assigned a Guardian as a result of the incident on 12/1/22. -He/she felt that Resident #10's needs were being met with the assignment of the Guardian. -Resident #10 would usually follow his/her redirections. -Resident #10 did not usually have behaviors when sober. -Nurses did not normally document all incidents with Resident #10 because he/she was able to be easily re-directed and would usually stop the behavior. -Every shift Resident #10 had behavioral monitoring, when marked no, the documentation did not show-up on the Electronic Medical Record (EMR). - He/she did not think anything different could have been done with Resident #10 following the situation on 12/1/22. During an interview on 1/26/23 at 1:40 P.M. the Administrator said: -When residents have behaviors there were procedures that were in place such as behavior contracts. -There was no specific policy for Behavioral Management. During an interview on 1/26/23 at 1:54 P.M. the SSD said: -He/she did not think anything could have been done differently for Resident #10 after the 12/1/22 incident. -Did not think Resident #10 needed anymore assistance besides the psychiatric services he was already receiving. -Did not think the Guardian was helping Resident #10's behaviors. During an interview on 1/26/23 at 2:04 P.M. the Administrator said: -Resident #4 and Resident #10 were in a relationship. -There have been attempts made for Resident #4 to receive services. -There had been issues in the past with Resident #4 refusing services and inpatient settings not having beds. -The SSD was available to come up and help with behavioral issues with the residents and he/she was always available by phone call to help alleviate altercations. -He/she had tried to stop Resident #4 from leaving the facility to drink in the past, but had not documented it. -He/she thought that the Guardian was helping Resident #10's behaviors. During an interview on 1/26/23 at 2:40 P.M. the DON said: -The incident report showed that Resident #4 had lied about the physical contact with Resident #10 and that was reflected in the conclusion. -Resident #4 was verbally aggressive with everyone, and not just with Resident #10. -Resident #4 and Resident #10 had an on-again/off-again relationship. -The relationship was that way due to their drinking. -Resident #4 usually exhibited verbally aggressive behavior while drinking. -Resident #10 did not usually exhibit behaviors while drinking to Resident #4, or anyone. -The separation of Resident #4 and Resident #10 was the best thing to do when they were intoxicated. -Resident #4 and Resident #10 were not currently receiving services for alcohol abuse. -Resident #4 had usually refused services. -He/she did not think that Resident #10 would have anymore issues with the assignment of the Guardian. -The facility was terrible at documentation, as there had been multiple attempts made to offer services to Resident #4 that had not been documented. -He/she expected all staff to document when offering a service and the response. -He/she expected the nurses to document behavioral monitoring in the resident EMR. -He/she expected the nurses to document the behavior and the intervention. -He/she was responsible for the follow-up of behavior documentation. -He/she expected the nurses to report behaviors at shift change. -He/she expected the SSD to perform post altercation/incident interviews. -He/she expected all staff to assist with any behaviors that were exhibited. -He/she expected care staff to perform preventative measures when residents were drinking before a behavior could be exhibited. -All staff were aware that Resident #4 and Resident #10 needed to be separated when intoxicated. During an interview on 1/27/23 at 12:26 P.M. the DON said: -He/she expected staff to monitor residents when they were drinking to keep them safe from themselves and others. -He/she had told staff that when a resident became verbally or physically aggressive from drinking, that resident was to not have contact with any other resident. -He/she was unsure how to control Resident #4 when he/she drank. -The facility had verbal conversations with Resident #4 and he/she had agreed to not be around other residents when drinking. -The facility had not developed a written contract with Resident #4 regarding his/her behavior. -He/she had provided a resource for counseling services with telehealth options to the Administrator, but was not sure what happened after that. -He/she would expect all interventions that the facility had attempted with Resident #4 to be documented. 5. Record review of Resident #12's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including depression. There was no documentation showing the resident had a diagnosis of post traumatic stress disorder (PTSD- a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event. Symptoms may include nightmares or unwanted memories of the trauma, avoidance of situations that bring back memories of the trauma, heightened reactions, anxiety, or depressed mood). Record review of the resident's Physician's Order Sheet (POS) dated 1/2023, showed the resident had a diagnosis of depression and there were physician's orders for Amitriptyline 10 milligrams (mg) daily for depression. Monitor for drowsiness, slurred speech, dizziness, nausea, aggressive/impulsive behavior. There were no diagnoses showing the resident had substance or alcohol abuse. Record review of the resident's Nursing Notes dated 4/21/22 to 7/27/22, showed the resident exhibited no behaviors. There was no documentation showing