Based on observation, interview and record review, the facility failed to ensure a comfortable and homelike environment for 64 sampled residents out of 73 sampled residents with room temperatures ranging from 81.8 degrees Fahrenheit (°F) to 87.0 °F and halls A, B, C, D and F temperatures ranged from 81.5 °F to 82.8 °F. The facility had failed to have a comprehensive monitoring system including documentation for the air temperatures to maintain documentation for all ongoing maintenance for cooling units in the facility and to conduct random monitoring. This had the potential to affect all residents in the building. The facility census was 116 residents. Review of the facility's Emergency Operations Plan policy dated 4/1/23 showed: -Temperature thresholds: --Each facility shall establish and implement policies and procedures in a written plan to provide for the health, safety, welfare and comfort of all residents when the heat index/apparent temperature as established by the National Oceanic and atmospheric Administration, inside the facility exceeds 80 degrees F. Review of the facility Temperature policy revised March 2024 showed: -The facility temperature will be maintained between 71-81 degrees F. -There may be brief periods of time when the inside temperature falls out of this range in the event of inclement weather, power outages, or other unforeseen circumstances, -In these aforementioned instances, facility staff will take immediate and appropriate steps to ensure resident comfort. -During heat waves or excess heat, additional fluids will be offered or made available unless contraindicated. Review of the facility Direct Supply Logbook Documentation for temperatures: test and log air temperatures dated marked done on-time by the facility Director of Environmental Services/Maintenance (DOM) on May 17, 2024, showed: -Steps: --All buildings are required to maintain an ambient temperature throughout resident and patient areas in a temperature range of 71-81 degrees F. or at a more restrictive range required by state or local requirements. Exceptions to this range may be available for brief periods of unseasonably warm or cold temperatures; however, the variance in temperatures must not adversely affect resident or patient health and safety. -Instructions: --Take environmental temperature readings approximately 36 inches from the floor. --Using a digital thermometer take random location temperatures throughout the building. --The time of day that the temperatures are taken should vary to ensure that the desired temperature range is achieved under a variety of conditions. --While meeting the requirement for the indoor air temperature, it is also important to consider the effective air temperature and the impact that humidity and air movement in the building may be having on comfort. --If air temperature monitoring tests are not within acceptable ranges, immediately create a high priority TELS work order. Review of the Weather Underground's website for local weather for the city and state where the facility was located from 6/8/24 through 6/10/24, showed the daily high temperatures and heat index were: -On 6/8/24; Daily high temperature of 86 °F. -On 6/9/24; Daily high temperature of 80 °F. -On 6/10/24; Daily high temperature of 80 °F. 1. Observation and interview on 6/9/24 at 2:25 P.M., Director of Maintenance (DOM) said: -He/She does not keep regular facility temperature logs unless there was a problem. -The facility runs off a boiler system and air handler/chiller unit. -It runs about 20 degrees cooler then outside. -It will never get as cool as some residents would like it to. -Observed with the DOM the unit information screen/gage showing the unit was working and the water temperature going through the unit was 65.3 degrees F. -The air from the cold water in the system will stay the same throughout the facility. -The outside temperature was 83 degrees F. -Each room in the facility has a wall unit that can adjust the room temperature. -The facility had two wall units down at this time and new parts came in 6/8/24 and would be installed on 6/10/24. -One unit was in room H-4 and there was no resident in that room. -The other unit was at the common area at the end of hall E that was not used by residents unless going to the vending machine. -He/She had ordered a total of eight new motors and fans one each for those units and six extra since weather will be getting hotter. Observation on 6/9/24 from 3:38 P.M. to 4:14 P.M. showed: -The A hallway was 81.5 °F. -The B hallway was 82.8 °F. -Resident room A5 was 81.8 °F, Resident #1 said the room was hotter than the hallway and he/she was hot. Resident #2 nodded his/her head in an up and down motion when asked if he/she were hot. -Resident room B10 was 83.9 °F, Resident #10 was in bed and asleep. -Resident room B6 was 86.0 °F, the room air unit was turned off and the window was opened about 2 inches. During an interview on 6/9/24 at 3:40 P.M., Family Member A said: -The resident room was hot. -He/she had just told the DOM and the Med Records/Central Supply person who was Manager on Duty (MOD) for the shift on 6/9/24 at 3:47 P.M., the room was too hot. During an interview on 6/9/24 at 3:47 P.M., the DOM said: -Had just been told by resident 1's family member that the air conditioning unit was not turning on in room A-5. -He/She checked for a work order and did not find one. -He/She will repair it tomorrow morning. During an interview on 6/9/24 at 3:54 P.M., Certified Nursing Assistant (CNA) A said: -Felt that resident 1's room was hot since the 17th of May. -Did not report to anyone because both residents in the room were not hot. -His/Her face was swollen up on Friday 5/24/24, due to the facility being too warm for him/her. -Resident 1 told him/her on Friday 5/24/24, the room was too hot. -He/She called and told the Clinical Staffing Coordinator, the MOD on Saturday morning 5/25/24, that the temperature in facility was too hot for him/her. -He/She was back on duty on 5/27/24, and the facility was cooler then. -Resident 10 in room B-10-1 had told him/her on 6/8/24, that it was hot. -He/She told Licensed Practical Nurse (LPN) C, only works as needed (PRN) that resident 10 was hot. -He/She did not believe LPN C told anyone else about resident 10 being hot. During an interview on 6/9/24 at 4:20 P.M., LPN A said: -He/she was not aware that the room window in B6 was opened. -Room windows should not be open. Observation on 6/9/24 from 4:22 P.M. to 4:46 P.M., showed: -The C Hall was 81.9 °F. -LPN B was passing medications, was sweating and wiping his/her neck and face with a cloth. He/She said no residents had told him/her yet that it was hot and he/she had not asked them if they were comfortable. He/She had told the MOD the C hall was too hot. The MOD told him/her the air conditioning was being worked on at this time. -Resident room C10 was 86.9 °F, there was an oscillating floor fan near Resident #5's bed. -The D hall was 83.1 °F. -Resident room D7 was 87 °F. Resident #7 was in bed. He/she had an oscillating floor fan near his/her bed and a small fan on the overbed table blowing on him/her. He/She was covered with a sheet and wearing oxygen. He/She said it was uncomfortable to breathe and it was too hot. Resident #8 had a small fan near his/her bed and said if the thermostat by the door setting gets turned down lower than 90 °F the air conditioning wall unit in the room shuts off. -Resident room F8 was 83.1 °F. The wall air unit was not turned on. Resident #9 had a thick blanket pulled up around him/her and said it was hot. During an interview on 6/9/24 at 5:17 P.M., the Director of Nursing (DON) had arrived at the facility and said: -Had contacted the air conditioning company that the facility contracted with and the company was sending a technician. -He/she had staff start moving residents from the hotter rooms to the cooler areas. -He/she had staff checking on all residents providing cold drinks and fans to those who wanted fans. -Activated the Emergency Disaster Plan including: --Room moves. --Nursing assessments of residents. --Hydration rounds. --Offering fans. --Cooling locations in the therapy gym and private dining area. During an interview on 6/9/24 from 6:01 P.M., the DOM said: -He/She had checked the Chiller at 4:34 P.M. and it was not running. -He/she had taken a picture of the information gages and it showed the Chiller had shut off at 3:15 P.M., probably due to a power surge. -The water in the Chiller was 80 Degrees F. -He/She contacted the air conditioning company, and they had a technician on the way. Observation on 6/9/24 from 6:06 P.M. to 6:25 P.M. with the MOD showed: -Resident Room A1 was 81.5 °F., the wall unit was not working. Resident #22 said he/she was hot and there was a fan near his/her bed. -Resident Room A3 was 82.3 °F. -Resident Room A5 was 82.5 °F. Resident #2 was asleep with no apparent signs of distress at this time. -Resident Room A6 was 82.4 °F, the wall unit was not working. -Resident Room A8 was 85.1 °F. There were no residents in this room. During an observation on 6/9/24 from 7:17 P.M. to 8:19 P.M. with the Regional Resource [NAME] President (RRVP) showed: -Resident Room A7 was 82.5 °F. -Resident Room A9 was 82.2 °F. -Resident Room A10 was 82.0 °F. -Resident Room A11 was 82.4 °F, the wall unit was turned off. -Resident Room A14 was 82.0 °F. -Resident Room B1 was 82.5 °F. Resident #6 said the temperature was much better than earlier. -Resident Room B2 was 83.5 °F. -Resident Room B3 was 83.5 °F. -Resident Room B4 was 83.4 °F. -Resident Room B5 was 83.7 °F. Resident #39 and Resident #40 both said the temperature is a little warm but better than earlier. -Resident Room B6 was 84.2 °F. -Resident Room B7 was 83.7 °F. -Resident Room B8 was 83.0 °F. -Resident Room B9 was 83.0 °F. Resident #44 said the temperature was a little warm but ok with it. -Resident Room B10 was 83.1 °F. Resident #10 and #11 both said the temperature was ok and better than earlier. -Resident Room B11 was 84.2 °F. Resident #46 next to the window with curtain open said he/she was hot. -Resident Room B12 was 84.2 °F. -Resident Room C1 was 82.8 °F. Resident #51 said he/she was comfortable and temperature better than earlier. -Resident Room C2 was 82.0 °F, resident belongings were on top of the wall unit and it was turned off. -Resident Room C4 was 81.7 °F. -Resident Room C3 was 84.5 °F, the room window was open. Resident #54 was next to the window and said he/she was hot. -Resident Room C6 was 85.4 °F. Resident #55 and Resident #56 both said the temperature was better than earlier and it was cooling off some. -Resident Room C5 was 83.6 °F. -Resident Room C8 was 83.2 °F. -Resident Room C7 was 82.5 °F. -Resident Room C10 was 88.0 °F. Resident #5 said the temperature was better than earlier and waiting to be moved to another room. Hospitality Aide A said Resident #6 was out moved to another room onto B hall. -Resident Room C9 was 83.1 °F. -Resident Room C12 was 82.7 °F. Resident #62 and Resident #63 both said the room is cooling down and they were comfortable. -Resident Room E11 was 83.5 °F. the wall unit was turned off and the RRVP turned the unit on. Observation on 6/9/24 from 8:00 P.M. to 8:30 P.M., with the DOM showed: -Resident room D3 was 86.7 °F, the window was open, and the wall unit and thermostat were off. Resident #12 said it was warm. He/she had short sleeved shirt and shorts on and was up in his/her wheelchair. -Resident room D2 was 86.5 °F, the window was open and wall unit and thermostat were off. The wall unit was set at 63 °F. Resident #13 said he/she was really hot, there was no point in telling anyone. he/she had no shirt on. He/she said the wall unit was giving no air. -Resident room D4 was 86.9 °F, the wall unit and the thermostat were off. Both residents were in bed and uninterviewable. -Resident room D5 was 84.3 °F, the window as open, the wall unit and the thermostat were off. Resident #14 had a personal fan directly on him/her and said he/she had told the nurse it was too hot. -Resident Room D6 was 87.2 °F, the wall unit and the thermostat were off. Resident #15 said it was a little hot. His/her shades were drawn, and the wall unit was off. He/she had told the direct care facility staff it was too hot more than once over the last couple of days. -Resident Room D7 was 86.5 °F, the window was open, the wall unit was off, and the thermostat was off. Resident #16 said that the heat had a been a problem for several days since it was getting hotter. He/she had told the facility staff, and nothing was done. Resident #7 said the hospital aide had tried to adjust the thermostat and the thermostat shut completely off. Resident #7 said it was too hot and something needed to be done. -Resident Room D11 was 84.8 °F, the window was open, the wall unit and the thermostat were off. Resident #17 said the air had never worked. He/she had told several staff, but no one had come to work on it. He/she spends time outside of his/her room because of the heat. -Resident Room D8 was 88.5 °F, the wall unit and the thermostat were not working. Resident #18 said he/she was hot and was wearing oxygen. He/she said it had been uncomfortable for 2-3 days and he/she began to feel sick the night of 6/8/24. He/she had told the facility staff. Resident #20 said he/she was hot and had told everyone that had come thru the room. He/she was given a fan just a bit ago. The DOM said the wall unit was not working. -Resident Room D9 was 84.7 °F, the wall unit and the thermostat were off. Resident #19 said it was not working and it was too hot. He/she said it was his/her choice if the unit was off and he/she did not mind it a little hot. He/she said the DOM had fixed the wall unit about two months ago and put a new motor in, the motor had stopped working. During an interview on 6/9/24 at 8:33 P.M., CNA C said: -The facility rooms and hall had been hot for about 3 days. -It was alarming hot in the building. -He/she had turned down thermostats in rooms that seemed hot and or for residents that had complained of heat. During an interview on 6/9/24 at 8:35 P.M., CNA D said only one resident had complained to him/her about it being too hot. He/she told the nurse. During an interview on 6/9/24 at 9:00 P.M., the Mechanical Contractor said: -The facility had purchased a new unit a few months back, there was nothing wrong with the unit itself. -The unit had a phasing issue (a power blip - a short outage) when it lost a phase of power. -He/she restored the unit through a hard reset in the navigator controls. -He/she was unable to determine what cause the phasing issue and could not see how long the power outage was. -When the unit was down it could not provide cooling to the units inside. During an interview on 6/9/24 at 9:30 P.M., the DOM & the RRVP said: -The only way all the wall units and thermostats on the D Hall were off was because someone (a human) would have had to turn them off. -There was no plan in place to check every wall unit and every thermostat unless a resident or facility staff person reported there was a problem. During an interview on 6/13/24 at 2:55 P.M. The DON and CCO said: -They were notified on 6/9/24 that state surveyor was in building about increased facility temperatures. -Put their heat plan in to action. -Called the facility environmental response team for that day to bring in fans and lowered the temperature in the cooling rooms in facility. -Moved the residents from D Hall, the hottest area at that time, to other rooms if the resident chose to. -Room D-8 air unit was not working, had to convince one resident to move to a cooler room. -Room D-8 air unit was repaired. -Enacted guardian rounds which consisted of: --Checking all rooms to be sure all air units were functioning. --Some room air units were turned off, mostly by the resident, turned the units back on. --Room temperatures and the Chiller checked every hour. --Offered hydration rounds. --Providers were notified. --Resident assessments were done every 8 hours for respiratory residents and every 12 hours for other residents. -On 6/9/24 about 7:30 P.M. The contracted heating/air conditioning company arrived: --Deemed an unexpected loss of power to the Chiller unit. --Reset the unit no repairs made to the unit. --The unit was up and running by 8:20 P.M. on 6/9/24. -RRVP in-serviced the DON and the facility DES concerning: -- monitoring all room temperatures and the Chiller every hour till rooms and facility temperatures were within the acceptable range of 71 degrees F. to 81 degrees F. --Providing hydration to residents and fans were needed. --Moving residents to cooler rooms and areas. --Checking that room windows were closed, and air units turned on. -The DON started in-servicing the staff on shift on 6/9/24 -Rooms D-8, 9, and 11 were the only rooms above 81 degrees F. at 12:00 A.M. on 6/10/24 and residents had been moved out of those rooms, -Rooms D-8 and D-11 were below 81 degrees F at 1:00 A.M. on 6/10/24. -Room D-9 was below 81 degrees at 3:00 A.M. on 6/10/24 -The resident in D-9 wants his/her room hot and likes the room air unit turned off. The resident was educated not to turn the air unit off in the room and to let staff know if cool and the staff will adjust the air in room so the staff will be aware of the room temperature. -The facility staff have done hourly room temperature checks on D Hall and random temperature room checks on the other halls till today, 6/13/24 at 9:00 A.M. and will continue to monitor while the weather is warmer. MO00237318 & MO00236930

Based on interview and record review, the facility failed inquire about or address the negative balance of one resident (Resident #37) who had a negative balance since from 1/27/23 through 1/23/24 on the facility statement document. The facility census was 122 residents. 1. Review of Resident #37's deposit receipt dated 1/15/23, showed the resident received a check for $237.54 from a pension organization. Review of the resident's statement document dated 1/25/23, showed the resident withdrew $40.00 for personal needs. Review of the resident's statement document dated 1/27/23 showed the check was returned for insufficient funds which created a $48.00 negative balance in the resident's account. Review of the resident's statement document dated 3/14/23, showed a deposit of $20.00 by the resident which caused the negative balance to decline to $28.00. Review of the resident's trial balance dated 1/23/24, 9 months later, showed a negative balance of $28.00. During an interview on 1/23/24 at 2:06 P.M., the Business Office Manager (BOM) said: -He/she has only been at that position for three weeks. -He/she only became aware of the negative balance on 1/18/24. -The previous BOM did not contact the organization which sent that check to find out why there was a negative balance. During a phone interview on 2/5/24 at 3:16 P.M., the Receptionist from the pension organization said that check cleared their system on 7/21/21.

Based on interview and record review, the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (form CMS-10055) for one sampled resident (Resident #1000) who was discharged from Medicare part A services out of three residents sampled for reviewing Medicare Beneficiary Notices and out of 33 sampled residents. The facility census was 122 residents. Record review of the Centers for Medicare and Medicaid Services Survey and Certification memo (S&C-09-20), dated 1/9/09, showed the following: -The Notice of Medicare Provider Non-Coverage (NOMNC, form CMS-10123) is issued when all covered Medicare services end for coverage reasons; -If the skilled nursing facility (SNF) believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable or necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. The SNF's responsibility to provide notice to the resident can be fulfilled by the use of either the SNFABN (form CMS-10055) or one of the five uniform denial letters; -The SNFABN provides an estimated cost of items or services in case the beneficiary had to pay for them him/herself or through other insurance they may have; -If the SNF provides the beneficiary with either the SNFABN or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits, the provider has met is obligation to inform the beneficiary of his/her potential liability for payment and related standard claim appeal rights. Issuing the NOMNC to a beneficiary only conveys notice to the beneficiary of his/her right to an expedited review of a service termination. 1. Review of Resident #1000's SNF Beneficiary Protection Notification Review showed: -The resident's last skilled covered day was 11/19/23 and the resident remained in the facility. -A NOMNC (CMS 10123) form was provided to the resident an the resident signed the form on 11/17/23. -The resident was not provided a SNFABN/CMS-10055. During an interview on 1/26/24 at 8:43 A.M., with the Administrator and Administrator in Training, the Administrator said: -Normally the Social Service Director (SSD) was responsible for ensuring the SBN and NOMNC forms were completed for those residents receiving Medicare services. -At the time the resident's services were expiring, they had hired a new SSD who was in training and there were several management staff assisting with completing the NONMNC and SBN forms. -They did not know who issued the resident's Medicare documents. -The SBN form was missed and was not sent/given to the resident. -The Administrator in Training said he/she had been providing training to the SSD on completing the forms correctly and timely. -The facility's corporate management staff would be coming to the facility to provide in-service training to the SSD, Administrator in Training, Director of Nursing (DON), Director of Rehabilitation and the Director of Hospitality, all who may issue the NOMNC/SBN, will be included.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a bed hold form to the resident upon or during one sampled resident's (Resident #115) unplanned hospitalization out of four closed records and 33 sampled residents. The facility census was 122 residents. Review of the facility's undated Bed Hold policy and procedure showed: -Under normal circumstances, if you leave the facility for a hospitalization, you will be readmitted to the first available bed in a semi-private room. -Under certain conditions, we can reserve your existing bed for you at your request so when you return to the facility, you will have the same bed and room. -The Nursing Home Care Act requires a nursing facility to hold a bed for a maximum of 10 days when you are hospitalized . The facility must hold a bed for up to 10 days during a hospitalization. On the 11th day there is no requirement to hold a bed, but you are still a resident and will receive the next available bed when you are ready to return, even if there is a waiting list. -In Missouri a nursing home has an obligation to inform the resident or responsible party that paying them to hold a bed is voluntary. When a resident is transferred to a hospital, the nursing home is required by federal statute and by federal regulation to readmit the resident immediately upon the first availability of a bed in a semi-private room. 1. Review of Resident #115's Face Sheet showed he/she was admitted on [DATE], with diagnoses including stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) with hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), pain, heart disease, high blood pressure, arthritis, substance abuse, anxiety, and schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms). Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/21/23, showed: -Had no long or short term memory loss. -Had modified cognitive skills for daily living. -Had an acute onset mental status change-regarding signs of delirium, inattention and disorganized thought. -Had no mood indicators but had physical and behavioral symptoms and rejection of care. Review of the resident's undated Care Plan showed he/she had a self-care deficit and needed assistance with personal hygiene, bathing, dressing, toileting, transfers and bed mobility, and mobilized with a wheelchair. He/she was also at risk for falls, had the potential for nutritional deficit and had the potential for psychosocial well-being problems related to the new environment and his/her physical condition. Review of the resident's Administrative Note dated 12/22/23, showed: -Nursing staff called the police and emergency services due to the resident having bizarre behaviors with sexual advances toward staff with verbal threats and attempting to bite staff. Nursing staff was trying to assist the resident and get him/her to cooperate with going to the hospital and the resident became increasingly aggressive . The resident was on the telephone with his/her family and the writer also spoke with the family to notify them of the current incident and need to send the resident to the hospital for psychiatric evaluation. The resident's family was in agreement with sending the resident out for evaluation and treatment. Review of the resident's discharge MDS dated [DATE] showed this was an unplanned discharge with return not anticipated. It showed the resident was discharged to the hospital. During an interview on 1/26/24 at 2:12 P.M., the Administrator In Training said he/she was very involved with the discharge of the resident. He/she said: -On 12/22/23, he/she was completing rounds in the facility and staff told him/her that the resident started having behaviors (starting in the evening on 12/21/23) of making sexual advances toward nursing staff, trying to hit and bite staff and threatening staff with his/her fork and this behavior continued into the morning. -Nursing staff called the ambulance staff and police because the resident was refusing to leave and his/her behavior began to escalate. -He/she spoke with the resident's family and he/she was aware that the resident was going to the hospital. -He/she verbally informed the resident that he/she was going to the hospital, but they did not give him any bed hold information or have him/her sign the bed hold form. Complaint MO00229639

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to appropriately discharge on e sampled resident (Resident #115), that was a closed record, by failing to provide the resident a 30 day discharge notice and inform him/her of his/her rights to appeal; and to discharge to a placement that was comparable to the skilled services the resident was receiving at the facility out of four closed records and 33 sampled residents. The facility census was 122 residents. Review of the facility undated admission Contract, Section D, showed the facility may transfer or discharge the resident in compliance with facility standards: -If necessary for the resident's welfare and the resident's needs cannot be met in the facility. -If appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility. -If the health or safety of other individuals in the facility is endangered. -If the resident has failed, after reasonable and appropriate notice, to pay the rates and charges imposed by the facility. -The facility ceases to operate or as otherwise permitted by law. -Unless otherwise permitted or required by law, the facility shall provide the resident 30 days notice of involuntary discharge under this section. 1. Review of Resident #115's Face Sheet showed he/she was admitted on [DATE], with diagnoses including stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) with hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), pain, heart disease, high blood pressure, arthritis, substance abuse, anxiety, and schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms). Review of the resident's Hospital Discharge record dated 12/19/23, showed resident admitted to the hospital on [DATE] evaluation related to agitation, self care deficit and possible cocaine abuse-history of drug abuse. Discharge plan was to the nursing facility. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 12/21/23, showed he/she: -Had no long or short term memory loss. -Had modified cognitive skills for daily living. -Had an acute onset mental status change-regarding signs of delirium, inattention and disorganized thought. -Had no mood indicators but had physical and behavioral symptoms and rejection of care. -Needed assistance with self care and had a functional limitation on one side of his/her body. -Used a wheelchair for mobility. -Was not using any anti-psychotic, anti-anxiety or anti-depressant medications. Review of the resident's Care Plan showed he/she had a self-care deficit and needed assistance with personal hygiene, bathing, dressing, toileting, transfers and bed mobility, and mobilized with a wheelchair. He/She was also at risk for falls, had the potential for nutritional deficit and had the potential for psychosocial well-being problems related to the new environment and his/her physical condition. Interventions related to behavioral, psychosocial well-being showed: -Allow the resident to answer and verbalize feelings, perceptions and fears. -Consult with pastoral care, social services, and psychiatric services as needed. -Encourage participation from the resident who depends on others for decision making. -Increase communication between the resident/family/caregiver about care and living environment and explain all procedures and treatments, medications, results of lab tests, condition and all changes. -Initiate referrals as needed or increase social relationships. -Provide opportunities for the resident and family to participate in care. -When conflict arises, remove residents to a calm safe environment and allow him/her to vent and share his/her feelings. Review of the resident's Physician's Note dated 12/21/23, showed this was an admission note and the physician documented he/she reviewed the resident's medications, physical and health symptoms. He/she documented: -The resident was admitted to the facility for ongoing medical management as well as comprehensive therapies after hospitalization from 12/7/23-12/21/23. -The resident originally presented with agitation and self-care deficits. -The resident's family wanted to admit the resident to the hospital for placement at the facility due to his/her increased agitation, which they believe was due to cocaine abuse and progressive paralysis. -The resident was seen by psychiatry while he/she was in the hospital and was started on Seroquel (an antipsychotic) and increased Cymbalta (an anti-anxiety/anti-depressant). -The resident's social history included substance abuse, sexually transmitted disease and hepatitis C (a viral infection that causes liver swelling). -The resident assessment showed the resident was awake and alert, difficult to keep on subject during the assessment and continued to go off subject needing redirection to answer questions directly. The resident was thin and chronically ill appearing, and had difficulty with using his/her upper extremities above his/her waist and his/her fine motor skills were poor. Review of the resident's Administrative Note dated 12/22/23, showed: -Nursing staff called the police and emergency services due to the resident having bizarre behaviors with sexual advances toward staff with verbal threats and attempting to bite staff. -The police and emergency services arrived and the General Manager and nursing staff assisted. Nursing staff assisted with taking the resident to the bathroom (the resident was stalling going to the hospital). -The resident was on the phone with his/her family, who lived out of state and the writer also spoke with the resident's family and he/she understood the resident's mental health issue, recent substance issues and what needed to be done with him going out for psychiatric services. -The resident was cussing at the staff, police and emergency services, but the resident eventually went to the hospital without altercation. Review of the resident's Physician's Note dated 12/22/23, showed: -The facility contacted the physician regarding the resident's bizarre behavior, sexual advances, verbal threats toward staff, attempting to bite staff and the police and emergency services were notified. The resident was transported to the hospital for psychiatric evaluation due to these behaviors. -Upon review of the resident's medical record showed this was what prompted his/her family to have the resident hospitalized and the resident had a history of drug abuse, which was thought to be cause for some of his/her behavior, and would hope a toxicology screen would be completed upon this hospital evaluation. -This re-hospitalization was in the best interest of staff as well as the resident as he/she was a danger to them and himself/herself due to his/her behavior, and there were no further interventions to be put into place prior to emergency health services and police notification. Review of the resident's discharge MDS dated [DATE] showed this was an unplanned discharge with return not anticipated. It showed the resident was discharged to the hospital. Review of the resident's Hospital Psychiatry Note dated 12/26/23, showed the Psychiatrist saw the resident and reviewed his/her medical record and his/her case was discussed with the staff. The resident was angry and threatening and his/her telephone was removed due to the resident's yelling and being inappropriate during their conversation. The nurse gave the resident an antipsychotic after this interaction. When the resident aroused later in the day he/she said he/she did not remember the interaction or his/her earlier behaviors. There were no recommendations for follow up treatment documented on this partial report. Review of the resident's Hospital Discharge assessment dated [DATE], showed the resident was admitted on [DATE] for psychiatric evaluation-agitation, mood disorder unspecified psychosis, aggressive behavior, cocaine abuse. Discharge did not show any treatments provided while in hospital or labs, showed discharge was to the nursing home. Review of the resident's Medical Record showed there was no documentation showing the facility was not going to readmit the resident. There was no documentation showing the facility had planned to discharge the resident permanently and there was no documentation showing the facility was planning to transfer the resident to another facility where he/she could receive comparable care and treatment. There was no discharge plan for the resident in the resident's medical record. During an interview on 1/26/24 at 10:49 A.M., the Social Services Director said: -When the resident came into the facility, he/she was admitted on the rehabilitation unit, but he/she never had an interaction with the resident. -He/she did not remember anything about the resident and did not think the resident was in the facility very long. During an interview on 1/26/24 at 10:50 A.M., Assistant Director of Nursing (ADON) B said: -The resident's medical record showed the resident did not have a long stay, it was overnight. -The resident was on the rehabilitation unit. -He/she did not work with the resident but according to the medical record, it seemed when the resident arrived, he/she began having behaviors. Nursing staff notified the family and Nurse Practitioner/Physician, and sent the resident to the hospital. -The resident did not come back to the facility and there was no documentation showing where the resident went. During an interview on 1/26/24 at 1:41 P.M., the Director of Hospitality said: -He/she met with the resident the night he/she was admitted to the facility (on 12/21/23) and the resident seemed okay. -He/she thought the resident had some psychiatric diagnoses when he/she came to the facility, but the resident was not having any behaviors when he/she initially saw the resident. -They spoke about his/her family and his/her life. -On the following day, when he/she came to work, he/she checked on the resident that morning and he/she was sleeping. -Through the day he/she was okay but later in the evening, he/she was informed that the resident had started having behaviors with the nursing staff, making sexual advances toward the staff and being very aggressive. -The nursing staff called the police and emergency medical assistance and he/she went to see the resident in his/her room with the Administrator in Training and other management and nursing staff. -The resident was sitting on the side of his/her bed and he/she was cussing at the staff and was very angry. He/she had tried to hit at the staff. -The police came in and the resident remained aggressive and was cussing at the police and didn't want them to touch him/her and would not calm down. The resident stated he/she was going to kill everyone so they notified the physician to obtain physician's orders to send the resident to the hospital for a psychiatric evaluation and treatment. -One of the policemen eventually was able to get the resident to calm down and they were able to take him via ambulance to the hospital. -There was follow up done by upper management and it was decided that the resident would not be admitted back to the facility due to him/her being a danger to himself/herself and others. During an interview on 1/26/24 at 2:12 P.M., the Administrator In Training said he/she was very involved with the discharge of the resident. He/she said: -The resident had been admitted to the facility on ce before and was discharged to home with his spouse after a short-term stay and had never had any behavioral problems. -The resident was his/her own responsible party. -His/her most recent admission on [DATE], was also from the hospital and was admitted to the facility for a short rehabilitative stay. -On 12/22/23, he/she was completing rounds in the facility and staff told him/her that the resident started having behaviors (starting in the evening on 12/21/23) of making sexual advances toward nursing staff, trying to hit and bite staff and threatening staff with his/her fork and this behavior continued into the morning. -When he/she saw the resident that morning, the resident was in a chair in his/her room and the nursing staff informed him/her that he/she was going to be sent to the hospital for an evaluation. He/she saw the resident refusing to allow staff to assist him/her. -He/she called the Nurse Practitioner and informed him/her of the resident's behavior and he/she agreed the resident should be sent out to the hospital for a psychiatric evaluation and treatment. -Nursing staff called the ambulance staff and police because the resident was refusing to leave and his/her behavior began to escalate. -He/she assisted the nursing staff to help the resident to the toilet and while they were assist him/her, he/she was verbally abusive. The resident was also on the phone with a family member from out of town and the family member was trying to calm the resident down. -He/she spoke with the resident's family and he/she was aware that the resident needed to go to the hospital. -They all were trying to encourage the resident to go with the emergency medical assistance staff and eventually the resident agreed to go to the hospital. -He/she verbally informed the resident that he/she was going to the hospital, but they did not give him/her any discharge notice, any bed hold information or have him/her sign the bed hold form. -The ambulance services took the resident to the hospital behavior health center for a psychiatric evaluation. -They had to get an affidavit for the resident to leave the facility due to the resident's initial refusal to leave and because they felt the resident was a danger to self and others. -He/she had not received any documentation from the hospital showing the results of the psychiatric evaluation but he/she visited the resident while he/she was in the hospital. -He/she went to the hospital on [DATE], saw the resident and met with him/her, the hospital Social Worker and medical staff. The resident said he/she remembered the incident and he/she expressed that he/she really wanted to come back to the facility at that time, but the resident was still showing some aggressive behaviors during their meeting and was unable to follow any commands. -When he/she spoke with the Social Worker and Psychiatrist at the hospital, they wanted the resident to return to the facility, but he/she told them that they (facility management and physician) did not believe the facility could meet the resident's needs. He/she said he/she did not refuse to accept the resident back at this time. -The hospital Social Worker and hospital staff said this was considered abandonment and they were going to make a report to the state. -He/she spoke with the facility Medical Director about the resident's behaviors and their concerns, and the Medical Director said he/she agreed that the resident was not appropriate to come back to the facility and he/she would speak with the Medical Director at the hospital about the resident. -The facility Medical Director said they should not accept the resident back to the facility until the hospital could show the resident was stable for at least 14 days or until the resident could be managed without the use of Geodon injections ( antipsychotic medication). He/she said they were unable to manage this type of medication at the facility. -The facility Medical Director did not send any documentation showing why they decided they would not be able to manage the resident's needs any longer. -On 12/28/23 he/she informed the Social Worker at the hospital that they would not be accepting the resident back. The resident was still in the hospital at that time. -He/she told the hospital staff that if they could show that the resident was stable and was no longer receiving Geodon injections, they would consider readmitting the resident but he/she never heard anything from the hospital. -He/she kept notes regarding this discharge (was not in the resident's electronic medical record). -He/she and the management staff determined that they did not want to risk re-admitting the resident and risk him/her hurting himself/herself, another resident, or staff. -They did not send an immediate or 30 day discharge letter to the resident or his/her family. MO00229639

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASRR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis) prior to admission for two sampled residents (Residents #76 and #91) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy, dated May 2023, titled PASRR Policy showed: -Staff were to review all potential admissions Level 1 PASRR to determine if the individual would need further screening. -Staff were to review the Level 1 screening and not admit any individual with a mental or intellectual disability until the Level 2 screening process had been completed. Review of the facility's policy, dated May 2023, titled Behavior Health Services showed: -Staff were screen all residents prior to admission using the Preadmission Screening and Resident Review (PASRR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis). 1. Review of Resident #76's Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Schizoaffective Disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania). -Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). -Anxiety Disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool used for care planning), dated 12/27/23, showed: -Staff documented the resident was cognitively intact. -Staff documented the resident had no behavioral problems. Review of the resident's Level 1 PASRR, dated 1/25/24, showed staff submitted the screening 36 days after admission to the facility. During an interview on 2/7/23 at 2:48 P.M., a representative for the State of Missouri Central Office Medical Review Unit said the resident had triggered for a Level 2 screening. 2. Review of Resident #91's Face Sheet showed he/she was admitted [DATE] with the following diagnoses: -Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). - Adjustment Disorder with Mixed Disturbance of Emotions and Conduct (an emotional or behavioral reaction to a stressful event or change in a person ' s life; the reaction is considered an unhealthy or excessive response to the event or change within three months of it happening). Review of the resident's admission MDS, dated [DATE], showed: -Staff documented the resident was cognitively intact. -Staff documented the resident had no behavioral problems. Review of the resident's Level 1 PASRR, dated 11/12/23, showed: -Staff submitted the screening 45 after admission to the facility. -The resident had triggered for a Level 2 screening. 3. During an interview on 1/29/24 at 1:52 P.M., Social Services Designee (SSD) A said: -He/she was the SSD for both residents. -He/she did not know why neither resident had a PASRR completed before admission. -He/she was told when there was a new admission but did not review any records prior to accepting the resident. During an interview on 1/31/24 at 1:48 P.M., the Director of Nursing (DON) said: -He/she expected the Level 1 and Level 2, if indicated, PASRR to be completed and submitted prior to the resident being accepted into the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #366's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Other Asthma (a condition in which a person's airways become inflamed, narrow, swell, and produce extra mucus, which makes it difficult to breathe). -Obstructive Sleep Apnea (OSA- intermittent airflow blockage during sleep). Review of the resident's admission MDS dated [DATE] showed: -The resident was cognitively intact. -No indication the resident was on continuous oxygen therapy. -No indication the resident used Continuous Positive Airway Pressure (CPAP-a machine that uses mild air pressure to keep breathing airways open while you sleep) therapy. Review of the resident's Care Plan dated January 2024 showed: -The resident used oxygen but did not indicate the amount or duration. -An intervention to titrate and provide CPAP per physician's orders but did not indicate what the physician's orders were. Review of the resident's POS dated January 2024 showed: -An order that the facility may administer 2 Liters (L) supplemental oxygen as needed. -No order for the use of continuous oxygen. -No order of how the oxygen should be administered. -No order for when the tubing and other supplies needed to be changed out. -No order indicating the resident needed a Continuous positive airway pressure (CPAP- a method of respiratory therapy in which air is pumped into the lungs through the nose or mouth during spontaneous breathing). -No order for the settings and how to set up the CPAP for the resident. -No order for how to clean and store the CPAP tubing, mask, and other supplies. During an interview on 1/30/24 at 12:02 P.M. the resident said: -He/she used oxygen continuously. -He/she thought his/her oxygen amount was set at 2 L. -He/she had used the same CPAP tubing in mask that was lying on his/her bed for a while but could not remember if it had been changed out recently. -He/she used his/her CPAP every night. During an interview on 1/30/24 at 2:39 P.M. MDS Coordinator A said: -He/she and MDS Coordinator B were responsible for the entire facility's MDS assessments. -The MDS should match the care plan and the POS for each resident. -All MDS assessments should be accurate. -He/she did not realize Resident #366 was on oxygen because there was no order for it. -He/she did not realize Resident #366 had a CPAP because there was no order for it. During an interview on 1/31/24 at 9:41 A.M. Assistant Director of Nursing (ADON) A said: -He/she was a part of the care plan process. -There was a care plan meting completed daily for resident's who admitted to the facility from the day before. -The care plan meeting included himself/herself, the Director of Rehab (DOR), and the Social Worker. -The Director of Nursing (DON) ensures completion of the care plans. -Care plans should be up to date and reflect the resident's current status. -Any resident who used oxygen or CPAP therapy should have an order in place. -The order should include: --The type of oxygen therapy. --Cleaning regimen. --Titration settings. --How to store the equipment when not in use. --What kind of tubing the resident needed. -The resident's care plan should have included the orders for the oxygen and CPAP therapy. During an interview on 1/31/24 at 1:17 P.M. the DON said the resident's care plan should be up to date and include oxygen/CPAP therapy. Based on observation, interview or record review, the facility failed to ensure the resident's care plan was updated to show the resident's current capability/capacity for participation in activities or limitations to participating in activities for two sampled residents (Resident #6 and #366) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy titled Care Plans dated April 2023 showed: -The comprehensive care plan was developed within seven days of CAA completion. -The baseline care plan required the following: --Initial goals based on admission orders (services planned to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being including but not limited to: Activities of Daily Living (ADLs), nutrition, fall risk, skin integrity, and pain management) --Dietary orders. --Therapy services. --Social services (resident's goals and desired outcomes, advanced directives, preference and potential for future discharge from the facility, discharge plans including potential referrals, known or revealed history of trauma events in the life of the resident, transfer trauma interventions), --Pre-admission Screening and Resident Review (PASARR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/development disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of pay) recommendations, if applicable. -The care plan consisted of the following: --Problems as identified by reviewing the medical record and discussion with the resident and/or significant other. --Goals were set in conjunction with the family and resident. --Goals were realistic, measurable, behaviorally stated, and may be long or short term. --Interventions were actions taken to achieve the goal. --Evaluation of the care plan goals should occur at least every 90 days. 1. Review of Resident #6's Face Sheet showed he/she was admitted on [DATE], with diagnoses including brain degeneration (a condition that damages and destroys parts of your nervous system over time, especially your brain), cognitive communication deficit, muscle weakness, pain, hearing loss, history of falls, difficulty walking, high blood pressure, hearing loss and legal blindness (visual perception is less than 20/200 with glasses). Review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/24/23, showed the resident: -Was alert with significant cognitive memory loss. -Was dependent on staff for bathing, dressing, transfers, hygiene, mobility, toileting and used a wheelchair for transportation. -It was important to the resident to have activities including books, music, being around animals, keeping up with current events/news, doing things with groups of people, going outside, and participating in religious services. Review of the resident's Care Plan dated 12/22/23, showed the resident had self care deficits related to degeneration of the brain, significant changes in his/her ability to participate and legal blindness. The care plan showed the resident needed physical assistance with bathing, dressing, transfers, hygiene, toileting, bed mobility and used a wheelchair for mobility. The resident's activity care plan interventions showed staff would: -Encourage the resident to come to activities of interest, introduce him/her around to fellow residents, and help to facilitate social inclusion. -Encourage the resident to attend activities of choice for socialization and engagement benefits. -Encourage the resident to try to come to activities of choice or interest and remind him/her that he/she is free to leave activities at any time and is not required to stay. -Provide an enlarged monthly calendar in his/her room and remind the resident to look at the calendar for activities of choice and encourage attendance and participation as he/she chose to. -The resident watched television with his/her roommate in his/her room at times depending on what his/her roommate is watching. -Offer the resident independent leisure tools and materials as requested or needed to facilitate independent pursuits as desired. -The resident came to some social events with encouragement. -The resident attended trivia when he/she chose to. -The care plan was not individualized to show the one to one activities that resident was able to participate in or that were specific to residents with sight impairments. -The care plan did not show how many activities the resident participated in per week or the goal for the resident's participation in activities. -The care plan interventions were not updated to show the resident's current activity capability or capacity for participating in activities and did not show that the resident did not participate in any group activities. Observation on 1/23/24 at 5:12 P.M., showed the resident was in his/her bed with his/her stuffed animal. He/she was alert with confusion and was not interviewable. He/she said he/she was hungry. He/she was watching television. Observation on 1/26/24 at 9:12 A.M., showed the resident was sitting up in his/her bed with call light within reach dressed for the weather. He/she was looking out of the window his/her television was on but he/she was not watching it. He/she was holding onto his/her stuffed animal and was very pleasant. During an interview on 1/29/24 at 3:00 P.M., the Activity Director said: -He/she or the activity assistant completed one to one activities with the resident because he/she usually did not come to group activities. -They completed room visits with the resident and talked with him/her. -The resident's activities were according to the resident's preferences and they tried to accommodate the resident's preferences as they can. During an interview on 1/31/24 at 12:28 P.M., the Director of Nursing (DON) said: -Care plans should be comprehensive and reflect the current health status of the resident. -They should be updated as needed to reflect the current status of the resident.

Based on observation, interview and record review, the facility failed to ensure to have active physician order for use, monitoring/care and maintenance of a Peripherally Inserted Central Catheters (PICC) or Central Line Catheter (CVS) (is a long, thin, hollow, flexible tube that goes into a vein in your arm or chest and ends at the right side of your heart/right atrium. The PICC line is one type of catheter used to access the large veins in your chest, used to give intravenous (IV) therapy), and to document the flushing of the PICC line and dressing changes for one sampled resident (Resident #90) out of 33 sampled resident. Facility resident census of 122 residents. Review of the facility Policy for Physician Order revised on 5/2023 showed the facility will ensure all medication are administered as ordered by health professional in accordance with all state and federal guidelines. Review of the facility's Medication Administration policy revised on 4/2023 showed: -A physician or nurse practitioner order were required for the administration of all medication and treatments. -Read each physician order entirely. -Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. 1. Review of Resident's 90's admission Record showed he/she had the following diagnoses: -Stroke. -Severe protein-calorie malnutrition. -Dysphasia (difficulty swallowing). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning) dated 11/11/23 showed he/she: -Was moderately cognitively impaired. -Was admitted with a tube feeding. -Was dependent on facility staff for all cares. Review of the resident's undated Care Plan for his/her Central line Catheter showed: -The resident had CVS/PICC line in his/her upper right chest for intravenous (IV) therapy access. -Provide flushes as directed on his/her physician orders. -Follow facility policy and protocols for management and maintenance of the CVS/PICC line. Review of the resident's Physician Order Sheet (POS) dated 1/1/24 to 1/24/24 showed: -The Physician's Order to change PICC line dressing every 7 days (sterile process) one time a day every seven day(s) for PICC Line was. The PICC line was discontinued 1/2/24. -To monitor the PICC line site and dressing and to document in progress note any signs and symptoms of infection, notify provider of any infection. To be monitored every shift for per protocol was discontinued on 1/2/24. -To change needleless connector every week with dressing change and following blood draws one time a day every 7 day(s) for per protocol was discontinued on 1/2/24. Review of the residents Treatment Administration Record (TAR) dated 1/1/24 to 1/31/24 showed: -The physician order to change PICC line dressing every 7 days (sterile process) one time a day every seven day(s) for PICC Line was Discontinued 1/2/24. -To monitor of PICC line site and dressing and to document in progress note any signs and symptoms of infection, notify provider of any infection. Monitored every shift for per protocol was discontinued on 1/2/24. -To change needless connector every week with dressing change and following blood draws one time a day every 7 day(s) for per protocol was discontinued on 1/2/24. -Had no documentation of nursing staff had been flushing the PICC line or changing the dressing as ordered. Observation and interview on 1/24/24 at 9:59 A.M., showed the resident: -Had PICC line dressing on his/her right upper chest, dated 1/23/24. -Registered Nurse (RN) A said the resident's PICC line was used when he/she had active IV therapy treatment. The resident was no longer receiving IV therapy. -The nursing staff were maintaining the PICC line by flushing the line everyday. -He/she had no redness or swelling around the site. -RN A washed his/her hands prior placed gloves on hands. -He/she clean the port access site with alcohol wipe, then attached a 10 cc syringe of normal saline and flushed the line with any difficulty. -Removed his/her gloves and exited the resident room. During an interview and review on 1/24/24 at 2:33 P.M., RN A said: -In review of the resident's POS and TAR showed he/she did not have active physician order for flushing or maintenance of the the resident's PICC line. -PICC line care was last ordered on 11/7/23, and discontinued on 1/2/24. -It was possible the physician's order for PICC line had not been transferred over to current POS. -He/she would expect to have a PO for care of the PICC line or should of had PO to remove the resident's PICC line if not in use. Observation on 1/30/24 at 2:45 P.M. of the resident showed: -He/she had dressing over the PICC line site dated 1/29/24. -The dressing was clean and intact. During an interview on 1/30/24 at 2:50 P.M. , Licensed Practical Nurse (LPN) C said: -He/she was aware the resident had a PICC line. -He/she reviewed the resident's POS and TAR and they did not have a current order to flush PICC line or the care of PICC line site. -He/she would had document flushing and care of PICC line in the resident's nursing notes if not on the TAR. -He/she would expect the resident to have a physician's order for care or maintenance of his/her PICC line. -The Assistant Director of Nursing (ADON) or Director of Nursing (DON) would be responsible for the monitor of transcription of physician order were current and being followed. During an interview on 1/30/24 at 3:00 P.M., ADON B said: -He/she was aware of the resident having a PICC line. -The resident should had physician order for the care of the PICC line. -The nursing staff would have documented in the resident's TAR and nursing note flushing or care provided for his/her PICC line. -He/she was aware the resident still had the PICC and no IV medication ordered at that time, nursing staff were to flush the PICC line and dressing changes as ordered. -He/she would have to look at the resident's detail physician order to see why PICC line ordered were discontinued. During an interview on 1/31/24 at 12:45 P.M. the (Director of Nursing) DON said: -He/she would expect an have active physicians order to be in place for the use and care of the resident's PICC line. -Would expect nursing staff to document treatments in the the resident's nursing notes or TAR. MO 00230592

