**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two sampled residents (Resident #3 and Resident #5) medications were documented as administered as ordered by the physician out of 10 sampled residents. The facility census was 71 residents. Review of the facility's Medication Administration and Monitoring Policy dated 2025 showed: -To ensure quality of care delivery by instructing nursing staff to administer medications safely and appropriately. -Responsibility of nursing professional to: --Be aware of action, correct dosage and route, frequency and other considerations (pulse, blood pressure, meal) is required for administration of medications. --Notify physicians of any acute change in resident condition or status to obtain an order for holding or administering medication. --Coordinate communication between the pharmacy and the physician. --Report to the Director of Nursing (DON) when the resident refuses the medication on two consecutive occasions. -If the medications are not available from pharmacy and the physician authorizes for immediate implementation, use the Emergency box (E-kit) to obtain the medication to provide it to the residents if needed. -Document properly in the E-kit and in nurse notes and notify the pharmacy for replacement. -Circle initials on the Medication Administration Record (MAR) if medications are not administered as ordered and record reason in the as needed (PRN)/omission medication section of the chart (usually on the back of the MAR). -When auditing (monthly, quarterly and/or PRN) by designated licensed nurse, any omission of medication shall be investigated by the asking nurse/CMT and recount the medication. -If there is an actual medication error rather than documentation error, the physician shall be notified. 1. Review of Resident #3's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis: -High Blood Pressure (HTN). -Type II Diabetes Mellitus (DMII - a long-term condition in which the body has trouble controlling blood sugar and using it for energy). -Hyperlipidemia (HLD - high levels of fat particles in the blood). -Neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet). Review of the resident's Care Plan dated 4/10/25 showed: -Give medications as ordered. -Allow the resident to make decisions about treatment regime, to provide sense of control. -Educate resident of the possible outcome(s) of not complying with treatment or care. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 4/25/25 showed the resident was cognitively intact. Review of the resident's Physician's Order (POS) and Medication Administration Record (MAR) dated 4/1/25 through 4/30/25 showed: -Blood Pressure, obtain blood pressure once daily for HTN. --Blood pressure was not taken 22 out of 30 opportunities. --Eighteen of the missed blood pressure were left blank, three were the resident refused, and one the resident was out of the facility. -Accuchecks, obtain four times daily with meals and at bedtime for DMII. --Accuchecks were not taken 12 out of 120 opportunities. --Five of the missed checks were left blank, four were refused by the resident, and three of the missed checks the resident was out of the facility. -Amlodipine BES 10 milligrams (mg) Tablet, take one tablet by mouth every day for HTN. --Amlodipine BES 10 mg was not given 13 out of 30 opportunities. --Eleven doses were left blank, one resident was out of the facility, and one the resident refused. -Atorvastatin 20 mg Tablet, take one tablet by mouth every day for HLD. --Atorvastatin 20 mg was not given 13 out of 30 opportunities. --Twelve doses were left blank and one the resident was out of the facility. -Furosemide 40 mg Tablet, take one tablet by mouth every day for HTN. --Furosemide 40 mg was not given 11 out of 30 opportunities. --Ten doses were left blank and one the resident was out of the facility. -Jardiance 25 mg Tablet, take one tablet by mouth every morning for DMII. --Jardiance 25 mg was not given 11 out of 30 opportunities. --Ten doses were left blank and one the resident was out of the facility. -Losartan Potassium 50 mg Tablet, take one tablet by mouth every day for HTN. --Losartan Potassium 50 mg was not given 11 out of 30 opportunities. --Ten doses were left blank and one the resident was out of the facility. -Gabapentin 100 mg Capsule, take two capsules by mouth two times a day for neuropathy. --Gabapentin 100 mg was not given 26 out of 60 opportunities. --All 26 doses were left blank. -Janumet 50 - 1,000 mg Tablet, take one tablet by mouth two times a day for DMII. --Janumet 50 - 1,000 mg was not given 25 out of 60 opportunities. --Twenty-four doses were left blank and one dose the resident was out of the facility. -Insulin Aspart 100 unit/milliliter (ml) (prime pen prior to dose with two units per manufacture), inject eight units subcutaneously (under the skin) three times a day for DMII. --Insulin Aspart was not given 31 out of 90 opportunities. --Eight missed doses were left blank, four the resident was out of the facility, and 19 missed doses were held due to blood sugar levels. ---NOTE: Out of the 19 times the insulin was held due to blood sugar levels, the resident refused accuchecks two times and one time the blood sugar was 65. All other blood sugars documented during those time frames were between 87 - 134 (normal blood sugar ranges from 70-100). --NOTE: The POS and MAR does not have parameters for holding Insulin Aspart when out of range. -Lantus Solostar 100 unit (prime pen prior to dose with two units per MFG), inject 15 units subcutaneously at bedtime for DMII. --Lantus Solostar was not given five out of 30 opportunities. --One dose was blank, two doses were refused by the resident, and two doses were held due to blood sugar levels. ---NOTE: Out of the two times the Lantus was held due to blood sugar levels, the resident's blood sugar was within normal range. --NOTE: The POS and MAR does not have parameters for holding Lantus Solostar when out of range. Review of the resident's Nurse's Notes for April 2025 showed: -No documentation as to why the resident did not receive his/her medications. -No documentation that the physician was notified of the missed medications. Review of the resident's POS and MAR dated 5/1/25 through 5/31/25 showed: -Blood Pressure, obtain blood pressure once daily for HTN. --Blood pressure was not taken 31 out of 31 opportunities. --All 31 of the missed blood pressures were left blank. -Accuchecks, obtain four times daily with meals and at bedtime for DMII. --Accuchecks were not taken 35 out of 124 opportunities. --One of the missed checks was left blank, two were refused by the resident, and 32 of the missed checks the resident was out of the facility. -Amlodipine BES 10 milligrams (mg) Tablet, take one tablet by mouth every day for HTN. --Amlodipine BES 10 mg was not given eight out of 31 opportunities. --Seven doses were left blank and one the resident refused. --NOTE: Six of the missed doses were consecutive days. -Atorvastatin 20 mg Tablet, take one tablet by mouth every day for HLD. --Atorvastatin 20 mg was not given eight out of 31 opportunities. --Seven doses were left blank and one the resident was out of the facility. --NOTE: Six of the missed doses were consecutive days. -Furosemide 40 mg Tablet, take one tablet by mouth every day for HTN. --Furosemide 40 mg was not given two out of 31 opportunities. --Both doses were refused by the resident. -Jardiance 25 mg Tablet, take one tablet by mouth every morning for DMII. --Jardiance 25 mg was not given two out of 31 opportunities. --Both doses were refused by the resident. -Losartan Potassium 50 mg Tablet, take one tablet by mouth every day for HTN. --Losartan Potassium 50 mg was not given two out of 31 opportunities. --Both doses were refused by the resident. -Gabapentin 100 mg Capsule, take two capsules by mouth two times a day for neuropathy. --Gabapentin 100 mg was not given 11 out of 62 opportunities. --Eight doses were left blank and three were refused by the resident. -Janumet 50 - 1,000 mg Tablet, take one tablet by mouth two times a day for DMII. --Janumet 50 - 1,000 mg was not given 9 out of 62 opportunities. --Six doses were left blank and three were refused by the resident. -Insulin Aspart 100 unit/milliliter (ml) (prime pen prior to dose with two units per manufacture), inject eight units subcutaneously (under the skin) three times a day for DMII. --Insulin Aspart was not given 37 out of 93 opportunities. --One missed dose was left blank, 20 missed doses the resident was out of the facility, five doses the resident refused, and nine missed doses were held due to blood sugar levels. --NOTE: The POS and MAR does not have parameters for holding Insulin Aspart when out of range. -Lantus Solostar 100 unit (prime pen prior to dose with two units per MFG), inject 15 units subcutaneously at bedtime for DMII. --Lantus Solostar was not given eight out of 31 opportunities. --Two doses were left blank, one dose was refused by the resident, four doses the resident was out of the facility, and one dose was held due to blood sugar levels. --NOTE: The POS and MAR does not have parameters for holding Lantus Solostar when out of range. Review of the resident's Nurse's Notes for May 2025 showed: -No documentation as to why the resident did not receive his/her medications. -No documentation that the physician was notified of the missed medications. During an interview on 6/3/25 at 1:12 P.M. the resident said: -He/She does not receive his/her medications as ordered by the physician. -If he/she should go out of the facility on a pass he/she does not get his/her medications after returning to the facility if medication pass is done. -He/She needs his/her medications due to serious medical conditions. 2. Review of Resident #5's admission Record showed he/she was admitted to the facility on [DATE] with the following diagnosis: -High Blood Pressure. -Type II Diabetes Mellitus. -Hyperlipidemia. -Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). -Chronic Obstructive Pulmonary Disease (COPD - is a common lung disease causing restricted airflow and breathing problems). -Anxiety (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). -Insomnia (difficulty falling asleep, staying asleep. Or waking up too early). Review of the resident's undated Care Plan showed: -Give medications as ordered by the physician. -Monitor/document side effects and effectiveness. Review of the resident's quarterly MDS dated [DATE] showed the resident was cognitively intact. Review of the resident's POS and MAR dated 4/1/25 through 4/30/25 showed: -ANORO ELLIPTA 62.5 - 25 micrograms (mcg), inhale one puff every day for COPD. --ANORO ELLIPTA 62.5 - 25 mcg was not given five out of 30 opportunities. --All five doses were refused by the resident. -Aspirin EC 81 mg Tablet, take one tablet by mouth every day for HLD. --Aspirin EC 81 mg was not given five out of 30 opportunities. --Two doses were left blank and three were refused by the resident. -Atorvastatin 10 mg Tablet, take one tablet by mouth every day for HLD. --Atorvastatin 10 mg was not given five out of 30 opportunities. --Two doses were left blank and three were refused by the resident. -Escitalopram 20 mg Tablet, take one tablet by mouth every day for depression. --Escitalopram 20 mg was not given four out of 30 opportunities. --All four doses were refused by the resident. -Metformin HCL 500 mg Tablet, take one tablet by mouth every day with/after meals for DMII. --Metformin HCL 500 mg was not given four out of 30 opportunities. --All four does were refused by the resident. -Buspirone HCL 5 mg Tablet, take one tablet by mouth two times a day for anxiety. --Buspirone HCL 5 mg was not given 17 out of 60 opportunities. 11 of the missed doses were the 4:00 P.M. dose. --Thirteen doses were left blank, and four doses were refused by the resident. -Fluticasone PROP HFA 220 mcg, inhale one puff into lungs two times a day for COPD. --Fluticasone PROP HFA 220 mcg was not given 23 out of 60 opportunities. 10 of the missed doses were the 4:00 P.M. dose. --Thirteen doses were left blank, and 10 doses were refused by the resident. -Melatonin 3 mg Tablet, take two tablets (6 mg) by mouth at bedtime for insomnia. --Melatonin 3 mg Tablet was not given 15 out of 30 opportunities. --Thirteen doses were left blank, and two doses were refused by the resident. -Trazodone 100 mg Tablet, take two tablets (200 mg) by mouth at bedtime for insomnia. --Trazodone 100 mg Tablet was not given 20 out of 30 opportunities. --Thirteen doses were left blank, and seven doses were refused by the resident. Review of the resident's POS and MAR dated 5/1/25 through 5/31/25 showed: -Metformin HCL 500 mg Tablet, take one tablet by mouth every day with/after meals for DMII. --Metformin HCL 500 mg was not given two out of 31 opportunities. --Both does were on order and had not been delivered by the pharmacy. -Trazodone 100 mg Tablet, take two tablets (200 mg) by mouth at bedtime for insomnia. --Trazodone 100 mg Tablet was not given three out of four opportunities. --One dose was left blank, and two doses were refused by the resident. --NOTE: No documentation as to why the resident did not receive his/her medications or if the physician was notified of the missed doses. During an interview on 6/3/25 at 11:00 A.M. the resident said: -He/She was not concerned about missing medications. -The medications have been getting better. 3. During an interview on 6/3/25 at 1:29 P.M. the Administrator said: -He/She expects Certified Medication Technicians (CMT)s/nurses to pass medications as ordered by the physician. -The physician should be notified of any missed medications and documented in the resident's medical record the physician was notified. During an interview on 6/4/25 at 1:02 P.M. the Nurse Practitioner (NP) A said: -Would expect CMTs/nurses to give the residents their medications as ordered by him/her or the physician. -If a resident is refusing medications or out of the facility the missed medications should be documented why the medication was missed on the back of the MAR or resident's medical record. -He/She should be notified if a resident refuses his/her medications daily. -He/She had not been notified of medication refusals. -If a resident is out of the facility at the same time or refuses medications at a same time then he/she needs to find out why and change the time of the medication so the resident will take the medication. -He/She was not notified Resident #3 was gone at the same time each day and not getting his/her medications. During an interview on 6/4/25 at 1:29 P.M. CMT A said: -He/She will re-order medications when the resident has three days left of medication. -If the MAR was not signed then the resident did not get their medications. -He/She notifies the charge nurse if the resident refuses medications or if the resident was out of a medication. -The charge nurse is to notify the physician if the resident misses' medications due to refusal or out of the medication. -If the resident was out of the facility during medication pass, he/she would initial the medication and circle his/her initials that shows the resident did not get that medication. During an interview on 6/4/25 at 2:43 P.M. Licensed Practical Nurse (LPN) A said: -Resident #3 is out of the facility a lot during medication pass and comes back after the hour window. -He/She must call the physician to get an order to give the resident his/her medications when the resident get back to the facility. -He/She tried to give the resident his/her medications first when he/she first gets to work before the resident leaves for the day. -He/She notifies the NP/Physician if a resident refuses medications. -Staff should document physician and NP notification in the resident's nurse's notes. -The refusal should be charted on the back of the MAR because the medication was not given. During an interview on 6/4/25 at 3:10 P.M. the Director of Nursing (DON) said: -He/She had educated the CMTs and nurses in the past on making sure they are documenting the medication pass on the resident's MARs and to check the MARs after medication pass to make sure they have signed off on each medication given. -Medications should be given as ordered by the physician. -He/She expects to be notified if a resident keeps refusing medications or has a habit of being out of the facility during medication pass. -He/She expects staff to document on the residents' MARs when a medication had been administered. -He/She expected staff to document in the residents' notes when staff notify the resident's physician of refused medications, any missed doses, or if the resident was out of the facility during the medication administration times. -He/She would expect CMTs and nurses to reorder resident medications at least three days prior to the resident running out of the medication. MO00253692 MO00254572

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet the required discharge requirements for one resident (Resident #1) out of three sampled residents. The facility census was 68 residents. Review of the facility's Protocol for Discharge Planned dated 2022 showed: -Residents who were admitted to the facility would be assessed for potentials upon admission, quarterly and whenever needed as wished or voice by the resident or facility professional staff. -The Quality Assurance (QA) committee discussed the potential discharge (immediate discharge, involuntary discharge) to investigate and analyze if the discharge was the best interest for the residents in the facility and/or for the resident who was discharged . -The QA committee would carefully monitor and discuss before making the decision and consult with the resident's primary physician, family or designated power of attorney (DPOA). When the committee agreed with the decision, the director of operations would be notified and discussed. -The director of operations would authorize the discharge notice. The facility would obtain the physician's order for discharge. -The administrator would issue the letter of notice to the resident and family. 1. Review of Resident #1's admission Record face sheet showed he/he was admitted to the facility on [DATE] with the following diagnoses: -Anxiety disorder, (persistent and excessive worry about various aspects of life). -Depression, (a mental illness characterized by feelings of sadness, hopelessness and lack of interest or pleasure in activities once enjoyed). -Adjustment disorder, (a mental health condition characterized by emotional and behavioral symptoms in response to a stressor or group of stressors). -He/She was his/her own responsible party. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandate assessment tool required to be completed by staff), dated 2/6/24, showed he/she was cognitively intact. Review of the resident's Notice of Discharge (Immediate Notice) dated 4/29/24 effective at 2:15 P.M. showed: -The safety of individuals in the facility was endangered due to clinical or behavioral status of the resident. -The health of individual in the facility would otherwise be endangered. -The reason for the discharge was his/her physical attempt for suicide by taking a pair of scissors and trying to cut his/her left wrist and continued verbalization of suicide. -Due to the seriousness and/or violent nature of the discharge, filing the appeal would not allow him/her to remain in the facility until the hearing was held unless a hearing officer found otherwise. -There was no discharge location. During an interview on 5/10/24 at 9:46 A.M., Ombudsman A said: -The resident had filed an appeal effective 5/10/24. -The facility had been notified. -The facility would be recommended to take the resident back from the hospital. -There was no letter provided for discharge to the resident or the hospital. -There was a letter the resident signed in the ambulance and sent to the Ombudsman's office, however a copy was not given to the resident. -The resident was in crisis when he/she signed. Review of the resident's Order of Dismissal of discharge date d 5/15/24 showed: -The facility discharged the resident on 4/29/24. -The discharge notice failed to meet the requirements for the discharge notice. -The discharge notice failed to contact the required information prescribed in the provisions of 19 CSR 30-82.050, Specifically : --(4)(B)5. that filing an appeal will allow a resident to remain in the facility until the hearing is held unless a hearing official finds otherwise; --(4)(B)6. The location to which the resident is being transferred or discharged . -The facility did not meet the requirements for appropriate discharge to the resident. During an interview on 5/20/24, Ombudsman A said: -The letter provided to the resident was invalid, so the hearing unit sent a dismissal of the discharge notice. -The letter did not have the information that the resident was allowed to remain in the facility until the hearing decision and it did not have a location for new placement. -On 5/10/24, Ombudsman B reached out to the facility and spoke with the social worker and administrator on-site, advocating for the resident to come back, since the discharge letter was invalid and the resident was in mental health crisis when he/she signed it. -On 5/15/24, the hospital social worker reached out to the facility and the facility social worker said he/she could not return. During an interview on 5/30/31 at 3:00 P.M., Social Worker A said the resident got a copy of his/her discharge notice when he/she signed it. During an interview on 5/31/24 at 3:00 P.M., the Administrator said: -He/She made the decision to discharge the resident. -He/She got a letter stating the resident's discharge was inappropriate from [NAME] City. By that time the resident had already been placed at another facility. MO00235779

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit one sampled resident (Resident #1) to return to the facility out of three sampled residents. The facility census was 68 residents. 1. Review of Resident #1's admission Record face sheet showed he/he was admitted to the facility on [DATE] with the following diagnoses: -Anxiety disorder, (persistent and excessive worry about various aspects of life). -Depression, (a mental illness characterized by feelings of sadness, hopelessness and lack of interest or pleasure in activities once enjoyed). -Adjustment disorder, (a mental health condition characterized by emotional and behavioral symptoms in response to a stressor or group of stressors). -He/She was his/her own responsible party. Review of the resident's Care Plan dated 11/7/23 showed: -The resident had a diagnosis of depression and was being medicated and observed for it. -The resident did not have any care planning for behaviors. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool required to be completed by staff for care planning), dated 2/6/24, showed he/she was cognitively intact. Review of the resident's Nurse's Notes dated 4/29/24 at 2:00 P.M. showed he/she had a suicidal attempt and was transferred to the hospital. Review of the resident's Social Service Progress Notes dated 4/29/24 at 2:20 P.M. showed the resident was served an immediate discharge notification for suicidal attempt and ideation. Review of the hospital Progress Notes dated 5/2/24 showed: -The facility was contacted to inquire about discharge and return at 12:51 P.M. -Qualified Mental Health Professional/Social Worker A (QMHP) asked to speak with someone regarding discharge arrangements for the resident. He/she was transferred to the DON. -The DON asked for the resident's name and responded that he/she had been discharged . -The DON refused to state a date. He/She responded to each question that he/she didn't have the patient's information in front of him/her and refused or was unable to provide details to QMHP's questions. -The DON stated the resident was alert and oriented and able to share information to answer these questions. -QMHP said the resident had stated he/she had been discharged on 4/29/24. -The DON continued to insist the resident was discharged and could not return, and that a social worker would be able to find other placement. -QMHP stated the resident was by law required to have a 30-day written notice for evictions. The DON continued to repeat the same statement that the resident had been discharged . -QMHP asked if there was anyone else he/she could speak with regarding this resident. -The DON asked for the name, call-back number and title and said this information would be passed along. -QMHP informed supervisor, who left a voice mail for legal representative to inquire about patient rights at 1:00 P.M. -QMHP received a call back from the facility at 1:11 P.M. from the DON, who stated he/she was the person QMHP previously spoke with and was informed the facility would work on placement of the resident, but he/she still could not return to the facility due to being discharged . -The DON reported that a local homeless shelter's administrator would work on the referral and asked for his referral to be faxed to his/her number. -QMHP faxed referral and informed treatment team and supervisor of interaction. During an interview on 5/10/24 at 9:46 A.M., Ombudsman A said: -The resident had filed an appeal to the discharge effective 5/10/24. -The facility had been notified. -The facility would be recommended to take the resident back. -The facility social worker said the resident was suicidal and continued to be suicidal after the police had come. -The resident was sent to the hospital for evaluation. -There was no letter provided for discharge to the resident or the hospital. -There was a letter the resident signed in the ambulance and sent to the Ombudsman's office, however a copy was not given to the resident. -The resident was in crisis when he/she signed. Review of the resident's Order of Dismissal of discharge date d 5/15/24 showed: -The facility discharged the resident on 4/29/24. -The discharge notice failed to meet the requirements for the discharge notice. -The resident was given inadequate notice. -The resident could remain at the facility. During an interview on 5/20/24, Ombudsman A said: -On 5/10/24, Ombudsman B reached out to the facility and spoke with the social worker and administrator on-site, advocating for the resident to come back, since the discharge letter was invalid and the resident was in mental health crisis when he/she signed it. -On 5/15/24, the hospital social worker reached out to the facility and the facility social worker said he/she could not return. During an interview on 5/30/24 at 12:55 P.M., Ombudsman B said: -The facility was set in their decision not to take the resident back because he/she had actively been trying to cut his/her wrists, even when the staff were trying to stop him/her. -If the resident had an emotional emergency, the facility did the right thing by sending him/her to the hospital for evaluation. -Once the resident was stable, he/she did not meet the criteria for discharge from the facility. -The resident said he/she had made his/her home at the facility and hoped they would forgive him/her and allow him/her to come back. He/She was willing to go back. He/She was calling Ombudsman's office regularly to see if he/she could go back. During an interview on 5/30/31 at 1:55 P.M., the DON said: -The hospital social worker had called and spoke to the DON after hours and immediately said, I'm going to hotline you if you don't take the resident back. -The hospital never tried to send the resident back, have a nurse call report or give them a pick-up time. -He/she was aware that the administrator said he could not come back. -He/She knew they could not discharge the resident to the hospital. During an interview on 5/30/31 at 3:00 P.M., Social Worker A said: -The resident was not given a bed hold because he/she had been discharged . -The administrator made the decision of not allowing the resident to come back. During an interview on 5/31/24 at 3:00 P.M., the Administrator said: -He/she had made the decision the resident could not return to the facility after the resident hospital stay. He/she had discharged the resident. -He/She did not talk to an ombudsman, but got a letter stating the resident's discharge was inappropriate from [NAME] City. By that time the resident had already been placed at another facility. During an interview on 6/5/24 at 2:00 P.M., Hospital Social Worker A said: -The facility did not provide any paperwork for the resident. -The hospital staff checked through the resident's clothing and found nothing. -The resident signed his/her discharge notice while being transported by the EMTs. MO00235779