the resident expressed any prior trauma, substance or alcohol use/abuse, fear, anxiety or depressive symptoms. Record review of the resident's Care Plan dated 4/25/22, showed no area related to depression and no goals to maintain the resident's psychosocial and mental health. There were no interventions showing the resident had depression, received medication for depression or had any depression symptoms. There was no documentation showing the resident had past trauma, physical or verbal abuse, substance or alcohol abuse or any triggers that would cause the resident trauma. There were no interventions that showed any preventive interventions, how the facility would address these behaviors if they occurred and how the facility would provide support to the resident. Record review of the resident's undated Social Service Assessment showed: -The resident had no documented diagnoses of depression, PTSD, substance/alcohol abuse, psychosis or trauma. -The section titled, Significant Life Experiences, showed the resident had several marriages and divorces and was widowed from his/her last marriage. -Had a history of substance abuse addiction that resulted in loss of custody of two children, which he/she was able to regain. -It was noted the resident did not want to continue the interview at that time. -The section titled, Significant Medical and Psychiatric History, showed the resident wanted to resolve issues related to diabetes and insulin management and dental concerns. There was no documentation showing the resident had ever had any counseling/therapy or treatment for depression or substance abuse or was receiving therapy or treatment at the time the assessment was completed. -The assessment did not address alcoholism or any physical or verbal abuse. Record review of the resident's quarterly Social Service Notes showed: -On 5/5/22 the resident had been homeless and a substance abuser that could no longer take care of himself/herself and needed assistance and was ready to get his/her life .cleaned up and back on track. The note did not show how the facility was supporting him/her or whether the resident had any current supports. -On 7/13/22 the resident seemed to be doing better, enjoyed living at the facility and visits with family. The note showed the resident sat outside and drank liquor while listening to music. It did not show if the resident had any behaviors associated with drinking alcohol. -The notes did not show the facility offered or were providing any supportive services to the resident to address depression or alcohol/substance abuse. Record review of the resident's Nursing Notes from 7/27/22 to 12/30/22, showed there were no notes showing the facility provided a psychiatric/psychological evaluation on the resident to address his/her trauma and did not show that any counseling or supportive services were provided to the resident. Record review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert and oriented with no confusion. -Had no psychosis, hallucinations or delusions. -Had a diagnosis of depression and had depressive symptoms-feeling bad about self, hopeless, depressed, little interest in doing things and trouble concentrating on things during the look back period. -Received anti-depressant medication, and did not receive any anti-psychotic medications. -Did not show the resident had any substance or alcohol abuse and did not show the resident had any mood or behaviors related to physical or verbal abuse, or was physically or verbally abusive towards self/others. Record review of the resident's Behavior Notes showed: -On 12/30/22 the resident was outside when another resident (former roommate) hit him/her. They both began to fight each other, falling to the ground, punching each other in the face and pulling each other's hair. Staff attempted to separate the residents but was but unsuccessful. Police had to be called along with the ambulance. The resident's physician, Administrator and SSD were also notified. Documentation showed the emergency services completed a full body assessment of the resident and found no reason to transport him/her for further services/hospitalization. The note showed the resident was not transported to the police station. The notes did not show any immediate behavioral interventions the facility initiated or any long-term interventions implemented. Record review of the resident's Incident/Investigation Report dated 12/30/22 showed: -On 12/30/22 the resident was observed on the ground fighting with another resident. -The resident said he/she was called a bitch and was hit by the other resident. -The resident was oriented to person, place and time, was ambulatory without assistance. -The resident sustained a scratch to his/her face by his/her lip with no additional injuries. -The predisposing factor was that the resident was intoxicated. -The report did not show new interventions implemented to prevent further incidents of this type. Record review of the resident's Care Plan updated 12/31/22 showed the resident had potential to be physically aggressive related to anger, poor impulse control. Interventions showed staff would: -Analyze the times of day, places, triggers, and what de-escalates the resident's behavior and document. -Separate the resident and complete constant monitoring as scheduled to ensure safety of the resident until further notice. -Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out staff when agitated. -Monitor and document observed behavior and