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #49's admission Record showed the resident had the following diagnosis: -Required assistance with personal cares. -Fracture of left knee cap. -Coronary Artery Disease (CAD, narrowing of the coronary arteries). -Congestive Heart Failure (disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). Review of the resident's Care Plan for Mobility and Falls revised on 5/22/23 showed: -The resident required physical assistance with transfer and was dated 3/12/23. -The resident had potential for experiencing falls related to health conditions, reduced physical function and immobility, cognitive loss, poor safety awareness, history of falls. -On 4/5/23 he/she had rolled out of bed no injury. -On 4/17/23 he/she had a non-injury fall. -On 5/22/23 he/she had a fall from his/her bed with a complaint of pain in his/her back and knees. -Review of the resident's interventions added included: --Ensure footwear fits properly. --Ensure the resident call lights is within reach and encourage the resident to use it for assistance as needed. --Anticipate and meet the resident's needs. --Cares to be provided in pairs due to resident accusations again staff. --On 5/22/23 sent to hospital for evaluation of injury due to complaint of pain. Therapy to evaluate the resident once returns. Review of the resident's Electronic Medical Record (EMR) for nursing health status or Incident notes dated 11/13/23 showed no detail documentation related to a resident fall on 11/13/23 to include who, what, when and how. Review of the resident's Fall Risk Evaluation dated 11/13/23 at 11:59 A.M. showed: -Reason for evaluation-post-fall. -The resident had a Fall risk score is: 19, (and a Fall risk scored above 5, resident was a HIGH risk for falls). -Vital signs taken and within range for resident. -There was new pain, post fall. -He/She was sent out to hospital for evaluation and treatment for left knee pain. -The resident had a fracture from the fall. -Noted the resident's left patella fracture (knee cap) was verified per the hospital computerized tomography (CT) scan (an imaging test that helps healthcare providers detect diseases and injuries). Review of the resident's typed witness statement dated 11/13/23 and not timed showed: -The form did not have a witness signature to verify the statement and had no time when witness statement was type/written or obtained from CNA T. -CNA T had walked into Resident #49's room. -The resident had ask to getup and CNA T had then asked the resident how he/she transfer. -The resident said that he/she can stand and pivot. -CNA T reported that he/she pivoted the resident into the his/her chair. -Later that evening, the resident wanted to lay back down, CNA T started to pivot the resident, but the resident's knee gave out and he/she landed on the floor. -CNA T called for a nurse. -The nurse evaluated the resident and than placed a call to the physician. -New physician's orders were given to send the resident to hospital for evaluation and treatment. Review of the resident's facility Witness Fall Incident Report dated 11/13/23 at 11:59 A.M. showed: -Was completed by the Director of Nursing (DON). -Had no witness found. -The resident had a fall in his/her room. -Nursing description documented showed: The nurse had received report, that resident had a witnessed fall during a transfer from his/her bed to chair. -The resident description documented as the resident said happened was staff wanted the resident to pivot and the resident knew he/she should have done that. -Immediate action taken, the resident was sent out to hospital for evaluation and treatment do to left knee pain. -He/She had injury of front of his/her left knee. -The resident had interventions in place at time of incident/fall. (did not listed previous interventions). -The resident fall happened during a transfer, he/she had footwear in place, and call light was on. -On 11/14/23 the facility had notified the resident's physician at 10:08 A.M. and family member notified on 11/14/23 at 11:24 A.M. -Under notes dated 11/15/23 had physical therapy (PT) and occupational therapy (OT) ordered for evaluation and treatment. -Did not have a final conclusion or root cause documented. -No detail nursing description of what happen during the witness fall. Review of the resident's Care Plan for Mobility and Falls revised on 11/14/23 showed: -The resident required physical assistance with transfers. -The resident had potential for experiencing falls related to health conditions, reduced physical function and immobility, cognitive loss, poor safety awareness, history of falls. -On 11/14/23 he/she had a fall, and was sent to hospital resulting in a major injury/fracture. -Review of the residents interventions added include: --On 11/14/23 had a referral to therapy regarding his/her fall. --On 11/14/23 The resident was to have PT/OT to evalute and treat for safe transfer and mobility. Review of the residents Nursing Health Status note 11/14/23 at 7:57 A.M. showed: -The resident was sent out to hospital for further medical evaluation and treatment while this nurse was off duty. -Another nurse responded to resident's fall. -Resident returned back to facility from the hospital with broken knee cap and was to follow up with an orthopedic physician. -The staff would continue to monitor the resident. Review of the resident Interdisciplinary Team (IDT) Note dated 11/14/23 at 11:24 A.M. showed: -The IDT had reviewed the resident's fall on 11/13/23 and he/she had been transferred to the hospital. -He/She had returned to facility that morning (11/14/23) with new orders for Norco 5-325 1 tab every four hours for pain times two days for pain control. -The resident had a scheduled follow-up appointment with an orthopedic physician related to his/her left patella fracture. -The resident was with soft immobilizer (a device tht keeps the knee/leg in place) in place. -The staff discussed new physician's orders with the resident's primary care provider. -The staff followed up with the resident's family to provide questions and answers. Review of the resident's physician progress note dated 11/14/23 at 10:12 P.M. showed: -The resident was seen on 11/14/23 for post fall follow up and hospital visit, the resident had reported his/her had fractured of the left patella. -The resident said facility staff were helping him/her getting back into bed and he/she fell on the floor. -The resident said Tylenol had helped with pain and he/she was resting comfortably in bed. -The resident had knee immobilizer on left lower extremities (LLE). -Fall follow-up for frequent checks, transfer the resident with mechanical lift. -His/Her left patella fracture will continue use LLE immobilizer and follow up with orthopedist specialist. Review of the resident's Quarterly MDS dated [DATE] showed he/she: -Had a Brief Interview for Mental Status (BIMS) score of 12. The score of 8-12, the resident were to have moderate cognitive impairment. -Occasionally incontinent of urine and frequently incontinent of bowel. -Had one major injury fall while a resident at the facility. Review of Physician progress note dated 12/18/23 at 12:11 A.M. showed Late Entry: The resident had been seen that day for follow up on left knee pain. -He/She continues to have pain in left knee. It is slightly edematous (swollen). -The resident was out of his/her knee immobilizer while resting in bed. -His/Her left patella fracture plan was to continue in left leg extremity (LLE) in an immobilizer and follow up with orthopedic specialist. During an interview on 1/23/24 at 4:52 P.M., the resident said: -He/She thought it was a CNA's child who had assisted the resident. -The child got scared while trying to help him/her transfer to his/her bed. -He/She had when he/she had last his/her balance during the transfer and fallen. -He/She thought his/her fall happen about two months ago. -He/She thought the non-staff member had assisted him/her to bed and the person assisting could not hold the resident during the transfer resulting in the resident falling. -He/She had broken his/her leg from the fall. -He/She did receive therapy after his/her fall. -The resident was not very interviewable. During an interview on 1/30/24 at 9:13 A.M., LPN C said: -The resident was to transferred with a Hoyer lift after the fall with injury. -Nursing on shift would be responsible for completing a fall note and risk management report. During an interview on 1/30/24 at 9:43 A.M., ADON B said: -The resident should be transfer with Hoyer lift after the fall with injury on 11/13/23. -Prior to this the resident transferred with one staff member and would pivot. -The resident fell on [DATE], which happened during a transfer of the resident by a new CNA who was no longer here. --CNA T said the resident stated he/she was able to pivot transfer. -A gait belt (a belt, usually made of heavy canvas with a sturdy buckle, used to help residents move) was used. -He/she not aware of any family member assisting the resident with a transfer. During an interview on 1/31/24 at 8:31 A.M., CNA L said: -He/she was familiar with resident care needs, but under CNA task are care task, which included how the resident should be transferred. -If resident found on the floor he/she would notify the nursing staff. -The nurse would complete an assessment when an incident occurred and document in in the resident's electronic medical record. During an interview on 1/31/24 at 9:08 A.M., CNA J said: -Resident #49 gets confused at time or forgot what they just talked about. -He/She does have a history of refusal of care at times and falls. -The resident requires a Hoyer lift now after his/her recent fall. -When the resident worked with therapy staff he/she would practice standing and pivot transfer. During an interview on 1/31/24 at 12:40 P.M. DON said: -He/She would expect nursing staff to immediately assess the resident, notify the resident physician and family members and complete an incident note and or progress note with details of the fall. -Nursing should have document fall details. -In the residents' EMR, they have a section for incident report which would popup, and he/she would expect nursing staff to have completed the section that was required in incident/fall report. -He/She would not except to have a detail nursing note of the event only that resident had fallen, and the action taken. -Nursing staff would be responsible for initial fall interventions and would document this in the residents' EMR. -The risk management investigate team would be responsible for review for root cause, documentation of any follow-up investigation and update the resident's care plan as needed. -The resident that required physical assistance would mean the resident would transfer without a device or mechanical lift, such as a gait belt transfer. Based on observation, interview and record review, the facility failed to ensure a safe transfer with a full body mechanical lift (an assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) for one sampled resident (Resident #69) and to ensure a comprehensive fall investigation and initial detail fall nursing note or incident note was completed for one sampled resident (Resident #49) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's Mechanical Lift Transfer policy revised 3/2023 showed: -At least two staff are required to transfer a resident with a mechanical lift. Review of the facility's Investigation policy revised 3/2023 showed: -Investigation will be completed by the Director of Nursing (DON) or designee. -Investigation may include if applicable: -Investigation summary, resident interviews, staff interview, any reports to state or local law enforcement authorities, staff reeducation provided. 1. Review of Resident #69's Face Sheet showed he/she was admitted on [DATE], with diagnoses including heart failure, difficulty walking, pain, muscle weakness, high blood pressure, oxygen dependency and kidney disease. 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 11/8/23, showed the resident: -Was alert with confusion. -Was dependent on bathing, dressing, was incontinent and mobilized in a wheelchair. -Was dependent on bed mobility and needed extensive assistance with transfers. Review of the resident's Care Plan dated 11/9/23, showed he/she had self care deficits related to his/her diagnoses and required the physical assistance of two persons to transfer with a mechanical lift. Observation on 1/30/24 at 9:48 A.M., showed the resident was sitting in a specialized wheelchair with padding for positioning. The resident was alert and oriented with confusion and was wearing oxygen. Certified Nursing Assistant (CNA) G then: -Removed the resident's oxygen tubing, opened the base of the lift and pushed it up to the resident's wheelchair. -He/She attached the sling to the lift and then lifted the resident, while holding onto the resident's legs to keep the resident from swinging. -CNA G moved the resident to the bed then lowered the resident onto his/her bed while positioning him/her in the middle of the bed. During an interview 1/30/24 at 10:10 A.M., CNA G said: -He/She was working on the A hall by himself/herself. -He/She usually transferred the resident using the full body lift by himself/herself because there was usually no one available to assist him/her to transfer the resident. -There was not enough staff to be able to transfer residents that need a full body lift with two people. -There were four to five residents on the hall that need a full body lift to transfer. -He/She was aware that they were supposed to have two persons to transfer residents using a full body lift. -He/She transferred the resident because the resident was ready to lay down and needed incontinence care and he/she could not find anyone to help him/her. During an interview on 1/31/24 at 9:30 A.M., Licensed Practical Nurse (LPN) B said: -The nursing staff is supposed to transfer everyone who needs a full body lift to transfer, with two people. -Often times they cannot do this because there was often no one available to assist with the transfer. -Sometimes the CNAs do have to complete the full body lift transfers independently. -It is not safe to do this, but they don't want the resident to sit in incontinence for long periods while they wait for someone to assist and risk resident's skin breakdown, so they would transfer the resident. -Those residents that are more at risk for falling or are heavier (weight/size) they will try to get someone to help with the transfer. -The expectation was the nursing staff would ask for assistance with the residents who need a full body lift transfer. -There was only one aide on the hall to do all of the resident care. -He/she tries to assist the nursing staff as he/she can but he/she was also busy with his/her own nursing responsibilities and was sometimes not available to help. During an interview on 1/31/24 at 12:28 P.M., the Director of Nursing (DON) said: -There should be a minimum of two persons using the full body mechanical lift to transfer a resident. -If there was no one available to assist, the staff should find the nurse manager, DON, Assistant Director of Nursing (ADON) or call the clinical number to request assistance. -They do not expect the nursing staff to complete the transfer using only one person to manage the lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident's physician's orders for a catheter (a tube placed in the body to drain and collect urine from the bladder) were complete to include the catheter size and indication for the catheter, failed to assess and document the resident's ability to provide self-care of his/her catheter, failed to ensure the catheter bag was kept below his/her bladder, and failed to ensure the resident's care plan showed the resident performed self-care of his/her catheter for one sampled resident (Resident #12) out of 33 sampled residents. The facility census was 122 residents. Review of the facility Catheter policy and procedure revised 4/2023, showed: -The purpose of catheter care was to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the bladder. -Physician's orders should include the reason/indication for the catheter, frequency and type of irrigation if necessary. -Assistance if needed, depending on the resident's mental status and stability to understand the procedure. The catheter should be taped or anchored to the upper thigh to avoid tension on the catheter. -The catheter and drainage bag should be kept as a closed system with the drainage bag kept at a level lower than the bladder to allow drainage by gravity. -The drainage bag was to be emptied at the end of each shift into an empty labeled measured graduate with the total documented in the medical record. 1. Review of Resident #12's Face Sheet showed the resident was admitted on [DATE], with diagnoses including stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain that can affect walking, speaking, understanding and muscle movement or paralysis), muscle weakness, difficulty walking, history of hip fracture, history of falling, hemiplegia (partial paralysis on one side of the body) and neuromuscular dysfunction of the bladder(when a person lacks bladder control due to brain, spinal cord or nerve problems). Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment tool to be completed by facility staff for care planning dated 12/21/23, showed the resident: -Was alert and oriented with no short or long term memory loss. -Was independent with transfers, mobility, dressing, toileting and needed supervision with eating. -Had a catheter. -Was unsteady walking, transferring surface to surface and on/off the toilet, but was able to stabilize without staff assistance. - Had no limitations in range of motion and used a walker and wheelchair for mobility. Review of the resident's Care Plan dated 12/21/23, showed the resident had a self-care deficit and limited physical mobility related to a right hip fracture and a history of stroke with right side weakness. It showed the resident had an alteration in elimination related to conditions with a catheter for urinary elimination and need for assistance with toileting tasks and catheter management. Interventions showed the resident: -Needed physical assistance with bed mobility, transfers, toileting, bathing, dressing and hygiene. -Monitor and document output. -Monitor for signs and symptoms of discomfort on urination and frequency. -Monitor/document for pain/discomfort due to catheter. -Monitor/record/report to MD for signs and symptoms of urinary infection. -Evaluate resident for urinary infection and if appropriate, urinary labs and treatment as indicated from the physician. -Resident will place urine drainage bag above level of bladder, staff to provide oversight and educate and encourage to place drainage bag below level of bladder. -The care plan did not show that the resident had been educated and was able to complete any of his/her catheter care to include emptying the drainage bag. Review of the resident's Physician's Order Sheet (POS) dated 1/2024, showed physician's orders for: -Catheter care every shift and as needed for maintenance (ordered on 7/26/23). -Change catheter drainage bag as needed (ordered on 7/25/23). -The physician's orders did not show the size of the resident's catheter tubing or the indication for the catheter. Review of the resident's Medical Record showed there was no documentation that showed the facility had educated or assessed the resident's ability to perform any of his/her catheter care to include emptying his/her catheter drainage bag. Observation on 1/23/24 at 1:32 P.M., showed the resident was sitting in his/her wheelchair and was watching television in his/her room. His/Her catheter bag was at the level of his/her bladder hanging at the side of his/her wheelchair. Observation and interview on 1/24/24 at 10:00 A.M., showed the resident was sitting in his/her wheelchair in his/her room. His/Her catheter bag was sitting at the level of his/her bladder and was hanging at the side of his/her wheelchair. The resident said: -The nursing staff change his catheter monthly. -He/She emptied his/her own catheter bag when it gets full. -No one trained him/her on how to empty his/her catheter bag and he/she was okay emptying it. -He/She has not had a urinary tract infection. Observation on 1/26/24 at 10:19 A.M., showed the resident was in his/her wheelchair in his/her room watching television. His/Her catheter bag was sitting at the level of his/her bladder at the side of his/her wheelchair. During an interview on 1/31/24 at 9:01 A.M., Certified Nursing Assistant (CNA) F said: -When he/she was working on this hall, he/she has completed catheter care and emptied the resident's catheter bag periodically during the day. -He/She checked to see if the resident's catheter bag was full, but the resident sometimes emptied his/her catheter bag himself/herself. -They tried to tell the resident that they will empty his/her catheter bag, but the resident does not always comply. -The resident's catheter bag was supposed to be placed below the resident's bladder and he/she usually will place it at the back of his/her wheelchair below his/her bladder. -If the resident's catheter bag is at the level of his/her bladder at the side of his wheelchair the resident probably placed it there. -Sometimes after he/she has placed the resident's catheter bag below his/her bladder, the resident will remove it and they next time he/she saw the resident the catheter bag will be sitting at the level of his/her bladder at the side of his/her wheelchair. -He/She had not seen that it was not below his/her bladder today. During an interview on 1/31/24 at 9:14 A.M., Licensed Practical Nurse (LPN) B said: -Sometimes the resident will refuse general cares, like catheter care. -The CNA staff would complete his/her catheter care every shift and they try to encourage him/her to allow the staff to complete care and empty his/her catheter bag, but the resident will also empty his/her catheter bag himself/herself (He/she did not know if the resident had an assessment of his/her ability to perform any of his/her catheter care). -They try to observe the resident to ensure he/she was doing it correctly, but he/she would sometimes become irritable. -The resident's physician's orders should show a complete catheter order. -The resident completing his/her own catheter care should be in his/her care plan. -The resident's catheter bag should be below his/her bladder, but the resident will put it at the side of his/her wheelchair at the level of his/her bladder. -They continue to try to educate him/her on why he/she needed to keep the catheter bag below his/her bladder, but the resident would still place it at the side of his/her wheelchair. During an interview on 1/31/24 at 12:28 P.M., the Director of Nursing (DON) said: -Catheter bag placement should be below the level of the bladder unless the resident's preference was to have it elsewhere-other than lower than the bladder. -He/She expected the nursing staff to educate the resident on the placement of the catheter bag and document that. -He/She expected staff to monitor the placement of the catheter bag-making sure its not dragging or stored properly. -If a resident is emptying his/her own catheter bag it should be documented on the care plan. -There should be catheter orders on the POS that showed the type, size and diagnosis for the catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary mental and behavioral health treatment and services, consistent with professional standards of practice, to promote mental health wellness by not providing mental health counseling and therapy services for one sampled resident (Resident #91), who had a mental health diagnosis. The facility census was 122 residents. Review of the facility's policy, dated May 2023, titled Behavior Health Services showed: -Staff were screen all residents prior to admission using the Preadmission Screening and Resident Review (PASARR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis). -Staff were to provide mental health and behavioral health services in accordance with state and federal laws. 1. Review of Resident #91's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). - Adjustment Disorder with Mixed Disturbance of Emotions and Conduct (an emotional or behavioral reaction to a stressful event or change in a person's life; the reaction is considered an unhealthy or excessive response to the event or change within three months of it happening). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool used for care planning), dated 10/3/24, showed: -The resident was cognitively intact. -The resident had displayed no behaviors. Review of the resident's Level 1 PASARR, dated 11/12/23, showed: -The resident had triggered for a Level 2 screening due to a serious mental illness. -No documentation of the Level 2 screening provided at time of exit. Review of the resident's undated Care Plan showed staff documented: -The resident had a behavioral problem of refusing medication. -The resident received multiple anti-depressants (medicine used to treat depression). -The resident received antipsychotic (a medicine for psychotic episodes. Review of the resident's undated Order Summary Report showed the physician ordered: -A psychiatrist to evaluate and treat the resident as needed on 10/11/23. -Staff to monitor the resident's behaviors for delusional thinking and auditory or visual hallucinations on 12/21/23. -Seroquel (an antipsychotic medication) to be given at bedtime for bipolar disorder on 12/19/23. Review of the resident's Antipsychotic/Psychotropic Medication Informed Consent, dated 12/21/23, showed: -Staff documented the resident had delusional thinking (an inability to distinguish between what is real and what only seems to be real) and hallucinations (a belief of having seen, heard, touched, tasted, or smelled something that wasn't actually there). -Staff provided light/soft hand massages to manage behaviors prior to beginning medication. 2. During an interview on 1/29/24 at 9:29 A.M., the Administrator said: -The facility had a psychiatrist that saw residents in the facility. -Social Services Designee (SSD) A frequently got side-tracked and missed things. -He/She had requested the resident's psychiatric notes and would provide a copy for review. During an interview on 1/30/24 at 12:39 P.M., the Administrator said: -The resident had not been seen by a psychiatrist while residing at the facility. -The hospital was setting up mental health services for when the resident returned to the facility. During an interview on 1/30/24 at 1:26 P.M., Certified Nursing Assistant (CNA) E said the resident did not have behaviors. During an interview on 1/30/24 at 1:40 P.M., Certified Medication Technician (CMT) D said: -The resident was a handful. -He/She was aware the resident had a mental health diagnosis. During an interview on 1/30/24 at 2:38 P.M., Licensed Practical Nurse (LPN) D said he/she expected a resident with a psychiatric diagnosis and on antipsychotic medications to be followed by a mental health professional. During an interview on 1/31/24 at 9:22 A.M., Assistant Director of Nursing (ADON) A said: -He/She expected any resident with an order for an antipsychotic medication to be followed by a mental health professional. -He/She expected any resident with delusions to be followed by a mental health professional. During an interview on 1/31/24 at 1:48 P.M., the Director of Nursing (DON) said he/she expected any resident taking an antipsychotic medication to be seen by a mental health professional.

Based on observation, interview, and record review, the pharmacy failed to provide the correct anti-psychotic medication (medications that alter brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disorganized thinking) as ordered by the physician for one sampled resident (Resident #91), out of 33 sampled residents. The facility census was 122 residents. A written request for policies related to pharmacy services was requested and not received at time of exit. 1. Review of Resident #91's medical record showed he/she was admitted to the facility with an allergy to Seroquel (a brand name anti-psychotic medication, generic name of Quetiapine). Review of the resident's undated Order Summary Report showed the physician ordered Seroquel Extended Release 200 milligrams (mg) with a note that indicated name brand only on 12/19/23. Review of the resident's January 2024 Medication Administration Record (MAR) showed staff administered Quetiapine (generic version of Seroquel) 200 mg to the resident 21 times. During an interview on 1/26/24 at 12:24 P.M., Pharmacy Technician A said: -The resident had been receiving the generic version of the drug (Quetiapine). -He/She believed the generic version was ordered due to issues with insurance coverage. -When the facility last ordered the medication, they did not click the option for name brand only so the pharmacy automatically filled it with the generic form. -The resident could have the brand name if that was what he/she wanted. During an interview on 1/26/24 at 12:43 P.M., Pharmacist A said: -If a generic version of a medication had a different color in the dye as compared to the brand name then that could cause an allergy. -Seroquel Extended Release 200 mg and Quetiapine Extended Release 200 mg both had white dye and were essentially the same medication. -The generic and brand name were the same and the pharmacy would send the same medication either way. Observation on 1/26/24 at 12:52 P.M. showed the resident's medication card was for Quetiapine 200 mg. During an interview on 1/26/24 at 12:52 P.M., Certified Medication Technician (CMT) F said: -He/She worked on 1/23/24. -He/She had been told by the resident on 1/23/24 that it was the wrong medication. -He/She had not been notified by the resident about the allergy until after administering the medication. -He/She did not have the authority to argue with the pharmacy. -He/She gave whatever the pharmacy sent. During an interview on 1/26/24 at 12:52 P.M., the resident said: -He/She had, on 1/23/24, put the medication in her mouth and didn't swallow it so he/she had proof when he/she went to court. -He/she refused to give the medication to the CMT. During an interview on 1/26/24 at 1:05 P.M., Nurse Practitioner (NP) A said: -The pharmacy was expected to fill the order as written. -The pharmacy was responsible for reviewing all medications entered and ensuring an allergy check was performed. -He/She spoke with the other NPs and the resident had said he/she had an allergy to the generic form of the medication but was not allergic to the brand name form. -It was acceptable to put brand name only if the resident reported an allergy to a generic version of a drug. During an interview on 1/29/24 at 1:54 P.M., NP B said: -The resident had reported an allergy to Quetiapine but there was no documentation to verify a reaction had occurred. -The resident was to take Seroquel and not Quetiapine. -The pharmacy was expected to fill the order as written. -He/She had just been notified the resident had been taking Quetiapine since admission. -He/She did not believe the resident suffered any negative side effects from Quetiapine and had no concerns about complications due to this medication. During an interview on 1/29/24 at 2:24 P.M., the Pharmacy Manager said: -The pharmacy normally did an allergy check but he/she could not find any notes verifying this had been checked. -The resident had been on the generic version of the drug for a while. -The pharmacy had been sending Quetiapine for this resident since September 2023. -The pharmacy had called for clarification on 10/2/23 and spoke with a nurse at the facility who told the pharmacist the resident was allergic to the generic version of the medication (Quetiapine) but not the name brand (Seroquel). -The pharmacy was having trouble getting Seroquel in the correct dosage so they changed it to the generic. During an interview on 1/30/24 at 1:40 P.M., CMT A said he/she would not give a medication that was on a resident's allergy list; he/she would hold it, make a note, and let the Assistant Director of Nursing (ADON) know about the discrepancy. During an interview on 1/30/24 at 2:38 P.M., LPN D said: -He/She expected the physician's orders to be followed. -If an order said name brand only and the pharmacy sent the generic form, he/she would call the pharmacy and also the physician before giving the medication. During an interview on 1/31/24 at 1:48 P.M., the Director of Nursing (DON) said: -He/She expected the physician's orders to be followed. -If the physician ordered a medication as name brand only, he/she expected the resident to only get the name brand version of the medication. MO 00230592, MO00229876, and MO00230644

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who admitted to the facility with infected pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure) received the ordered antibiotics (a drug used to treat infections caused by bacteria and other microorganisms) for one sampled resident (Resident #319) out of 33 sampled residents. The facility census was 122 residents. Review of Medlineplus.gov's article, dated 5/15/18, titled Ampicillin and Sulbactam (antibiotics) Injection showed: -Missed doses could cause the infection to not be fully treated and could allow the bacteria to become resistant to this medication. Review of Medlineplus.gov's article, dated 6/15/22, titled Vancomycin (an antibiotic) Injection showed: -Missed doses could cause the infection to not be fully treated and could allow the bacteria to become resistant to this medication. 1. Review of Resident #319's Face Sheet showed he/she was admitted [DATE] with the following diagnoses: -Osteomyelitis (inflammation of the bone) of vertebra (small bones that form the spine), sacral (a triangular bone located at the base of the spine) and sacrococcygeal region (includes the sacral area and the tailbone). -Pressure Ulcer of the Right Buttock. -Pressure Ulcer of the Sacral Region (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity). -Local Infection of the Skin and Underlying Tissue. -Pressure Ulcer of the Left Buttock. -Resistance to Multiple Antimicrobial (medicines used to prevent and treat infectious diseases) Drugs. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool used for care planning), dated 1/26/24, showed: -The resident was cognitively intact. -The resident had one Stage 3 pressure ulcer (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). -The resident had one Stage 4 pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunnelling). -The resident had taken antibiotics prior to admission and at the facility. Review of the resident's undated Medication Review Report showed the physician ordered: -Ampicillin-Sulbactam Sodium (an antibiotic) 9 grams (g) to be given intravenously (IV-through the vein) every eight hours for an infected wound on 1/19/24. -Vancomycin 1 g to be given IV in the afternoon for an infected wound on 1/19/24. Review of the resident's undated care plan showed staff: -Were to provide skin and wound treatments as ordered. -Documented the resident was receiving IV medications. Review of the resident's Wound Summary reports showed: -A non-infected Deep Tissue Injury (DTI - may be characterized by a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Presentation may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue) of the left heel identified on 1/23/24 with measurements and descriptions. -An infected Stage 3 pressure ulcer to the right buttock identified on 1/23/24 with measurements and descriptions. -A non-infected DTI of the right heel identified on 1/23/24 with measurements and descriptions. -An infected Stage 4 pressure ulcer to the sacral area identified on 1/23/24 with measurements and descriptions. Review of the resident's Treatment Administration Record (TAR), dated January 2024, showed: -Staff documented the administration of Vancomycin 4 out of 9 opportunities. -Staff documented the administration of Ampicillin-Sulbactam Sodium 17 out of 32 opportunities. Review of the resident's Physician's Note, dated 1/25/24, showed: -Staff had missed two doses of Vancomycin. -The physician discussed with the Assistant Director of Nursing (ADON) the importance of ensuring the resident received his/her antibiotics as ordered as it was imperative the resident received them to clear his/her infection. Review of the resident's Nursing Note, dated 1/26/24 at 10:49 A.M., showed: -Staff documented the resident accidentally dislodged his/her Peripherally Inserted Central Catheter (PICC- a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart that is used to access the blood stream). -He/She notified Nurse Practitioner (NP) B and the physician that the PICC was no longer usable. -He/She had received orders to replace the PICC. -He/She removed the non-functional PICC and placed an order with an outside vendor to have a new PICC placed. Review of the resident's Physician's Note, dated 1/26/24 at 4:30 P.M. showed: -The physician documented the new PICC he/she had ordered had not been placed and the resident's antibiotics were being missed. -The resident was upset about missing his/her antibiotics. -The physician told the nursing staff a peripheral (away from the body, generally refers to the arms) IV was to be placed until a new PICC was placed to ensure the resident received his/her antibiotics. Review of the resident's Physician's Note, dated 1/28/24 at 11:30 A.M. showed: -The physician saw the resident. -The resident still did not have an IV or PICC placed. -The physician was concerned as the resident had missed his/her antibiotics for over 48 hours. -The physician wanted a peripheral IV placed and nursing to follow up with the company responsible for the PICC placement, as well as notify the Infectious Disease physician of missed doses of medication. Observation on 1/29/24 at 12:52 P.M. showed the resident did not have a peripheral IV or PICC. During an interview on 1/29/24 at 1:54 P.M., NP B said: -He/She had ordered the resident to have a peripheral IV inserted 1/26/24 until a PICC could be placed. -He/She was aware the resident still did not have a peripheral IV or PICC on 1/25/24. -He/She expected the resident to get medication as prescribed. During an interview on 1/30/24 at 1:40 P.M., Certified Medication Technician (CMT) D said: -Only Registered Nurses (RNs) could place an IV line. -He/She was not sure why the resident had not had an IV line placed. -He/She expected staff to follow the physician's orders. -The resident was at the facility specifically to get antibiotics. -He/She believed the facility expectation was to call the physician and notify them each time a resident missed a dose of a medication. During an interview on 1/30/24 at 2:38 P.M., Licensed Practical Nurse (LPN) D said: -He/She had been notified by the resident that the PICC had become dislodged on 1/26/24 and notified NP B. -NP B told him/her to remove the PICC and have a new one placed. -He/She was done with his/her shift so he/she notified the nurse taking over and that nurse was going to arrange for a new PICC to be placed by an outside vendor. -He/She did not know why the resident still did not have a line to receive the ordered antibiotics. -He/She would have sent the resident to the hospital to have a new PICC placed if the outside vendor had not arrived by the next day. -It was inappropriate for the resident to have gone that long without antibiotics. During an interview on 1/31/24 at 1:48 P.M., the Director of Nursing (DON) said: -He/She expected physician's order to be followed. -It was unacceptable for the doctor's order for antibiotics to not be followed. -He/She expected staff to place a peripheral IV or have a new PICC placed immediately. -If staff were unable to insert a peripheral IV for whatever reason, the staff should have notified the provider and wrote a note regarding the conversation and orders going forward. Complaint# MO 00230592

Based on observation, interview, and record review, the facility failed to provide one sampled resident (Resident #65) with his/her stated food preferences as documented on his/her meal ticket out of 33 sampled residents. The facility census was 122 residents. 1. Review of Resident #65's breakfast meal ticket showed the resident wanted wheat farina (a form of milled wheat popular in the United States which was often cooked as a hot breakfast cereal), grits, raisin bran, fruit loops, and rice krispies with breakfast. -The resident wanted cottage cheese and fruit for a snack. Observation on 1/29/24 at 7:08 A.M., during the breakfast meal preparation showed the Production Manager (PM) cooked a large pot of oatmeal cereal. Further observation showed there were no other cereals cooked at that time. Observation on 1/30/24 at 8:45 A.M., showed the resident was served oatmeal cereal as part of his/her breakfast. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 12/13/23, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status, determines 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. During an interview on 1/30/24 at 9:31 A.M., the resident said: - He/she was tired of asking for fried eggs and not receiving fried eggs. - He/she did not like oatmeal but liked grits or wheat farina. - He/she asked for cottage cheese or peaches, did not get that. During an interview on 1/31/24 at 11:38 A.M., the Production Manager (PM) said he/she did not know preferred preferred wheat farina instead of oats. During an interview on 1/31/24 at 12:49 P.M., the Consultant Registered Dietitian (RD) said: - He/she expected the dietary staff to complete the food likes and dislikes assessments. -Resident preferences should be honored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's undated policy titled Room Cleaning Procedure showed: -Every room was to be cleaned daily. -To clean resident bathrooms, staff were to spray down the toilet, use a bowl mop inside the bowl and wipe the outside with a disinfectant. Review of the facility's Work Orders, dated 11/24/23 through 1/23/24 showed staff had put in a request for maintenance for Resident #317's toilet and shower (no date or time listed). Review of Resident #317's Face Sheet showed he/she was admitted on [DATE] with a need for assistance with personal hygiene. Review of the resident's admission MDS, dated [DATE], showed the resident: -Was cognitively intact. -Required moderate assistance for toileting and hygiene. -Required extensive assistance from staff with toileting, including transferring and hygiene. During an interview on 1/23/24 at 10:28 A.M., the resident's family member said: -The toilet in the room did not flush and had not flushed since the resident was admitted on [DATE]. -Several people from maintenance had looked at it but it still didn't work. Observation on 1/23/24 at 10:28 A.M. showed: -The resident's toilet had urine, feces, and toilet paper in the bowl. -The toilet bowl and rim had significant amounts of feces on the top and sides. During an interview on 1/25/24 at 9:28 A.M., the resident said: -The toilet had not flushed since he/she had been admitted to the facility. -He/she was bothered a great deal that the toilet didn't flush as he/she had frequent, soft stools. -The toilet not flushing caused an odor in the room. -He/she felt disgusted and frustrated that he/she did not have a working toilet in his/her room. -He/she had been pouring water in the toilet to get it to flush because it smelled bad and no one seemed to care. -If the toilet at his/her home hadn't worked, he/she would have had it fixed immediately. -The facility had offered to move rooms after a few days of the toilet not working but he/she was already settled into the room and would be leaving soon so he/she declined. During an interview on 1/30/24 at 1:26 P.M., CNA E said: -All residents were to have a working toilet in their room. -If a resident reported an issue to him/her, he/she would put in a maintenance work order. -He/she expected the work orders regarding toilets to be corrected within a day. -If he/she had turned in a work order and found it had not been completed by the next day, he/she would continue to turn in work orders until it had been fixed. During an interview on 1/30/24 at 1:40 P.M., CMT D said: -He/she expected all residents to have working toilets. -If he/she found a toilet that did not work, he/she would turn in a work order for maintenance. -If maintenance had not corrected the issue by the time he/she came to work the next time, he/she would go find someone from maintenance and make them fix it. -It was unacceptable for a resident to have a toilet that did not work. During an interview on 1/30/24 at 2:38 P.M., LPN D said: -He/she was assigned to Resident #317 that day. -Every resident was to have a working toilet. -If he/she found a toilet that didn't work, he/she would fill out a maintenance work order. -If maintenance had not corrected the problem by the next day, he/she would fill out another work order. -If maintenance had not corrected the problem after the second work order was turned in, he/she would find someone from maintenance and tell them verbally. -He/she did not know Resident #317's toilet had not been working. During an interview on 1/31/24 at 1:48 P.M., the Director of Nursing (DON) said: -He/she expected every resident to have a working toilet. -He/she expected a work order for a non-working toilet to be addressed and fixed within 24 hours. Based on observations and interview, the facility failed to maintain a comfortable environment and safe environment by failing to ensure the temperature was comfortable and to prevent a draft from the window in the room for two sampled residents (Residents #23 and #42) which caused the relative (Family Member E) of Resident #42 to bring in portable heaters to maintain a comfortable temperature in the room and to maintain one sampled resident's (Resident #317) toilet in good repair our of 33 sampled residents. The facility census was 122 residents. 1. Review of Resident #23's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 1/9/24, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status, determines 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. Observation on 1/23/24 at 11:17 AM, showed the resident was in his/her bed and the presence of two space heaters in his/her room, which were plugged into an orange extension cord and the presence of cardboard and blankets in the window. During an interview on 1/23/24 at 11:18 A.M., the resident said: - He/she has been at the facility for a month. - The room was cold due to the air coming through the window. Review of Resident #42's Annual MDS dated [DATE], showed the resident was cognitively intact with a BIMS of 13 out of 15. During an interview on 1/23/24 at 11:40 A.M., the resident said it was freezing in his/her room when it was cold outside and the room climate control unit did not give out much heat. Observation on 1/23/24 at 11:44 A.M., showed the room climate control unit gave off heat at a very low level and a draft which came in from outside of the window. During an interview on 1/23/24 at 4:12 P.M., Family Member E said: - He/she brought the space heaters into the room because the room was so cold and the facility staff had not made any effort to either move the resident or fix the draft from the window. - He/she brought in the portable heaters approximately three weeks ago. -The residents told staff the room was cold. -The Assistant Director of Nursing (ADON) B called him/her to come get the heaters because they have the heat turned back on. During an interview on 1/29/24 at 11:41 A.M., Certified Medication Technician (CMT) E said: - Both residents in that room complained to him/her that the room was cold. - The residents mentioned there was a little heat coming out of the room climate control unit, but the heat was not enough. - He/she (CMT E) reported that situation to a charge nurse, but could not remember which charge nurse. During an interview on 1/29/24 at 11:43 A.M. Licensed Practical Nurse (LPN) D said: - He/she remembered that both Residents #23 and #42 complained about the lack of heat in their room. - He/she let the Administrator in Training know about the lack of heat in their room. During an interview on 1/29/23 at 11:48 A.M., Certified Nurse's Assistant (CNA) G said: -Both residents (Residents #23 and #42) told him/her it was cold in their room. -He/she reported it to maintenance that the heater was not working. During an interview on 1/29/23 at 12:03 P.M., ADON B said he/she reported that Resident #23 and #42's room was cold on 1/13/24 and it was after that date, the portable heaters showed up in the room. During an interview on 1/29/24 at 12:45 P.M., the Maintenance Director said: - He/she would seal the outside of the resident's window to reduce any draft. - He/she will check on the climate control unit in that room. - During the time the room was cold he/she didn't measure temperatures in that room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to submit a Third-Party Liability (TPL) form to Missouri (MO) Health Net, for three deceased residents (Resident #118, #117, and #166) within 30 days after the deaths of those three residents; and to submit a written notice to one resident (Resident #57) when his/her fund balance remained above the limit of $5,726.00 for three months. The facility census was 122 residents. 1. Review of the Closed Account Summary Report dated 9/23 through 12/23 showed: - Resident #118 passed away on [DATE], (a period of 56 days before the resident trust fund review on [DATE]) with a balance of $855.40 in his/her resident trust account. - Resident #117 passed away on [DATE], (a period of 75 days before the resident trust fund review on [DATE]) with a balance of $1,992.87 in his/her resident trust account. - Resident #166 passed away on [DATE], (a period of 133 days before the resident trust fund review on [DATE]) with a balance of $80.32 in his/her account. During an interview on [DATE] at 2:35 P.M., Business Office Manager (BOM) A said: -He/she has been in this position for 3 weeks. -He/she did not find any copies of TPL forms which were sent to MO health Net on behalf of any of those residents. -Those residents passed away before he/she started employment at the facility. 2. Review of Resident #57's Resident Fund statement dated [DATE] through [DATE], showed: - On [DATE], there was $6,469.26 in the resident's trust fund account. - On [DATE], there was $7915.65 in the resident's trust fund account. - On [DATE], there was $8927.86 in the resident's trust fund account. - On [DATE], there was $8,391.42 in the resident's trust fund account. - On [DATE], there was $11,334.31 in the resident's trust account. During an interview on [DATE] at 2:47 P.M., the Business Office Manager (BOM) B said: -The facility started to contact Medicaid since the resident's trust fund amount was over the limit. -The Resident's family member was notified on [DATE] about spending down resources. -That was when the facility found out the resident had a significant past due tax bill, and their was no documentation of that contact. During a phone interview on [DATE] at 8:10 A.M., Family member D said: - He/she was initially contacted either in 11/23 or in 12/23 that his/her relatives funds were over the allowable limit, but was not exactly sure of the date. - The former facility BOM at that time told him/her that the resident's funds have not been applied appropriately. - He/she had purchased items like a refrigerator and chair for the resident to use in his/her room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the floors of resident rooms D4 and C8, free of a buildup of tube feeding debris on the tube feeding poles and the floors in those rooms; to maintain the floors in many resident rooms, free of dust and debris on the floors; to maintain ceiling vents of resident rooms and showers free of a dust buildup and on those vents; to maintain the mattresses in resident rooms D4 and D11, and G3 in an easily cleanable condition; to maintain resident rooms B2 and B12, free of urine odors; to ensure that used adult briefs were picked up from the floors of resident room B7; and to ensure that trash containers in resident room D4 were cleaned to be free of a grime buildup. The facility census was 122 residents. Record review of the facility's undated policy entitled Room Cleaning procedure, showed: Pull trash recycle. - Remove liners, clean waste receptacles, place 5 liners on side of receptacles and one new one. - High dust everything above shoulder level or out of reach. Use an extension pole with duster head. - Clean bathroom start at the door spray down all surfaces and wipe down sink, spray window cleaner on mirror and wipe down with paper towels. Sweep and damp mop floor. Discard the dirty mop head after uses. - Dust behind and underneath all furniture and doors. - Damp Mop-Mop corner to prevent build up. Start with the corner farthest from the door and work your way out. - Inspect room for needed repair which need to be reported. - Every room and common areas will be cleaned once daily. 1. Observation on 1/23/24 at 12:17 P.M. and at 4:06 P.M., on 1/24/24 at 8:42 A.M. and 2:01 P.M., of Resident room D4, showed: - The presence of a brown, thick, sticky, tan substance under and next to the right side of the resident's bed. - The presence of a brown, thick, and sticky substance on the tube feeding pole. Observation on 1/24/24 at 3:14 P.M., showed the presence of brown, thick, sticky, tan substance on the floor and on the tube feeding pole in resident room C8. Observation on 1/25/24 at 8:45 A.M., of resident room D4, showed: - The presence of a brown, thick, and sticky substance on the tube feeding pole. - The presence of a brown, thick, sticky, tan substance under and next to the right side of his/her bed. During an interview on 1/29/24 at 12:20 P.M., the Housekeeping Director said the following, after looking at the tube feeding poles in resident rooms C8 and D4: - The tube feeding poles should be looked at daily, but he/she does not have a housekeeper on each hall daily. - The substance on the floor in D4 was very hard and stuck-on, and will take more effort to remove it. During an interview on 1/29/24 at 11:35 A.M., Assistant Director of Nursing (ADON) B said the substances should be cleaned up by housekeeping department. 2. Observations on 1/23/24 at 3:36 P.M. with the Maintenance Director showed a buildup of dust was present inside the ceiling vent in the restroom, the restroom door did not latch when it was closed, and the railing of the privacy curtain was in good repair resident room A11. During an interview on 1/23/24 at 4:38 P.M., the Maintenance Director said no one mentioned the issues in resident room A11 to him/her. Observation on 1/23/24 showed: - At 4:39 P.M., a used adult brief was on the floor of the restroom, and a buildup of hair in the corner on the floor of the restroom in resident room A9. - At 4:43 P.M., a buildup of dust and hair on the floor in resident room A12. - At 4:52 P.M., there was heavy buildup of dust on the fan blades in Resident #99's room. Review of Resident #99's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 1/19/24, showed the resident had moderate cognitive impairment, 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, determines the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) of 10 out of 15. During an interview on 1/23/24 at 4:53 P.M., the resident said he/she did not know the last time the housekeeping department cleaned his/her fan. Observation on 1/23/24 showed: - At 4:56 P.M., a heavy buildup of dust was present inside the ceiling vents in resident room A10. - At 5:09 P.M., there was a heavy buildup of dust on the floor and debris behind the fridge in resident room A1. - At 5:20 P.M., a heavy buildup of dust in the ceiling vent of the A Hall shower room. -At 5:22 P.M., a heavy buildup of dust in the ceiling vent of resident room A2. 3. Observations on 1/24/24 with the Maintenance Director, showed: - At 2:09 P.M., debris was present on the floor close to the bed closest to the door of resident room B12. - At 2:13 P.M., a buildup of dust on the restroom vent and on the sprinkler head in the restroom of resident room B11. - At 2:16 P.M., A buildup of food crumbs was present behind the bed in resident room B9. - At 2:18 P.M., there was a buildup of dust behind Resident #3's bed and the restroom door did not latch when it was closed. Review of Resident #3's admission MDS, dated [DATE], showed the resident was cognitively intact with a BIMS of 14 out of 15. During an interview on 1/24/24 at 2:19 P.M., the resident said that door has not latched for several years. Observations on 1/24/24 with the Maintenance Director, showed: - At 2:22 P.M., a heavy buildup of dust, was present on the floor of resident room B7. - At 2:27 P.M., a heavy buildup of dust was present behind the bed farthest from the resident room door in Resident #87's room. Review of Resident #87's quarterly MDS, dated [DATE], showed the resident was cognitively intact with a BIMS of 14 out of 15. During an interview on 1/24/24 at 2:29 P.M., the resident said sometimes they (facility staff) clean behind the beds and sometimes they do not. Observation on 1/24/24 with the Maintenance Director, showed at 2:36 P.M., a heavy buildup of dust was present on the ceiling vent in the restroom of resident room B3. During an interview on 1/24/24 at 2:37 P.M., the Housekeeping Director said the housekeeping department was staffed less than the number of housekeepers needed and some of the housekeepers feel rushed and may not do as thorough job as they should. Observations on 1/24/24 with the Maintenance Director, showed at 2:35 P.M., a buildup of debris on the floor in the restroom and on the floor of the room itself in resident room C12. Observations on 1/24/24 with the Maintenance Director, showed at 3:02 P.M., cobwebs (a spider's web, especially when old and covered with dust) were present on an outlet and there was scattered debris on the floor of Resident #46's room. During an interview on 1/24/24 at 3:03 P.M., Family Member E said he/she saw debris on the floor of the resident's room many times when he/she visits. Observations on 1/24/24 with the Maintenance Director, showed: - At 3:06 P.M., a buildup of debris was present on the floor behind the bed closest to the door in resident room C5. - At 3:14 P.M., a buildup of debris was present on the floor in resident room C8. - At 3:21 P.M., debris was present on the floor of resident room C6. - At 3:27 P.M., cobwebs were present in the corners of and debris was present on the floor of resident room C4. - At 3:30 P.M., dust was present on the restroom ceiling vent and debris was present on the floor of resident room C1. - At 3:31 P.M., cobwebs and spiders were present in and debris was present on the floor in resident room C2. 4. Observations on 1/25/24, with the Maintenance Director showed: - At 8:14 A.M., there was a section of torn flooring in resident room D9. - At 8:23 A.M. there was debris on the floor and a heavy buildup of dust on the fan blades in resident room D7. - At 8:38 A.M., a buildup of debris was present on the [NAME] resident room D6. - At 8:49 A.M., there was debris present on the floor in resident room D3. - At 8:51 A.M., there was a heavy buildup of dust on the fan and debris on the floor in resident room D2. - At 9:40 A.M., there were dead insects on the floor E Hall shower room. - At 9:42 A.M., there was a buildup of dust on the restroom ceiling vent in resident room F2. - At 9:44 A.M., there was a buildup of dust on the restroom ceiling vent in resident room F3. - At 9:48 A.M., there was a buildup of dust on the restroom ceiling vent in resident room F4. - At 9:49 A.M., there was a buildup of dust on the restroom ceiling vent in resident room F5. - At 9:50 A.M., there was a buildup of dust on the restroom ceiling vent in resident room F7. - At 9:54 A.M., there was a buildup of dust on the restroom ceiling vent in resident room F9. - At 9:56 A.M., there was a buildup of dust on the restroom ceiling vent in resident room F8. - At 9:58 A.M., there was debris on the floor of resident room F11. 6. Observation on 1/25/24 at 8:13 A.M., showed a mattress in D11 with two 10-inch (in.) diameter areas where the mattress cover was peeling away leaving the mattress not easily cleanable. During an interview on 1/26/24 at 11:55 A.M., (ADON) B said no one told him/her about the damaged mattress in in room D11 after he/she saw two frayed areas in the mattresses in D11, which were about 10 in. in diameter. During an interview on 1/26/24 at 11:59 A.M., Certified Nurse's Assistant (CNA) L said: - The mattress in D11 has been like that for a few months. - He/she has told the nurse that was on duty and he/she she had told maintenance. - He/she said was not familiar with the TELS (a building management platform designed for Senior Living with integrated Asset Management, Life Safety, and Maintenance solutions) system of placing work orders. 7. Observation on 1/25/24 at 8:45 A.M., showed a mattress in D4 with two holes that were about 2 in. in diameter which rendered the mattress not easily cleanable. During an interview on 1/26/24 at 11:29 A.M., ADON B said the CNAs should recognize the damaged mattresses D4, but they missed that one, and no one reported the damaged mattress in resident room D4 to her/him. During an interview on 1/31/24 at 1:41 P.M., the Director of Nursing (DON) said: - The CNAs should look for damaged mattresses when they make up the beds. - The CNAs should place the equipment needs in TELS and report to unit manager when needed. Observation on 1/25/24 at 12:03 P.M., showed the mattress in resident room G3 with a frayed cover. 8. Observation on 1/23/24 at 1:30 P.M., showed a very odorous-urine smell in resident room B2. Observation on 1/24/24 at 2:42 P.M., with the Housekeeping Director showed a strong urine odor in resident room B2. During an interview on 1/24/243 at 2:44 P.M., the Housekeeping Director said one of the residents in resident room B2 hid his/her used adult briefs on the side of his/her bed. During an interview on 1/29/24 at 12:52 CNA U said: - One of the residents in resident room B2 urinated on himself/herself. - The urine may originate from the bed in room B2. - One of the residents like to place a pile of used adult briefs on the floor of the restroom which contributes to the urine smell in that room. - He/she tried to remove used adult briefs when he/she was on shift., but he/she could not speak for when he/she was not on shift. Observation on 1/24/24 at 2:09 P.M. and again at 1/25/24 at 7:15 A.M., showed a pungent urine odor in resident room B12. 9. Observation on 1/24/24 at 2:22 P.M. and again on 1/25/24 at 7:16 A.M., showed a used adult brief on the restroom floor of B7. Observation on 1/26/24 at 8:14 A.M. and 2:48 P.M., showed a used adult brief on the floor of resident room B7 which caused a urine odor in the room. During an interview on 1/26/24 at 2:51 P.M., CNA F said housekeeping staff had not been on the B hall that day and if housekeeping were on that hall, they would have picked up the used briefs from the floor in resident room B7. During an interview on 1/31/24 at 1:28 P.M. the Housekeeping Director said it was possible that the housekeeper may have been pulled to another hall on Friday 1/26/24. 10. Observation on 1/23/24 at 1:18 P.M., and at 1/31/24 at 1:24 P.M., showed a heavy buildup of grime in the trash containers in resident room D4. During an interview on 1/31/24 at 1:28 P.M., the Housekeeper Director said: - He/she wanted the trash cans cleaned more often. - He/she wanted the curtains to be taken down often and washed. - The mattresses were soaked through with urine which creates the source of urine odors. During an interview on 1/29/24 at 11:27 A.M., the Administrator in Training (AIT) said the housekeeping department was short about 3 housekeepers and that was why some rooms were not cleaned like the should have been. MO00230433, MO00230644