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a call light was within reach for two sampled residents (Resident #41 and #15) out of 21 sampled residents. The facility census was 68 residents. Review of the facility's policy, dated 2/21/12, titled Answering of Call Lights and Alarms showed the policy did not address resident access to call lights. 1. Review of Resident #41's Quarterly Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 9/15/23, showed: -The resident had moderate cognitive impairment. -The resident had a diagnosis of paraplegia (the loss of muscle function in the lower half of the body, including both legs). Review of the resident's undated care plan showed: -The resident was totally dependent on staff for dressing. -The resident required a mechanic lift for transferring. -The resident was non-weight bearing. Observation on 12/5/23 at 11:32 A.M. showed: -The resident was in his/her room in a wheelchair. -The call light was behind the head of his/her bed on the floor. During an interview on 12/5/23 at 11:32 A.M., the resident said: -Sometimes he/she could get to the call light and sometimes he/she couldn't. -He/she could not find the call light at this time. -He/she would holler for help if unable to find the call light. Observation on 12/5/23 at 2:45 P.M. showed: -The resident was lying in bed. -The call light remained behind the head of his/her bed on the floor. Observation on 12/6/23 at 9:21 A.M. showed: -Certified Nursing Assistant (CNA) B took the resident to his/her room and turned on the television. -CNA B left the room without giving the resident his/her call light. -The call light remained behind the head of his/her bed on the floor. Observation on 12/6/23 at 10:05 A.M. showed Housekeeper A entered the resident's room and began cleaning. Observation on 12/6/23 at 10:46 A.M. showed: -Housekeeper A was no longer in the room. -The call light remained behind the head of the resident's bed on the floor. Observation on 12/6/23 at 1:35 P.M. showed: -The resident was in his/her room in a wheelchair. -Housekeeper A entered the room, cleaned the corners of the walls, and left the room. -The call light remained behind the head of his/her bed on the floor. Observation on 12/6/23 at 2:31 P.M. showed: -CNA B and CNA D brought the resident in his/her room, transferred him/her to their bed, and dressed him/her. -CNA B and CNA D both left the room. -The call light remained behind the head of his/her bed on the floor. Observation on 12/6/23 at 2:48 P.M. showed: -Licensed Practical Nurse (LPN) D entered the resident's room, performed wound care, and left the room. -The call light remained behind the head of his/her bed on the floor. Observation on 12/7/23 at 1:31 P.M. showed: -The resident was in his/her room. -The call light remained behind the head of his/her bed on the floor. 2. Review of Resident #15's Significant Change MDS, dated [DATE], showed the resident was rarely/never understood. Review of the resident's undated Care Plan showed: -The resident was totally dependent on staff for dressing, eating, personal hygiene, toileting, and transferring. -The resident used a geri-chair (a large, padded chair that is designed to help seniors with limited mobility). -The resident had impaired visual function. Observation on 12/4/23 at 3:15 P.M. showed: -The resident was in his/her room in a geri-chair attempting to get out of the chair. -The call light was on the floor under the resident's bed. 3. During an interview on 12/8/23 at 9:19 A.M., CNA A said: -Staff were to ensure all residents in their room had access to a call light. -No resident in the facility had the ability to get to a call light from under the bed. -All staff, including housekeeping, were to ensure any resident in their room had their call light before leaving the room. During an interview on 12/8/23 at 9:28 A.M., CNA B said: -Staff were to ensure all residents in their room had access to a call light. -No resident in the facility had the ability to get to a call light from under the bed. -All staff, including housekeeping, were responsible for ensuring residents had their call light before leaving the room. During an interview on 12/8/23 at 10:05 A.M., LPN A said: -All residents were to have access to a call light when in their room. -No resident in the facility had the ability to get to a call light from under the bed. During an interview on 12/8/23 at 10:26 A.M., LPN B said: -Staff were to ensure call lights were accessible to any resident while in their room. -A call light under the bed would not be accessible to the resident. During an interview on 12/8/23 at 1:49 P.M., the Director of Nursing (DON) said: -Call lights were to be accessible to any resident in their room. -No resident in the facility had the ability to get to a call light from under the bed. -The staff member that placed the resident in their room was responsible for ensuring the call light was accessible to the resident. -All nursing staff were to ensure each resident had a call light every time they entered a resident room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the emergency contact was notified of one sampled resident's transfer to the hospital when the resident had a change in condition for one closed record sample (Resident #39) out of 21 sampled residents. The facility census was 68 residents. 1. Review of the Resident #39's Face Sheet showed the resident was admitted to the facility on [DATE], with diagnoses including depression, arthritis, high blood pressure, kidney failure (a condition in which the kidneys are damaged and cannot filter blood as well as they should), diabetes (a disease in which the body' s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), hypo-osmolality (a condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal) and hyponatremia (a lower than normal level of sodium in the bloodstream), acidosis (a condition in which there was too much acid in the body fluids), heart disease, anxiety, and insomnia (difficulty sleeping). The face sheet showed the resident was his/her own responsible party but there was an emergency contact listed. Review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 9/1/23, showed the resident: -Was alert and oriented with no memory difficulties. -Had some bladder incontinence but was continent of bowel. -Had no falls during the look back period. -Had no wounds, pain and did not utilize any treatments or therapies. -The resident's activity of daily living section (mobility, transfers, eating, bathing, dressing and hygiene) was not documented. Review of the resident's Nursing Notes dated 11/8/23, showed: -Nursing staff documented the resident had increased confusion and complained of generalized discomfort. -The resident had a very poor appetite, refused to get up for meals at breakfast and lunch. -The nurse was unable to obtain the resident's oxygen saturation level (the fraction of oxygen-saturated hemoglobin relative to total hemoglobin in the blood). -The nurse notified the resident's physician of the resident's condition and received orders to send him/her to the hospital for further evaluation. -There was no documentation showing the resident's emergency contact was notified. Review of the resident's Physician's Order Sheet (POS) dated 11/17/23, showed physician's orders for: -admission to Hospice services (end of life care) due to diagnosis of severe protein calorie malnutrition. -Morphine 20 milliliters (ml) take 0.25 ml every four hours as needed for air hunger/pain. -Barrier cream to his/her bottom twice daily and as needed for impaired skin integrity. Review of the resident's Nursing Notes dated 11/17/23, showed: -The resident returned to the facility from the hospital. The resident was alert and oriented to person and place. -The resident had multiple bruises to his/her bilateral upper extremities and poor skin turgor (skin elasticity). -The resident was incontinent of bowel and bladder and had limited range of motion to all of his/her extremities due to weakness. -The resident had a wound measuring 0.5 centimeters (cm) length by 0.5 cm width. -Hospice nursing staff was at the resident's bedside with the resident's family. Review of complaint report dated 12/7/23, showed the facility did not notify the resident's family or emergency contact of the resident's change in condition before he/she entered the hospital or that the resident had been sent to the hospital. The hospital notified them of this information. During an interview 12/08/23 at 12:34 P.M., Licensed Practical Nurse (LPN) A said: -He/she was familiar with the resident and when the resident first arrived, he/she was healthy, ambulated without assistance. -The resident was his/her own responsible party, was alert and oriented, ambulatory without assistance and was independent with completing all of his/her own cares up until a month or so before he/she passed. -The resident's health began to decline about a year ago. -The resident had family but the resident was estranged from all of his/her family and they had no contact with the resident. -The resident had an emergency contact, but that person never visited and had limited contact with the resident. -The resident would normally not want staff to notify his/her emergency contact of any previous health issues and they documented this in the resident's medical record. -He/she did not think they notified the resident's emergency contact when the resident began to decline. -He/she did not remember having any contact with the emergency contact until last week. -He/she did not remember notifying the resident's emergency contact when the resident went into the hospital. -Normally when a resident had a change in condition, they would notify the responsible party. -If the resident was their own responsible party and had a family member or emergency contact listed, they would notify them of the resident's change in condition. -The resident did have an emergency contact listed in his/her medical record, and they should have notified him/her when the resident began to decline and upon him/her going to the hospital. -The resident went on Hospice services prior to passing. During an interview on 12/08/23 at 1:50 P.M., the Director of Nursing (DON) said: -Usually upon admission they have the resident state a responsible party or emergency contact if they do not have a Power of Attorney or Guardian as someone to notify of changes in condition or support to the resident. -If the resident had an emergency contact or responsible party listed, even though this contact was not actively in the resident's life, they would notify them with the resident's change in condition. -Most of the residents in their facility do not have family involvement and they were used to not having to notify anyone regarding the resident and this was missed. -They did not notify the resident's emergency contact once the resident's condition changed and they should have. MO00227590

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Pre admission Screening and Resident Review (PASARR-a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or resident in Medicaid Certified beds in a nursing facility regardless of the source of payment) was completed for one supplemental Resident (Resident #4) out of 21 sampled residents and 8 supplemental residents. The facility census was 68 residents. Review of the facility's undated policy titled PASARR Policy showed: -The screening assures appropriate placement of persons known or suspected of having mental impairment(s) and also that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment. -All potential admitting residents will be assessed by the Social Services Director (SSD) and/or nursing staff to complete the PASARR. 1. Review of Resident #4's Face Sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). -Paranoid Schizophrenia (a subtype of Schizophrenia which includes a pattern of behavior when a person feels distrustful and suspicious of other people and acts accordingly). -Borderline Intellectual Functioning (a group of people who function on the border between normal intellectual functioning and intellectual disability). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment of daily life). Review of the Resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 11/6/23 showed: -The resident had depression. -The resident had Schizophrenia. The resident's PASARR was requested on 12/5/23 at 2:45 P.M. and was not received at the time of exit. During an interview on 12/5/23 at 3:28 P.M. the SSD said: -The resident was transferred to the facility originally. -He/she did not have a record of the Resident's PASARR. -He/she was responsible for completing PASARRs and keeping record of the PASARRs. During an interview on 12/8/23 the Director of Nursing (DON) said: -He/she was unsure of what a PASARR was, but thought the SSD would be responsible for keeping the record of it. -He/she would expect the facility to follow the regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a recapitulation of the resident's stay (describes the resident's course of treatment while at the facility) was completed for one sampled resident (Resident #72) out of 21 sampled residents. The facility census was 68 residents. A policy for Recapitulation of Stay was requested and not received at the time of exit. 1. Review of Resident #72's Face Sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Seizures (a sudden, uncontrolled burst of electrical activity in the brain causing changes in behavior, movements, feelings, and levels of consciousness). -Hypertension (High Blood Pressure) -Obsessive Compulsive Disorder (OCD- a personality disorder characterized by excessive orderliness, perfectionism, attention to details, and need for control in relating to others). Review of the resident's discharge Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/3/23 showed the resident discharged on 10/3/23. Review of the resident's nurse's notes dated 10/3/23 did not have any information showing the resident discharged from the facility. Review of the resident's Social Service's note dated 10/3/23 showed: -The resident was being discharged to a different nursing facility. -The resident left with all of his/her belongings. -The resident was picked up by a friend. NOTE: There was no recapitulation of stay or discharge summary. During an interview on 12/7/23 at 12:19 P.M. the Social Services Director (SSD) said: -The resident went to another facility. -He/she does not document a recapitulation of stay or summary in his/her notes. During an interview on 12/8/23 at 1:49 P.M. the Director of Nursing (DON) said: -He/she was unsure of what a recapitulation of stay meant. -He/she was not aware that a recapitulation of stay or discharge summary was needed when a resident discharges home or to another facility. -He/she was unsure of who was responsible for completing the recapitulation of stay. -He/she would expect the regulation to be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #15) was bathed a minimum of twice a week to maintain adequate hygiene, out of 21 sampled residents. The facility census was 68 residents. A policy regarding bathing was requested and not received at time of exit. 1. Review of Resident #15's Discharge Assessment Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 11/10/23, showed the resident was transferred to the hospital. Review of the resident's Entry Tracking Record MDS, dated [DATE], showed the resident returned from the hospital. Review of the resident's Significant Change MDS, dated [DATE], showed: -The resident was now on hospice services (end of life care). -The resident was rarely/never understood. -The resident was always incontinent of bowel and bladder. Review of the resident's undated Care Plan showed: -Staff documented the resident was totally dependent on staff for bathing, dressing, eating, hygiene, toileting, and transferring. -The resident had communications problems. -The resident had potential for impairment to the skin. Review of the resident's bath sheets for November and December 2023 showed: -The resident did not receive a bath for nine days, from 11/1/23-11/10/23. -The resident did not receive a bath for seven days, from 11/17/23-11/24/23. -The resident did not receive a bath for twelve days, from 11/24/23-12/6/23. -No documentation of refusals. -No documentation of oral care provided. Observation on 12/4/23 at 3:19 P.M. showed: -The resident's hair was disheveled and not brushed. -The resident tongue was brown and cracked. Observation on 12/5/23 at 10:18 A.M. showed the resident's hair was disheveled and not brushed. 2. During an interview on 12/5/23 at 9:06 A.M., the Director of Nursing (DON) said: -Skin assessments were done during bathing. -Staff were to bathe residents three times a week. During an interview on 12/8/23 at 9:19 A.M., Certified Nursing Assistant (CNA) A said: -Staff were to bath residents every other day. -Staff were to document a refusal to be bathed on a bath sheet. -Every resident was to have a minimum of two bath sheets a week indicating cares received or refused. During an interview on 12/8/23 at 9:28 A.M., CNA B said: -Staff bathed each resident three times a week or more. -Staff were to document refusals on a bath sheet and notify the charge nurse. -Every resident was to have multiple bath sheets each week indicating cares provided or refused. During an interview on 12/8/23 at 10:05 A.M., Licensed Practical Nurse (LPN) A said: -Staff were to bathe residents three times a week or more. -Refusals were to be documented on the bath sheets. -Each resident was to have at least two bath sheets each week indicating cares provided or refused. During an interview on 12/8/23 at 1:49 P.M., the DON said: -Staff were to bathe residents three times a week. -Refusals were to be documented on a bath sheet. -The bath sheets should indicate what cares were received and/or refused. -Every resident was to have multiple bath sheets for each week, regardless of whether they were hospitalized , as that's how he/she kept a record of skin assessments.

Based on interview and record review, the facility failed to ensure skin assessments were being completed and documented for one sampled resident (Resident #66) out of 21 sampled residents. The facility census was 68 residents. A facility policy on skin assessments was requested and not received at the time of exit. 1. Review of Resident #66's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Hemiplegia (paralysis to one side of the body) following Unspecified Cerebrovascular (relating to the brain and its blood vessels) Disease Affecting the Right Dominant Side. -Coronary Artery Disease (CAD- plaque build-up in the wall of the arteries that supply blood to the heart) without Angina Pectoris (chest pain). -Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Review of the resident's Skin Monitoring: Comprehensive Certified Nursing Assistant (CNA) Shower Review dated 10/2/23 showed: -The document does not indicate if the Resident had a skin issue or not. -The only documentation on the sheet is the CNA's signature and the Director of Nursing's (DON) signature. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 10/9/23 showed: -The resident had moderately impaired cognition. -The resident did not exhibit the behavior of rejection of care. -The resident needed substantial/maximal assistance for showering/bathing. -The resident had Moisture Associated Skin Damage (MASD- caused by prolonged exposure to various sources of moisture). Review of the resident's care plan dated 10/11/23 showed: -The resident did not have a focus or any interventions related to his/her skin. -The resident did not have a focus or any interventions related to Activities of Daily Living (ADL) care. Review of the resident's Treatment Administration Record (TAR) dated October 2023 showed: -The resident had the following order: --Cleanse Right Second Digit with Normal Saline (NS- a mixture of sodium chloride and water with numerous uses including the cleansing of wounds) and apply Triple Anti-biotic Ointment (TAO) and cover with Band-Aid every day until healed dated 10/16/23. -The wound healed on 10/20/23. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review dated 10/25/23 showed: -The document did not indicate if the Resident had a skin issue or not. -The only documentation on the sheet is the CNA's signature and the Licensed Practical Nurse's (LPN) signature. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review dated 10/27/23 showed the resident refused his/her shower/skin assessment. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review dated 10/30/23 showed: -The resident refused his/her shower/skin assessment. -No other Skin Monitoring Shower Review Sheets were received beyond this date. Review of the resident's Physician Order Sheet (POS) dated 11/30/23 showed a written order for the resident to have weekly skin assessments on Mondays. NOTE: No weekly skin assessments were received or found for the Months of October 2023 and November 2023. During an interview on 12/5/23 at 1:41 P.M. the resident said: -He/she did not have any skin issues. -He/she could not remember if any staff person had recently looked at his/her skin. Review of the resident's TAR on 12/7/23 at 11:40 A.M. showed: -The Resident's skin assessments were pre-signed. -The following dates were pre-signed: --12/13/23. --12/20/23. --12/27/23. During an interview on 12/8/23 at 10:37 A.M. CNA B said: -The CNAs looked at all residents' skin at every shower. -The resident received assistance in showering. -The resident was recently moved to his/her hallway, so he/she was not sure why there were no records of the Resident's Skin Monitoring: Comprehensive CNA Shower Review sheets. -Anytime a resident is showered the Skin Monitoring: Comprehensive CNA Shower Review Sheet was to be filled out. During an interview on 12/8/23 at 10:43 A.M. LPN A said: -The resident's skin was assessed at every shower. -Whoever performs the shower was responsible for completing the Skin Monitoring: Comprehensive CNA Shower Review Sheet. -Nurses were responsible for completing the weekly skin assessments. -The weekly skin assessments were documented on the TAR. -Weekly skin assessments were automatically put on the POS and he/she was unsure why there was no previous order. -The weekly skin assessments should never be documented ahead of time or pre-signed. During an interview on 12/8/23 at 1:49 P.M. the DON said: -The Skin Monitoring: Comprehensive CNA Shower Review Sheets were what the facility normally used as skin assessment documentation. -The resident's POS should have had an order for weekly skin assessments before 11/30/23. -The order was missed on the POS. -He/she would expect the nurses to complete the skin assessment documentation on the TAR. -The weekly skin assessments should never be pre-signed. -It was not appropriate for the nurse to have pre-signed the Resident's weekly skin assessments. -Skin assessments were performed at every shower. -It was the Administrator's expectation for the nurses to peek into the shower room and look at each resident's skin. -If a resident refuses a shower then the staff were responsible for checking the resident's skin while getting the resident dressed.