Based on observation and interview, the facility failed to maintain an exhaust pipe in the attic space over the storage room, in good repair to prevent that pipe from emitting steam into the attic area. This practice potentially affected at least five residents who resided in that part of the facility. The facility census was 14 residents. 1. Observation with the Maintenance Director (MD) on 1/26/23 at 10:43 A.M., showed: - One exhaust pipe in the attic area which emitted steam which caused several of the nearby wood beams to become wet. - The pipe was warm when it was held. During an interview on 1/26/23 at 10:47 A.M., the MD said that pipe came from the furnace room and he/she did not know that pipe emitted steam which could possibly cause some decay on the wood beams.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the floor area behind and under the dishwasher free of food debris and grime;to maintain the floor behind the reach in fridge with the clear glass, free of food debris; to maintain the toaster free of a heavy buildup of bread crumbs; to maintain the six burner stove free from a buildup of burnt--on grime; to prevent a buildup of dust on sprinkler head and the emergency light fixture in the kitchen; to maintain the gasket (a piece of rubber or some other material that is used to make a tight seal between two parts that are joined together) of a freezer in storage room [ROOM NUMBER] in good repair; to prevent an opened bag of corn meal from being stored in dietary storage room [ROOM NUMBER]; to maintain the floor of dietary storage room free of debris; and to ensure the Dietary Aide (DA) A checked the temperature of a hamburger, a potentially hazardous food (PHF - foods that must be kept at a particular temperature to minimize the growth of food poisoning bacteria that may be in the food ) after it was cooked and before placing the burger on a bun. This practice potentially affected all residents. The facility census was 14 residents. 1. Observations on 1/24/23 from 9:35 A.M. through 10:45 A.M., showed: - A buildup of food and dust debris was on the floor behind and under the dishwasher area on the floor. - A buildup of food debris was on the floor under and behind fridge. - A large amount of bread crumbs was stuck inside the toaster and on the removable plates of the toaster. - A buildup of burnt-on debris on the stove top of the six burner stove. - A heavy dust buildup was present on the sprinkler head above reach-in fridge. - A handle of a butter brush that was not easily cleanable. - A pot that was used to to keep the melted margarine on one of the burners of the six burner stove with a layer of grease and food debris on the outside. - An open bag of corn meal, was present in dietary storage room [ROOM NUMBER]. - A buildup of debris was present on the floor behind the refrigerator in dietary storage room [ROOM NUMBER]. - An area of a damaged gasket of freezer #1 that was 20 inches (in.). high by 28 in. wide. During an interview on 1/24/23 at 9:46 A.M., the Dietary Manager (DM) said: - A complaint was made by another non-dietary employee about how the outside of the toaster looked. - He/she was the only one that worked in the kitchen full time until about 2-3 weeks prior to the survey. - The last time he/she cleaned the burnt on debris on the metal grates, was before Thanksgiving of 2022. - Another employee opened the bag of cornmeal, but may not have been able to lift that bag, so that employee just left the bag there. - There was a plumbing problem in the past which caused the debris to be placed on the floor. - He/she had a hard time closing the freezer door in dietary storage room [ROOM NUMBER], but he/she did not know why it was hard to close the freezer until that day (1/24/23), because he/she saw the gasket was damaged. 2. Observation on 1/24/23 at 11:46 A.M. Dietary Aide (DA) A placed a frozen hamburger in the frying pan. Observation on 1/24/23 at 11:51 A.M., DA A removed the burger from the frying pan and placed it in a bun for service to a resident who asked for alternate that day, without measuring the temperature to find out if it was fully cooked to proper temperature of 165 ºF (degrees Fahrenheit). During an interview on 1/24/23 at 12:29 P.M., DA A said he/she went by how the burger looked because he/she knew how the resident wanted it cooked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the handrails located at the following locations: outside resident rooms [ROOM NUMBERS], outside resident room [ROOM NUMBER], between resident rooms [ROOM NUMBERS], and between resident rooms [ROOM NUMBERS]. The facility census was 14 residents. 1. Observations with the Maintenance Director (MD) on 1/26/23, showed: - At 12:09 P.M., the two hand rails outside resident rooms [ROOM NUMBERS], moved back and forth when they were held. - At 12:14 P.M., the hand rail outside resident room [ROOM NUMBER], moved back and forth, when it was held. - At 12:20 P.M., the hand rail on the wall between resident rooms [ROOM NUMBERS], moved back and forth when it was held. - At 12:29 P.M., the hand rail on the wall outside resident rooms [ROOM NUMBERS], moved back and forth when it was held. During an interview on 1/30/23 at 2:22 P.M., the MD said he/she: - Checked the hand rails as he/she walked by the hand rails. - Checked the handrails as much as he/she could. - Replaced the brackets of one of the hand rails, around the Christmas Holiday season in 2022. - Relied particularly on housekeeping staff particularly to let him/her know because the housekeeping department cleaned the handrails once per month.