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the screening section of the abuse prevention policy, by failing to conduct Federal Indicators (FI) through the Nurse Aide (NA) Registry and to ensure they were completed prior to hire in accordance with State requirements and facility policy to ensure potential employees did not have a history of abuse or neglect or a disqualifying crime against persons registry check on 6 of 10 employees selected for the background review. This practice potentially affected all residents in the areas the staff worked. The facility census was 122 residents. Review of the Screening section the facility's policy updated 11/23 showed the following: The facility will not knowingly employ any individual who has been found guilty of abusing, neglecting or mistreating residents. Prior to employment, all potential employees will be interviewed by a facility representative. Prior to employment, this facility will also run all required background checks, state required database checks and licensure/certification checks. 1. Review of Employee A's file showed he/she was hired on 9/27/23 with the absence of a NA registry check. 2. Review of Employee B's file showed he/she was hired on 5/23/23, with the absence of a NA registry check. 3. Review of Employee C's file showed he/she was hired on 6/28/23 with absence of NA registry checks. 4. Review of Employee D's file showed he/she was hired on 7/27/23, with the absence of NA registry checks. 5. Review of Employee E's file showed he/she was hired on 10/2/23 with the absence of NA registry checks. 6. Review of Employee F's file showed he/she was hired on 1/11/23 with the absence of NA registry checks. 7. During an interview on 1/31/24 at 10:32 A.M, the Director of Cultural Engagement said the employees were mainly hired before his/her tenure which started on 1/8/24, and he/she did not know about the absence of the NA checks for the employees. During an interview on 1/31/24 at 10:53 A.M., the Vice-President of Cultural Engagement said: There have been three different persons in the position of Director of Cultural Engagement between November 2022 and [DATE]. -He/she did some of the training, but he/she was not as familiar with the Missouri (MO) requirements for a NA registry checks. -The former persons were not as familiar with conducting the NA registry checks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #366's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Other asthma (a condition in which a person's airways become inflamed, narrow, swell, and produce extra mucus, which makes it difficult to breathe). -Obstructive Sleep Apnea (OSA- intermittent airflow blockage during sleep). Review of the resident's POS dated January 2024 showed: -An order that the facility may administer 2 Liters (L) supplemental oxygen as needed. -No order for the use of continuous oxygen. -No order of how the oxygen should be administered. -No order for when the tubing and other supplies needed to be changed out. -No order indicating the Resident needed a CPAP. -No order for the settings and how to set up the CPAP for the Resident. -No order for how to clean and store the CPAP tubing, mask, and other supplies. Review of the resident's admission MDS dated [DATE] showed: -The resident was cognitively intact. -No indication the resident was on continuous oxygen therapy. -No indication the resident used CPAP therapy. Review of the resident's care plan dated January 2024 showed: -The resident used oxygen but did not indicate the amount or duration. -An intervention to titrate and provide CPAP per physician's orders but did not indicate what the physician's orders were. During an interview on 1/30/24 at 12:02 P.M. the resident said: -He/she used oxygen continuously. -He/she thought his/her oxygen amount was set at 2 L. -He/she had used the same CPAP tubing in mask that was lying on his/her bed for a while but could not remember if it had been changed out recently. -He/she used his/her CPAP every night. 4. Review of Resident #369's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Displaced Intertrochanteric Fracture of Left Femur (extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter), Subsequent Encounter for Closed Fracture with Routine Healing. -Metabolic Encephalopathy. -Need for Assistance with Personal Care. -Muscle Weakness (Generalized). Review of the resident's admission MDS dated [DATE] showed: -The resident was severely cognitively impaired. -The MDS did not show that the resident needed glasses. Review of the resident's Care Plan dated January 2024 showed: -The resident had the potential for alterations in psychosocial well-being with an intervention to encourage the resident to spend time awake up and out of bed engaged in activity as tolerated and desired. -The resident had potential for poor activity involvement related to report of little interest or pleasure in doing things with the following interventions: --Enlarged monthly calendar provided in room. --The resident was to receive the Daily Chronicle packets (the facility's daily activity packet) from Activity Assistant three to five times a week. During an interview on 1/24/24 at 10:49 A.M. the resident said: -He/she enjoyed reading and puzzles the most. -He/she could not read the Daily Chronicle or do the puzzle that was in his/her room due to not being able to see. -His/her glasses were missing and the facility had provided him/her with a pair of glasses that were not the correct prescription, and he/she could still not complete or enjoy the activities provided to him/her. 5. During an interview on 1/30/24 at 2:39 P.M. MDS Coordinator A said: -He/she and MDS Coordinator B were responsible for the entire facility's MDS assessments. -He/she went by the resident's POS and any related documentation when completing the MDS assessments. -The MDS should match the care plan and POS for each resident. -All MDS assessments should be accurate. -He/she did not realize Resident #366 was on oxygen because there was no order for it. -He/she did not realize Resident #366 had a CPAP because there was no order for it. -He/she was confused about the MDS for Resident #369 due to the resident re-admitting to the facility. -He/she thought Resident #369's glasses were missing but knew he/she needed glasses. During an interview on 1/31/24 at 9:40 A.M. Assistant Director of Nursing (ADON) A said he/she would expect all MDS assessments to be accurate for each individual resident. During an interview on 1/31/24 at 12:28 P.M. the Director of Nursing (DON) said he/she expected the MDS to be accurate and reflect the current status of the resident. Based on observation, interview and record review, the facility failed to ensure the admission Minimum Data Set, (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) was accurate for four sampled residents (Resident #23, #96, #366, and #369) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy titled Coordination and Certification of Assessments dated April 2023 showed each individual assessor was responsible for certifying the accuracy of responses relative to the resident's condition and discharge or entry status. 1. Review of Resident #23's Face Sheet showed he/she was admitted on [DATE], with diagnoses including falls, high blood pressure, oxygen dependent, dysphagia (difficulty swallowing) chronic obstructive pulmonary disease (COPD-a condition involving constriction of the airways and difficulty or discomfort in breathing), hip fracture, depression, pain and nausea. Review of the resident's POS 1/24, showed a physician order to administer 2 liters of supplemental oxygen as needed (order dated 1/4/24). Review of the resident's admission MDS dated [DATE], showed the resident: -Was alert and oriented without any confusion. -Was dependent for bathing, dressing, toileting, hygiene and used a wheelchair for mobility. -The resident did not receive any oxygen therapy. Review of the resident's Care Plan dated 1/22/24, showed the resident had an altered respiratory status and difficulty breathing. Interventions showed: The resident will have no complications related to Short of Breath (SOB) though the review date. -Give the resident medications as ordered by his/her physician and monitor/document the side effects and effectiveness. -Monitor for signs and symptoms of potential respiratory infections. -Monitor for signs and symptoms of respiratory distress and report to the physician. -Monitor the resident's vital signs (respirations, pulse, blood pressure, oxygen level). Observation on 1/25/24 at 6:38 A.M., showed the resident was in bed with his/her call light within reach and was dressed in a gown. His/her oxygen nasal cannula was in her nose, but his/her oxygen was not on and running. There was no bag to place the nasal cannula and tubing in. His/her eyes were closed, and he/she was resting comfortably. 2. Review of Resident #96's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including respiratory failure, diabetes, kidney failure, obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), pain, high blood pressure and muscle weakness. Review of the resident's admission MDS dated [DATE], showed he/she: -Was alert and oriented without confusion. -Was dependent on staff for bathing, dressing, toileting, transferring, hygiene and used a wheelchair for mobility. -Did not receive oxygen therapy. Review of the resident's Care Plan dated 11/22/23, showed he/she required oxygen therapy and a continuous positive airway machine (CPAP-a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing, used in the treatment of sleep disorder and other respiratory disorders) related to respiratory failure. Interventions showed staff was to: -The resident will have no signs and symptoms of poor oxygen absorption through the review date. -Administer oxygen at 2 liters per physician's orders. -Observe for signs of respiratory compromise, anxiety, weakness, confusion and shortness of air. Assess and update the physician as needed. -Monitor the resident's vital signs as ordered. -Provide respiratory treatments as ordered. -Assist the resident to place CPAP each night and off in the morning. -Keep the head of the bed elevated to prevent shortness of air. -Provide routine care for CPAP, routine cleaning and filling the water reservoir. Review of the resident's POS dated 1/24, showed physician's orders for a CPAP -wipe mask, nasal pillows daily with damp cloth, empty humidifier chamber, fill humidifier with warm water shake well, rinse and air dry in the morning (ordered 12/30/23). Observation and interview on 1/24/24 at 9:21 A.M., showed the resident was in his/her bed, awake with his/her call light and tray table within reach. The resident's nasal pillow and tubing to his/her CPAP machine was sitting on the dresser on top of the CPAP machine, uncovered. There was a plastic bag hanging on the drawer handle below the machine. The resident said: -He/she wore the CPAP as needed at night. -He/she wore his/her CPAP yesterday. -He/she did not use oxygen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of Resident #369's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Displaced Intertrochanteric Fracture of Left Femur (extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter), Subsequent Encounter for Closed Fracture with Routine Healing. -Metabolic Encephalopathy. -Need for Assistance with Personal Care. -Muscle Weakness (Generalized). Review of the resident's Care Plan dated January 2024 showed the resident did not have a care plan related to his/her vision needs or activity preferences. Review of the Resident's admission MDS dated [DATE] showed: -The resident was severely cognitively impaired. -The resident was marked as somewhat important for all the activity preferences listed in the MDS which included: --To have books, magazines, newspapers to read. --To listen to music. --To be around animals such as pets. --To keep up with the news. --To do things with groups of people. --To do his/her favorite activity. --To go outside when the weather is nice. --To participate in religious activities. NOTE: The MDS did not indicate the resident needed glasses. During an interview on 1/24/24 at 10:49 A.M. the resident said: -He/she enjoyed reading and puzzles the most. -He/she could not read the Daily Chronicle or do the puzzle that was in his/her room due to not being able to see. -His/her glasses were missing and the facility had provided him/her with a pair of glasses that were not the correct prescription, and he/she could still not complete or enjoy the activities provided to him/her. 7. Review of Resident #366's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Muscle Weakness (generalized). -Need for Assistance with Personal Care. -Metabolic Encephalopathy (an alteration in consciousness caused due to brain dysfunction). Review of the resident's Care Plan dated January 2024 showed the resident did not have a care plan related to his/her activity preferences. Review of the resident's admission MDS dated [DATE] showed: -The resident was cognitively intact. -The resident was marked as very important for the following activity preferences as very important: -- To listen to music. --To keep up with the news. --To do his/her favorite activity. -The resident was marked as somewhat important for the following activities: -- To have books, magazines, newspapers to read. --To be around animals such as pets. --To do things with groups of people. --To go outside when the weather is nice. --To participate in religious activities. During an interview on 1/24/24 at 11:33 A.M. the resident said he/she would love to go to bingo if the facility held that activity. During an interview on 1/30/24 at 12:02 P.M. the resident said: -He/she had not been to any activities since he/she was admitted to the facility. -He/she would love to get more things to read like magazines because he/she loved to read. -He/she was bored and wished he/she could get out of his/her room more often. 8. During an interview on 1/30/24 at 1:10 P.M., MDS Coordinator B said: -He/she and MDS Coordinator A were responsible for care plans. -He/she expected any resident on dialysis to have a care plan that included the location of where the resident dialyzed, what time they dialyzed, location of the dialysis access, and any special concerns related to the access. During an interview on 1/31/24 at 9:41 A.M. Assistant Director of Nursing (ADON) A said: -He/she was a part of the care plan process. -There was a care plan meting completed daily for resident's who admitted to the facility from the day before. -The care plan meeting included himself/herself, the Director of Rehab (DOR), and the Social Worker. -The Director of Nursing (DON) ensures completion of the care plans. -Care plans should be up to date and reflect the resident's current status. -Care plans should include any vision needs and activity preferences. During an interview on 1/31/24 at 12:28 P.M., the DON said: -Care plans should be comprehensive and reflect the current health status of the resident. -They should be updated as needed to reflect the current status of the resident. -Activities and vision needs should be on the care plan. -He/she expected care plans to include where the resident received dialysis, where the access was located, what type of access they had, and what time their dialysis appointment was. 4. Review of Resident #75's Face Sheet showed he/she had the following diagnoses: -End Stage Renal Disease (the final, permanent, stage of kidney disease in which the kidneys can no longer function on their own) as of 2/16/23. -Dependence on Renal (kidney) Dialysis as of 2/16/23. Review of resident's admission MDS, dated [DATE], showed: -Staff documented the resident was on dialysis. -The resident was cognitively intact. Review of the resident's undated Care Plan showed: -Staff were to encourage the resident to attend dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). -The resident had a failed kidney transplant (an organ is removed from one body and placed in the body of a recipient, to replace a damaged or missing organ) and required dialysis. -Staff were to change the dressing on the resident's access site daily. --NOTE: Care plan does not state what type of access, where it was located, or special instructions for care or where the information was located in the medical record. -Staff listed where the resident received dialysis, what days, with a time of second shift. Observation on 1/24/24 at 11:01 A.M. showed the resident had a left forearm AV fistula (a surgical connection created between an artery and a vein for dialysis). 5. Review of Resident #76's undated Order Summary Report showed physicians orders: -Apixaban (an anticoagulant medication that works by blocking the action of a certain natural substance that helps blood clots to form) 5 milligrams (mg) two times a day on 12/20/23. -Morphine Sulfate (an opioid medication, opioids work in the brain to produce a variety of effects, including pain relief) 5 milligrams per milliliter (mg/ml) every six hours as needed on 12/20/23. -Morphine Sulfate Contin (an opioid medication) 15 mg every 12 hours on 12/20/23. Review of the resident's admission MDS, dated [DATE], showed staff documented the resident: -Received an anticoagulant. -Received an opioid. -Was cognitively intact. Review of the resident's undated Care Plan showed: -The resident received medications that had a Black Box Warning (the highest safety-related warning that medications can have assigned by the Food and Drug Administration). -No further information was listed, does not list which medications or the potential side effects for which staff were to monitor. Based on observation, interview, and record review, the facility failed to establish an activity care plan for six sampled residents (Resident #23, #96, #75, #76, #366, and #369); and to establish a comprehensive care plan for two sampled residents (Resident #75 and #76) out of 33 sampled residents. The facility census was 122 residents. Review of the National Kidney Foundation's webarticle, dated 2015, titled Hemodialysis Access (hemodialysis-the process of removing excess water, solutes, and toxins from the blood of people whose kidneys can no longer perform these functions); access-a way to reach the blood to perform dialysis) showed the proper care of an arteriovenous fistula (AV fistula-a surgical connection between a vein and artery to allow for increased blood flow) included ensuring: -Blood pressures were not obtained using the arm with the access. -Blood was not to be drawn using the arm with the access. -No pressure was placed on the arm with the access (by laying on it, wearing tight-fitting clothing, etc). Review of the facility's policy titled Care Plans dated April 2023 showed: -The comprehensive care plan was developed within seven days of CAA completion. -The baseline care plan required the following: --Initial goals based on admission orders (services planned to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being including but not limited to: Activities of Daily Living (ADLs), nutrition, fall risk, skin integrity, and pain management) --Dietary orders. --Therapy services. --Social services (resident's goals and desired outcomes, advanced directives, preference and potential for future discharge from the facility, discharge plans including potential referrals, known or revealed history of trauma events in the life of the resident, transfer trauma interventions), --Pre-admission Screening and Resident Review (PASARR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/development disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of the source of pay) recommendations, if applicable. -The care plan consisted of the following: --Problems as identified by reviewing the medical record and discussion with the resident and/or significant other. --Goals were set in conjunction with the family and resident. --Goals were realistic, measurable, behaviorally stated, and may be long or short term. --Interventions were actions taken to achieve the goal. --Evaluation of the care plan goals should occur at least every 90 days. 1. Review of Resident #23's Face Sheet showed he/she was admitted on [DATE], with diagnoses including falls, high blood pressure, oxygen dependent, dysphagia (difficulty swallowing) chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), hip fracture, depression, pain and nausea. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 1/9/24, showed the resident: -Was alert and oriented without any confusion. -Was dependent for bathing, dressing, toileting, hygiene, transfers and used a wheelchair for mobility. -Books, music, animals, religious activities and being around groups of people were somewhat important activities for the resident. -Current events/news, going outside and doing favorite activities were very important to the resident. Review of the resident's Care Plan dated 1/22/24, showed there were no activities care plan showing the resident preferences, activity goals, activity participation or measurable interventions for the resident's participation in activities. 2. Review of Resident #96's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including respiratory failure, diabetes, kidney failure, obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), pain, high blood pressure and muscle weakness. Review of the resident's admission MDS dated [DATE], showed the resident: -Was alert and oriented without confusion. -Was dependent on staff for bathing, dressing, toileting, transferring, hygiene and used a wheelchair for mobility. -Showed activities such as books, music, going outside, religious activities, current events/news, being around groups of people, were somewhat important to the resident. Review of the resident's Care Plan dated 11/22/23, showed the resident self-care performance deficits and limitations in physical mobility related to chronic and acute conditions impacting her physical function and mobility. The care plan showed the resident will have support from staff to ensure daily care needs are met while promoting resident participation in care tasks as tolerated through review. There was no activity care plan for the resident that showed activity preferences, activities the resident chose to attend or any measurable activity goals for the resident. 3. During an interview on 1/29/24 at 3:00 P.M., the Activity Director said: -All of the activities on the activity calendar were group activities the facility provided to the residents. -For those residents who did not come to activities or could not come to activities, they would assess the resident for one to one activities in the resident's room. - They completed an activity assessment for all of the residents and established a care plan that reflected the resident's activity goals and interests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Review of Resident #366's Face Sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Muscle weakness (generalized). -Need for assistance with personal care. -Metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction). Review of the resident's Care Plan dated January 2024 showed: -The resident had an Activities of Daily Living (ADL) self-care performance deficits and limitations in physical mobility related to his/her Metabolic Encephalopathy. -The resident was completely dependent on staff for showering/bathing. Review of the resident's admission MDS dated [DATE] showed: -The resident was cognitively intact. -The resident was completely dependent on facility staff for showering/bathing. Observation on 1/24/24 at 12:10 P.M. of the resident showed: -He/she was in a hospital gown. -He/she had body odor. During an interview on 1/24/24 at 12:10 P.M. the resident said: -He/she had not received a bath since admitting to the facility. -He/she had not been offered a bath since admitting to the facility. Review of the resident's bath sheets on 12/29/24 at 10:06 A.M. showed the resident received a bath on 1/9/24, 1/12/24, and 1/18/24. NOTE: The resident admitted to the facility on [DATE]. 9. Review of Resident #367's Face Sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Pressure Ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of Left Buttock, Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle). -Need for assistance with personal care. -Muscle weakness (Generalized). - Personal history of Transient Ischemic Attack (TIA- a stroke like attack which may be [NAME] sign of a future stroke). Review of the resident's care plan dated January 2024 showed: -The resident had an ADL self-care performance deficits and limitations in physical mobility related to his/her pressure ulcer. -The resident was completely dependent on facility staff for showering/bathing. Review of the resident's admission MDS dated [DATE] showed: -The resident was severely cognitively impaired. -The resident was completely dependent on facility staff for showering/bathing. Observation on 1/23/24 at 11:50 A.M. ; 1/25/24 at 7:22 A.M. and 1/29/24 at 9:17 A.M., showed the resident had facial hair on his/her chin. Review of the resident's bath sheets on 1/29/24 at 10:04 A.M. showed the resident received a bath on 1/12/24, 1/15/24, and 1/22/24. During an interview on 1/29/24 at 2:00 P.M. the resident's family member said: -The resident would not want the facial hair on his/her chin. -In the past the resident would be able to remove his/her facial hair, but now the resident would be dependent on facility staff to help remove the facial hair. 10. Review of Resident #369's Face Sheet showed he/she admitted to the facility on 1/3/24 and was re-admitted on [DATE] with the following diagnoses: -Displaced Intertrochanteric fracture of the left femur (extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter). -Metabolic encephalopathy. -Need for assistance with personal care. -Muscle Weakness (Generalized). Review of the resident's care plan dated January 2024 showed: -The resident had an ADL self-care performance deficits and limitations in physical mobility. -The resident needed substantial/maximal assistance for bathing. Review of the resident's admission MDS dated [DATE] showed: -The resident was severely cognitively impaired. -The resident needed substantial/maximal assistance for bathing. Review of the resident's bath sheets on 1/29/24 at 1:58 P.M. showed the resident had received a bath on 1/8/24, 1/15/24, and 1/19/24. 11. During an interview on 1/25/24 at 6:45 A.M., CNA H said: -He/she worked from 7:00 P.M. to 7:00 A.M. on long term care B hall. -There were between 23 to 24 residents on the hall. -Of the residents on the hall, about half of the resident's need assistance with care, are incontinent and need assistance with mobility. -There is only one CNA assigned per hall. -On the 7:00 P.M. to 7:00 A.M. shift there are between two to three CNAs covering the A,B,C and D halls. -The CNAs try to help each other, but sometimes it is very difficult because they have call lights they have to answer on their halls also, and if they leave the hall, there is no one there to answer the call light. -Usually he/she was able to get all of his/her cares completed, but it may not be timely because he/she was the only staff on the hall. -There were only two to three CNAs scheduled on the night shift on A, B, C and D hall with one nurse. During an interview on 1/26/24 at 9:21 A.M., CNA M said: -He/she worked from 7:00 A.M. to 7:00 P.M. on long term care A hall. -There were 25 residents on this hall. -Of the resident's on the hall, between 18 to 20 residents need assistance with care, are incontinent and need assistance with transfers (do not ambulate independently). -He/she was the only staff scheduled to work on the hall because there is only one CNA scheduled per hall and they try to assist each other with transfers and baths and cares, but it's just not always possible. -They used to have two bath aides, but due to staffing, they had to pull the bath aides to the floor to provide care to the residents. -Now the CNAs are responsible for bathing residents on their assigned hall in addition to the other cares and responsibilities. -They are expected to complete 4 baths daily. -The residents are supposed to receive two baths weekly. -Depending on the resident, it takes at minimum 20 minutes to give a shower (for some residents it takes longer). -He/she cannot get 4 baths completed daily, he/she tries but it is impossible with all of the cares that he/she has to provide, answering call lights and passing out meals at meal times. -He/she tries to get the bed baths done twice weekly on residents that are in bed most of the time or at least he/she tried to wipe them off with a wet towel. During an interview on 1/30/24 at 9:00 A.M., Agency CNA A said: -CNA A was assigned to hallway and were given a care sheet for those residents. -The nurse would report to the CNA on how to care for the residents. -CNAs who were assigned to that hallway would be responsible for completing baths for assigned resident that day. -He/she would document resident cares and baths given or not in the resident's electronic recorded under CNA task section. During an interview on 1/31/24 at 8:31 A.M., CNA L said: -He/she had 19 residents on the D hallway. -He/she was assigned to give four baths on his/her shift and while caring for the other resident. -He/she felt this was difficulty at times, to be able to complete the baths with only CNA on the unit. -It was hard to meet the needs of the residents and he/she was not always able to ensure residents' baths were given at least two times a week. -He/She documented the care/baths in electronic medical record under CNA task and should have completed the CNA shower sheet also. -He/she would notify the nurse related to resident's skin changes and document skin assessment or changes on shower sheet. -He/she was familiar with resident's care needs that were assigned to him/her, but under CNA task care area showed what type cares the resident would require. -He/she tries to round on the resident when passing meal trays and after meals to ensure personals care were completed at that time. -The CNAs try to assist each other with resident's care if they can. During an interview on 1/31/24 at 9:00 A.M. CNA N said: -The CNAs were responsible for giving the residents baths. -Therapy could also assist in resident bathing. -The Assistant Director of Nursing (ADON) would be responsible for ensuring baths were being completed. -He/She could not get baths completed due to the facility being short-staffed. -The baths were to be documented on the bath sheets and in the Electronic Medical Record (EMR). -The residents were supposed to get showered/bathed two times a week. -He/She did not think that baths/showers were getting completed for each resident two times a week. During an interview on 1/31/24 at 9:08 A.M., CNA J said: -There were 18 residents on C hall at that time. -He/she had 14 resident that required assist with personal cares. -He/she were assigned to complete four showers a day and was not always able to get to complete the bathing task. -If he/she was not able provide bathing or shower for the resident, he/she would document in the EMR a bath was not given and on the CNA's log sheet. -He/she would also notify nurse if resident refused care or was not able finish resident cares. -He/she would expect CNAs to document resident bath on his/her Shower Review & Skin Monitoring sheets and in the EMR under the CNA task. -Both the EMR Task and shower sheet should match with cares provided to the resident that shift. -A bed bath would include a head to toe sponge bath with soap and water. -CNA had given resident #49 and resident #65 a bed bath on 1/26/24. -On 1/23/24 he/she was the CNA assigned care for two hallways that day and he/she were not able to complete the resident's shower or bed baths assigned that day. -He/she was not always able to assist the resident in timely manner, due to number of resident and with only one CNA assigned to that hallway. -Resident #49 and Resident #65 did have a history of refusal of care at times. During an interview on 1/31/24 at 9:13 A.M. Certified Medication Technician (CMT) C said: -The showers aides or the CNAs assigned to the halls were responsible getting baths completed. -Residents were supposed to be bathed/showered two times a week. -The unit manager was responsible for ensuring baths were being completed. -He/she had overheard residents complaining of not getting bathed two times a week. -The facility should follow the residents preference when it came to facial hair. -If the family of Resident #367 did not want the resident to have facial hair, then the facility would be responsible for managing the facial hair. During an interview on 1/31/24 at 9:30 A.M., Licensed Practical Nurse (LPN) B said: -The CNA staff were scheduled one per hall and they have tw CMT's) that pass medications on two halls each, and two nurses that cover two halls each on the 7:00 A.M. to 7:00 P.M. shift. -The CNA staff do the best they can but they do not have enough staff to complete all of the cares they are responsible for. -Because there is only one aide assigned to each hall to do all of the resident care, and they have a lot of residents that require assistance, he/she tries to assist the nursing staff as much as possible, but it is not always possible due to his/her nursing responsibilities. -They have asked for more CNA assistance on the units, but they have not received it. -It was unrealistic to expect the call lights to be answered in 15 minutes and for 4 showers a day to be completed and all of the care that the CNA is responsible for to be completed with only one CNA on the hall for 25 residents that need assistance. -When they have call ins, it becomes more difficult for the staff that come in to work and they do not always have a replacement. -Management staff tries to get people to fill the vacancies, and sometimes they can and sometimes they cannot. During an interview on 1/31/24 at 9:51 A.M., LPN C said: -He/she has worked the 7:00 A.M. to 7:00 P.M. shift and the 7:00 P.M. to 7:00 A.M. shift and there were usually two nurses that covered two hall each (on the long term care unit) and there was only one CNA scheduled per hall. -Sometimes the CNA staff have too much to do to adequately do all of their duties. -He/She tries to help the staff by answering call lights when they are busy or need help to provide care. -On the 7:00 P.M. to 7:00 A.M. shift the staff have less cares they have to do and during the night they have not had as many issues getting cares completed. -When nursing staff call in it is more difficult to get the care tasks completed-it takes longer to complete and it is more difficult for the CNA staff because they still only have one CNA per hall to care for the residents. During an interview on 1/31/24 at 9:42 A.M. ADON A said: -CNAs were responsible for bathing the residents. -The nurses and Assistant Chief Nursing Officers (ACNOs) were responsible for ensuring baths/showers were getting completed. -residents were to be bathed two times a week. -He/she thought most of the residents within his/her responsibility were getting bathed two times a week. -Bath sheets would get lost, making it more difficult to track bathing. -Showers/Baths were also to be charted in the EMR. -The bath sheets should match the EMR documentation. -He/she had not received any complaints from residents related to bathing. -The facility would need to follow resident preference related to facial hair. -If a resident were unable to communicate their preference then he/she would shave the facial hair. During an interview on 1/31/24 at 12:28 P.M., the Director of Nursing (DON) said: -He/she expected for all residents to receive two baths weekly. -If the resident does not receive a bath twice weekly, he/she expects nursing staff to re-schedule the bath or try to adjust the schedule and try to find out the root cause for why the bath was not given. -All baths should be documented on the bath sheet or in the electronic record. -If the resident had a history of refusals of bathing, the nursing staff usually document this on the bath sheet but it should also be in the resident's care plan. MO00230143, MO00230592, MO00229757, MO00229876, MO00230143 4. Review of resident #49's admission Record showed he/she had the following diagnosis: -Requires assistance with personal cares. -Fracture of left knee cap. -End stage renal disease (inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes) -Dependence on Renal dialysis (dialysis is process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood). -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -Congestive Heart Failure (disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body). Review of the resident's POS dated 9/28/23 showed: -Nystatin External Cream 1000 unit/gram (Topical, antifungal cream), apply to under skin folds topically every 6 hours as needed for Candidiasis rash (yeast infection). --Wash with warm water, dry and then apply under breast skin folds and pannus (abdominal skin folds)area. Review of the resident's Quarterly MDS dated [DATE] showed he/she: -Had a Brief Interview for Mental Status (BIMS) score of 12. The score of 8-12, the resident were to have moderate cognitive impairment. -Was occasionally incontinent of urine and frequently incontinent of bowel. -Had no documentation related to rejection of cares noted. Review of the resident Care plan revised 1/8/24 showed: -He/she was resistive to care and became physically aggressive with staff related to his/her diagnosis of dementia. -The resident had cognitive loss related to health conditions and requires support and oversight of safety and encouragement to make basic needs known, dated 4/6/23. -He/she had potential for impaired skin integrity related to reduced function and declines in mobility as well as medically complex conditions that decrease skin healing time and increase potential for breakdown (diabetes, irregular heart beat) dated 5/17/23. Review of the resident's Certified Nursing Assistant (CNA) Shower Review and Skin Monitoring sheets from 1/1/24 to 1/25/24 showed: -On 1/2/24, he/she had refused bath. -On 1/5/24 the resident had a bed bath, documented a redden area skin folds, and applied cream to the area. Had no signature of the nursing staff had reviewed the resident's Shower-Skin Monitoring sheet. -On 1/9/24 and 1/12/24, the staff did not indicate if he/she had received a bed bath or shower was given, the resident had a red open area around skin folds. Had no signature of nursing staff showing they had reviewed the resident's Shower-Skin Monitoring sheet. -On 1/16/24, he/she had refused baths. -On 1/19/24, he/she had no skin issue. The staff did not indicate the resident received a bed bath or shower was given. -On 1/22/24, CNA had signed and dated the shower sheet, and did not indicate if the resident received a bed bath or if a shower was given. -For the seven bath sheets provided, they did not have documented nurses signature showing the nurse's staff had reviewed the resident's Shower-Skin Monitoring sheet. Review of the resident's Electronic Medical Record (EMR) under bath/shower Task sheet dated 1/1/24 to 1/25/24 showed: -He/she had yes checked marked as bath given on following dates; 1/2/24 ,1/3/24 ,1/6/24, 1/9/24, and 1/19/24. -No was checked marked by the staff as no bath given on 1/10/24 and 1/26/24. The resident's handwritten Shower Sheet and EMR bath/shower task documentation dated from 1/1/24 to 1/25/24 were not matching as when bathes/showers were given, refused or not given. Observation and interview 1/23/24 at 10:46 A.M., the resident said: -He/she had pushed his/her call light, waiting for care staff to answer. -He/she had complaints that he/she had soiled himself/herself and had asked care staff assist the resident with his/her personal cares. The resident said the staff had refused to help the resident. -No odors noted at that time. -At 10:57 A.M., the staff had not responded to the resident's call light and there were no staff observed in the hallway. -The resident said an unknown certified nursing assistant (CNA) had turned off the his/her call light but the care staff did not assist the resident with incontinent care needs. -He/she had turned his/her call light back on. -He/she said had yeast under his/her skin folds area. -He/she had a hospital gown on, complaints of dry skin, and he/she required staff assistance in applying lotion to his/her dry skin. During an interview on 1/23/24 at 4:52 P.M., the resident said: -The facility care staff had left him/her wet and soiled and he/had urine running down his/her leg. (resident unable to give date when happened). -He/she should had receive a bed bath at least two times a week. -He/she felt the irritation on his/her skin folds area from not getting changed or cleaned well after cares. 5. Review of Resident #65 admission Record showed he/she had a diagnosis of end stage renal disease and stroke. Review of the resident's Care Plan dated 9/12/23 showed: -He/she had an ADL self-care performance deficit and limited physical mobility related end stage renal disease with dialysis, history of stroke with left sided weakness, noncompliance with dialysis and medications. -Interventions include: --The resident requires physical assistance with toileting. Review of the resident's Quarterly MDS dated [DATE] showed: --Was cognitive intact with a BIMS score of 12-15 (score of 15). --Was always incontinent of bladder and of bowel. --Was on dialysis services. --No documentation related to rejection of cares noted. Review of the resident's POS dated 1/23/24 showed the resident had a physician's order to cleanse abdominal folds with soap and water, pat dry and apply A&D ointment until healed, every shift for wound care. Observation and interview on 1/23/24 at 10:46 A.M., showed: -Therapy staff were providing the resident with a bed bath, due to not getting CNA help him/her that morning. -The resident was soiled and inflamed under his/her breast and scratching self due to dry skin. -The resident had reported that the care staff had not applied any lotion to his/her dry skin, which had caused the resident to start scratching his/her skin to point was bleeding. -He/she said the night nurse would not clean the resident up after the resident had reported bleeding from scratching. -The resident said he/she was not getting showers or bed baths at least two times a week from the care staff. During an interview on 1/24/24 at 10:45 A.M., the resident said: -He/she felt the facility staff were lazy and do not want to provide care as needed. -He/she required a bed bath due to not able to get dialysis port wet. -He/She felt the staff are not performing bed bath well, does not feel clean and the CNAs were not cleaning underneath his/her skin folds areas. -He/she would only get incontinence care three to four times a day within 24 hours. -He/she had been left soiled for long periods of time. Record review of the resident's bath sheets for 1/1/24 to 1/25/24 showed: -On 1/2/24, he/she had no skin issue. The staff did not indicate type of bed bath or shower was given. -On 1/5/24, the resident had a bed bath, had no skin issue noted. -On 1/9/24, the staff did not indicate type of bed bath or shower was given and did not have a nursing signature indicated shower review and skin monitoring sheet were reviewed. -On 1/12/24, had signed and dated the form, then wrote another CNA name had given the resident a bath on 1/11/24. -On 1/16/24, he/she had a bed bath. -On 1/19/24, he/she had no skin issue. Did not indicate type of bed bath or shower was given. -On 1/23/24, the resident had left facility, no bath given. -On 1/24/24, he/she had no skin issue. Did not indicate type of bed bath or shower was given. -On 1/26/24, he/she had no skin issue. The staff did not indicate type of bed bath or shower was given. -The resident's Shower Review/Skin Monitoring sheets did not have a nursing signature indicated shower review and skin monitoring sheet were reviewed by nursing staff. Review of the resident's bath/shower Task sheet dated 1/1/24 to 1/30/24 showed: -He/she had yes checked marked as shower/bath given on following dates; 1/2/24, 1/3/24, 1/6/24 ,1/9/24, 1/19/24, 1/25/24, and 1/27/24. -No was check marked by the staff as shower/bath not given on 1/10/24, 1/26/24 and 1/30/24. Review of the resident's documented Shower Sheets and Care Task from 1/1/24 to 1/26/24 showed, the documentation of care task for shower/bathing did not match the handwritten shower sheets provided. Observation on 1/26/24 at 2:37 P.M., the resident skin showed: -His/her groin area had no irritation noted. -Care staff were applying Vaseline as needed for dry skin. -The resident's brief was dry. Review of the resident's Skin assessment dated [DATE] at 12:29 P.M., showed: -Had skin issue of skin irritation in the groin area on his/her right side. -Physician was notified of the resident skin issue in the groin area. -A treatment was put in place. 6. Review of Resident #80's admission Record showed the following diagnoses: -Need for assistance with personal cares. -Muscle weakness. Review of the resident's Dietary Evaluation dated 1/9/24 showed the resident: -Required assistance with meals -Resident at risk for malnutrition. Review of the resident's Significant Change MDS dated [DATE] showed he/she: -Had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. -Needed ADL assistance for eating. Review of the resident's Physician Order Sheet ( POS) dated 1/1/24 to 1/31/24 showed a physician order for regular textures diet, offer larger portions per resident request and offer yogurt or ice cream with meals. Observation on 1/23/24 at 12:12 P.M. of the D-hallway showed: -Meal trays were in metal food warmer cart. -An unknown Certified Nursing Assistant (CNA) and facility staff were passing out room trays to the residents on the D-hallway. During an observation and interview on 1/23/24 at 1:26 P.M., of the resident showed: -The resident said he/she was not getting the assistance needed with meals. -His/her lunch meal tray was covered located on the resident's bedside table and not within reach of the resident. -The resident had no care staff assisting in feeding him/her with his/her lunch meal at that time. -The resident was observed to require total assistance from care staff for all activities of daily living to include feeding assistance. -The resident said he/she was waiting on care staff to come assist him/her with lunch meal. -At 1:32 P.M., had no staff in hallway and the resident have not been assisted with his/her lunch meal. -At 1:35 P.M., a Certified Medication Technician (CMT) had picked up the resident's roommate meal tray. -It had been hour since room trays were delivered to the unit. The resident's lunch tray remained covered on the bedside table. -At 1:41 P.M., two unknown CNAs and nursing staff were at the nursing station talking to other staff. -At 1:47 P.M., the resident said the unit was was short staff today due to staff member called in sick. -At 1:50 P.M., Assistant Director of Nursing (ADON) B and CNA U (who assigned to gather resident weights and assist as needed) in were in D hallway area. -CNA U walked into the resident room and then left. The resident lunch meal tray remained on the resident's bedside table. -The resident said he/she was waiting for CNA U to returned to assist him/her with the lunch meal. -The ADON B enter the resident's room at 1:53 P.M., ADON B said he/she would go warm up the resident meal meal tray while waiting on CNA U to assist the resident with meal. Review of the facility staffing on 1/23/24 during the day shift showed two halls (D and G) did not have a specific CNA assigned. Observation and interview on 1/26/24 at 9:23 A.M., of the resident showed: -CNA L said he/she were getting ready to feed the resident. -The breakfast meal tray was on the resident's bedside table. During an interview on 1/23/24 at 11:20 A.M., CNA J said: -He/she was assigned to C and D hallways due to staff member calling in sick. -The facility did not have a additional CNA coverage for the D-hallway at that time. 7. During an interview on 1/31/24 at 8:31 A.M., CNA L said: -He/she cared for 19 residents on the D hallway. -It was difficult to be able to complete all resident care needs when there was only one CNA on the unit. -Resident #80 required total feeding assistance with all meals. -He/she would keep the resident's meal tray in a warmer until all other residents' room meal trays were delivered. -He/she would warm the resident food trays as needed. -He/she did not have other staff coverage for other residents on the hallway when he/she has to provide cares or when he/she was feeding a resident. During an interview on 1/31/24 at 9:08 A.M., CNA J said: -There were 18 residents on C hall at that time. -He/she had 14 residents that required assist with personal cares. -He/she were assigned to complete four showers a day and was not always able to get to complete the bathing task. -If he/she was not able provide care for the resident, he/she would document in the EMR and on the CNA's log sheet. -He/she would also notify nurse if resident refused assistant or was not able assist the resident. -He/she was not always able to assist the resident in timely manner, due to number of resident and with only one CNA assigned to that hallway. During an interview on 1/31/24 at 12:45 P.M., the Director of Nursing (DON) said: -He/she would expect CNAs to ensure those residents who require assistance were fed first or last depending on CNA choice of assist and timing of the resident needs. -It was not acceptable for a resident having to wait over an hour and 30 minutes for assist with a meal. -Resident #80 required total assistance with all cares, including feeding assistance. -A CNA who was assigned to specific hallway, would be responsible for ensure the residents were fed in a timely manner and room meal trays were to be warmed up as needed. -All care staff would be responsible to ensure coverage of the units when another CNA was providing resident cares as needed. Based on observation, interview and record review, the facility failed to ensure bathing was completed for six sampled residents (Resident's #23, #34, #96, #367, #366, #369); to ensure a consistent and accurate process for documenting of bathing was completed, and failed to ensure handwritten bathing sheets were signed as reviewed by nursing staff for five sampled residents (Resident 's #23, #34, #49, #65 and #96); and to ensure provide feeding assistance in timely manner for one sampled resident (Resident #80) resulted in hour and half delay in meal assistance, out of 33 sampled resident. The facility resident census of 122 resident. Review of the facility's policy titled Bathing dated April 2023 showed: -All residents were given a bath or shower in accordance with their preferences. -If no preference on a bath is voiced, a bath or shower will be offered twice per week. 1. Review of resident #96's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including respiratory failure, diabetes, kidney failure, obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), pain, high blood pressure and muscle weakness. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 11/10/23, showed the resident: -Was alert and oriented without confusion. -Was dependent on staff for bathing, dressing, toileting, transferring, hygiene and used a wheelchair for mobility. Review of the resident's Care Plan dated 11/22/23, showed the resident self-care performance deficits and limitations in physical mobility related to chronic and acute conditions impacting her physical function and mobility. The care plan showed the resident will have support from staff to ensure daily care needs are met while promoting resident participation in care tasks as tolerated through review. Interventions showed: -The resident needed maximum assistance with bathing. -The interventions did not show how the resident would be bathed or how often the resident was to receive bathing. -The care plan showed the resident at times refused medications/medical care, but it did not show the resident refused bathing. Review of the resident's handwritten Bath/Shower Sheets showed for January 2024 showed: -Nursing staff documented the resident's family member gave the resident a bath on 1/3/24, 1/6/24, 1/10/24, 1/13/24, 1/20/24, and on 1/24/24. -On 1/17/24 nursing documented the resident preferred a bed bath. This was signed by the charge nurse. -On 1/22/24 and 1/25/24 there was no bathing documentation. -The Certified Nursing Assistant (CNA) signed all of the bath/shower sheets except on 1/17/24. -There were no nurse signatures on any of the bath sheets except on 1/17/24. Review of the resident's Shower/Bathing Task Sheet document in the electronic medical record from 1/6 to 1/24 showed: -Nursing staff bathed the resident on 1/6/24, 1/10/24, 1/20/24 and 1/24/24. -There were no additional notes or documentation on the document. -The dates on this electronic record compared to the handwritten bath sheets was inconsistent. Review of the resident's Medical Record and Nursing Notes did not show the residen

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #369's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Displaced Intertrochanteric Fracture of Left Femur (extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter), Subsequent Encounter for Closed Fracture with Routine Healing. -Metabolic Encephalopathy. -Need for Assistance with Personal Care. -Muscle Weakness (Generalized). Review of the resident's Care Plan dated January 2024 showed: -The resident had the potential for alterations in psychosocial well-being with an intervention to encourage the resident to spend time awake up and out of bed engaged in activity as tolerated and desired. -The resident had potential for poor activity involvement related to report of little interest or pleasure in doing things with the following interventions: --Enlarged monthly calendar provided in room. --The resident was to receive the Daily Chronicle packets (the facility's daily activity packet) from Activity Assistant three to five times a week. Review of the resident's admission MDS dated [DATE] showed: -The resident was severely cognitively impaired. -The resident was marked as somewhat important for all the activity preferences listed in the MDS which included: --To have books, magazines, newspapers to read. --To listen to music. --To be around animals such as pets. --To keep up with the news. --To do things with groups of people. --To do his/her favorite activity. --To go outside when the weather is nice. --To participate in religious activities. NOTE: The MDS did not indicate the resident needed glasses. During an interview on 1/24/24 at 10:49 A.M. the resident said: -He/she enjoyed reading and puzzles the most. -He/she could not read the Daily Chronicle or do the puzzle that was in his/her room due to not being able to see. -His/her glasses were missing and the facility had provided him/her with a pair of glasses that were not the correct prescription, and he/she could still not complete or enjoy the activities provided to him/her. During an interview on 1/29/24 at 2:51 P.M. Activities Director (AD) A said: -He/she had spoken with the resident's family regarding the resident's glasses and the family was working in bringing in a backup pair. -The activity assistant met with the resident, which counted as an activity. -He/she was unsure how well the resident could see without his glasses. -He/she could not answer whether the activity packet and puzzle were appropriate activities for the resident. -He/she would be able to make the Daily Chronicle for the resident. -The activities assistant had not reported any problems to him/her, so he/she was unaware that the resident could not read the Daily Chronicle. -The activities assistant was not responsible for any documentation related to his/her visits to any of the residents he/she visited with. Observation on 1/30/24 at 9:20 A.M. of AD B showed: -He/she was handing out the Daily Chronicle to the resident. -He/she told the resident that it was the Daily Chronicle. -He/she left the room and was in the resident's room for less than a minute. During an interview on 1/30/24 at 11:58 A.M. the resident said: -He/she had not been provided his/her glasses from home yet. -He/she was still unable to see the Daily Chronicle packet and the puzzle that was in his/her room. During an interview on 1/30/24 at 12:13 P.M. the resident's family said: -The glasses that were in the resident's room did not belong to the resident. -The facility had just given them to the resident until the family could bring in new glasses. -The resident needed prescription glasses and the resident was unable to see out of the glasses that the facility provided. -The resident would not be able to read the Daily Chronicle or complete the puzzle in his/her room without his/her glasses. 5. Review of Resident #366's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Muscle Weakness (generalized). -Need for Assistance with Personal Care. -Metabolic Encephalopathy (an alteration in consciousness caused due to brain dysfunction). Review of the resident's admission MDS dated [DATE] showed: -The resident was cognitively intact. -The resident was marked as very important for the following activity preferences as very important: -- To listen to music. --To keep up with the news. --To do his/her favorite activity. -The resident was marked as somewhat important for the following activities: -- To have books, magazines, newspapers to read. --To be around animals such as pets. --To do things with groups of people. --To go outside when the weather is nice. --To participate in religious activities. Review of the resident's care plan dated January 2024 showed the resident did not have a care plan related to activities. Review of the resident's admission Activity Interview dated 1/22/24 showed: -The evaluation was marked as a quarterly evaluation. -The rest of the evaluation was blank. During an interview on 1/24/24 at 11:33 A.M. the resident said: -He/she was unsure if he/she had met with AD A or AD B. -He/she would love to go to bingo if the facility held that activity. During an interview on 1/29/24 at 2:56 P.M. AD A said: -He/she was unsure why the Activity Evaluation was blank. -The MDS for the resident had been completed indicating that he/she had met with the resident. -He/she would not be able to provide any activity related documentation for the resident. -The activities assistant visits with the resident. -The activities assistant would inform him/her of any issues that residents may have related to the activities. -He/She did not have any notes form the activities assistant for the resident. During an interview on 1/29/24 at 3:00 P.M., the Activity Director said: -On the daily activity participation record, the activity Television and Movies, were self-initiated activities that were independent and were not part of the activities the facility provided to the resident, but they will document it on the resident's participation record if they go to the resident's room and observe the resident watching television or movies. -They chart it on the individual participation record. -The Group Discussion activity represented anytime they see a resident interacting with their roommate, staff, or peer to show the resident is receiving human interaction and engagement. -Gardening can be the activity of caring for plants in the resident's room which several residents have, so if they water the plant then it is considered gardening activity. -Computer/Cell activity was marked on the participation record if the resident has a computer or cell phone and staff saw the resident using it, they will mark this on the activity participation sheet as an activity, but it was also a self-initiated independent activity. -Several residents had cell phones and if the staff had to assist the resident to use the cell phone, they also marked this on the resident's activity sheet. -These activities were not activities that the facility provided to or for the resident but they document them on the participation record. -They provided activity packets to all residents and the activity packet included a sheet stating what activities will be that day, a prayer, the daily chronicle which contains news articles and the daily perk which may be current events or stories, and a word puzzle the resident can complete. -They passed the activity calendar out to all residents monthly. -All of the activities on the activity calendar were group activities the facility provided to the residents. -For those residents who did not come to activities or could not come to activities, they would assess the resident for one to one activities in the resident's room. -One to one activities usually began from 12:00 noon to 2:00 P.M., and the activities were more focused to the resident's preferences or abilities. They completed an activity assessment for all of the residents and established a care plan that reflected the resident's activity goals and interests. Observation on 1/30/24 at 9:34 A.M. of AD B showed: -He/she entered the resident's room and asked the resident how he/she was doing. -Handed the resident the Daily Chronicle and asked if the resident wanted his/her curtains open. -He/she then left the room, spending less than a minute with the resident. During an interview on 1/30/24 at 12:02 P.M. the resident said: -He/she had not been invited to any activities since he/she was admitted to the facility. -He/she would love to get more things to read like magazines because he/she loved to read. -He/she was bored and wished he/she could get out of his/her room more often. -He/she had only been to the therapy room and back to his/her room. -The activities assistant only brings the Daily Chronicle and did not meet or do other activities with the resident. -He/she felt his oxygen use prevented him from leaving his/her room more often. 6. Review of the Resident #317's admission MDS, dated [DATE], showed the resident: -Was cognitively intact. -Scored an 11 on the Patient Health Questionnaire-9 (PHQ-9: an instrument screening, diagnosing, and measuring the severity of depression) which indicated moderate depressive symptoms. -Scored the following activities as very important: keeping up with the news and doing his/her favorite activities. -Scored the following activities as somewhat important: having books to read, listening to music, interacting with animals, doing things with groups of people, going outside, and participating in religious services. Review of the resident's undated Care Plan showed staff documented: -The resident had depressive symptoms as evidenced by PHQ-9 score with no interventions related to engaging the resident. -The resident had potential for poor activity involvement due to little pleasure in doing things. -The resident's only preferred activity was to receive the Daily Chronicle packet 3-5 times a week. -Staff were to encourage the resident to attend activities of his/her choice. During an interview on 1/23/24 at 4:20 P.M., the resident said: -He/she hadn't went to any activities because nothing appealed to him/her. -Staff had never asked what he/she liked to do. -He/she would be interested in any activities with animals. -He/she liked to read on his/her tablet but was unable because the Internet signal was not strong enough to download books from the library. -He/she was only able to watch television and felt he/she had become more sedentary. During an interview on 1/29/24 at 2:41 P.M., the Activities Director said: -He/she assessed residents for activity preferences on the initial assessment and then followed up after seven days. -He/she had asked the resident if there was anything they wanted to do and the resident replied they went to therapy. -The activity assistant brings each resident a newspaper every day. -The activities were mainly for the long-term care residents and this was a short-stay resident. -For residents with potential for social isolation, he/she expected staff to promote those residents to go to activities. During an interview on 1/30/24 at 9:41 A.M., Certified Medication Technician (CMT) F said the Internet signal did not work well in the facility. 6. During an interview on 1/30/24 at 9:31 A.M. AD B said: -He/she was responsible for passing out the Daily Chronicle to the residents. -Each resident was provided an activity calendar. -Every resident was invited to any of the activities the facility held. During an interview on 1/30/24 at 1:26 P.M., CNA E said: -He/she expected activities for be evaluated and then performed with reach resident. -Most of the short-stay residents only received the Daily Chronicle. During an interview on 1/31/24 at 9:02 A.M. CNA N said: -The AD was the only person responsible for activities within the facility. -He/She did try to invite residents to activities. -He/she was unsure if there were separate activities for the residents who were at the facility for rehabilitation compared to the residents on the Long-Term Care side. -If a resident who could not see without his/her glasses reading and puzzles would be a hard activity to complete. -There were other activities that the resident could participate in besides reading and puzzles. -If a resident had reported any issues related to activities to him/her then he/she would tell the charge nurse. During an interview on 1/31/24 at 9:15 A.M. Certified Medication Technician (CMT) C said: -The AD oversaw all activities within the facility. -All residents were invited to all the activities. -He/she was unsure if there were separate activities held for the resident who were at the facility for rehabilitation compared to the residents on the Long-Term Care side. -residents could do activities one to one (1:1) with the AD if they could not participate in the activities outside of his/her room. -If a resident who could not see without his/her glasses reading and puzzles would not be appropriate activities for the resident. During an interview on 1/31/24 at 9:45 A.M. Assistant Director of Nursing (ADON) A said: -AD B was the new AD for the building. -All residents were invited to the parties that the facility held. -There were not separate activities held for the residents who were at the facility for rehabilitation. -The hospitality director could do 1:1 activity with the residents if needed. -He/she had not received any complaints related to activities from the residents on his/her halls. - If a resident who could not see without his/her glasses reading and puzzles would not be appropriate activities for the resident. -The facility did have iPads and giant puzzles that would be more appropriate for the resident. During an interview on 1/31/24 at 10:41 A.M. the Administrator said he/she had received no complaints from the residents related to activities. During an interview on 1/31/24 at 1:21 P.M., the Activities Assistant said the calendar was edited by the Activities Director after being questioned about the activities provided to residents. Based on observation, interview and record review, the facility failed to ensure activity assessments were completed for two sampled resident (Resident #96 and #366 ); to ensure activities, that were not self initiated, were provided for three sampled residents (Resident #23, #96, #317); to ensure one to one activities were individualized and met resident preferences and abilities for three sampled residents (Resident #6, #366, and #369), and to ensure the care plan included measurable activity goals and interventions for three sampled residents (Resident #23, #96, and #366) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy titled Activities Policy dated April 2023 showed: -Residents will be offered a variety of activities based on their preferences. -Suitable and appropriate activities will be made available for Residents unable to leave their rooms. 1. Review of Resident #6's Face Sheet showed he/she was admitted on [DATE], with diagnoses including brain degeneration (a condition that damages and destroys parts of your nervous system over time, especially your brain), cognitive communication deficit, muscle weakness, pain, hearing loss, history of falls, difficulty walking, high blood pressure, hearing loss and legal blindness (visual perception is less than 20/200 with glasses). Review of the resident's significant change Minimum Data Set (MDS-a) federally mandated assessment tool to be completed by facility staff for care planning dated 9/24/23, showed the resident: -Was alert with significant cognitive memory loss. -Was dependent on staff for bathing, dressing, transfers, hygiene, mobility, toileting and used a wheelchair for transportation. -It was important to the resident to have activities including books, music, being around animals, keeping up with current events/news, doing things with groups of people, going outside, and participating in religious services. Review of the resident's Care Plan dated 12/22/23, showed the resident had self care deficits related to degeneration of the brain, significant changes in his/her ability to participate and legal blindness. The care plan showed the resident needed physical assistance with bathing, dressing, transfers, hygiene, toileting, bed mobility and used a wheelchair for mobility. The resident's activity care plan interventions showed staff would: -Encourage the resident to come to activities of interest, introduce him/her around to fellow residents, and help to facilitate social inclusion. -Encourage the resident to attend activities of choice for socialization and engagement benefits. -Encourage the resident to try to come to activities of choice or interest and remind him/her that he/she is free to leave activities at any time and is not required to stay. -Provide an enlarged monthly calendar in his/her room and remind the resident to look at the calendar for activities of choice and encourage attendance and participation as he/she chose to. -The resident watched television with his/her roommate in his/her room at times depending on what his/her roommate is watching. -Offer the resident independent leisure tools and materials as requested or needed to facilitate independent pursuits as desired. -The resident came to some social events with encouragement. -The resident attended trivia when he/she chose to. -The care plan was not individualized to show the one to one activities that resident was able to participate in or that were specific to residents with sight impairments. It did not show how many activities the resident participated in per week or the goal for the resident's participation in activities. -The care plan interventions were not measurable. Review of the resident's quarterly Activity assessment dated [DATE], showed: -Goal: The resident would participate in leisure activities as desired through the review period. -The resident watched television with his/her roommate in his/her room at times depending on what his/her roommate is watching. -The resident was admitted to hospice services (end of life care) and stopped coming to group activities. -The resident was now receiving one to one room visits. -The resident has been enjoying one to one room visits and enjoyed talking, hand lotions/massages, soft blankets, stuffed animals, snacks, and listening to music. Occasionally the resident requested to look through bags on his/her bedside table or folding clothes. Continue to check in with the resident about what her preferences and desired room activities were. -The resident had occasional family visitors and loved seeing them, but then also thinks he/she was going home with them sometimes. -Encourage the resident to come to activities of interest, introduce him/her around to fellow residents, and help to facilitate social inclusion. -Encourage the resident to attend activities of choice for socialization and engagement benefits. -Encourage the resident to try to come to activities of choice or interest and remind him/her that he/she is free to leave activities at any time and is not required to stay. -Offer the resident independent leisure tools and materials as requested or needed to facilitate independent pursuits as desired. -Provide an enlarged monthly calendar in his/her room and remind the resident to look at the calendar for activities of choice and encourage attendance and participation as he/she chose to. Review of the resident's Activity Participation Record dated January 2024, showed a log of one to one visits. The log showed the date of the one to one visit and activity provided as follows: -1/2/24-room visit-calendar, change and talk. -1/3/24 to 1/7/24 showed the activity personnel was on vacation. -1/10/24-room visit-organized bags in his/her drawer. -1/12/24-intergenerational room visit. -1/15/24-room visit (unidentified activity). -1/17/24-room visit-television. -1/22/24-room visit help organize bears (stuffed animals) and talk. -1/26/24-room visit offered brunch and talk. -The activities did not reflect the resident's preferences as shown on the activity assessment, and did not reflect the resident's abilities or preferences. Observation on 1/23/24 at 5:12 P.M., showed the resident was in his/her bed with his/her stuffed animal. He/she was alert with confusion and was not interviewable. He/she said he/she was hungry. He/she was watching television. Observation on 1/26/24 at 9:12 A.M., showed the resident was sitting up in his/her bed with call light within reach dressed for the weather. He/she was looking out of the window his/her television was on but he/she was not watching it. He/she was holding onto her stuffed animal and was very pleasant. During an interview on 1/26/24 at 9:15 A.M., Certified Nursing Assistant (CNA) M said: -The resident usually stayed in bed most of the time. -They try to get him/her up 1-2 times a week, but he/she does not stay up in a chair very long when he/she gets up, and would say that he/she was hurting so they lay him/her back down. -Regarding activities, he/she has not seen anyone provide activities to the resident in his/her room, no one to one activities or visits from the activity person. -Most of the time the resident just sits in his/her bed and looks out the window or watches television. -The activity person brought an activity calendar to the resident's room every month, but he/she had not seen the activity person provide one to one activities to anyone on the hall that was unable to go to the activities. During an interview on 1/26/24 at 10:00 A.M. CNA E said: -He/she has sometimes seen activities staff go in to do one to one activities with the resident, but he/she does not know what type of activities they do with him/her. -The resident was able to see to eat his/her food and drink independently, they do not have to identify where things are on his/her plate and he/she can see to get personal items and stuffed animals from his/her tray table. -At this time the resident was sitting up in his/her bed eating a bowl of hot cereal. During an interview on 1/29/24 at 3:00 P.M., the Activity Director said: -He/she or the activity assistant completed one to one activities with the resident because he/she usually did not come to group activities. -They complete room visits with the resident and talked with him/her. -The resident's activities were according to the resident's preferences and they tried to accommodate the resident's preferences as they can. During an interview on 1/30/24 at 10:26 A.M., CNA G said: -The resident was bed bound and did not get up for activities. -Everyone received a daily activity packet that had current events and puzzles in it, but he/she had not seen activity staff complete one on one activities with the resident. 2. Review of Resident #23's Face Sheet showed he/she was admitted on [DATE], with diagnoses including falls, high blood pressure, oxygen dependent, dysphagia (difficulty swallowing) chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), hip fracture, depression, pain and nausea. Review of the resident's Activity assessment dated [DATE], showed the resident's goal would be to participate in leisure activities throughout the next review. The resident's preferences showed: -The resident's family had been visiting. -The resident received the Daily Chronicle (facility news and activity packet) three to five times weekly. -The resident was spiritual and staff was to invite the resident to in house bible study or church services. -Staff was to offer independent leisure tools and materials as requested or as needed to help facilitate independent pursuits as desired. -Encourage the resident to attend activities of choice for socialization and engagement benefits. -The resident is new to the facility. Introduce him/her around to other residents as he/she settles in and try to facilitate communication and connections. -Provide an enlarged monthly calendar provided in his/her room. Remind the resident to look at the calendar for activities of choice and encourage attendance and participation as he/she chooses. Review of the resident's admission MDS dated [DATE], showed the resident: -Was alert and oriented without any confusion. -Was dependent for bathing, dressing, toileting, hygiene, transfers and used a wheelchair for mobility. -Books, music, animals, religious activities and being around groups of people were somewhat important activities for the resident. -Current events/news, going outside and doing favorite activities were very important to the resident. Review of the resident's Care Plan dated 1/22/24, showed there were no activities care plan showing the resident preferences, activity goals, activity participation or measurable interventions for the resident's participation in activities. Review of the resident's Activity Participation Record dated January 2024, showed: -On 1/4/24, 1/5/24, 1/8/24 and 1/9/24 the resident participated in television. -On 1/8/24, 1/10/24, 1/11/24, 1/16/24 and 1/22/24, the resident participated in group discussion. -On 1/9/24 and 1/14/24 the resident participated in gardening. -On 1/22/24, 1/23/24, 1/24/24, and 1/25/24 the resident participated in television. Review of the resident's Medical Record showed there were no activity notes in the resident's electronic medical record. Observation and interview on 1/23/24 at 4:31 P.M., showed the resident was in bed wearing oxygen with his/her call light and tray table within reach. The resident had a television that was not on and on his/her tray table there were personal items and papers. There was no activity calendar in his/her room. The resident said: -He/she had been living here about a month after admitting from the hospital after a hip surgery from a fall at home. -He/she was in bed daily and did not get up. -Nursing staff provided all of his/her care. -The television did not work and they said they were going to fix it (put in a cable box) but they have not done so since he/she was admitted . -He/she did not go to activities and did not get any one to one activities in his/her room. -He/she would like to go to activities sometimes. -He/she did not have an activity calendar and was not invited to activities. -The activity staff provided an activity paper with word search puzzles, but he/she did not have anything to write with, so he/she was unable to complete them. Observation and interview on 1/25/24 at 1:39 P.M., showed the resident was in his/her bed with his/her call light in reach. On his/her night stand were two sheets of paper. The resident said they were word search puzzles, but he/she could not do them because he/she did not have anything to write with and the facility staff had not provided him/her with any writing utensil. Observation and interview on 1/30/24 at 10:38 A.M., showed the resident was laying in his/her bed with his/her call light and tray table within reach. He/she was watching television. The resident said: -He/she was happy that his/her television was finally working. -The Maintenance staff came in and fixed his/her television on Thursday when he/she moved into his/her new room. -Because his/her television was not working before, he/she had to watch television on his/her roommates television and when his/her roommate was ready to go to bed and turned the television off, he/she wasn't always ready to stop watching. -Now he/she was able to watch TV as late as he/she wanted to. During an interview on 1/29/24 at 3:00 P.M., the Activity Director said: -The resident was recently admitted , and his/her goal was to get settled in the facility and get oriented. -The resident did not trigger for or requested one to one visits. -His/her family came to visit, but the resident has yet to come out of his/her room to participate in activities. -The resident spent most of his/her day in his/her room in bed watching television. -He/she was aware that the resident's television stopped working and the resident began watching his/her roommates television. They would watch movies and interact with each other. -About a week or so ago he/she began evaluating whether the resident needed one to one activities because the resident had not come to any of the group activities. -They provided the resident with activity packets daily. -Last week the resident moved to a different room and there were plants in the window that belonged to his/her roommate and the resident watched as they watered and cared for the plants which is an activity. 3. Review of Resident #96's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including respiratory failure, diabetes, kidney failure, obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), pain, high blood pressure and muscle weakness. Review of the resident's admission MDS dated [DATE], showed the resident: -Was alert and oriented without confusion. -Was dependent on staff for bathing, dressing, toileting, transferring, hygiene and used a wheelchair for mobility. -Showed activities such as books, music, going outside, religious activities, current events/news, being around groups of people, were somewhat important to the resident. Review of the resident's Care Plan dated 11/22/23, showed the resident self-care performance deficits and limitations in physical mobility related to chronic and acute conditions impacting her physical function and mobility. The care plan showed the resident will have support from staff to ensure daily care needs are met while promoting resident participation in care tasks as tolerated through review. There was no activity care plan for the resident that showed activity preferences, activities the resident chose to attend or any measurable activity goals for the resident. Review of the resident's Activity Participation Record dated January 2024, showed: -Every day of the week the resident participated phone/computer, family and friend visits, movies, and television. On 1/2/24 and 1/14/24, the resident participated in religious studies. -On 1/10/24 the resident participated in an unidentified P.M. activity. -On 1/10/24 the resident participated in group discussion. -On 1/2/24, 1/8/24, 1/9/24 and 1/15/24 the resident participated in current events. Review of the resident's Medical Record showed there was no activity assessment completed on the resident that showed the resident's activity preferences and there were no activity notes in the resident's medical record. Observation and interview on 1/24/24 at 9:21 A.M., showed the resident was in bed sitting up with his/her call light in reach. There was an activity calendar posted on the door in his/her room. He/she was watching television and said: -He/she stayed in his/her bed for most of the day by choice, so he/she spent his/her day watching television. -He/she did not get activities or an opportunity for daily activities in his/her room. -He/she received puzzles once, but did not regularly get any word search, nail painting or anything like that. -The activity staff did not come to his/her room to provide activities. -He/she received an activity calendar, but the activities on it did not interest him/her because there we