Based on observation, interview, and record review, the facility failed to ensure the treatments were being completed and documented for one sampled resident (Resident #12) who had a newly developed pressure ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin) out of 21 sampled residents. The facility census was 68 residents. Review of the facility's undated policy titled Ulcer Documentation showed proper documentation is necessary for medical, legal, and reimbursement reasons. Review of the facility's Weekly Wound Assessment Sheet dated from 2007 showed: -The following were Nursing Interventions to be completed: --Follow the treatment order and document the wound description. --Monitor the healing process. --Support pressure relieved position and provide pressure relieved devices. -Document on the wound daily/weekly until healed. 1. Review of Resident #12's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). -Unspecified Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -Hepatic (liver) Failure (loss of liver function). Review of the resident's annual Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 9/21/23 showed: -The resident had severely impaired cognition. -The resident was not at risk for developing pressure ulcers. -The resident had no skin issues at the time of the assessment. Review of the resident's Skin Monitoring: Comprehensive Certified Nursing Assistant (CNA) Shower Review sheet dated 11/3/23 showed: -The top of the first and second toes on the left foot were purple. -The right big toe was swollen. -The nurse separated the toes, applied ointment, and 4x4 gauze between the toes. -The facility doctor had been notified. -The Director of Nursing (DON) signed off on the sheet on 11/7/23 and wrote in that a treatment had been ordered. There was no documentation in the resident's medical record on the Physician's Orders Sheet (POS) or Treatment Administration Record (TAR) showing the physician's order on 11/7/23 was completed. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review sheet dated 11/9/23 showed the Resident had no other skin issues other than the treatment order to the right great toe and blisters. Review of the resident's POS dated November 2023 showed: -An order dated 11/14/23 for the right great toe wound to be cleansed with wound cleanser, apply gauze between big toe and second toe, wrap in kerlix (a white gauze dressing that can be wrapped around a wound area), which ended on 11/22/23. -An order dated 11/22/23 to add Hydrofera Blue (an anti-bacterial wound dressing) to the right great toe dressing. Review of the resident's TAR dated November 2023 showed: -The treatment ordered on 11/14/23 for the right great toe did not have the treatment signed off on seven of the nine times in which the treatment was due. -The treatment ordered on 11/22/23 for the right great toe did not have the treatment signed off on eight of the nine times in which the treatment was due. Review of the resident's Skin Monitoring: Comprehensive CNA Shower Review sheet dated 11/14/23 showed: -The resident had a pressure ulcer and scheduled treatment. -The DON signed off on the sheet on 11/18/23. Review of the resident's nurse's note dated on 11/19/23 showed the treatment for the right great toe pressure ulcer had been completed by the DON. Review of the resident's care plan dated 12/1/23 showed: -The resident had a wound on great toe. -Interventions included: --Inspect the feet daily, especially between the toes. --Make sure the resident is wearing non-skid socks. --Teach the resident/family/caregiver to avoid risks for skin injury and decreased circulation including constrictive shoes, cutting and trimming corns and calluses, adhesive tapes, improper shaving, vigorous message, constrictive garment, crossing of the legs, caffeine. Review of the resident's Wound Assessment-Pressure Ulcer Skin Observation Tool dated 12/7/23 showed: -The resident was found to have a Stage II pressure ulcer (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red or pink wound bed, without slough (a by-product of the inflammatory phase of wound healing) or bruising) on 11/14/23 to his/her Right Great Toe which measured 1.5 centimeters (cm) x 1.5 cm x 0.2 cm. -The resident's measurement of the pressure ulcer on 12/7/23 measured 0.7 cm x 0.8 cm x 0.1 cm. Observation of the right great toe pressure ulcer on 12/7/23 at 1:15 P.M. showed a dime sized area of dry, pink tissue to the front part of the toe. During an interview on 12/7/23 at 1:30 P.M. the DON said the resident's pressure ulcer to his/her right great toe was improving. During an interview on 12/8/23 at 10:37 A.M. CNA B said: -The resident got the pressure ulcer due to wearing tennis shoes that had paper stuffed in them. -The resident no longer wears those shoes. During an interview on 12/8/23 at 10:51 A.M. Licensed Practical Nurse (LPN) A said: -The nurses were responsible for completing the wound treatments. -The nurses were responsible for documenting when the wound treatments were completed. -The completed treatments were documented in the TAR. -When he/she was at the facility, the treatments usually were completed. During an interview on 12/8/23 at 1:49 P.M. the DON said: -The nurses were responsible for completing the wound treatments. -He/she expected the nurses to document wound treatments on the TAR. -He/she would have expected the nurses to sign off on the Resident's TAR when wound treatments were completed. -The facility had an on-going issue with staff signing things off on the Medication Administration Record (MAR) and TAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician's orders for providing health shake supplements, to complete Dietary/Nutritional Assessments annually and to monitor the resident's dietary needs as needed for one sampled resident (Resident #9) who had a history of weight loss out of 21 sampled residents. The facility census was 68 residents. Review of the facility Physician's Orders policy and procedure dated 2013, showed: -Nursing was to transcribe all physician's orders to the Physician Order Sheet (POS) and note the medication, dosage, route, resident, and time. -Transcribe the order to the appropriate administration record. Requested facility dietary policy was not received at the time of exit. 1. Review of Resident #9's Face Sheet showed he/she was admitted on [DATE], with diagnoses including Alzheimer's Disease (progressive mental deterioration due to generalized degeneration of the brain), dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), high blood pressure, diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), depression, seizure disorder (seizure is a sudden, uncontrolled burst of electrical activity in the brain) and arthritis(the swelling and tenderness of one or more joints). Review of the resident's Registered Dietician (RD) Assessment (annual) dated 8/11/22 showed: -The resident's weight was 140 pounds. -The resident had lost and gained weight over the previous 6 months. -The recommendation showed staff was to encourage fluid intake with and between medications, to add health shakes twice daily with meals and to continue to monitor. Review of the resident's RD Note dated 9/29/22 showed: -The resident's weight was 140 pounds. -The resident received a regular diet and health shakes three times daily due to weight loss over the past 6 months that was at 14 percent. -On 9/21/22 the RD recommended to add Remeron a medication to stimulate the resident's appetite. -Nursing staff stated the resident's intake varied. The resident liked fried chicken, chips and candy. -The resident sometimes was up all night and sometimes slept all day. -The resident drank the health shake supplements at times. -The recommendation was to continue to monitor the resident's weights. -There were no additional notes after 9/29/22. There was no annual RD Assessment completed and in the resident's medical record since 8/11/22. Review of the resident's Dietary Note dated 8/28/23, showed: -The residents weight documented July 2023 was 147 pounds. -The resident's weight in June 2023 was 139 pounds and August 2023 was 139.5 pounds. It showed comparison to prior weights and the resident's usual weight of 130 to 135 pounds, this weight (147 pounds) may be incorrect. -Recommendations showed nursing staff would continue the resident's current plan of care. -Recommendations did not show reweighing the resident to obtain an accurate weight or any changes in his/her diet order. -There were no additional dietary notes or quarterly dietary notes in the resident's medical record after 8/28/23, to show any updates in the resident's weight status or dietary interventions. 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 9/18/23, showed the resident: -Was alert with cognitive incapacity and significant memory loss. -Current weight was 140 pounds. -Had no chewing or swallowing problems. -Had no significant weight loss within the lookback period. -There was no documentation recorded regarding the resident's transfer/mobility status, eating ability or whether assistance was needed. Review of the resident's Care Plan updated 9/20/23 showed the resident was at risk for nutritional problems related to not wanting to get out of bed and missing meals. The care plan showed the resident was able to feed himself/herself independently, but needed tray set up and cueing through the meal, had a history of wanting to stay in bed and missing meals. Interventions showed nursing staff interventions: -If the resident chose not to get up for meals, staff would provide a health shake or eat a snack for missed meals daily. -Nursing staff would administer medications as ordered, monitor and document any side effects. -Nursing staff would assist the resident with developing a support system to aid in weigh loss efforts. -Nursing staff would explain and reinforce to the resident the importance of maintaining the diet ordered and encourage the resident to comply, explain the consequences of refusal, obesity/malnutrition risk factors. -Nursing staff would invite the resident to activities that promote additional intake. -Nursing staff would monitor document and report signs and symptoms of chewing and swallowing problems. -Nursing staff would obtain and monitor labs as ordered, report results to the physician and follow up as indicated. Review of the resident's Physician's Note dated 9/21/23, showed the physician visited the resident and examined him/her, reviewed the resident's medical record to include medications, physician's orders and labs. The physician documented the resident's weight was currently stable and he/she had no weight loss. The recommendation was to continue the current plan of care. There were no new dietary orders or orders to discontinue any dietary interventions. Review of the resident's POS dated 12/2023 showed physician's orders for: -Regular diet, consistency as tolerated. -Health Shakes three times daily. -Remeron 15 milligrams (mg) daily (appetite stimulant). Review of the resident's Medication Administration Record (MAR) dated 12/2023, showed there were no physician's orders showing the resident was to receive health shake three times daily and there was no documentation showing how the facility was monitoring the administration of health shakes. Review of the facility dietary list showing residents who received dietary supplements showed there were six residents on the list that were to receive health shake supplements. The resident was not on the list. Observation on 12/05/23 at 8:48 A.M., showed the resident was sitting in his/her wheelchair in the dining room eating breakfast. The resident was served a regular diet of scrambled eggs with bacon, a muffin and cold cereal. The resident was served water, juice and milk for his/her cereal. He/she was not served a health shake. Observation on 12/06/23 at 9:15 A.M., showed the resident was sitting in his/her wheelchair in the dining room eating a regular breakfast of scrambled eggs a muffin, cold cereal with milk, water and a red juice. The resident was not served a health shake with his/her meal. At 9:26 AM when he/she was finished eating, staff took the resident out of the dining room. The resident ate everything except the scrambled eggs and drank all beverages. Observation on 12/06/23 at 1:15 P.M., showed the resident was in his/her wheelchair in the dining room eating a hamburger with fries, green beans with chocolate milk and water. He/she had ice cream for dessert. The resident was not provided a health shake. When the resident was finished staff took him/her to his/her room. The resident ate all of his/her hamburger, part of the fries and all of his/her green beans. During an interview on 12/07/23 at 7:45 A.M., Certified Nurses Aide (CNA) C said: -If the resident is in a good mood, he/she will eat everything on his/her plate, but if he/she is in a bad mood or says he/she doesn't want to eat, they have to try to encourage him/her to eat or give him/her other food items to eat. -The resident will eat a peanut butter and jelly sandwich because he/she likes sweets, or a snack. -The resident had a weight loss history and he/she used to have health shakes with all meals. -He/she was not sure if the resident currently was supposed to receive health shakes or if they were discontinued. -The dietary department gave the health shakes according to the physician's orders. -He/she had not seen the resident receive health shakes. During an interview on 12/07/23 at 9:35 A.M., the Dietary Manager said: -The resident used to receive health shakes due to having significant weight loss, but he/she does not currently receive health shakes. -When a resident has a change in dietary orders, the nurse will complete a dietary change form that states what the new order is, and then the dietary staff implements the order. -He/she did not receive the physician's order when/if the dietary order is discontinued. -The nursing staff will let him/her know verbally that the order was discontinued and then he/she will discontinue the order. -He/she did not receive a list of dietary orders for resident's month to month, he/she just received the dietary communication form. -He/she received a dietary form that showed the resident was to receive health shakes back when the resident was losing weight, but since his/her weights had improved/stabilized, the resident no longer received health shakes. -The nursing staff told him/her that the order for health shakes was discontinued, but he/she did not remember getting a change in dietary order form stating this. -He/she was not aware that the resident's POS still showed that the resident was to receive health shakes three times daily. During an interview on 12/08/23 at 9:49 A.M., CNA A said: -The dietary staff provide the residents health shakes with their meal according to the physician's orders. -The dietary staff has a list of residents who have orders for health shakes they obtain from the nurse. -The nurses also inform the nursing staff know who is supposed to have health shakes or the dietary staff will let them know. -The CNA and Certified Medication Technician (CMT)'s pass out the meal trays and they have the resident's diet cards on them, so they check to make sure the resident is getting the ordered diet. -The resident received a regular diet, but he/she was unaware that there was an order for him/her to receive health shakes three times daily. -He/she had never seen the resident with a health shake supplement since he/she started his/her employment at the facility in May 2023. During an interview on 12/08/23 at 12:34 P.M., Licensed Practical Nurse (LPN) A said: - Physician's dietary orders should be followed. -They have a dietary communication sheet the nurses complete with any change in dietary orders. Once they receive the diet order, they document it on the communication sheet and give it to the Dietary Manager or head cook, who then implemented the order. -The resident was ordered health shakes for weight loss, but the resident would not drink them, so they stopped giving them to the resident. -The order was still showing on the resident's POS because they forgot to get an order to have them discontinued. -He/she received the order to discontinue the health shakes for the resident. During an interview on 12/08/23 at 1:50 P.M., the Director of Nursing (DON) said: - Physician's dietary orders should be followed. -The nurses should get an order to discontinue the health shakes if the resident no longer needs the health shakes. -Nursing staff should have gotten the order to discontinue health shakes and documented it on the resident's POS. -They have a dietary order communication form that the nurses use to notify of any/all dietary changes. The form is to be given to the Dietary Manager, who kept the current dietary orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #32's face sheet showed he/she was admitted with a diagnosis of asthma (a respiratory condition that causes difficulty breathing). Review of the resident's Quarterly MDS, dated [DATE], showed the resident had moderate cognitive impairment. Review of the resident's POS, dated December 2023, showed no medication ordered for a nebulizer treatment. Observation on 12/4/23 at 8:51 A.M. and 12/5/23 at 9:49 A.M. showed the resident's nebulizer mouthpiece: -Was not dated. -Was not covered. -Was touching the floor. During an interview on 12/5/23 at 10:10 A.M., the resident said: -He/she had used the nebulizer once during his/her stay. -The nebulizer had been in the resident's room for months. -He/she did not use the nebulizer anymore. 3. During an interview on 12/8/23 at 9:19 A.M., CNA A said: -All nasal cannulas, oxygen tubing, and nebulizer mouthpieces were to be stored in a bag. -He/she would replace any nasal cannulas, oxygen tubing, or nebulizer mouthpieces that he/she found uncovered. -Uncovered nasal cannulas, oxygen tubing, and nebulizer mouthpieces put the residents at risk for infections because of the bacteria that may contaminate them. During an interview on 12/8/23 at 9:28 A.M., CNA B said: -All oxygen supplies, including nasal cannulas, tubing, and nebulizer mouthpieces, were to be stored in a bag when not in use. -If a resident did not use their oxygen supplies, he/she expected it to be removed from the resident's room. During an interview on 12/8/23 at 10:05 A.M., Licensed Practical Nurse (LPN) A said: -Nebulizer mouthpieces and nasal cannulas were to be stored in a plastic bag. -The nebulizer mouthpiece in Resident #32's room should have been stored in a plastic bag or disposed of once no longer in use. -The nebulizer machine and mouthpiece should not have been in Resident #32's room as there was no order for any nebulizer treatments. -All oxygen supplies, including the nebulizer and mouthpiece, were to be removed when the order for it was discontinued. -It was unacceptable for Resident #32's nebulizer mouthpiece to be on the ground. During an interview on 12/8/23 at 10:26 A.M., LPN B said: -All nasal cannulas and nebulizer mouthpieces were to be dated and stored in a bag. -Staff were to ensure nasal cannulas and nebulizer mouthpieces did not come into contact with the floor. -Any nasal cannula or nebulizer mouthpiece on the floor could cause the resident an infection because it would now have bacteria on it and the resident would breathe in the bacteria. -Any resident no longer using oxygen or a nebulizer were to have it removed from their room. During an interview on 12/08/23 at 12:34 P.M., LPN A said: -There should be physician's orders for oxygen and they should be on the POS and the MAR/TAR and show the rate of oxygen and frequency. -Nasal cannulas and tubing were supposed to be stored in a plastic bag when not in use. -Nursing staff should check every shift to ensure they are in bags and if not they should get a storage bag and place the nasal cannula and tubing in it. -The humidifier bottle should be cleaned after use and stored on the oxygen concentrator. -The humidifier bottle should not be on the floor and there should not be any yellow liquid in it. -All of the oxygen supplies should be changed out weekly and as needed. During an interview on 12/08/23 at 1:50 P.M., the Director of Nursing (DON) said: -Oxygen supplies (nasal cannulas/ tubing, facemasks, nebulizer mouthpieces) should be stored in a plastic bag when not in use. -Humidifier bottles should be rinsed out after use and stored on the oxygen concentrator, not on the floor. -The nursing staff were supposed to do rounds every two hours and they should check to ensure the oxygen supplies were covered. -There should be an order for oxygen on the resident's POS and it should show the route (nasal cannula, face mask), frequency (liters per minute) and duration (continuous or as needed) that oxygen should be worn. The order should also be on the resident's TAR. -He/She and the MDS Coordinator completed the changeover monthly and they check the physician's orders from month to month to ensure they were correct and had all of the current orders on it. -If there were any physician's orders that were added before the change over, the charge nurses were supposed to write any new physician's orders on the resident's POS. -He/She became aware that Resident #45's POS did not have orders for oxygen and he/she will make sure that the orders are on the resident's POS and TAR. -He/she expected the nebulizer machine and mouthpiece to be removed from a resident's room if there was no order for nebulizer treatments. 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 #45); to ensure oxygen tubing, nasal cannula, and nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mouthpiece were kept covered when not in use to prevent contamination for one sampled resident (Resident #45) and one supplemental resident (Resident #32); and to monitor to ensure the humidifier bottle was kept clean and sanitary for one sampled resident (Resident #45) out of 21 sampled residents. The facility census was 68 residents. Review of the facility Physician's Orders policy and procedure dated 2013, showed: -Nursing was to transcribe all physician's orders to the POS and note the medication, dosage, route, resident, and time. -Transcribe the order to the appropriate administration record. -Note by documenting in the nursing notes the order received by the physician. Requested oxygen policy was not received at the time of exit. 1. Review of Resident #45's Face Sheet showed he/she was admitted on [DATE], with diagnoses including respiratory disorder, dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses), heart failure, and stroke (damage to the brain due to interrupted blood supply). Review of the resident's Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 10/25/23, showed the resident: -Was alert and oriented with minimal memory difficulties. -Was independent with dressing, eating, , transferring, toileting and only needed set up for bathing and hygiene. -Did not show the resident had oxygen therapy. Review of the resident's Care Plan updated 11/3/23, showed the resident had a respiratory disorder, smoked cigarettes and was receiving Hospice services. Interventions showed staff was to monitor for adjustment of changing abilities and observe the resident for signs of pain, provide maximum comfort, encourage family support, instruct the resident about smoking hazards and monitor. The care plan did not show that the resident had ever or continued to use oxygen and there were no interventions showing when the resident would need to have oxygen. Review of the resident's Physician's Order Sheet (POS) dated 12/2023, showed the resident did not have a physician's order for oxygen. Review of the resident's Medication Administration Record (MAR) 12/2023 showed the resident did not have a physician's order for oxygen or how the facility monitored the resident's oxygen. Review of the resident's Treatment Administration Record (TAR) dated 12/2023 showed the resident did not have a physician's order for oxygen or how the facility would monitor the resident's oxygen. Observation and interview on 12/4/23 at 10:08 A.M., showed the resident was sitting in his/her wheelchair in his/her room watching television. There was an oxygen concentrator (a medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen) in his room that was next to his/her bed, beside the wall. The nasal cannula (a medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen) and oxygen tubing was coiled around the handle of the concentrator, uncovered. The humidifier canister (a refillable plastic bottle that infuses the normal flow of oxygen with water droplets) was empty and resting beside the concentrator. There were no storage bags in the room. The resident said: -He/she did not use oxygen routinely, only as needed. -He/she usually used his/her oxygen at night and whenever he/she was having difficulty catching his/her breath. Observation on 12/05/23 at 3:39 P.M., showed the resident was laying on top of his/her bed with his/her eyes closed, resting comfortably. The resident's oxygen concentrator was sitting beside his/her bed against the wall. The nasal cannula and tubing were coiled around the handle of the concentrator, uncovered with no date on the humidifier bottle. There was no storage bag available. Observation on 12/06/23 at 11:51 A.M., showed the resident was sitting on his/her bed in his/her room watching television. The oxygen concentrator was beside his/her bed against the wall. The nasal cannula and oxygen tubing was coiled around the handle of the concentrator, uncovered and the humidifier cup was on the floor beside the concentrator. The lid was off of the container and there was yellow fluid inside of the container that was one third full. The resident said it was his/her container but he/she did not identify what the fluid was inside or who put it there. He/She said he/she had not used oxygen last night. During an interview on 12/06/23 at 2:22 P.M., Hospice (end of life care) Nurse A said: -The resident has a diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) and had episodes where he/she would become unresponsive so they placed the resident on oxygen at that time, but for the last two months, he/she has only needed to have oxygen as needed when he/she has shortness of breath at night or if he/she has an episode of low oxygen levels. -The resident also smoked and they have tried to encourage the resident to stop smoking, but the resident was not willing to do so. -This was why the oxygen concentrator was in his/her room. -Most of the time, the resident was okay and did not needed to be on oxygen continuously. During an interview on 12/07/23 at 7:41 A.M., Certified Nursing Assistant (CNA) C said: -If a resident has oxygen, they are supposed to have a plastic bag to store the nasal cannula and tubing in when it is not in use. -The resident used his/her oxygen at night and whenever he/she had shortness of breath. -When he/she last worked on Sunday, he/she saw the resident's oxygen storage bag on the floor and he/she replaced the storage bag and put his/her nasal cannula and tubing inside. -Today was his/her first day back at work so he/she did not know what happened to the storage bag. -The resident wore his/her oxygen within the last week or two for shortness of air. -He/she said she did not notice this morning that his/her oxygen cannula and tubing were uncovered and was also unaware that the humidifier bottle was on the floor with a yellow substance in it. -He/she said she would check it when he/she went to his/her room. -The resident's humidifier bottle should not be on the floor and he/she will change it out this morning. During an interview on 12/08/23 at 9:49 A.M., CNA A said: -Oxygen tubing and supplies should be covered with a bag when not in use. -The nursing staff were supposed to check to ensure oxygen tubing and nasal cannulas were covered and in the plastic bag every time they were in the resident's room. -The humidifier bottle should not be on the floor. It should be cleaned out and attached to the oxygen concentrator. -The resident used oxygen as needed, not continuously. -There usually was a physician's order for oxygen. -He/she was unaware that this week the resident's oxygen tubing and cannula were uncovered, or that his/her humidifier bottle was on the floor or that it had a yellow fluid inside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications kept in one resident room were stored in a locked compartment; and to ensure the resident that had medication in his/her room had an order to self-administer the medication for one sampled resident (Resident #68) out of 21 sampled residents. The facility census was 68 residents. Review of the facility's policy, dated 6/5/23, titled Storage of Medication at the Resident's Bedside showed: -The physician was required to write may keep at bedside for each medication that the resident was allowed to keep in his/her room. -Staff were to ensure any medications kept at bedside were stored in a locked drawer or box to prevent other residents from having access to the medication. 1. Review of Resident #68's Face Sheet showed he/she was admitted on [DATE]. Review of the resident's Self Administration of Inhaler, dated 10/19/23, showed: -Staff observed the resident self-administer his/her Spiriva (a medication that is delivered through an inhaler, it relaxes muscles in the airways and increases air flow to the lungs) and signed that the resident was competent to administer the medication independently. -Staff observed the resident self-administer his/her Albuterol Sulfate (a fast-acting medication delivered through an inhaler that relaxes muscles in the airways and increases air flow to the lungs, commonly referred to as a 'rescue inhaler') and signed that the resident was competent to administer the medication independently. Review of the resident's Assessment for Self-Administration of Medication, dated 10/19/23, showed: -Staff observed the resident self-administer his/her Nitroglycerin (a medication that was placed under the tongue to dissolve, used to treat and/or prevent chest pain) and determined the resident was competent to administer the medication independently. Review of the resident's admission Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 11/1/23, showed the resident was cognitively intact. Review of the resident's Physician Order Sheet (POS), dated December 2023, showed an order for: -Spiriva 2.5 micrograms (mcg) two puffs to be inhaled daily. -Albuterol Sulfate 90 mcg two puffs to be inhaled every four hours as needed for shortness of air. -Nitroglycerin 0.4 milligrams (mg) one tablet to be dissolved under the tongue every five minutes as needed for chest pain with a maximum dose of 3 tablets. -Sevelamer Carbonate (a pill that binds to phosphorus in foods eaten to prevent absorption into the blood stream) 800 mg three tablets three times a day. -NOTE: None of these medications had may keep at bedside included in the order. Observation on 12/5/23 at 11:44 A.M. showed an Albuterol sulfate inhaler on the resident's bedside table. Observation on 12/5/23 at 3:16 P.M. showed the resident's top dresser drawer contained: -Two inhalers. -Four white pills identified by their imprint (ASO58) as Sevelamer Carbonate. During an interview on 12/6/23 at 9:35 A.M., the resident said: -He/she had an Albuterol Sulfate inhaler, Spiriva inhaler, and a small bottle of Nitroglycerin in his/her room. -The Director of Nursing (DON) had watched him/her take the medication independently. -Staff gave him/her Sevelamer Carbonate when he/she was eating meals. -He/she did not a lockbox. -He/she did not have a lock on any drawers or cabinets in his/her room. Observation on 12/6/23 at 9:35 A.M. showed the resident's unlocked dresser contained: -A Spiriva inhaler. -An Albuterol Sulfate inhaler. -A small bottle of Nitroglycerin tablets. During an interview on 12/8/23 at 9:28 A.M., Certified Nursing Assistant (CNA) B said: -Staff were to remove any medications found in a resident room and take them to the charge nurse. -Residents were not allowed to have medications stored in their rooms. During an interview on 12/8/23 at 10:05 A.M., Licensed Practical Nurse (LPN) A said: -The DON was responsible for evaluating residents for the ability to self-administer medications. -If the resident was determined to be capable of self-administering, staff were to obtain a physician's order for self-administration and for the resident to keep the medication in their room. -Any medications stored in a resident room were required to be in a container that was locked. During an interview on 12/8/23 at 10:26 A.M., LPN B said: -Staff were to educate and assess any resident that wanted to self-administer their own medication. -Staff were to obtain a physician's order for the resident to self-administer any medications. -He/she was not sure how medications were to be stored if kept in a resident room. During an interview on 12/8/23 at 1:49 P.M., the DON said: -Before a resident could self-administer any medication, staff were to educate them, have the resident correctly demonstrate taking the medication, and both the nurse and resident were to sign that the resident was competent. -A physician's order to keep medications at bedside was required. -Medications in resident rooms were to be stored where other residents could not have access to them. -He/she was aware the resident had medications in his/her room. -He/she was unaware medications stored in a resident room were required to be in a locked compartment.

Based on observation, interview and record review, the facility failed to ensure the pureed (cooked food, usually vegetables, fruits or legumes, that has been ground, pressed, blended or sieved to the consistency of a creamy paste or liquid) chicken was processed according to the recipe on 12/4/23; to monitor the temperature of the pureed chicken to ensure the chicken was served at a temperature of 120 ºF (degrees Fahrenheit) on 12/4/23; and to follow the recipe for pureed eggs and pureed sausage on 12/7/23. This practice potentially affected one sampled resident (Resident #15) out of 21 sampled residents who had physician's orders for a pureed diet. The facility census was 68 residents. 1. Review of Resident #15's Physician's Order Sheet (POS) dated 12/23, showed a physician's order for the resident to have a diet of pureed food consistency. Review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 11/15/23 showed the following: - A resident for which a Brief Interview for Mental Status (BIMS - a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) was not conducted. - A resident who had disorganized thinking. - A resident who had short and long term memory problem. - A resident who was severely impaired in decision-making. - A resident who had no natural teeth. - A resident who had a swallowing disorder. Review of the facility recipe dated 2022, for pureed chicken, showed the following for 3 servings: - 3 pieces of fried chicken with the meat removed from the bone. - 1 cup of water. - 1 teaspoon (tsp.) of chicken base. Observation on 12/4/23 from 1:07 P.M. through 1:11 P.M., showed: - Dietary [NAME] (DC) A peeled the chicken away from the bone of two pieces of chicken since there was only one resident who received a pureed diet. - DC A added hot water to the chicken in the food processor and ground the chicken with the water in the food processor. - DC A did not add the chicken base. Observation during a taste test on 12/4/23 at 1:12 P.M., showed the pureed chicken tasted bland. During an interview on 12/4/23 at 1:13 P.M., DC A said: - He/she did not have any chicken base. - Chicken base was needed to bring up the flavor of the pureed chicken. During an interview on 12/4/23 at 1:25 P.M., the Dietary Manager (DM) said they were out of chicken base that day. 2. Observation on 12/4/23 at 1:14 P.M. showed the temperature of pureed chicken was 115.3 ºF after preparation. Observation on 12/4/23 at 1:21 P.M., showed the pureed chicken and other pureed items were taken to the resident at his/her table and no dietary person checked the temperature of the pureed items before the foods were delivered. During an interview on 12/4/23 at 1:28 P.M., the DM said he/she expected employees to check the temperatures of foods before they were delivered to the resident. 3. Review of the facility recipe dated 2023 showed the recipe for 3 servings of pureed eggs showed: - 1 cup of scrambled eggs. - 2 tablespoons (Tbsp.) and 1 tsp. of milk. Directions were as follows: - If product needs thinning, gradually add an appropriate amount of liquid (not water) to achieve a smooth pudding or soft mashed potato consistency. - If the product needs thickening, gradually add a commercial or natural food thickener ex (potato flakes or baby rice cereal) to achieve a smooth pudding or soft mashed potato consistency. Observations on 12/7/23 at 8:48 A.M., showed DC A placed a serving of eggs with two slices of bread and the milk into the food processor and ground the ingredients into a smooth texture. Note: The recipe did not say to add bread to the egg mixture. Observations on 12/7/23 at 8:50 A.M., showed the pureed eggs tasted bland. 4. Review of the facility recipe dated 2023 showed the recipe for 3 servings of pureed sausage showed: - 3 sausage patties. - 1/8 tsp. of ham or pork base. - 4 Tbsp. + 2 tsp. of hot water. Observation on 12/7/23 at 8:53 A.M., showed DC A added water to the sausage in the food processor and ground it to a smooth mixture. DC A did not add any pork/ham base. Observation on 12/7/23 at 8:55 A.M., the sausage tasted bland. During an interview on 12/7/23 at 9:01 A.M., the DM said: - He/she did not want to taste the pureed eggs. - He/she expected dietary staff to follow the recipes to but sometimes they did not have all the ingredients. During an interview on 12/8/23 2:12 P.M., the DM said: - He/she did not know why DC A added bread to the pureed mixture since the recipe did not call for bread. - He/she expected the dietary person who made the pureed foods to sample the pureed foods. - DC A has been trained in making pureed foods but DC A did not always follow the recipe. During a phone interview on 12/12/23 at 1:35 P.M., the Registered Dietitian (RD) said: - He/she had not had an in-service with the Dietary Cooks in making pureed foods. - He/she expected dietary cooks to follow the recipe the correct way when they made pureed foods. - He/she expected dietary staff to check the temperature of the pureed foods before delivering the foods to the resident.