Based on interview and record review, the facility failed to maintain receipts or signatures of transactions that were done for one sampled resident (Resident #16) out of three residents sampled for examining resident funds. The facility census was 16 residents. 1. Record review of Resident #16's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning ) dated 1/18/21, identified Resident #16 as the following: - A resident who had clear comprehension. - A resident who is able to make himself/herself understood. - A resident who was assessed as having a 15 on the Brief Interview for Mental Status (BIMS). - A resident who had correct orientatation to time. - A resident who had ability to recall colors, objects, and furniture. - A resident who participated in his/her assessment. Record review of the resident's transactions dated 11/20, 12/20 and 1/21 showed the absence of receipts or authorized transactions during those three months. During an interview on 2/10/21 at 11:31 A.M., the Business Office Manager (BOM) said the following: -He/she gets the resident's debit card (a card issued by a bank allowing the holder to transfer money electronically to another bank account when making a purchase) and used the resident's debit card to spend on cigarettes and liquor. -He/she did not keep receipts of past transactions. -He/she/she did not verify the starting amount on the debit card. -He/she understood the need to verify the starting amount on the debit card before he/she bought anything for the resident and the need to keep copies of receipts with the resident's signatures to protect himself/herself and the residents from any financial mishandling. During a phone interview on 2/19/21 at 10:40 A.M., the resident said: -The monthly allowance he/she received was applied to his/her debit card. -The BOM has used his/her debit card to purchase cigarettes. -Sometimes he/she allowed the BOM to use his/her debit card to purchase cigarettes and other times, he/she gave the BOM cash. -Yes, he/she was provided receipts for purchases made with the debit card. -He/she placed the receipts in an envelope. -He/she had not noticed any foul play on his/her debit card.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure advanced directives or a responsible party were in place for one cognitively impaired sampled resident (Resident #6) out of eight sampled residents. The facility census was 16 residents. Record review of the facility's undated Advanced Directive Policy and Procedure showed: -The facility would ensure a resident's choice regarding advanced directives. -The facility would provide the family and/or resident with information regarding their right to accept or refuse medical treatment. -The facility would obtain the resident's advanced directive during the admission process. -The policy did not include information regarding residents who were cognitively impaired who did not have an advanced directive in place. 1. Record review of Resident #6's admission Record showed: -The resident was admitted to the facility on [DATE] with the following diagnoses: --Human Immunodeficiency Virus (HIV-a virus that attacks the body's immune system). --Parkinson's disease (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait). --Mood disorder. --Anxiety disorder. --Psychological and behavioral factors associated with disorders or diseases. --Pseudobulbar affect (a nervous system disorder that can make you laugh, cry, or become angry without being able to control when it happens). -There was no complete contact information for a family member or a responsible party for the resident. Record review of the resident's Social Services Quarterly assessment dated [DATE] showed there was no documentation related to the resident's advanced directive status. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated tool completed by facility staff for care planning dated 8/22/20 showed the resident was severely cognitively impaired. Record review of the resident's Social Services Quarterly assessment dated [DATE] showed there was no documentation related to the resident's advanced directive status. Record review of the resident's annual MDS dated [DATE] showed the resident was severely cognitively impaired. Record review of the resident's Care Plan dated 12/2/20 showed the resident had impaired cognition and impaired thought processes related to decision making. Record review of the resident's medical record on 2/8/21 showed no advanced directives. Observation on 2/8/21 at 10:48 A.M. showed the resident: -Was in the