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #367's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Encounter for Attention to Gastrostomy. -Moderate Protein-Calorie Malnutrition. - Coronary Artery Disease (CAD- plaque build-up in the wall of the arteries that supply blood to the heart). -Personal history of Transient Ischemic Attack (TIA- a stroke like attack which may be warning sign of a future stroke). Review of the resident's POS dated January 2024 showed: -Nothing by mouth (NPO) diet. -Jevity 1.5 (a calorically dense, fiber fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding (a way to provide nutrition when a person cannot eat or drink safely by mouth) continuous 50 ml per hour to provide a total of 1200 ml every day and night shift. -Enteral (involving or passing through the intestine)- Flush enteral feeding tube- 175 milliliters (ml) free water flush every six hours. -Enteral- Head of Bed (HOB) elevated 30 degrees. Review of the resident's quarterly MDS dated [DATE] showed: -The resident had severely impaired cognition. -The resident received 51% or more of his/her daily total calories via tube feeding. -The resident received 501 ml or more of his/her daily fluid intake via tube feeding. Observation on 1/23/24 at 11:50 A.M. showed the resident was lying flat in his/her bed while the tube feeding was running. Observation on 1/24/24 at 10:27 A.M. showed: -The resident's tube feeding was not running due to a flow error. -The resident's bottle of tube feeding bottle was labeled from 1/23/24 at 9:00 A.M. -The resident's water flush bag was labeled from 1/23/24 at 9:00 A.M. Observation on 1/25/24 at 12:32 P.M. showed: -The resident's tube feeding bag was not labeled with a time or date. -The resident's water flush bag was not labeled with a time or date. Observation on 1/29/24 at 9:16 A.M. showed: -The resident's tube feeding bag was not labeled with a time or date. -The resident's water flush bag was not labeled with a time or date. Observation on 1/30/24 at 12:41 P.M. showed: -The resident's tube feeding bag was not labeled with a time or date. -The resident's water flush bag was not labeled with a time or date. Observation on 1/31/24 at 9:29 A.M. showed: -The resident's tube feeding bag was not labeled with a time or date. -The resident's water flush bag was not labeled with a time or date. -The resident's tube feeding had been turned off. 4. During an interview on 1/31/24 at 9:48 A.M. ADON A said: -Any resident that received tube feeding should have their HOB elevated to a Semi-Fowler's position (a supine position in which an individual lies on their back on a bed, with the HOB elevated between 30-45 degrees, and the legs of the Resident can be either straight or bent at the knees. -This position helped prevent aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airways). -If he/she walked into a resident's room with tube feeding running and the resident was lying flat. He/she would sit the resident up immediately and check for any change of condition. -The resident's tube feeding supplies were changed daily. -The tube feeding bottle/bag and flush bag needed to be labeled with a date and time. -If he/she were to walk into a resident's room with tube feeding and the feeding bottle/bag and/or flush bag were not labeled, then he/she would contact the nurse from the previous shift to see when he/she changed out the supplies and would re-educate the nurse on labeling the bags. -The resident received continuous tube feeding and the Jevity 1.5 and water flush bag were usually hung at the beginning of the shift. -If he/she were to walk into a resident's room and the tube feeding had been turned off, then he/she would check the resident's condition, determine why the tube feeding had been turned off, and resume the tube feeding if applicable. During an interview on 1/31/24 at 10:04 A.M. LPN B said: -Any resident that received tube feeding needed to remain at a 30-45-degree angle while the tube feeding was running to prevent aspiration. -Tube feeding supplies were usually changed out every 24 hours for Residents with continuous feeding orders. -Any time the supplies were changed the feeding bottle/bag and flush bag needed to be labeled with the date, time, the flow rate. -If he/she were to walk into a resident's room with tube feeding and the feeding bottle/bag and/or flush bag were not labeled, then he/she would take down the supplies and restart the feeding with new supplies. -The reason why feeding bottles/bags and water bags were labeled with a date and time was to ensure the supplies were changed out every 24 hours. -If he/she were to walk into a resident's room and the tube feeding had been turned off, then he/she would restart the tube feeding if it was one of his/her Residents or let the nurse in charge of the Resident know. During an interview on 1/31/24 at 11:54 A.M., Infection Control Preventionist (ICP)/ADON B said: -He/She would expect the tube feeding formula to be labeled with the date and time hung, resident name, feeding rate and the name of formula. -If the nurses found a bag to be unlabeled, he/she would expect nursing staff stop the tube feeding and replace with a new bottle of formula. -Tube feeding medications should always be flushed between each medication. -He/She would expect residual be check prior to medication administration via feeding tube. -Medication should not be left unattended by facility nursing staff. During an interview on 1/31/24 at 12:40 P.M. Director of Nursing (DON) said: -The head of the residents' bed needed to be elevated at a 30-45 degree angle to prevent aspiration. -He/She would expect nursing staff to have flushed with water in between each medication administered, unless order otherwise. -He/She would expect to have mix crushed medication with water to ensure medication were dissolved. -Medication should not be left unattended in a resident room. -He/She would expect nursing staff to label the supplemental formula bag or bottle with date and time hung, name of the resident, type of formula, the flow rate and nurse initial. -If nursing staff found bag or bottle not labeled, staff should through away hang a new labeled formula bag or bottle. -He/She would expect nursing staff to have check residual before medication administration or flushing the tube. Based on observation, interview, and record review, the facility failed to ensure appropriate care for three sampled residents (Resident #90, #94 and #367) with a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube is passed into a resident's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy titled Administration of Medications via PEG Tube dated March 2023 showed: -Check placement of the tube by gently drawing back on the position of the syringe. -Medication should be administered separately with flushing of approximately 30 cc of water before and after each medication. -Verify that the medication cup were clear of any remnants of crushed pills or liquid medication. -Flush the G-tube after checking for placement, and before any medication are administered, between each medication, and following administration of all medications. -Check physician orders for amount of fluid to be used for the flush. A tube feeding policy was requested but not received from the facility. 1. Review of Resident's 90's admission Record showed he/she had the following diagnoses: -Stroke. -Severe protein-calorie malnutrition. -Dysphasia (difficulty swallowing). Review of the resident's Nutritional/Tube feeding Care Plan revised on 11/8/24 showed: -The resident had nutritional risk related to dysphasia, nothing by mouth, -Nursing staff were to check placement of the PEG-Tube and gastric contents (residual volume per facility protocol. hold per physician order. -The resident was dependent with tube feeding and water flushes. se physician order for current feeding order. -Provide additional fluids with medication administration per facility protocol. -Provide continuous tube feeding as directed on physician order sheet (POS) via pump. Glucerna 1.5 at rate of 65 milliliters (ml)/hours (hr). -Provide water flushes as directed on POS, 200 cc water flush every four hours. -Monitor and document intake. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning) dated 11/11/23 showed he/she: -Was moderately cognitively impaired. -Was admitted with a tube feeding. -Was dependent on facility staff for all cares. Review of the resident's POS updated on 1/17/24 showed: -Glucerna (Enteral supplemental formula )1.2 per tube feeding (TF) via pump at 65 ml/hr continuous times 24 hr, to provide 1560 ml tube feeding formula every day and night shift ordered on 1/17/24. -Flush enteral feeding tube every four hours for hydration 125 ml via pump ordered on 1/17/24. -Check residual every shift and nurse to check tube feeding residual and record amount. If greater than 100 ml, stop tube feeding and restart in one hour. Elevate Head of the bed 30-45 degrees while TF is running and for one hour after completion, ordered on 11/7/23. -Amlodipine Besylate tab (is used to treat high blood pressure) 10 mg give one tab via Peg-tube one time a day. -Calcium (bone health) 80 mg one time a day. -Carvedilol (is used to treat heart failure and high blood pressure) 12. 5 mg, give one tab via PEG-tube two times a day. -Clopidogrel Bisulfate (blood thinner) 75 mg, give one tab via PEG-tube one time a day. -Levetiracetam (is a medicine used to treat seizures) 750 mg, give one tab via PEG-tube one time a day. Observation on 1/23/24 at 11:22 A.M., of the resident showed: -He/she had tube feeding formula running via pump connected to a unlabeled kangaroo bag (is a enteral feeding bags were would pour supplemental formula ran through feeding tube), with a tan liquids substance inside the bag. (Supplemental formula). -Did not have a date or time when started, type of formula, the rate to flow, and no resident name on the bag. -The enteral feeding pump was set at a of rate 65 ml/hour and water flushes of 125 ml every four hours. -At bedside the resident had a unopened bottle of Glucerna with carb-steady 1.2 calorie (supplemental tube feeding formula). Observation 1/24/24 at 9:45 A.M., of the resident medication administration via tube feeding showed: -Registered Nurse (RN) A and Assistant Director of Nursing (ADON) B in resident's room. -RN A did not wash hand upon enter of the resident's room. -Upon enter of the resident room, five dissolved medications in a 4-ounce (oz) cup of water on resident's bedside table. -No staff were in the room at that time. -RN A had already prepped the medications and placed the medications on resident's bedside table. -He/She had left the resident room after he/she had setup the medications. -There were five medications cups with individual medication in each cup, mixed with water (cup was half full). -RN A clamped the feeding line and stopped the tube feeding. -He/She did not check for residual after tube feeding was stopped. -He/She flushed the feeding tube with 125 ml of water and then added one cup of medication at a time. -He/She did not flush with additional water after each medication given. -After the final medication was administered to the resident, he/she flushed the tube with another 125 ml of water, then primed the feeding line and reconnected the resident tube feedings. Review of the resident's Nursing Medication Administration Record (MAR) on 1/24/24 at 9:45 A.M., showed the medication already prepped by RN A: --Amlodipine Besylate tab 10 mg give one tab via Peg-tube one time a day. --Calcium 80 mg , one tab one time a day. --Carvedilol 12. 5 mg, give one tab via PEG-tube two times a day. --Clopidogrel Bisulfate 75 mg, give one tab via PEG-tube one time a day. --Levetiracetam 750 mg, give one tab via PEG-tube one time a day. During an interview on 1/31/24 at 10:18 A.M., Licensed Practical Nurse (LPN) C said: -Tube feeding formula or bag should be labeled with date and time hung, type of formula, resident name, room number and the flow rate. -If he/she noticed a kangaroo bag of formula hung and not labeled, he/she would replace the formula and label the bag. -Medication administration per tube feeding should be flushed with water between each medication. -Depending on the physician's orders, the tube feeding could be flushed with 10-30 ml of water after each medication was given. -He/She would expect to have detail physician's orders on tube feeding medication administration and to include the amount to flush between each medication. -He/She should not leave medication unattended during tube feeding administration. -He/She would expect nursing staff to check for residual before medication administration or feedings. 2. Review of Resident #94's admission record showed the following dignosis: -Stroke. - Gastrostomy (surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube). Review of the resident's undated Nutritional/Enteral Feeding care plan showed: -Glucerna 1.2 per tube feeding (TF) via pump at 65 ml/hr continuous times 24 hr, to provide 1560 ml tube feeding formula. -Hydration interventions per physician order, receive water flushes of 125 ml every 4 hours. -Administer medication as ordered. Review of the resident's POS showed: -Enteral Feed Order every day and night shift for feeding rate of 60 ml/hour, Lucerne 1.5 calories every day and night shift for nothing by mouth /enteral feed ordered 11/13/23. -Water flush 200 ml per Feeding Tube via Pump every 4 hours for Hydration. -Water flush 200 ml per Feeding Tube via Pump order dated 8/20/23. -Amlodipine besylate tablet 10 mg give one tablet via PEG-Tube one time a day for blood pressure hold if BP is less than 100 or Pulse less than 60, ordered on 8/16/23. Review of the resident's Quarterly MDS dated [DATE] showed: -Was severely cognitive impairment. -Was admitted with tube feeding. -Was dependent on facility staff for all cares. Observation on 1/23/24 at 12:17 P.M.,of the resident showed: -The tube feeding was running via pump, with an unlabeled kangaroo bag of brown liquid substance connected to the PEG-tube. The pump was set at a flow rate of 60 ml an hour. -The bag was not labeled with resident's name, type of formula, date and time feeding started and the rate of flow. Observation on 1/23/24 at 4:06 P.M., of the resident showed: -The tube feeding was running via pump, with a unlabeled kangaroo bag of brown liquid substance. -The bag was not labeled with resident's name, type of formula, date and time feeding started and the rate of flow. Observation on 1/25/24 at 9:18 A.M., the resident medication administration showed: -Medication administered by LPN C and assisted by ADON B was present. -LPN C washed his/her hand upon entrance of the resident's room and had sanitized at bed side table prior to administering the medications. -LPN C cleaned the top of medication cart prior prepping medication with gloves on hands. -LPN C administered the following medications to the resident: --ASA 81 mg (preventive to help reduce the chance of a heart attack) times a day. --Amlodipine Besylate tablet 10 mg give one tablet via PEG-tube, one time a day for blood pressure. Hold if Systolic blood pressure (BP) is less than 100 or Pulse less than 60. --MiraLAX 17 grams (constipation relief) of powder mix with water one time daily. -He/She had crushed two of the medication and placed in a separate medication cup. -He/She had places supplies on the clean table. -He/She added water to MiraLAX powder to mix and dissolve, but he/she did not add water to the two crushed medications prior to giving via feeding tube. -He/She did not check residual prior to administration of the medication via feeding tube. -He/She had poured crushed medication one at a time into the PEG-tube and flushed in between each medication, then poured liquid MiraLAX into PEG- tube. -LPN C completed medication administration, then added the final flush of water in the PEG-tube after all medication were given. During an Interview 1/25/24 at 9:49 A.M., LPN C said: -He/she should have added water to mix and dissolved the crushed medication. -Medication should be dissolve before giving, so does not clog the feeding tube and to ensure all medication was given. During an interview on 1/25/24 9:40 A.M., ADON B said: -He/she would expect nursing staff to mix crushed medication with water to ensure all dissolved and have obtain all the medication ordered. -He/She did see the LPN C had not added water to two of the crushed medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #366's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Other Asthma (a condition in which a person's airways become inflamed, narrow, swell, and produce extra mucus, which makes it difficult to breathe). -Obstructive Sleep Apnea (OSA- intermittent airflow blockage during sleep). Review of the resident's POS dated January 2024 showed: -An order that the facility may administer 2 Liters (L) supplemental oxygen as needed. -No order for the use of continuous oxygen. -No order of how the oxygen should be administered. -No order for when the tubing and other supplies needed to be changed out. -No order indicating the Resident needed a CPAP. -No order for the settings and how to set up the CPAP for the Resident. -No order for how to clean and store the CPAP tubing, mask, and other supplies. Review of the resident's admission MDS dated [DATE] showed: -The resident was cognitively intact. -No indication the Resident was on continuous oxygen therapy. -No indication the Resident used CPAP therapy. Review of the resident's Care Plan dated January 2024 showed: -The resident used oxygen but did not indicate the amount or duration. -An intervention to titrate and provide CPAP per physician's orders but did not indicate what the physician's orders were. Observation on 1/23/24 at 11:23 A.M. showed: -The resident's CPAP tubing and mask were lying on the resident's bedside table and not stored in a bag. -Extra CPAP tubing stored in a bag that was not dated or labeled. Observation on 1/24/24 at 9:59 A.M. showed the resident's CPAP tubing and mask were lying on the resident's bed and not stored in a bag. Observation on 1/24/24 at 11:41 A.M. showed the resident's CPAP tubing and mask were lying on the resident's bedside table and not stored in a bag. Observation on 1/29/24 at 9:10 A.M. showed the resident's CPAP tubing and mask were lying on the resident's bedside table and not stored in a bag. Observation on 1/30/24 at 12:02 P.M. showed the resident's CPAP tubing and mask were lying on the resident's bed and not stored in a bag. During an interview on 1/30/24 at 12:02 P.M. the Resident said: -He/She used oxygen continuously. -He/She thought his/her oxygen amount was set at 2 L. -He/She had used the same CPAP tubing in mask that was lying on his/her bed for a while but could not remember if it had been changed out recently. -He/She used his/her CPAP every night. 4. Review of Resident #316's admission MDS, dated [DATE], showed the resident: -Was cognitively intact. -Required moderate assistance from staff for personal hygiene, rolling from side to side, and upper and lower body dressing. -Used a CPAP machine. Review of the resident's undated Order Summary Report showed: -The physician ordered the resident to have a CPAP applied at bedtime and removed in the morning. Observation on 1/23/24 at 10:28 A.M. showed: -A CPAP mask was lying face down on the resident's table without a barrier or cover. Observation on 1/24/24 at 2:52 P.M. showed: -A CPAP mask was lying face down on the resident's table without a barrier or cover. -A staff member answered the resident's call light and left the room without addressing the CPAP mask. Observation on 1/24/24 at 2:56 P.M. showed: -Three staff members entered the resident's room to transfer the resident. -After all three staff members left the resident's room, the CPAP mask remained uncovered on the table without a barrier. Observation on 1/25/24 at 8:47 A.M. showed: -A CPAP mask was lying on the resident's side table uncovered, without a barrier, and with no bag present. -Certified Nursing Assistant (CNA) A was in the resident's room. -CNA A left the resident's room while the CPAP mask remained on the table uncovered and without a barrier. Observation on 1/25/24 at 10:23 A.M. showed: -The CPAP mask had been moved to a further corner of the resident's side table but remained uncovered, undated, and not on a barrier. -The portion of the mask that lays against the face was in direct contact with the tabletop. Observation on 1/29/24 at 10:41 A.M. showed: -The resident was awake and his/her CPAP mask was lying on the bed next to him/her. -A member of the therapy staff entered the room and assisted the resident with personal cares. Observation on 1/29/24 at 11:22 A.M. showed: -The CPAP mask was now on the resident's bedside table which was out of reach for the resident. -The CPAP mask was not covered, dated, or on a barrier. Observation on 1/29/24 at 3:14 P.M. showed: -The CPAP mask remained on the resident's bedside table-uncovered, undated, and not on a barrier. 5. Review of Resident #317's admission MDS, dated [DATE], showed: -The resident was cognitively intact. Review of the resident's undated Order Summary Report showed the physician ordered: -Albuterol Sulfate (a short-acting bronchodilator that provides relief from an asthma attack by relaxing the smooth muscles in the airways) two puffs every six hours as needed for shortness of breath and wheezing (a whistling or rattling sound in the chest). -Ipratropium-Albuterol Inhalation Solution (used to help control the symptoms of lung diseases) three milligrams (mg) inhaled every six hours as needed for shortness of breath and wheezing. Observation on 1/23/24 at 5:00 P.M. showed: -A nebulizer (a device for producing a fine spray of liquid, used for inhaling a medicinal drug) with an attached mouthpiece in the resident's room. -The mouthpiece was not covered, dated, or on a barrier. -The mouthpiece was lying on the resident's bedside table with the portion that enters the mouth in direct contact with the surface of the table. During an interview on 1/23/24 at 5:00 P.M., the resident said: -He/she had stopped getting nebulizer treatments a few days prior. 6. Review of Resident #318's admission MDS, dated [DATE], showed the resident: -Was cognitively intact. -Required moderate assistance from staff for personal hygiene. -Required maximum assistance from staff to roll left and right. -Used a non-invasive mechanical ventilator (the delivery of oxygen into the lungs via positive pressure without the need for a tube to be inserted into the person). Review of the resident's undated Order Summary Report showed: -The physician ordered a Trilogy machine (an all-in-one ventilation device, capable of delivering both invasive and non-invasive ventilation modes) set a 2 liter per minute (lpm) of oxygen at bedtime. During an interview on 1/23/24 at 5:11 P.M., the resident said: -A respiratory therapist set up the Trilogy machine and taught the nurses and him/her how it worked and what settings were to be used. Observation on 1/24/24 at 2:59 P.M. showed: -A CPAP mask on the resident's table was uncovered, undated, and not on a barrier. -The resident was in his/her wheelchair waiting to be transferred to bed. Observation on 1/25/24 at 8:53 A.M. showed: -The resident was lying in bed. -A CPAP mask was lying on the resident's bedside table out of his/her reach. -An unknown staff member entered the resident's room and delivered breakfast. -The CPAP mask remained uncovered and not on a barrier. During an interview on 1/25/24 at 8:58 A.M., the Director of Nursing (DON) said: -The resident used the Trilogy machine as a CPAP. 7. During an interview on 1/31/24 at 9:04 A.M. Certified Nursing Assistant (CNA) N said: -There should be a physician's order for the use of a CPAP machine and oxygen. -CPAP tubing and mask needed to be stored in a bag after each use. -The bag used for storage should have the resident's name and date labeled on the bag. -If he/she were to walk into a resident's room and see CPAP tubing or supplies not stored in a bag, then he/she would see if the resident had a bag to store the supplies in, if no bag could be found, he/she would go get one. -If able he/she would also replace the CPAP tubing. During an interview on 1/31/24 at 9:17 A.M. Certified Medication Technician (CMT) C said: -There should be physician's orders in place for oxygen use and CPAP therapy. -The order should include how the Resident received the oxygen, the amount, and any settings. -The resident's care plan should include more specific details on how the Resident received oxygen and use of the CPAP machine. -If he/she walked into a resident's room and saw CPAP tubing and supplies not stored in a bag, then he/she would get a bag if there was not already one and place the supplies in the bag. During an interview on 1/31/24 at 9:23 A.M., Licensed Practical Nurse (LPN) B said: -All oxygen nasal cannulas, tubing, face masks, mouthpieces, nasal pillows, were supposed to be stored in plastic bags when not in use. -Night shift nursing staff were supposed to change the supplies out every Sunday and they also obtain the plastic bags so everyone that has oxygen or respiratory supplies should have a bag for storage. -All nursing staff were responsible for ensuring the supplies were stored in a bag when not in use, but they are so busy, it is possible that they do not check to ensure the supplies are stored when they enter the residents' rooms. During an interview on 1/31/24 at 9:51 A.M. Assistant Director of Nursing (ADON) A said: -Any Resident who used oxygen or CPAP therapy should have an order in place. -The order should include: --The type of oxygen therapy. --Cleaning regimen. --Titration settings. --How to store the equipment when not in use. --What kind of tubing the Resident needed. -The resident's care plan should have included the orders for the oxygen and CPAP therapy. -He/She would expect staff to disinfect CPAP tubing and place in a dated bag if they were to walk into a resident's room and see it lying on the bed or the bedside table. During an interview on 1/31/24 at 12:28 P.M., the DON said: -Oxygen supplies: face masks, nasal cannulas, oxygen tubing, mouthpieces should be in a bag labeled and dated when not in use. -They have storage bags in the central supply the nursing staff can use. -The night shift nurse or nurse management are responsible for overseeing this (changing out of oxygen supplies and providing storage bags). -He/She expected the nurses to monitor (to ensure compliance). During an interview on 1/31/24 at 1:17 P.M. the DON said: -He/She would expect a physician's order to be in place for the use of oxygen and CPAP therapy. -When not in use oxygen supplies should be stored in a bag. -He/She would expect staff to place CPAP tubing and supplies in a bag or respect the resident's preference if they walked into a resident's room the tubing was lying on the bed or bedside table. -The resident's care plan should be up to date and include oxygen/CPAP therapy. Based on observation, interview, and record review, the facility failed to ensure a physician's order for oxygen was documented on the Resident's Physician's Order Sheet (POS) that included the amount and duration oxygen should be administered, when tubing and supplies should be changed for one sampled resident (Resident #366); failed to ensure a physician's order for a Continuous positive airway pressure (CPAP- a method of respiratory therapy in which air is pumped into the lungs through the nose or mouth during spontaneous breathing) device including the settings for the device, when tubing and mask should be cleaned for one sampled Resident (Resident #366); and failed to store oxygen supplies to prevent contamination when not in use for six sampled residents (Resident #23, #96, #366, #316, #317, and #318) out of 33 sampled residents. The facility census was 122 residents. Review of the facility Oxygen Storage policy revised 5/2023, showed the policy and procedure for storage of oxygen cylinders, but did not show storage for oxygen supplies such as nasal cannulas (a device that delivers extra oxygen through a tube and into your nose), face masks, mouthpieces, nasal pillows (a device that fits at the nostrils to supply air pressure) and oxygen tubing. Review of the facility's policy titled Physician's Orders dated May 2023 showed: -Orders for treatments would include: --Description of treatment. --Frequency of treatment. --Specific precautions or directions if needed. --Clinical rationale for order (indication/diagnosis). 1. Review of Resident #23's Face Sheet showed the resident was admitted on [DATE], with diagnoses including falls, high blood pressure, oxygen dependent, dysphagia (difficulty swallowing) chronic obstructive pulmonary disease (COPD-a condition involving constriction of the airways and difficulty or discomfort in breathing), hip fracture, depression, pain and nausea. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment tool to be completed by facility staff for care planning dated 1/9/24, showed the resident: -Was alert and oriented without any confusion. -Was dependent for bathing, dressing, toileting, hygiene and used a wheelchair for mobility. -The resident did not receive oxygen therapy. Review of the resident's POS 1/2024, showed the following physician's order: -May administer 2 liters of supplemental oxygen as needed (order dated 1/4/24). Review of the resident's Care Plan dated 1/22/24, showed the resident had an altered respiratory status and difficulty breathing. Interventions showed: -The resident will have no complications related to Shortness of Breath (SOB) though the review date. -Give the resident medications as ordered by his/her physician and monitor/document the side effects and effectiveness. -Monitor for signs and symptoms of potential respiratory infections. -Monitor for signs and symptoms of respiratory distress and report to the physician. -Monitor the resident's vital signs (respirations, pulse, blood pressure, oxygen level). Observation on 1/25/24 at 6:38 A.M., showed the resident was in bed with his/her call light within reach and was dressed in a gown. His/her oxygen nasal cannula was in his/her nose, but her oxygen was not on and running. He/She did not seem to be in respiratory distress. There was no evidence of a bag to place the nasal cannula and tubing in. His/Her eyes were closed, and he/she was resting comfortably. Observation and interview on 1/25/24 at 9:11 A.M., showed the resident was in bed awake and did not have his/her oxygen nasal cannula in his/her nose. The resident's oxygen was not turned on, but the resident did not seem to be having any respiratory distress. The resident's nasal cannula and tubing were beside him/her in his/her bed, uncovered. There was no evidence of a bag to place the nasal cannula and tubing in. The oxygen concentrator (a medical device that gives you extra oxygen) was beside the resident's bed and it was turned off. The resident said: -He/She was not wearing her oxygen because there was no oxygen blowing through the tubing, so he/she took it off. -No one had come in to check his/her oxygen or to turn it on. Observation and interview on 1/25/24 at 1:39 P.M., showed the resident was in his/her bed with his/her call light in reach. He/She was not wearing his/her oxygen but said that he/she was not having difficulty breathing. The resident's oxygen concentrator was off and the nasal cannula was laying on the resident's mattress uncovered. There was no evidence of a bag to place the nasal cannula and tubing in. The resident said nursing staff was in his/her room and delivered his/her breakfast and checked on him/her. Observation on 1/30/24 at 10:38 A.M., showed the resident was laying in his/her bed with his/her oxygen nasal cannula on. The resident's oxygen was on and running at 2 liters per minute. He/She said the nurse had come in to turn his/her oxygen on. 2. Review of Resident #96's Face Sheet showed the resident was admitted to the facility on [DATE] with diagnoses including respiratory failure, diabetes, kidney failure, obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), pain, high blood pressure and muscle weakness. Review of the resident's admission MDS dated [DATE], showed the resident: -Was alert and oriented without confusion. -Was dependent on staff for bathing, dressing, toileting, transferring, hygiene and used a wheelchair for mobility. -Did not receive oxygen therapy. Review of the resident's Care Plan dated 11/22/23, showed the resident required oxygen therapy and a continuous positive airway machine (CPAP-a method of respiratory therapy in which air is pumped into the lungs through the nose or nose and mouth during spontaneous breathing, used in the treatment of sleep disorder and other respiratory disorders) related to respiratory failure. Interventions showed staff was to: -The resident will have no signs and symptoms of poor oxygen absorption through the review date. -Administer oxygen at 2 liters per physician's orders. -Observe for signs of respiratory compromise, anxiety, weakness, confusion and shortness of air. Assess and update the physician as needed. -Monitor the resident's vital signs as ordered. -Provide medications as ordered for respiratory health. -provide respiratory treatments as ordered. -Assist the resident to place CPAP each night and off in the morning. -Keep the head of the bed elevated to prevent shortness of air. -Provide routine care for CPAP, routine cleaning and filling the water reservoir. -Complete vital signs as ordered. Review of the resident's POS dated 1/2024, showed physician's orders for: -CPAP -wipe mask, nasal pillows daily with damp cloth, empty humidifier chamber, fill humidifier with warm water shake well, rinse and air dry in the morning (ordered 12/30/23). Observation on 1/23/24 at 1:07 P.M., the resident was in his/her bed, dressed for the weather with his/her call light in reach beside the resident's bed. The nasal pillow and tubing was lying beside the machine, uncovered. There was a plastic bag hanging from a handle on the dresser. There was a CPAP machine sitting on the dresser - noted the resident had a CPAP machine next to the bed with a face mask that was uncovered. Observation and interview on 1/24/24 at 9:21 A.M., showed the resident was in his/her bed, awake with his/her call light and tray table within reach. The resident's nasal pillow and tubing to his/her CPAP machine was sitting on the dresser on top of the CPAP machine, uncovered. There was a plastic bag hanging on the drawer handle below the machine. The resident said: -He/She wore the CPAP as needed at night. -He/She wore his/her CPAP yesterday. She said she does not use oxygen.

Based on observation, interview and record review, the facility failed to ensure the recipe for pureed (cooked food, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) eggs during the breakfast meal on 1/29/24. This practice potentially affected 7 residents who had pureed diets. The facility census was 122 residents. 1. Review of the undated recipe for pureed scrambled eggs showed: -10 one ounce (oz.) serving of scrambled eggs. - 5 oz. of milk. Observation on 1/29/24 from 8:13 A.M. through 8:16 A.M., showed the following: - The Production Manager (PM) took 7 portions of eggs from the flat pan of scrambled eggs and placed those portions in the food processor. - The PM did not have a recipe book open during that time. - The PM did not add milk to the pureed eggs. - PM pureed the eggs and placed them in the pan and placed them back into the convection oven to keep them warm. During an interview on 1/29/24 at 9:44 A.M., the PM said he/she did not have the recipe open that morning, because the recipe was not available to him/her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the hot foods of the breakfast meal on room trays for at least seven residents on the F Hall and at least six residents on the C Hall was served to residents at or close to a temperature of 120ºF (degrees Fahrenheit) including interviews with four residents sampled residents (Resident #23, #68, #317, and #65) out of 33 sampled residents. The facility census was 122 residents. 1. Review of Resident #23's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning), dated 1/9/24, showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status, determines the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions) of 14 out of 15. During an interview on 1/23/24 at 11:21 A.M., the resident said the food is always cold. 2. Review of Resident #317's admission MDS dated [DATE], showed the resident was cognitively intact with a BIMS 15 out of 15. During an interview on 1/23/24 at 4:28 PM, the resident said the food temperatures were tepid (only slightly warm). 3. Review of the breakfast portion of the Week 2 At-a-Glance menu, dated 1/29/24, showed the following items for breakfast on that date: -Choice of hot or cold cereal. -Egg of choice. -Sausage or bacon. -Waffles (French Toast was substituted for waffles on that day). 4. Observations during the breakfast meal preparation on 1/29/24, showed: -At 7:22 A.M., the temperature of the mechanical soft sausage 155.4º F. -At 7:49 A.M., the temperature of the French Toast when it came out of the oven was 163.2º F. /-At 8:17 A.M., the temperature of French Toast, was 154.4º F. -At 8:25 A.M., the test tray placed on the cart for F Hall. -At 8:27 A.M., Dietary Aide (DA) B delivered the meal cart for F Hall and left it outside rooms F1 and F3. DA B did not tell any facility staff working in the area that the cart was delivered. -At 8:36 A.M., and 8:39 A.M., the meal cart was still in the same area that DA B left the cart. -At 8:45 A.M., DA B started to pass room trays by himself/herself then stopped after passing five trays and went back to the kitchen. -At 9:10 A.M., Certified Nurse's Assistant (CNA) F started passing trays -At 9:16 A.M., the temperature of food items on the test tray on F Hall was checked in front of CNA F: --The sausage was 87.1º F. --The eggs were 95.4º F. --The French toast was 80.4º F. Observation on 1/29/24 at 9:18 A.M. showed one additional tray was checked, and the following temperatures was discovered: -The sausage was 85.6º F. -The eggs were 94.2º F. -The French Toast was 81.2º F -There were six more trays left to be delivered on F Hall. 5. Observation on 1/29/24 at 8:51 A.M., showed the food cart was delivered to C Hall. CNA B was the only CNA who delivered food during that time. Observation on 1/29/24 at 9:22 A.M., the temperature of food items on the C Hall test tray, was checked in front of CNA F and the following temperatures were found: -The sausage was 91.2º F -The eggs were 89.5º F, and -The French Toast was 84.4º F During an interview on 1/29/24 at 9:25 A.M., CNA B said: -He/She was the only person delivering trays on C Hall that day. -He/She was not told the meal cart was on his/her hall. -During the meal delivery to certain rooms. He/she has had to remove items from beside tables and the bedside tables themselves which caused the meal delivery to be slowed down a bit. During an interview on 1/29/24 at 9:34 A.M., the Production Manager (PM) said no dietary staff took temperatures of the room trays since he/she has been here since November 2022. 6. Review of Resident #68's admission MDS, dated [DATE], showed the resident was cognitively intact with a BIMS of 14 out of 15. During an interview on 1/29/24 at 9:29 A.M., the resident said his/her food was lukewarm when it was delivered to her and they could rewarm the food for him/her if they were not too busy. 7. Review of Resident #65's quarterly MDS dated [DATE], showed the resident was cognitively intact with a BIMS 15 out of 15. During an interview on 1/30/24 at 9:31 A.M., the resident said he/she did not like the food because of the following: -He/she wanted more flavor in the food. -In the course of a week, about 4 out 7 breakfasts are cold, when the breakfast were delivered to his/her room. During an interview on 1/31/24 at 12:49 P.M. the Consultant Registered Dietitian (RD) said he/she expected dietary staff to monitor room trays for appropriate temperatures. MO00230143

Based on observation, interview and record review, the facility failed to ensure that pureed (cooked food, that has been ground, pressed, blended, or sieved to the consistency of a creamy paste or liquid) versions of items such as sausage and French Toast on the breakfast menu was available for 7 residents with pureed diets. The facility census was 122 residents. 1. Review of the breakfast portion of the Week 2 At-a-Glance menu, dated 1/29/24, showed the following items for breakfast on 1/29/24: -Choice of hot or cold cereal. -Egg of choice. -Sausage or bacon. -Waffles (French Toast was substituted for waffles on that day). -Syrup. -Margarine. -2% milk. -Coffee. -Condiments. Observation on 1/29/24 from 7:06 A.M. through 7:40 A.M., during the breakfast meal preparation showed: - The Production Manager (PM) took eggs out of the steam table and pureed a portion of those eggs for the number of residents with pureed diets. - The PM cooked oatmeal cereal and pureed a portion of oatmeal cereal for the number of residents with pureed diets. - The PM took a portion of the sausage made mechanical soft sausage but did not puree the sausage. - The PM did not puree the French Toast. During an interview on 1/29/24 at 10:13 A.M., the PM said the residents with pureed diets only received pureed eggs and oatmeal, not pureed French Toast and/or pureed sausage. During an interview on 1/29/24 at 10:48 A.M. the Dietary Manager (DM) said dietary staff should have pureed the sausage and the French Toast for residents with pureed diets. During an interview on 1/31/24 at 11:38 A.M., the PM said: - He/She has only been in the position of Production Manager since 1/1/24. - In the past, if there were not enough breakfast meats, they did not puree the breakfast meats such as sausage. - There were enough meats on 1/29/24. During an interview on 1/31/24 at 12:49 P.M., the Consultant Registered Dietitian (RD) said the residents who are on pureed diets, should receive all the items on the menu in pureed form and it stated that clearly on the resident's meal tickets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain appropriate staffing numbers to adequately provide resident care and meet resident needs. This had the potential to affect all residents who resided at the facility. The census was 122 residents. A policy regarding staffing by acuity was requested and not received at time of exit. 1. Review of the working staff schedules, dated 1/1/24 to 1/30/24 showed: -The facility had seven halls where residents resided; A-D were long term care, F-H were rehabilitation. -Each hall was assigned one Certified Nursing Assistant (CNA) each shift. -Nurses were each assigned to two halls per shift. -On 1/1/24 (holiday), two halls (F and G) did not have a CNA assigned during the day, and one hall (G) did not have a CNA at night. -On 1/2/24, two halls (D and G) did not have a CNA assigned at night. -On 1/3/24, two halls (C and H) did not have a CNA assigned during the day, and one hall (F) did not have a CNA at night. -On 1/5/24, one hall (F) did not have a CNA assigned during the day, and one hall (D) did not have a CNA at night. -On 1/6/24 (weekend), one hall (A) did not have a CNA assigned during the day, and two halls (D and G) did not have a CNA at night. -On 1/7/24 (weekend), two halls (A and F) did not have a CNA assigned until 12:00 P.M. during the day, and two halls (D and F) did not have a CNA at night. -On 1/9/24, one hall (H) did not have a CNA assigned during the day, and one hall (F) did not have a CNA at night. -On 1/10/24, one hall (D) did not have a CNA assigned at night. -On 1/11/24, one hall (G) did not have a CNA assigned at night. -On 1/13/24 (weekend), two halls (G and D) did not have a CNA assigned at night. -On 1/14/24 (weekend), two halls (B and H) did not have a CNA assigned during the day. -On 1/15/24, two halls (C and F) did not have a CNA assigned during the day. -On 1/18/24, one hall (H) did not have a CNA assigned during the day, and one hall (G) did not have a CNA assigned at night. -On 1/20/24 (weekend), one hall (G) did not have a CNA assigned at night and one hall (D) did not have a CNA until 11 P.M. -On 1/21/24 (weekend), one hall (G) did not have a CNA assigned at night. -On 1/22/24, two halls (D and H) did not have a CNA assigned until 1:00 P.M., and one hall (B) did not have a CNA assigned at night. -On 1/23/24, two halls (D and G) did not have a CNA assigned and a third hall (H) did not have a CNA assigned until 1:00 P.M. during the day. -On 1/26/24, two halls (F and H) did not have a CNA assigned during the day, and two halls (B and H) did not have a CNA assigned at night. -On 1/27/24 (weekend), the rehab unit had a nurse scheduled from 12:00 P.M. to 7:00 P.M. then another nurse from 11:00 P.M. to 7:00 A.M. leaving multiple hours with no nurse for those halls, and three halls (D, F, and G) did not have a CNA assigned during the day. -On 1/28/24 (weekend), all three rehab halls (F, G, and H) had CNAs until 4:00 P.M. during the day with night shift coming on duty at 7:00 P.M., and one hall (A) did not have a CNA assigned at night. -On 1/30/24, one hall (F) did not have a CNA assigned during the day. Review of the facility's Device Activity Report (shows what room/date/time/duration of activation for call lights used in the facility) from 1/19/24-1/22/24 showed: -On 1/19/24, room: --D1's bed call light alarmed for 15 minutes (min) and 14 seconds (sec) starting at 12:15 A.M. --D1's bed call light alarmed for 15 min and 14 sec starting at 12:30 A.M. --A3's bed call light alarmed for 16 min and 37 sec starting at 12:47 A.M. --F6's bed call light alarmed for 16 min and 15 sec starting at 1:01 A.M. --A3's bed call light alarmed for 15 min and 37 sec starting at 1:03 A.M. --A5's bed call light alarmed for 17 min and 51 sec starting at 1:18 A.M. --A5's bed call light alarmed for 17 min and 51 sec starting at 1:36 A.M. --H7's bed call light alarmed for 16 min and 47 sec starting at 1:48 A.M. --G14's bed call light alarmed for 23 min and 54 sec starting at 1:55 A.M. --H7's bed call light alarmed for 16 min and 47 sec starting at 2:04 A.M. --B2's bed call light alarmed for 15 min and 59 sec starting at 3:45 A.M. --D7's bed call light alarmed for 21 min and 27 sec starting at 8:00 A.M. --A5's bed call light alarmed 17 min and 11 sec starting at 9:16 A.M. --A5's bed call light alarmed for 17 min and 11 sec starting at 9:33 A.M. --B2's bed call light alarmed for 22 min and 7 sec starting at 9:37 A.M. --D1's bed call light alarmed for 19 min and 8 sec starting at 9:58 A.M. --B2's bed call light alarmed for 22 min and 7 sec starting at 9:59 A.M. --D1's bed call light alarmed for 19 min and 8 sec starting at 10:17 A.M. --F6's bed call light alarmed for 25 min and 32 sec starting at 11:56 A.M. --F6's bed call light alarmed for 25 min and 32 sec starting at 12:22 P.M. --G3's bed call light alarmed for 21 min and 12 sec starting at 3:17 P.M. --G3's bed call light alarmed for 21 min and 12 sec starting at 3:38 P.M. --D1's bed call light alarmed for 16 min and 37 sec starting at 3:47 P.M. --D1's bed call light alarmed for 16 min and 37 sec starting at 4:04 P.M. --B8's bathroom call light alarmed for 17 min and 52 sec starting at 4:05 P.M. --C9's bed call light alarmed for 18 min and 58 sec starting at 4:15 P.M. --B8's bathroom call light alarmed for 17 min and 52 sec starting at 4:34 P.M. --H7's bed call light alarmed for 16 min and 54 sec starting at 4:35 P.M. --H7's bed call light alarmed for 16 min and 54 sec starting at 4:52 P.M. --H8's bed call light alarmed for 17 min and 44 sec starting at 4:54 P.M. --F5's bed call light alarmed for 22 min and 52 sec starting at 5:33 P.M. --F5's bed call light alarmed for 22 min and 52 sec starting at 5:56 P.M. --B2's bed call light alarmed for 15 min and 3 sec starting at 6:12 P.M. --D4's bed call light alarmed for 18 min and 44 sec starting at 6:23 P.M. --H8's bed call light alarmed for 26 min and 48 sec starting at 6:46 P.M. --D8's bed call light alarmed for 16 min and 6 sec starting at 7:12 P.M. --C9's bed call light alarmed for 18 min and 58 sec starting at 7:16 P.M. --H7's bed call light alarmed for 19 min and 59 sec starting at 7:53 P.M. --C1's bed call light alarmed for 17 min and 13 sec starting at 7:54 P.M. --C1's bed call light alarmed for 17 min and 13 sec starting at 8:11 P.M. --H7's bed call light alarmed for 19 min and 59 sec starting at 8:13 P.M. --D1's bed call light alarmed for 22 min and 37 sec staring at 8:27 P.M. --F13's bed call light alarmed for 24 min and 33 sec starting at 8:39 P.M. --B2's bed call light alarmed for 15 min and 3 sec starting at 8:42 P.M. --D1's bed call light alarmed for 22 min and 37 sec starting at 8:50 P.M. --B7's bed call light alarmed for 15 min and 17 sec starting at 9:23 P.M. --D4's bed call light alarmed for 18 min and 44 sec starting at 9:28 P.M. --H7's bed call light alarmed for 17 min and 53 sec starting at 9:29 P.M. --B2's bed call light alarmed for 23 min and 54 sec starting at 9:42 P.M. --H7's bed call light alarmed for 17 min and 53 sec starting at 9:47 P.M. --G14's bed call light alarmed for 24 min and 31 sec starting at 9:59 P.M. --B2's bed call light alarmed for 23 min and 54 sec starting at 10:06 P.M. -On 1/20/24, room: --B11's bed call light alarmed for 16 min and 6 sec starting at 1:53 A.M. --F3's bed call light alarmed for 15 min and 12 sec starting at 2:07 A.M. --B11's bed call light alarmed for 16 min and 6 sec starting at 2:09 A.M. --F3's bed call light alarmed for 15 min and 12 sec starting at 2:22 A.M. --A5's bed call light alarmed for 16 min and 8 sec starting at 6:39 A.M. --A5's bed call light alarmed for 40 min and 30 sec starting at 7:26 A.M. --F6's bed call light alarmed for 23 min and 19 sec starting at 8:47 A.M. --F8's bathroom call light alarmed for 18 min and 6 sec starting at 8:52 A.M. --A4's bed call light alarmed for 18 min and 56 sec starting at 8:56 A.M. --H3's bed call light alarmed for 16 min and 42 sec starting at 8:57 A.M. --F5's bed call light alarmed for 15 min and 9 sec starting at 8:57 A.M. --A5's bed call light alarmed for 17 min and 33 sec starting at 9:06 A.M. --F8's bathroom call light alarmed for 18 min and 6 sec starting at 9:10 A.M. --F6's bed call light alarmed for 23 min and 19 sec starting at 9:11 A.M. --F5's bed call light alarmed for 15 min and 9 sec starting at 9:12 A.M. --H3's bed call light alarmed for 16 min and 42 sec starting at 9:14 A.M. --H8's bed call light alarmed for 25 min and 28 sec starting at 9:18 A.M. --A5's bed call light alarmed for 17 min and 33 sec starting at 9:23 A.M. --H3's bed call light alarmed for 16 min and 36 sec starting at 9:54 A.M. --B2's bed call light alarmed for 16 min and 55 sec starting at 10:21 A.M. --F13's bed call light alarmed for 16 min and 21 sec starting at 10:22 A.M. --F13's bed call light alarmed for 16 min and 21 sec starting at 10:38 A.M. --C10's bed call light alarmed for 15 min and 39 sec starting at 10:47 A.M. --A4's bed call light alarmed for 18 min and 56 sec starting at 10:55 A.M. --F4's bed call light alarmed for 18 min and 11 sec starting at 10:56 A.M. --C10's bed call light alarmed for 15 min and 39 sec starting at 11:03 A.M. --F5's bed call light alarmed for 18 min and 11 sec starting at 11:14 A.M. --C10's bed call light alarmed for 23 min and 55 sec starting at 11:21 A.M. --B7's bed call light alarmed for 23 min and 45 sec starting at 11:28 A.M. --B8's bed call light alarmed for 19 min and 31 sec starting at 11:32 A.M. --C10's bed call light alarmed for 23 min and 55 sec starting at 11:45 A.M. --B7's bed call light alarmed for 23 min and 45 sec starting at 11:51 A.M. --B8's bed call light alarmed for 19 min and 31 sec starting at 11:52 A.M. --F6's bed call light alarmed for 22 min and 59 sec starting at 11:54 A.M. --C2's bed call light alarmed for 21 min and 9 sec starting at 12:02 P.M. --F6's bed call light alarmed for 22 min and 59 sec starting at 12:17 P.M. --C2's bed call light alarmed for 21 min and 9 sec starting at 12:23 P.M. --C2's bed call light alarmed for 21 min and 59 sec starting at 12:53 P.M. --G14's bed call light alarmed for 22 min and 23 sec starting at 12:54 P.M. --H13's bed call light alarmed for 19 min and 28 sec starting at 12:55 P.M. --A3'd bed call light alarmed for 17 min and 35 sec starting at 1:10 P.M. --C2's bed call light alarmed for 21 min and 59 sec starting at 1:15 P.M. --A3's bed call light alarmed for 17 min and 35 sec starting at 1:27 P.M. --B1's bed call light alarmed for 15 min and 15 sec starting at 1:28 P.M. --C2's bed call light alarmed for 16 min and 55 sec starting at 2:07 P.M. --H8's bed call light alarmed for 19 min and 2 sec starting at 2:27 P.M. --H8's bed call light alarmed for 19 min and 2 sec starting at 2:45 P.M. --B8's bed call light alarmed for 20 min and 52 sec starting at 2:51 P.M. --B8's bathroom call light alarmed for 19 min and 54 sec starting at 2:57 P.M. --C7's bed call light alarmed for 42 min and 15 sec starting at 2:59 P.M. --F2's bed call light alarmed for 17 min and 18 sec starting at 3:11 P.M. --B8's bed call light alarmed for 20 min and 52 sec starting at 3:12 P.M. --B1's bed call light alarmed for 26 min and 48 sec starting at 3:13 P.M. --B8's bathroom call light alarmed for 19 min and 54 sec starting at 3:17 P.M. --H3's bed call light alarmed for 20 min and 56 sec starting at 3:41 P.M. --H13's bed call light alarmed for 21 min and 5 sec starting at 4:00 P.M. --H3's bed call light alarmed for 20 min and 56 sec starting at 4:02 P.M. --C2's bed call light alarmed for 16 min and 55 sec starting at 4:54 P.M. --C8's bed call light alarmed for 18 min and 3 sec starting at 5:14 P.M. --B8's bed call light alarmed for 19 min and 32 sec starting at 6:31 P.M. --F6's bed call light alarmed for 17 min and 48 sec starting at 6:33 P.M. --F6's bed call light alarmed for 17 min and 48 sec starting at 6:51 P.M. --C2's bed call light alarmed for 15 min and 10 sec starting at 6:54 P.M. --C2's bed call light alarmed for 15 min and 10 sec starting at 7:09 P.M. --A7's bed call light alarmed for 22 min and 54 sec starting at 7:11 P.M. --H13's bed call light alarmed for 21 min and 5 sec starting at 7:30 P.M. --B8's bed call light alarmed for 19 min and 32 sec starting at 8:31 P.M. --A2's bed call light alarmed for 20 min and 58 sec starting at 8:47 P.M. --C7's bed call light alarmed for 15 min and 15 sec starting at 8:49 P.M. --F6's bed call light alarmed for 19 min and 18 sec starting at 8:58 P.M. --G14's bed call light alarmed 20 min and 17 sec starting at 8:59 P.M. --C7's bed call light alarmed for 15 min and 15 sec starting at 9:05 P.M. --A2's bed call light alarmed for 20 min and 58 sec starting at 9:08 P.M. --F6's bed call light alarmed for 19 min and 18 sec starting at 9:17 P.M. --C2's bed call light alarmed for 16 min and 6 sec starting at 10:20 P.M. --A2's bed call light alarmed for 15 min and 16 sec starting at 10:25 P.M. --A2's bed call light alarmed for 15 min and 15 sec starting at 10:40 P.M. -On 1/21/24, room: --D1's bed call light alarmed for 17 min and 14 sec starting at 12:52 A.M. --D1's bed call light alarmed for 17 min and 14 sec starting at 1:09 A.M. --A5's bed call light alarmed for 19 min and 16 sec starting at 2:34 A.M. --A5's bed call light alarmed for 19 min and 16 sec starting at 2:53 A.M. --F8's bed call light alarmed for 16 min and 30 sec starting at 3:42 A.M. --F5's bed call light alarmed for 21 min and 46 sec starting at 5:25 A.M. --F2's bed call light alarmed 20 min and 36 sec starting at 5:28 A.M. --F5's bed call light alarmed for 21 min and 46 sec starting at 5:47 A.M. --F2's bed call light alarmed 20 min and 36 sec starting at 5:48 A.M. --A5's bed call light alarmed for 16 min and 44 sec starting at 7:42 A.M. --A5's bed call light alarmed for 16 min and 44 sec starting at 7:59 A.M. --B8's bed call light alarmed for 25 min and 46 sec starting at 8:03 A.M. --C1's bed call light alarmed for 15 min and 40 sec starting at 8:32 A.M. --C1's bed call light alarmed for 15 min and 40 sec starting at 8:47 A.M. --F6's bed call light alarmed for 21 min and 59 sec starting at 9:13 A.M. --F6's bed call light alarmed for 21 min and 59 sec starting at 9:35 A.M. --D4's bed call light alarmed for 19 min and 55 sec starting at 9:36 A.M. --G5's bathroom call light alarmed for 16 min and 24 sec starting at 9:52 A.M. --A5's bed call light alarmed for 25 min and 34 sec starting at 10:00 A.M. --G5's bathroom call light alarmed for 16 min and 24 sec starting at 10:09 A.M. --B1's bed call light alarmed for 24 min and 53 sec starting at 10:33 A.M. --C6's bed call light alarmed for 16 min and 6 sec starting at 10:37 A.M. --H13's bed call light alarmed for 15 min and 32 sec starting at 10:47 A.M. --C6's bed call light alarmed for 16 min and 6 sec starting at 10:53 A.M. --D8's bed call light alarmed for 17 min and 18 sec starting at 11:05 A.M. --H9's bed call light alarmed for 26 min and 45 sec starting at 11:09 A.M. --C7's bed call light alarmed for 18 min and 38 sec starting at 11:15 A.M. --D4's bed call light alarmed for 19 min and 55 sec starting at 11:26 A.M. --F2's bed call light alarmed for 17 min and 14 sec starting at 11:35 A.M. --H5's bed call light alarmed for 20 min and 10 sec starting at 11:42 A.M. --B8's bed call light alarmed for 25 min and 46 sec starting at 11:48 A.M. --H5's bed call light alarmed for 20 min and 10 sec starting at 12:02 P.M. --C2's bed call light alarmed for 22 min and 23 sec starting at 12:02 P.M. --H13's bed call light alarmed for 15 min and 32 sec starting at 12:43 P.M. --D8's bed call light alarmed for 17 min and 18 sec starting at 12:52 P.M. --A3's bed call light alarmed for 16 min and 48 sec starting at 1:08 P.M. --A3's bed call light alarmed for 16 min and 48 sec starting at 1:25 P.M. --F13's bed call light alarmed for 21 min and 20 sec starting at 1:30 P.M. --D6's bed call light alarmed for 19 min and 28 sec starting at 1:31 P.M. --D8's bed call light alarmed for 20 min and 0 sec starting at 1:32 P.M. --A9's bed call light alarmed for 17 min and 41 sec starting at 1:37 P.M. --D6's bed call light alarmed for 19 min and 28 sec starting at 1:51 P.M. --F13's bed call light alarmed for 21 min and 20 sec starting 1:51 P.M. --D8's bed call light alarmed for 20 min and 0 sec starting at 1:52 P.M. --A9's bed call light alarmed for 17 min and 41 sec starting at 1:55 P.M. --C7's bed call light alarmed for 18 min and 38 sec starting at 2:24 P.M. --F2's bed call light alarmed for 17 min and 14 sec starting at 2:33 P.M. --D8's bed call light alarmed for 21 min and 36 sec starting at 3:44 P.M. --G3's bed call light alarmed for 21 min and 26 sec starting at 3:59 P.M. --D8's bed call light alarmed for 21 min and 36 sec starting at 4:06 P.M. --G3's bed call light alarmed for 21 min and 26 sec starting at 4:20 P.M. --F13's bed call light alarmed for 22 min and 5 sec starting at 4:27 P.M. --A5's bed call light alarmed for 21 min and 54 sec starting at 5:27 P.M. --A5's bed call light alarmed for 21 min and 54 sec starting at 5:49 P.M. --A5's bed call light alarmed for 19 min and 53 sec starting at 6:33 P.M. --A6's bed call light alarmed for 20 min and 54 sec starting at 6:33 P.M. --A5's bed call light alarmed for 19 min and 53 sec starting at 6:53 P.M. --F5's bed call light alarmed for 40 min and 14 sec starting at 6:53 P.M. --A6's bed call light alarmed for 20 min and 54 sec starting at 6:54 P.M. --D7's bed call light alarmed for 18 min and 48 sec starting at 7:21 P.M. --F6's bed call light alarmed for 22 min and 44 sec starting at 9:39 P.M. --H13's bed call light alarmed for 16 min and 1 sec starting at 9:58 P.M. --F6's bed call light alarmed for 22 min and 44 sec starting at 10:02 P.M. --H13's bed call light alarmed for 16 min and 1 sec starting at 10:14 P.M. --B2's bed call light alarmed for 23 min and 17 sec starting at 10:16 P.M. --D7's bed call light alarmed for 18 min and 48 sec starting at 10:26 P.M. -On 1/22/24, room: --H13's bed call light alarmed for 16 min and 51 sec starting at 1:50 A.M. --C5's bed call light alarmed for 15 min and 50 sec starting at 4:31 A.M. --C5's bed call light alarmed for 15 min and 50 sec starting at 4:47 A.M. --A5's bed call light alarmed for 25 min and 3 sec starting at 5:52 A.M. --C10's bed call light alarmed for 19 min and 5 sec starting at 5:52 A.M. --C10's bed call light alarmed for 19 min and 5 sec starting at 6:11 A.M. --H8's bed call light alarmed for 16 min and 5 sec starting at 6:24 A.M. --B1's bed call light alarmed for 23 min and 51 sec starting at 7:22 A.M. --F5's bed call light alarmed for 15 min and 33 sec starting at 7:29 A.M. --A5's bed call light alarmed for 15 min and 54 sec starting at 7:42 A.M. --F5's bed call light alarmed for 15 min and 33 sec starting at 7:44 A.M. --H9's bed call light alarmed for 21 min and 23 sec starting at 8:29 A.M. --H9's bed call light alarmed for 21 min and 23 sec starting at 8:50 A.M. --H7's bed call light alarmed for 18 min and 59 sec starting at 10:13 A.M. --H7's bed call light alarmed for 16 min and 48 sec starting at 11:27 A.M. --F2's bed call light alarmed for 19 min and 44 sec starting at 12:26 P.M. --F2's bed call light alarmed for 19 min and 44 sec starting at 12:46 P.M. --F5's bed call light alarmed for 24 min and 30 sec starting at 1:31 P.M. --A3's bed call light alarmed for 19 min and 49 sec starting at 2:22 P.M. --G14's bed call light alarmed for 22 min and 5 sec starting at 2:35 P.M. --H10's bed call light alarmed for 15 min and 14 sec starting at 2:36 P.M. --G14's bed call light alarmed for 22 min and 5 sec starting at 2:58 P.M. --A3's bed call light alarmed for 19 min and 49 sec starting at 4:21 P.M. --F5's bed call light alarmed for 24 min and 40 sec starting at 5:02 P.M. --H10's bed call light alarmed for 24 min and 6 sec starting at 5:07 P.M. --D1's bed call light alarmed for 18 min and 54 sec starting at 5:13 P.M. --H5's bed call light alarmed for 20 min and 25 sec starting at 5:57 P.M. --B2's bed call light alarmed for 16 min and 2 sec starting at 6:04 P.M. --B1's bed call light alarmed for 16 min and 30 sec starting at 6:04 P.M. --B6's bed call light alarmed for 18 min and 24 sec starting at 6:26 P.M. --C2's bed call light alarmed for 17 min and 44 sec starting at 6:41 P.M. --G14's bed call light alarmed for 17 min and 19 sec starting at 6:55 P.M. --H8's bed call light alarmed for 17 min and 24 sec starting at 7:10 P.M. --D1's bed call light alarmed for 18 min and 54 sec starting at 7:11 P.M. --G14's bed call light alarmed for 17 min and 19 sec starting at 7:12 P.M. --C8's bed call light alarmed for 16 min and 3 sec starting at 7:22 P.M. --H8's bed call light alarmed for 17 min and 24 sec starting at 7:27 P.M. --D4's bed call light alarmed for 26 min and 13 sec starting at 7:43 P.M. --D4's bed call light alarmed for 26 min and 13 sec starting at 8:09 P.M. --C2's bed call light alarmed for 22 min and 24 sec starting at 8:32 P.M. --C1's bed call light alarmed for 22 min and 55 sec starting at 8:58 P.M. --C1's bed call light alarmed for 22 min and 55 sec starting at 9:21 P.M. --D8's bed call light alarmed for 15 min and 16 sec starting at 10:39 P.M. --D8's bed call light alarmed for 15 min and 16 sec starting at 10:54 P.M. --D5's bed call light alarmed for 15 min and 21 sec starting at 11:10 P.M. --D5's bed call light alarmed for 15 min and 21 sec starting at 11:26 P.M. --H13's bed call light alarmed for 25 min and 6 sec starting at 11:39 P.M. Review of the Facility Assessment Tool, dated 1/23/24, showed: -An average daily census of 120 residents. -An average of two residents admitted per weekend. -An average census of 32 residents on the rehabilitation (rehab) unit. -An average census of 84 residents on the long-term care unit. -121 residents required some to maximum assistance from staff for dressing. -121 residents required some to maximum assistance from staff for bathing. -94 residents required some to maximum assistance from staff for transferring. -100 residents required some to maximum assistance from staff for toileting. -109 residents spent most of their time in a chair. 2. Review of Resident #49's admission Minimum Data Set (MDS-a federally mandated assessment tool compleed by facility staff for care planning), dated 3/14/23, showed the resident was dependent on staff for toilet hygiene, showering, lower body dressing, and toilet transfers. Review of the resident's Quarterly MDS, dated [DATE], showed the resident: -Had moderate cognitive impairment. -Was occasionally incontinent of urine and frequently incontinent of bowel. During an interview on 1/23/24 at 10:31 A.M., the resident said he/she had soiled their brief, asked for staff assistance, and staff had refused. Continuous observation on 1/23/24 from 10:31 A.M. to 10:57 A.M. showed: -The resident used his/her call light for assistance at 10:31 A.M. -No staff were in the hallway. -No staff responded to the call light during this time. 3. Review of Resident #316's admission MDS, dated [DATE], showed the resident: -Was cognitively intact. -Was dependent on staff for toileting hygiene. -Was dependent on staff for lower body dressing. -Required moderate assistance to roll left and right. -Was occasionally incontinent (lack of the ability to control) of urine. -Was frequently incontinent of stool. Observation on 1/29/24 at 9:00 A.M. showed: -The resident was lying in bed flat on his/her back. -The resident's face was shiny and hair was disheveled. -The resident was in a hospital gown. During an interview on 1/29/24 at 9:00 A.M., the resident said: -He/she was uncomfortable and didn't feel well. -Staff had not transferred him/her out of the bed at any time on 1/28/24. -He/she had asked staff to get out of bed that morning but he/she was still waiting. During an interview on 1/29/24 at 10:41 A.M., the resident said he/she still wanted to get out of bed but was desperate for a urinal (a bottle for urination) as he/she felt he/she would burst. Observation on 1/29/24 at 10:41 A.M. showed: -The resident remained in bed lying flat on his/her back. -Physical Therapist (PT) A entered the room and gave the resident a urinal. -The resident asked PT A to get him/her out of bed; PT A said he/she would notify the care staff. Observation on 1/29/24 at 11:22 A.M. showed the resident remained in bed lying flat on his/her back. Observation on 1/29/24 at 11:57 A.M. showed the resident remained in bed lying flat on his/her back. Observation on 1/29/24 at 12:15 P.M. showed the resident remained in bed lying flat on his/her back. Observation on 1/29/24 at 12:54 P.M. showed the resident remained in bed lying flat on his/her back. Observation on 1/29/24 at 1:49 P.M. showed the resident remained in bed lying flat on his/her back. During an interview on 1/29/24 at 1:49 P.M., the resident said: -Staff had still not come to get him/her out of bed. -He/she had used his/her call light and asked several staff members to get out of bed. During an interview on 1/29/24 at 3:14 P.M., the resident said: -Staff had just got him/her out of bed and into his/her wheelchair. -Staff had refused to get him/her out of bed on 1/28/24 and told him/her to defecate in his/her brief and they would clean him/her afterward. Observation on 1/30/24 at 8:56 A.M. showed Certified Nursing Assistant (CNA) A was standing in the resident's room. During an interview on 1/30/24 at 8:56 A.M.: -CNA A said he/she was waiting for another staff member to assist him/her reposition the resident. -The resident said he/she was not able to turn side to side without help. Observation on 1/30/24 at 8:57 A.M. showed: -CNA A returned to the resident's room with the Staffing Coordinator. -The two staff members rolled the resident and removed his/her brief. During an interview on 1/30/24 at 10:47 A.M.: -CNA A said the resident had not needed his/her brief changed at all that day. -The resident said he/she started feeling pain on his/her tailbone on 1/28/24 but couldn't see back there. -The resident said he/she had urinated in his/her brief while waiting for the urinal earlier that morning because he/she couldn't wait any longer. -Licensed Practical Nurse (LPN) A told CNA A that the resident's brief was wet and had soaked through to the resident's pants. -LPN A said he/she was first told about the wound on the resident's buttocks that day. 4. During an interview on 1/24/24 at 2:47 P.M., CNA A said sometimes there was not enough staff to complete resident cares. During an interview on 1/24/24 at 3:06 P.M., LPN E said he/she felt the facility was understaffed. During an interview on 1/25/24 at 6:45 A.M., CNA S said: -There was supposed to be one CNA per hall at night. -There were only three CNAs working the long-term unit (halls A, B, C, and D) the previous night and they all had to assist with D hall as there was no CNA assigned. -He/she did not feel like there was enough staff. -Management had never had a conversation with him/her about staffing. -When staff did not come to work, management did not always find a replacement, so they worked short-staffed. -The rehabilitation units needed additional CNAs because those residents required a lot of assistance. During an interview on 1/25/24 at 6:45 A.M., CNA H said: -He/she had approximately 23-24 residents assigned to him/her each night. -Approximately half of those needed assistance with cares and transfers. -There were two to three CNAs scheduled to cover four halls at night. -When providing cares, it frequently took 30 minutes to complete and he/she could not answer any other call lights during that time. During an interview on 1/26/24 at 9:21 A.M., CNA M said: -There were 25 residents on his/her assigned hall. -Approximately 18-20 residents on his/her hall were incontinence and 9-10 residents required the use of a mechanical lift. -Some resident cares took 45 minutes to complete and he/she could not answer call lights during that time. -He/she has had residents that waited 45 minutes to an hour for help because he/she was busy with another resident. -He/she felt overwhelmed with the workload. -He/she had talked to management but nothing had changed in regard to staffing. -When he/she required assistance, he/she had to leave his/her assigned hall to find someone to help. During that time, no other staff member covered his/her hall or monitored the residents. -He/she was to perform four baths a night but he/she believed it impossible. -It took him/her approximately 20 minutes to give a shower and during that time no one was watching the residents on his/her assigned hall. -Other staff would occasionally find him/her while he/she was providing cares and say a call light has been on for a long time but they won't answer the call light themselves. During an interview on 1/26/24 at 10:25 A.M., the Director of Nursing (DON) said if a CNA does not come to work, the residents they were assigned to care for are split up among the rest of the CNAs. During an interview on 1/29/24 at 11:01 A.M., the Staffing Coordinator said: -He/she was not sure how many residents required a full body mechanical lift. -A full body mechanical lift required two staff members to operate. -When a mechanical lift was needed, the CNAs were to get a CNA from another hall to assist. -The facility frequently had only three CNAs for halls A, B, C, and D because of call-ins. During an interview on 1/29/24 at 11:01 A.M., the DON said he/she frequently received complaints about lack of staffing on nights and weekends but that was normal. During an interview on 1/30/24 at 8:24 A.M., PT C said: -He/she was occasionally asked to help with resident cares outside of therapy sessions due to staffing issues. -Therapists frequently found residents in soiled briefs when they went to get them for their therapy appointment. -Therapists would assist the residents in personal hygiene and brief changing prior to starting the therapy session. During an interview on 1/30/24 at 9:28 A.M., Certified Medication Technician (CMT) E said: -He/she was always late passing medications because they are all due at the same time. -He/she would try to assist a resident with their call light on but frequently cannot as he/she was responsible for passing medication timely. During an interview 1/30/24 at 10:10 A.M., CNA G said: -He/She was working on the A hall by himself/herself. -He/She usually transferred the residents using the full body lift by himself/herself because there was usually no one available to assist him/her to transfer the resident. -There was not enough staff to be able to transfer residents that need a full body lift with two people. -There were four to five residents on the hall that need a full body lift to transfer. -He/She was aware that they were supposed to have two persons to transfer residents using a full body lift. -He/She transferred the resident because the resident was ready to lay down and needed incontinence care and he/she could not find anyone to help him/her. Observation on 1/30/24 at 10:47 A.M showed the Administrator in Training (AIT) and Staffing Coordinator were passing breakfast on the F hall. During an interview on 1/30/24 at 11:31 A.M., the Staffing Coordinator said: -Therapy helped tre