Based on observation and interview, the facility failed to remove a buildup of dust from the ceiling tiles and ceiling vents in the north section of the dining room; to remove a buildup of dust from the ceiling vent in the North Hall shower room; to maintain a fan in resident room North Hall 21-24 free of a buildup of dust; and to remove a buildup of dust on the sprinkler head in North 19-20. This practice potentially affected at least 40 residents who used or resided in those areas. The facility census was 68 residents. 1. Observation on 12/5/23 at 10:31 A.M., with the Maintenance Director and the Regional Maintenance Director showed the presence of dust on the ceiling tiles and around the ceiling vents in the north section of the dining room. During an interview on 12/5/23 at 10:33 A.M. the Maintenance Director said he/she had only been employed at the facility for about two months and had not had a chance to get to clean the ceiling in the dining room. 2. Observation on 12/5/23 at 12:29 P.M., with the Maintenance Director and the Regional Maintenance Director showed a buildup of dust on the ceiling vent in the North Hall shower room. 3. Observations on 12/5/23 at 12:55 P.M., with the Maintenance Director and the Regional Maintenance Director showed a heavy buildup of dust on the fan in resident room North 21-24. During an interview on 12/5/23 at 12:55 P.M., the Regional Maintenance Director said the housekeepers did not clean the fans often enough. 4. Observations on 12/5/23 at 1:05 P.M., with the Maintenance Director and the Regional Maintenance Director showed a buildup of dust on the sprinkler head in North 19-20. During an interview on 12/8/23 at 11:52 A.M., the Housekeeping Supervisor said the housekeepers have not cleaned the ceiling tiles in the dining room but the housekeepers have cleaned the vents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff were aware of which employees were certified in cardiopulmonary resuscitation (CPR-a lifesaving technique useful in many emergencies, in which someone's breathing or heartbeat has stopped). This had the potential to affect all residents who required CPR. The facility census was 68 residents. A policy regarding staff CPR certification and staff scheduling was requested and not received at time of exit. 1. During an interview on [DATE] at 10:50 A.M., Certified Nursing Assistant (CNA) D said: -He/she was unsure what staff were CPR certified. -He/she did not know how he/she would know who was CPR certified. During an interview on [DATE] at 10:52 A.M., CNA A said: -He/she knew the people that attended CPR training with him/her were certified. -The facility did not have a list of what staff was certified. During an interview on [DATE] at 11:00 A.M., the Administrator said: -All nursing staff were CPR certified. A written request was made on [DATE] at 11:19 A.M. to the Administrator for five randomly selected nursing staff. The facility was only able to produce three of the selected employee's certifications. During an interview on [DATE] at 10:05 A.M., Licensed Practical Nurse (LPN) A said: -All staff at the facility attended the CPR training class on the same date. -All nursing staff was CPR certified. -During a code (code-used to indicate a patient requiring resuscitation or otherwise in need of immediate medical attention, most often as the result of a respiratory or cardiac arrest), he/she could ask any nursing staff to assist because all were certified. During an interview on [DATE] at 10:26 A.M., LPN B said: -He/she knew the people that attended CPR training with him/her were certified. -During a code, he/she hoped to see someone that attended the training class with him/her so he/she knew the other staff member was certified. During an interview on [DATE] at 1:49 P.M., the Director of Nursing (DON) said staff knew who was CPR certified because all employees in the building, including non-nursing staff, were certified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of Resident #19's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Localization-Related (focal) (partial) Symptomatic Epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures) and Epileptic Syndromes with Simple Partial Seizures (a seizure that does not affect awareness). -Personal History of Transient Ischemic Attack (TIA- a brief stroke-like attack) and Cerebral Infarction (ischemic stroke- occurs as a result of disrupted blood flow and restricted oxygen to the brain) without residual deficits. Review of the resident's Individual Resident Activities Log Sheet dated November 2023 showed: -The resident participated in conversation on 11/9/23 and 11/24/23. -The resident participated in bingo on 11/9/23 and 11/24/23. -The resident participated in current events on 11/10/23. -The resident liked bingo, reading, and being in his/her room. Review of the resident's quarterly MDS dated [DATE] showed the resident was cognitively intact. Review of the Resident's care plan dated 11/29/23 showed the resident did not have a focus or goal related to activities. During an interview on 12/5/23 at 9:19 A.M. the resident said: -The facility does games for activities sometimes. -He/She thought the activities were geared more towards the female residents including finger nail painting and arts and crafts. During an interview on 12/7/23 at 10:31 A.M. the resident said: -He/she had not been told the barber was in the facility on Monday and had not known that was Monday's activity. -He/she had not received an activity packet on Tuesday, 12/5/23, which was the activity scheduled for Tuesday 12/5/23. -He/she did not know what free play meant on the activity calendar. -He/she had previously enjoyed playing bingo, but the bingo prizes were not prizes he/she wanted and gave examples of soap and lotion. -When leisure time is the scheduled activity for the day that means there is no activity planned for the day. -He/she liked to read books and the facility used to have a book club, but that was no longer an activity. During an interview on 12/8/23 at 11:00 A.M.,CNA B said: -He/she was unsure if attendance was recorded during activities. -He/she would ask residents what activities they wanted to participate in and would take them to the activity if indicated or needed. -There were no activities held on the weekends. -Activities should reflect the residents' likes and interests. 6. Observation on 12/5/23 at 12:32 A.M. showed the Activities Director was hanging the activity calendar for the month of December 2023 on the bulletin board. During an interview on 12/6/23 at 1:14 P.M., the Activities Director said: -He/she did not document activity attendance for all residents. -The residents care plans indicated who refused activities. -His/her main job function was to assess each residents' interests and complete the Activities Evaluation Form. -He/she placed calendars in the hallway and in each resident room. During an interview on 12/7/23 at 12:28 P.M., the Activities Director said: -He/she tried to do two activities throughout the day: one at 10:00 A.M. and one at 2:00 P.M. -He/she gave non religious residents word searches. -The facility did offer some church services. -He/she had been the Activities Director since September 2023; the facility had not had an Activity Director for a while before he/she took the position. -He/she did not know Resident #41 had a religious preference. -He/she had only interacted with Resident #41 three times and the resident did not talk much. -Resident #41 mainly stayed in his/her room. -The facility did not assist Resident #41 with his/her religious preference as he/she believed the resident did this independently. -Leisure time meant time for the residents to relax on their own. -He/she worked Monday through Friday, so no activities were done on the weekends. During an interview on 12/8/23 at 9:19 A.M., CNA A said: -He/she normally saw residents watching TV or doing coloring packets. -The facility did offer some church services. -He/she saw residents involved in activities approximately twice a week. During an interview on 12/8/23 at 9:28 A.M., CNA B said: -The Activity Director generally had activities three times a week. -The facility had a period of two or three months where there was no Activities Director. -No activities were performed by staff during the time frame where the facility did not have an Activities Director. During an interview on 12/8/23 at 10:05 A.M., LPN A said: -The facility use to have non-denominational worship services but that had stopped. -Residents were to request any non-Christian worship services. During an interview on 12/8/23 at 1:49 P.M., the Director of Nursing (DON) said: -The Administrator and Activities Director were responsible for monitoring the residents to ensure they were all involved in activities. -Staff occasionally helped the Activities Director but it was mostly the Activity Director's job to help residents during activities. -He/she expected the Activities Director to evaluate all residents' religious beliefs. -He/she expected the facility to accommodate all residents' religious beliefs. -He/she expected every resident to have an activity calendar in their room. -He/she expected staff to try to get Resident #3 involved in any and all activities as the resident was at risk for social isolation. Based on observation, interview, and record review, the facility failed to ensure the ongoing program of activities were designed to meet the interests and physical, mental, and psychosocial well-being; to provide activities according to the resident's preferences, and capabilities for five sampled residents (Resident #41, Resident #3, Resident #9, Resident #68, and Resident #19); and to develop an activity care plan with measurable goals, objectives and interventions for three sampled residents (Resident #68, #9 and #28) out of 21 sampled residents. The facility census was 68 residents. Review of the facility's policy titled Activity Policy dated from 2013 showed: -The policy purpose was to: --Ensure each resident receives the recreations activities that are appropriate in accordance with health and preferences. --Provide increased self-esteem, pleasure, comfort, education, creativity, success, and financial or emotional independence. --Provide stimulation or solace; spiritual well-being; promote physical, cognitive and/or emotional health. --Enhance the resident's physical and emotional status and promote self-respect by supporting self-expression and choice. -All residents should be included in some form of activity. -Activity calendars are being utilized as an attendance record for tracking participation by highlighting on each resident's calendar programs attended and placing the form in the medical record, with color-coding to indicate level of participation. -Residents needing more individualized involvement can have an additional form to track participation. -Care should be taken to tailor the activities to fit the individual's condition. -Assess the resident's level of tolerance and consult family/significant others for more information such as past interests and life styles for residents who are cognitively impaired. An Activity Calendar for the month of November 2023 was not received at time of exit. Review of the facility Activity Calendar for December 2023 showed: -There were no more than two activities each day that began at 10:00 A.M., with the last activity occurring no later than 2:00 P.M. on any given day. -The Saturday and Sunday activity was Leisure Day. -On 12/4/23 the activity calendar showed Barber's Here with no additional activities scheduled for the day. -On 12/5/23 the activity calendar showed 2:00 P.M. Activity Packets with no other activities scheduled for the day. -On 12/6/23 the activity calendar showed 10:00 A.M. Care Plans and Free Play. -On 12/7/23 the activity calendar showed 10:00 A.M. Arts and Crafts and 2:00 P.M. Beading. -On 12/8/23 the activity calendar showed 10:00 A.M. Hot [NAME] Social and 2:00 P.M. Bingo. 1. Review of Resident #41's Face Sheet showed he/she had a religious preference. Review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 9/15/23, showed: -The resident had moderate cognitive impairment. -The resident had a diagnosis of paraplegia (the loss of muscle function in the lower half of the body, including both legs). Review of the resident's undated care plan showed: -The resident was totally dependent on staff for dressing. -The resident required assistance for personal hygiene. -The resident required a mechanic lift for transferring. -Staff were to encourage the resident to participate in activities of his/her choice. -Staff were to introduce the resident to residents with a similar background, interests, and encourage/facilitate interaction. -The resident was having difficulty adjusting to the facility as evidenced by false accusations of discrimination. Review of the resident's Individual Resident Daily Activities Log Sheet, dated November 2023, showed: -The resident attended four events during the month. -The resident attended two events on 11/10/23: watching TV and current events. -The resident attended two events on 11/16/23: watching TV and current events. -A notation that the resident liked to be in his/her room most of the time. During an interview on 12/5/23 at 11:19 A.M., the resident said: -He/she did not attend any activities because of his/her religious preference. -The facility did not provide his/her type of religious services. -He/she felt discriminated against because the facility did not provide means for him/her to worship. 2. Review of Resident #3's Quarterly MDS, dated [DATE], showed staff documented the resident had severe cognitive impairment. Review of the resident's undated Care Plan showed: -The resident was at risk for social isolation. -Staff were to encourage the resident to attend activities. -Staff were to remind the resident of activities he/she had shown interest in previously. Review of the resident's Individual Resident Daily Activities Log Sheet, dated November 2023, showed: -The resident participated in nine activities during the month. -All nine activities were conversation, talks, and exercise. -A notation that the resident loved walking and would sometimes eat a snack. During an interview on 12/5/23 at 10:53 A.M., the resident said: -He/she didn't go to activities. -He/she loved activities but never knew when they were happening. -He/she was unable to hear the announcement of activities over the facility's intercom. -He/she was interested in crafts, playing cards, and socializing. Observation on 12/5/23 at 10:53 A.M. showed no activity calendar in the resident's room. During an interview on 12/5/23 at 3:30 P.M., the resident said: -The lack of activities made him/her feel isolated. -The lack of activities made it difficulty for him/her to get to know people in the facility. -He/she stayed in his/her room most of the time because he/she didn't have anything else to do. -He/she would love to leave his/her room if there was an activity. Observation on 12/7/23 at 7:44 A.M. showed the resident's walls were bare, no activity calendar was present. 3. Review of Resident #68's admission MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's undated Care Plan showed: -The resident left the faciity on Mondays, Wednesdays, and Fridays for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). -Staff did not address activities. Review of the resident's Activity Evaluation Form, dated 10/20/23, showed staff documented the resident was interested in cards, games, sports, music reading, computer, religious activities, trips, watching television, woodshop, hunting, golfing, social events, and community outings. Review of the resident's Individual Resident Daily Activities Log Sheet, dated November 2023, showed: -The resident participated in a total of four events during the month: bingo and current events. -A notation that the resident loved coffee and went to activities when he/she didn't have dialysis. During an interview on 12/5/23 at 11:48 A.M., the resident said: -He/she didn't go to many activities. -The activities did not interest him/her. -The activities were frequently held while he/she was at dialysis and could not attend. During an interview on 12/6/23 at 9:37 A.M., the resident said: -He/she was shy. -He/she did not have much to do at the facility. 4. Review of Resident #9's Face Sheet showed he/she was admitted on [DATE], with diagnoses including Alzheimer's Disease (progressive mental deterioration due to generalized degeneration of the brain), dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), high blood pressure, diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), depression, seizure disorder (seizure is a sudden, uncontrolled burst of electrical activity in the brain) and arthritis(the swelling and tenderness of one or more joints). Review of the resident's annual MDS dated [DATE], showed the resident: -Was alert with cognitive incapacity and significant memory loss. -Preferences for activities included listening to music, participating in group activities. -Participating in favorite activities. Review of the resident's quarterly Activity Participation Review dated 9/19/23, showed the resident: -Enjoyed participating and attending various group activities. -Enjoyed socializing with staff, playing bingo, watching movies, listening to music and completing word search puzzle books. -The activity plan remained appropriate and current with the current care plan, his/her activity goals were met and interventions were effective in reaching his/her goals. Review of the resident's Care Plan updated 9/20/23 showed the resident had impaired thought processes, and needed assistance with transfers and mobility. The care plan did not include any interventions for the resident's activity preferences, there was no measurable activity goal or interventions to assist in meeting those goals for and with the resident. Review of the resident's Daily Activity Log Sheet dated November 2023, showed out of a selection of 20 activity opportunities daily, the resident participated in the following: -The resident did not participate in any activities from 11/1/23 to 11/9/23, 11/11/23 to 11/13/23, 11/15 to 11/27/23 and 11/30/23 to 11/31/23. The only activities the resident participated in was on the following dates: -On 11/10/23 the resident participated in radio/television and passive activity (unidentified). -On 11/14/23 the resident participated in nail care and passive activity (unidentified). -On 11/28/23 the resident participated in nail care. -On 11/29/23 the resident participated in conversation and passive activity (unidentified). -Notes showed the resident loved popcorn and movies. -There was no Daily Activity Log Sheet for December 2023 provided. Observation on 12/05/23 at 8:48 A.M., showed the resident was sitting in his/her wheelchair in the dining room eating breakfast. The resident was friendly with some confusion. There were no behaviors noted. When the resident finished eating, nursing staff took the resident back to his/her room. At 10:00 A.M., the resident was in his/her room with his/her spouse and was sitting in his/her wheelchair. The television was not on and there was no evidence there was an activity packet provided to him/her. The resident did not have an activity calendar in his/her room. Observation on 12/06/23 from 9:15 A.M. to 11:00 A.M. showed, the resident was sitting in his/her wheelchair in the dining room eating breakfast. At 9:26 AM when he/she was finished eating, nursing staff took the resident out of the dining room and moved him/her to and area in front of the nursing station. There were no activities scheduled or provided and the resident was not interacting with anyone. The nursing staff took the resident to his/her room around 11:00 A.M. Observation on 12/06/23 from 12:00 P.M. to 1:15 P.M., showed at 1:15 P.M.,the resident was sitting in his/her wheelchair in the dining room waiting for lunch to be served. The television in the dining room was on but the resident was not in the view of the television. At 1:15 P.M., the resident was eating his/her lunch. When the resident was finished staff took the resident to his/her room. There were no activities provided at this time. During an interview on 12/07/23 at 7:48 A.M., Certified Nursing Assistant (CNA) C said: -He/she had seen activities in the day and sometimes on the evening shift. -He/she had seen the Activity Director do one to one activities with some residents, like paint her nails, give hand massages. -He/she did not know how often activities occurred but had seen residents participate in movies, and residents will usually attend the activities that have a food component primarily. -He/she did not know what activities were occurring today, but they have an activity calendar. -The resident spent a lot of time in his/her room, but he/she also participated in some activities. Observation on 12/07/23 at 10:52 A.M., showed the resident was sitting in her wheelchair at the nursing station. Staff was combing and braiding her hair. At this time there was a small group activity of between 5 to 7 residents, that were participating in a crafts activity in the dining room. 5. Review of Resident #28's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, hearing loss, heart disease, anxiety disorder, pain, shortness of breath and heart failure. Review of the resident's Activity Evaluation dated 6/2/22, showed the resident used to be a beautician. His/her activity preferences showed: -It was very important for the resident to listen to music he/she liked, participate in group activities, do favorite activities, go outside to get fresh air when the weather is good, participate in religious services and have snacks between meals. -Exercising, listening to music, spiritual and religious activities, spending time outside, watching television/listening to the radio, watching movies, talking to others, attending parties and social events and participating in groups. Review of the resident's quarterly MDS dated [DATE], showed the resident: -Had significant cognitive impairment and memory loss. -Activity preferences showed the resident liked listening to music. Review of the resident's quarterly Activity Participation Review dated 9/12/23, showed: -The resident received one to one activities that he/she enjoyed greatly from facility staff, Hospice staff and his/her peers. He/She also enjoyed visits from his/her family. -The resident enjoyed listening to music, laughing, rapping, and interacting with staff, peers and visitors. -The activity plan remained appropriate and current with the current care plan, his/her activity goals were met and interventions were effective in reaching his/her goals. Review of the resident's Care Plan updated on 9/13/23, showed the resident needed total assistance with transfers, mobility and all personal cares. He/She could answer some yes or no questions but spoke in rhyming words most of the time. The care plan did not include any interventions for the resident's activity preferences, there was no measurable activity goal or interventions to assist in meeting those goals for and with the resident. Record review of the resident's Daily Activity Log Sheet dated November 2023 showed: -No activity was provided to the resident from 11/1/23 to 11/5/23, 11/7/23 to 11/9/23, 11/11/23 to 11/13/23, 11/15/23, 11/17/23 and 11/18/23, 11/21/23 to 11/27/23, 11/29/23 and 11/30/23. The only activities the resident participated in was on the following dates: -On 11/6/23 the resident participated in religious/tapes and passive (unknown). -On 11/10/23 the resident participated in radio/television and passive. -On 11/14/23 the resident participated in nail care and passive. -On 11/16/23 the resident participated in radio/television and passive. -On 11/19/23 the resident participated in passive. -On 11/20/23 the resident participated in radio/television. -On 11/28/23 the resident participated in nail care and passive. -On 11/30/23 the resident participated in religious/tapes and passive. -Notes showed the resident listened to religious music and rap songs. -There was no Daily activity Log Sheet for December 2023. Observation on 12/4/23 from 8:30 A.M. to 12:00 P.M. showed the resident sat in his/her specialized wheelchair against the wall at the nursing station with his/her radio turned on with music playing. At 9:30 A.M. nursing staff fed the resident breakfast in the same area. After breakfast there were no activities provided to the resident and he/she remained sitting in the same area at the nursing station. At 12:00 P.M. the resident's family came in and fed the resident lunch, then afterward, stayed and read to him/her. Observation on 12/5/23 from 8:30 A.M. to 12:00 P.M. showed the resident was sitting up in his/her specialized wheelchair against the wall by the nursing station. The resident's radio was not on and there were no additional activities or one to one activities provided to the resident. At 12:30 P.M., the nursing staff provided the resident with lunch and fed him/her. After the resident finished eating, he/she remained at the nursing station. There were no activities provided to the resident at 2:00 P.M. when there was a scheduled art and craft activity occurring. Observation on 12/6/23 from 6:30 A.M. to 12:00 P.M. showed the resident was sitting in his/her specialized wheelchair by the nursing station. The music on his/her radio was playing. At around 9:30 A.M., Hospice Nurse A came and began to interact with the resident, talking to him/her and massaging his/her hands and legs. Once the resident's breakfast arrived, Hospice Nurse A fed the resident. Once he/she was done the resident continued to remain by the nursing station without any facility initiated one to one activities. At 1:30 P.M., Hospice Nurse A took the resident to his/her room and with the assistance of the Hospice Nursing Aide, began providing incontinence care to the resident. When they were done, they took the resident to the shower room and gave the resident a shower. The resident came out of the shower at 2:15 PM and staff placed her in front of the nursing station. The resident remained in a reclined position in front of the nursing station. The resident's radio was not on and he/she was not provided with any activities. During an interview on 12/06/23 at 1:16 P.M., the Activity Director said: -He/she had just been hired as the Activity Director since September 2023 and was still learning his/her job. -He/she completed an activity assessment on each resident to identify their preferences and abilities and then tried to provide activities for them. -For residents who were not able to actively participate, he/she completed one to one activities with them. -He/she documented the activities that he/she completed on the resident's participation record, specifically on residents who are passive participants. -He/she completed a monthly activity calendar. During an interview on 12/06/23 at 1:30 P.M., Hospice Nurse A said: -They come to provide care to the resident on Monday ,Wednesday and Friday. -They had been trying to manage the resident's anxiety and agitation and had started the resident on medication, but the family (due to religion) did not want the resident on a lot of medications. -They decided to start the resident on a medication to manage his/her agitation at night and that seemed to work much better. -The family was usually in the facility daily and spent a lot of time with the resident and were very supportive/involved with the resident's care. -The resident usually had music playing on his/her radio and was usually across from the nursing station when they came in to visit. During an interview on 12/07/23 at 7:48 A.M., CNA C said: -They usually get the resident up when he/she comes onto his/her shift and the resident stayed up in his/her wheelchair until they completed incontinence care or when it was time to lay him/her down after dinner. He/She stayed up most of the day. -The resident's family was very involved and usually came to visit daily with the resident and would stay for most of the day. -The resident had a radio on his/her specialized wheelchair that they play for him/her because he/she likes music. -He/she did not know how often the resident received one to one activities, but he/she had seen the activity Director do nail care and hand massages with him/her. During an interview on 12/08/23 at 9:49 A.M., CNA A said: -He/she had never seen anyone do one to one activities with the resident. -Most of the time, the resident was either at the nursing station, or sometimes he/she was in the dining room and would watch television or movies. -When his/her family visited he/she spent a lot of time with them. -The resident has a noise maker, like a baby toy, that sang and his/her family brought in snacks that he/she liked to eat when they visited. -He/she had not seen the resident attend any formal activities.

Based on interview and record review, the facility failed to ensure all narcotics were accounted for by not having the on-going and off-going nurses sign the Controlled Substance Log during shift change or document the amount of each medication left. This had the potential to affect all residents that received narcotics. The facility census was 68 residents. Review of the facility's policy, dated 6/9/22, titled Protocol for Managing the MAR (Medication Administration Record)/Narcotics Records showed: -At shift change, both the on-going and off-going nurse were to review the medication cards and sign out sheets. -Every pill was to be accounted for on the sign-out sheet. 1. Review of the facility's Shift Change Controlled Substance Check Sheet for November 2023 for the North Hall showed: -Missing signatures 9 out of 40 opportunities. -The medication count was not recorded 17 out of 20 opportunities. Review of the facility's Shift Change Controlled Substance Check Sheet for November 2023 for the South Hall showed: -Missing signatures 27 out of 182 opportunities. -The medication count was not recorded 63 out of 91 opportunities. Review of the facility's Shift Change Controlled Substance Check Sheet for December 2023 for the North Hall showed: -Missing signatures 13 out of 36 opportunities. -The medication count was not recorded 17 out of 19 opportunities. Review of the facility's Shift Change Controlled Substance Check Sheet for December 2023 for the South Hall showed: -Missing signatures 9 out of 34 opportunities. -The medication count was not recorded 14 out of 18 opportunities. During an interview on 12/6/23 at 11:54 A.M., Certified Medication Technician (CMT) A said: -During shift change, the off-going and on-going staff were to count the narcotics and log it on the Shift Change Controlled Substance Check Sheet. -Both the off-going and on-going staff were to sign the form to attest they were in agreement of the narcotic count. During an interview on 12/8/23 at 10:05 A.M., Licensed Practical Nurse (LPN) A said: -Narcotics were to be counted at every shift change by the off-going and on-going staff that would be responsible for that medication cart. -Both staff members were to count the narcotics separately and sign the Shift Change Controlled Substance Check Sheet to indicate agreement. During an interview on 12/8/23 at 10:26 A.M., LPN B said: -The narcotics were to be counted at each shift change. -The on-going and off-going staff member were to count the narcotics to make sure the count was accurate. -Both staff members were to sign the log to verify accuracy. During an interview on 12/8/23 at 1:49 P.M., the Director of Nursing (DON) said: -Blanks on the Shift Change Controlled Substance Check Sheet were inappropriate. -He/she expected the on-going and off-going staff to count the narcotics and both to sign the log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #60's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Personal History of Other Diseases of the Digestive System. -Diabetes Mellitus (DM II- a complex disorder of carbohydrate, fat, and protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin. -Malignant Neoplasm (cancer) of the prostate, colon, and bladder. Review of the resident's Quarterly MDS dated [DATE] showed: -The resident had moderately impaired cognition. -No active diagnosis for Hypothyroidism (a medical condition in which the thyroid gland does not produce enough thyroid hormone). -No active diagnosis for Gastric-Esophageal Reflux Disease (GERD- a digestive disease in which stomach acid or bile irritates the food pipe lining). Review of the resident's Medication Assessment Record (MAR) dated December 2023 showed: -An order for Pantoprazole Sodium (Protonix- a medication used to treat high levels of stomach acid causing irritation in the esophagus) Delayed Release (DR) 40 milligrams (mg) tablet, take one tablet by mouth every day for GERD to be given on an empty stomach 30-60 minutes prior to eating. -Levothyroxine (Synthroid- a medication used to treat Hypothyroidism) 150 micrograms (mcg) tablet, take one tablet by mouth daily to be given on an empty stomach separate from other medications. Observation of the resident's morning medication administration on 12/7/23 at 7:39 A.M. given by Licensed Practical Nurse (LPN) B showed: -The resident did not receive his/her dose of Levothyroxine. -The resident did not receive his/her dose of Pantoprazole. Review of the Resident's December 2023 POS showed: -An order for Pantoprazole Sodium DR 40 mg tablet by mouth, one tablet to be given at 8:00 A.M. for GERD on an empty stomach 30-60 minutes before eating. -An order for Levothyroxine 150 mcg tablet, take one by mouth at 8:00 A.M. daily on an empty stomach separate from other medications. During an interview on 12/7/23 at 7:47 A.M. LPN B said: -He/she thought the medication pass went well. -He/she would not have done anything differently. During an interview on 12/7/23 at 8:34 A.M. LPN B said: -He/she thought the Pantoprazole and Levothyroxine were 6:00 A.M. medications. -He/she did not realize they were scheduled for 8:00 A.M. and was not sure what to do because he/she thought the medications were to be given by the night nurse during the 6:00 A.M. medication pass. -He/she thought that the DON would need to be notified of the mistake. -He/she thought the Pantoprazole and Levothyroxine could have already been given and not signed out by the night nurse. -He/she reviewed the MAR binder and ensured the Pantoprazole and Levothyroxine were 6:00 A.M. medications. During an interview on 12/7/23 at 12:29 P.M. LPN C said: -Pantoprazole and Levothyroxine were normally medications given at 6:00 A.M., but some could be ordered for 8:00 A.M. -If he/she saw the medications ordered for 8:00 A.M., he/she would call the doctor to get the order clarified. -If he/she saw that the resident did not receive the medications then he/she would notify the DON and call the doctor. During an interview on 12/8/23 at 10:54 A.M. LPN A said: -Medications that were scheduled for 8:00 A.M. should be given at 8:00 A.M. -Pantoprazole and Levothyroxine were usually scheduled to be given at 6:00 A.M. -If he/she saw the order for the Pantoprazole and Levothyroxine scheduled at 8:00 A.M. then he/she would call the doctor and get the order clarified. -He/she would have given the Pantoprazole and Levothyroxine during the 8:00 A.M. medication pass. -He/she would also check to see if the night nurse gave the Pantoprazole or Levothyroxine. Review of resident's MAR on 12/8/23 at 12:03 P.M. showed the Pantoprazole and Levothyroxine had not been signed off as given during the 8:00 A.M. medications pass. During an interview on 12/8/23 at 1:49 P.M. the DON said: -He/she would have expected the nurse to give the Pantoprazole and Levothyroxine with the 8:00 A.M. medication pass. -Pantoprazole and Levothyroxine were normally scheduled to be given at 6:00 A.M. -The night nurses were normally responsible for passing the 6:00 A.M. medications. -He/she would have expected the nurse to look at the previous month's POS to see if the medication had been order for 6:00 A.M. in the past. -He/she was not made aware that the medications were not given. -The order should have been clarified by that point in time. -He/she expected all medications to be given as ordered. -He/she expected staff to follow the physician's order for timing. -He/she expected staff to clarify any order that they found questionable. -The facility had an on-going problem with staff not signing when medications were given. -He/she expected Resident #60's order to have been clarified. -He/she expected medications to be given correctly. -He/she expected insulin pens to be primed with two units once the needle was attached, before injecting the insulin into the resident. -He/she did not prime the insulin pen for Resident #66 because he/she was nervous. Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% with a medication error rate of 8.82% which affected one sampled resident (Resident #60) and one supplemental resident (Resident #66) out of 21 sampled residents and nine supplemental residents. The facility census was 68 residents. A policy related to medication administration was requested and not received at the time of exit. Review of the facility's policy titled Insulin Administration dated from 2007 showed no policy or procedure for the use of insulin pens. 1. Review of Resident #66's admission Minimum Data Set (MDS-a federally mandated assessment tool to be used for care planning), dated 10/9/23, showed: -The resident had moderate cognitive impairment. -The resident had Diabetes Mellitus (a disease that results in too much sugar in the blood). Review of the resident's Physician Order Sheet (POS), dated December 2023, showed the physician ordered Lispro (a type of fast-acting insulin [a hormone that works by lowering levels of sugar in the blood]) four units to be given with meals. Observation on 12/7/23 at 7:51 A.M. showed the Director of Nursing (DON) attached a needle to the insulin pen, set the dose to four units, and injected it into the resident. During an interview on 12/8/23 at 10:05 A.M., Licensed Practical Nurse (LPN) A said: -Staff were to prime the insulin pens with two units of insulin each time a needle was applied. -If the pen was not primed with an additional two units when attaching the needle, the resident would not receive the ordered amount as it would remain in the length of the needle. During an interview on 12/8/23 at 10:26 A.M., LPN B said: -Staff were to prime insulin pens with two units after attaching a needle. -If the pen was not primed, it was likely the resident would not receive their full dose of insulin.