common area in his/her wheelchair. -Verbalized repetitive words over and over. -Was not interviewable. Observation on 2/8/21 at 11:20 A.M. showed the resident: -Was in his/her room in his/her wheel chair. -Was verbalizing repetitive words over and over. -Was not interviewable. Observation on 2/9/21 at 12:33 P.M. showed the resident: -Was in the dining room in his/her wheel chair. -Was repetitively laughing over and over. -Was not interviewable. During an interview on 2/10/21 at 9:58 A.M. Licensed Practical Nurse (LPN) A said: -The nurses do not complete advanced directives for the resident. -The Social Services Designee (SSD) was responsible for resident advanced directives. During an interview on 2/10/21 at 10:58 A.M. the SSD said: -He/she was responsible for ensuring the status of the residents' advanced directives. -He/she did talk about the advanced directives in the residents' care plan meetings to see if any updates were needed. -The resident did not have a Durable Power of Attorney (DPOA-a document whereby a person designates another to be able to make health care decisions if he or she is unable to make those decisions) and he/she was estranged from his/her family. -The resident seemed to answer all his/her questions about daily life. -The resident was cognitively impaired. -He/she had not applied for a Public Administrator (PA-a court appointed person that made decisions for someone who was cognitively impaired) at this time because he/she did not think it was time to apply for a PA for the resident since he/she could answer questions. During an interview on 2/10/21 at 11:07 A.M. LPN A said: -The resident could make daily decisions. -The resident was cognitively impaired and could not make important life decisions. During an interview on 2/10/21 at 11:37 P.M. the Director of Nursing (DON) said: -The SSD was responsible for ensuring the residents were offered the right to formulate advanced directives and ensuring the resident had advanced directives. -He/she was unsure how often the SSD offered to formulate advanced directives to the residents. -If a resident was cognitively impaired and not able to make decisions, he/she expected the SSD to talk physician to see what the next steps were if they did not have any advanced directives. -There was no contact information for Resident #6's family. -The resident could make his/her needs known but could not make big decisions. -The resident probably needed a PA.

Based on interview and record review, the facility failed to maintain an escrow (a deed, a bond, money, or a piece of property held in trust by a third party to be turned over to the grantee only upon fulfillment of a condition (the escrow company) guarantees the performance or obligations of a second party (the principal (the nursing home) to a third party (the oblige-- the residents who are a part of the resident trust)) that was 1.5 times the average of the monthly balance of the reconciled bank statements for the resident trust. This practice potentially affected 12 residents who allowed the facility to manage their resident funds. The facility census was 16 residents. 1. Record review of the instructions for determining what amount a surety bond should be, showed: - The monthly reconciled bank statements and the monthly ending petty cash (the amount of cash that the facility keeps to be accessible to the residents) are added together for each of the previous (usually 9-12) months since the last survey; - The total amount of those totals are added together for a grand total; - That grand total is divide the number of active months for a monthly average; - That monthly average is rounded up or down to the nearest thousand; and - That new figure is multiplied by 1.5 for the required bond amount. Record review of the facility's escrow documents date 6/02, showed the amount of money in escrow, was $6,000.00 Record review of the average balance of the resident trust for 12 months dating from February 2020 through January 2021, showed a balance of $6,556.60 which was rounded up to $7,000.00. Then that $7,000.00 was multiplied by 1.5 to get a figure of $10,500.00, which is what was needed in escrow. During an interview on 2/10/21 at 10:58 A.M., the Business Office Manager (BOM) said -He/she did a calculation of the amount of escrow that was needed back in June 2020 and - The average monthly balance was $3,130.00 which was under their escrow limit of $6000, when they multiplied it by 1.5 they were at $4500.00, which was still $1500.00 under the escrow limit at that time.