Based on observation, interview, and record review, the facility failed to ensure staffing sheets were posted daily, visible, and accessible to residents and visitors at the beginning of each shift including facility name, date, census, and the total number and actual hours worked per shift which could have the potential to affect all residents in the facility. The facility census was 122 residents. Review of the facility's policy, dated April 2023, titled Posting of Nursing Hours showed: -Each day staff were to post, at the facility entrance, the number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) scheduled; the name of the facility; the census of the facility; and the total number of hours for each position. -Staff were to post the staffing sheet to be accessible for residents, family members, and visitors. -Staff were to instruct residents on the location of the daily staffing sheet at admission. 1. Observation on 1/23/24 at 11:25 A.M. showed: -No staffing sheet was posted at the main entrance. -One staffing sheet was found in the facility; located on the F hall, dated 10/12/23. Observation on 1/24/24 at 10:45 A.M. showed no staffing sheet was posted at the main entrance. Observation on 1/24/24 at 3:23 P.M. showed: -The staffing sheet was filled out vertically but posted horizontally making it difficult to read. -The staffing sheet was posted to the left and behind the receptionist. During an interview on 1/26/24 at 10:25 A.M., the Director of Nursing (DON) said the staffing coordinator was responsible for posting daily staffing sheets. During an interview on 1/26/24 at 2:44 P.M., Family Member A said: -He/she had no idea how many staff or residents were in the building. -He/she had never seen any staff posting. Observation on 1/29/24 at 11:15 A.M. showed: -The staff posting was to the left and approximately one and a half feet behind the receptionist. -The posting was not able to be read when standing at the receptionist's desk. During an interview on 1/29/24 at 12:25 P.M., Family Member B said he/she had never seen any posting showing how many residents or staff were in the building.

Based on observation, interview, and record review, the facility failed to ensure appropriate medication storage throughout the entire facility which had the potential to affect all residents within the facility. The facility census was 122 Residents. Review of the facility's policy titled Medication Storage dated January 2020 showed: -All drug containers will be labeled, and drug labels must be clear, consistent, legible and in compliance with state and federal requirements. -Each prescription medication label includes: --Resident's name. --Specific direction for use, indicating route of administration. --Medication name. --Strength of medication. --Physician's name. --Date medication was dispensed. --Quantity. --Expiration date if medication not used within 24 hours. --Expiration time if medication expires in less than 24 hours. -- Name, address, and telephone number of provider pharmacy. --Prescription number. -Upon opening of insulin pens, the licensed nurse will write the date of expiration. -Nonprescription medications not labeled by the pharmacy are kept in the manufacturer's original container. -Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels are returned to the issuing pharmacy for relabeling or destroyed in accordance with the medication destruction policy. Review of the facility's policy titled Administration of Medications dated April 2023 showed: -Staff were never to leave the medication cart unlocked and unattended. -Staff were to return the locked medication cart to the nurse's station once the medication pass was completed. Review of the facility's policy titled Refrigeration Medication Storage dated June 2023 showed: -The facility will assure that medication refrigerators and freezers are clean, contents are properly stored, and the temperatures are monitored in accordance with all state and federal regulations. -An accurately calibrated thermometer or digital probe will be kept in each refrigerator and freezer at all times. -Separate temperature logs will be maintained for each refrigerator. -If temperatures register above or below the appropriate range, all stored items will be removed, the viability of the items stored will be determined and non-viable items will be discarded. 1. Observation on 1/26/24 at 8:54 A.M. of the C and D halls Nurse Cart showed: -One bottle of Docusate Sodium (Colace- stool softener) with an expiration date of September 2023. -One bottle of Enteric Coated (designed to resist dissolving and being absorbed in the stomach) Aspirin (pain reducer) with an expiration date of December 2023. -45 free-standing pills scattered in one compartment of the cart. During an interview on 1/26/24 at 9:05 A.M. Agency Licensed Practical Nurse (LPN) A said: -He/She had only been at the facility once before. -It was his/her first day assigned to C and D halls Nurse Cart. -He/She would destroy all the expired medications with Assistant Director of Nursing (ADON) B once finished with the medication cart check. Observation on 1/26/24 at 9:06 A.M. of the C and D halls Nurse Cart showed a bottle of Ammonium Lactate 12% (used to treat dry skin) with no open date and the expiration date could not be found. 2. Observation on 1/26/24 at 9:30 A.M. showed heparin (a blood thinner) was stored in one of the drawers at the Long-Term Care nurse's station. 3. Observation on 1/26/24 at 9:46 A.M. of Medication Room C showed: -One bottle of Ocular Vitamins (helps with maintenance of eye health) with an expiration date of October 2023. -Three bottles of Enteric Coated Aspirin with an expiration date of October 2023. -One bottle of Docusate Sodium with an expiration date of September 2023 -One box of Acetaminophen (Tylenol- pain reliever and fever reducer) Suppositories (medication that is inserted into the rectum to dissolve) with an expiration date of June 2023. 4. Observation on 1/26/24 at 10:12 A.M. of Medication Room F showed: -Ferrex 150 polysaccharide-iron complex (used to prevent and/or treat iron deficiencies) with an expiration date of September 2023. Observation on 1/26/24 at 10:22 A.M. of Medication Room F showed: -One packet of Cholestyramine for Oral Suspension (used to lower high cholesterol) with an expiration date of February 2020. -One box of Ipratropium Bromide (used to help control the symptoms of lung diseases) and Albuterol Sulfate (used to prevent bronchospasm (when the muscles that line the bronchi tighten) for people with lung diseases) Inhalation Solution with an expiration date of December 2022. -One box of Ipratropium Bromide and Albuterol Sulfate Inhalation Solution with an expiration date of December 2023. -One package of Ipratropium Bromide and Albuterol Sulfate Inhalation Suspension with an expiration date of January 2023. -One 250 milliliter (ml) bag of 0.9% Sodium Chloride Injection (used as a source of electrolytes and water for hydration) with an expiration date of July 2023. -One bottle of Sucralfate Oral Suspension (used to treat and prevent duodenal (the first part of the small intestine) ulcers) without a resident name and specific direction for use on the medication label. -One bottle of Enulose (Lactulose Solution- used to prevent complications of liver disease) without resident name, specific direction for use, Physician's name, and name, address, telephone number of the provider pharmacy on the label. -An Intravenous (IV) Administration Set with an expiration date of March 2023. -A Secondary IV Administration Set with an expiration date of March 2023. -A Heparin lock flush (used to keep IV catheters open and flowing freely) with an expiration date of April 2023. 5. Observation on 1/26/24 at 10:43 A.M. of the medication refrigerator in Medication Room F showed: -There was no thermometer in the refrigerator. -A 250 ml bag of Ampicillin/Sulbactam (an antibiotic used to treat bacterial infections) that was frozen. NOTE: No other medications were frozen at that time, but there were multiple medications stored in the refrigerator. Observation on 1/30/24 at 10:09 A.M. of the medication refrigerator in Medication Room F showed there was no thermometer in the refrigerator. Observation on 1/30/24 at 10:33 A.M. of the Medication Room F temperature log showed: -The most recent temperature taken was on 1/28/24. -The temperature that was recorded on 1/28/24 was 39 degrees F. Observation on 1/30/24 at 10:48 A.M. of the medication refrigerator in Medication Room F showed the temperature of the refrigerator at that time was 47 degrees F that had been taken by the SA. 6. Observation on 1/26/24 at 12:57 P.M. of the G and F halls Medication Cart showed one box of Acetaminophen Suppositories with an expiration date of June 2023. 7. During an interview on 1/26/24 at 12:57 P.M. the Assistant Director of Nursing (ADON) A said: -There was a temperature log for the medication refrigerator in Medication Room F. -He/She was unsure why there was a froze antibiotic in the refrigerator. -He/She was unsure where the thermometer went that was supposed to be in the refrigerator. Observation on 1/26/24 at 1:00 P.M. of the Medication Room F temperature log showed: -The most recent temperature taken was on 1/26/24. -The temperature that was recorded on 1/26/24 was 39 degrees Fahrenheit (F). 8. Observation on 1/26/24 at 1:10 P.M. of H and E halls Nurse Cart showed: -One Basaglar (Insulin Glargine- a long-acting insulin used to treat diabetes) Kwikpen that had been opened on 1/13/24 with no expiration date or initials of who opened the pen. -Two Humalog (Insulin Lispro- a short-acting insulin used to treat diabetes) Kwikpen that had been opened on 1/13/24 with no expiration date or initials of who opened the pen. -Four free-standing pills scattered in the top drawer of the medication cart. -One bottle of Enteric Coated Aspirin with an expiration date of October 2023. -One bottle of Famotidine (Pepcid- an antacid used to treat heartburn or Gastroesophageal Reflux Disease (GERD)) with an expiration date of September 2023. -One bottle of Muli-Vitamins with an expiration date of October 2023. -One bottle of Bisacodyl (Dulcolax- a laxative) with an expiration date of September 2023. -One 473 ml bottle of Hydrogen Peroxide 3% (an antiseptic used to prevent infection in minor cuts, scrapes, or burns) with an illegible month for the expiration date but had expired in 2022. 9. Observation on 1/23/24 at 11:44 A.M. showed: -A medication cart in the hallway facing away from the nurse's desk was unlocked. -The staff member assigned to the medication cart was in a resident room, out of view of the cart. -Two drawers of the medication cart were partially open, and medication could be seen to anyone passing by. -Multiple, unidentified, pills were laying on top of the cart. 10. During an interview on 1/30/24 at 1:40 P.M., Certified Medication Technician (CMT) D said: -Medication carts were to be locked any time staff was not present. -If staff walked by an unlocked medication cart, he/she expected them to lock the cart or stay with it until the CMT returned. During an interview on 1/30/24 at 2:38 P.M., Licensed Practical Nurse (LPN) D said: -Medication carts were to be locked any time staff was not with them. -It was important the medication carts be locked because anyone could get into them and tamper with or steal medication. During an interview on 1/31/24 at 9:18 A.M. CMT C said: -There was an audit completed of the medication carts and medication rooms completed every 30 days. -The facility's pharmacy was responsible for the audits. -There should not be expired medications in the medication carts, nurse carts, or medication rooms. -There should not be any free-standing pills in the medication carts or nurse carts. -Medication carts should always be locked when unattended for resident safety. -The night shift was responsible for taking refrigerator temperatures. -Temperatures of all refrigerators were recorded every night. -He/She was unsure how the refrigerator in Medication Room F was being properly monitored without a thermometer in the refrigerator. -Medications should never be stored at the nurse's station. -Once an insulin pen was opened, the pen should have an expiration date labeled on it. -If he/she found any insulin pen that did not have an expiration date labeled on it, then the insulin pen would need to be replaced. During an interview on 1/31/24 at 9:53 A.M. Assistant Director of Nursing (ADON) A said: -The medication carts, nurse carts, and medication rooms were monitored every week. -He/She was responsible for checking all the medication carts, nurse carts, and medication rooms within his/her unit. -The CMTs and nurses could also check the medication carts. -There should not be expired medications in the medication carts, nurse carts, or medication rooms. -Any expired medication would need to be properly disposed. -There should not be any free-standing pills in the medication carts or nurse carts. -Any free-standing pills would need to be properly disposed. -When the medication carts or nurse carts are unattended, they should be locked for resident safety. -Medications should not be stored at the nurse's station. -All insulin pens should have a written expiration date once opened. During an interview on 1/31/24 at 10:00 A.M. LPN B said: -The refrigerator temperatures are checked every night shift. -Night shift was responsible for taking the temperatures of the refrigerators. -He/She was unsure how the temperature could be accurately recorded for the medication refrigerator in Medication Room F if there was not a thermometer in the refrigerator. -He/She had not needed to get into that refrigerator recently, so he/she was unsure if there had been an issue with the temperature. -If he/she saw a frozen antibiotic in the refrigerator, he/she would make the ADON and pharmacy aware of it. During an interview on 1/31/24 at 1:17 P.M. the Director of Nursing (DON) said: -Medication carts and medication rooms were to be checked every night, on night shift. -The night shift was responsible for pulling all the discharged resident's medications and checking the expiration dates of medications. -There should not be any expired medications in the medication carts, nurse carts, or medication rooms. -There should not be any free-standing medication in the medication carts or nurse carts. -The medication carts and nurse carts were to be locked when unattended, for resident safety. -The refrigerator temperatures were recorded once a day. -Night shift was responsible for checking the refrigerator temperatures. -The ADONs were responsible for ensuring the temperatures for the refrigerators were recorded daily. -The medication refrigerator in Medication Room F had recently been defrosted. -He/She had told staff to not use the refrigerator while it was being defrosted. -He/She was the one who told the staff to defrost the refrigerator. -He/She had instructed staff that a thermometer was needed to be placed back into the refrigerator once defrosted and to ensure the refrigerator was between 36- and 46-degrees F before the refrigerator could be used again. -They had issues in the past with the refrigerator. -He/She expected staff to put an open date, expiration date, and their initials when opening an insulin pen. -He/She would expect staff to check that an expiration date was labeled on the insulin pen.

Based on observation and interview, the facility failed to maintain the floors under the automated dishwasher free of broken dishes, grime and debris; failed to prevent a buildup of dust on the fan blades in the dishwasher area; failed to repair a leak from one of the sinks of three-compartment sink across form the food preparation table; failed to maintain the floor under the convection oven and the six-burner stove keeping it free of grease, grime and food debris; failed to ensure there was an air gap (the unobstructed vertical space between the water outlet and the flood level of a fixture) between the drainage pipe from the ice machine and the drainage hole in the floor; failed to ensure the mops and brooms were stored properly in the mop closet; failed to ensure three light fixtures in the kitchen area illuminated; failed to remove food debris from the upper nozzles of the automated dishwasher; failed to ensure two of three cutting boards were free from numerous nicks and grooves; failed to remove dust from the ceilings over the food preparation area; failed to ensure a bottle of sweet and sour sauce was refrigerated after opening according to the label; and failed to ensure the gasket (a flat piece of soft material or rubber that is put between two joined metal surfaces to prevent gas, oil, or steam from escaping ) in the door to the walk-in fridge was in good repair. This practice potentially affected 119 residents who ate food from the kitchen. The facility census was 122 residents. 1. Observation on 1/23/24 from 10:39 A.M. through 11:07 A.M., during the initial kitchen observations, showed: -The presence of grime and debris under the dishwasher station. -A buildup of dust on the fan blades in the dishwasher area. -A steady leak from the washing sink of the three-compartment sink. -Grime and debris under the six-burner stove and the convection oven. -Mops and brooms not stored properly in mop storage room there was a dustpan with dust. -The lack of an air gap between drainage pipe from ice machine and the drainage hole in the floor. -Two light fixtures over the serving table not illuminated. -The presence of food debris in the upper nozzles of the automated dishwasher. -A heavy buildup of dust on the ceiling in the dishwashing area and the food serving area. -Peeling paint on ceiling vent above 3 compartment sink. -A broken gasket on the walk-in fridge door. During an interview on 1/23/24 at 10:58 A.M., the Production Manager said those lights have not been working for about two weeks. During an interview on 1/23/24 at 11:02 A.M., Dietary [NAME] (DC) A said those ceiling lights have not illuminated for about a month and a half. 2. Observation on 1/25/24 at 12:40 P.M., showed the drainage pipe from the ice machine was inside the drainage hole in the floor next to the ice machine. During an interview on 1/25/24 at 12:41 P.M. the Dietary Manager (DM) said he/she could place something under the drainage pipe from the ice-machine to raise the pipe up so that it would not be inside the drainage hole in the ground. 3. Observation on 1/29/24 from 6:36 A.M. to 8:22 A.M. during the breakfast meal preparation showed: -The presence of grime and debris under the dishwasher station. -A buildup of dust on the fan blades in the dishwasher area. -A steady leak from the washing sink of the three-compartment sink. -Grime and debris under the six-burner stove and the convection oven. -Mops and brooms not stored properly in mop storage room there was a dustpan with dust. -The lack of an air gap between drainage pipe from ice machine and the drainage hole in the floor. -Two light fixtures over the serving table not illuminated. -The presence of food debris in the upper nozzles of the automated dishwasher. -A heavy buildup of dust on the ceiling in the dishwashing area and the food serving area. -Peeling paint on ceiling vent above 3-compartment sink. -A broken gasket on walk-in fridge door. During an interview on 1/29/24 at 6:47 A.M. the DM said the night shift dietary crew should take apart the dishwashing machine on a nightly basis and the night shift crew said the night shift dietary crew have not been performing their duties as they should have been. During an interview on 1/29/24 at 6:53 A.M., the Production Manager (PM) said the leak originated from the pipe. During an interview on 1/29/24 at 6:54 A.M., the DM said the leak came from the sink and needed to be repaired. During an interview on 1/29/24 at 7:05 A.M., the PM said he/she took out the sweet and sour sauce bottle from the fridge a few days ago and just forgot to put it back in the fridge. During an interview on 1/29/24 at 10:16 A.M., the DM said the last time he/she cleaned the ceiling tiles, to remove dust, was November 2023. During an interview on 1/29/24 at 10:17 A.M., the DM said he/she notified the Maintenance Director about that the peeling paint from the vent cover a few months ago. During an interview on 1/29/24 at 10:10 A.M., the DM said he/she would teach the dietary staff to notice what a damaged cutting board looked like. 4. Observation on 1/30/24 at 9:10 A.M., showed the presence of food debris, French fries pieces, grease and dishes and condiment containers under the steam table. During an interview on 1/30/24 at 9:13 A.M., DC A said he/she did not know how often the dietary staff got under the deep fat fryer, the steam table and under the dishwasher to remove the food debris and grime.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of resident #367's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Encounter for Attention to Gastrostomy (needing care for a PEG tube). -Moderate Protein-Calorie Malnutrition. (lack of proper nutrition with at least two of the following characteristics: some muscle wasting, loss of subcutaneous fat, nutritional intake of less than 50% of recommended intake for one week, reduced functional capacity, or weight loss of one-two percent in one week, five percent in one month, seven and a half percent in three months). -Coronary Artery Disease (CAD- plaque build-up in the wall of the arteries that supply blood to the heart). -Personal history of Transient Ischemic Attack (TIA- a stroke like attack which may be warning sign of a future stroke). Review of the resident's POS dated January 2024 showed: -An order for Famotidine (Pepcid- used to treat heartburn caused by acid indigestion) 20 milligrams (mg), give one tablet via PEG tube two times a day for Gastroesophageal Reflux Disease (GERD- a digestive disease in which stomach acid or bile irritates the food pipe lining). -An order for Modafinil (Provigil- a wakefulness promoting agent) 200 mg give one tablet via PEG tube one time a day for hypersomnolence (excessive sleepiness). -An order for Clopidogrel Bisulfate (Plavix- a blood thinner) 75 mg give one tablet via PEG tube one time a day for blood thinner. Review of the resident's admission MDS dated [DATE] showed: -The resident had severely impaired cognition. -The resident had a feeding tube. -The resident received 51% or more of his/her nutrition through the feeding tube. Observation on 1/25/24 at 7:41 A.M. of the resident's PEG tube medication administration performed by Assistant Director of Nursing (ADON) A showed: -He/She sanitized his/her hands and entered the resident's room. -He/She set all supplies on a barrier and put on gloves, stopped the resident's tube feeding and disconnected it from the resident. -He/She measured the PEG tube and checked for residual (fluid/contents that remain in the stomach). -He/She then went to the resident's bathroom, touched the handle of the sink without removing his/her gloves or sanitizing/washing his/her hands and rinsed out the syringe. -He/She then walked back to the resident's bedside and mixed the medications with water with the same pair of gloves on. -He/She then flushed the resident's PEG tube, administered the medication, and flushed the PEG tube again with the same gloves on. -He/She then re-connected the tube feeding to the resident's PEG tube with the same gloves on. -He/She resumed the resident's tube feeding, removed his/her gloves, left the resident's room, and sanitized his/her hands. During an interview on 1/25/24 at 7:51 A.M., Assistant Director of Nursing (ADON) A said: -He/She would not have done anything different. -Hand hygiene should happen before and after medication administration. -He/She had not realized that he/she had kept the same gloves on throughout the procedure. -He/She should have removed his/her gloves, used the sink, washed/sanitized his/her hands, and put new gloves on during the medication administration. During an interview on 1/31/24 at 9:58 A.M., Licensed Practical Nurse (LPN) B said: -Hand hygiene should be performed before and after medication administration. -Gloves should be worn during PEG tube medication administration. -The nurse did not perform hand hygiene appropriately. -The nurse should have removed his/her gloves before accessing the sink and sanitized/washed his/her hands and put on new gloves before returning the resident's bedside to complete the medication administration. During an interview on 1/31/24 at 1:17 P.M. the Director of Nursing (DON) said: -Hand hygiene should be performed before PEG tube medication administration and after completing the administration. -He/She would have expected the nurse to have removed his/her gloves before accessing the sink, sanitized/washed his/her hands, and put on new gloves before resuming the administration. 4. Review of Resident #319's Face Sheet showed he/she was admitted [DATE] with the following diagnoses: -Osteomyelitis (inflammation of the bone) of vertebra (small bones that form the spine), sacral (a triangular bone located at the base of the spine) and sacrococcygeal region (includes the sacral area and the tailbone). -Pressure Ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of the Right Buttock. -Pressure Ulcer of the Sacral Region (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity). -Local Infection of the Skin and Underlying Tissue. -Pressure Ulcer of the Left Buttock. Review of the resident's admission MDS, dated [DATE], showed the resident: -Was cognitively intact. -Had one Stage III pressure ulcer (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). -Had one Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunnelling). -Received antibiotics prior to admission and as a resident at the facility. Review of the resident's Wound Summary reports 1/23/24 showed: -A non-infected Deep Tissue Injury (DTI-purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shearing) of the left heel. -An infected Stage III pressure ulcer to the right buttock. -A non-infected DTI of the right heel. -An infected Stage IV pressure ulcer to the sacral area. Observation on 1/25/24 at 11:11 A.M. showed: -LPN A entered the resident's room and appropriately set up for the wound dressing process. -LPN A put on new gloves after sanitizing hands, removed the old wound dressings, removed gloves, sanitized hands, put on new gloves, and sprayed wound cleanser on two separate piles of gauze. -LPN A picked up one stack of gauze and cleaned the infected wound on the sacral area and threw away the gauze. -LPN A then picked up the other stack of gauze, with the same gloves used to clean the sacral wound, and cleaned the infected wound on the right buttock. -LPN A then removed his/her gloves, washed his/her hands, put on new gloves, and began placing the dressings on the wounds. -Once all wounds were covered, LPN A removed his/her gloves, put on new gloves without performing hand hygiene, and removed all the used supplies and placed them in the trash. -LPN A then removed his/her gloves, and without performing hand hygiene, put on new gloves to clean the resident's dresser with disinfectant. During an interview on 1/25/24 at 11:11 A.M., LPN A said: -There was nothing he/she would have done differently. -Staff were to always perform hand hygiene after removing their gloves. -He/She used a different gauze to clean each wound so he/she hadn't needed to change gloves between cleaning the infected wounds. 5. During an interview on 1/30/24 at 1:26 P.M., CNA E said staff were expected to perform hand hygiene before putting on gloves and after taking off gloves. During an interview on 1/30/24 at 1:40 P.M., Certified Medication Technician (CMT) E said staff were to perform hand hygiene every time they removed their gloves. During an interview on 1/30/24 at 2:38 P.M., LPN D said staff were expected to perform hand hygiene prior to putting on gloves and every time gloves were removed. During an interview on 1/31/24 at 9:08 A.M., CNA J said: -He/She would wash or sanitize his/her hands upon entering and exiting of the resident room, before touching the resident or his/her personal items. -He/She would complete frontal care, then remove gloves apply new gloves to finish incontinence care. -He/She would perform hand hygiene between each glove change. During an interview on 1/31/24 at 9:51 A.M., LPN C said: -Nursing staff, upon entering a resident room, should immediately wash their hands or use hand sanitizer unless their hands were visibly soiled. -Before providing any resident care (after washing or sanitizing their hands) they should put on gloves. -Nursing staff should remove their gloves and sanitize or wash their hands anytime their gloves become soiled, when going from a dirty to a clean task, after providing care, in between cares and after care was completed, before they left the resident's room. -Nursing staff should wash their hands and turn the water off with a paper towel, not with their hands. -He/She would expect nursing staff to remove their gloves and wash their hands after cleaning bowel movement. -Nursing staff should not leave their same gloves on throughout the resident's incontinence care and then provide additional assistance to the resident before removing their gloves and washing their hands. During an interview on 01/31/24 at 10:18 A.M., LPN C said he/she would perform hand hygiene before and after care, from a dirty to clean process and between each glove change. During an interview on 1/31/24 at 10:55 A.M., Infection Control Preventionist (ICP) said: -He/She would expect care staff to sanitize their hands then use soap and water to clean hands. -If hands were visibly soiled or touch bodily fluids, he/she would expect care staff to complete hand hygiene. -He/She would expect care staff to change gloves from a dirty to clean process. -He/She would expect glove change from one body part to other body part, During an interview on 1/31/24 at 12:40 P.M., the DON said: -He/She would expect care staff to perform hand hygiene before and during incontinence care or with catheter care. -He/She would expect hand hygiene between each glove change and from a dirty to clean process. -He/She would expect care staff to change their gloves when gloves were visually soiled during care. During an interview on 1/31/24 at 1:48 P.M., the DON said he/she expected hand hygiene to be performed any time a glove came off a hand. Based on observation, interview and record review the facility failed to ensure handwashing to prevent cross-contamination was completed prior to and during incontinence care for two sampled residents (Resident #90 and #69); failed to ensure appropriate hand hygiene was completed during medication administration for one sampled resident (Resident #367) with a Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube is passed into a resident's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate); and failed to ensure appropriate hand hygiene was completed during wound care for one sampled resident (Resident #319) out of 33 sampled residents. The facility census was 122 residents. Review of the facility's policy titled Administration of Medications via PEG Tube dated March 2023 showed no indication of when hand hygiene needed to be performed during the procedure. Review of the facility's policy titled Gloves dated April 2023 showed: -Gloves were worn when there was a chance of coming into contact with excretions, secretions, blood, body fluids, mucous membranes, non-intact skin, or other potentially infective material. -Hands should always be washed after removing gloves. -Gloves were a one-time use only item. Review of the facility's policy titled Hand Hygiene dated April 2023 showed: -The following were indications for handwashing: --When hands are visibly dirty or contaminated with proteinaceous material or were visibly soiled with blood or other body fluids. -The following were indications for Alcohol-Based Hand Rub (ABHR): --Before and after having direct contact with residents. --Before and after contact with a resident's intact skin such as when taking a pulse or blood pressure and transferring or repositioning a resident. --Before and after contact with inanimate objects including medical equipment in the vicinity of the resident. --After removing gloves. --Before and after medication administration. -Change gloves during resident care if moving from a contaminated body site to a clean body site. -Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before care for another resident. 1. Review of Resident #90's admission Record showed he/she had the following diagnoses: -History of sepsis (infection in blood). -Pressure injury/pressure ulcer (localized injury to the skin and/or underlying. tissue usually over a bony prominence, as a result of pressure. or pressure in combination with shear and/or friction). -Neurogenic bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). Review of the resident's Physician Order Sheet (POS) updated on 11/7/23 showed: -Had a physician's order for Indwelling catheter care every shift and as needed. -Had a diagnosis of neurogenic bladder and change Indwelling catheter as needed for leakage/blockage. -Record output for shift every shift. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 11/11/23 showed he/she: -Had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS, score of 8 - 12) score of 8. -Was admitted with a tube feeding (PEG tube) and indwelling catheter. -Was admitted with pressure ulcer. -Was dependent on facility staff for all cares. Observation on 1/30/24 at 11:38 A.M., of the resident's incontinence care and Indwelling catheter care showed: -Agency Certified Nursing Assistant (CNA) A sanitized his/her hands upon entering the resident's room and donned clean gloves. -He/She cleaned the resident's front perineal area. -With the same gloves Agency CNA A, had turned the resident to his/her left side with the bed draw sheet. -The resident had a large amount of soft brown bowel movement (BM). -Agency CNA A continued to clean the resident's bottom area. -The resident had an undated dressing on his/her coccyx area (tailbone, is at the very bottom of your spine) and had BM on the border of the dressing. Agency CNA A said he/she would inform the charge nurse after completing cares of the soiled wound dressing. -With the same soiled gloves, he/she had applied a clean brief under the resident, touching the resident with the contaminated gloves as he/she rolled onto his/her back. -He/She had removed soiled gloves and did not sanitize his/her hands prior to donning clean gloves on his/her hands. -Agency CNA A provided catheter care including wiping the tubing of the catheter. -With the same soiled gloves he/she touched the resident and attempted to roll the resident to his/her right side but was unable to do by himself/herself. -He/She removed gloves and without washing and/or sanitizing his/her hands, he/she touched the door handle, opened the door and left the resident room to get staff assistance. -Agency CNA A and another care staff member entered the resident's room and without washing or sanitizing their hands, both staff members donned new gloves on their hands and pulling on the draw sheet and touching the resident's upper body, rolled the resident to his/her right side. -Put on a clean brief, adjusted the brief under the resident and rolled the resident to his/her back. -Agency CNA A assisted the resident to a comfortable position. -With the same gloves, he/she drained the catheter bag of yellow urine into a graduate. -He/She emptied the urine in the toilet then threw away the graduate. -He/She gathered the trash with one gloved hand and took it out of the resident's room. He/She did not wash and/or sanitize his/her hands, touched the door handle to open the door, exited the room. -He/She dumped the trash in a container in the hallway, then sanitized his/her hands afterwards. During an interview on 1/30/24 at 12:00 P.M., Agency CNA A said: -He/She should have sanitized his/her hands upon entering and exiting the room. -He/She should have washed or sanitized his/her hands between each glove change and from the dirty to clean process. 2. Review of Resident #69's Face Sheet showed the resident was admitted on [DATE], with diagnoses including heart failure, difficulty walking, pain, muscle weakness, high blood pressure, oxygen dependency and kidney disease. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert with confusion. -Was dependent on bathing, dressing, was incontinent and mobilized in a wheelchair. -Was dependent on bed mobility and needed extensive assistance with transfers. Review of the resident's Care Plan dated 11/9/23, showed the resident had self-care deficits related to his/her diagnoses and required the physical assistance for incontinence care, bathing, dressing and transfers. Observation on 1/30/24 at 9:48 A.M., showed the resident was sitting in a specialized wheelchair with padding for positioning. CNA G brought clean linen into the resident's room and asked if he/she was ready to lay down and the resident said he/she was. Without washing or sanitizing his/her hands, CNA G put gloves on and began to wipe down the resident's mattress. He/She then left the resident's room to get a full body mechanical lift without de-gloving, washing or sanitizing his/her hands. He/She re-entered the resident's room at 9:51 A.M. and without washing or sanitizing his/her hands upon re-entering the resident's room, put the clean linen on the resident's bed. CNA G then: -Without washing or sanitizing his/her hands, he/she opened the base of the lift and pushed it up to the resident's chair, attached the sling to the lift then transferred the resident to his/her bed. -CNA G then disconnected the sling, moved the lift and assisted the resident to roll to the side to remove the sling from under the resident. -CNA G began to prepare the resident's incontinence supplies then removed the resident's soiled brief (that contained urine and bowel movement). -Once he/she was done cleaning the resident, CNA G took the soiled cloths and brief and discarded them in the trash. -Without removing his/her gloves or washing his/her hands, CNA G put a clean brief on the resident. -Using the same gloves, he/she then put the resident's pants back up and ensured the resident was comfortable and had no further need. -CNA G then lowered the resident's bed, raised the head of his/her bed, placed the resident's oxygen tubing back on the resident, then he/she de-gloved and washed his/her hands. -CNA G turned off the water with his/her hands, then dried them with a paper towel. -He/She placed the resident's call light within reach and put his/her tray table within the resident's reach before leaving the resident's room. During an Interview on 1/30/24 at 10:10 A.M., CNA G said: -When he/she first enters the resident's room, he/she was supposed to wash or sanitize his/her hands before putting on gloves. -He/She did not recognize that he/she had not sanitized his/her hands. -During incontinence care he/she would only de-glove, sanitize or wash his/her hands and re-glove if his/her gloves were soiled during the care, or if he/she had to leave the room. -He/She usually would de-glove and wash his/her hands when he/she was done providing incontinence care, before he/she left the resident's room.

Based on observation and interview, the facility failed to maintain the kitchen steam table (a type of food-holding equipment designed to keep hot foods at a safe holding temperature in high-volume businesses such as kitchens) in a safe operating manner by not maintaining one well (a section of the steam table) in a working manner. This practice potentially affected 119 residents who ate food from the kitchen. The facility census was 122 residents. 1. Observation on 1/23/24 at 10:53 A.M., during the initial kitchen observation, showed one well of the steam table well not operating due to the burner of that steam table not properly connected and loosely hanging under the steam table. During an interview on 1/25/24 at 12:38 P.M., the Dietary Manager (DM) said: - A service technician came to the facility back in 11/23 to work on the steam table. - That service technician said he/she could not work on the steam table because the wires were not connected properly and were all over. During a phone interview on 2/7/24 at 12:19 P.M., the Service Manager from the service company said: - He/She reviewed the technician's notes. - The service technician wrote that he/she would not service the steam table because the steam table was not safe, and the customer needed to replace the steam table As Soon As Possible (ASAP).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 11. Review of Resident #23's Face Sheet showed the resident was admitted on [DATE], with diagnoses including falls, high blood pressure, oxygen dependent, dysphagia (difficulty swallowing) chronic obstructive pulmonary disease (a condition involving constriction of the airways and difficulty or discomfort in breathing), hip fracture, depression, pain and nausea. Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning dated 1/9/24, showed the resident: -Was alert and oriented without any confusion. -Was dependent for bathing, dressing, toileting, hygiene and used a wheelchair for mobility. Review of the resident's Care Plan updated 1/22/24, showed the resident had a self-care performance deficit and limitations in physical mobility. Interventions showed the resident: -Was independent with eating and bed mobility. -Needed moderate assistance with sitting up and laying down. -Was dependent on staff for toileting, bathing, dressing and hygiene. -Needed maximum assistance with transferring. -It showed the resident used a wheelchair. Observation and interview on 1/23/24 at 11:17 A.M., showed the resident was laying in his/her bed with oxygen on at 2 liters. His/Her call light was within reach. The resident was alert and oriented and said: -He/she had been living here about a month after admitting from the hospital after a hip surgery from a fall at home. -He/she was in bed daily and did not get up. -Nursing staff provided all of his/her care, including bathing. -Nursing staff here was very nice, but sometimes he/she had to wait two to three hours for the call light to be answered. -He/she thought the facility had enough staff but that they were lazy. -He/she was unaware of how many (CNA) staff were assigned to the hall. 12. Review of Resident #96's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including respiratory failure, diabetes, kidney failure, obstructive sleep apnea (a sleep disorder in which breathing repeatedly stops and starts), bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), pain, high blood pressure and muscle weakness. Review of the resident's admission MDS dated [DATE], showed the resident: -Was alert and oriented without confusion. -Was dependent on staff for bathing, dressing, toileting, transferring, hygiene and used a wheelchair for mobility. Review of the resident's Care Plan dated 11/22/23, showed the resident self-care performance deficits and limitations in physical mobility related to chronic and acute conditions impacting her physical function and mobility. The care plan showed the resident will have support from staff to ensure daily care needs are met while promoting resident participation in care tasks as tolerated through review. Interventions showed: -The resident needed set up assistance with eating and oral hygiene. -Was dependent or required substantial assistance with bed mobility, sitting and laying, dressing, personal hygiene and toileting. -The resident needed maximum assistance with bathing. -The resident used a wheelchair. Observation and interview on 1/24/24 at 9:21 A.M., showed the resident was in bed sitting up with his/her call light and tray table within reach. The resident was alert and oriented and said: -He/she could not get up independently and he/she did not choose to get up out of bed most days. -When staff provide his/her care they are not rough with her or rude and they accommodate his/her needs but there are not enough staff so he/she often does not get her call light answered for sometimes over an hour and he/she is often left wet. Observation and interview on 1/25/24 at 1:19 P.M., showed the resident was sitting up in his/her wheelchair with a gown on. The resident said: -Nursing staff had gotten him/her up this morning, but he/she had not gotten a shower or bath yet. -He/she was also wet and needed to be changed and no one had come in yet. -He/she said he/she pushed his/her call light. -Observation of the call light screen (an electronic screen in the hallway showed the date and time the resident's call light had been initiated) showed the resident turned his/her call light on at 1:09 P.M. The nursing staff went into the resident's room at 1:20 P.M. 13. Review of Resident #69's Face Sheet showed he/she was admitted on [DATE], with diagnoses including heart failure, difficulty walking, pain, muscle weakness, high blood pressure, oxygen dependency and kidney disease. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Was alert with confusion. -Was dependent on bathing, dressing, was incontinent and mobilized in a wheelchair. -Was dependent on bed mobility and needed extensive assistance with transfers. Review of the resident's Care Plan dated 11/9/23, showed the resident had self-care deficits related to his/her diagnoses. The care plan showed the resident: -Was dependent or required substantial assistance with bed mobility, sitting and laying, dressing, personal hygiene and toileting. -Required the physical assistance of two persons to transfer with a mechanical lift. Observation on 1/30/24 at 9:48 A.M., showed the resident was sitting in a specialized wheelchair with padding for positioning. The resident's call light was not within reach. The resident was alert and oriented with confusion and was wearing oxygen.CNA G brought clean linen into the resident's room and asked if he/she was ready to lay down and the resident said he/she was. CNA G put gloves on and began to wipe down the resident's mattress. He/She then left the resident's room to get a full body mechanical lift (an assistive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power). He/She re-entered the resident's room at 9:51 A.M. put the linen on the resident's bed then transferred the resident using the mechanical lift into his/her bed. CNA G then began incontinence care. Once he/she was done caring for the resident he/she washed his/her hands and left the resident's room. CNA G left the resident's room at 10:10 A.M. During an interview at 1/30/24 at 10:10 AM CNA G said: -He/she was working on the A hall by himself/herself. -It takes between 15 to 30 minutes to provide care to a resident and when he/she is in the resident's room, he/she cannot be on the hall at the same time to answer call lights. -If the CMT was on the hall at the time, they will answer call light, but if there was no one on the hall then no one is there to assist any of the residents until he/she is done with the care he/she is providing at the time. -Sometimes he/she was not able to answer the call lights timely if he/she is providing care to another resident. 14. During an interview on 1/25/24 at 6:45 A.M., CNA H said: -He/she worked from 7:00 P.M. to 7:00 A.M. on long term care B hall. -There were between 23 to 24 residents on the hall. -Of the residents on the hall, about half of the resident's need assistance with care, are incontinent and need assistance with mobility. -There is only one CNA assigned per hall. -On the 7:00 P.M. to 7:00 A.M. shift there are between two to three CNAs covering the A, B, C and D halls. -When the call lights sound, he/she received a page from the pager that lets him/her know there was a resident needing care on his/her hall. -Sometimes when there are several call lights going off at the same time, he/she will go to each resident room, find out what they need then depending on who needs the most immediate attention, he/she will assist that person first. -He/She said he will tell the other residents he/she will be back. -Sometimes it takes a while to complete the care of a resident, up to 30 minutes. When this happens, he/she sometimes does not get to the other call lights on his/her hall for 30 minutes or longer. -While he/she was providing care to a resident on his/her hall, there was usually no one else there to provide any additional assistance to other residents on the hall who may need help. -The CNAs try to help each other, but sometimes it is very difficult because they have call lights they have to answer on their halls also, and if they leave the hall, there was no one there to answer the call light. -Usually he/she was able to get all of his/her cares completed, but it may not be timely because he/she was the only staff on the hall. -There were only two to three CNAs scheduled on the night shift on A, B, C and D hall with one nurse. During an interview on 1/26/24 at 9:21 A.M., CNA M said: -He/She worked from 7:00 A.M. to 7:00 P.M. on long term care A hall. -There were 25 residents on this hall. -Of the resident's on the hall, between 18 to 20 residents need assistance with care, are incontinent and need assistance with transfers (did not ambulate independently). -He/She was the only staff scheduled to work on the hall because there is only one CNA scheduled per hall and they try to assist each other with transfers and baths and cares, but it's just not always possible. -The nurse will help sometimes when he/she can. -There are times when there are a lot of call lights going off at the same time and when this happens, he/she will go to each room and let the resident know he/she will be back and he/she would turn the call light off. -He/She had to prioritize who will be cared for first. -Some residents take between 20 to 45 minutes to assist (depending on their care need) before he/she can get to the next call light. There have been residents on his/her hall that have had to wait 45 minutes to an hour to get help because he/she is busy with another resident and is not able to get to them more timely. -It makes him/her upset and he/she felt overwhelmed because there was no one to assist on the hall. -He/She has expressed this to management, and nothing happens. -With there being only one CNA scheduled per hall, they try to assist each other with transfers, baths and cares, but it's just not always possible. During an interview on 1/31/24 at 9:30 A.M., Licensed Practical Nurse (LPN) B said: -The CNA staff were scheduled one per hall and they have two Certified Medication Technicians (CMT) that pass medications on two halls each, and two nurses that cover two halls each on the 7:00 A.M. to 7:00 P.M. shift. -The CNA staff do the best they can but they do not have enough staff to complete all of the cares they are responsible for. -Because there was only one aide assigned to each hall to do all of the resident care, and they have a lot of residents that require assistance, he/she tries to assist the nursing staff as much as possible, but it is not always possible due to his/her nursing responsibilities. -They have asked for more CNA assistance on the units, but they have not received it. -It was unrealistic to expect the call lights to be answered in 15 minutes and for 4 showers a day to be completed and all of the care that the CNA is responsible for to be completed with only one CNA on the hall for 25 residents that need physical assistance. -When they have call ins, it becomes more difficult for the staff that come in to work and they do not always have a replacement. -Management staff tries to get people to fill the vacancies, and sometimes they can and sometimes they cannot. During an interview on 1/31/24 at 9:51 A.M., LPN C said: -He/She has worked the 7:00 A.M. to 7:00 P.M. shift and the 7:00 P.M. to 7:00 A.M. shift and there were usually two nurses that covered two hall each (on the long term care unit) and there was only one CNA scheduled per hall. -Sometimes the CNA staff have too much to do to adequately do all of their duties. -He/She tries to help the staff by answering call lights when they are busy or need help to provide care. -On the 7:00 P.M. to 7:00 A.M. shift the staff have less cares they have to do and during the night they have not had as many issues getting cares completed. -When nursing staff call in, it was more difficult to get the care tasks completed-it takes longer to complete and it was more difficult for the CNA staff because they still only have one CNA per hall to care for the residents. During an interview on 1/31/24 at 10:41 A.M., with the Administrator, Director of Nursing (DON) and Administrator in Training, the DON and Administrator said: -They look at call light logs and have determined that they have call lights that have gone off for longer than 15 minutes and they have tried to monitor it. -They are looking at the pagers daily and trying to monitor their functioning. -The nursing staff work 12 hour shifts. -On the rehabilitation unit they have two nurses, a Certified Medication Technician (CMT) and three CNAs on day shift with a full census .On the second shift they have two nurses or a nurse and a CMT for first four hours and two to three CNAs on nights. They also have an evening nurse supervisor. -On the long term care unit they have two nurses, four CNAs, two CMTs, a restorative aide and on Monday,Wednesday and Friday, they have an aide that takes dialysis residents to their appointments that works from 4:00 A.M. to 4:00 P.M. -They are staffing the units appropriately, but they are struggling with staff doing their jobs. -They will also get feedback from the staff especially when they are admitting persons. -They also have staffing agency they use to fill in for call ins to try to address this issue. MO00230143 Based on observation, interview and record review, the facility failed to ensure the call light system operated as per the manufacturing guidelines and with the exception granted to the facility on [DATE], by failing to ensure that all Certified Nurse's Aide (CNAs) had pagers, failed to ensure the pagers operated properly, failed to ensure the call light activation devices in the resident rooms operated properly, and failed to ensure call lights were being answered timely for three sampled residents (Resident #23, #96 and #69) out of 33 sampled residents. This practice potentially affected all residents. The facility census was 122 residents. 1. Review of the Exception letter dated 10/13/21, showed: -19 CSR 30-85.012 paragraph (124) Facilities shall provide an electrically powered nurses' call system with indicator lights at the corridor entrance of each bedroom. - Audible signals and indicating panels shall be located in each nurses' station and utility room. Facilities shall provide signal buttons at the head of each resident bed, in each toilet room and in each bathroom. - Section 2--The operator will ensure that the wireless call system is fully operational twenty-four (24) hours per day, seven (7) days a week. - Section 3--The operator will maintain, at a minimum and in accordance with the manufacturer's recommendations all the features of the the wireless call system provided to the Section for Long Term Care Regulation on March 19, 2021 and notify SLCR of any system changes. - Section 4--The operator will ensure that all direct care staff carry and utilize the wireless nurse call pagers at all times. 2. Observation on 1/23/24 at 5:10 P.M., during a call light test, showed the call light from resident room A12 was activated. During an interview on 1/23/24 at 5:12 P.M., Certified Nurse's Assistant (CNA) M said his/her pager showed no signals were recieved from resident room A12. 3. Observation on 1/23/24 at 5:37 P.M., during a call light test, showed the call light from resident room A2 was activated. During an interview on 1/23/24 at 5:48 P.M., CNA M said his/her pager had no pages from resident room A2. 4. Observation on 1/24/24 at 3:20 P.M., with the Maintenance Director, showed the call light activation switch in resident room C6 did not activate when it was activated. During an interview on 1/24/24 at 3:21 P.M., the Maintenance Director said the batteries within the call light activation switch, may need to be changed. 5. Observation on 1/25/24 at 8:14 A.M., during a call light test showed the call light from resident room D9 was activated. During an interview on 1/25/24 at 8:16 A.M., Certified Medication Technician (CMT) A said he/she has been employed at the facility for four months and he/she has not been given a pager to carry on his/her person and without a pager, he/she would not be aware if his/her help was needed on another hall. During an interview on 1/25/24 at 8:18 A.M., CNA B said he/she had only been employed for two days and no one told him/her about using a pager, so he/she did not have a pager in his/her person. Observation on 1/25/24 at 8:21 A.M., showed the pager, which no one used at the time, on the desk at the center core nurses' station, showed a signal was sent from resident room D9. 6. During an interview on 1/25/24 at 10:29 A.M., Licensed Practical Nurse (LPN) C, a charge nurse for a part of F and all of G halls, said the call lights would activate and send a signal to the pagers, one reason was the pagers may be programmed for individual units. 7. Observation on 1/25/24 at 11:19 A.M., during a call light test, the call light for resident room F8 was activated. During an interview on 1/25/24 at 11:21 A.M., LN C said a signal from resident room F8 did not show up on the pager at the desk in the Post Acute Nurse's station. 8. Observation on 1/25/24 at 11:21 A.M., during a call light test, showed the call light from resident room H8, was activated. During an interview on 1/25/24 at 11:33 A.M., CNA C said he/she did not see a signal from resident room H8 on the pager he/she she carried. During an interview on 1/25/24 at 11:34 A.M. CNA A said there was no signal from resident room H8, which should have appeared on his/her pager. During an interview on 1/25/24 at 11:35 A.M., CNA D said his/her pager was not working at the time and he/she did not know that his/her pager was not working properly when he/she started his/her shift earlier that day, and he/she would not know if another resident would need help, if he/she was helping a resident in a different room. 9. Observation on 1/25/24 at 11:58 A.M., with the Maintenance Director, showed the call light activation switch in resident room G1,did not activate when it was pushed. During an interview on 1/24/24 at 3:21 P.M., the Maintenance Director said the batteries within the call light activation switch in the resident room, may need to be changed. 10. During an interview on 1/26/24 at 10:46 A.M., Assistant Director of Nursing (ADON) A said: - The signal for any of the rooms in the Post Acute Unit (E, F G and H Halls) should be visible on the pagers that are used on that unit. - The pagers needed to be reprogrammed. - Sometimes if a battery was placed in the pager the wrong way, that action could cause a pager to malfunction. - If the room that shows on the matrix board (a board which was posted at the end of the halls on which a room where a call light button was pressed, is made visible), does not show on the pager, then that staff member knows the pager was not working properly. - If the room does appear on the pager, then the staff member would know the pager was working properly. - The pagers were a problem until this whole situation is fixed. During an interview on 1/26/24 at 10:58 A.M., the Vice-President of Clinical Operations said: - He/she had knowledge of some of concerns which pertained to the call light system. - He/she knew that that the Director of Nursing (DON) attempted to reprogram the pagers twice. - He/she knew that some facility staff have attempted to contact persons at the facility's corporation and persons at the pager monitoring company. During an interview on 1/26/24 at 11:04 A.M., ADON B said he/she has not been trained in reprogramming the pagers. During an interview on 1/29/24 at 12:09 P.M., the DON said: - The pagers should be programmed per hall. - The pager acknowledgement signed by staff indicated that they are responsible for any damage to the pagers. - If they are issues with the pagers, the staff members can report those issues to the Nurse supervisors or Maintenance. - The CNAs should get the pagers from the person they are relieving. - Some facility staff just start looking at the monitors in the hallways. - There were extra pagers from other facilities that were not compatible. - The pager system works well but the pagers even though they were coded correctly were not compatible with the facility's system. - The real issue was that staff should keep their pagers on them and pass it to the next person coming on shift. - Pagers from other facilities were brought in to this facility, but it was later found out that those pagers were not compatible with the facility's system. - Some facility staff unwittingly walk out with the pagers after their shifts. Review of an On-Site Visit Report (a report completed after an a visit by a company who went to the facility to address concerns with the facility call light system), dated 1/29/24, showed: - The paging encoder worked fine and sent alerts to the pagers. - The pager programming appears correct and should work but it did not work on all pagers. - They (the facility) received pagers from 3rd party vendor and those pagers were not properly programmed and needed to be sent in to the pager programming company and reworked. During a phone interview on 2/5/24 at 12:54 P.M., the Chief Executive Officer from the Pager Programming company said: - Some of the pagers at the facility came from a third-party vendor, not from his/her company, or other authorized distributors of pagers that would be compatible with that system. - To program the pagers correctly, the pagers were placed on a cradle (a device that is used to program the pagers by accessing the memory boards inside the pager) for baseline programming. - The pagers have to be programmed at the time they were ordered. They (the Pager Programming Company) would ask the facility personnel for the 2nd level of programming to be more specific for the units that facility staff would work on. -Some facilities did not know that when they obtain pagers from outside vendors that those pagers were not programmed to the facility's system. - The pagers have to be programmed on 2 different levels, the first level is the initial programming for those pagers to work with the nurse call system and the 2nd level is for code and frequency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to observe, monitor and assess one sampled resident (Resident #5) as he/she self-administered his/her medication, and to ensure an order for self-administration of medication was on the physician's order sheet out of 13 sampled residents. The facility census was 121 residents. 1. Review of Resident #5's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including respiratory failure, diabetes, difficulty walking, kidney disease, heart failure, muscle weakness, chronic obstructive pulmonary disease (COPD- a progressive disease that is characterized by shortness of breath and difficulty breathing), hypotension (low blood pressure) and anemia (low iron). 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 8/12/23, showed the resident: -Was alert, oriented and cognitively intact. His/her Brief Interview for Mental Status (BIMS-a test used to get a quick snapshot of how well you are functioning cognitively at the moment; a score of 0 to 7 was severely impaired, 8 to 12 was moderately impaired and 13 to 15 was cognitively intact) was 14. -Needed supervision with toileting (was occasionally incontinent of urine) and hygiene, limited assistance with transfers and was unable to move from surface to surface without the assistance of one staff, needed extensive assistance with bathing and dressing. -Did not walk and used a wheelchair for mobility. Review of the resident's Physician's Order Sheet (POS) dated 8/2023, showed physician's orders for: -Spiriva Respimat Aerosol 2.5 micrograms (MCG), inhale 2 puffs orally once daily for COPD (ordered 8/28/23). -Advair Aerosol 250-50 MCG, one inhalation orally in the evening for allergies (ordered 8/17/23). -Ipratroplum-Albuterol 0.5-2.5 milligrams (MG) inhale one vial orally every four hours as needed for heart failure (ordered 8/17/23). -There were no physician's orders showing the resident was able to self-administer any of these medications. There were no physician's orders showing the resident could self-administer any of his/her medications. Review of the resident's Medical Record showed there was no assessment for self-administration of medications, or specifically Spiriva or any inhaler medication. Observation and interview on 8/31/23 at 10:30 A.M., showed: -The resident was sitting in his/her room in his/her wheelchair wearing oxygen at 2 liters per minute. He/she was dressed for the weather and alert and oriented. The resident said that he/she had difficulty breathing and needed to wear oxygen and also used inhalers to clear his/her lungs. During the interview Certified Medication Technician (CMT) A came into the resident's room and brought the resident's medication, specifically two inhalers (a medical device for administering a drug which is to be breathed in). The following occurred: -CMT A asked the resident which of the inhaler devices he/she was supposed to take. The resident pointed to one inhaler, the CMT gave it to him/her and said he/she was going to get the resident a glass of water to rinse with. -CMT A left the resident's room (he/she did not stay to observe the resident inhale the medication or to administer the inhaler to him/her). -The resident then inhaled two puffs of his/her inhaler medication (Spiriva), waiting a couple seconds in-between puffs. -CMT A came back into the resident's room and gave the resident a small cup of water. CMT A asked the resident if he/she had taken his/her inhaler medication and the resident said he/she had taken it. CMT A then gave the resident the rest of his/her medication. -The resident said he/she normally self-administered his/her inhalers and knew which one he/she took in the morning and which he/she took at night (he/she said he/she was a nurse by trade). During an interview on 8/31/23 at 11:14 A.M., CMT A said: -The resident was alert and oriented and knew which of his/her inhalers he/she took in the morning. -The resident used to have to use two inhalers in the morning. -The resident had physician's orders for all of the medications he/she took via inhalation. -CMT A looked at the resident's POS and said the resident was supposed to take Spiriva in the morning and he/she did not see an order for self-administration of the medication. -He/she did not normally work with the resident and was filling in for the regular CMT for the hall. -He/she gave the resident his/her inhaler because the resident was able to take his/her inhaler independently and she went to get the resident some water to rinse her mouth with. During an interview on 8/31/23 Licensed Practical Nurse (LPN) B said: -The nurse and CMT should look at the resident's physician's order before giving the resident's medication to ensure they are giving the correct medication, dose, route. -The nurse or CMT should never leave the resident while the resident administers any medication or inhaler, unless the resident had an order for self-administration of the medication. -There should be an order for self-administration of the medication on the resident's POS if the resident is able to self-administer. -The CMT should not have left the resident's room because he/she did not know if the resident administered the inhaler or administered it correctly. During an interview on 9/1/23 at 2:35 P.M., the Director of Nursing (DON) said: -When the nurse or CMT was administering medication, they should always check the resident's POS prior to administering the medication. -There should be a physician's order for self-administration of medication of any medications that were to be self-administered and it should be on the POS. -The nurse or CMT should never leave the resident's room while medications were administered. -Even if the resident was able to self-administer an inhaler, the nurse or CMT should observe the resident as they self-administer the inhaler to ensure they administered it and administered it correctly. MO00223293