Based on observation and interview, the facility failed to remove a buildup of dust on the baffle vents (metal devices which trap oil and grease that makes it into the kitchen's atmosphere by passing air through a series of interlocking baffles) of the range hood (an open metal enclosure over cooking surfaces through which air is drawn in from the surrounding spaces to exhaust heat and grease, and to control the flow of rising hot air into the range hood and filter grease ); to remove a buildup of dust on the walls ceiling and pipes of the kitchen including over food preparation areas; to remove food debris from the floor under the Refrigerators #1 and #2 and Freezer #2; to ensure Dietary Aide (DA) A did not handle clean dishes after handling soiled dishes without washing/his/her hands or changing gloves; to ensure DA B handled cups with drinks which were going to be served to residents, without placing his/her fingers in the cups; and to have a trash container that was opened through the activation of a foot operated lid opening system. This practice potentially affected all residents who received food from the kitchen. The facility census was 68 residents. 1. Observations on 12/4/23 from 9:17 A.M. through 12:46 P.M. during the lunch meal preparation showed: - A heavy buildup of dust on all the baffle vents on the range hood above the six-burner stove and the tilt skillet area. - A layer of dust on the sprinkler pipes which were over the food preparation area and the cooking area. - A buildup of dust on the walls behind the refrigerator across from the food preparation area; - A buildup of food debris under the Refrigerators #1 and #2 and Freezer #1. - At 10:04 A.M., DA A handled soiled dishes then handled clean dishes without changing gloves or washing/sanitizing hands. - At 10:07 A.M., DA placed a rack of soiled dished into the dishwasher and then proceeded to handle clean dishes. - At 10:19 A.M., DA A rinsed a rack of soiled dishes then proceeded to pack away clean dishes. - At 12:38 P.M., DA B picked up a glass of juice by hold the rim of the glass and had his/her gloved fingers inside the glass, when he/she picked up the glass and placed into a tray. - At 12:43 P.M., DA B lifted the lid of the trash container and discarded the trash that was in his/her hand then proceeded to handle three consecutive glasses of juice by holding them with his/her fingers inside the glass. During an interview on 12/4/23 at 1:22 P.M., DA B declined to be interviewed. During an interview on 12/4/23 at 1:25 P.M., the Dietary Manager (DM) said the following: - He/she expected dietary staff to change gloves after they handled trash lids. - He/she expected dietary staff to hold the glasses on the outside. - The dietary staff should pull out the refrigerators daily because the refrigerators were on wheels. - He/she told the Regional Maintenance Person about the dust on the pipes, and he/she said he/she would get to it. - The baffle vents were cleaned about two months ago. - He/she expected the dishwashers to change gloves before handling clean dishes. During an interview on 12/4/23 at 1:43 P.M., DA A said: - Some people were off that day. - There was supposed to be another dishwasher on the other side so that one dishwasher could handle clean dishes and one dishwasher could handle soiled dishes. - Because of people being off, he/she had to rush the process a little bit more. 2. Observation on 12/4/23 at 12:43 P.M., and on 12/7/23 at 9:02 A.M., showed the trash container behind the serving line was a trash container that had to be operated by removing the lid with hands. During an interview on 12/7/23 at 9:08 A.M., the DM said he/she did not know how long the trash container with the foot operated lid has not operated the way it was supposed to. During an interview on 12/5/23 at 10:16 A.M., the Regional Maintenance Director said the facility did not have a regular maintenance person in a few years and if this were his/her usual home he/she would clean the dust off the pipes every two weeks.

Based on interview and record review, the facility failed to ensure the infection control antibiotic stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients/residents) was completed monthly. This had the potential to affect all residents in the facility. The facility census was 68 residents. A copy of the facility's policy related to antibiotic stewardship was requested and not received at the time of exit. 1. Review of the facility's infection control log dated March 2023 showed no documentation of antibiotic stewardship for that month. Review of the facility's infection control of dated October 2023 showed: -A list of two residents that were on antibiotics. -The antibiotics that each resident was on. -There was no documentation related to why the antibiotics were prescribed. Review of the facility's infection control log dated November 2023 showed no documentation of antibiotic stewardship for that month. During an interview on 12/6/23 at 11:25 A.M. the Infection Preventionist (also the MDS-a federally mandated assessment tool required to be completed by facility staff Coordinator) said: -He/she could not find the documentation for the month of April. -He/she was still working on the month of November. During an interview on 12/6/23 at 1:25 P.M. the Infection Preventionist Coordinator said: -He/she had not realized it was March that was missing and not April. -He/she had not realized the October 2023 antibiotic stewardship had not been completed. -He/she would not have given out his/her infection control binder if he/she had known the October 2023 month had not been completed. -He/she would normally review all of the infections and antibiotics with the Director of Nursing (DON) throughout the month. -He/she would also discuss any relevant infections during care plan meetings. -He/she was shown the October 2023 antibiotic stewardship and said it was not complete. -The nurses were expected to tell the DON if a resident were to be prescribed an antibiotic. -The DON was then expected to tell him/her if a resident was prescribed an antibiotic. -He/she would then complete the antibiotic stewardship sheet used when a resident is prescribed an antibiotic. During an interview on 12/8/23 at 10:40 A.M. Certified Nursing Assistant (CNA) B said the MDS Coordinator who was also the Infection Preventionist was in charge of the facility's antibiotic stewardship. During an interview on 12/8/23 at 10:59 A.M. Licensed Practical Nurse (LPN) A said: -The MDS Coordinator was in charge of the facility's antibiotic stewardship. -He/she would tell the MDS Coordinator if a resident was prescribed an antibiotic. -That was all the nurses were responsible for related to antibiotic stewardship. During an interview on 12/8/23 at 1:49 P.M. the DON said: -He/she and the MDS Coordinator/Infection Preventionist completed the infection control antibiotic stewardship review together. -He/she would have expected October and November's antibiotic stewardship to have been completed by that date. -He/she was unsure if the March 2023 antibiotic stewardship had been completed and was unaware that it could not be found. -The nurses were expected to call the facility doctor if a resident were to show signs or symptoms of an infection. -The nurses were expected to let him/her know if a resident were to be put in an antibiotic. -He/she would then let the MDS Coordinator know the resident was prescribed an antibiotic. -The MDS Coordinator/Infection Preventionist would then complete the documentation related to antibiotic stewardship.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain the fan in the laundry room free of a buildup of dust; to remove a buildup of dust from under the vending machines in the dining room; to ensure the light fixture in the North Hall shower room was installed properly; to maintain the mirror in North room [ROOM NUMBER]-24; and to maintain the light fixture in North 1-2 in good repair. This practice potentially affected 50 residents who resided on the North Hall and used the dining room. The facility census was 68 residents. 1. Observation on 12/5/23 at 10:03 A.M., with the Maintenance Director and the Regional Maintenance Director showed a buildup of dust on the fan in the laundry. During an interview on 12/5/23 at 10:03 A.M., the Regional Maintenance Director said the fan was not cleaned in the past, but the fan would be cleaned going forward. During an interview on 12/8/23 at 11:54 A.M., the Housekeeping Supervisor said he/she had not cleaned the fan in the laundry in a while. 2. Observation on 12/5/23 at 10:28 A.M., with the Maintenance Director and the Regional Maintenance Director, showed a heavy buildup of dust and food debris under the vending machines in the dining room. During an interview on 12/5/23 at 10:29 A.M., the Housekeeping Supervisor said it had been a while since the vending machines were pulled out and cleaned underneath by staff. 3. Observation on 12/5/23 at 12:27 P.M., with the Maintenance Director and the Regional Maintenance Director, showed a light fixture that was not properly installed in the North Hall shower room because one side of the light fixture was not properly affixed to the ceiling. 4. Observation on 12/5/23 at 12:55 P.M., with the Maintenance Director and the Regional Maintenance Director, showed a cracked mirror that was attached to a closet door in North 21-24. During an interview on 12/5/23 at 12:56 P.M. the Maintenance Director said mirrors from that closet door and other closet doors in the facility would be removed because of the risk of cracking. 5. Observations on 12/5/23 at 1:29 P.M., with the Maintenance Director and the Regional Maintenance Director, showed a cracked light cover in North resident room [ROOM NUMBER]-2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to prevent the existence of mice and mouse droppings in the following resident rooms: North Hall room [ROOM NUMBER]-28, North Hall room [ROOM NUMBER]-20, North Hall 13-14, North Hall room [ROOM NUMBER]-8, South room [ROOM NUMBER]-44, South room [ROOM NUMBER]-36, South room [ROOM NUMBER]-12, South room [ROOM NUMBER]-32, South room [ROOM NUMBER]-28, South room [ROOM NUMBER]--20, and South room [ROOM NUMBER]-24. This practice potentially affected 26 residents who resided in those rooms. The facility census was 68 residents. 1. Observation on 12/5/23, with the Maintenance Director and the Regional Maintenance Director, showed: - At 12:48 P.M., mouse droppings were present on the floor behind the bed in North Hall room [ROOM NUMBER]-28. - At 1:05 P.M. mouse droppings were present on the floor and behind the bed in North Hall room [ROOM NUMBER]-20. - At 1:18 P.M., mouse droppings were present on the floor in North room [ROOM NUMBER]-14. - At 1:27 P.M., mouse droppings were present on the floor of North room [ROOM NUMBER]-8. - At 2:49 P.M., mouse droppings were on the floor behind the drawer in South room [ROOM NUMBER]-36. - At 2:50 P.M., mouse droppings were present on the floor behind the drawer in South 29-32. - At 3:09 P.M., mouse droppings were present on the floor next to the bed closets to the window in South room [ROOM NUMBER]-28. - At 3:14 P.M., mouse droppings were present on the floor next to the bed closest to the window in South room [ROOM NUMBER]-20 and a hole was present in the cove base (the piece of trim installed around the base of a room to create a transition between the floor and the wall - typically to hide an unsightly seam) in the corner. - At 3:17 P.M., mouse droppings were present on the floor in South room [ROOM NUMBER]-24. 2. Review of Resident #20's Admission's Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 11/19/23, showed the resident had a Brief Interview for Mental Status (BIMS - mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) of 12, which indicated moderate cognitive impairment. During an interview on 12/5/23 at 1:28 P.M., the resident said he/she has seen mice on the floor of his/her room. 3. Review of Resident #51's quarterly MDS dated [DATE], showed the resident had a BIMS of 11 which indicated the resident had moderate cognitive impairment. During an interview on 12/5/23 at 2:56 P.M., the resident said he/she saw mice in other resident rooms across the hall. 4. Review of Resident #56's Annual MDS dated [DATE], showed the resident had a BIMS 15 which indicated the resident was cognitively intact. During an interview on 12/5/23 at 3:16 P.M., the resident said he/she saw mice in his/her room. 5. Review of Resident #68's Admission's MDS dated [DATE], showed the resident had a BIMS of 14, which indicated the resident was cognitively intact. During an interview on 12/5/23 at 3:19 P.M., the resident said a mouse jumped out of his/her drawer once when he/she opened his/her drawer. During an interview on 12/8/23 at 11:52 A.M., the Housekeeping Supervisor said: -The housekeepers should pull the beds out and the dressers to sweep and mop. - In the past, he/she has told the housekeepers that they were in and out of the resident rooms too fast and he/she would tell them to go back and clean more. During a phone interview on 12/13/23 at 2:59 P.M., the Maintenance Director said: -He/she saw some mice, when he/she was first hired back in August 2023. - He/she had no idea how the mouse problem was addressed before he/she got hired in August, 2023. -He/she did not receive complaints from residents about the mice but she had noticed some himself/herself. - The pest control person said that he/she needed to fill openings on the outside to prevent mice from entering the building. - It was possible that mice were trapped in the building, because they could not get out. - The pest control has been going to the facility once a month, but she has spoken with the pest control company to increase the number of visits to the facility to twice per month. - They are going to cover any openings that were within the old floor mounted climate control units where water used to come in to those older units. - They have encouraged residents not bring items in from the outside.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) received 12 hours of in-service education (which was to include abuse, neglect, and dementia training) per year by not being able to produce documentation for all CNAs, not providing adequate training, and not monitoring what education CNAs had received. This had to potential to affect all residents. The facility census was 68 residents. Review of the facility's undated policy titled Abuse/Neglect Training and Orientation showed: -All current and newly hired employees were to be in-serviced with the Abuse/Neglect Hot Topic In-Service recommended by the Department of Aging and the pages in the CNA Course Manual currently used by the state. -Employees were to receive training upon hire and a minimum of twice a year. -Copies were to be placed in the employee's file. 1. Review of the facility's in-services showed: -No dementia training documented for the year. -Abuse and neglect training was provided on 11/29/23 but not all CNAs were in attendance. -The summary of abuse and neglect training provided to staff on 11/29/23 was to approach residents in a calm manner. During an interview on 12/5/23 at 9:06 A.M., the Director of Nursing (DON) said the Administrator was responsible for staff training. During an interview on 12/6/23 at 10:50 A.M., CNA D said he/she had not had abuse, neglect, or dementia training in 2023. During an interview on 12/7/23 at 12:07 P.M., the Administrator said: -He/she provided in-services for the staff which took the place of training. -He/she ensured all staff received their 12 hours of education by having in-services. -He/she did not track education for each staff member. During an interview on 12/8/23 at 1:49 P.M., the DON said: -He/she expected CNAs to receive 12 hours of training each year. -He/she expected each employees education hours to be monitored to ensure 12 hours of education was received.

Based on observation, interview, and record review, the facility failed to have a Registered Nurse (RN) for eight consecutive hours a day for seven days a week, and failed to ensure the Director of Nursing (DON) did not serve as the charge nurse, when the facility maintained a daily census of more than 60 residents. This deficiency had the ability affect all residents. The facility census was 68 residents. Review of the facility's undated policy, titled Policy for Staffing showed: -A RN was required eight hours a day, seven days a week. -The DON was not to provide cares of treatments for residents unless the facility had 60 or less residents. 1. Review of DON's time sheet from 1/1/23-11/31/23 showed he/she did not work eight consecutive hours for 184 days out of 334 days. 2. Review of the facility's daily census showed the facility had greater than 60 residents during the survey. During an interview on 12/6/23 at 11:00 A.M., the Administrator said: -When the facility is short-staffed due to an employee not showing up, the DON will occasionally come in and work in their place. -The DON provided treatments for residents when he/she covered a shift for another employee. Observation on 12/7/23 at 7:59 A.M. showed the DON was passing medications to residents. During an interview on 12/7/23 at 8:06 A.M., the DON said: -The facility had staffing issues since he/she had been employed so he/she generally worked extra hours. -He/she came in on the weekend to assist the Licensed Practical Nurses (LPNs) so they did not become overwhelmed. -He/she provided treatment and cares to resident during his/her hours worked. -He/she assisted with medications and orders when the facility was short-staffed. -He/she was not in his/her office much except for the weekends. Observation on 12/7/23 at 8:58 A.M. showed the DON was feeding a resident. During an interview on 12/8/23 at 9:19 A.M., Certified Nursing Assistant (CNA) A said: -The DON provided treatments and cares to the residents at least four times a week, as well as on the weekends and overnight. -He/she frequently saw the DON passing medications and providing nursing care. During an interview on 12/8/23 at 9:28 A.M., CNA B said the DON worked the floor all the time. During an interview on 12/8/23 at 10:05 A.M., LPN A said: -The DON worked as nursing staff whenever an employee did not show up. -He/she believed the DON provided nursing cares to residents an average of a week or more each month. During an interview on 12/8/23 at 10:26 A.M., LPN B said the DON provided nursing cares to resident every day. 3. During an interview on 12/7/23 at 10:26 A.M., the Administrator said the DON was the only RN that worked in the facility from 1/1/23-11/30/23. During an interview on 12/7/23 at 12:07 A.M., the Administrator said: -He/she was aware the DON was not to provide resident cares or treatments when the average daily census was more than 60 residents. -He/she was aware the DON helped out with resident cares and treatments. -He/she was aware there were days when the facility did not have a RN for eight consecutive hours, seven days a week. During an interview on 12/8/23 at 1:49 P.M., the DON said: -He/she provides resident treatment and cares when needed. -He/she performed a majority of his/her DON responsibilities while assisting staff with resident cares and treatments. -He/she assisted staff by entering orders, providing wound care to residents, and reviewing labs. -He/she was not aware that he/she was the only RN that worked in the facility from 1/1/23-11/30/23. -He/she expected federal and state regulations to be followed. -He/she was not aware the DON could not provide resident cares or treatment when the facility's average daily census was greater than 60 residents.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) received yearly evaluations and education based on the result of those findings. This had the potential to affect all residents. The facility census was 68 residents. A copy of the facility's CNA yearly evaluation policy was requested and not received at time of exit. 1. A request for the evaluations and education of CNAs was made to the Administrator and not received at time of exit. During an interview on 12/6/23 at 11:00 A.M., the Administrator said: -He/she did not perform staff evaluations yearly. -He/she performed evaluations only when there was a problem. During an interview on 12/8/23 at 9:28 A.M., CNA B said: -He/she had worked at the facility for two years. -He/she had never had an evaluation.

Based on observation, interview, and record review, the facility failed to ensure staffing was posted correctly 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 68 residents. The facility's undated policy, titled Policy for Staffing showed a staffing board was required to be displayed in a public area. 1. Observation on 12/4/23 at 8:52 A.M. showed no staffing sheets posted at the front desk or either nurse station. Observation on 12/5/23 at 9:04 A.M. showed: -Staffing sheets were taped under the counter of both nurse stations, facing the staff, unable to be seen by residents or visitors. -Staffing sheets did not include the resident census or number of hours for each discipline. During an interview on 12/5/23 at 9:06 A.M., the Director of Nursing (DON) said: -He/she was responsible for posting the staffing sheets. -He/she posted staffing sheets at both the north and south nurse stations. -He/she had not had time to posting the staffing sheets that day. Observation on 12/6/23 at 9:28 A.M. showed no staffing sheets posted at the front desk or either nurse station. Observation on 12/7/23 at 7:49 A.M. showed: -No staffing sheets posted at the front desk or either nurse station. -The DON was in the building. Observation on 12/8/23 at 9:53 A.M. showed: -No staffing sheet posted at the front desk or south side nurse station. -A staffing sheet was taped under the counter of the north nurse station, facing the staff, unable to be seen by residents or visitors. During an interview on 12/8/23 at 1:49 P.M., the DON said: -He/she posted the staffing sheets every day. -He/she posted the staffing sheets to face toward the nurse station so nursing staff could see it. -He/she did not know the staffing sheets were to be visible to visitors and residents, he/she thought it was for the staff only.

Based on observation, interview and record review, the facility failed to follow the menu for breakfast on 12/7/23, by not serving cinnamon rolls according the menu for that day. This practice potentially affected all residents who received food from the kitchen. The facility census was 68 residents. 1. Record review of the Week 2 Week-at-a-Glance Menu, dated 2023, showed the following items for breakfast: - Assorted juice. - Choice of hot or cold cereal. - Egg of choice. - Bacon. - Cinnamon Roll. - Margarine. - Milk/Beverage. Observation on 12/7/23 from 8:15 A.M. through 8:42 A.M., during the breakfast meal service showed no cinnamon rolls were served with breakfast to any resident and no substitution was served to the residents. During an interview on 12/7/23 at 8:44 A.M., Dietary Aide (DA) C said there were no cinnamon rolls to serve during the breakfast meal that morning. During an interview on 12/8/23 at 2:14 P.M., the Dietary Manager (DM) said the following: - The facility's supplier of baked goods does not have cinnamon rolls. - The facility food delivery service did not have cinnamon rolls for the facility to order. - In the future, he/she would request the Registered Dietitian (RD) to change cinnamon rolls to Danishes (a sweet pastry for one person, often filled with fruit or cheese) on the menu. During a phone interview on 12/12/23 at 1:32 P.M., the RD said: - He/she has been going to the facility once per month. - The facility has a substitution log that they should write down substitutions used. - He/she was not aware that the facility's grocery supplier did not have cinnamon rolls.

Based on interview and record review, the facility failed to submit accurate information to the Payroll Based Journal data (PBJ-a report that provides staffing dataset information submitted by nursing homes on a quarterly basis) for two of the last four quarters, which had the potential to affect all residents. The facility census was 68 residents. A copy of the Centers for Medicare and Medicaid (CMS) policy, dated August 2015, titled Electronic Staffing Data Submission Payroll-Based Journal showed: -Staff were required to submit accurate and timely information. -The nursing home was ultimately responsible for accuracy of each submission, even if the facility used a third party vendor to submit information on behalf of the nursing home. 1. Review of the facility's PBJ Quarter One (2023) from 10/1/22-12/31/22 showed no licensed nurse coverage 24 hours a day. Review of the facility's payroll, dated 10/1/22-12/31/22 showed a licensed nurse was on duty each shift. Review of the facility's PBJ Quarter Two (2023) from 1/1/23-3/31/23 showed no licensed nurse coverage 24 hours a day. Review of the facility's payroll, dated 1/1/23-3/31/23 showed a licensed nurse was on duty each shift. During an interview on 12/7/23 at 9:21 A.M., the Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) Coordinator said: -He/she was responsible for submitting information to the PBJ. -He/she received the information from the Administrator. -The facility used a third party vendor for payroll. -The vendor sent a file with hours worked for each department but they were coded and he/she did not know what the codes meant. -He/she normally submitted to the PBJ early so he/she could find problems and fix them before the deadline for submission. During an interview on 12/7/23 at 12:06 P.M., the MDS Coordinator said: -The PBJ submissions were not correct for Quarter One (2023) or Quarter Two (2023). -The facility had a licensed nurse on each shift for both quarters. During an interview on 12/8/23 at 1:49 P.M., the Director of Nursing (DON) said he/she expected the PBJ submissions to be submitted on time and accurately.

Based on interview and record review, the facility failed to ensure the infection control tracking and trending was completed monthly. This had the potential to affect all residents in the facility. The facility census was 68 residents. Review of the facility's policy titled Infection Control Program-Surveillance dated from 2006 showed: -A system for surveillance was designed to establish and maintain a data base which describes endemic rates of nosocomial (facility-acquired) infections. -A systematic observation on the occurrence and distribution of facility-acquired infections among the residents for the purpose of prevention and control. -The term surveillance implies that the data has been compiled to be examined and reviewed in order to determine problems that may exist within a certain environment. -The process of surveillance: --Documenting baseline rates of endemic infections. --Identifying epidemics or other infection problems. --Convincing physicians or nursing home personnel of the seriousness of a particular problem. --The needs for vigorous control measures including evaluating the effects of control measures and satisfying standards. 1. Review of the facility's infection control log dated March 2023 showed no documentation of the infection tracking or trending for that month. Review of the facility's infection control of dated October 2023 showed: -A list of two residents that were on antibiotics. -The antibiotics that each resident was on. -The area of the sheet used for tracking was blank. -There was no mapping of the infections completed for that month. Review of the facility's infection control log dated November 2023 showed no documentation of the infection tracking or trending for that month. During an interview on 12/6/23 at 11:25 A.M. the Infection Preventionist (also the MDS-a federally mandated assessment tool required to be completed by facility staff Coordinator) said: -He/she could not find the documentation for the month of April. -He/she was still working on the month of November. During an interview on 12/6/23 at 1:25 P.M. the Infection Preventionist said: -He/she had not realized it was March that was missing and not April. -He/she had not realized the October 2023 infection tracking and trending had not been completed. -He/she would not have given out his/her infection control binder if he/she had known the October 2023 month had not been completed. -He/she would normally review all of the infections and antibiotics with the Director of Nursing (DON) throughout the month. -He/she would also discuss any relevant infections during care plan meetings. -He/she was shown the October 2023 infection tracking and trending and said it was not complete. -The nurses were expected to tell the DON if a resident were to be prescribed an antibiotic, then the DON would inform him/her. During an interview on 12/8/23 at 10:40 A.M. Certified Nursing Assistant (CNA) B said the MDS Coordinator who was also the Infection Preventionist was in charge of the facility's infection control. During an interview on 12/8/23 at 10:59 A.M. Licensed Practical Nurse (LPN) A said: -The MDS Coordinator was in charge of the facility's infection control. -He/she would tell the MDS Coordinator if a resident was prescribed an antibiotic. -The nurses were not responsible for anything else related to the infection control tracking and trending. During an interview on 12/8/23 at 1:49 P.M. the DON said: -He/she and the MDS Coordinator/Infection Preventionist completed the infection control tracking and trending together. -He/she would have expected October and November's infection tracking and trending to have been completed by that date. -He/she was unsure if the March 2023 infection tracking and trending had been completed and was unaware that it could not be found. -The nurses were expected to call the facility doctor if a resident were to show signs or symptoms of an infection. -The nurses were expected to let him/her know if a resident were to be put on an antibiotic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility denied one sampled resident (Resident #2) visitation privileges in or out of the facility and to assist with finding other solutions with his/her justice involved domestic partner of 22 years out of eight sampled residents. The facility census was 64 residents. Review of the facility's Resident Rights policy dated 5/10/23 showed: -The resident has a right to a dignified existence, self-determination, and communication with access to persons and services inside and outside the facility. -The facility must protect and promote the rights of each resident, including: --The resident has the right to exercise his or her rights as a resident of the facility and citizen or resident of the United States. --The resident has the right to be free from interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights. -Access and Visitation Rights: -The facility must provide reasonable access to any resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time. -Resident's rights under Missouri Omnibus Nursing Home Act: --The facility shall permit a resident to meet alone with person of his/her choice and provide an area which assures privacy. Review of the facility Policy for Visitation dated 2021 addressed only the spread of COVID - 19. (Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus). 1. Review of Resident #2's admission Record showed the resident: -Was admitted on [DATE]. -Was his/her own responsible party. -Had diagnoses of seizures, attention and concentration deficits, and muscle weakness. Review of the resident's admission Agreement dated 5/10/23 showed: -All documents were signed by the resident. -All documents were signed by the facility Social Worker. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 5/23/23 showed: -He/she had a cognitive impairment. -Mood was: --Little interest or pleasure doing things. --Feeling depressed and hopeless. --Trouble sleeping. --Feeling tired. During an interview on 8/7/23 at 1:07 P.M., the resident said: -He/she relocated from out of state to be able to have in person contact with his/her justice involved domestic partner of 22 years. -He/she was aware of the criminal conviction of his/her domestic partner who was recently released on parole. -Since he/she was admitted to the facility, his/her domestic partner had not been allowed in person contact with him/her due to the domestic partner being justice involved. During an interview on 8/7/23 at 1:50 P.M., the Administrator said: -He/she would not allow the resident's justice involved domestic partner of 22 years in the facility. -He/she would not consider any kind of visits due to the nature of the conviction for the domestic partner of the resident. -He/she would quit his/her job before he/she would allow the resident's domestic partner to visit the resident in any way. -He/she was aware of the resident's domestic partner's justice involvement prior to the resident being admitted to the facility. During an interview on 8/14/23 at 1:52 P.M. the Social Worker said the prior facility informed them of the friend's (domestic partner) justice involvement prior to the resident being admitted . During an interview on 8/14/23 at 1:58 P.M. the resident said: -The prior facility allowed his/her justice involved domestic partner to visit in person three or four times but then refused to allow him/her back in the facility. -The current facility has not allowed the resident's domestic partner to visit in person at all since his/her admission. -The facility Administrator and Social Worker informed him/her that his/her domestic partner was not allowed to visit in any capacity or set up any off site visits. -He/she and his/her domestic partner were married by common law in another state, but Missouri does not recognize common law marriage. -While in the prior facility they were attempting to be legally married but that was terminated by the facility staff, so they have not yet been able to become a married couple. -The plan was to become husband and wife, but they have not been able to have any in person contact. -The only contact he/she has had with his/her domestic partner has been by phone and by a third party who bringing items his/her domestic partner has purchased for him/her. -Not being able to have a meaningful in person visits with his/her domestic partner makes him/her feel bad. -If he/she was not able to have visits with his/her domestic partner he/she wanted to return to the out of state facility to get better care. -During the interview with the resident his/her domestic partner called him/her and said I love you. -He/she felt bad because he/she came here to see and be with his/her domestic partner. -He/she and his/her domestic partner thought they were going to get to spend time together, and now they can't even see each other in person. During an interview on 8/14/23 at 3:04 P.M. the Domestic Partner said: -He/she had been in a relationship with the resident for 22 years, 14 years of that he/she was incarcerated. -He/she and the resident planned on getting married once he/she was released on parole. -They also planned on being able to reside together in a facility at some point as he/she would also need assistance due to his/her own health failing. -He/she had not been able to get a copy of the facility visitation policy. -When he/she spoke to the Administrator and he/she was told he/she wasn't welcome in the facility and called a scum bag. -He/she was directed by his/her parole officer if the facility had a policy prohibiting his/her presence in the facility he/she must abide by the policy. -He/she was more concerned about the emotional well-being and care for the resident than his/her ability to be in the facility. -His/her parole conditions do not prevent him/her from being inside healthcare facilities. -He/she had gotten threats from the administration through the resident that if he/she entered the facility the administration would have him/her arrested. -He/she has an electronic monitoring device which would alert if he/she was in a place he/she is not supposed to be. -He/she requested contact with his/her parole officer for confirmation of compliance guidelines. During and interview on 8/15/23 at 8:53 P.M. the Parole Officer said: -The domestic partner was on parole with electronic monitoring. -Parole conditions will conclude in November, electronic monitoring will remain in place for the domestic partner's lifetime. -He/she had no concerns about the domestic partner getting married to or being in contact with the resident. -There have been no concerns about the domestic partner's behaviors or any violations since release. -He/she had advised the domestic partner if there was a policy prohibiting him/her in the facility, he/she must abide by the policy to remain in compliance with his/her parole conditions. During an interview on 8/16/23 at 10:57 A.M. the Parole Officer said: -The domestic partner could have been allowed in the facility as long as a safety plan was in place and signed by the parole officer, the domestic partner and the facility Administrator. -Due to the facility Administrator's strong feelings about the domestic partner's conviction, he/she did not feel the Administrator would acknowledge or approve of a safety plan for the resident to be able to visit the domestic partner. -He/she would have facilitated some kind of agreement before now if the facility Administrator would have requested a way to allow the resident to have meaningful contact with his/her domestic partner. MO00222406