Based on observation, interview, and record review, the facility failed to ensure two items in one resident use refrigerator, were labeled with the date those items were placed in the refrigerator; failed to ensure one item was labeled with a name or a date; and failed to ensure one item in the other resident use refrigerator, was discarded after the expiration date. This practice potentially affected at least three residents who used the refrigerator to store food items. The facility census was 16 residents. Record review of the facility's policy entitled Resident Food Brought by Family and Other Visitors dated 7/16/18, showed: -Purpose: To assure resident safety relative to all food brought to residents by family or other visitors. -Policy: All food brought to residents by family or other visitors will be managed by facility staff in a way that ensures safe and sanitary storage, handling, and consumption. -Procedure: All food brought to residents by family or other friends will be handled using the following procedures: - Staff will note the resident's name on the food packaging. - Staff will ask the family member or other visitor on what date the food was prepared and will note the date on the food packaging. - Resident food that requires refrigeration will be kept in a designated resident refrigerator which will be locked. - Such food will be kept separate from facility provided food. - The key to the refrigerator will be kept in the nurses' station for 24-hour access at the resident's request. - The Dietary staff will monitor the refrigerator daily for food that must be discarded and for a maximum temperature of 41 degrees Fahrenheit and document such on a temperature log. - Resident food that does not require refrigeration will be kept in the resident's room. - All food will be kept only three days from the noted day. After three days food will be discarded. - Staff will assist the residents in accessing their food and in consuming it if the resident is unable to do so on his or her own. 1. Observation on 2/8/21 at 12:41 P.M., showed a 16 ounce (oz.) container of sour cream in one of the resident use refrigerators that had an expiration date of 1/22/21. Observation with the Assistant Director of Nursing (ADON) on 2/8/21 at 12:43 P.M., showed the following: - Unlocked resident use refrigerators. - Three undated items which included two plates of food with a resident's name on them, which were wrapped in plastic and one container with the absence of a name or a date on it in the other resident use refrigerator. During an interview on 2/9/21 at 2:27 P.M., the ADON said: - The residents did not know about placing a date on the food they place in the fridge. - The container of sour cream should have been discarded. - He/she would have to in-service all the nursing staff about encouraging residents to place a date on the food they place in the refrigerator. - The best system is for the refrigerators to be locked so staff would have keys to open the fridge and they could place a date on any food before placing it in the fridge.

Based on observation, interview and record review, the facility failed to do the following: ensure there were shatter proof shields on the fluorescent lights; identify nine bags of meat in a freezer in the storage room with the contents that were in those bags; place a date on the tray where two packages of meat were pulled from the freezer and placed into a refrigerator for defrosting; and replace cutting boards with numerous nicks and grooves which caused the cutting boards to not be easily cleanable. This practice potentially affected all residents because all residents ate food from the kitchen. The facility census was 16 residents. 1. Observations on 2/8/21, showed: - At 9:43 A.M., the absence of shatter proofing from fluorescent lighting above the microwave area. - At 10:10 A.M., nine bags of meat without a label, were present in a freezer in downstairs storage room. - At 10:14 A.M. one roll of ground meat and one container of pork loin were pulled for defrosting, without the date that it was taken from the freezer for defrosting. - At 11:43 A.M., there were four cutting boards with numerous nicks and grooves, which caused the cutting boards to not be easily cleanable. During an interview on 2/8/21 at 9:45 A.M., the Dietary Manager (DM) said the lighting was newly installed, not even a month. During an interview on 2/8/21 at 10:15 A.M., Dietary Aide (DA) A understood that if the item is not easily identifiable, it needed to be labeled. He/she also said the meat may have been just pulled this am. During an interview on 2/8/21 at 10:47 a.m. the DM said the meat was pulled for defrosting on 2/7/21 and understood why a date was needed. During an interview on 2/8/21 at 10:49 A.M., the DM said the box the nine bags of meat came was labeled with chicken but he/she did not label the individual bags once he/she took the chicken bags out of the box. During an interview on 2/8/21 at 11:46 A.M., the DM said he changed the cutting boards back in September 2019. During an interview on 2/9/21 at 1:04 P.M., the Maintenance Director said: - He/she