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to administer the correct form of insulin to one sampled resident (Resident #2) out of three sampled residents for insulin administration. The facility census was 121 residents. On 9/7/23 the Administrator was notified of the past noncompliance which occurred on 8/20/23. Chief Nursing Officer (CNO) provided immediate education to nursing staff on medication administration, including accessing the emergency medications, two person verification process added to all insulin orders and education on the five rights of medication administration. All education to nursing staff was done prior to the start of shift. The deficiency was corrected on 8/21/23. Review of the facility policy titled Insulin Administration Procedure, dated November, 2018 showed: -Insulin is only given with a physician or nurse practitioner order. -The standard insulin syringe needle is 5/8 inch and 27 gauge. -Wash hands.-Draw up the insulin in and and remove any air bubbles. -Explain procedure to resident and provide privacy, -Clean area with an alcohol swab. -Inject needle at a 90 degree angle and administer insulin. -Dispose of needle in sharps container, do not recap. -Record on the Medication Administration Record that insulin was given and site, rotating site. Review of the National Institute of Health, Nursing Rights of Medication Administration, published January 2023, showed: -Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. -It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the five rights of medication administration: --Right patient. --Right drug. --Right route. --Right time. --Right dose. 1. Review of Resident #2's facility face sheet showed he/she was admitted to the facility on [DATE] with diagnoses that include: -Sepsis (a life threatening complication of an infection). -Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes sugar (glucose). -High Blood Pressure. -Acute Respiratory Failure. -Paroxysmal Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 8/30/23 showed: -His/her Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. -He/she required assistance of one staff for most Activities of Daily Living (ADL- those activities that people perform everyday such as bathing, dressing, transferring). Review of the resident's care plan dated 8/29/23 showed: -Resident has Diabetes Mellitus and will have no complications related to diabetes. -Diabetes medication to be administered as ordered by the doctor. -Monitor/document/report as needed, any signs or symptoms of hyperglycemia (high blood sugar): --increased thirst and appetite. -Frequent urination. -Weight loss. -Fatigue. -Dry skin. -Poor wound healing. -Monitor/document/report as needed, any signs or symptoms of hypoglycemia: -Sweating. -Tremor. -Increased heart rate. -nervousness. -Confusion. -Slurred speech. Review of the resident's physician orders dated 8/23 showed: -Humalog (a fast acting insulin) sliding scale with meals. -Semglee (a long acting insulin) 50 units at bedtime. -Accuchecks (blood sugar check) four times a day before meals and at bedtime. -Notify physician if blood sugar is less than 60 or over 400. Review of the facility investigation dated 8/28/23 showed: -Registered Nurse (RN) B administered the wrong insulin, Lantus (a short acting insulin) to the resident at approximately 10:00 A.M., on 8/20/23. The resident did not have an order for Lantus. -After realizing the medication error, RN B returned to assess the resident within approximately 30 minutes of the error. -RN B gave the resident candy to eat and left the room. -Certified Nursing Assistant (CNA) A answered the resident's call light at 1:09 P.M., and noticed no signs or symptoms of hypoglycemia or other concerns, and left the room. -RN B returned to the resident's room to reassess the resident at approximately 2:45 P.M., re checked blood glucose and the results were 31 (normal blood sugar level for any individual before meals is between 80 and 130 milligram (mg)/deciliter (dL). -Resident was disoriented. -RN attempted to use glucose gel orally. -Chief Nursing Officer (CNO) notified and Emergency Medical Services (EMS) were on scene. -On 8/21/23 RN B spoke with CNO about the incident and admitted to giving the wrong insulin. During an interview on 9/1/23 at 10:00 A.M., RN B said: -The day he/she made the insulin error, it was horrible. -He/she felt that it was an overwhelming situation, he/she was really stressed and grabbed the wrong insulin. -After he/she gave the insulin, he/she was returning the insulin to the cart, which was when he/she realized that he/she had given the wrong insulin. -He/she panicked. -He/she told the resident to eat a bunch of candy that the resident had in his/her room. -The resident was really happy about that. -It was entirely his/her mistake for not checking the insulin carefully, but it was a perfect storm that day, he/she was very stressed and a lot was going on. During an interview on 9/1/23 at 11:10 A.M., the resident said: -Yes, he/she guesses that they gave him/her the wrong insulin. -He/she was fine now and now the staff have a couple people checking the medicine before he/she gets it. -He/she remembers eating a lot of candy after given the wrong medicine. During an interview on 9/1/23 at 11:30 A.M., the Administrator and CNO said: -The two person verification which was now in place should have been in place to begin with to mitigate any errors. -All licensed staff had been educated on the new protocol of two nurses checking insulin before it was administered. -RN B had been re-educated on insulin administration as well. MO00223293

Based on observation, interview and record review, the facility failed to ensure there were enough nursing staff available to provide resident cares for 121 residents in the facility. The facility sample was 13 residents. The facility census was 121 residents. 1. Review of the facility's Facility Assessment updated on 5/17/23 showed: -The facility was licensed for 162 beds and the average daily census was 110 residents. -The average census on the long term care unit was 75 residents and the average census on the rehabilitation unit was 30. -Of the residents in the facility who required 1-2 staff assistance or were totally dependent, 97 residents needed assistance with dressing and bathing, 89 residents needed assistance with transfers, 48 residents needed assistance with eating and 87 needed assistance with toileting. -Of the residents in the facility 17 residents used an assistive device to ambulate and 83 residents were in the wheelchair most of the time. -The budgeted hours per payroll for 2 weeks (7 day week) showed the facility budgeted 672 hours for Registered Nurses (RN); 672 hours for Licensed Practical Nurses (LPN); 2464 hours for Certified Nursing Assistants (CNA), and 672 hours for Certified Medication Assistants (CMT); based on this information the budgeted hours daily are: RN hours-48, LPN hours-48, CMT hours-48 and CNA hours-176, for a total of 320 total nursing hours per day. Review of the facility's Daily Nursing Schedule from 8/17/23 to 8/31/23 showed the total daily staffing hours of the RN, LPN, CMT and CNA staff. The staffing was 12 hour day shift (6:00 A.M. to 6:00 P.M.) 12 hour night shift (6:00 P.M., to 6:00 A.M.). The schedule also showed the facility had 7 halls (A, B, C, D, F, G, H and E), showed the staff that was assigned to each hall. It showed the following: -8/17/23 It showed on day shift, there was one CNA assigned to each hall, one nurse assigned to cover two halls (A/B, C/D, G/F and H/E for a total of 4 nurses) and one CMT assigned to two halls each. On the night shift there was one CNA assigned to each hall, one nurse assigned to cover 2 halls each (A/B, C/D, H/E for a total of 3 nurses) and G/F were assigned to a CMT. -8/18/23 It showed on day shift, there was one CNA assigned to each hall, one nurse assigned to cover two halls (total of 4 nurses) and one CMT assigned to two halls each (total of 2 CMTs). On the night shift there was one CNA assigned to each hall, one nurse assigned to cover 2 halls each (total of 4 nurses). -8/19/23 It showed on day shift, there was one CNA assigned to each hall (one CNA covered 2 halls), one nurse assigned to cover two halls (total of 4 nurses) and one CMT assigned to two halls each. On the night shift there was one CNA assigned to each hall, one nurse assigned to cover 2 halls each (total of 4 nurses). -8/20/23 It showed on day shift, there was one CNA assigned to each hall except C, D and F (there was no one assigned to these halls), one nurse assigned to cover two halls each (A/B, C/D, and G/F for a total of 3 nurses) and one CMT assigned to two halls each (A/B, C/D and H/E for a total of 3 CMT's). On the night shift there was one CNA assigned to each hall, one nurse assigned to cover 2 halls each (total of 4 nurses). -8/21/23 It showed on day shift, there was 2 CNA's assigned to A hall and one CNA assigned to all other halls except H (showed no assigned staff), one nurse assigned to cover two halls each (A/B, C/D was unassigned, and G/F for a total of 2 nurses) and one CMT assigned to two halls each (total of 3 CMT's). On the night shift there was one CNA assigned to each hall, one nurse assigned to cover 2 halls each (A/B, G/F and H/E for a total of 3 nurses. C/D was assigned to a CMT). -8/22/23 It showed on day shift, there was one CNA assigned to each hall except D (there was no one assigned to this hall), one nurse assigned to cover two halls each (total of 4 nurses) and one CMT assigned to two halls each (for a total of 4 CMT's). On the night shift there was one CNA assigned to each hall, one nurse assigned to cover 2 halls each (total of 3 nurses). H/E was assigned to a CMT). -8/23/23 It showed on day shift, there was one CNA assigned to each hall except C, D and F (there was no one assigned to these halls), one nurse assigned to cover two halls each (total of 3 nurses) and one CMT assigned to two halls each (total of 3 CMT's). On the night shift there was one CNA assigned to each hall, one nurse assigned to cover 2 halls each (total of 3 nurses). H/E was assigned to a CMT. -8/24/23 It showed on day shift, there was one CNA assigned to each hall except C, D and F (there was no one assigned to these halls), one nurse assigned to cover two halls each (total of 3 nurses) and one CMT assigned to two halls each (total of 4 CMT's). On the night shift there was one CNA assigned to each hall, one nurse assigned to cover 2 halls each (total of 4 nurses). -8/25/23 It showed on day shift, there was one CNA assigned to each hall, one nurse assigned to cover two halls each (total of 4 nurses) and one CMT assigned to two halls each (total of 2 CMT's on the halls and one mid shift CMT). On the night shift there was one CNA assigned to each hall, one nurse assigned to cover 2 halls each (total of 4 nurses (one nurse left mid shift). -8/26/23 It showed on day shift, there was one CNA assigned to each hall, one nurse assigned to cover two halls each (total of 4 nurses) and one CMT assigned to two halls each (total of 2 CMT's). On the night shift there was one CNA assigned to each hall, one nurse assigned to cover 2 halls each (total of 4 nurses). -8/27/23 It showed on day shift, there was one CNA assigned to each hall, one nurse assigned to cover two halls each (total of 3 nurses. H/E was unassigned) and one CMT assigned to two halls each and one mid shift CMT (total of 3 CMT's). On the night shift there was one CNA assigned to each hall (two came in late), one nurse assigned to cover 2 halls each (total of 4 nurses). -8/28/23 It showed on day shift, there was one CNA assigned to each hall except D and F (there was no one assigned to these halls), one nurse assigned to cover two halls each (total of 4 nurses) and one CMT assigned to two halls each (total of 3 CMT's). On the night shift there was one CNA assigned to each hall except H (was unassigned), one nurse assigned to cover 2 halls each (total of 4 nurses). -8/29/23 It showed on day shift, there was one CNA assigned to each hall except B which had two CNA's assigned to the hall, one nurse assigned to cover two halls each (total of 4 nurses) and two CMT's assigned to two halls each (total of 4 CMT's). On the night shift there was one CNA assigned to each hall except F (a staff call-in did not show it was filled), one nurse assigned to cover 2 halls each (total of 4 nurses H/E was partially assigned to a CMT). -8/30/23 It showed on day shift, there was one CNA assigned to each hall except on B and C (there were two CNA's assigned to these halls only), one nurse assigned to cover two halls each (total of 4 nurses) and one CMT assigned to two halls each (total of 3 CMT's). On the night shift there was one CNA assigned to each hall except H (was only staffed for 7 hours), one nurse assigned to cover 2 halls each (total of 4 nurses). -8/31/23 It showed on day shift, there was one CNA assigned to each hall except B and C (which had two CNA's assigned to these halls only), one nurse assigned to cover two halls each (total of 4 nurses) and two CMT's assigned to two halls each (total of 3 CMT's). On the night shift there was one CNA assigned to each hall, one nurse assigned to cover 2 halls each (total of 4 nurses). -The staffing sheets showed the facility also used agency staff to fill shortages. Review of the facility Resident Roster and Census dated 8/31/23, showed a facility census of 121 residents. Resident per hall were as follows: -A Hall-24 residents. -B Hall 24 residents. -C Hall 17 residents. -D Hall 15 residents. -E Hall 5 residents. -F Hall 12 residents. -G Hall 12 residents. -H Hall 13 residents. Review of Facility Statement (undated) showed currently the facility has 35 residents who required assistance of two persons with transfers to include those needing a full body mechanical lift. Review of the facility admission Report from 8/1/23 to 8/31/23, showed the facility admitted 75 residents. Observation on 8/31/23 at 8:40 A.M., showed: -On the long term care unit (Halls A, B, C and D) there were 2 Nurses (each covering two halls) 2 CMTs (each covering two halls), and 4 CNAs (one per hall). -On the rehabilitation unit (Hall E, F, G, and H) there were 2 Nurses (each covering two halls) 2 CMTs (each covering two halls), and 3 CNAs (one per hall). There were only 5 residents on E Hall. During an interview on 8/31/23 at 8:47 A.M., CNA A said: -Usually there was only one CNA on each hall, two CMTs cover two halls each and two nurses cover two halls each. -There were supposed to be at least two CNA's per hall but they have not been able to staff the halls adequately due to lack of staff and call-ins. -Most of the halls have between 22 and 25 residents and they are difficult to manage because most of the residents need assistance with all of their care needs (toileting, bathing, dressing transfers and mobility). -They have a couple halls that have 15 to 17 residents and those halls were more manageable. -He/She was working on D Hall today with about 15 residents but several of them were heavy care. -All of the nursing staff work 12 hour shifts and they have two shifts (6:00 A.M. to 6:00 P.M., and 6:00 P.M. to 6:00 A.M.). -The CNA staff have to also give their resident baths because they do not have bath aides. When they are giving a bath, there was no one to cover their hall. -The nurses try to assist on the floor when they can, but they were covering two halls each. -Sometimes the call lights were not always answered timely (within 10 to 15 minutes). -Several of the nursing staff are already working double shifts and try to fill in when there were call-ins. -Management staff was trying to hire more staff but they can't keep staff and new hires will come to work and then quit. -They use a staffing agency but a lot of the time those staff call-in also or they don't show up at all. -He/She does his/her best to get all of his/her duties completed but sometimes he/she does not get all of his/her showers completed because he/she does not have enough time to do them all. -He/She liked working at the facility but they need more help. During an interview on 8/31/23 at 8:53 A.M., CNA B said: -Usually there was only one CNA per hall and he/she thought he/she was able to get all of his/her work done during the shift, but they need more help due to call-ins. -The nursing staff works 12 hour shifts and it was difficult to find people to cover when there are call-ins. -They have a staffing agency they use, but the agency staff are not reliable and they also call-in or if they are scheduled, sometimes they don't show up to work. -The CNA staff now have to give the showers on their hall because they no longer have bath aides (they are supposed to give 4 baths per day). -He/She tries to get it done but when he/she gives a bath, there is no one to cover the hall so she informs the charge nurse when he/she gives a bath. -The nurse tries to help on the floor when they can. -He/She normally worked on C hall which has 22 residents, 11 of which are total care and 9 require a full body lift to transfer. -He/She had to get assistance with any resident that needs a lift and has to wait for another CNA, CMT or nurse to come to assist. -He/She was working on A hall which only had 16 residents which was much more manageable since he/she was the only CNA on the hall. -Management staff was trying to hire more staff and they have new hire orientation classes every Tuesday, but they don't stay on as employees, people are always quitting. During an interview on 8/31/23 at 9:16 A.M., CMT A said: -There was one CMT per two halls. -He/She was able to get his/her medications passed within the two hour allowed timeframe for passing medications. -Sometimes he/she was not able to get the resident medications passed as quickly because he/she has several blood pressures that he/she has to get prior to passing the resident's medication, which slows him/her down. -The nurses also had medications they have to pass. -The CMT staff sometimes also were pulled to work the floor due to shortages with staffing and call-ins and when this happens they pass as much medication as they can and then the nurse will pass the rest. During an interview on 8/31/23 at 9:21 A.M., LPN A was preparing to begin passing medications and said: -He/She was a newer employee and so far he/she was able to get all of his/her assigned duties completed within the working hours (12 hour shift). -There were usually 2 nurses on the long term care unit and 2 nurses on the rehab unit, each nurse covered two halls. -He/She has been asked to fill in shifts due to call-ins twice in the last week. -He/She has had to assist the CNAs on the floor because there are not enough CNA staff and they are unable to get everything done or need assistance with performing cares. -There was only one CNA assigned per hall and they actually needed at least two CNAs per hall especially on the heavier halls. During an interview on 8/31/23 at 11:33 A.M., the Director of Nursing (DON) said: -He/She was new to the facility (7 weeks) and they have had problems with staffing and currently were trying to manage it. -He/She has worked on the floor to assist the CNA staff and has worked as a Charge Nurse to assist when they have had staff to call-in or not show up to work on both shifts, and he/she often works double shifts. -His/Her Assistant Director of Nursing (ADON) has also filled in to assist due to short staffing. -They currently staff two nurses per unit and each nurse covers two halls; two CMTs per unit (each covers two halls) and one CNA per hall. -They used to have bath aides in addition to CNAs, but they had to pull the bath aides to the floor to work as CNAs due to there not being enough staff to cover the halls. -The CNA's now have to also give their own baths on their assigned halls. -Each hall on the long term care unit typically has between 20 to 25 residents and the A and B halls were the heaviest for care. -They have had some residents to pass away and others are in the hospital so not all of the halls are at capacity. -They were continuing to admit new residents to the facility. -They should have at least two CNAs per hall, especially on the heavier care halls. -They were having to ask nursing staff to work overtime or pick up additional shifts in order to cover staffing on the floor/halls. -They have a new employee orientation almost weekly and are hiring nursing staff staff but they are not staying. -When they hire CNAs and they find out they will be working the hall by themselves, they will quit or not show up at all. -They were also hiring CMT staff because they have similar concerns with them getting the medication pass completed especially when they have call-ins, but the CMT staff were more consistent. -Nursing staff have expressed concerns with being overworked due to staffing needs and he/she and the Administrator have expressed these concerns to their corporate staff. -They have an internal agency that they use to supplement the facility staffing needs, but the agency staff also call-in and sometimes when they are scheduled in advance to work a shift, they don't show up or also call-in on the day they are to work. -They do not use any other or additional staffing agencies to obtain additional workers. -The Staffing Coordinator they worked with works at one of their sister facilities and was not in their building (he/she said they did not have their own Staffing Coordinator at this time, they were trying to hire one). -They have staffing meetings twice daily and discuss their staffing needs, admissions and discharges daily, census and acuity. -They have a lot of heavy care residents and they need to staff based on the acuity and assistance needed. -He/She was trying to do the best with what he/she was able to do to try to assist the nursing staff in all areas. During an interview on 8/31/23 at 12:00 P.M., the Administrator said: -He/She was hired at the facility about 6 months ago and there were staffing concerns at that time. -He/She had been working with corporate management to try to hire more staff overall, but nursing staff especially because it was a primary concern. -They were unable to keep a Staffing Coordinator at the facility and are still trying to hire someone in this position, but in the meantime, they are utilizing the Staffing Coordinator at a sister facility to staff their facility. -He/She, the DON, ADON, Human Resource Director, Staffing Coordinator and Corporate Management meet twice daily to discuss the daily staffing, the staffing need for the current and next shift, any call-ins/no shows, the census, acuity of residents in the building and they staff the units and halls based on this information. -They have continued to admit new residents. -They are always hiring new staff, especially nursing staff, and have staff orientations every Tuesday. -He/She did not know what their retention rate was, but they have several staff hired that either do not come to work or they will work for a short time then quit. -Currently on the Rehabilitation (post acute) unit there are 4 halls and about 38 total residents. -Staffing on the Rehabilitation unit is 2 nurses, 1-2 CMTs and 3 CNAs per shift. -Currently on the Long Term Care unit there are 4 halls each hall with a capacity for up to 25 residents. -Staffing on the Long Term Care unit is 2 nurses, 2 CMTs and 4 to 6 CNAs per shift. -They have noticed that the acuity of residents are primarily on the A and B halls and they recognize that they need to spread the acuity out more amongst all of the halls. -The A and B halls were heavier care halls and the C and D halls have less residents due to recent hospitalizations and/or deaths. During an interview on 8/31/23 at 1:36 P.M., CNA C said: -He/She was the only CNA working on A Hall today and he/she needed help. -He/She worked 12 hours on his/her shift and there are about 25 residents on his/her hall and of those 12 were total care. Some needed two person assistance with transfers. -He/She used to be one of the bath aides, but he/she was pulled to work the floor due to short staffing. -All of the CNA staff have to give their own baths on their assigned hall. -He/She tried to complete 4 showers but he/she does not have the time to do it. -The residents were supposed to get 2 showers weekly, but it was impossible with only one CNA per hall. During an interview on 9/1/23 at 9:15 A.M., CNA E said: -He/She was the only CNA working on D Hall today and he/she was trying to get all of his/her work done but it was a little overwhelming at times because he/she did not have any help with cares or answering call lights. -He/She was pulled to work the floor today due to call-ins. -He/She was the Restorative Aide, but he/she was pulled to the floor due to call-ins. -He/She was caught up with all of his/her restorative duties and it would not be difficult to re-schedule those residents he/she will not be able to get to today. -He/She often tried to fill in whenever the facility had call-ins or no show staff as he/she could to help the other CNAs. During an interview on 9/1/23 at 9:36 A.M., CMT B said: -There were two CMTs working on long term care unit and each had two halls they covered. -He/She was passing medications to 47 people and he/she was able to get all of the medications passed, but he/she sometimes went past the two hour window for passing the medications because he/she had so many. -The nurses help, but it was sometimes impossible to get them all passed on time due to there being so many. -The nurses and management staff were aware of the staffing issues. They are hiring staff but they don't stay. During an interview on 9/1/23 at 9:42 P.M., LPN C said: -Normally they have two nurses on the long term care unit and two on the rehabilitation unit. -Each nurse covers two halls. -He/She was usually able to get all of his/her tasks completed within the shift but sometimes he/she has to work over his/her shift. -He/She was asked to pick up extra shifts weekly due to call-ins or no shows. He/She said the facility has a lot of call-ins weekly. -Usually there was only one CNA per hall. -He/She had to assist the CNAs on the floor because there are not enough CNA staff for them to get all of their work done. -They need at least two CNAs on each hall, especially on the heavier care and heavier populated halls. -They have agency staff who are supposed to come in to fill in for staff that can't come to work or call-in, but they call-in also and are not reliable. -Management staff were constantly hiring people to help, but staff keep quitting. During an interview on 9/1/23 at 9:25 A.M., Registered Nurse (RN) A said: -He/She was the only nurse working on the rehabilitation unit and was covering four halls. -He/She informed management that he/she needed help and they said they were working on getting him/her some assistance. -There were two CMTs and three CNAs working on the rehabilitation unit today. -At this time, CNA F said there was one CNA per hall and they all covered E Hall since there were only a few residents on that hall. During an interview on 9/1/23 at 12:58 P.M., CNA D said: -He/She primarily worked night shift (6:00 P.M. to 6:00 A.M.) and he/she just recently started working the day shift. -While working night shift on the rehabilitation unit, they were assigned one CNA per hall (E, F, H, and G) and usually had three CNAs on the unit. They would split E Hall because it was the lightest. -They did not have as many residents on the rehabilitation unit as they did on the long term care unit so it was more manageable to get cares completed and completed timely. -They have been short staffed but some staff were more responsive to the residents than others and would answer the call lights faster. During an interview on 9/1/23 at 1:25 P.M., LPN B said: -There were usually four CMT's on the floor, two on the long term care unit and two on the rehabilitation unit and each CMT covered two halls. -There were usually four nurses (two on each unit) and they also cover two halls each. -The CMT working on A/B Hall has to pass medications for 46 residents and in order to get all of the medications passed, some of them will be late because they do not have liberalized/flexible medication pass times. -They do try to get all of their medications passed and the nurses will also help. -They have one CNA assigned per hall and depending on the acuity on the hall, they need two CNAs per hall in order to get all of their cares done, especially now that they no longer have bath aides and have to give their own baths. -It takes longer to get the cares done especially with resident's that need two persons to assist. -When the staff is assisting a resident they are not able to assist anyone else that may need help until after they are done. -He/she and other nurses try to help on the floor when they can because the CNA's need the extra help. -They have an internal staffing agency, but those staff also call-in or don't show up at all so they are very unreliable and the facility will not use any other outside staffing agency. -Today there was an agency nurse that was scheduled to come in and work on the rehabilitation unit and he/she called in and did not show up. MO00223828, MO00223951, MO00223604

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the call light display monitor was working properly on one hall, and to ensure call lights were answered timely for three sampled residents (Resident #5, #8 and #11) out of 13 sampled residents. The facility census was 121 residents. Review of the facility Daily Device Activity Report showed documentation that showed each time a call light was turned on. Documentation showed the date, time it was turned on, hall, bed and how long the call light was on before it was answered/turned off. Documentation from 8/29/23 to 8/31/23 showed: -On 8/29/23 on the day shift (6:00 A.M. to 6:00 P.M.) there were 12 call lights that were on longer than 20 minutes. The longest call light was on for 55 minutes. On the evening shift (6:00 P.M. to 6:00 A.M.) there were 5 call lights that were on longer than 20 minutes. The longest call light was on for 41 minutes. -On 8/30/23 on the day shift (6:00 A.M. to 6:00 P.M.) there were 26 call lights that were on longer than 20 minutes. The longest call light was on for 51 minutes. On the evening shift (6:00 P.M. to 6:00 A.M.) there were 26 call lights that were on longer than 20 minutes. The longest call light was on for 59 minutes. -On 8/31/23 on the day shift (6:00 A.M. to 6:00 P.M.) there were 28 call lights that were on longer than 20 minutes. The longest call light was on for 252 minutes (the second longest call light was on for 144 minutes and the third longest call light was on for 98 minutes). 1. Review of Resident #5's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including respiratory failure, diabetes, difficulty walking, kidney disease, heart failure, muscle weakness, chronic obstructive pulmonary disease (COPD- a progressive disease that is characterized by shortness of breath and difficulty breathing), hypotension (low blood pressure) and anemia (low iron). 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 8/12/23, showed the resident: -Was alert, oriented and cognitively intact. His/her Brief Interview for Mental Status (BIMS-a test used to get a quick snapshot of how well you are functioning cognitively at the moment; a score of 0 to 7 was severely impaired, 8 to 12 was moderately impaired and 13 to 15 was cognitively intact) was 14. -Needed supervision with toileting (was occasionally incontinent of urine) and hygiene, limited assistance with transfers and was unable to move from surface to surface without the assistance of one staff, needed extensive assistance with bathing and dressing. -Did not walk and used a wheelchair for mobility. During an interview on 8/31/23 at 10:14 A.M., Certified Nursing Assistant (CNA) A said: -The call light display screens in each hallway display the call lights that were turned on in which room, which bed at what date and time they were turned on. -Each screen showed all of the call lights on the unit that are on. -When the call light is answered, that persons display disappears from the screen (when the aide turns off the resident's call light). -Sometimes they forget to turn off the resident's call light. Observation on 8/31/23 at 10:30 A.M., showed on the hall the call light display monitor in the D Hall hallway the resident's call light was turned on at 10:05 A.M. There was no sound indicating any call lights were on and there were no lights outside of the room to signal his/her call light was on. Observation and interview on 8/31/23 at 10:30 A.M., showed the resident was sitting in his/her wheelchair in his/her room wearing oxygen. The resident's call light was on but there was no sound. -He/she needed assistance with bathing, dressing primarily. But he/she can also do some things on his/her own. -He/she has trouble catching his/her breath so he/she still needs assistance from staff. -Today he/she pulled his/her call light at 10:00 A.M. because he/she wanted to find out of the podiatrist was going to see him/her today and there have been a couple staff that came into his/her room to assist his/her roommate, but no one ever asked him/her what he/she needed and so the call light is still on. -Often times staff will pass by his/her room after he/she has turned the call light on and will not stop to see why he/she turned it on or if he/she needed any assistance. -He/she has waited an hour or longer to have his/her call light answered at times and it did not matter what time of day or night he/she turned it on. -When the staff respond, they do provide the assistance he/she needs, it just takes a very long time for them to come most of the time. -They don't have enough staff on the hall. There is only one CNA for each hall and they cannot get to everyone timely and there are rarely other available staff that are able to help. -Sometimes his/her medications are passed late because the Certified Medication Assistant (CMT) has to pass medications on two halls (he/she said this does not happen too often but it has happened). -During this interview CMT A came into the resident's room to pass his/her medication. CMT A did not ask the resident what he/she needed or why his/her call light was turned on. The CMT left the resident's room after passing his/her medications and the resident's call light was still on. -At 10:40 A.M. another CNA came into the resident's room to ask what he/she needed and turned the resident's call light off. At this time the resident had waited 35 minutes until his/her call light was answered. 2. Review of Resident #8's Face Sheet showed he/she was admitted on [DATE], with diagnoses including heart failure, pulmonary edema (fluid around the heart), difficulty walking, knee pain, kidney disease, high blood pressure, muscle weakness and palliative care (comfort care for end of life). Review of the resident's Significant Change MDS dated [DATE] showed the resident: -Was alert with significant cognitive impairment and memory loss (BIMS of 4). -Needed extensive assistance with bed mobility, dressing and hygiene and was totally dependent on staff for transfers, toileting (and was incontinent of bowel and bladder), and bathing. -Did not walk and used a wheelchair for mobility. Observation on 8/31/23 at 1:17 P.M., showed the resident's room was on the A Hall (room A2.) The resident was laying in his/her bed (low bed with a mat on the floor beside it) wearing oxygen and he/she was alert and oriented. The resident's family was visiting the resident at this time. -He/she needed total assistance from staff for all of his/her care (bathing, dressing, toileting, grooming). -When he/she pushed his/her call light, it took at least an hour for the nursing staff to respond and it did not matter if it was during the day or at night. -He/she turned his/her call light on this morning because he/she needed incontinence care and no one came in for at least an hour. -The actual care the nursing staff provided was good, but it took too long for them to answer the call lights. -There does not seem to be enough nursing staff working and they only have one CNA working on the hall. -They need to hire more nursing staff to care for the resident's on the day and night shift, especially on weekends. -Family Member A said he/she visited the resident daily at 10:30 A.M.-11:00 A.M., and stays until about 2:00 P.M. and sometimes he/she will come back during the night shift. He/she said he/she has seen the resident turn on his/her call light and the nursing staff usually take about 45 minutes to an hour to respond even when he/she has gone up to the nursing station to inform them himself/herself that the resident needs assistance. Observation on 9/1/23 at 9:00 A.M., showed the call light display monitors (2 monitors) in the A hall were on but the screens were black. The display at the back of the hall was not on. Observation of the call light display monitors in the C Hall showed the call light in room A2 was turned on at 5:09 A.M. Observation and interview on 9/1/23 at 9:09 A.M., showed the resident was in his/her bed wearing oxygen. His/her legs were hanging off the side of his/her bed and he/she was trying to sit up. The resident said: -The last time anyone had come into his/her room was at 7:00 P.M. last night. -He/she turned his/her call light on today and no one has come in to assist him/her yet. -He/she is incontinent and needed to be changed and no one has come in to change him/her. -At this time the resident had waited 4 hours and 9 minutes since his/her call light was turned on. During an interview on 8/31/23 at 1:36 P.M., CNA C said: -He/she was the only CNA working on A Hall today and he/she needed help. -He/she works 12 hours on his/her shift and there are about 25 residents on his/her hall and of those 12 were total care. Some needed two person assistance with transfers. -He/she used to be one of the bath aides, but he/she was pulled to work the floor due to short staffing. -The call light display in the A Hall did not work and so the only way he/she knew what call lights were on was to either complete rounds on the hall, go to the nursing station to look at the display there or go to another hall to look at the display monitor on that hall. -He/she asked for help today because it was too much and there was only one CNA on each hall. 3. Review of Resident #11's Face Sheet showed he/she was admitted on [DATE], with diagnoses including kidney failure with dependence on dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally), muscle weakness, heart disease, difficulty walking, high blood pressure, high cholesterol, and sepsis (a condition when chemicals released in the bloodstream to fight an infection trigger inflammation throughout the body. This can cause a cascade of changes that damage multiple organ systems, leading them to fail, sometimes even resulting in death). Review of the resident's Entry MDS dated [DATE] showed he/she was admitted to the facility on [DATE] from the hospital. There was no additional information documented (the resident's 14 day admission assessment had not been completed yet). Observation on 9/1/23 at 9:20 A.M., showed the call light display monitor on the H Hall showed the resident had turned his/her call light on at 8:55 A.M. Observation and interview on 9/1/23 at 9:24 A.M., showed the resident was laying in his/her bed awake and alert and oriented. -He/she had turned his/her call light on at about 9:00 A.M., because he/she was soiled and needed assistance to get changed. -At this time the resident had waited 25 minutes since he/she turned on his/her call light. During an interview on 9/1/23 at 12:58 P.M. CNA D said: -He/she primarily worked night shift (6:00 P.M. to 6:00 A.M.) and he/she just recently started working the day shift. -While working night shift on the rehabilitation unit, they were assigned one CNA per hall (E, F, H, and G) and usually had three CNAs on the unit. They would split E Hall because it was the lightest. -They did not have as many residents on the rehabilitation unit as they did on the long term care unit so it was more manageable to get cares completed and completed timely. -They used the call light displays that were on the walls in the hallway to know which call lights were on because it showed on the screen what room which bed and the date and time the call light was pulled. -Some staff also used pagers to identify which call lights were on, but most staff just looked at the call light display monitors. -The call lights did not sound in the resident rooms, but they did sound at the nursing station where there were display monitors are also. -They have been short staffed but some staff were more responsive to the residents than others and would answer the call lights faster. -Today there was one CNA per hall and they all helped on E hall. -They were supposed to be hiring more staff. 4. During an interview on 8/31/23 at 11:33 A.M., the Director of Nursing (DON) said: -He/she was new to the facility (7 weeks) and they have had problems with staffing and currently were trying to manage it. -He/she has worked on the floor to assist the CNA staff and has worked as a Charge Nurse to assist when they have had staff to call-in or not show up to work on both shifts, and he/she often works double shifts. -His/her Assistant Director of Nursing (ADON) has also filled in to assist due to short staffing. -They currently staff two nurses per unit and each nurse covers two halls; two CMTs per unit (each covers two halls) and one CNA per hall. The CNA's now have to also give their own baths on their assigned halls. -Each hall on the long term care unit typically has between 20 to 25 residents and the A and B halls were the heaviest for care. -Nursing staff have expressed concerns with being overworked due to staffing needs and he/she and the Administrator have expressed these concerns to their corporate staff. -This affects the nursing staff ability to provide care timely (to include answering call lights). -To his/her knowledge all of the call light monitors were working properly. During an interview on 8/31/23 at 12:00 P.M., the Administrator said: -He/she was hired at the facility about 6 months ago and there were staffing concerns at that time. -He/she had been working with corporate management to try to hire more staff overall, but nursing staff especially because it was a primary concern. -Currently on the Rehabilitation (post-acute) unit there are 4 halls and about 38 total residents. -Staffing on the Rehabilitation unit is 2 nurses, 1-2 CMTs and 3 CNAs per shift. -Currently on the Long Term care unit there are 4 halls each hall with a capacity for up to 25 residents. -Staffing on the Long Term Care unit is 2 nurses, 2 CMTs and 4 to 6 CNAs per shift. -They have noticed that the acuity of residents are primarily on the A and B halls and they recognize that they need to spread the acuity out more amongst all of the halls. -He/she said they are trying to address all staffing, particularly nursing. -The call light system shows the date, room, bed and time the call light was initiated and it will go off when the nursing staff turns it off in the resident's room. -He/She was aware the call light monitors on A Hall were not working and they were in process of resolving this issue. -He/she expected all of the call lights should be answered within 15 minutes, but he/she was aware that this does not always occur. The/She was aware call lights were not always answered within 15 minutes. -Residents should not wait 25 minutes, 30 minutes or longer to have call lights answered. -They were able to pull reports that showed each time a call light was activated and when it was turned off daily. -They did not look at average response time as part of their quality assurance process. -They were starting to re-implementing the use of pagers for all nursing staff to wear or carry with them so that they will know when they have a call light they need to answer on their assigned hall. During an observation and interview on 9/1/23 at 10:37 A.M., the Maintenance Director went to the A Hall and both monitors were on but showed no display. There was no display showing on the display at the back of the hall. He/She turned the monitors on and off and the monitors came on but then showed no display (were black). -He/she was employed three weeks ago and to his/her knowledge all of the call light display monitors were working and were on. -No one had informed him/her that the monitors in the A Hall were not working. -When the nursing staff have any issues, they were supposed to submit a work order (notify the nurse manager) and then he/she will make the repairs. -He/she had not received a work order for the call light monitors in the A Hall. -He/she had noticed that in the morning when he/she arrived at work, the monitor at the nursing station on the long term care unit were always turned off and he/she had to turn the monitor on daily. -He/she did not know why the nurses were turning the monitor off at the nursing station. -The monitors all worked independently from each other and in order for them to be off they would need to be turned off manually. -The nursing staff looked at the call light monitors which displayed what hall lights were on in which hall, room and the date and time the call light was activated. -The call light only sounded at the nursing station. -They had pagers that he/she was programming for the nursing staff to carry with them which will also inform them that call lights were going off. -He/she was told that the nursing staff used to use the pagers in addition to the display monitors, but the pagers began disappearing and getting lost so they discontinued their use. He/She said they are now in the process of re-implementing the pagers (two weeks ago). -The pagers were programmed to each hall but he/she has not gotten them all programmed yet. MO00223828, MO00223951, MO00223604, MO00223418, MO00223143

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed failed to ensure three hallways, A Hall, B Hall, and C Hall, were free of strong urine odors that permeated through the carpeting and down into the concrete below the carpet. This deficient practice affected 64 residents that resided on those halls. The facility census was 106 residents. 1. Observation on 7/24/23 at 10:45 A.M., showed a strong, ammonia-like urine odor permeating from the carpet on A Hall, B Hall, and C Hall of the facility. During an interview on 7/24/23 at 12:30 P.M., Licensed Practical Nurse (LPN) A said: -The carpet smell on A, B and C hallways was awful. -He/she had been trying to get the facility to replace it for as long as he/she had worked there which was around a year. -It was not fair to the residents to have that horrible smell in their home. Review of Resident #6's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 5/9/23 showed: -He/she was admitted on [DATE]. -He/she was cognitively intact. During an interview on 7/24/23 at 12:50 P.M., the resident said: -He/she was out of his/her room in his/her wheelchair every day. -The urine smell coming from the carpet on B hallway was horrible. -He/she could not leave his/her room without wearing a mask as the smell made him/her nauseated. During an interview on 7/24/23 at 2:30 P.M., the Maintenance/Housekeeping Director said: -He/she had done everything he/she could to get the smell out of the carpet, including frequent steam cleaning. He/she deep cleaned them and within two days, the carpet would smell like urine. -When the weather was warm and humid, the smell was especially strong. -If he/she could replace the carpet, he/she would do it immediately. -The facility had many recent large expenses which were unexpected, and the facility budget had taken a large hit because of it. -With all the extra unexpected expenses, he/she just was not sure the money was available to remove and replace the old carpet. -He/she had noticed areas in the carpet which were sunken, and he/she felt as though that was due to the urine penetrating the carpet and actually destroying the cement underneath. -The cement would likely need to be ground down and replaced before any new carpet could be placed. Observation on 7/24/23 at 3:20 P.M., showed: -Large stains in the carpet across from rooms A-3, A-8 and A 12 with a strong urine odor and the surveyor shoes where sticking on the carpet. -Large stains on B Hall across from rooms B-1, B-2, B-5, B-6 B-7 and B-8 with a strong urine odor and sunken areas in the flooring under the carpet in the areas with the stains. -Large carpet stains on C Hall across from rooms C-6, C-7, C-8 and C-9 with a strong urine smell. -An area of the carpet with tape at the entrance of the hallway. During an interview on 7/24/23 at 3:45 P.M., Certified Nursing Assistant (CNA) A said: -He/she had just begun his/her shift and the first thing he/she did every day at the beginning of the shift was take disinfectant spray and spray the entire carpet on B Hall to try and alleviate the strong urine smell coming from the carpet. -He/she hated the residents had to live on a hallway where the urine odor was so strong it made him/her sick. -Spraying the carpet with disinfectant spray helped cut down on the odor for a few hours at least. During an interview on 7/24/23 at 4:00 P.M., the facility Administrator said: -He/she had tried to get the carpet on A, B, and C hallway replaced since he/she had been the Administrator, especially since the flooring in the rest of the facility had been replaced with wood laminate before he/she was employed there. -The facility had so many recent unexpected expenses, he/she was not sure if the money was there to replace the old carpet. -He/she would have expected the residents have nice flooring in their home that had no urine odor. MO00221217

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to correctly transcribe a physician's medication order for one sampled resident (Resident #1) out of four sampled residents, resulting in the resident receiving an incorrect dose of his/her Insulin on 1/26/23 and was sent to the emergency room (ER) due to lower blood sugars. The facility census was 127 residents. On 1/30/23 the Administrator was notified of the past noncompliance which occurred on 1/26/23. On 1/26/23 the facility administration was notified of the incident and the investigation was started. Assistant Director of Nursing (ADON) A transcribed an order for Lantus insulin (a long-acting insulin) incorrectly, resulting in an incorrect dose given to Resident #1 one time. It was instituted by the facility on 1/27/23 that all insulin orders put in the electronic medical record (EMR) were now to be double checked by a second nurse manager at all times. The orders could not be activated from a pending status without the second nurse check. No employees were allowed to work prior to re-education, which began on 1/27/23. The deficiency was corrected on 1/29/23. Record review of the facility's Physician's Orders policy dated 11/18 showed: -Orders might be called, hand-written, faxed or electronically generated by the physician. -The physician's order should be documented completely with sufficient content to clearly convey the provider's intent. Indications for as needed (PRN) orders should be included in the order. -After the authorized provider completed the orders, the Registered Nurse (RN) or Licensed Practical Nurse (LPN) was responsible to promptly and accurately transcribe all written orders. The RN or LPN should include his/her signature, the date and time of the transcription and credentials. -Orders that were unclear should be clarified prior to implementation. 1. Record review of Resident #1's admission Record face sheet dated 1/27/23 showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). -Long-term (current) use of insulin (a medication that helps regulate blood sugar levels). Record review of the resident's Care Plan dated 1/26/23 showed: -He/she had diabetes mellitus and required medication to manage blood sugars. -Diabetes medication was to be given as ordered by the doctor. -He/she was to be monitored for any signs or symptoms of low blood sugar, including increased heart rate, nervousness, confusion, slurred speech, lack of coordination or staggering gait. Record review of the residents hospital Discharge Medications dated 1/26/23 showed an order for Insulin Glargine (Lantus Solostar U-100 unit/milliliters (ml) subcutaneous (beneath the skin) pen. 12 units were to be injected under the skin at bedtime daily. Quantity 45 ml. Record review of the resident's Order Summary Report dated 1/26/23 at 10:11 A.M. showed an order for Lantus Subcutaneous Solution 100 units/ml (Insulin Glargine). 45 units to be injected subcutaneously at bedtime for diabetes mellitus. This order was discontinued on 1/26/23 at 10:27 P.M. Record review of the resident's Treatment Administration Record (TAR) dated 1/26/23 showed: - Lantus Subcutaneous Solution 100 units/ml (Insulin Glargine) 45 units were to be injected subcutaneously at bedtime for diabetes mellitus was ordered. -This was administered to the resident for a blood sugar of 378 at 8:17 P.M. Record review of the resident's Progress Notes written by Nurse Practitioner (NP) B, dated 1/26/23 at 10:30 P.M. showed: -An insulin order was placed in the EMR with incorrect dosing. -The order was for Lantus 12 units at bedtime, but was placed in the EMR to give 45 units at bedtime. -The resident did receive the incorrect dose. -Hourly blood sugar checks would start. -Glucagon (an emergency medication used to treat severe low blood sugar in people with diabetes who cannot take some form of sugar by mouth) would be prepared if needed. Record review of the resident's Order Summary Report dated 1/26/23 at 10:35 P.M. showed: -An order for Lantus Subcutaneous Solution 100 units/ml (Insulin Glargine). 12 units to be injected subcutaneously at bedtime for diabetes mellitus. The order start date was 1/27/23. -Hourly blood sugar checks were to be done for 12 hours, every hour for incorrect insulin amount given. Record Review of the resident's Blood Sugar Summary dated 1/26/23 showed on 1/26/23 at 11:49 P.M., his/her blood sugar was 69. Blood sugar range should be between 80 - 130. Record review of the resident's Medication Administration Record (MAR) dated 1/26/23 showed: -An order for Glucagon subcutaneous solution 1 milligram (mg)/0.2 ml to be injected subcutaneously as needed for a blood sugar less than 60. -Glucagon was administered to the resident on 1/26/23 at 11:51 P.M. Record review of the resident's Blood Sugar Summary dated 1/27/23 showed on 1/27/23 at 4:19 A.M., his/her blood sugar was 35. Record review of the resident's eMAR Medication Administration Note dated 1/27/23 showed: -Glucagon was administered to the resident on 1/27/23 at 4:20 A.M. -Glucagon was administered to the resident on 1/27/23 at 5:08 A.M by the Emergency Medical Service (EMS) staff based on a blood sugar result obtained by their staff. Record review of the resident's hospital ER notes dated 1/27/23 at 6:15 A.M. showed: -He/she was brought to the ER overnight with hypoglycemia (low blood sugar). -He/she was given Lantus insulin the previous night per the nursing staff. -He/she had a low blood sugar and was referred to the ER. -He/she required a D50 (50% dextrose solution, a treatment for low blood sugar) injection as well as a D10 (10% dextrose solution) intravenous (IV - process of giving medication directly into a resident's vein) drip overnight. -He/she was currently stable with blood sugar levels. Record review of the resident's hospital History of Present Illness notes dated 1/27/23 at 8:08 A.M. showed: -He/she was sent to the hospital from the facility for evaluation of hypoglycemia. -Per resident records, he/she was given 45 units of Lantus insulin instead of 12 units the previous night. -Per resident records, his/her blood sugar was in the 30s. -Glucagon was administered twice, then 125 ml of D10 via EMS. -His/her blood sugar had been stable on D10. -At the time, he/she was lethargic, opened and closed eyes and followed minimal commands. -Family had reported the resident was at baseline the previous day with no complaint. During an interview on 1/30/23 at 11:30 A.M., the Chief Clinical Officer said: -ADON A transcribed the insulin order. -The resident arrived at the facility in mid-afternoon. -It was possibly an hour between the time the insulin was given to the resident and the time NP B caught the transcription error. -The NP called and talked to the nurse, who changed and corrected the order. -The resident's blood sugar was monitored every hour after that. -This resident was a short term care resident. -EMS administered a bolus to the resident right at the facility and started an IV drip. -If the resident had responded, he/she would have stayed at the facility. -For these residents, when the actual discharge orders were received, they were transcribed into the electronic medical record (EMR). -The nurse who was in charge with entering orders would put the resident's orders in the EMR. -It could be the nurse who was going to give care to the resident or it could be the charge nurse or nurse manager who would put the orders in. -It would not necessarily be abnormal for a 45 unit dose of insulin, so it would not necessarily flag. -If a nurse were transcribing, he/she should be aware the orders he/she is entering are the same as the previous facility's final discharge orders. -If needed, the orders could be printed out. -It should be clarified with the provider if there are any questions on orders. -He/she thought this could have been prevented; it was an unfortunate error. -This nurse was a competent nurse. -The facility wanted the nurses to report medication errors. During an interview on 1/30/23 at 11:50 A.M., NP B said: -He/she reviewed the resident's discharge orders from the hospital. -NP A glanced through the orders in the EMR and saw that 12 units was the correct dose of insulin and 45 ml was the dose in the insulin pen. -As soon as they discovered the error, they called the nurse and asked if the insulin had been given. -The nurse said he/she had given the insulin. -He/she then ordered hourly blood sugar tests to be done, and monitoring the resident for symptoms. -Glucagon was ordered in case the resident needed it. -The nurse called him/her about every hour. -When the resident became unresponsive, EMS was called. -He/she said it was alright to keep the resident at the facility if they could get his blood sugar up and he/she became responsive. -Since that didn't happen, the resident was sent to the hospital. During an interview on 1/30/23 at 12:10 P.M., ADON A said: -Typically when the facility got orders for a resident from the hospital, someone in upper management would put the orders in the EMR. -The orders would go into a queue until the resident actually arrived at the facility. -When the resident arrived, the orders would be activated. -Within 24 hours, a chart audit would be done. -Pharmacy would also do an audit of the hospital orders and facility orders within 24 hours. -The transcription error was caught because NP A was doing an order reconciliation and found it. -NP A called the nurse and asked if the insulin had been given. -New orders were given by NP B. -He/she had been a nurse for 20 years and had never had this happen before -He/she should have checked the orders. During an interview on 1/30/23 at 1:43 P.M., NP A said: -He/she caught the order transcription error on 1/26/23 at about 10:30 P.M. -He/she called the nurse and asked if the insulin had already been administered. -He/she told the nurse to check Resident #1's blood sugar and notified NP B. -The nurse called NP B with the blood sugar result. -At that point, he/she was done because NP B took over. During an interview on 1/30/23 at 2:00 P.M., ADON B said: -They were notified by their marketer that an admission was coming to the facility, and they would get the resident's hospital discharge orders. -Either the ADON, DON, or wound nurse would input those orders into the resident's EMR. -When the resident arrived at the facility, the nurse on duty should double check the EMR orders against the hospital orders prior to activating them. -This should be happening with every admission. -A chart audit would be done the next morning. -A dose of 45 units of insulin would not necessarily be an unusual order. During an interview on 1/30/23 at 2:30 P.M., the Administrator said: -The expectation was that the orders would be transcribed correctly, and the orders would be followed. That should have happened. -The nurse who administered the insulin followed the order as it had been entered in the EMR. -The staff and team did everything they could have done considering the situation. During an interview on 1/30/23 at 3:15 P.M., the hospital RN A said: -The resident would go back to his/her facility that evening. -He/she was not cognitively intact. -He/she was at his baseline, regarding blood sugars levels. -Upon arrival at the hospital, his/her blood sugar was 115 and had been within normal limits. During an interview on 2/14/23 at 9:50 A.M., LPN A said: -The resident was given 45 units of Lantus one time. -He/she did not think this was an unusual dose, because the resident's blood sugar was so high. -He/she called NP B when the resident had a blood sugar of 69, because this seemed a rapid drop and the resident was behaving abnornally, first combative and then lethargic. -He/she received a verbal order from NP B to give the Glucagon. -He/she should have charted the verbal order. -The last dose of Glucagon the resident received was given by the EMT in his/her IV. MO00213169 MO00213225