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain 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) or have a plan in place for two cognitively impaired residents (Resident's #34 and #60) who were unable to make day to day decisions due to cognitive impairment out of 17 sampled residents. The facility census was 66 residents. 1. Record review of Resident #34's admission Record showed: -He/she was admitted on [DATE]. -He/she was listed as a Full Code (allows all interventions needed to restore breathing or heart functioning). -He/she was listed as his/her own responsible party (a person who has responsibility for all or a portion of the patient's healthcare and can include the patient, a guardian or other guarantor (responsible party)). -He/she had no contacts listed. -He/she had the following diagnoses: --Dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning) without behavioral disturbance. --Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. --Alcohol abuse. --Muscle weakness. Record review of resident's Care Plan dated 1/19/22 showed: -Resident has little or no activity involvement related to his low cognitive and physical disabilities. -Has a communication problem. --Encourage to continue stating thoughts even if having difficulty. Record review of resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 4/8/22 showed: -BIMS (Brief Interview for Mental Status) score was 3 (indicating severe cognitive impairment). -Cognition (mental action or process of acquiring knowledge/understanding through thought, experience, and the senses) severely impaired. 2. Record review of Resident #60's admission Record showed: -He/she was a Full Code. -He/she listed as his/her own Responsible party. -Listed as emergency contacts: --A sister as contact #1. --A son as contact #2. -admitted [DATE] with the following diagnoses: --Dementia without behavioral disturbance. --Mild cognitive impairment (having memory and thinking problems). --Intracranial (within the skull) injury without loss of consciousness, initial encounter. --Epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), unspecified, not intractable (not easily managed or relieved), with status epilepticus (a seizure lasting longer than five minutes). Record review of resident's Quarterly MDS dated [DATE] showed: -His/her BIMS score was 2 (indicating severe cognitive impairment). -Cognition severely impaired. 3. During an interview on 6/2/22 at 11:15 A.M., the Administrator said: -Resident's #34 and #60 do not have a DPOA or a Public Administrator (PA- appointed by a court to serve as a guardian and/or conservator for those determined to be incapacitated and/or disabled). -Neither resident had family members who would accept the responsibility of being their DPOA. -The facility has trouble getting a PA to come and take on a resident. -The facility finds it easier to get a PA for a resident, if a resident needs to go to the hospital. -The hospital seems to be able to get a PA easier for a resident. During an interview on 6/8/22 at 1:30 P.M., the MDS Coordinator filling in for the Director of Nursing (DON) said: -Residents having a BIMS score of 2 or 3 in reality should not be their own responsible party. -A lot of the residents in this facility have come from homeless shelters or have no family to be the responsible party for them. -The facility would need to step in to make any health care decisions for residents who have no one as a responsible party. -The Social Services Director (SSD) was the person who would try and get a DPOA or PA for a cognitively impaired resident. During an interview on 6/8/22 at 2:43 P.M., the SSD said: -He/she tries to get a family member to be a DPOA for a resident who was cognitively impaired. -Some resident's family do not want to take on the responsibility. -The facility does not get a PA for a resident. -A lawyer is needed to get a PA for a resident. -The facility does what it can for a resident's healthcare choices if there is no DPOA or a PA. -If a resident goes to the hospital and the hospital needs a DPOA the hospital calls the facility. -The facility will let the hospital know if the resident does not have a DPOA. -The hospital will then usually start the process for getting the resident a PA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to investigate the missing narcotic medication Tramadol HCl(a controlled opioid used to treat moderate to severe pain in adults) for one sampled resident (Resident #53) out of 17 sampled residents. The facility census was 66 residents. Record review of the facility Policy for Management of Schedule II medication dated 2010 showed: -All controlled medications shall be checked and counted each shift by two licensed nurses. -The counting record shall be kept separately from other medication records. -The licensed nurse will count the medications with the on-coming shift licensed nurse and document on the provided sheet with both licensed signatures. -A missing or discrepancy in counting shall be notified immediately to the Director of Nursing (DON) or the Administrator. -The DON and the Administrator shall initiate the investigation immediately. -Upon investigation, any serious violation (stealing) against the Missouri State Board of Nursing and/or regulatory requirements shall be reported to the appropriate agency. -Errors in documentation shall be investigated by the DON and Administrator -The DON or designated licensed staff shall perform weekly checking and audit the controlled medications cart and records. 1. Record review of Resident #53's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Osteoarthritis (inflammation of the bone with progressive cartilage deterioration). -Migraine (a recurrent throbbing headache that typically affects one side of the head and is often accompanied by nausea and disturbed vision), unspecified, not intractable (typically lasts up to 72 hours and can be treated with migraine medications), without status migrainosus (a type of migraine that is considered dangerous and requires emergency medical care). Record review of the resident's Physician's Order Sheet (POS) dated 6/1/22 to 6/30/22 showed: -Tramadol HCL 50 milligram (mg) tablet. -Take one tablet by mouth (PO) every six hours as needed (PRN) for pain. -Ordered 11/30/21. Record review of the resident's Controlled Drug Record for Tramadol HCl 50 mg tablet showed: -Received 90 tablets on 5/10/22. -Take one tablet PO every six hours PRN for pain. -The resident received one tablet on 6/3/22 at 5:00 A.M., with a remaining count of 32 tablets. Record review on 6/3/22 at 6:09 A.M., of the resident's Shift Change Controlled Substance Check Sheet for showed: -On 6/3/22 at 5:00 A.M., 32 tablets of Tramadol HCl 50 mg tablets remaining. -The night Licensed Practical Nurse (LPN) D pre signed the off going nurse 7:00 A.M., spot without completing the shift change narcotic count with the oncoming nurse. Observation on 6/3/22 at 8:05 A.M., of the the south side narcotic count for the resident's Tramadol HCl 50 mg tablet showed: -LPN B and the Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) Coordinator were verifying the count. -There were 32 tablets of Tramadol HCl 50 mg tablets remaining on the resident's narcotic count sheet. -There were 31 tablets of Tramadol HCl 50 mg tablets remaining in the medication card. -One tablet of Tramadol HCl 50 mg tablets were missing. Observation on 6/3/22 at 8:06 A.M., showed the MDS Coordinator called the DON to notify him/her of the missing Tramadol HCL 50 mg tablet. Observation on 6/3/22 at 8:10 A.M., showed: -The DON, the MDS Coordinator, and LPN B were recounting the resident's Tramadol HCl 50 mg. -The resident's narcotic count sheet indicated 32 tablets of Tramadol 50 mg. -There were 31 tablets of Tramadol 50 mg in the card. -One tablet of Tramadol HCl 50 mg tablets was missing. -The DON crossed out the number 32 and changed the count to show 31 tablets on the 5:00 A.M. signature line. During an interview on 6/3/22 at 8:10 A.M., the DON said he/she would check with the night shift nurse to see if he/she gave the medication and did not chart it. During an interview on 6/3/22 10:58 A.M., LPN B said: -He/she floated between the North and South sides. -He/she signed the narcotic count sheet after counting when coming on to a shift and when going off of a shift. -Nurses should not sign the narcotic count sheet ahead of time before doing the count. -When a nurse signed the narcotic count sheet it was verification that the count was correct. -If the count was off both on coming and off going nurses recount to see if someone miscounted. -If the count was off, one of the nurses would call the DON to notify him/her and the DON would take care of the situation. -There was usually two night nurses working one each side of facility. -Each shift nurse going off counts with the oncoming nurse and signs the narcotic count sheet as accurate. -Last night there was only one nurse on for the facility. -The off going nurse should have counted both North and South side medication carts for the narcotic count. -The night nurse did not do the narcotic count for the south side with him/her this morning on 6/3/22. -He/she did the South side narcotic count this morning 6/3/22 with the MDS Coordinator. -Today he/she was the only day shift nurse scheduled, he/she had two Certified Medication Technicians (CMT)'s passing non narcotics. -He/she passed the narcotic medications, checked resident's blood sugars, and gave insulin. -The MDS Coordinator covered and helped when needed. During an interview on 6/3/22 at 11:33 A.M., the DON said: -He/she had not had a chance to call the night shift nurse yet. -He/she was orienting a new nurse. -He/she gave the phone number of night nurse LPN D to Department of Health and Senior Services (DHSS) to call. During an interview on 6/3/22 at 11:45 A.M., the DON said: -He/she had not contacted LPN D about the missing Tramadol. -He/she has been busy orientating a new nurse. -He/she would contact LPN D. -LPN D probably just forgot to sign that he/she gave the Tramadol. During a phone interview on 6/3/22 at 11:33 P.M., LPN D said: -Was not sure if he/she worked on 6/2/22 to 6/3/22 11:00 P.M. to 7:00 A.M., night shift. -He/she would have to look at the schedule. --LPN D said yes, he/she did work last night. -He/she was the only nurse and worked both North and South sides of the facility. -He/she was not sure what time he/she left the facility in the morning on 6/3/22. -He/she counted the narcotic medications with the day nurse on both sides of facility. -On Friday morning 6/3/22 he/she counted with the day nurse LPN E for both sides of the facility. -He/she did the narcotic medication count when he/she comes on to the night shift with the off going nurse and signed the narcotic count sheet in the oncoming spot. -He/she did the narcotic medication count when going off shift with the day nurse and signed the narcotic count sheet in the off going spot. -He/she was supposed to do the narcotic medication count with both the North and South side on coming nurses before leaving the building when he/she was the only nurse. -When he/she was the only nurse working he/she would sometimes sign the oncoming spot on the narcotic count sheet and the off going spot at the same time. -He/she was not sure if he/she signed the off going 7:00 A.M., spot for 6/3/22 when he/she came on at 11:00 P.M., on 6/2/22 night shift. -There were two residents, Resident #53 and Resident #43 on the South side of facility that would get upset if they did not get Tramadol first thing in the morning. -He/she did give these two residents Tramadol on 6/3/22 at 5:00 A.M. -He/she was not sure if he/she signed off Resident #43's Tramadol for 5:00 A.M., on 6/3/22, it was very busy being the only nurse. -He/she knows he/she signed off Resident #53's Tramadol for 5:00 A.M., on 6/3/22. -He/she said the Tramadol count was correct when signed on shift on 6/2/22 at 11:00 P.M. -It was his/her mistake for signing the narcotic count off going spot for 7:00 A.M., on 6/3/22 when he/she came on shift at 11:00 P.M. on 6/2/22. -It was his/her mistake for not counting with the oncoming day nurse for the South side on 6/3/22. -He/she said he/she counted twice with the oncoming day nurse LPN E on the North side. -He/she was not aware that the Tramadol narcotic count was off for any residents on the South side on the morning of 6/3/22. -He/she did not know why there would be a missing Tramadol medication for any resident on the South side. -He/she did not take pain medications due to being allergic to them. -If the narcotic count sheet was off during the count he/she would notify the DON. -The DON had not contacted him/her about any missing medication, including Tramadol. During an interview on 6/7/22 at 10:07 A.M., the Administrator said: -He/she and the DON started an investigation on Friday 6/3/22. -Not sure who the DON talked to. -He/she spoke with Resident #53 and the resident said he/she had not missed any of his/her Tramadol doses. -He/she said they are still working on the investigation and would provide a copy once it was completed. During an interview on 6/7/22 at 2:04 P.M., LPN C said: -Not all nurses sign the Shift Change Controlled Substance Check Sheet. -The nurses should do the medication count and sign the sheet when coming on shift that the count was correct. -The nurses should do the medication count and sign the sheet when going off the shift that the count was correct. -If the narcotic medication count was off the two nurses do a recount. -If the narcotic medication count was still off the two nurses notify the DON. -If the error was found the nurse would circle the correct count indicating the count was correct. During an interview on 6/8/22 at 5:00 P.M., the Administrator said: -The DON was out for the week. -He/she had been working on the investigation of the resident's missing Tramadol tablet. NOTE: As of 6/14/22 at 1:30 P.M., the facility had not faxed or emailed the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #23's face sheet, dated 4/16/21 showed: -The resident was admitted to the facility on [DATE]. -The resident's diagnoses included vascular dementia (a serious loss of cognitive ability, caused by an impaired blood supply to the brain) and epilepsy (a central nervous system disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations and sometimes loss of awareness). Record review of the resident's consent for use of restrictive devices, dated 4/14/21, showed: -The resident's Durable Power of Attorney (DPOA a document where you appoint another person to make healthcare decisions for you should you become incapable of making them yourself. Occasionally, one instrument will be used to appoint an agent with powers and authority over both healthcare and financial decisions ) signed the form. -Education on the risks and benefits were reviewed with the resident and the DPOA. -Family requested the bed rails. Record review of the resident's restrictive device use evaluation, dated 6/10/21, showed: -The resident was assessed on 6/10/21. -No on-going reassessment completed since 6/10/21. Record review of the resident's care plan, revised on 1/12/22, showed: -Bed rails on bed used during periods of personal choice to assist in movement and preventing falls. -Side rails were used to assist resident with mobility. -Signed consent form on bed rails was on file. -Bed rails to be removed upon request. Record review of the resident's POS dated March 2022 showed no order for the bed rails. Record review of the resident's quarterly MDS dated [DATE], showed: -The resident had a BIMS score of 11. --This showed that the resident had mild cognitive impairment. -The section for restraints showed the resident used bed rails daily. Record review of the resident's POS dated April 2022 showed no orders for bed rails. Record review of the resident's POS dated May 2022 showed a hand written note on the bottom of the POS was four 1/4 side rails may be used. Record review of the resident's June 2022 POS, showed no orders for bed rails. During an interview on 6/2/22 at 11:35 A.M., Licensed Practical Nurse (LPN) A said: -The resident had a bed rail, floor mat and low-positioned bed. -These were used as the resident had epilepsy and when he/she had seizures the bed rails were used subsequently to keep the resident from rolling off the bed while seizing. -The bed rails were only in the up position at night. -The resident was out of bed during the day. -Bed rails and mat were used only as a precaution for seizures, not for a restraint. -The resident had unpredictable and infrequent seizures. -The resident refused to take most medications. -When the resident seized he/she would have typically have more than one. -Mats and bedrails were used as a precaution to keep safe when he/she seizes while in bed. Observation on 6/2/22 at 11:47 A.M., showed LPN A: -Demonstrated how to put the bedrail to the up position. -Demonstrated when the tension knob was turned the bedrail tipped inward, lessening the space between the mattress and the rail. -Demonstrated a fist was unable to fit between the rail and mattress. -Had a foam cushion folded up next to the resident's bed. -had the bed in the low position. During an interview on 6/3/22 at 6:16 A.M. Certified Nursing Assistant (CNA) A said: -There was usually a mat on the floor. -He/she did not always see the rails in the up position on the left side of the bed (facing bed from the foot). -The side rails were used for safety when the resident had seizures. During an interview on 6/8/22 at 1:32 P.M., the MDS Coordinator said: -Using side rails for residents was a nursing judgement. -If residents were in bed, nursing puts the side rails up. -If the resident was not in bed the side rails go down. -Staff knew to use side rails by looking at the resident's care plan. -Orders for side rails should be on the POS. -An audit was performed and it was noted that some of the physician's orders had dropped off the order sheet. -POS's had the orders hand written on them. -The audit was last year. -All side rails were ordered by the physician. -Residents were assessed yearly. Based on observation, interview and record review, the facility failed to ensure there were physician's orders for full side rails, that were documented as a restraint (a device or other means of limiting movement) on both sides of the bed and per facility policy, to have a nurse or physical therapist re-assess when the resident could no longer assist with bed mobility and the continued use of full side rails on both sides of the bed for two sampled residents (Resident's #41 and #23) out of 17 sampled residents. The facility census was 66 residents. Record review of facility's physical restraint policy dated 2007 showed: -If a restricted device is needed to enhance resident mobility and serve as an enabler, for positioning and/or supporting posture, an evaluation shall be completed by a licensed nurse. -Assessments can be done by a physical therapist or a licensed nurse to identify the medical symptom/condition. Record review of the facility's side rails policy dated 2021 showed if a side rail meets the definition of a restraint, the side rail must be required to treat a medical symptom and there must be a physician's order for the side rail. 1. Record review of Resident #41's face sheet showed he/she moved into the facility on 3/13/15 and some of his/her diagnoses included: -Multiple sclerosis (a neurological disease in which there is impaired sensory and motor nerve function). -Muscle spasms. -Anxiety (nervousness, fear, apprehension, and worrying). Record review of the resident's consent for use of restrictive devices showed the resident consented to the use of side rails on 3/13/15. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 3/24/15, quarterly MDS dated [DATE] and quarterly MDS dated [DATE] showed the resident was independent with bed mobility. Record review of the resident's undated restrictive device use evaluation showed: -The type of devices were side rails. -The resident could turn and reposition with staff assistance. -The resident could transfer with staff assistance. -The resident was totally dependent upon staff for locomotion. -The medical symptom that required the use of side rails was quadriplegia (paralysis of all four extremities and usually the trunk). -The device was an enabler that enhanced safety. -The form was reviewed three times and showed there was no change in condition, it was not signed by the person completing the form and the form was not dated any time it was reviewed. Record review of the resident's second undated restrictive device use evaluation form showed: -The type of restrictive devices were side rails. -The resident could turn and reposition with staff assistance. -The form was not signed or dated by the initial assessor. -The form was reviewed once and showed there was no change in condition and was not signed or dated when it was reviewed. Record review of the resident's undated evaluation of side rail usage showed: -The resident preferred the use of two side rails. -The resident had muscle spasms and a diagnosis of quadriplegia. -The resident was immobile and did not make any attempt to exit or did not lean to one side. -Side rails were determined to be appropriate. -Side rails were not marked as to whether they were a restraint or an enabler. -The form was not signed or dated by the initial assessor. -The form was reviewed once and showed there was no change in condition and it was not signed or dated by the person completing the form when it was reviewed. Record review of the resident's quarterly MDS dated [DATE] and all MDSs through 1/8/22 showed the resident was totally dependent upon staff for bed mobility. Record review of the resident's care plan last reviewed on 1/17/22 showed: -The resident had side rails for movement assistance and fall prevention. -The side rails were a personal choice of the resident. Record review of the resident's quarterly MDS dated [DATE] showed two side rails were used daily and the resident was totally dependent upon staff for bed mobility. Record review of the resident's June 2022 POS showed there were no physician's orders for full side rails on both sides of the resident's bed. Observation on 6/1/22 at 10:55 A.M. showed: -The resident was in bed which had full side rails on both sides of the bed. -The resident could only move his/her head and not the rest of his/her body. During an interview on 6/8/22 at 8:32 A.M., the MDS Coordinator said the resident can't move and can't assist with movement in bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a transfer/discharge notice in writing to one sampled resident (Resident #50) or his/her family when he/she was transferred to the hospital out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's undated policy, Transfer/Discharge, showed: -A transfer or discharge from the facility would take place when the transfer was necessary to meet the resident's welfare the and resident's welfare could not be met in the facility. -The resident was given the reason for transfer and the effective date of transfer. -If known, the family member, surrogate, or legal representative would be notified. -A written notice of transfer was made so as to allow appropriate arrangement. -The notice must have been provided at least 30 days prior to the transfer except if it was a resident's urgent medical needs that required a more immediate transfer. 1. Record review of Resident #50's face sheet showed he/she was admitted on [DATE], was his/her own person and had the following diagnoses: -Polyosteoarthritis (a joint disease involving at lest five joints). -History of traumatic fracture (broken bones caused by impact or falls). -Anemia (a condition in which the blood does not have enough red cells). -Anorexia (an eating disorder where people abscess about what they eat). -Hearing loss. Record review of the resident's nurse's notes dated 5/23/22 showed: -The resident was found on the floor. -After evaluating the resident he/she was sent via ambulance to a nearby hospital. -The resident's nephew was notified via telephone. -The resident's physician was notified. -There was no documentation the resident or family was notified of the transfer in writing. Record review of the resident's Physician's Order Sheet (POS) dated May 2022 showed an order to send the resident to the hospital on 5/23/22. Record review of the resident's nurse's notes dated 6/2/22 showed he/she was readmitted to the facility. During an interview on 6/2/22 at 12:30 P.M. Licensed Practical Nurse (LPN) A said: -The resident had fallen last week and was sent to a hospital. -He/she was not able to find in the resident's chart where a transfer letter was sent or given to the resident or family. -The Charge Nurse should have done that. -He/she does not do that. During an interview on 6/3/22 at 6:45 A.M. LPN D said: -He/she sent the face sheet and labs with a resident if they went to the hospital. -Maybe the business office sends the transfer letter. During an interview on 6/3/22 at 2:00 P.M. the resident said: -He/she did not feel well enough to talk. -He/she was just put on Hospice (end of life care). During an interview on 6/8/22 the Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) Coordinator who was filling in for the the Director of Nursing (DON) said: -The DON was on vacation. -They did not have a transfer policy. -If a resident was sent to the hospital the nurse caring for the resident would have been expected to give the resident a transfer letter in writing. -The family and physician should also have been notified in writing. -The nurse should have documented in the nurses' notes the written transfer letter was given to the family and the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a bed hold policy in writing to one sampled resident (Resident #50) or his/her family when he/she was transferred to the hospital out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's policy, Bed-hold and readmission dated 2018 showed: -At the time of a transfer of a resident for hospitalization the facility would provide to the resident and a family member or legal representative written notice which specifies the duration of the bed-hold policy. 1. Record review of Resident #50's face sheet showed he/she was admitted on [DATE] and was his/her own person had the following diagnoses: -Polyosteoarthritis (a joint disease involving at lest five joints). -History of traumatic fracture (broken bones caused by impact or falls). -Anemia (a condition in which the blood does not have enough red cells). -Anorexia (an eating disorder where people abscess about what they eat). -Hearing loss. Record review of the resident's nurse's notes dated 5/23/22 showed: -The resident was found on the floor. -After evaluating the resident he/she was sent via ambulance to a nearby hospital. -The resident's nephew was notified via telephone. -The resident's physician was notified. -There was no documentation the resident or family was notified of the bed hold policy in writing. Record review of the resident's Physician's Order Sheet (POS) dated May 2022 showed an order to send the resident to the hospital on 5/23/22. Record review of the resident's nurse's notes dated 6/2/22 showed; -The resident was readmitted to the facility. -There was no documentation the written bed hold policy was given to the resident or the resident's family. During an interview on 6/2/22 at 12:30 P.M. Licensed Practical Nurse (LPN) A said: -The resident had fallen last week and was sent to a hospital. -He/she was not able to find in the resident's chart where a bed hold policy was sent or given to the resident or family. -The Charge Nurse should have done that. -He/she does not do that. During an interview on 6/3/22 at 6:445 A.M. LPN D said: -He/she sent the face sheet and labs with a resident if they went to the hospital. -Maybe the business office sends the bed hold paperwork. During an interview on 6/3/22 at 2:00 P.M. the resident said: -He/she did not feel well enough to talk. -He/she was just put on Hospice (end of life care). During an interview on 6/8/22 the Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) Coordinator who was filling in for the Director of Nursing (DON) said: -The DON was on vacation. -If a resident was sent to the hospital the nurse would have been expected to give the resident a bedhold paperwork in writing as well as tell them why they were going to the hospital. -The family and physician should also have been notified. -The resident's family also should have received in writing the bed hold policy. -The nurse should have documented in the nurse's notes the written bed hold policy was given to the family and the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) for two sampled residents (Residents #41 and #58) out of 17 sampled residents. The facility census was 66 residents. 1. Record review of Resident #41's care plan last reviewed 1/17/22 showed he/she had side rail restraints (any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body) for movement assistance and fall prevention. Record review of the resident's quarterly MDS dated [DATE] showed two side rail restraints were used daily and the resident was totally dependent upon staff for bed mobility. Record review of the resident's June 2022 Physician's Order Sheet (POS) showed there were no orders for side rails. Observation on 6/1/22 at 10:55 A.M. showed the resident: -Had full side rails on both sides of his/her bed. -Could only move his/her head and not the rest of his/her body. During an interview on 6/8/22 at 8:32 A.M., the MDS Coordinator said the resident's side rails really weren't a restraint because the resident can't move and can't assist with mobility in bed. 2. Record review of Resident #58's MDS dated [DATE] showed: -The resident was cognitively intact. -The resident was independent with most self-cares. -Continuous Positive Airway Pressure (C-pap-a machine that provides pressure during exhalation to decrease work of breathing and assist with obstructive tissues)/(Bi-level Positive Airway Pressure (bi-pap- a machine that provides pressure during inhalation and exhalation for oxygenation, decrease work of breathing and assistance with obstructive tissues) was not marked as being used by the resident in the look-back period. Record review of the resident's care plan dated 5/10/22 showed the resident used a C-pap. Record review of the resident's June POS showed a physician's order a C-pap. Observation on 6/2/22 at 9:22 A.M. showed the resident had a C-pap on his/her bedside table and the resident said he/she used it at night. Observation on 6/3/22 at 6:10 A.M. showed the resident had a C-pap on his/her bedside table and the resident was not in the room. During an interview on 6/8/22 at 8:10 A.M., Licensed Practical Nurse (LPN) A said the resident has had his/her C-pap on if he/she was still asleep when he/she's arrived at work in the morning. During an interview on 6/8/22 at 8:32 A.M., the MDS Coordinator said: -He/she thought the resident wasn't wearing the C-pap because there was a recall on it. -He/she doesn't know when the resident wasn't wearing the C-pap and would have to check the dates. Record review of the resident's nurses' notes dated 1/26/21-6/8/22 at 1:08 P.M. showed no notes regarding the resident's C-pap being recalled or the resident refusing to wear the Cpap.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure current orders were documented on the Physician Order Sheet (POS) and Medication Administration Record (MAR) and to clarify orders with the physician after the Pharmacists review/recommendation for one sampled resident (Resident #14); and to administer pain medication as ordered for one sampled resident (Resident #53) out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's Policy for Physician Order dated 2013 showed: -To ensure the accuracy of transcribing an order. -To have physician orders transcribed from the POS to the appropriate administration record. -The POS will be reviewed by a licensed nurse monthly during the changeover (assuring all orders are correct on the POS for the following month) to capture all information for the next month. -The POS will be reviewed by the physician/Nurse Practitioner (NP) monthly to ensure the appropriate treatment and orders. -The pharmacy consultant will review the Drug Regimen Review (DRR) monthly and makes recommendations to nursing staff or/and physician concerning medications. -Transcribe order to the appropriate administration record (MAR, treatment record, etc.). Record review of the facility's Policy for Pharmacy Services dated 2015 showed: -The pharmacy consultants check and review the medication carts monthly and make the recommendations to the nursing staff for better managing. -The Nursing Department is responsible to implement the recommendations from the pharmacist or pharmacy consultants. -The designated licensed nurse is to check and compare with the previous monthly POS during the monthly changeover procedure. -Procedure: --Transcribe correctly to the MAR, Treatment Administration Record (TAR) and POS upon receiving the orders. --Review the POS and MAR on monthly changeover. --Notify physician or pharmacist if needed. --Any missing or overlap, double orders or unclear orders shall be clarified with the physician and document correct orders on the POS, MAR, and TAR. --A licensed nurse must sign on the POS to attest the nursing review. --The physician is to sign on the POS monthly upon completion. 1. Record review of Resident #14's admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). -Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). Record review of the resident's POS dated 4/1/22 to 4/30/22 showed: -Lorazepam (Ativan a medication used to treat anxiety) 0.5 milligram (mg) tablet take 1 tablet by mouth (PO) daily at 2:00 P.M., for Anxiety. --Start date 3/22/22. Record review of the resident's Controlled Substance Record dated 4/21/22 to 5/26/22 showed: -Lorazepam 0.5 mg received 30 tablets on 4/21/22. -Lorazepam 0.5 mg was not administered on 4/25. -Lorazepam 0.5 mg was administered from 5/1/22 to 5/26/22. -Lorazepam 0.5 mg zero (0) tablets on 5/26/22. Record review of the resident's Nurses Notes dated 4/25/22 at 8:45 P.M., showed: -The resident was very anxious. -The resident pulled the fire alarm. -The resident was combative and uncooperative with staff. -The resident was unable to be redirected. Record review of the resident's Nurses Notes dated 4/25/22 at 9:15 P.M., showed: -The Charge Nurse called the Nurse Practitioner and received an order for Melatonin (a hormone in your body that plays a role in sleep) 3 mg give 2 tablets (6 mg) PO at HS. -The Charge Nurse had some difficulty getting the resident to take the Melatonin but after several attempts the resident finally took it. Record review of the resident's Nurses Notes dated 4/25/22 at 10:30 P.M., showed the resident had calmed down and staff was able to redirect him/her. Record review of the resident's POS dated 5/1/22 to 5/31/22 showed: -No order to discontinue the Lorazepam. -No order for the Lorazepam. Record review of the resident's MAR dated May 2022 showed no order for Lorazepam. Record review of the resident's Consultant Pharmacist Recommendations to Nursing Staff dated 5/11/22 showed: -The resident's Lorazepam orders do not appear on 5/2/2022 POS. -Please check and make sure resident was still to receive this medication and if so write it on his/her POS and MAR. Record review of the resident's POS dated 6/1/22 through 6/30/22 showed: -No order to discontinue the Lorazepam. -No order for the Lorazepam. Record review of the resident's MAR for June 2022 showed no order for Lorazepam. Record review of the resident's medical record showed no Controlled Substance Record for Lorazepam for June 2022. During an interview on 6/7/22 at 2:04 P.M., Licensed Practical Nurse (LPN) C said: -He/she was unsure who was responsible for the end of month POS change over review. -He/she was unsure of what the change over review entailed. -The Director of Nursing (DON) may be responsible for the monthly POS change over review. -He/she could not find a discontinue order at this time for the resident's Lorazepam. -The resident's Lorazepam order was not on the May or June POS. During an interview on 6/8/22 at 1:32 P.M., the Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) Coordinator/Infection Control Nurse who was filling in for the DON who was on vacation said: -The monthly MAR change over should be done by the DON -If monthly orders were not carried over on the change over it is called a fall over. -If an order was discontinued it should have been discontinued by the Physician and put on the resident's POS. -Sometimes the resident would refuse medication. -Sometimes the resident was too sleepy so the medication was not given so the resident was not overdosed. -If the medication was not given it should be circled on the MAR as not administered and the reason not given should be written on the back of the MAR. -He/she notified the Physician of the resident's missing Lorazepam order and awaiting call back to verify order. 2. Record review of Resident #53's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Osteoarthritis (degeneration of joint cartilage and the underlying bone, most common from middle age onward). -Migraine (a recurrent throbbing headache that typically affects one side of the head and is often accompanied by nausea and disturbed vision), unspecified, not intractable (typically lasts up to 72 hours and can be treated with migraine medications), without status migrainosus (a type of migraine that is considered dangerous and requires emergency medical care). Record review of the resident's POS dated 6/1/22 to 6/30/22 showed: -Tramadol HCL (Ultram- a controlled opioid used to treat moderate to severe pain in adults) 50 mg tablet take one tablet by mouth every six hours as needed (PRN) for pain. --Ordered 11/30/21. Record review of the resident's Controlled Drug Record for Tramadol HCL 50 mg tablet dated 5/10/22 to 5/31/22 showed 90 tablets were received on 5/10/22 and the orders were to take one tablet by mouth every six hours as needed for pain, and further showed the resident received the following: -On 5/15/22 at 6:00 A.M., received one tablet. -On 5/15/22 at 8:12 A.M., received one tablet. -On 5/15/22 at 9:30 A.M., received one tablet --There was not six hours between these doses. He/she received a total of three doses in three and a one half hours. -On 5/16/22 at 9:00 A.M., received one tablet. -On 5/16/22 at 1:00 P.M., received one tablet --There was not six hours between these doses. He/she received two doses in four hours. -On 5/15/22 at 6:00 P.M., received one tablet. --There was not six hours between these doses. He/she received two doses in five hours. -Between 5/22/22 at 6:00 P.M. and 5/23/22 at 2:00 A.M., a dose was given without a nurse's signature or time listed with a total of 63 tablets remaining. -On 5/23/22 at 2:00 A.M., received one tablet. -On 5/23/22 at 7:00 A.M., received one tablet. --There was not six hours between these doses. He/she received two doses in five hours. -On 5/26/22 at 6:00 P.M., received one tablet. -On 5/26/22 at 10:00 P.M., received one tablet. --There was not six hours between these doses. He/she received two doses in four hours. -On 5/27/22 at 4:45 A.M., received one tablet. -On 5/27/22 at 9:30 A.M., received one tablet. --There was not six hours between these doses. He/she received two doses in four hours and 45 minutes. -On 5/30/22 at 2:00 P.M., received one tablet. -On 5/30/22 at 6:00 P.M., received one tablet. --There was not six hours between these doses. He/she received two doses in four hours. -On 5/31/22 at 1:00 P.M., received one tablet. -On 5/31/22 at 5:00 P.M., received one tablet. --There was not six hours between these doses. He/she received two doses in four hours. During an interview on 6/7/22 at 12:19 P.M., LPN C said: -A PRN medication should not be given sooner than the time frame ordered. -The physician should be notified if the medication was not relieving the resident's pain. -The physician should be notified that the resident received the medication sooner than the six hours ordered. During an interview on 6/8/22 at 1:32 P.M., the MDS Coordinator said: -A medication should not be given more often then ordered. -A PRN medication ordered every six hours should have six hours between each dose. -The physician should be notified if the medication was not relieving the resident's pain. -The physician should be notified that the resident had received the medication sooner than the six hours ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #41) was provided with staff supervision, a smoking apron and assistance while smoking out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's smoking policy dated 2018 showed: -Smoking was permitted under the supervision of facility staff only in the designated smoking areas in the building, where posted, and during designated smoking times for those residents that exhibit risk behaviors. -Residents who were with physical limitation should be assessed for safely smoking with or without assistance and monitor. -Safe smoking ability is completed yearly or on quarterly assessment and when the resident has a change in condition to ensure the resident's smoking ability to be safe. The interdisciplinary team will determine the frequency of assessment. -Assess residents' safe smoking behavior. -Determine needs for safety such as a smoking apron/jacket and/or one-on-one supervision and address in the care plan. Record review of the smoking times sign showed the residents would have smoke times every two hours. 