installed the lighting in the kitchen a few weeks ago. - He/she is in the process of installing (a light-emitting diode (a semiconductor diode which glows when a voltage is applied)) LED lights in throughout the building. - He/she got side tracked with other tasks. Review of the 2017 Food and Drug Administration (FDA) Food Code showed: - In Chapter 3-501.17: When the food is removed from the freezer, to indicate the date by which the food shall be consumed which is: (a) seven calendar days, minus the time before freezing, that the food is held refrigerated if the food is maintained at 41 ºF (degrees Fahrenheit) or less before and after freezing, or (b) four calendar days, minus the time before freezing, that the food is held refrigerated if the food is maintained at 45 ºF or less as specified under 3-501.16(C) before and after freezing. - In Chapter 3-602.11 Food Labels. A) Food Packaged in a Food Establishment shall be labeled as specified in law, including 21 CFR 101 -Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. B) Label information shall include: 1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; -In Chapter 4-501.12 Cutting Surfaces. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and SANITIZED, or discarded if they are not capable of being resurfaced. - In Chapter 6-202.11 Light Bulbs, Protective Shielding. A) Except as specified in paragraph (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed food; clean equipment, utensils, and linens; or unwrapped single-service and single-use articles.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents and staff who reside in, use, or work in the facility. The facility census was 16 with a licensed capacity of 16 residents. Record review of CMS's Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD -A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever), revised 7/6/18, showed facilities are expected to have a water management policy and procedures in place to reduce the risk of growth/spread of Legionella and other opportunistic pathogens in the building water systems. The facilities must do the following: - Conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. - Implement a water management program that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard and the Centers for Disease Control (CDC) toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens; - Specify testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. 1. Record review of the facility's disaster manual entitled Emergency Preparedness, reviewed on in April 2019, showed an absence of a waterborne pathogen prevention program, which included, but not limited to, the following: - A facility-specific risk assessment that considers the ASHRAE industry standard. - A completed CDC toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. - A schematic or diagram of the facility's water system. - A facility-specific infection prevention program or plan on how to manage outbreaks of Legionella and/or other waterborne pathogens. - A program and flowchart that identifies and indicates specific potential risk areas of growth within the building. - Assessments of each individual potential risk level. - Facility-specific interventions or action plans for when control limits are not met. Observations during the facility room-by-room life safety code/environmental inspection with the Maintenance Director on 2/9/21 between 1:25 P.M. and 2:38 P.M., showed the following: - Resident rooms contained both sinks and toilets. - A boiler room, which contained two hot water heaters. - A three-compartment sink and an automatic dishwasher in the kitchen. - A central bath with a whirlpool tub only, which was located adjacent to resident room [ROOM NUMBER], a central bath with a toilet and sink, which was located adjacent to resident room [ROOM NUMBER], and a central bath with a shower only was located between resident room [ROOM NUMBER] and resident room [ROOM NUMBER]. During an interview on 2/10/21 at 1:05 P.M., the Maintenance Director said he/she had assessed the facility for areas of stagnant water, but the assessment of those areas were not written in a facility plan. During an interview on 2/10/21 at 1:10 P.M., the Administrator said there was not a diagram of water flow from the main pipe which came in from the street level to the rest of the facility. During an interview on 2/10/21 at 1:17 P.M., the Maintenance Director and Administrator said they needed a plan to account for changes in water quality such as water main breaks and construction in the local area. During an interview on 2/10/21 at 1:19 P.M., the Maintenance Director and the Administrator said they needed to develop a plan to specifically delineate specific actions the facility would implement in response to a Legionella positive water sample. During an interview on 2/10/21 at 1:20 P.M., the Maintenance Director and the Administrator said they are the members of the Water Management Program team. During an interview on 2/10/21 at 1:54 P.M., the Director of Nursing (DON) said he/she and the nursing staff have not been trained in recognizing the symptoms of Legionella.