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to find appropriate long-term placement prior to discharging one sampled resident (Resident #4) out of three residents discharged from the facility. Review of the resident's written discharge notice showed the facility listed the discharge location as an acute hospital and did not list a long-term placement for the resident. The facility also notified the hospital that they would not take the resident back. The facility census was 109 residents. Record review of the facility's undated policy Facility-initiated Discharge Policy with Criteria showed: -The facility Administrator would notify the resident and/or the resident's representative of the need for a transfer and reasons for discharge in writing. -The letter would include the location to which the resident is expected to be transferred or discharged to, address, phone number and name and direct contact phone number of contact person at planned transfer location. 1. Record review of Resident #4's admission record showed he/she was admitted on [DATE]; his/her primary payer source was Missouri Medicaid and was his/her own responsible party. Record review of the resident's discharge assessment dated [DATE] showed: -The resident was being discharged /transferred to an acute hospital. -The discharge/transfer was unplanned. -The resident's return to the facility was anticipated. Record review of the resident's bed hold notice dated 10/24/22 at 11:45 A.M. showed: -The resident chose not to reserve his/her room. -If the resident's stay was paid by Medicaid, the resident's bed would be held at no cost to the resident for a maximum of 10 days in a calendar month. If the resident was hospitalized beyond 10 days, the resident or their representative could choose to request the bed hold to be extended but the resident must use their own funds to pay for the extended bed hold. -If a resident did not hold their bed and they wished to return to the facility, they would be allowed to return to their previous room if it was available, or immediately upon the first availability of another bed in a semi-private room if the resident was eligible for Medicaid nursing facility services or Medicare skilled nursing facility services. Record review of the resident's Notice of Transfer/discharge date d 12/12/22 showed: -The resident was being discharged from the facility because the resident had not resided in the facility for more than 30 days. -The discharge was effective 12/12/22. -The discharge was appropriate because the resident's welfare and the resident's needs could not be met by the facility. -The resident was being discharged to the hospital. -There was no appropriate long-term care placement. During an interview on 12/16/22 at 8:15 A.M., the Administrator said: -The Business Office Manager talked to the resident about holding his/her bed, told the resident how much it would cost and asked the resident if he/she wanted to hold his/her bed and he/she declined. -They told the hospital Social Worker that the resident did not want to hold his/her bed. -The resident called him/her on 11/22/22 about returning to the facility and he/she reminded the resident he/she wasn't holding his/her bed. -The resident was out of the building for more than 30 days. -They did not hear anything from the hospital for a couple of weeks. -The hospital Social Worker closed the resident's case with the facility over two weeks ago so they couldn't tell what was going on because they no longer have the referral access to the resident's hospital records. -On 12/9/22, the hospital called and said the resident wanted to come back to the facility so they issued an immediate discharge notice on 12/12/22. During an interview on 12/16/22 at 10:50 A.M., the Administrator said: -The hospital Case Manager called the facility on 12/12/22 and said the resident was ready to come back to the facility. -He/she explained to the hospital Case Manager that the hospital closed the referral and they no longer had access to the resident's records for admission review. During an interview on 12/16/22 at 11:13 A.M., the hospital Case Manager A said: -The resident was medically stable to be discharged from the hospital back to the facility on [DATE]. -They closed the referral (on 11/30/22) to this facility because the facility declined to accept the resident back. -On 12/12/22, the facility delivered a discharge letter to the resident at the hospital. -The resident was still in the hospital and they were working on finding other placement for the resident since the facility would not accept the resident back. During an interview on 12/16/22 at 2:02 P.M., the [NAME] President of Business Development said he/she tried to deliver the immediate discharge letter to the resident on 12/12/22 and the resident refused to take it so he/she left it with hospital Case Manager B. During an interview on 12/16/22 at P.M., the Administrator said, when asked if he/she understood the hospital to be an appropriate place to discharge the resident to long-term, he/she thought the resident was discharged since he/she did not want a bed hold, had previously said he/she did not want to come back and had been gone from their facility for more than 30 days without a bed hold. MO00210661

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #297's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Abscess (a confined pocket of puss) of the groin. -Unsteadiness of the feet. -Difficulty walking. Record review of the resident's POS dated June 2022 showed: -Nystatin Powder (used to treat fungal infections) 100,000 unit per gram to be applied to the perineal area (peri area an area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum) topically three times a day for yeast prevention, dated 6/16/22. -There was no order for the resident to self administer the medication. Record review of the resident's admission MDS dated [DATE] showed: -His/her Brief Interview for Mental Status BIMS score was 15 indicating he/she was cognitively intact. -He/she needed supervision or oversight to walk between locations in his/her room. -He/she used a walker. -He/she had an application of medication other than to his/her feet. Record review of the resident's undated care plan showed: -The resident had the potential for impairment to skin integrity related to reduced mobility. -The resident had an Activity of Daily Living (ADL) self-care performance deficit and limited physical mobility related to abscess of the groin and obesity. -The resident use a wheelchair. Observation on 6/28/22 at 9/21 A.M. during a medication pass showed LPN J: -Removed the resident's Nystatin powder from the medication cart. -Took the resident's Nystatin powder into the resident's room and placed it on the resident's bedside table. -Left the Nystatin powder in the resident's room and left the room. -Did not apply the Nystatin powder and did not see the resident apply the Nystatin powder to his/her peri area. During an interview on 6/28/22 at 9:25 A.M., LPN J said: -The resident would go into the bathroom and apply the Nystatin powder to his/her peri area himself/herself. -There was no order for the resident to self administer the Nystatin powder. -The resident was alert and oriented and he/she did not think a physician's order was needed. 3. During an interview on 6/28/22 at 10:32 A.M., the Nurse Practitioner (NP) said: -He/she would expect there to be an order for residents to have medication at bedside. -He/she would expect staff to follow protocol on medication administration and policy for keeping medications at bedside. During an interview on 6/30/22 at 9:09 A.M. LPN H said: -Staff should not leave any medications at a resident's bedside. -Staff would need a physician's order to leave a medication at bedside. -There would have to also be an evaluation for self administering the medication for the resident. -There was no evaluation or physician's order to allow the resident to have the Nystatin powder left at his/her bedside for self administration. During an interview on 6/30/22 at 4:15 P.M., the Acting Chief Director of Nursing (DON) said: -He/she would not expect a nurse to ask a resident if he/she had their own pain cream in their room. -Nurses should not leave medications of any type at a resident's bedside or in their room unless there was a Physician's order to have the medication at bedside. -There should be a Physician's order for any medication to be kept in a resident's room. -If a resident had an order to keep a medication in his/her room he/she should be educated on the usage of the medication, demonstrate proper usage of it, and understand proper storage of the medication. Based on observation, interview and record review, the facility failed to have a physician's order to keep medications at the resident's bedside and to assess the resident's ability to self administer for one supplemental resident (Resident #4) and one sampled resident (Resident #297) out of 21 sampled and supplemental residents. The facility census was 103 residents. Record review of the facility's Administration of Medications policy dated February 2018 showed: -If medication was ordered but not available, check to see if it was misplaced and then call the pharmacy to obtain the medication. -Remain with the resident to ensure that the resident swallows the medication. -Once the resident took the medication hit save on the Electronic Medication Administration record (eMar). -NOTE: This policy did not address resident's having medications at bedside. The facility did not provide a policy to include keeping medications at a resident's bedside. 1. Record review of the Resident #4's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 6/16/22 showed: -He/she was admitted on [DATE]. -His/her cognition was intact. -He/she had the following diagnoses: --Renal Insufficiency (also known as Renal Failure a condition in which the kidneys can't filter waste from the blood). --Coronary Artery Disease (CAD-the arteries that supply blood to the heart get clogged with fatty deposits and increases the risk for a heart attack). --Heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). During an observation of the resident's medication pass on 6/24/22 at 5:25 A.M., showed Licensed Practical Nurse (LPN) D: -Telling the resident that his/her Lidocaine Cream (an anesthetic (a substance that induces insensitivity to pain causing loss of feeling in the skin and surrounding tissues to prevent and treat pain from some procedures) was not in the medication cart. -Ask the resident if he/she had his/her Lidocaine Cream in the drawer of his/her nightstand. -Looking in the resident's nightstand drawer, there was no Lidocaine Cream in the drawer. -Found the resident's Lidocaine Cream in a small basket on the resident's sink. -Applied the Lidocaine Cream to the resident's left arm Dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) Fistula/Shunt (a surgically placed device that connects an artery to a vein in preparation for dialysis). During an interview on 6/24/22 at 5:25 A.M., LPN D said: -He/she didn't have the resident's tube of Lidocaine Cream on the medication cart. -The resident had his/her own tube in his/her room. -He/she would use that until he/she got a new tube for the resident. -The resident usually kept a tube of the Lidocaine Cream in his/her room. -As far as he/she knew the resident could have the Lidocaine Cream in his/her room. -The Lidocaine Cream was ordered by the Physician. Record review of the resident's Physician Order Summary (POS) dated June 2022 showed there was no order to have or keep the resident's Lidocaine Cream at bedside or that the resident could self administer the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pain medications were administered as ordered for one supplemental resident (Resident #10) out of 21 sampled and supplemental residents. The facility census was 103 residents. Record review of the facility's pain management policy dated November 2018 showed: -If the resident has been identified with pain, the resident will undergo reassessment of pain at least once per shift and before and after every pain control mechanism employed by the elder's care providers. -Healthcare providers that have implemented a pain control mechanism, will reassess the resident to determine amount of pain control or relief achieved. -Pain control mechanisms may include administering medications for the control or relief of pain. 1. Record review of Resident #10's face sheet showed he/she was admitted to the facility on [DATE] and some of his/her diagnoses included: -Diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -Chronic kidney disease (kidneys are damaged and can't filter blood the way they should). -Lymphedema (swelling of one's arms and/or legs). -Multiple myeloma (cancer of plasma cells that can cause bone pain). -Kyphosis (abnormally curved spine). -Osteoporosis (decrease in bone mass and density and enlargement of bone spaces producing fragility). -Peripheral Vascular Disease (PVD-the build-up of fatty material inside the blood vessels). Record review of the resident's undated care plan showed the resident received pain medication related to multiple myeloma, neuropathy (damage to the nerves resulting in sensory loss in the extremities), osteoporosis, PVD and lymphedema. Record review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 6/21/22 showed the following facility assessment of the resident: -Was cognitively intact. -Understands others. -Is understood by others. -Some of his/her diagnoses included PVD, kidney disease, diabetes, osteoporosis. -Received scheduled pain medication, pain medication as needed and non-medication interventions for pain. -Reported constant pain with the worst pain experienced rated as a 10 (out of a scale of 0-10 with 10 being the worst pain). -Reported pain made it hard to sleep at night at times. -Reported pain limited his/her day to day activities at times. Record review of the resident's June 2022 Medication Administration Records (MAR) and his/her June 2022 Medication Administration Audit Report showed: -A physician's order for Lyrica (used to treat pain from nerve damage) 75 milligram (mg) twice a day for chronic pain management that was scheduled for 8:00 A.M. and 5:00 P.M. -Lyrica was documented as administered on the MAR but the evening dose was not on the audit report. -A physician's order for Morphine (a narcotic pain medicines that acts on the central nervous system to relieve pain) 15 mg twice a day for chronic pain management that was scheduled for 8:00 A.M. and 8:00 P.M. Record review of the resident's Medication Administration Audit Report showed the dates and times the resident received his/her Morphine and morning dose of Lyrica more than one hour over or less than the previous dose (Morphine scheduled for 12 hours apart): -6/2/22 8:06 P.M. to 6/3/22 9:43 A.M. was 13 hours 37 minutes (13:37) apart with a pain scale of 10 (0-10 with 10 being the worst pain). -6/6/22 7:47 A.M. to 9:03 P.M. was 13:16 apart with a pain scale of 10. -6/7/22 7:39 P.M. to 6/8/22 10:03 A.M. was 14:24 apart with a pain scale of 10. -6/8/22 10:03 A.M. to 6/9/22 5:56 A.M. was 19:53 apart with a pain scale of 10. -6/9/22 5:56 A.M. to 6/9/22 3:10 P.M. was 9:14 apart with a pain scale of 10. -6/9/22 3:10 P.M. to 9:43 P.M. was 6:33 apart with a pain scale of 10. -6/9/22 9:43 P.M. to 6/10/22 2:42 P.M. was 16:59 apart with a pain scale of 10. -6/10/22 2:42 P.M. to 8:53 P.M. was 6:11 apart with a pain scale of 10. -6/11/22 7:54 A.M. to 9:44 P.M. was 13:50 apart with a pain scale of 2. -6/12/22 7:56 A.M. to 9:25 P.M. was 13:29 apart with a pain scale of 0. -6/13/22 7:21 A.M. to 9:52 P.M. was 13:31 apart with a pain scale of 10. -6/14/22 8:39 A.M. to 10:43 P.M. was 14:04 apart with a pain scale of 0. -6/15/22 8:43 P.M. to 6/16/22 10:30 was 13:37 apart with a pain scale of 10. -6/16/22 9:06 P.M. to 6/17/22 10:51 A.M. was 13:45 apart with a pain scale of 10. -6/18/22 9:31 P.M. to 6/19/22 11:43 A.M. was 14:03 apart with a pain scale of 10. -6/21/22 7:19 P.M. to 6/22/22 11:29 A.M. was 16:10 apart with a pain scale of 10. -6/22/22 11:29 A.M. to 8:37 P.M. was 9:08 apart with a pain scale of 10. -6/22/22 8:37 P.M. to 6/23/22 2:24 P.M. was 17:47 apart with a pain scale of 10. -6/23/22 2:24 P.M. to 9:29 P.M. was 7:05 apart with a pain scale of 10. -6/26/22 7:30 A.M. to 10:09 P.M. was 14:39 apart with a pain scale of 2. -6/26/22 10:09 P.M. to 6/27/22 7:36 A.M. was 9:27 apart with a pain scale of 2. -6/27/22 7:36 A.M. to 9:32 P.M. was 13:56 apart with a pain scale of 10. -The resident's Morphine and Lyrica were administered on 6/28/22 at 9:57 A.M. with a pain scale of 10. During an interview on 6/28/22 at 10:15 A.M., the resident said he/she just got his/her pain medications and that he/she was supposed to get them at 8:00 A.M. During an interview on 6/28/22 at 1:29 P.M., the resident said he/she was in pain that morning between 8:00 A.M. and 10:00 A.M. During an interview on 6/30/22 at 4:00 P.M., the Acting Director of Nursing (DON) said the resident should be getting his/her pain medication so that is generally 12 hours apart, giving up to an hour before or an hour after the scheduled times.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%. The facility had two errors out of 25 opportunities making the facility error rate 8%. The facility census was 103 residents. Record review of the facility's Administration of Medications policy dated February 2018 showed: -Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. -Remove medication from (medication) drawer and read label three times. -If there is a discrepancy between the Medication Administration Record (MAR) and the label, check orders before administering medications. Record review of the facility's Pharmacy Services dated April 2022 showed: -Assure that the correct medication is administered in the correct dose, in the correct dosage form. 1. Observation on 6/24/22 at 5:25 A.M. of the resident's medication pass, showed Licensed Practical Nurse (LPN) D: -Told the resident that his/her Lidocaine Cream (an anesthetic causing loss of feeling in the skin and surrounding tissues) was not in the medication cart. -Asked the resident if he/she had his/her Lidocaine Cream in the drawer of the nightstand. -Looked in the resident's nightstand drawer, there was no Lidocaine Cream in the drawer. -Looked around the room for the resident's Lidocaine Cream. -Found the resident's Lidocaine Cream in a small basket on the resident's sink. -Applied the Lidocaine Cream to the resident's left arm Dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) Fistula/Shunt (a surgically placed device that connects an artery to a vein in preparation for dialysis) site. -The resident's tube of Lidocaine Cream was 2.5 percent (%) Lidocaine. -The resident's MAR showed Lidocaine Cream 4%. -The Lidocaine Cream was at the resident's bedside without a physician's order and using the resident's own medication which was not the correct strength (dose). -15 medications were administered with one error. During an interview on 6/24/22 at 5:25 A.M., LPN D said: -He/she didn't have the resident's tube of Lidocaine Cream on the medication cart. -The resident has his/her own tube in his/her room. -He/she would use that till he/she gets a new tube for the resident. -The resident usually keeps a tube of the Lidocaine Cream in his/her room. -The Lidocaine Cream was ordered by the Physician. 2. Observation on 6/28/22 at 9:21 A.M. during a medication pass showed LPN J showed: -Removed the resident's Nystatin powder (an antifungal that works by stopping the growth of fungus) from the medication cart. -Took the resident's Nystatin powder into the resident's room and placed it on the resident's bedside table. -Left the Nystatin powder in the resident's room and left the room. -Did not apply the Nystatin powder and did not see the resident apply the Nystatin powder to his/her perineal (peri area an area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum) area. -10 medications were observed with one error. -The Nystatin powder was left at bedside without a physician's order. During an interview on 6/28/22 at 9:25 A.M., LPN J said: -The resident would go into the bathroom and apply the Nystatin powder to his/her peri area himself/herself. -There was no order for the resident to self administer the Nystatin powder. -The resident was alert and oriented and he/she did not think a physician's order was needed. 3. During an interview on 6/28/22 at 10:32 A.M., the Nurse Practioner (NP) said: -He/she would expect nurses to follow policy and protocol on medication administration. -He/she would expect nurses to check for the right dose of a medication before administering. -He/she would expect resident to have an order to leave medications at bedside. -He/she would expect resident's to be evaluated to determine their ability to self administer medications. During an interview on 6/30/22 at 4:15 P.M., the Acting Chief Director of Nursing (DON) said: -He/she would not expect a nurse to ask a resident if he/she had their own pain cream in their room. -He/she would expect the nurse to double check a medication order and the actual medication to be sure the medication was the right dose before administering it. -If the right dosage of a medication was not on the medication cart he/she would expect the nurse to obtain the right dosage of a medication and not use the resident's wrong dosage of the medication. -There should be a Physician's order for any medication to be kept in a resident's bedside.

Based on observation, interview and record review, the facility failed to maintain an air gap (the unobstructed vertical space between the water outlet and the flood level of a fixture) between the drainage pipe from the ice machine and the floor drain on the floor next to the ice machine and failed to place a grate over an 8 inch (in.) diameter drainage hole for the washing machines in the laundry area. This practice affected two non-resident use areas. The facility census was 103 residents. 1. Observations on 6/22/22 at 9:22 A.M. and on 6/27/22 at 1:31 P.M., showed: -The absence of an air gap between the ice machine drainage pipe. -The ice machine drainage pipe resting on top of a white padding over the drainage hole under the ice machine with a black substance around the drainage pipe. During an interview on 6/27/22 at 1:32 P.M., the Dietary Manager (DM) said the drainage pipe needed to be lifted from the drainage area so there could be an air gap. Observation on 6/27/22 at 1:33 P.M., showed Maintenance Director B lifted up the drainage pipe from the floor drain next to the ice machine. 2. Observations on 6/23/22 at 9:41 A.M. and on 6/29/22 at 10:40 A.M., showed the absence of a grate (a framework of parallel or crossed bars, used as a partition, a guard, or as a cover, over an opening to prevent objects that should not go into that opening, from going into that opening). During an interview on 6/23/22 at 9:42 A.M., the Maintenance Director said he/she did not have a grate for that opening in the drainage area from the washing machines and in the past, drainage from the washing machines, has backed up because larger objects sometimes get down in there. Observation with Housekeeper C on 6/29/22 at 10:40 A.M. showed the width of the opening at the washing machine drainage area, was 8 in. Record review of the 2009 Food and Drug Administration (FDA) Food Code showed: -In Chapter 5-202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment, shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch (in.) MO 00202729

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Record review of Resident #88's face sheet, dated 6/29/22, showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Encephalopathy (brain disease, disorder, or damage. The term refers to temporary or permanent conditions that affect the brain's structure or function). -Acute kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance). -Generalized muscle weakness. Record review of the resident's care plan, dated 6/9/22, showed: -The resident had impaired cognitive ability related to health conditions of recent encephalopathy and infection. --The resident will be able to communicate basic needs on a daily basis. -The resident had an Activities of Daily Living (ADL) deficit and limited physical mobility related to weakness. -The resident had actual falls related to weakness and anxiety. --The resident will be free of minor injury. --Interventions included: ---Ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. ---The resident needed prompt response to all requests for assistance. Record review of the resident's quarterly MDS dated [DATE], showed: -The resident scored a 10 on the Brief Interview for Mental Status (BIMS). --This showed that the resident had moderate cognitive impairment. Record review of the resident's Call Light Device Activity Log dated 6/14/22 through 6/28/22, showed: -The resident used the call light 100 times in an 15 day period. -Of the 100 times the resident pushed the call light there were 12 instances that the response time was more than 10 minutes: -On 6/14/22, the response time was 42 minutes and 31 seconds. -On 6/14/22, the response time was 15 minutes and 40 seconds. -On 6/17/22, the response time was 19 minutes and 58 seconds. -On 6/18/22, the response time was 17 minutes and 26 seconds. -On 6/18/22, the response time was 17 minutes and 12 seconds. -On 6/18/22, the response time was 32 minutes and 7 seconds. -On 6/18/22, the response time was 37 minutes and 35 seconds. -On 6/22/22, the response time was 16 minutes and 15 seconds. -On 6/24/22, the response time was 44 minutes and 42 seconds. -On 6/24/22, the response time was 16 minutes and 45 seconds. -On 6/27/22, the response time was 11 minutes and 23 seconds. -On 6/26/22, the response time was 37 minutes and 29 seconds. During an interview on 6/29/22 at 2:26 P.M., the wound nurse said: -The resident had a paddle/easy touch call light. -All the resident had to do was bump it or light touch it. -The resident was aware how to use it. 9. Record review of Resident #17's face sheet showed the resident was re-admitted to the facility on [DATE] with the following diagnoses: -Difficulty in walking. -Congestive Heart Failure (a chronic condition in which the heart does not pump blood as effectively as it should). -Need for assistance with personal cares. -Glaucoma (a group of eye conditions that can cause blindness). -Chronic fatigue (a disease characterized by profound fatigue, sleep abnormalities, pain and other symptoms that are made worse by exertion). -Renal Dialysis (a treatment for people whose kidneys are failing). Record review of the resident's Annual MDS dated [DATE] showed the resident: -Was cognitively intact. -Needed extensive assistance of two or more staff. -Was totally dependent on staff for cares. Record review of the resident's care plan dated 4/4/22 showed: -The resident had a activity of daily living self-care deficit and limited physical mobility related to fatigue, impaired balance, and limited mobility. -Staff were to encourage the resident to use the call light for assistance. -Staff were to ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. -The resident needed prompt response to all requests for assistance. Observation on 6/22/22 at 11:50 A.M. showed: -He/she did not know where his/her call light was at. -The call light was attached to the bed frame behind him/her. -He/she was in his/her wheelchair facing the door with his/her back to the bed. -He/she was not able to reach call light. -The call light was more than four feet behind him/her. Observation on 6/22/22 at 12:24 P.M. showed: -The call light was attached to the bed frame behind him/her. -He/she was in his/her wheelchair facing the door with his/her back to the bed. -He/she was not able to reach call light. -The call light was more than four feet behind him/her. -He/she was not able to move the wheelchair over to the bed to reach the call light. During an interview on 6/22/22 at 12:24 P.M. the resident said he/she had to remind the staff to give him/her the call light every day. Observation on 6/30/22 at 12:35 P.M. showed: -The call light was laying on the resident's bed. -The resident was up in his/her wheelchair with his/her back to the bed. -The resident was not able to reach the call light. During an interview on 6/30/22 at 12:35 P.M. the resident said he/she would just have to wait until staff came around again. 10. Record review of Resident #302's face sheet showed the resident was admitted on [DATE] with the following diagnoses: -Hemiplegia (paralysis of one side of the body). -Transient Ischemic Attack (TIA a brief stroke like attach that could resolve within minutes to hours requiring immediate medical attention). -Aphasia (a language disorder that affects a person's ability to speak). -Seizures (a sudden electrical disturbance in the brain). -Paroxysmal Atrial Fibrillation (an irregular rapid heart rate that causes poor blood flow). Record review of the resident's care plan dated 6/13/22 showed: -He/she was severely cognitively impaired. -Was difficult to assess related to aphasia diagnosis. -The resident was able to communicate only basic needs. -The staff were to ensure and provide a safe environment. -Call light should be within reach. Record review of the residents admission MDS dated [DATE] showed: -His/her BIMS score was three - severely cognitively impaired. -He/she was totally dependant on staff to transfer with the assistance of two staff members. Observation on 6/29/22 at 9:10 A.M. showed: -The resident's call light was on the floor. -The resident put his/her hand under the pillow reaching for the call light. During an interview on 6/29/22 at 9:10 A.M. the resident said: -The call light was usually under his/her pillow. -He/she did not know what he/she would do if he/she needed the nurse. -The staff checked on him/her every couple of hours. -He/she would have to wait until the staff came back to check on him/her. Observation on 6/29/22 at 11:00 A.M. showed the call light was on the nightstand not within reach of the resident. During an interview on 6/29/22 at 11:00 A.M. the resident said: -The staff must have left the call light on the nightstand. -He/she was not able to reach the call light. 11. Record review Resident #303's face sheet showed he/she was admitted with the following diagnoses: -Acute kidney failure (a condition in which the kidneys can't filter waste from the blood. -Acute embolism and thrombosis of left lower extremity (a blood clot that reduces the blood flow throughout the vessel). -Generalized muscles weakness. -Anemia (a condition in which the blood does not have enough healthy red blood cells). -Edema (swelling caused by excess fluid trapped in the body's tissues). -Osteoarthritis (wearing down of the protective tissue at the end of the bones). -Sleep apnea (a sleeping disorder where breathing starts and stops). -Pneumonia (infection in which it inflames the air sacs in the lungs which may fill with fluid). -Old Myocardial infarction (the patient had a heart attack in the past). -Dizziness and giddiness (a possible inner ear infection, motion sickness, or an effect from medications). -Shortness of breath. Record review of the resident's admission MDS dated [DATE] showed: -The resident needed extensive assistance for bed mobility. -The resident did not walk. Record review of the resident's care plan dated 6/29/22 showed: -The resident had an ADL self-care performance deficit and limited physical mobility. -The resident was at risk for falls. -The resident had altered respiratory status and difficulty breathing related to sleep apnea. -Staff were to ensure the resident's call light was within reach and to encourage the resident to use it. -The resident needed prompt response to all requests for assistance. Observation on 6/29/22 at 9:30 A.M. showed: -The resident's call light was attached to the top of the mattress. -The resident was not able to lift his/her arms above his/her shoulders to reach the call light. -He/she could not see where the call light was. During an interview on 6/29/22 at 9:35 A.M. the resident said: -Sometimes the staff will put the call light out of reach. -He/she had to wait until someone came into the room to ask for help. -The call light should be attached to his/her clothing at chest level or lower for him/her to reach it. -He/she did not like the call light being out of reach because he/she could not get the help when he/she needed it. 12. During an interview on 6/27/22 at 11:45 A.M., CNA A said: -He/she answered the call lights as soon as he/she saw them. -Some resident cares took longer, and when he/she was in the middle of the care then it would take a little longer to get to the other residents. -He/she would ask the resident what was needed. -He/she would turn the call light off when he/she went into the room to answer the call light and assist the resident. -He/she made sure the call light was in reach with bed control. -He/she checked each resident every two hours. -He/she had customer service training before being hired. -He/she had training also from facility. -He/she had been a CNA for 10 years. During an interview on 6/27/22 at 11:51 A.M., CNA B said: -He/she had been at the facility for three months. -He/she tried to answer call lights in three to five minutes. -He/she answered call lights as soon as he/she saw them on the marquee at the end of the hall. -He/she recently had an in-service on resident rights and being respectful. During an interview on 6/27/22 at 12:00 P.M., Licensed Practical Nurse (LPN) A said: -It was everyone's responsibility to answer call lights. -Staff had to stay within the scope of their abilities. -He/she tried to answer the call lights within 15 minutes. During an interview on 6/28/22 at 1:50 P.M. LPN C said: -Staff were to do rounds on the residents to see if they need anything. -Staff would ensure the call light was within reach in case the resident needed anything. During an interview on 6/29/22 at 12:50 P.M. CNA Q said: -He/she checked on the residents at a minimum of every two hours. -Before he/she left the room he/she ensured the call light was within the resident's reach. -If a resident could not raise their arms, the call light should not be above their head. -If a resident was in a wheelchair the call light should be in their lap. -He/she had education during orientation and they just had a skills fair about call lights. During an interview on 6/30/22 at 8:19 AM CNA F said: -He/she was unaware of the facility having call lights frequent issues. -Sometimes they got pulled out of the wall and had to be plugged back in. -Sometimes the call light got wrapped up in the blankets on the bed and may come unplugged. -Response time varied, he/she tried to keep it under five minutes. -Sometimes it took longer when he/she was tied up doing something with another resident, maybe took ten minutes. -Most cares weren't too difficult but if they were it took longer to complete and get to the other call lights. -Sometimes he/she forget to turn off the call light. During an interview on 6/30/22 at 9:37 A.M., CNA E said: -He/she had not noticed if the call lights were not working correctly. -His/her response time was pretty quick. -He/she may be helping another resident and it may have slowed his/her response time. -If a resident had more intense cares it might take longer to get to the next call light. During an interview on 6/30/22 at 2:13 P.M., the Administrator said: -Call lights were an ongoing concern and an identified issue. -Two months ago the facility identified call lights as an area of opportunity for improvement. -Three weeks ago the facility started doing angel rounds where each director had a specific set of five to eight rooms where they went in and talked to the resident. -The residents had an opportunity to identify concerns. -Those concerns were brought to the Stand-up and Stand down meetings as well as Quality Assurance Performance Improvement(QAPI) meetings. -The staff were struggling with using the pagers, they were difficult to use and the staff didn't like them. -He/she was still working on how to handle the pager issue. -The marquee boards at end of hallway were in proper use and visible from all areas of the hall. -Call light issues were addressed daily. -Sometimes staff forgot to turn the light off. -He/she provided constant education to staff on not forgetting to turn the call light off. During an interview on 6/30/22 at 4:09 P.M., the acting Chief Nursing Officer (CNO) said: -The residents should be checked on at a minimum of every two hours. -The staff should ensure the call light was in reach before they left the resident's room. -The call light should always be within reach of the resident. -He/she expected call lights to be answered within ten minutes, sometimes 20 minutes, given the situation at the time. -Benchmark was under ten minutes but a reasonable time line was less than 20 minutes. -He/she would expect the call light to work. -Sometimes staff left the call light on after checking the resident. -Staff were provided training regarding checking call light equipment, batteries in the pagers and response time. -Call light response was discussed as an ongoing issue. -Sometimes residents' perception of time was a little altered, five minutes could have felt like an hour. -There was a Performance Improvement Plan (PIP) in place for call lights. -In the clinical administration office on the unit there were call light monitors that nursing administration could look at to see how the long call light was on. -Administration had instituted guardian rounds with call lights. MO00203209 Based on observation, interview and record review, the facility failed to ensure the resident's bed fit him/her properly for one sampled resident (Resident #194); failed to ensure resident needs were met by facility staff not answering call lights in a timely manner for five sampled residents (Residents #62, #194, #80, #26, and #88) and three supplemental residents (Residents #4, #68 and #12); and to ensure call lights were within reach for one sampled resident (Resident #17) and two supplemental residents (Residents #302, and #303) out of 21 sampled residents. The facility census was 103 residents. Record review of the facility's call light policy dated November 2018 showed: -The call light system was provided as a tool for residents to communicate with staff. -Staff members would ensure the call lights were within reach of the resident who is able to use it each time they leave the room. 1. Record review of Resident #194's admission nursing evaluation dated 6/21/22 showed the resident: -Verbalized/demonstrated use of call light. -Was oriented to person. -Had clear speech. -Had weak hand grasps on his/her right side. -Was incontinent of bladder and bowel. Record review of the resident care plan initiated 6/21/22 showed: -The resident had self-care deficits related to a stroke, a decline in physical strength and function with some right-side weakness and instability. -The resident received physical assistance as needed and requested for bed mobility and positioning. -Instructions to staff to provide set-up for getting dressed and encourage self-dressing as able, provide additional support with lower body dressing as needed. -Instructions to staff to provide set-up with daily hygiene and grooming, encourage self-completion as able. -The resident required physical assistance with toileting/incontinence care. -The resident required set-up assistance and oversight to limited assist with transferring from one surface to another (such as from the bed to a wheelchair). -The resident used a wheelchair for independent mobility. -Physical and Occupational therapy evaluation and treatment as ordered. -Instructions to staff to ensure that the resident's heels are elevated while he/she is lying in bed, heel lift boots to be worn. -Provide skin prep to bilateral heels for preventive treatment. -The resident had potential for experiencing pain related to his/her knees. -Instructions for staff to assist the resident with positioning for comfort. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 6/28/22 showed the following assessment of the resident: -Was admitted to the facility on [DATE]. -Had clear speech. -Understood others and was understood by others. -Was cognitively intact. -His/her height was 5'11. -Required supervision with setup for transfers, walking in his/her room and personal hygiene. -Required limited assistance of one person with bed mobility and dressing. -Required extensive assistance of one person with toilet use. -Used a walker and a wheelchair for mobility. -Was always continent of bladder and occasionally incontinent of bowel. -Some of his/her diagnoses included heart disease, stroke, hemiplegia or hemiparesis and depression. -He/she received scheduled and as needed pain medication. -He/she occasionally experienced pain. A. Observation and interview on 6/22/22 at 10:19 A.M. showed: -The resident was lying in bed with the head of his/her bed at a 90 degree angle. -The resident was scrunched up where the bed went up. -The resident's feet were over the footboard at the end of bed with foot drop boots on. -The resident said he/she was not comfortable. -The Regional Chief Director of Nursing knocked on the door and asked if he/she could come in and he/she responded to the resident's call light. Observation and interview on 6/22/22 at 10:55 A.M. showed: -The resident was lying in bed with his/her feet on top of the footboard of the bed with foot drop boots on. -The resident said it bothered him/her having to have his/her feet on the footboard of the bed. Observation and interview on 6/27/22 at 12:55 P.M. showed: -The resident was lying in bed with foot drop boots on both feet with his/her feet on top of the footboard. -The resident said the bed was too short and someone was supposed to fix it today. Observation and interview on 6/28/22 at 1:22 P.M. showed: -The resident was lying in bed with his/her left foot in a foot drop boot which was resting on top of the footboard. -The resident's right foot was in a foot drop boot which was flat against the footboard of the bed. -The resident said he/she was uncomfortable due to his/her feet being on the footboard. During an interview on 7/12/22 at 11:26 A.M. the Administrator said: -The resident sits up in his/her bed a lot and the bed can be too short for taller people particularly when sitting up. -They have longer beds available. -He/she will ask the resident if he/she wants a longer bed. B. Record review of the device (a system that allows the residents to call for staff assistance through a communication system) activity report for this resident showed: -From 6/1/22-6/28/22 at 11:44 A.M., the resident's call light was on: --For 15-29 minutes 34 times. --For 30-59 minutes 15 times. --For 60-89 minutes six times. --For 90-119 minutes three times. --For over two hours once. During an interview on 6/22/22 at 10:55 A.M., the resident said: -It took a long time for staff to answer the call lights. -Sometimes no one answered the call light and he/she just had to wait until someone came in. -People walked by and didn't answer the call lights. -Sometimes he/she had to yell out to get someone to respond to the call light. Observation and interview on 6/28/22 at 1:31 P.M. showed: -The resident asked if his/her call light was on. -The red light on the call light plate on the wall was lit, indicating it was on. -The resident said when he/she had his/her call light on, he/she had to use his/her grab bar and twist and turn to look behind him/her to see if the red light was on. 2. Record review of Resident #4's face sheet showed the resident: -Moved into the facility on 6/19/21. -Had end stage kidney disease and heart disease. Record review of the resident's undated care plan showed the resident: -Required extensive assistance with dressing. -Was totally dependent upon staff for bed mobility, toilet use, transferring from one surface to another. Record review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Cognitively intact. -Required extensive assistance of two people for bed mobility. -Was totally dependent upon staff for transferring from one surface to another, locomotion, hygiene and toilet use. -Did not walk. During an interview on 6/23/22 at 9:58 A.M., the resident said: -He/she used the call light. -Sometimes the call lights didn't work. -The facility was going to re-[NAME] the call lights. -He/she had a beater stick to make noise on his/her over-bed tray and staff could hear him/her. -He/she could also holler out for staff. Record review of the device activity report for this resident showed: -From 6/1/22-6/28/22 at 10:37 A.M., the resident's call light was on: --For 15-29 minutes eight times. --For 30-59 minutes nine times. --For 60-89 minutes four times. --For 90-119 minutes once. --For over two hours twice. Record review of the device activity report showed: -From 6/1/22-6/28/22 at 10:37 A.M., the call light in the bathroom shared with his/her roommate in the resident's room was on: --For 15-29 minutes four times. --For 30-59 minutes three times. --For over two hours twice. --For over two and a half hours three times. 3. Record review of Resident #62's face sheet showed the resident: -Moved into the facility on 1/17/20. -Had diagnoses of hemiplegia (paralysis of one side of the body) or hemiparesis (a slight paralysis or weakness on one side of the body, diabetes (a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin), high blood pressure, heart disease and anxiety disorder (psychiatric disorders that involve extreme fear, worry and nervousness). Record review of the resident's care plan revised 4/26/22 showed the resident: -Had impaired cognitive function or impaired thought processes due to a stroke. -Required physical assistance with bed mobility, dressing, hygiene, toilet use, transferring from one surface to another. -Was incontinent of bowel and bladder. Record review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Had moderately impaired cognition. -Was totally dependent upon staff for bed mobility, transferring from one surface to another, dressing and hygiene. -Was always incontinent of bowel and bladder. During an interview on 6/22/22 at 10:07 A.M., the resident said call light response could take 30 minutes on average. During an interview on 6/23/22 10:23 A.M., the resident said it took about two hours the other night to get someone to reposition his/her leg in bed. Record review of the device activity report for this resident showed: -From 6/1/22-6/28/22 at 11:43 A.M., the resident's call light was on: --For 15-29 minutes five times. --For 30-59 minutes three times. --For 60-89 minutes two times. 4. Record review of Resident #68's face sheet showed the resident: -Moved into the facility on 2/13/21. -Had diagnoses of diabetes, lung disease, high blood pressure, major depressive disorder (depressed mood most of the day and a loss of interest in normal activities and relationships), overactive bladder, heart failure and kidney disease. Record review of the resident's undated care plan showed the resident: -Had impaired cognitive function. -Required limited assistance with bed mobility. -Required extensive assistance with dressing. -Required physical assistance with hygiene, toilet use and transferring from one surface to another. Record review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Was cognitively intact. -Required limited assistance of two people for bed mobility. -Required limited assistance of one person for dressing and hygiene. -Was totally dependent upon one person for toilet use. -Was totally dependent upon two or more staff for transferring from one surface to another. -Did not walk. During an interview on 6/23/22 at 10:33 A.M., the resident said: -His/her call light didn't work at times. -Sometimes he/she would holler for staff when he/she needed help. Record review of the device activity report for the resident showed: -From 6/1/22-6/28/22 at 10:03 A.M., the resident's call light was on: --For 15-29 minutes eight times. --For 30-59 minutes four times. --For 60-89 minutes two times. --For 90-119 minutes two times. 5. Record review of Resident #80's entry tracking form showed the resident moved into the facility on 3/16/21. Record review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Cognitively intact. -Required limited assistance of one person with hygiene. -Required extensive assistance of two people for bed mobility. -Was totally dependent upon one person for toilet use. -Was totally dependent upon two or more people for transferring from one surface to another. -Had a catheter (a tube passed through the urethra into the bladder to drain urine). -Was incontinent of bowel. -Some of his/her diagnoses included heart disease, kidney failure, diabetes, depression and lung disease. During an interview on 6/22/22 at 11:38 A.M., the resident said sometimes he/she had to wait a long time to get changed. Record review of the device activity report for this resident showed: -From 6/1/22-6/28/22 at 11:41 A.M., the resident's call light was on: --For 15-29 minutes 15 times. --For 30-59 minutes 17 times. --For 60-89 minutes six times. --For 90-119 minutes two times. --For 120-149 minutes two times. --For 150-179 minutes two times --For 188 minutes, 192 minutes and 197 minutes. 6. Record review of Resident #12's entry tracking form showed the resident moved into the facility on 9/15/21. Record review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Moderately cognitively impaired. -Required limited assistance of one for bed mobility, transferring from one surface to another, dressing, toilet use and hygiene. -Did not walk. -Was always incontinent of bowel and bladder. -Some of his/her diagnoses included heart failure, high blood pressure, diabetes, dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes), hemiplegia or hemiparesis and lung disease. Observation and interview on 6/24/22 at 5:48 A.M. showed: -The resident was in his/her wheelchair in his/her room. -The resident said he/she wanted someone to put him/her in bed. -The resident's call light was disconnected. -At 5:58 A.M., the resident wheeled out of his/her room in his/her wheelchair calling for a nurse, then asked a male resident to push him/her to the Administrator's office. The male resident pushed the resident towards Administrator's office. Observation on 6/27/22 at 12:31 P.M. showed: -The resident's call light did not turn on when pressed. -The resident's roommate turned on his/her call light for the resident. Record review of the device activity report for the resident showed: -From 6/1/22-6/28/22 at 10:03 A.M., the resident's call light was on: --For 15-29 minutes six times. --For 30-59 minutes seven times. --For 60-89 minutes one time. --For 90-119 minutes three times. --For over two hours twice. 7. Record review of Resident #26's face sheet showed the resident: -Moved into the facility on 4/22/21. -Diagnoses including hemiplegia and hemiparesis, high blood pressure, dementia, depression, kidney disease and heart disease. Record review of the resident's undated care plan showed the resident: -Had impaired cognitive function or impaired thought process related to dementia. -Required extensive to total physical assistance with dressing. -Was totally dependent upon assistance of two staff with transferring from one surface to another. -Required physical assistance with bed mobility, hygiene and toilet use. -Had bowel and bladder incontinence. -Required supervision to limited physical assistance of one person with bed mobility. -Required extensive assistance to total physical assistance with dressing. -Required extensive assistance of two or more people with transferring from one surface to another. Record review of the resident's annual MDS dated [DATE] showed the following staff assessment of the resident: -Cognitively intact. -Required supervision of one person with bed mobility. -Required extensive assistance of one person with dressing, toilet use and hygiene. -Required extensive assistance of two people with transferring from one surface to another. -Did not walk. -Was occasionally incontinent of bladder and frequently incontinent of bowel. -Some of his/her diagnoses included heart disease, high blood pressure, kidney disease, arthritis (an inflammatory condition of the joints), stroke, dementia, hemiplegia or hemiparesis and depression. -Experienced pain and received pain medication. During an interview on 6/22/22 11:40 A.M., the resident said: -He/she had trouble getting staff to respond to his/her call light. -Some of the Certified Nursing Assistant (CNA)s ignored his/her call light. During an interview on 6/23/22 at 1:15 P.M., the resident said that he/she had his/her call light on the previous night because he/she needed his/her urinal emptied so he/she could use it again but they did not respond to his/her call light. Record review of the device activity report for the resident showed: -From 6/1/22-6/28/22 at 11:04 A.M., the resident's call light was on: --For 15-29 minutes 57 times. --For 30-59 minutes 62 times. --For 60-89 minutes 23 times. --For 90-119 minutes seven times. --For 120-149 minutes seven times. --For 150-179 minutes two times. --For 180-210 minutes three times. --216 minutes and 332 minutes.

Based on interview and record review, the facility failed to maintain authorization forms for three sampled residents (Resident's #30, #43 and #63) out of five sampled residents selected for the resident trust fund review portion of the survey. The facility census was 103 residents. 1. Record review on 6/24/22, of authorization forms for the five residents selected, showed: - The absence of authorization forms for Resident's #30 and #43. - Resident #63 did not sign the authorization forms. During an interview on 6/24/22 at 11:43 A.M., the Business Office Manager (BOM) said Resident #30 had been at facility since 5/31/19 and has had a guardian since 5/28/19. During an interview on 6/24/22 at 11:45 A.M., the BOM said Resident #43 had been at facility since 11/20/20, and has had a guardian since 6/27/19. During an interview on 6/24/22 at 11:49 A.M. the Regional BOM said the facility had approval from the guardians to manage funds for Resident's #30 and #43, but they were not able to find the authorization forms.

Based on interview and record review, the facility failed to reconcile (to account for) the petty cash (a small amount of cash that is kept in a facility's business office to dispense to residents who have a resident trust account) on a monthly basis and to ensure there were resident signature approved withdrawals which accurately reflected the amount of money in the petty cash in the account at the beginning of June 2022. This practice potentially affected 48 residents who had resident trust accounts. The facility census was 103 residents. 1. Record review of the monthly accounts for the months of June 2021 through May 2022 showed the absence of documentation of the ending balances for petty cash for the months of June 2021 through May 2022. During an interview on 6/24/22 at 11:04 A.M., the Business Office Manager (BOM) said: -The facility did not calculate the total amount of petty cash on hand at the end of the months, while he/she was at the facility from March 2022 until the present. -Prior to his/her start of employment and there were not any records of the petty cash totals for any months prior to his/her employment. 2. Record review of the Petty cash count sheet (a calculation that is completed on a document to ascertain how much money was left in the petty cash account from a beginning amount of cash at the beginning of the month), showed the following: -At the beginning of June 2022, there was $541.55 in the account. -Based on the count conducted by the BOM on 6/24/22, the petty cash account was $220.83. -The BOM showed $260.00 of resident signature approved withdrawals so far for that time in the month. -According to the calculations, of subtracting the total of the resident signature approved withdrawals of $260.00 from the $541.55 amount at the beginning of June 2022, there should be $281.55 in the petty cash account. During an interview on 6/24/22 at 12:37 P.M., the BOM said they have not been doing the calculations for the petty cash in the past or the present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a surety bond (a promise to be liable for the debt, default, or failure of another; It is a three-party contract by which one party (the surety or bond 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 one and one half times the average of the monthly balance of the reconciled bank statements for the resident trust. This practice potentially affected 48 residents who allowed the facility to manage their resident funds. The facility census was 103 residents. 1. Record review of the instructions for determining what a surety bond amount 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 divided by the number of active months for a monthly average. -That monthly average is rounded up or down to the nearest thousand. -That new figure is multiplied by 1.5 for the required bond amount. Record review of the facility's surety bond with a Department of Health and Senior Services (DHSS) approval date of 9/20, showed a bond limit of $50,000.00. Record review of the average balance of the resident trust showed: -A balance of $53,139.88 which was rounded down to $53,000.00. -$53,000.00 was multiplied by 1.5 indicating that the facility's required bond amount should have been $79,500. Record review of a surety bond document that was not approved by the Division of Regulation and Licensure of the Missouri Department of Health and [NAME] Services (MO DHSS) showed an amount for $100,000.00 as the surety bond. During written communication on 6/24/22 at 11:39 A.M., the DHSS Accountant wrote the bond they had on file was for $50,000.00 and he/she could not find where they received the increase rider for the bond for $100,000.00 from the facility. During an interview on 6/24/22 at 1:31 P.M., the Business Office Manager (BOM) said he/she did not know the facility bond was not updated to the $100,000.00 level just yet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the floor in the restroom of Resident #193's room free of a sticky substance; to maintain a shower chair in resident room H9 without a crack; to maintain commode risers (a device which fit over a commode seat which adds some height to the seat, making it easier for a person to sit or stand without bending) in resident rooms H12 and F4 without rust; to maintain shower chairs in resident rooms G4 and G6, without rust; to maintain the trash container in resident room D12 without a black/brown substance which had a white substance on the black/brown substance and to maintain the floors of resident rooms C12, B9, B12, B5, A11, A7, A10, without food crumbs and debris. This practice potentially affected at least 20 residents who resided in or used those rooms. The facility census was 103 residents. 1. Record review of Resident #193's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 6/24/22 showed the resident was admitted on [DATE] and was cognitively intact. During an interview on 6/23/22 at 10:41 A.M., the resident said: -His/her bathroom was dirty and the floor was sticky. -The facility staff cleaned his/her bathroom last week. -The facility staff said they ordered some stuff to clean it and they supposedly cleaned it. Observation on 6/23/22 at 10:41 A.M. showed: -The bathroom floor in the resident's room was sticky when walking on it. -The floor tiles were discolored with an amber color that was more discolored on the toilet-side of the bathroom. Observations on 6/23/22 at 12:46 P.M., 6/24/22 at 9:15 A.M., and on 6/27/22 at 12:37 P.M. showed: -The resident's bathroom was dirty. -The bathroom floor was as sticky as it was during the observation on 6/23/22 at 10:41 A.M. 2. Observations with the Maintenance Director on 6/23/22, showed: -At 10:50 A.M., an 11 inch (in.) crack was present in the shower chair in resident room H9. -At 10:57 A.M., rust was present on the legs of a commode riser which made the legs of the commode riser, difficult to clean. -At 11:11 A.M., rust was present on the legs of a commode riser in resident room F4 which made the legs of the commode riser, difficult to clean. -At 11:46 A.M., rust was present on the legs of a shower chair in resident room G6. -At 1:15 P.M., a trash container with a black substance on the bottom of the trash container with a white substance on top of the black substance, was present in resident room D12. -At 1:19 P.M., there was the presence of plastic bags and debris on the floor besides the bed in resident room D6. -At 1:37 P.M., there were food crumbs on the floor and the restroom floor was sticky in resident room C12. -At 2:39 P.M., food crumbs were present under the sink area on the foot rest of the wheelchair in resident room B9. -At 3:13 P.M. there was grime on the floor of the restroom of resident room A11. -At 3:20 P.M., cobwebs and debris were present behind the bed and in the restroom of resident room A7. -At 3:26 P.M., food debris was present under the bed in resident room A10. -At 3:34 P.M., food crumbs and debris were present on the floor of resident room A6. During an interview on 6/23/22 at 3:37 P.M., the Maintenance Director said: -He/she is over the Maintenance and the Housekeeping Departments. -There has been a shortage of housekeepers at the facility in the last few months. During an interview on 6/24/22 at 9:11 A.M., Housekeeper B said the following after he/she looked at the debris on the floor in resident room A6: -He/she was not able to get behind all the furniture in the rooms. -He/she was the only housekeeper for the center core area that day. During an interview on 6/24/22 at 9:15 A.M., Housekeeper B said the following after he/she looked at the debris on the floor in resident room A7: -They have not deep-cleaned that room. -They have to move all the furniture. -Sometimes it was difficult for him/her to move furniture because of an ongoing injury. During an interview on 6/29/22 at 11:19 A.M. the Central Supply Coordinator said: -He/she started to work at the facility on 5/5/22. -If facility staff see damaged equipment, they should report those issues to the maintenance department, then maintenance would tell him/her. -If the commode risers were in bad condition, they should notify him/her. -He/she had not been asked to order equipment yet. -He/she did not know what the process was for ordering any equipment yet. -The staff had to know that the equipment being in bad condition was an issue to bring to his/her attention. During an interview on 6/30/22 at 11:31 A.M., the Administrator said the following about the equipment: -If equipment was damaged, it should be removed. -If equipment was over $500.00, the Administrator made the order, if the price was under $500.00, that equipment should be ordered by the Central Supply Coordinator. -If staff finds damaged equipment, they should notify the Director of Nursing and the Maintenance Department or communicate the information through an application (app-- a program or software designed and written to fulfill a particular purpose of the user) called The Equipment Lifecycle System (TELS-a program that is used to design building management solutions that combine technology and services). MO 00202155 and MO 00202729