1. Record review of Resident #5's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/21/22 showed the following staff assessment of the resident: -Moved into the facility on 8/4/20. -Was severely cognitively impaired. -Was independent with activities of daily living (ADL - dressing, grooming, bathing, eating, toileting, etc.) except he/she required supervision for eating, toileting, personal hygiene and bathing. -Did not use a mobility device. -Had impairment on one side of his/her upper extremities. -Some of his/her diagnoses included heart failure, respiratory failure and schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). 2. Record review of Resident #41's face sheet showed he/she moved into the facility on 3/13/15 and some of his/her diagnoses included multiple sclerosis (a neurological disease in which there is impaired sensory and motor nerve function) and anxiety (nervousness, fear, apprehension, and worrying). Record review of the resident's annual MDS dated [DATE] showed the resident currently used tobacco. Record review of the resident's care plan last reviewed on 1/17/22 showed: -The resident's smoking care plan goal was that he/she was not supposed to smoke without supervision. -An intervention in his/her smoking care plan was that the resident could smoke unsupervised. -An intervention in his/her smoking care plan was that the resident required a smoking apron while smoking. Record review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Had unclear speech. -Was usually understood by others. -Understood others. -Had adequate hearing and vision. -Was cognitively intact. -Was totally dependent upon staff for all ADLs. -Had impaired range of motion on both sides of his/her upper and lower extremities. -Used a wheelchair. -Some of his/her diagnoses included multiple sclerosis and anxiety. Record review of the resident's Annual Physician's Exam dated 5/25/22 showed the resident smoked in the smoking room and someone helped him/her smoke. Record review of the resident's June 2022 Physician's Order Sheet showed a physician's order dated 5/19/19 for the resident to use an apron when smoking for burn prevention. Observation on 6/1/22 at 10:55 A.M. showed: -The resident was in bed awake. -The resident was able to speak slowly. -The resident was only able to move his/her head and not the rest of his/her body. During an interview and observation on 6/2/22 at 12:06 P.M., the resident was sitting in the hallway in his/her Broda chair (a wheelchair specialized for the resident's comfort that usually reclines and is padded) and said he/she wanted to smoke but no one had taken him/her to smoke so far today. During an interview on 6/2/22 at 12:22 P.M., the resident said he/she was supposed to smoke every odd hour. During an interview and observation on 6/2/22 at 3:15 P.M. the resident: -Was in the hall in his/her Broda chair watching a music video on his/her phone. -He/she asked the MDS Coordinator if someone could take him/her to smoke. -The MDS Coordinator said ok, let me see who is available to smoke you. -No staff member came to take the resident to smoke. Observation on 6/2/22 at 3:51 P.M. showed: -Resident #5 pushed the resident in his/her Broda chair into the smoking room. -The resident said Resident #5 was his/her friend and he/she pushed him/her to the smoking room. -Resident #5 did not put a smoking apron on the resident. -Resident #5 put a cigarette in the resident's mouth and lit it for him/her. -The resident was not able to hold his/her own cigarette. -Resident #5 took the cigarette out of the resident's mouth and discarded the ashes in the ash tray and returned the cigarette to the resident's mouth. -There were no staff supervising the smoking room. During an interview on 6/7/22 at 2:45 P.M., the resident said the staff were not taking him/her to smoke at his/her smoking times. During an interview on 6/7/22 at 2:50 P.M. Certified Nursing Assistant (CNA) C and Certified Medication Technician (CMT) A said: -The resident was out of cigarettes. -The resident's friend would bring him/her cigarettes. -Resident #5 was not supposed to help the resident smoke. During an interview on 6/8/22 at 8:32 A.M., the MDS Coordinator said: -They tell the resident he/she can smoke if he/she has his/her own cigarettes and if they have time. -Other residents are not supposed to help the resident smoke or push him/her in his/her chair. -The smoking care plans are done by the Social Services Designee. During an interview on 6/8/22 at 9:38 A.M., the Social Services Designee said: -He/she did smoking assessments annually or if they had a change in status. -All departments were responsible for updating the care plan. -He/she needed to change the resident's care plan intervention to the resident cannot smoke unsupervised. -The resident was supposed to be supervised and assisted when smoking. -Other residents were not supposed to help the resident smoke or push him/her in his/her chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure non-pharmacological interventions were documented as used prior to pain medications being documented as given for one sampled resident (Resident #55) out of 17 sampled residents. The facility census was 66 residents. Record Review of the facility Pain Assessment Policy dated 2013 showed: -Nursing staff were responsible for pain management. -Pharmacological management included the scheduled pain medication and as needed (PRN) pain medication. -Non-Pharmacological interventions included activities, massage, soft pillow or mattress, relaxation, and breathing techniques. -Staff were to complete pain assessments. -Staff were to review pain medications and contact the physician if the resident continued to complain of pain. -Staff were to provide non-pharmacological techniques to help alleviate pain. 1. Record review of Resident #55's undated face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Venous Insufficiency (when the blood vessels in the legs have trouble sending blood back to the heart). -Cellulitis (inflammation of connective tissue within the skin). -Chronic Embolism (a blockage) and Thrombosis (a blood clot) of unspecified deep veins of lower leg, bilaterally (both legs) (DVT a blockage or blood clot in the legs). -Osteoarthritis (a degenerative disease that affects the bones and joints). Record review of the resident's Annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/21/22 showed: -The resident had not been on a scheduled pain management regimen. -The resident experienced pain frequently. -The resident did not have any functional limitation in range-of motion (ROM). Record review of the resident's care plan dated 5/10/22 showed: -The resident had chronic pain related to DVT in bilateral lower legs. -The resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. -The resident had the following care plan interventions: -- Administer medication as ordered for pain. Give 30 minutes before or after treatments. --Monitor/document for side effects of pain medication. --Monitor/record/report to the nurse if the resident complained of pain or requested pain medication. --Notify the resident's physician if interventions were unsuccessful or if current compliant was a significant change from residents past experience of pain. --Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in ROM, withdrawal or resistant to care. --Report to nurse any change in usual activity attendance patterns or refusal to attend activities related to signs or symptoms or complaints of pain or discomfort. --The resident was able to: call for assistance when in pain, reposition self, ask for medication, say how much pain was experienced, say what increased or alleviated pain. -NOTE: The care plan did not include any non-pharmacological pain treatment methods. Record review of the resident's Medication Administration Record (MAR) dated March 2022 showed: -Acetaminophen 325 milligram (mg)(Tylenol a pain reliever and fever reducer). Give one tablet by mouth. --Was used a total of six times. -NOTE: the order did not specify how often to give or have parameters. -Acetaminophen 325 mg Give two tablets by mouth every four hours PRN for pain. --Was used a total of 17 times. -Ibuprofen 600 mg (Motrin a pain reliever and fever reducer). Give one tablet every six hours PRN for pain. --Was used a total of six times. -No place to document non-pharmacological interventions used prior to medications being given. Record review of the resident's nurses notes dated March 2022 showed no documentation of any non-pharmacological interventions used prior to medications being given for complaints of pain. Record review of the resident's MAR dated April 2022 showed: -Acetaminophen 325 mg give one tablet by mouth. -- Was used a total of eight times. -NOTE: the order did not specify how often to five or have parameters. -Acetaminophen 325 mg give two tablets by mouth every four hours as needed for pain. --Was used a total of 15 times. -No place to document non-pharmacological interventions used prior to medications being given. Record review of the resident's nurses notes dated April 2022 showed no documentation of any non-pharmacological interventions used prior to medications being given for complaints of pain. Record review of the resident's nurses notes dated May 2022 showed no documentation of any non-pharmacological interventions used prior to medications being given for complaints of pain. During an interview on 6/1/22 at 1:14 P.M., the resident said: -He/she used over-the counter (OTC) pain medication regularly. -The staff do not offer different forms of pain treatment, only pain medication is offered and given. During an interview on 6/2/22 at 1:00 P.M. the Director of Nursing (DON) said he/she was not able to find the resident's MAR for May 2022. During an interview on 6/3/22 at 9:18 A.M., the resident said: -The staff do not involve me in revising pain management strategies. -He/she had moderate to severe pain on a daily basis. -He/she had pain in his/her legs, feet, and middle of the back. -He/she was sent to the hospital in March due to pain in his/her legs. -His/her pain was currently at an eight on a scale from one to 10. -He/she could typically tolerate pain rated at five or lower. -Staff did not recommend trying anything other than pain medications. During an interview on 6/6/22 at 11:34 A.M., Certified Nursing Assistant (CNA) (B) said: -He/she did not perform any non-pharmacological pain interventions for the resident. During an interview on 6/6/22 at 12:07 P.M., Licensed Practical Nurse (LPN) (B) said: -The resident normally complained of pain in the morning and in the evening before bed. -He/she did try to help the resident elevate his/her legs when he/she was in pain. -He/she would ask the resident if he/she would like a warm towel to assist in pain relief. -He/she did not go straight to pain medication when resident complains of pain. -He/she did not believe the resident needed stronger pain medication. -He/she was not sure if documentation was needed for the non-pharmacological interventions. -He/she did not document anywhere if he/she did use non-pharmacological interventions. During an interview on 6/8/22 at 1:32 P.M., the MDS Coordinator/Infection Preventionist who was filling in for the DON said: -He/she would expect the staff to perform non-pharmacological pain treatments before going straight to pain medication. -He/she would expect the staff to document the non-pharmacological treatments in the resident's chart. -He/she would expect the non-pharmacological pain treatments to be in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #14's admission Record showed he/she was admitted on [DATE] with the following diagnoses: -Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). -Anxiety Disorder (anticipation of impending danger and dread accompanied by restlessness, tension, fast heart rate, and breathing difficulty not associated with an apparent stimulus). Record review of the resident's MAR dated March 2022 showed no order for Ativan. Record review of the resident's POS dated March 2022 showed no order for Ativan. Record review of the resident's Controlled Substance Record dated 3/6/22 showed: -Lorazepam 0.5 mg received 30 tablets on 3/6/22. -Lorazepam 0.5 mg zero (0) tablets on 4/11/22. Record review of the resident's MAR dated April 2022 showed: -Lorazepam 0.5 mg tablet take 1 tablet by mouth (PO) daily at 2:00 P.M., no diagnosis was listed. --Start date of 3/22/22. --Was not administered on the following dates and there was no documentation of a reason why it was not administered: ---4/1/22. ---4/3/22. ---4/8/22. ---4/10/22. ---4/16/22 to 4/20/22. ---4/22/22. ---4/25/22 to 4/28/22. ---4/30/22. -Melatonin 3 mg tablet, give 2 tabs (6 mg) PO at hour of sleep (HS) for insomnia. --Start date 4/25/22. --Administered on 4/25/22 to 4/28/22. Record review of the resident's POS dated 4/1/22 to 4/30/22 showed: -Lorazepam 0.5 mg tablet take 1 tablet PO daily at 2:00 P.M., for Anxiety. --Start date 3/22/22. -New hand written order dated 4/25/22 for Melatonin 3 mg tablet, give 2 tabs (6 mg) PO at HS no diagnosis listed. Record review of the resident's Controlled Substance Record dated 4/21/22 showed: -Lorazepam 0.5 mg received 30 tablets on 4/21/22. -Lorazepam 0.5 mg was administered on 4/26/22, 4/27/22 and 4/30/22. -Lorazepam 0.5 mg was not administered on 4/25 -Lorazepam 0.5 mg zero (0) tablets on 5/26/22. Record review of the resident's Nurses Notes dated 4/25/22 at 8:45 P.M., showed: -The resident was very anxious. -The resident pulled the fire alarm. -The resident was combative and uncooperative with staff. -The resident was unable to be redirected. Record review of the resident's Nurses Notes dated 4/25/22 at 9:15 P.M., showed: -The Charge Nurse called the Nurse Practitioner and received an order for Melatonin 3 mg give 2 tabs (6 mg) PO at HS. -The Charge Nurse had some difficulty getting the resident to take the Melatonin but after several attempts the resident finally took it. Record review of the resident's Nurses Notes dated 4/25/22 at 10:30 P.M., showed the resident had calmed down some and staff was able to redirect him/her better. Record review of the resident's POS dated 5/1/22 through 5/31/22 showed: -No order to discontinue the Lorazepam. -No order for the Lorazepam. Record review of the resident's MAR for May 2022 showed no order for Lorazepam. Record review of the resident's Consultant Pharmacist Recommendations to Nursing Staff dated 5/11/22 showed: -The resident's Lorazepam orders do not appear on 5/2/2022 POS. -Please check and make sure resident is still to receive this medication and if so write it in on his/her POS and MAR. Record review of the resident's POS dated 6/1/22 through 6/30/22 showed: -No order to discontinue the Lorazepam. -No order for the Lorazepam. Record review of the resident's MAR for June 2022 showed no order for Lorazepam. Record review of the resident's medical record showed no Controlled Substance Record for Lorazepam for June 2022. During an interview on 6/7/22 at 2:04 P.M., LPN C said: -He/she was unsure who was responsible for the end of month POS change over review. -He/she was unsure of what the change over review entailed. -The Director of Nursing (DON) may be responsible for the monthly POS change over review. -He/she could not find a discontinue order for the resident's Lorazepam. -The resident's Lorazepam order was not on the May or June POS. During an interview on 6/8/22 at 1:32 P.M., the MDS Coordinator/Infection Control Nurse who was filling in for the DON said: -The monthly MAR change over should be done by the DON. -If monthly orders were not carried over on the change over it was called a fall over. -If an order was discontinued it should have been discontinued by the Physician and put on the resident's POS. -Sometimes the resident would refuse medication. -Sometimes the resident was too sleepy so the medication was not given so the resident was not overdosed. -If the medication was not given it should be circled on the MAR as not administered and the reason not given should be written on the back of the MAR. -Notified the Physician of the resident's missing Lorazepam order and awaiting a call back to verify the order. Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident #40) was provided with lab services and was able to have his/her labs drawn twice a week in order to maintain a therapeutic level of Coumadin (an anticoagulant (blood thinner) used to treat or prevent blood clots) and to notify the resident's physician regarding the resident's labs and to ensure one sampled resident's (Resident #14) order for Lorazepam (Ativan-a controlled medication used to treat anxiety) was transcribed from the April 2022 monthly Physician Order Summary (POS) to the May and June POS and the Medication Administration Record (MAR) or have a discontinued order written out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's laboratory services policy dated 12/2/04 showed: -It was the responsibility of nursing professionals to ensure all lab services were completed and results provided to the facility within timeframes normal for appropriate intervention. -It was the responsibility of nursing professionals to notify the physician of all lab results so prompt, appropriate action may be taken if indicated for the resident's care. -The technician will check off what labs were drawn on the list in the lab book and notify the charge nurse of any refusals or lab not able to be drawn. -If the resident refused a blood draw, the charge nurse would assist the lab technician with a different approach to encourage the resident to allow the lab test completed. -If a resident continued to refuse a blood draw, the charge nurse would notify the Director of Nursing (DON) and the physician and document the refusal in the medical record. -Refusal of lab tests would be discussed with the care plan team to implement a new plan or new approaches and discussed with the resident/responsible party. -The physician would be notified by the charge nurses of any lab work unable to be drawn and any new orders would be followed. -The DON would distribute lab results to charge nurses and the charge nurses would place them in the medical record and document notification of physician and any new orders. -Licensed nurses would monitor that labs are being completed per physician orders monthly when checking new physician order sheets. Record review of the facility's Policy for Physician Order dated 2013 showed: -To ensure the accuracy of transcribing an order. -To have physician orders transcribed from the POS to the appropriate administration record. -The POS will be reviewed by a licensed nurse monthly during the changeover (assuring all orders are correct on the POS for the following month) to capture all information for the next month. -The POS will be reviewed by the physician/Nurse Practitioner (NP) monthly to ensure the appropriate treatment and orders. -The pharmacy consultant will review the Drug Regimen Review (DRR) monthly and makes recommendations to nursing staff or/and physician concerning medications. -Transcribe order to the appropriate administration record (MAR, treatment record, etc.). Record review of the facility's Policy for Pharmacy Services dated 2015 showed: -The pharmacy consultants check and review the medication carts monthly and make the recommendations to the nursing staff for better managing. -The Nursing Department is responsible to implement the recommendations from the pharmacist or pharmacy consultants. -The designated licensed nurse is to check and compare with the previous monthly POS during the monthly changeover procedure. -Procedure: --Transcribe correctly to the MAR, Treatment Administration Record (TAR) and POS upon receiving the orders. --Review the POS and MAR on monthly changeover. --Notify physician or pharmacist if needed. --Any missing or overlap, double orders or unclear orders shall be clarified with the physician and document correct orders on the POS, MAR, and TAR. --A licensed nurse must sign on the POS to attest the nursing review. --The physician is to sign on the POS monthly upon completion. 1. Record review of Resident #40's face sheet showed he/she: -Was his/her own responsible party. -Moved into the facility on 9/24/19 with a diagnosis of acute embolism (when a piece of a blood clot, foreign object, or other bodily substance becomes stuck in a blood vessel and largely obstructs the flow of blood) and thrombosis of deep veins of lower extremity (DVT - a blood clot in a deep vein in the thigh or leg). Record review of the resident's nurses' notes dated 12/4/21 to 4/30/22 showed the following notes were the only notes regarding the resident's International Normalized Ratio ((INR) used to monitor the effectiveness of blood thinning medications) labs and Coumadin orders: -On 12/7/21, the NP was notified of the resident's high INR and no changes were made. -On 12/13/21, the NP was notified of the resident's INR results of 1.6 and he/she increased the order for Coumadin to 5 milligrams (mg) for one day and return to 3 mg the next day. -On 12/14/21, the NP was notified of the resident's INR results of 1.4 and he/she increased the order for Coumadin to 5 mg for one day and return to 3 mg the next day. Record review of the resident's lab results showed: -The normal INR range was 0.9-1.2. -Standard anticoagulant 2.0-3.0. -Aggressive anticoagulant 2.5-3.5. -The INR results on 12/2/21 were 1.5 with an order to increase Coumadin from 3 mg to 5 mg for three days and then return to 3 mg. -The INR results on 12/6/21 were 1.5 with no order change. -The INR results on 12/9/21 were 1.6 with an order for Coumadin 5 mg for one day. -The INR results on 12/13/21 were 1.4 with an order for Coumadin 5 mg for one day. -The INR results on 12/16/21, 12/20/21, 12/23/21, 12/27/21 and 12/30/21 were 1.4. Record review of the resident's 2022 physician's progress notes showed: -On 1/5/22, the resident was seen for INR management. The resident's INR was 1.2. The resident was on 3 mg of Coumadin and the resident's dose would be increased to 5 mg. -On 2/1/22, the resident was on Coumadin. The plan was to continue Coumadin and adjust the dosage based on INR results. -On 2/15/22, the physician did not mention Coumadin or INR. -On 4/15/22, the plan was to continue Coumadin and monitor INR. -On 5/25/22, the resident was on Coumadin and needed to continue to have labs ordered and monitored. The resident had no signs of bleeding. The resident had a history of DVT. Record review of the resident's lab results showed: -The INR results on 1/3/22 were 1.4 with an order for Coumadin 5 mg until stabilized with an INR of 2.5-3.0. -The INR results were 1.4 on 1/6/22, 1.4 on 1/10/22, 1.8 on 1/13/22, 1.9 on 1/14/22, and 2.1 on 1/17/22. -No INR was completed as scheduled on 1/20/22. -The INR results were 1.8 on 1/24/22 and 2.3 on 1/27/22. -No INR was completed as scheduled on 1/31/22. Record review of the resident's POSs for February 2022 through June 2022 showed the resident had a physician's order dated 1/5/22 for Warfarin (Coumadin) 5 mg daily and lab orders for an INR every Monday and Thursday. Record review of the resident's lab results showed: -No INR was completed as scheduled on 2/3/22. -The INR results were 2.7 on 2/4/22 and 2.1 on 2/7/22. -No INR was completed as scheduled on 2/10/22. -The INR results were 1.7 on 2/14/22 and 1.7 on 2/16/22. -No INR was completed as scheduled on 2/17/22. -The INR results were 1.7 on 2/21/22 and 1.9 on 2/24/22. -No INR was completed as scheduled on 2/28/22. -The INR results were 2.0 on 3/3/22 and 2.4 on 3/7/22. -No INR was completed as scheduled on 3/10/22. -The INR results were 2.3 on 3/14/22. -No INR was completed as scheduled on 3/17/22 or 3/21/22. -The INR results were 2.2 on 3/23/22. -No INR was completed as scheduled on 3/24/22. -On 3/28/22, the lab results stated, Attempted to contact nurse but no answer at nurses station. Report sent to advise testing not performed due to specimen quantity not sufficient. Please contact lab if redraw is needed STAT or make a new requisition for redraw on the next routine lab day. -No INR was completed as scheduled 3/31/22 and 4/4/22. -On 4/7/22, the lab results stated, Attempted to contact nurse but no answer at nurses station. Report sent to advise testing not performed due to specimen quantity not sufficient. Please contact lab if redraw is needed STAT or make a new requisition for redraw on the next routine lab day. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/10/22 showed the resident received an anticoagulant seven out of the past seven days. Record review of the resident's care plan dated as reviewed on 4/29/22 showed the resident had a history of refusing care. The care plan did not address labs. Record review of the resident's lab results showed: -On 4/11/22 and 4/14/22, the lab results stated, Attempted to contact nurse but no answer at nurses station. Report sent to advise testing not performed due to specimen quantity not sufficient. Please contact lab if redraw is needed STAT or make a new requisition for redraw on the next routine lab day. -The INR results were 2.1 on 4/18/22 -No INR was completed as scheduled on 4/21/22 and 4/25/22. -The INR results were 2.2 on 4/26/22. -No INR was completed as scheduled on 4/29/22. -On 5/2/22 and 5/5/22, the lab results stated, Attempted to contact nurse but no answer at nurses station. Report sent to advise testing not performed due to specimen quantity not sufficient. Please contact lab if redraw is needed STAT or make a new requisition for redraw on the next routine lab day. -The INR results on 5/9/22 were 1.9. -No INR was completed as scheduled on 5/12/22. -The INR attempted on 5/13/22 and reported on 5/17/22 reported the resident has refused lab work for today. We will try to obtain specimens two more times and then order will be discontinued due to resident's wishes. Please inform physician of patient's refusal for lab work. -On 5/16/22, the lab results stated, Attempted to contact nurse but no answer at nurses station. Report sent to advise testing not performed due to specimen quantity not sufficient. Please contact lab if redraw is needed STAT or make a new requisition for redraw on the next routine lab day. -No INR was completed as scheduled on 5/19/22. -No INR was completed as scheduled on 5/23/22. -On 5/25/22, the lab results stated, Attempted to contact nurse but no answer at nurses station. Report sent to advise testing not performed due to specimen quantity not sufficient. Please contact lab if redraw is needed STAT or make a new requisition for redraw on the next routine lab day. -No INR was completed as scheduled on 5/26/22. -On 5/27/22, the lab results stated, Attempted to contact nurse but no answer at nurses station. Report sent to advise testing not performed due to specimen quantity not sufficient. Please contact lab if redraw is needed STAT or make a new requisition for redraw on the next routine lab day. -No INR was completed as scheduled on 5/30/22. -The INR attempted on 6/1/22 and reported on 6/1/22 reported the resident has refused lab work for today. We will try to obtain specimens two more times and then order will be discontinued due to resident's wishes. Please inform physician of patient's refusal for lab work. Record review of the resident's nurses' notes dated 5/1/21 to 6/3/22 showed the following notes were the only notes regarding the resident's INR labs and Coumadin orders: -On 5/13/22, the resident refused to have blood drawn for labs (type of labs not documented) stating that he/she wanted to wait until tomorrow. -On 6/2/22, the resident refused to have labs drawn and there was no reason documented. During an interview on 6/8/22 at 9:42 A.M., Licensed Practical Nurse (LPN) C said: -The resident refused his/her labs. -The note on the labs that say no one answered at the nurses' station is not true. -The resident didn't like the lab technician that came and the DON was supposed to take care of that. -It might be documented that the resident refused labs but he/she didn't know if it was. -He/She was not sure if someone told the doctor the resident refused his/her lab draws. -The doctor knew the resident refused his/her lab draws. During an observation and interview on 6/8/22 at 11:30 A.M., -The resident said: --He/she did not like the person who drew the labs because they don't do it correctly. --A different person drew labs on Monday and he/she was bad too. --They did not draw blood from his/her veins. -The resident had a circular hole with a dark purple circle around it on the inside of the resident's left elbow, not visibly near a vein and was according to the resident, from the blood draw attempt on Monday. -The resident had several other small, circular bruises on his/her arms and hands that were bluish-purple that according to the resident were from them trying to draw his/her blood. During an interview on 6/8/22 at 8:32 A.M., the MDS Coordinator said: -The resident didn't like the way the lab technician draws the blood and therefore, he/she had a lot of refusals. -They requested a different person to draw the labs. -The lab sent another technician and the resident didn't like that one either so he/she refused the next lab draw. -They were having problems with the lab such as the lab had the wrong sample, used the wrong tube, etc. so they are looking for another lab. -The resident has had bruises from the lab draws. -He/she called lab three times about their concerns. -The Administrator had called the lab about their concerns. -He/she knows another nurse has called the lab as well. -When he/she told the resident's doctor about the lab issue, the doctor said ok. -The resident's doctor was aware of the lab issue and told him/her to monitor the resident. -It does not make sense when the lab puts on the lab sheet that they attempted to contact nurse but no answer at nurses' station because the staff are there. -Sometimes the lab had to take another sample because they used the wrong tube. -The nursing staff should document the refusals and if they talked to the lab or the doctor. Phone calls were made to the resident's physician on 6/8/22 at 11:56 A.M., on 6/10/22 at 1:46 P.M. and on 6/13/22 at 1:25 P.M. On 6/13/22 at 2:25 P.M., the resident's physician said he/she would have to look at the resident's chart to know if he/she was notified. He/she knows his/her INR was done on 6/6/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents had the ability to participate in a resident council where they would be able to express grievances and make recommendations concerning issues of resident care and life in the facility for five sampled residents (Resident's #2, #40, #45, #65 and #58) out of 17 sampled residents. This deficiency has the potential to affect all cognitively intact residents. The facility census was 66 residents. Record review of Centers for Medicare and Medicaid services (CMS) guidance for activities showed: -August 31, 2020: --Phase 1: Restrict group activities, but some activities may be conducted (for COVID-19 (a new disease caused by a novel (new) coronavirus that emerged in December 2019, led to severe social restrictions beginning in March 2020 and led to a pandemic)negative or asymptomatic residents only) with social distancing, hand hygiene, and use of a cloth face covering or facemask. --Phase 2: Group activities, including outings, limited (for asymptomatic or COVID-19 negative residents only) with no more than 10 people and social distancing among residents, appropriate hand hygiene, and use of a cloth face covering or facemask. --Phase 3: Group activities. including outings, allowed (for asymptomatic or COVID-19 negative residents only) with no more than the number of people where social distancing among residents can be maintained, appropriate hand hygiene, and use of a cloth face covering or facemask. -September 17, 2020 (Quality Safety & Oversight (QSO) memoranda 20-39 NH): Communal Activities and Dining: While adhering to the core principles of COVID-19 infection prevention, communal activities may occur. Facilities should consider additional limitations based on status of COVID-19 infections in the facility. Additionally, group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, or with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering. Facilities may be able to offer a variety of activities while also taking necessary precautions. For example, book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. -March 24, 2021: Communal Dining and Group Activities: Group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, or with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering (except while eating). -April 27, 2021 (QSO 20-39 revised): Communal Activities and Dining: While adhering to the core principles of COVID-19 infection prevention, communal activities may occur. Book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. The Centers for Disease Control and Prevention (CDC) has provided additional guidance on activities and dining based on resident vaccination status. For example, residents who are fully vaccinated may participate in activities without face coverings or social distancing if all participating residents are fully vaccinated; if unvaccinated residents are present during communal dining or activities, then all residents should use face coverings when not eating and unvaccinated residents should physically distance from others. -November 12, 2021 (QSO 20-39 revised): Communal Activities, Dining and Resident Outings: While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. Book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. The safest approach is for everyone, regardless of vaccination status, to wear a face covering or mask while in communal areas of the facility. -March 10, 2022 and still current (QSO 20-39 revised): Communal Activities, Dining and Resident Outings: While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. Book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. The safest approach is for everyone, regardless of vaccination status, to wear a face covering or mask while on in communal areas of the facility. 1. During the entrance conference on 6/1/22 at 9:00 P.M., the Administrator said: -They have not had a resident council meeting since before COVID-19 (March 2020). -They were just now getting the Activity Department up and running again so they don't have a resident council president. Note: The last three months of resident council meetings minutes were requested during the entrance conference and again during the survey but were not received. 2. Record review of Resident #45's quarterly Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) dated 4/16/22 showed: -He/she had a Brief Interview for Mental Status (BIMS) score of 15. --This indicated he/she was cognitively intact. During an interview on 6/8/22 at 7:58 A.M., the resident said he/she had not heard of the facility having a resident council but they had one at the facility he/she previously resided in and he/she participated in it. 3. Record review of Resident #65's quarterly MDS dated [DATE] showed: -He/she had a BIMS score of 15. --This indicated he/she was cognitively intact. During an interview on 6/8/22 at 8:02 A.M., the resident said: -It's been a long time since they had resident council meetings. -He/she was not sure when they last had a resident council meeting. -He/she was not aware of any other way to let the facility know their concerns without the resident council. -He/she wished they still had a resident council. 4. Record review of Resident #2's annual MDS dated [DATE] showed: -He/she had a BIMS score of 15. --This indicated he/she was cognitively intact. During an interview on 6/8/22 at 8:05 A.M., the resident said: -It's been over a year since they had a resident council meeting. -They have to take their concerns to the nurses or the Administrator and he/she has not seen any responses doing it this way. 5. Record review of Resident #40's quarterly MDS dated [DATE] showed: -He/she had a BIMS score of 15. --This indicated he/she was cognitively intact. During an interview on 6/8/22 at 8:26 A.M., the resident said he/she had never heard of a resident council but he/she would like to be president. 6. Record review of Resident #58's quarterly MDS dated [DATE] showed: -He/she had a BIMS score of 15. --This indicated he/she was cognitively intact. During an interview on 6/8/22 at 8:28 A.M., the resident said: -The last resident council meeting was way before COVID-19. -He/She enjoyed resident council. -They were able to get their grief's out in resident council. 7. During an interview on 6/6/22 at 9:44 A.M., the Social Services Designee said activities staff were the ones who helped gather residents for previous resident council meetings. During an interview on 6/6/22 at 2:07 P.M., the Administrator said: -They did not have a resident council since COVID-19. -They do not have a resident council president now because of behaviors. -The previous resident council president and vice-president both passed away. During an interview on 6/8/22 at 8:23 A.M., Certified Medication Technician (CMT) B said they haven't had a resident council meeting since COVID-19 started.