Based on interview and record review, the facility failed to ensure they completed a check of the Employee Disqualification List (EDL) and/or Criminal Background Check (CBC) prior to hire for four out of 10 staff sampled. The facility census was 103 residents. Record review of the facility's background checks and pre-hire process policy dated November 2020 showed background checks should be completed prior to hire. 1. Record review of the facility's list of employees hired since their last annual survey showed employee A was hired on 2/8/22. Record review of employee A's employee files showed the EDL was requested for employee A on 2/25/22 (27 days after date of hire). 2. Record review of the facility's list of employees hired since their last annual survey showed employee B was hired on 2/15/22. Record review of employee B's employee files showed the EDL was requested for employee B on 2/25/22 (10 days after date of hire). 3. Record review of the facility's list of employees hired since their last annual survey showed employee D was hired on 3/15/22. Record review of employee B's employee files showed the EDL and CBC were requested for employee D on 6/22/22 (approximately three months after date of hire). 4. Record review of the facility's list of employees hired since their last annual survey showed employee E was hired on 6/11/22. Record review of employee E's employee files showed the EDL and CBC were requested for employee E on 6/22/22 (11 days after date of hire). During an interview on 6/27/22 at 8:40 A.M., the Director of Human Resources said he/she knew the pre-employment screens had to be completed prior to hire.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation on 6/24/22 at 6:00 A.M. showed: -LPN G signed the narcotic count sheet for H/F halls before shift change at 7:00 A.M. -There was no other nurse present when LPN G signed the narcotic count sheet. Record review of the narcotic count sheets on 6/24/22 at 6:00 A.M. for the H/F hall medication cart showed: -There was a narcotic count sheet for the month of May. -There were 28 blank lines out of 124 opportunities for signatures for the May narcotic count sheet. -There was a narcotic count sheet for the month of June. -There were 22 blank lines out of 94 opportunities for signatures for the June narcotic count sheet. -NOTE: two nurse signatures were required for each shift change an on-coming nurse and an off-going nurse. During an interview on 6/24/22 at 6:05 A.M. LPN G said: -Two nurses were supposed to count the narcotics together one on-coming and the second off going. -He/she should not have signed the sheet without counting with the on-coming nurse. -He/she had noticed many blank spots that had not been signed. -If it was not signed it was not done. -He/she had not said anything to anyone about this issue. 4. Observation on 6/24/22 at 6:15 A.M. showed: -LPN F signed the narcotic count sheet for G/F halls before shift change at 7:00 A.M. -There was no other nurse present when LPN F signed the narcotic count sheet. Record review on 6/24/22 at 6:15 A.M. of the narcotic count sheets for the G/F hall medication cart showed: -There was a narcotic count sheet for the month of June. -There were 18 blank lines out of 94 opportunities for signatures for the June narcotic count sheet. -NOTE: two nurse signatures were required for each shift change an on-coming nurse and an off-going nurse. During an interview on 6/24/22 at 6:15 A.M. LPN F said: -He/she should not have signed the narcotic sheet before counting with the oncoming shift. -He/she did audits of the F/G halls narcotic count sheets twice a week. --The audit included the oncoming and off going nurses had both signed the narcotic count sheet and that the count was correct together. -The audits showed the nurses had not been signing the count sheet as they should have been. -He/she had notified the Assistant Director of Nursing (ADON) that the narcotic count sheets were not being signed correctly. -The audit was put in the audit notebook for the ADON to view on Fridays. Record review of the audit sheets from the Narcotic count sheet showed: -The medication cart on F/G Halls had been audited on 5/26/22 and was not correct. -The medication cart on F/G Halls had been audited on 6/3/22 and was not correct. -The medication cart on F/G Halls had been audited on 6/6/22 and was not correct. -The medication cart on F/G Halls had been audited on 6/17/22 and was not correct. -The medication cart on F/G Halls had been audited on 6/19/22 and was not correct. During an interview on 6/24/22 at 7:30 A.M. LPN B said: -When he/she comes to work the off going nurse counts the narcotics with him/her. -They are not supposed to sign the sheet without the second nurse there to count and check if the count was correct. -He/she has been at the facility about six weeks and at least twice the person before had not counted with him/her. -He/she told the ADON. During an interview on 6/30/22 at 9:09 A.M. LPN H said: -Both nurses should count the narcotics and document together at change of shift. -The count should be done twice a day, when you come on shift and when the next shift comes on shift. -If the nurse before you did not sign they would need to come back in to the facility and sign the narcotic count sheet to verify the count was correct. During an interview on 6/30/22 at 3:00 P.M. the DON said: -Two nurses should count the narcotics at the beginning and end of each shift. -There should have been a signature from the two nurses at the same time. -He/she would not have expected the off-going nurse to sign before the on-coming nurse was there to count with him/her. Based on observation, interview and record review, the facility failed to ensure the narcotic count sheet was signed by both the on-coming and the off-going staff; to verify the correct count of narcotics; and to ensure the narcotic count sheet was not pre signed before the end of a shift and to administer the correct dose of Lidocaine Cream (an anesthetic [a substance that induces insensitivity to pain] causing loss of feeling in the skin and surrounding tissues to prevent and treat pain from some procedures) for one supplemental resident (Resident #4) out of 21 sampled and supplemental residents. The facility census was 103 residents. Record review of the facility's Administration of Medications policy dated February 2018 showed: -Check medication administration record prior to administering medication for the right medication, dose, route, patient and time. -Remove medication from (medication) drawer and read label three times. -If there is a discrepancy between the Medication Administration Record (MAR) and the label, check orders before administering medications. Record review of the facility's policy, Narcotic Monitoring, dated November 2018 showed: -Two nurses must count narcotics at the beginning and end of each shift, initialing the narcotic count record, the two nurses counting should be an incoming and outgoing nurse. -If there was a discrepancy in the narcotic count, the Director of Nursing (DON) should be notified immediately. -If the DON cannot reconcile the count, the Administrator and Corporate Director of Risk Management should be notified. Record review of the facility's Pharmacy Services dated April 2022 showed: -Assure that the correct medication is administered in the correct dose, in the correct dosage form. 1. Record review of Resident #4's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 6/16/22 showed: -He/she was admitted on [DATE]. -His/ser cognition was intact. -He/she had the following diagnosis: --Renal Insufficiency (also known as Renal Failure a condition in which the kidneys can't filter waste from the blood). Observation on 6/24/22 at 5:25 A.M. of the resident's medication pass showed Licensed Practical Nurse (LPN) D: -Told the resident that his/her Lidocaine Cream was not in the medication cart. -Asked the resident if he/she had his/her Lidocaine Cream in the drawer of his/her nightstand. -Looked in the nightstand drawer, there was no Lidocaine Cream in the drawer. -Found the resident's Lidocaine Cream in a small basket on the resident's sink. -Applied the Lidocaine Cream to the resident's left arm Dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood) Fistula/Shunt (a surgically placed device that connects an artery to a vein in preparation for dialysis) site. -The resident's tube of Lidocaine Cream was 2.5 percent (%). -The resident's MAR showed an order for Lidocaine Cream 4%. During an interview on 6/24/22 at 5:25 A.M., Licensed Practical Nurse (LPN) D said: -He/she didn't have the resident's tube of Lidocaine Cream on the medication cart. -The resident had his/her own tube in his/her room. -He/she would use that until he/she got a new tube for the resident. -The resident usually kept a tube of the Lidocaine Cream in his/her room. -The Lidocaine Cream was ordered by the Physician. Record review of the resident's Physician Order Summary (POS) dated June 2022 showed: -Lidocaine Cream 4%. -Apply to Left Arteriovenous (AV- connecting the arteries to the veins) fistula topically one time a day every Monday, Wednesday, and Friday for pain relief prior to dialysis access. During an interview on 6/28/22 at 10:32 A.M., the Nurse Practitioner (NP) said: -He/she would expect nurses to follow protocol on medication administration and policy. -He/she would expect nurses to check for the right dose of a medication before administration. During an interview on 6/30/22 at 4:15 P.M., the Acting Chief Director of Nursing (DON) said: -He/she would not expect a nurse to ask a resident if he/she had their own pain cream in their room. -He/she would expect the nurse to double check a medication order and the actual medication to be sure the medication was the right one before administering it. -If the right dosage of a medication was not on the medication cart he/she would expect the nurse to obtain the right dosage of a medication and not use the wrong dosage of the medication. -There should be a Physician's order for any medication to be kept in a resident's room. 2. Record review of the facility's Shift Count-Controlled Drugs/Medication sheet for the A/B hall cart for the time period of 6/9/22, through 6/27/22, showed: -37 slots available to put the signature of the nurse going off duty, the signature of the nurse coming on duty and count correct yes or no. -The off going nurses' signature slot was blank 14 times. -The oncoming nurses' signature slot was blank 12 times. -The count correct slot was blank 23 times. Record review of the facility's Shift Count-Controlled Drugs/Medications sheet for the B/C/D hall cart for the time period of 5/12/22, through 6/24/22, showed: -88 slots available to put the signature of the nurse going off duty, the signature of the nurse coming on duty and count correct yes or no. -The off going nurses' signature slot was blank 67 times. -The oncoming nurses' signature slot was blank 67 times. -The count correct slot was blank 79 times. During an interview on 6/30/22 at 4:15 P.M., the Acting Chief Director of Nursing (DON) said: -Narcotic medications are counted at beginning each shift by both the on coming and off going nurses. -Both nurses should then sign the narcotic count sheet for either the off going or oncoming shift slot. -The area for the count being correct should also be marked yes or no. -When the nurses sign they are showing that the narcotic medication count is correct. -Nurses should not sign the narcotic sheet before counting with another nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident monthly pharmacy drug regimen recommendations (DRR) were reviewed and acted upon by the physician for five sampled residents (Resident #39, #49, #24, #62, and #80) out of 21 sampled residents. The facility census was 103 residents. Record review of the facility's Pharmacy Services policy dated April 2022 showed: -The Pharmacy Services guideline purpose was: --To maintain accurate and timely medication records. --To minimize medication-related adverse consequences or events. --The overall goal is to ensure the safe and effective use of medications. --The Interdisciplinary Clinical Team is the responsible party. -The facility will employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility. 1. Record review of Resident #39's admission Record showed he/she admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Alcoholic Cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure) of liver with ascites (swelling in the abdomen caused by excess abdominal fluid). -Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of the resident's Pharmacy Recommendations from April 2021 through May 2022 showed no physician response for the following: -October 2021 the resident was taking: --Trazodone (a sedative and antidepressant used to treat depression) 100 milligrams (mg) daily for one year. --Effexor XR (an antidepressant and nerve pain medication uses to treat depression, generalized anxiety disorder, panic disorder and social anxiety disorder) 150 mg daily for one year. -Recommend a trial reduction of at least one of these agents at this time. ---No Physician response. -February 2022 the resident had been taking: --Omeprazole (treats heartburn and indigestion) 40 mg every day (QD) since 2020. --Gastric inhibitors effects can last for up to 72 hours. --Some studies show taking longer than one year increase risk of hip fractures. -The Pharmacist listed the following responses for the Physician to check: --Reduce dose to 20 mg daily. --Discontinue therapy. --Start the following: (___________). --This Resident's therapy has been re-evaluated and is appropriate for continued use; dose reduction is contraindicated and the benefit of use outweighs the risk. ---No Physician response. -April 2022 Physician must reorder PRN Hydroxyzine (helps control anxiety and tension caused by nervous and emotional conditions) for a specific number of days via stop date, or discontinue. --No Physician response. 2. Record review of Resident #49's admission Record showed he/she admitted on [DATE] with the following diagnoses: -Major Depressive Disorder. -Chronic Obstructive Pulmonary Disease (COPD-condition involving constriction of the airways and difficulty or discomfort in breathing). -Hypertension (high blood pressure). -Muscle weakness (a lack of strength in the muscles). -Dysphagia (inability or difficulty swallowing), oropharyngeal phase (difficulty initiating a swallow and may be accompanied by regurgitation or aspiration). -Constipation. Record review of the resident's Pharmacy Recommendations from April 2021 through May 2022 showed no physician response for the following: -September 2021 Patient is taking Quetiapine (used to treat bipolar disorder (a form of mental illness associated with episodes of mood swings ranging from depressive lows to manic (a state of mind characterized by high energy, excitement, over a sustained period of time) highs) depressive and manic episodes) which can cause movement disorders. --Recommend a movement test such as AIMS (Abnormal Involuntary Movement Scale) be performed and repeated at least every 6 months. -Last tested 1/2021. ---No Physician response. -November 2021 Resident has been taking Quetiapine 25 mg for a year without a gradual dose reduction (GDR). --Attempt a dose reduction to 12.5 mg daily. ---No Physician response. -December 2021 please add do not crush to: --Nifedipine (used to treat high blood pressure). --Aspirin (used to treat mild to moderate pain from headaches, arthritis, muscle aches). --Depakote (can be used to treat acute manic symptoms in patients with bipolar disorder). --Omeprazole. ---No Physician response. -February 2022 has had Metoprolol (used to treat high blood pressure) held numerous times recently without documentation of reason. --Please ensure medication holds or refusals are always documented as such. --Also, given the numerous recent episodes of hypotension (low blood pressure) and bradycardia (slower-than-expected heart rate, generally beating fewer than 60 beats per minute), which are likely the reasons for the holds, recommend addition of actual hold parameters to this order. ---No Physician response. -April 2022 due to non-use in more than 60 days please consider discontinuation of resident's PRN: --Tramadol (used to relieve moderate to moderately severe pain). --Senna (used to relieve occasional constipation). ---No Physician response. 3. Record review of Resident #24's pharmacy recommendations had no documented response for: -7/15/21 regarding medication errors for a medication used to treat low blood pressure. -8/19/21 a recommendation for a movement test to be performed and repeated every six months due to the resident's use of an antipsychotic (a group of psychoactive drugs (pertaining to a drug or other agent that affects such normal mental functioning as mood, behavior, or thinking processes) medication and it was noted the last movement test was completed in January 2021. -12/15/21 regarding medication errors for a medication used to treat low blood pressure. -3/15/22 a recommendation for a movement test to be performed and repeated every six months due to the resident's use of an antipsychotic medication and it was noted the last movement test was completed in January 2021. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/7/22 showed the following staff assessment of the resident: -Was cognitively intact. -The resident received an antipsychotic medication, an antianxiety medication and an antidepressant medication seven out of the past seven days. Record review of the resident's care plan revised 6/29/22 showed: -Instructions to staff to monitor the resident's blood pressure. -Instructions to staff to monitor the resident for any complications of antipsychotic medication related complications such as signs and symptoms of a movement disorder. -The resident had a diagnosis psychosis (a mental state involving loss of contact with reality and causing deterioration of normal social functioning). -Instructions to staff to administer medications as ordered and to monitor/document for side effects and effectiveness. -The resident received antipsychotic medications for psychosis. Record review of the resident's June 2022 Medication Review Report showed: -The resident had a physician's order for a medication used to treat low blood pressure. -The resident had a physician's order for an antipsychotic medication. -There was no physician's order for a movement test. 4. Record review of Resident #62's pharmacy recommendations had no documented response for: -5/21/21 recommended removing hold directions from Amlodipine (used to lower blood pressure) and Metoprolol (used to lower blood pressure) since the resident's blood pressure was stable and only checked once a month. -2/14/22 a recommendation for a movement test to be performed and repeated every six months due to the resident's use of an antipsychotic medication and it was noted there was no initial test. 4/15/22 instructions to remove hold parameters from Amlodipine and Metoprolol since the resident's blood pressure was only monitored once a month, nullifying any possibility of applying hold parameters. Record review of the resident's care plan revised 4/26/22 showed: -The resident received antipsychotic medications. -Instructions to administer medications as ordered by the physician and to monitor for side effects and effectiveness. -Instructions to monitor, document and report any adverse reactions of antipsychotic medications including abnormal movements. -Consult with the pharmacy and the physician to consider dosage reduction when clinically appropriate at least quarterly. -Obtain monthly blood pressure and notify the physician if out of normal range. Record review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -admitted to the facility on [DATE]. -Was cognitively intact. -Received routine antipsychotic medications seven out of the past seven days. -Had not had a gradual dose reduction on antipsychotic medications. Record review of the resident's June 2022 Medication Review Report showed: -Hold directions included for Amlodipine and Metoprolol. -The resident had physician's orders for an antipsychotic medication. -There was no physician's order for a movement test. 5. Record review of Resident #80's pharmacy recommendations had no documented response for: -9/20/21 a recommendation for a movement test to be performed and repeated every six months due to the resident's use of an antipsychotic medication. -10/21/21 a recommendation that anyone handling intact tablets or administering from unit-dose packaging Azathioprine (a medication that treats diseases that have to do with the immune system) wear gloves. Record review of the resident's quarterly MDS dated [DATE] showed the resident received an antipsychotic medication seven out of the past seven days. Record review of the resident's care plan revised 6/17/22 showed: -The resident received antipsychotic medications. -Instructions to administer medications as ordered by the physician and to monitor for side effects and effectiveness. -Instructions to monitor, document and report any adverse reactions of antipsychotic medications including abnormal movements. -Consult with the pharmacy and the physician to consider dosage reduction when clinically appropriate at least quarterly. Record review of the resident's June 2022 Medication Review Report showed: -There was no physician's order for a movement test. -A physician's order for an antipsychotic medication. -A physician's order for Azathioprine tablet, 50 mg, one tablet twice daily for myasthenia gravis (a chronic autoimmune disorder in which antibodies destroy the communication between nerves and muscle, resulting in weakness of the skeletal muscles) management. 6. During an interview on 6/30/22 at 4:15 P.M., the Acting Chief Director of Nursing (DON) said: -The Consultant Pharmacist did new resident medication chart reviews and all resident's monthly medication reviews and the report is sent to the Administrator, DON and to the Physician within a month. -The Physician and Nurse Practioner (NP - a nurse who is qualified to treat certain medical conditions without the direct supervision of a doctor) were in the facility almost daily. -The DON would let the Physician know when there were Pharmacist recommendations. -The DON was responsible for ensuring the Physicians were responding to the Pharmacist's recommendations. -The Pharmacist's recommendations were printed off electronically and the Physician would write on the printout if he/she agreed with the recommendation or not and any changes he/she may want done. -There was a record kept of the Physician's responses to the Pharmacist, it was processed and uploaded to the electronic record under the miscellaneous tab.

3. Observation on 6/24/22 at 5:30 A.M. of a medication pass with LPN G showed: -The nurse went into a resident's room to take his/her vital signs before administering their medication and left the medication cart unlocked outside of his/her room in the hallway. -The cart was unlocked and out of the nurse's line of vision for three minutes. -Two residents passed by the medication cart within one foot of the cart while it was unlocked. -One resident was in a wheelchair. -One resident was walking. -The nurse returned to the cart to get an intravenous (IV - medications administered directly into a person's vein) medication for the same resident. -The nurse went back into the room to administer the resident's IV antibiotic. -He/she did not lock the medication cart and was out of line of sight for three minutes. -One resident walked by the unlocked medication cart within one foot. During an interview on 6/24/22 at 5:45 A.M. LPN G said he/she would not have done anything differently during the medication pass. During an interview on 6/30/22 at 9:09 A.M. LPN H said: -The medication cart should be locked if staff were not in front of it. -They teach you not to leave the cart unlocked in nursing school. -They gave education of not leaving the cart unlock during orientation. During an interview on 6/30/22 at 3:00 P.M. the DON said: -The medication cart should be locked if not within the nurse's sight. -The staff was educated on keeping the medication carts locked if not within sight during the skills fair on 6/21/22. 4. Observation on 6/24/22 at 6:27 A.M. of the F Hall medication refrigerator with LPN F showed: -The temperature in was 34 degrees F. -LPN F verified the temperature was 34 degrees F. -There was a build up of frost in the freezer compartment of the medication refrigerator. -The following medications were in the F Hall medication refrigerator: --Three bags of Cefazolin (medication used to treat bacterial infections) two grams(gm) per 100 milliliter (ml) for Intravenous (IV administered through a vein). DO NOT FREEZE was written on the container. --Adacel (medication used to reduce Diptheria - a serious infection of the nose and mouth and Pertussis - a highly contagious respiratory infection) injection tetanus vaccine. --Two Tresheba insulin (a medication used to treat high blood sugar) pens, 40 units. --Two Toujeo/Lantus insulin pens. --One Lantus insulin pen opened on 6/17/22, no residents was on name on pen. --One Basaglar insulin three ml pen. --Two Lispro insulin three ml pens. --One Levimir insulin for a resident who was discharged three weeks ago insulin was still in refrigerator. --Two Lantus insulin 10 ml vials. --Two Lispro insulin 10 ml vials. --One Aspart insulin 10 ml vial for a resident. --One Humulin R insulin pen 3 ml for a resident. --Nine Fluclox quad (a medication used to treat infections) three ml tubes. --One Tuberculin (an injectable culture used to test for tuberculosis (TB)- a serious infectious bacterial disease which affects the lungs) to have been stored between 36 - 46 degrees F a 5 ml as indicated on the opened vial. --One Tuberso (a test for TB) vial, one ml. --Twenty-nine Fluzone (a vaccination for the prevention of influenza - a viral infection) 0.7 ml injectable syringes. --Thirteen Bisacodyl (a suppository - inserted into a person rectum for treatment of constipation) 10 mg During an interview on 6/24/22 at 6:27 A.M. LPN F said: -The temperature of the medication refrigerator was to be between 27 to 35 degrees F. -It should be checked daily by the night shift. -If it was not in range staff should tell the management the next day. -He/she had not told the management it was not within range. -If it was in the 20's the refrigerator should be defrosted. -The refrigerator had not been defrosted in a while. -The refrigerator looked like it needed to be defrosted. -The temperature range used to be on the refrigerator log sheet. -The current temperature log sheet did not have the temperature range on it. -He/she did not know what temperature medications would freeze at. -There were many temperatures on the June 2022 log that were not within range. -Somebody should have done something about it. -He/she did not know who was responsible for defrosting the refrigerator. -He/she had not told the management the temperature was not within range. -He/she had checked the temperature of the refrigerator the last couple of nights and the temperature had been 30 degrees F. -He/she thought it was within range. Record review of the F Hall medication refrigerator log dated June 2022 showed: -20 readings were out of range, less than 36 degrees F out of 23 opportunities. -14 readings were less than 32 degree F out of 23 opportunities. -The medication temperature log did not show what an acceptable range was supposed to be. -There was no documentation anyone in management had been told the temperature was out of range. During an interview on 6/30/22 at 9:09 A.M. LPN H said: -The night shift nurse should check the medication refrigerator's temperature. -The temperature should be done every day. -The medication refrigerator should be between 36 degrees F and 45 degrees F. -If the temperature of the medication refrigerator was out of range the nurse should call pharmacy to see it is safe for medications to have been used for the residents. -If the temperature was out of range the temperature should have been adjusted and rechecked to ensure it was within range. -If the Pharmacy said the medications were not safe to use, the medications should be destroyed and new ones ordered for the residents. -He/she would have notified the Director of Nursing (DON) and the Administrator if the temperature in the medication refrigerator was out of range. -If the temperature was 28 degrees F or above the refrigerator should have been defrosted and the temperature adjusted. During an interview on 6/30/22 at 3:00 P.M. the DON said: -The medication refrigerator should have been checked at least daily. -The medication refrigerator should have been between 36 degrees F and 46 degrees F. -If the temperature was not within range the temperature in the medication refrigerator should have been adjusted. -The temperature should have been rechecked in an hour to ensure it was within range. -The charge nurse was responsible to check the temperature in the medication refrigerator. -The temperature should have been charted on the temperature log. -The temperature should not have been less than 36 degrees F. -The nursing staff should tell the DON or Administrator if the refrigerator was not within the temperature range. Based on observation, interview, and record review, the facility failed to ensure the medication refrigerator was within range of 36 degrees Fahrenheit (F) to 46 degrees F for one out of two sampled refrigerators which stored residents' prescribed medications and failed to ensure that two medication carts were locked during medication pass. The facility census was 103 residents. Record review of the facility's policy, Refrigeration Medication Storage, dated June 2022 showed: -The facility will assure that all refrigerators and freezers were clean, contents were properly stored, and the temperatures were monitored in accordance with all state and federal regulations. -An accurately calibrated thermometer would be kept in each refrigerator at all times. -Temperatures at which drugs were stored will be maintained between 36 degrees F to 46 degrees F. -If the temperatures registered above or below the appropriate temperature all stored items would be removed, the viability of the items stored would be determined and non-viable items would be discarded. -Environmental Services would be notified for an out-of-range temperature finding. -The Environmental service staff would inform the user department when the refrigerator was safe for use. Record review of the facility's policy, Administration of Medications, dated February 2018 showed: -Never leave the medication cart open and unattended. 1. Observation on 6/24/22 at 8:05 A.M., of medication pass with Licensed Practical Nurse (LPN) C showed: -He/She entered a resident's room to check his/her blood sugar. -He/She left the B/C/D medication cart unlocked in the hall across from the resident's room. -The unlocked cart was out of his/her sight for four minutes. -A staff member walked by the unlocked medication cart while the medication cart was out of LPN C's sight. -He/She returned to the unlocked medication cart to prep the resident's insulin. -He/She re-entered the resident's room to administer the insulin. -The unlocked cart remained out of his/her sight for four minutes. -He/She returned to the medication cart and locked it. During an interview on 6/24/22 at 8:15 A.M., LPN C said: -He/She forgot to lock the medication cart when entering the resident's room. -He/She usually locked the cart when going into a resident's room. -The medication carts should be locked when the nurse was away from it. 2. Observation on 6/24/22 at 9:05 A.M., showed: -The A/B hall medication cart was unlocked for five minutes from the time it was observed. -LPN E was several rooms down the hall from the unlocked medication cart. -An unknown resident in a wheelchair was sitting on the left hand side of the medication cart. -Several residents returning from breakfast were in the hall passing within a foot of the unlocked medication cart. -An unknown Certified Nursing Assistant (CNA) walked past, within a few inches of the unlocked medication cart. -Two unknown residents stopped to visit with the unknown resident sitting next to the unlocked medication cart. -A housekeeper was within two feet of the unlocked medication cart. During an interview on 6/24/22 at 9:30 A.M., LPN E said: -Medication carts should be locked when the nurse or the Certified Medication Technician (CMT) was away from the cart. -The nurses and the CMT's have received education on keeping the medication carts locked when away from the cart.

Based on observation, interview, and record review, the facility failed to maintain the area under the automated dishwasher and resident rooms B 12, A 12 and A 3, free of gnats (small flies). The facility also failed to maintain the floors of resident rooms B 8 and B 5 free of food crumbs as to not provide harborage for ants. This practice potentially affected at least eight residents. The facility census was 103 residents. 1. Observation during the initial kitchen observation on 6/22/22 showed: -At 9:17 A.M., gnats flew around in the kitchen around the automated dishwasher area. -At 9:25 A.M., gnats flew around the area next to the breaker box on the east side of the kitchen. 2. Observation with the Maintenance Director on 6/23/22, showed: -At 2:33 P.M., many gnats flew around a cup with a brown colored drink in it, in resident room B 12. -At 2:51 P.M., there were numerous ants and food crumbs on the floor of resident room B 8. -At 2:53 P.M., there were numerous ants and food crumbs on the floor of resident room B 5. -At 3:18 P.M., numerous gnats flew around in the area under the sink in resident room A 12. -At 3:31 P.M., numerous gnats flew around in resident room A 3. During an interview on 6/24/22 at 9:20 A.M., Housekeeper B said the gnats in resident room A 12 were present because of the wet towels which were under the sink. During an interview on 6/28/22 at 11:25 A.M., Housekeeper C said: -The facility staff try to keep open trash out of the areas. -The gnats were attracted to uncovered food, uncovered drinks. -Facility staff try to reduce the occurrence of gnats by eliminating food from the rooms. -The gnats go into rooms where there is uncovered food. -The gnats started being more prevalent when the weather got warmer. -The ants were a problem in rooms with food. During an interview on 6/28/22 at 2:23 P.M., the Maintenance Director said the housekeepers are supposed to take the food away after each meal or supposed to cover the food. During an interview on 6/29/22 at 11:42 A.M., the Dietary Manager (DM) said: -The gnats have been stirred up by the ongoing construction. -He/she noticed the standing water under the dishwasher area. -He/she had noticed gnats here and there. Record review of the 2017 Food and Drug Administration (FDA) Food Code, showed the following: Chapter 6-202.15 Outer Openings, Protected. (A) Except as specified in paragraphs (B), (C), and (E) and under paragraph (D) of this section, outer openings of a Food Establishment shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings; (2) Closed, tight-fitting windows; and (3) Solid, self-closing, tight-fitting doors. Chapter 6-501.111 Controlling Pests. The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: A) Routinely inspecting incoming shipments of food and supplies; B) Routinely inspecting the premises for evidence of pests; C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and D) Eliminating harborage conditions. MO 00203209

Based on observation, interview and record review, the facility failed to maintain the area under the automated dishwasher free of dishes and debris; to maintain the wall mounted fan free of a heavy dust buildup in the dishwashing area; to maintain two out of three cutting boards without numerous grooves, indentations and stains, which made the cutting boards not easy to clean; to remove food debris such as a discarded sausage patty, jelly packets from under the steam table towards the front of the kitchen; to label a container which contained a white powdery substance; to take and record a temperature of unpasteurized eggs, a potentially hazardous food (PHF-a term used by food safety organizations to classify foods that require time-temperature control to keep them safe for human consumption) before placing them in a pan to be sent to the C and D hall kitchenette; and to ensure the light fixtures and vent covers on the ceiling of the kitchen, were free of a dust buildup. This practice potentially affected 97 residents who ate food from the kitchen. The facility census was 103 residents. 1. Observation during the initial kitchen observation on 6/22/22, showed: -At 9:17 A.M., debris including dishes, were under the dishwashing table. -At 9:17 A.M., a buildup of dust on the grate and the blades of the wall mounted fan located in the dishwasher area. -At 9:27 A.M., two out of three cutting boards with stains, and numerous grooves and indentations, which made the cutting boards not easily cleanable. -At 9:28 A.M., there was peeling paint from a vent cover over the three compartment sink in the food preparation area. -At 9:29 A.M., food debris including a piece of sausage patty and a jelly packet and several small condiment cups, were under the steam table. -At 9:31 A.M., one container of a white powdery substance, was not labeled. During an interview on 6/22/22 at 9:33 A.M., Dietary [NAME] (DC) A said that the powdery substance was food thickener (a powdery substance to make liquids, such as beverages and soups, a thicker consistency that is less likely to cause aspiration). 2. Observation during the breakfast meal preparation on 6/24/22, showed: -At 5:33 A.M., there was debris inside the upper nozzles of the automated dishwasher, before anyone used the automated dishwasher for that shift. -At 5:59 A.M., there was a buildup of grease on the floor under the deep fat fryer and under the six burner stove next to the deep fat fryer. -At 6:38 A.M., there was food debris inside the scoop drawer and at the edge of the scoop drawer. - At 7:45 A.M., DC B placed 9 eggs from a package which did not state the eggs were pasteurized, into a pan and fried them. - At 7:48 A.M., DC B removed 9 eggs from the pan, and did not check the temperature to ensure the eggs were at 145 °F (degrees Fahrenheit), before placing that batch into a pan for delivery to the C and D hall kitchenette. - At 7:49 A.M., DC B cooked 3 more eggs from the same package as the first 9 eggs came from, in the pan. - At 7:51 A.M., DA B, placed the eggs in a metal pan and wrapped that pan with plastic wrap. - Neither DC B nor DA B checked the temperature of the eggs after the eggs were removed from the frying pan. -At 9:58 A.M., there were three utensils with handles that had melted areas which were not easily cleanable. During an interview on 6/24/22 at 6:01 A.M., the Dietary Manager (DM) said: -The deep fat fryer has not been power washed. -It had been 4-5 months since the deep fat fryer had been pulled out to clean the floor under it and to clean the deep fat fryer itself. During an interview on 6/24/22 at 6:42 A.M., Dietary Aide (DA) A said the night shift dietary crew should clean the automated dishwasher, because the night shift was the last shift to use the dishwasher. During an interview on 6/24/22 at 9:53 A.M. DC B said he/she did not take a temperature of the eggs earlier that day. During an interview on 6/24/22 at 9:55 A.M., DC B said the dietary staff should clean out the utensil drawers weekly. During an interview on 6/24/22 at 10:00 A.M. , DC B said when the utensils get damaged like that, he/she has to tell the DM so he/she could order new ones. During an interview on 6/24/22 at 10:04 A.M., the DM: -Acknowledged the stains on the cutting boards. -Said the dietary department discarded a few cutting boards the previous week. -The dietary department needed to pull the steam table out and get the food debris including the sausage from 6/22/22 from that area. -Staff clean the fan every few weeks, but the fan in the dishwashing area gets dusty quick. 3. Observation with the Maintenance Director on 6/27/22 at 1:29 P.M., showed a buildup of dust on several vents and light fixtures throughout the kitchen, including over the food preparation areas and the dishwashing areas. During an interview on 6/27/22 at 1:30 P.M., the DM said he/she cleaned the vents and the light fixture a few weeks prior, but noticed the buildup of dust on those areas. During an interview on 6/28/22 at 2:24 P.M., the Maintenance Director said the last time they notified him/her about cleaning the kitchen ceilings, was March 2022. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: -In Chapter 3-305.14, During preparation, unPACKAGED FOOD shall be protected from environmental sources of contamination. -In Chapter 3-401.11 Raw Animal Foods. (A) Except as specified under paragraphs B, C and D of this section, raw animal FOODS such as EGGS, FISH, MEAT, POULTRY, and FOODS containing these raw animal FOODS, shall be cooked to heat all parts of the FOOD to a temperature and for a time that complies with one of the following methods based on the FOOD that is being cooked to 145 ºF or above for 15 seconds for (a) Raw EGGS that are broken and prepared in response to a CONSUMER'S order and for immediate service, -In Chapter 4-602.13, nonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues; -In Chapter 6-501.12, paragraph A, The physical facilities shall be cleaned as often as necessary to keep them clean. -In Chapter 6-501.14, part A, Intake and exhaust air ducts shall be cleaned and the filters changed so they are not a source of contamination by dust, dirt, and other materials. -In Chapter 4-202.11, regarding Food-Contact Surfaces; Multi-use FOOD-CONTACT SURFACES shall be: (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; (3) Free of sharp internal angles, corners, and crevices; and 4) Finished to have SMOOTH welds and joints; -In Chapter 4-501.11, showed Good Repair and Proper Adjustment. A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. -In Chapter 4-501.12, 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. 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.

Based on 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), which included the following: a risk assessment to identify where waterborne pathogens could grow and spread, diagrams of which hot water heaters provide hot water to which sections of the facility, testing protocols with acceptable ranges for control measures when control measures in water from the water company were not maintained, how will facility account for changes in water quality such as water main breaks and construction and specific actions that would be taken in response to a legionella positive water sample. This deficient practice had the potential to affect all residents and staff who reside in or work in the facility. The facility census was 103 residents with a licensed capacity of 162 residents. Record review of page 3 of Centers for Disease Control and Prevention (CDC) Legionella Environmental Assessment Form, dated 6/15, showed: -Obtain a written copy of the program policy. -Page 1 of the assessment noted that requirements for any occupant rooms taken out of service during specific parts of the year. -Note: It is important to gain an understanding of where and how water flows, starting where it enters the facility and including its distribution to and through buildings to the points of use. Obtain copies of these and/or draw a diagram and include with the completed assessment. Record review of the Centers for Medicare and Medicaid Services (CMS) Quality and Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. 1. Record review of the facility's Water Management Program, revised in 10/19, showed: -List any areas, temperature becoming ideal for growth, devices with standing water , decorative fountains, etc. Also identify any general areas of high risk such as areas with medical procedures, high risk populations (i.e. oncology, transplant or other vulnerable patients), or hydrotherapy rooms. Record review of written communications from the Director of Nursing (DON) on 7/1/22 at 4:22 P.M., showed: -There were 12 rooms on E Hall. -The hall had been vacant of residents since March 1, 2022. During an interview on 6/29/22 at 3:20 P.M., the Administrator said E Hall was an area of risk because it was vacant of residents. 2. Record review of the facility's Water Management Program, revised in 11/19, showed the absence of a diagram of which hot water heaters provide hot water to which areas of the facility. During an interview on 6/29/22 at 3:21 P.M., the Administrator said the areas that hot water heaters send water to needed to be specified in their plan. 3. Record review of the facility's Water Management Program, revised in 11/19, showed the absence of the protocols that facility personnel were using to check the water for acceptable ranges. During an interview on 6/29/22 at 3:26 P.M., the Administrator said the facility needed to state within its water management plan, that water temperatures were being checked weekly, as the method of ensuring the water was maintained at acceptable ranges. 4. Record review of the facility's Water Management Program, revised in 11/19, showed the absence of how the facility would account for changes in municipal or facility water quality, water main breaks and construction (including renovations and installation of new equipment). During an interview on 6/29/22 at 3:26 P.M., the Administrator said the facility would have to develop a plan on how to deal with the water after a potential water main break in the vicinity of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure its call light system was maintained in compliance with the stipulations outlined in their state approved exceptions letter dated 10/13/21. This practice potentially affected all residents. The facility census was 103 residents. Record review of the exception letter regarding call lights showed: -The facility had an approved exception for complying with state regulation 19 CSR 30-85.012 (124) Facilities shall provide an electrically-powered nurses' call system with indicator lights at the corridor entrance of each bedroom. Audible signals and indicating panels shall be located in each nurses' station and utility room. Facilities shall provide signal buttons at the head of each resident bed, in each toilet room and in each bathroom. -The following stipulations were spelled out in the exception letter: --The exception applies only to the omission of indicator lights at the corridor entrance of each bedroom door and omission of audible signals and indicating panels in each nurses' station and utility rooms. It does not apply to the remainder of the regulation. --The operator will ensure that the wireless nurse call system is fully operational twenty-four (24) hours per day, seven (7) days a week. --The operator will maintain, at a minimum and in accordance with the manufacturer's recommendations, all the features of the [NAME] Arial wireless call system provided to the SLCR on March 19, 2021, and notify the SLCR of any system changes. --The operator will ensure that all direct care staff carry and utilize the wireless nurse call pagers at all times. --The operator will ensure that resident care and services are not adversely affected in any way by the exception. 1. Observations on 6/28/22 showed the following: -At 11:29 A.M. the state surveyor pulled the call light in C8. -At 11:36 A.M., two Certified Nurse's Assistants (CNAs B and J) came to the room. During an interview on 6/28/22 at 11:37 A.M., CNA J said he/she and CNA B did not have any wireless nurse call pager on their persons. During an interview on 6/28/22 at 11:39 A.M., CNA B said: -If they (CNA B and CNA J) were in a room providing assistance to a resident, they would not have a way of knowing that another resident on that hall, needed help, while they are in the room. -It was only when they came out of the room and looked at the signaling board at the end of the hall, that they knew that the call light in room C8 was activated. During an interview on 6/28/22 at 11:44 A.M. Licensed practical Nurse (LPN) C said the nurses did not have wireless nurse call pagers and the computer screen at the nurse's station and the signaling board at the end of the hall showed from which room the call light was activated. During an interview on 6/28/22 at 12:44 P.M., CNA K said the CNAs used to have to carry wireless nurse call pagers on their persons, but he/she did not know how long it has been since they did not carry pagers. During an interview on 6/28/22 at 2:38 P.M., Restorative Aide (RA) A said: -He/she has worked at the facility for about eight years. -The staff used to have wireless nurse call pagers. -There was a time the system would send signals to the wrong pagers. -The new company brought in walkie talkies (a compact easily transportable battery-operated radio transmitting and receiving set) for the nurses to communicate with the floor staff, in November 2020, but they were still doing the pagers. -He/she was not sure why the wireless nurse call pagers were not being used anymore. During an interview on 6/28/22 at 2:54 P.M., CNA H said: -He/she did not have a wireless nurse call pager. -The CNAs were supposed to have pagers. -The facility did not stop using pagers. -Since the remodeling, they have not been using the walkie-talkies. -He/she could not hear the call light system over the noise that may exist in a resident room if he/she was in a room speaking with his/her coworker or a resident. During an interview on 6/28/22 at 3:10 P.M., the Regional Chief Director of Nursing said: -There is a pager system for the call lights. -Some of the wireless nurse call pagers were moved during the remodeling. -He/she noticed that certain staff did not have the wireless nurse call pagers on that day when he/she started asking staff about whether or not they had wireless nurse call pagers. -The wireless nurse call pagers used to be kept in the Chief Nursing Officer's office. -Some of the pagers were moved from their previous location. -A certain number of staff may not have known where the pagers were located. -The nurses are supposed to carry the walkie-talkies. -He/she believed the facility had enough wireless nurse call pagers for the floor staff. During an interview on 6/28/22 at 3:31 P.M., the Administrator said: -The call light system was equipped with pagers. -Some staff did not know where the wireless nurse call pagers were moved to. -They were moved from the nurse's station for remodeling purposes. -The center core nurse's station was remodeled about three weeks ago. -They (facility staff involved with the remodeling) forgot to put the pagers back. During an interview on 6/29/22 at 12:01 P.M. CNA D said he/she has not had his/her wireless nurse call pager until that day (6/29/22), but he/she has not had his/her wireless nurse call pager for the last month. 2. Observation on 6/30/22 at 8:42 A.M., showed the call light in resident room H8 was activated. During an interview on 6/30/22 at 8:42 A.M., CNA M said the signal from resident room H8 did not go to his/her wireless nurse call pager. During an interview on 6/30/22 at 8:43 A.M., CNA N said the signal from resident room H8 did not go to his/her wireless nurse call pager. During an interview on 6/30/22 at 8:44 A.M., LPN B said he/she did not have a wireless nurse call pager on his/her person. During an interview on 6/30/22 at 8:46 A.M., CNA P said he/she was assigned to H Hall on that day (6/30/22), but he/she did not have a pager that day. During an interview on 6/30/22 at 8:48 A.M., the Administrator said the wireless nurse call pagers for the Post-Acute Unit (F, G and H Halls) are programmed to signal the staff member no matter which of the three halls, the call light signal came from and as far as he/she knew, the wireless nurse call pagers were not reprogrammed to only get the signal from the hall that a staff member was on. During an interview on 6/30/22 at 10:52 A.M., the Regional Chief Director of Nursing said the facility did not have a policy on the functioning of call lights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #26's electronic medical record (EMR) showed he/she was admitted to the facility on [DATE] and readmitted on [DATE] and had a Durable Power of Attorney (DPOA- a person previously identified to make decisions for an individual in the event of inability to make wishes known) in effect as of 7/11/19 for his/her health care. His/her current diagnoses included: -End stage renal disease (ESRD-The kidneys have stopped working well enough to survive without dialysis or a kidney transplant). -Dependence on renal dialysis (process of cleansing the blood by passing it through a special machine - necessary when the kidneys are not able to filter the blood). -Chronic respiratory failure (results from inadequate gas exchange by the respiratory system). -Chronic obstructive respiratory failure (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -Peripheral vascular disease (PVD -a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). -Heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). -Hypertension (HTN- high blood pressure). -Major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Anxiety disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus) and -Adult neglect/abandonment (the lack of care by one's self or another). Record review of the resident's nurse notes dated 8/13/19 at 6:03 P.M. showed: -The resident was transferred to hospital for worsening labs with physician suspicion of compromised bile duct/head of pancreas. -The resident's skin currently yellow tinted with yellow sclera bilaterally and yellow tinted mucous membranes of mouth which is outside of resident baseline. -The resident was in agreement of the impending transfer. -The resident's nephew and DPOA were notified that the resident was being sent to the hospital and -The resident was given copy of the hospital transfer form with bed hold policy. Record review of the resident's medical record showed no documentation that a transfer letter was sent to the resident and his/her representative stating why the resident was transferred from the facility to a hospital. Record review of the resident's admission note dated 8/17/19 at 11:48 P.M., showed the resident readmitted to the facility at 8:00 P.M., from a hospital. During an interview on 8/23/19 at 11:46 A.M., the Administrator said: -A certified letter is sent to the resident's family/representative when a resident is transferred to a hospital. -He/She could not locate the letter for this resident and -The resident was given a transfer to hospital form with the bed hold policy on it upon transferring to the hospital. 3. During an interview on 8/23/19 at 2:52 P.M., the Director of Nursing (DON) said: -When a resident is transferred to the hospital, a transfer form is done and the resident gets a copy of the form. - If the resident is his/her own responsible party only the resident would get a copy of the letter. -If the resident has a responsible party other than himself/herself, that person would be notified, even if by phone and -Documentation can be put in the notes when a letter is given. Based on interview and record review, the facility failed to provide discharge/transfer letters to the residents and their representative(s) when transferred to the hospital, for two sampled residents (Residents #65 and #26), out of 20 sampled residents. The facility census was 100 residents. 1. Record review of Resident #65's electronic medical record (EMR) showed he/she was admitted to the facility on [DATE], and had a responsible party other than himself/herself. His/her current diagnoses included: -Chronic Kidney Disease (CKD - the gradual loss of kidney function). -Anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues); and -Peripheral Vascular Disease (PVD - a disease that causes restricted blood flow to the arms, legs, or other body parts). Record review of the resident's Discharge Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff for care planning) and tracking forms showed the resident: -discharged from the facility on 4/18/19 with his/her return anticipated, and re-entered the facility on 4/26/19. -discharged from the facility on 5/22/19 with his/her return anticipated, and re-entered the facility on 5/25/19 and -discharged from the facility on 6/11/19 with his/her return anticipated, and re-entered the facility on 6/26/19. Record review of the resident's medical files showed there were no records of the resident and his/her representative being given copies of the resident's transfer letters stating why the resident was transferred from the facility on 4/18/19, 5/22/19 and 6/11/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #35's electronic medical record (EMR) showed he/she was admitted to the facility on [DATE], and his/her diagnoses included: -Chronic Obstructive Pulmonary Disease (COPD - progressive lung diseases characterized by increasing breathlessness). -Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities). -Kidney Failure (when kidneys lose the ability to sufficiently filter waste from the blood) and -Bilateral (both sides) below the knee amputations. Record review of the resident's care plan showed no documentation that a summary of the resident's baseline care plan was provided to the resident or his/her responsible party. Record review of the resident's progress notes showed no documentation that a summary of the resident's baseline care plan was provided to the resident or his/her responsible party. 3. Record review of Resident #62's EMR showed he/she was admitted to the facility on [DATE]. His/her diagnoses included: -Parkinson's Disease (a progressive nervous system disorder that affects movement. -Hypertension (HTN - high blood pressure) and -Alzheimer's Disease (a type of dementia that causes problems with memory, thinking and behavior). Record review of the resident's care plan showed no documentation that a summary of the resident's baseline care plan was provided to the resident or his/her responsible party. Record review of the resident's progress notes showed no documentation that a summary of the resident's baseline care plan was provided to the resident or his/her responsible party. 4. During record review and interview on 8/23/19 at 8:35 A.M. the DON said: -The baseline care plan is initiated upon entrance into the facility. -The resident's care plan is continued from the baseline care plan which began upon entrance. -The first date on the care plan is the initial/baseline care plan date, completed within the first 48 hours after admission to the facility and -There was no documentation to show the resident or their responsible party received a copy of the baseline care plan. Based on interview and record review, the facility failed to provided a baseline care plan to the resident and the resident's representative for three sampled residents (Residents #45, #35, and #62) out of 20 sampled residents. The facility census was 100 residents. Record review of the facility's baseline care plans policy dated July 2018 showed: -A baseline care plan should be completed within 48 hours of admission. -The resident and/or their responsible party shall be provided a summary of the baseline care plan and -The associate providing the summary of the baseline care plan shall document delivery of the document in the resident's medical record. 1. Record review of Resident #45's entry tracking record showed he/she was admitted to the facility on [DATE]. Record review of the resident's contact information showed the resident had a Public Administrator (a county official with the responsibility to handle the affairs of someone who has no known or available relative, friend, guardian or executor) who was the resident's representative. Record review of the resident's medical records showed: -The resident's current care plan dated 8/19/19 showed it was initiated 11/20/18 and -No documentation of a baseline care plan that was provided to the resident and his/her representative. During an interview on 8/21/19 at 9:35 A.M: -The Director of Nursing (DON) said documentation showing the baseline care plan was provided to the resident and their representative would normally be in the care plan note or in the social worker's notes and -The Director of Social Services and the DON both looked in the resident's electronic health record and could not find documentation of a baseline care plan being provided to the resident and the resident's representative.

2. Observation on 8/21/19 at 7:00 A.M. of the post acute medication cart with the DON showed: -A resident's prescription Nystatin (a medication used to treat fungal infections) a 473 milliliter (ml) bottle was open without an opened date on it. -A resident's prescription Antac/Diph/Lidoc (an oral rinse containing diphenhydramine, lidocaine, and an antacid - used to numb the tissues in the mouth) a 240 ml bottle was open without an opened date on it. -A package of Veroform Petroleum dressing (a dressing that will not adhere to a wound) 5 x 9 inches was opened (single use). -A package of Petroleum gauze 3 x 9 inches was opened (single use) and -The container of Drug Buster (medication disposal system quickly turns most non-hazardous medications into a non-toxic slurry that can be safely put in the trash) was in the drawer with pudding cups (a food taken with medications for those residents who have a hard time swallowing medications). 3. Observation on 8/21/19 at 7:15 A.M. of the medication cart for E and F hallway with the DON showed: -The sharps container (a hard plastic container that is used to safely dispose of hypodermic needles and other sharp medical instruments) was not locked. -One of the drawers with the residents' prescribed medications had a pair of used toe nail clippers in it and -Two cans of a resident's Glucerna (a nutritional supplement) was in the same drawer as the Drug Buster. During an interview on 8/21/19 at 7:30 A.M. the DON said: -Medications should have an opened date written on them if they have been opened. -The dressings should not have been opened. -The sharps containers should have been locked. -Nothing should be in the drawer with the Drug Buster and -There is no reason to have toe nail clippers in with the medications. During an interview on 8/23/19 at 10:15 A.M. Certified Medication Technician (CMT) A said: -There should not be any expired medications in the medication carts. -There should not be any loose pills in the drawers. -There should not be any personal care items such as toenail clippers in the medication cart. -There should be a date written on the medication as soon as it was opened. -The CMT was responsible for keeping the cart clean. -Drug Buster or any type of cleaner should not be kept in a drawer with medications. -Drug Buster or any type of cleaner should not be kept in a drawer with food used for medication administration and -Drug Buster should be in their own compartment not kept with anything else. During an interview on 8/23/19 at 10:20 A.M. Licensed Practical Nurse (LPN) B said: -There should be a date written on a medication after it was opened. -There should not be any expired medications in the medication carts. -There should not be any loose pills in the drawers. -There should not be any personal items in the drawers. -Whoever used the medication cart was responsible for cleaning it. -The Drug buster should be in a compartment by itself and -Any cleaning agent such as bleach wipes should be in a compartment by itself. Based on observation, interview, and record review, the facility failed to ensure medications were stored, labeled and dated correctly for two sampled medication carts out of four sampled medication carts; to ensure the residents prescription and over the counter medications that were opened had an opened date written on them; to ensure foods used for the medication pass were not in with the facility's drug buster (chemical agent used to destroy drugs); to ensure personal belongings were not in the medication drawers; to ensure the sharps containers were locked; to ensure expired medications were removed from one medication cart, and to ensure loose pills in the medication drawers were removed. The facility census was 100 residents. Record review of the facility's 12/17 policy, Storage of Medications, showed: -Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. -The nursing associates shall be responsible for maintaining medication storage in a clean, safe, and sanitary manner. -Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy. -The community shall not use discontinued, outdated or deteriorated drugs or biologicals; -Drugs for external use, as well as poisons, shall be clearly marked as such, and shall be stored separately from other medications. -Antiseptics, disinfectants, and germicides used in any aspect of resident care must have legible, distinctive labels that identify the contents and shall be stored separately from regular medications; and -Compartment containing drugs shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. 1. Observation on 8/21/19 at 6:58 A.M., of the center hall A-B medication cart showed: -Two unidentifiable loose pills in a drawer, one white and oblong the other pink and round. -A container of Aspirin 325 milligrams (mg) with a expiration date of 7/2019 and an opened date of 8/6/19. -No open date for a bottle of Zinc Sulfate 220 mg. -No open date for a bottle of Calcium plus Vitamin D3 and -The Nurse Manager wrote the current date of 8/21/19 on both of the above non-dated medications. During an interview on 8/23/19 at 2:55 P.M., the Director of Nursing (DON) said: -The charge nurse was responsible for checking and removing expired medications from the medication carts. -Nurses or Certified Medication Technicians (CMT) should check for the expiration date on all medications before opening them. -All medications should be labeled with an open date by the staff opening the container. -There should not be any loose pills in a medication drawer and -It is the responsibility of the staff that is working on a medication cart to ensure that it is clean.

Based on observation, interview, and record review, the facility failed to educate all regular staff as to the existence, whereabouts, and/or contents of a written, on-site policy regarding the acceptance, usage, and storage of foods brought into the facility for residents by family and other visitors, to ensure the food's safe and sanitary handling and consumption. This deficient practice had the potential to affect all residents who ate food brought in by visitors. The facility census was 100 residents with a licensed capacity of 162 residents. During an interview on 8/19/19 at 9:03 A.M., the Director of Nutrition Services (DNS) said there was a facility policy on food brought in from outside for residents and he/she provided a copy of same. Record review on 8/19/19 at 12:33 P.M. of the facility policy entitled Foods Brought by Resident Representative(s)/Visitors and Personal Refrigerators provided earlier by the DNS showed the following: -Points D and E state that resident food brought into the community must be clearly marked and may be stored in the kitchenette refrigerators, and -Point G states that the kitchenette refrigerators shall have their refrigerator and freezer temperatures monitored. 1. Observation on 8/19/19 at 2:49 P.M. showed the refrigerator in the kitchenette by the H Hall had a sign on the outside of the door that stated ALL resident food and drink must be labeled with the name, date and placed in the activities refrigerator in the Activities Area. During an interview at the Post-Acute Nurse Station on 8/19/19 at 2:57 P.M., Licensed Practical Nurse (LPN) A said if food is brought in for a resident: -Their diet is checked to make sure it complies. -Their name, room number, and date is put on it. -It is stored in the kitchenette refrigerator. -It is given to them when they ask for it, hopefully within the next couple of days. -He/She learned of the procedure during orientation, and -The policy may be in a binder somewhere. During an interview at the Center Court Nurse Station on 8/19/19 at 3:03 P.M., Registered Nurse (RN) A said if food is brought in for a resident: -They check with their diet to make sure it is okay. -They put their name on the container. -It is put in the refrigerator in the Activities Area. -Some residents have their own refrigerator, and -He/She thought it was something everybody just knew. 2. Observation on 8/19/19 at 3:07 P.M. showed the refrigerator in the Activities Area was empty except for one employee lunch bag and there was no thermometer in the freezer. During an interview in the Activities Area on 8/19/19 at 3:11 P.M., the Activities Director said: -Occasionally they may have facility food for the resident's kept in the refrigerator. -It is not designated for resident food brought in, and -It is just for activity food for a function or seasonal stuff. During an interview on 8/21/19 at 2:09 P.M., the Activities Director said: -He/she had been the Dietary Manager there for about five years but recently switched to be the Activities Director. -He/she thought there was a policy for outside food brought in for residents in Nutrition Services somewhere, and -He/she thought they had seen it once. During an interview on 8/21/19 at 2:33 P.M., the Director of Nutrition Services said the staff should know the policy for food brought in for residents and if they don't, they should ask.

Based on observation and interview, the facility failed to adequately date opened foodstuff; to maintain sanitary food preparation and serving utensils; to ensure cutting boards were in good condition to avoid food safety hazards; to keep the kitchen and dry storage floors clean to prevent foodborne illness; and to properly refrigerate sauces. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 100 residents with a licensed capacity for 162. 1. Observation during the kitchen inspection on 8/19/19 between 9:03 A.M. and 12:34 P.M., showed the following: -There was a 7 pound can of pork and beans on a rack dispenser in the Dry Storage Room that was dented on the lip. -Some other cans on the rack dispenser were not dated as to when they came in. -Five 35 ounce (oz.) bags of cereal in the Dry Storage Room were undated. -There was some paper and plastic debris under some of the racks in the dry storage. -The manual can opener in the kitchen had paper residue on the right side of the blade. -There were foodstuffs and paper debris under the racks in the walk-in refrigerator and freezer. -A spatula in a utensil drawer had two spots of food on it. -An open, half full, 1 gallon jug of soy sauce under a food preparation table stated Refrigerate After Opening on the label. -A green cutting board was heavily scored and a red cutting board was heavily scored with a greasy food substance dripping down one corner of it. -Drawers for small plastic containers and paper cupcake holders had food debris in the bottom and streaks of residue on the inner sides. -There was a dried piece of food on the floor between the deep fryer and stove. -A plastic bread clip was on the floor between the steamer oven and the wall, and -There was plastic and paper debris under a food preparation table and rack in the dishwashing room. During an interview on 8/19/19 between 9:03 A.M. and 12:34 P.M., the Director of Nutrition Services said the following: -The regular Dietary Manager had been let go the previous week. -He/she was filling in as the Interim Dietary Manager. -Food deliveries were usually on Mondays and Thursdays, and -The canned and boxed foodstuffs came in before the previous manager left. 2. Observation during the follow-up kitchen inspection on 8/20/19 at 8:44 A.M. showed the following: -The manual can opener blade had paper residue on it as before, and -The walk-in refrigerator and freezer still had paper debris on the floors under the racks. Observation during the follow-up kitchen inspection on 8/21/19 at 2:25 P.M. showed the manual can opener blade continued to show paper residue on the right side of the blade. 3. During an interview on 8/21/19 at 2:33 P.M., the Director of Nutrition Services said the following: -The walk-in floors were to be cleaned weekly and the kitchen floors cleaned daily by the evening cook. -If cutting boards are deeply gouged or not cleanable he/she determines when they are thrown out. -All foodstuffs that come in should be dated. -If labels state to refrigerate after opening that should be followed. -Food preparation utensils were cleaned weekly, and -The manual can opener should be cleaned every shift.