Based on interview and record review, the facility failed to ensure resident safety by not conducting appropriate background screenings for new employees to include the checking of the Nurse Aide Registry (a data base that provides the list of eligible nursing assistants who can be employed by long-term care facilities as health workers) for possible Federal Indicators (FI) for six out of nine new employees. This practice had the potential to affect all residents, employees and visitors to the facility. The facility census was 66 residents. Record review of the facility's undated Policy on Employee Disqualification List (EDL) and Criminal Background Check (CBC) for Employees showed: -All CBC and EDL shall be completed no longer that five days prior to the first employment day. -EDL check, criminal background check, license or certification verification for hired staff on any restrictions for practice must be complete prior to hiring. -All registry information shall be mailed to the Family Care Safety Registry (FCSR) within 15 days of hire. -Keep track of mailing record by the log. -Verify the license. -All department heads were responsible to complete the employee file upon hiring. -Procedure: --Review applications. --Perform EDL and CBC. --Perform licensure/certification verification. 1. Record review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A was hired on 5/31/22. --He/she did not have a Nurse Aide (NA) Registry completed. -Employee B was hired on 4/1/22. --He/she did not have a Nurse Aide (NA) Registry completed. -Employee C was hired on 5/30/22. --He/she did not have a Nurse Aide (NA) Registry completed. -Employee D was hired on 3/23/22. --He/she did not have a Nurse Aide (NA) Registry completed. -Employee E was hired on 3/15/22. --He/she did not have a Nurse Aide (NA) Registry completed. -Employee H was hired on 9/15/21. --He/she did not have a Nurse Aide (NA) Registry completed. During an interview on 6 /8/22 at 2:31 P.M., the Social Services Designee (SSD) said: -He/she was responsible for completing background checks on new employees. -Only Certified Nurse Assistants (CNA) and Certified Medication Technicians (CMT) had to have Nurse Aide registries completed. -He/she was unaware that Nurse Aide Registries had to be run on all staff. During an interview on 6 /8/22 at 3:20 P.M., the Administrator said he/she was unaware Nurse Aide registries had to be completed on all staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to reassess the effectiveness of interventions, review and revise the resident's care plan with input from the resident or resident representative for three sampled residents (Resident's #45, #2, and #13) out of 17 sampled residents. The facility census was 66 residents. 1. Record review of Resident #45's face sheet, dated 9/13/21, showed: -The resident was admitted to the facility on [DATE]. -The resident had a legal Guardian. -The resident's diagnoses included schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others) and intellectual disabilities (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). Record review of the resident's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 4/16/22, showed: -The resident scored a 15 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions). --This showed that the resident had no cognitive impairment. Record review of the resident's undated care plan showed no dates as to when goals were set, achieved or reviewed. During an interview on 6/1/22 at 9:05 A.M., the resident said: -He/she used to be invited to care plan meetings before Covid-19 (a new disease caused by a novel (new) coronavirus). -He/she had not been to a care plan meeting in a long time. -He/she was unaware of any care planning done by the staff on his/her behalf. During an interview on 6/8/22 at 8:05 A.M., the resident said: -He/she was unaware of care plan meetings being notified over the intercom. -He/she said the intercom didn't always work in his/her room. 2. Record review of Resident #2's face sheet, dated 10/4/19, showed: -The resident was admitted to the facility on [DATE]. -The resident did not have a legal Guardian. -The resident's diagnoses included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) and major depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable). Record review of the resident's care plan, revised on 5/28/21, showed: -The resident had nine focus areas revised on 5/28/21. -No further updated entries noted. Record review of the resident's undated Social Service Progress Note showed: -The resident's care plan meeting was done today (unknown what date it was done as the note was not dated). -No complaints or concerns since last care plan meeting. -Continued to enjoy reading his/her books. -No behaviors. -No changes. Record review of the resident's quarterly MDS dated [DATE], showed: -The resident scored a 15 on the BIMS. --This showed that the resident had no cognitive impairment. Record review of the resident's Social Service Progress Notes, dated 5/18/22 showed: -The resident's care plan meeting was today. -No complaints or concerns at this time. -Continued to enjoy reading his/her books and smoking his/her pipe. -No eye, dental, or podiatrist needs at this time. During an interview on 6/1/22 at 2:57 P.M., the resident said: -He/she did not have a care plan. -He/she was unaware of any care plan process. -He/she had not been notified of the care plan process. During an interview on 6/8/22 at 9:25 A.M., the resident's Guardian said: -The last time he/she was notified of a care plan meeting was 8/13/21. -He/she had not been contacted by facility staff for a care plan meeting since that time. -He/she had his/her own goals for the resident and met with him/her regularly. 3. During an interview on 6/3/22 10:45 A.M., the Social Services Designee (SSD), said: -He/she started working at facility in 2007 and has been the SSD since 2008. -Care plan meetings were held in the conference room. -Prior to Covid-19 residents were invited to the conference room for their care plan meeting. -Since March of 2020 they had not had formal care plan meetings. -Residents stopped staff with a problem every day and the administrative staff considered that care planning. -He/she changed care plans right there on the spot. -The facility stopped individual care planning in March 2020. -He/she never sent out care plan notification letters to guardians or family representatives. -He/she called family members and guardians and asked if they had concerns, then used that information to update care plan. -Residents were paged over the intercom when care plans were updated. 4. Record review of Resident #13's face sheet showed he/she moved into the facility on 2/14/20 and it did not include any designated persons responsible for the resident. Record review of the resident's annual MDS dated [DATE] showed the following staff assessment of the resident: -Was cognitively intact. -Was independent with most ADLs. Record review of the resident's care plan dated as reviewed on 3/30/22 showed no dates as to when goals were set and achieved. During an interview on 6/2/22 at 10:23 A.M., the resident said they don't have care plan meetings that he/she knows about. 5. During an interview on 6/8/22 at 1:32 P.M., the MDS Coordinator said: -He/she, the Administrator, the dietary supervisor and the SSD all got together and did care plans every week on Wednesday's at 10:00 A.M. -Residents were allowed to attend. -Residents were notified over the intercom system. -During Covid-19 things were different. -He/she went to nursing staff and asked if any residents had any issues, concerns or problems. -He/she would also ask residents. -He/she and the administrative staff were getting back to scheduled care plan meetings. -The SSD contacted guardians for input. -There was no documentation of who attended the meetings or what was discussed. -Care plan notification letters were not completed and were not sent to resident families or representatives. -Haven't done notification letters since before Covid-19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #64's face sheet showed he/she was re-admitted to the facility on [DATE] with the following diagnosis Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block air flow and makes it difficult to breathe). Record review of the resident's quarterly MDS dated [DATE] showed: -The resident's Brief Interview for Mental Status(BIMS) score was 15 - cognitively intact. -The resident had pulmonary issues such as COPD or Asthma (a condition in which a person's airway becomes inflamed, narrow and swollen which produced extra mucous making it difficult to breathe). Observation on 6/3/22 at 7:36 A.M. showed: -Certified Medication Technician (CMT) C handed the resident an inhaler and the resident used that inhaler. -The resident had a different inhaler (ProAir - a medication used to treat wheezing and shortness of air) at his/her bedside which he/she picked up and administered to himself/herself. -The resident put the inhaler back on his/her bedside traytable. -CMT C did not ask about or removed the ProAir inhaler from the resident's room. Record review of the resident's MAR dated June 2022 showed: -The resident had a physician's order for ProAir one puff every six hours as needed. -The resident did not have a physician's order allowing the resident to keep the medication at his/her bedside. -The resident did not have a physician's order allowing the resident to self administer the ProAir inhaler as needed. During an interview on 6/3/22 at 8:05 A.M. CMT A said: -There was not an order on the June MAR for the resident to keep the ProAir inhaler at his/her bedside. -There was not an order on the June MAR allowing the resident to self administer the ProAir inhaler when needed. -There used to be an order that said the resident could keep the inhaler at bedside and self administer as needed. -He/she was not able to find the order in the resident's chart enabling the resident to keep the medication at bedside or to self administer the medication. -It must have dropped off of the POS from a previous month. -The resident should have had an order on the current POS and MAR. -He/she did not know who was responsible for ensuring the orders were correctly moved from one month to the next. During an interview on 6/3/22 at 8:15 A.M. Licensed Practical Nurse (LPN) B said: -There was not an order on the June MAR for the resident to keep the ProAir inhaler at his/her bedside. -There was not an order on the June MAR allowing the resident to self administer the ProAir inhaler when needed. -There used to be an order that said the resident could keep the inhaler at bedside and self administer as needed. -He/she was not able to find the order in the resident's chart enabling the resident to keep the medication at bedside or to self administer the medication. -It must have dropped off of the POS from a previous month. -The resident should have had an order on the current POS and MAR. -The Charge Nurse was responsible for ensuring the orders were correctly moved from one month to the next. During an interview on 6/8/22 at 1:30 P.M. the MDS Coordinator said: -The DON was on vacation so he/she would be answering the DON questions. -There should have been an order for the resident to keep an inhaler at his/her bedside and to self administer the medication as needed. -The DON was responsible for ensuring the orders were forwarded from month to month on the MAR. Based on observation, interview and record review, the facility failed to ensure each resident's medications had a documented diagnosis or symptom on the Physician's Order Sheet (POS) for each medication for two sampled residents (Resident's #58 and #13) and to ensure one sampled resident (Resident #64) had an order to keep his/her inhaler at his/her bedside and self administer the inhaler out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's policy for physician order showed: -A licensed nurse was responsible for reviewing the last month's POS, Medication Administration Records (MARs), Treatment Administration Records (TARs), physician telephone orders, etc. to the new month's documents for accuracy). -The policy did not include a requirement of having an appropriate diagnosis for each prescribed medication. 1. Record review of Resident #58's face sheet showed he/she moved into the facility on [DATE]. Record review of the resident's June 2022 POS showed there was no diagnosis in the physician's order or in the diagnosis box on the bottom of POS for: -Requip (used to treat Parkinson's (a chronic nervous disease characterized by a fine slowly spreading tremor, muscle weakness, muscle stiffness and a peculiar gait) and restless leg syndrome (a condition that causes an intense urge to move the legs and can cause uncomfortable feelings in the legs, typically in the evening or at night while sitting or lying down). -Trazodone (an antidepressant medicine that works to balance chemicals in the brain. It's used to treat depression and/or anxiety. It can help with low mood, poor sleep and poor concentration). -Astelin (used for seasonal allergies). -Hydroxyzine (can treat anxiety, nausea, vomiting, allergies, skin rash, hives, and itching). During an interview on 6/8/22 at 8:32 A.M., the Minimum Data Set (MDS) Coordinator said: -The nurses usually did the monthly change over. -The Director of Nursing (DON) was supposed to start doing the monthly change over. -When they do the monthly change over, they should be identifying any medications without diagnosis. 2. Record review of Resident #13's face showed he/she moved into the facility on 2/14/20. Record review of the resident's June POS showed no diagnosis in the physician's order or in the diagnosis box on the bottom of the POS for Levothyroxine (used to treat an underactive thyroid gland which can improve symptoms of thyroid deficiency such as slow speech, lack of energy, weight gain, hair loss, dry skin and feeling cold). During an interview on 6/8/22 at 8:32 A.M., the MDS Coordinator said: -The nurses usually did the monthly change over (reviewing the last month's POS, MARs, TARs, physician telephone orders, etc. to the new month's documents for accuracy). -The DON was supposed to start doing the monthly change over. -When they do the monthly change over, they should be identifying any medications without diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #45's face sheet, dated 9/13/21, showed: -The resident was admitted to the facility on [DATE]. -The resident had a legal Guardian. -The resident's diagnoses included schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others) and intellectual disabilities (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). Record review of the resident's Annual MDS dated [DATE], showed: -It was somewhat important to the resident to have group activities. -It was somewhat important to participate in favorite activities. Record review of the resident's quarterly MDS dated [DATE], showed: -The resident scored a 15 on the Brief Interview for Mental Status (BIMS), an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions). --This showed that the resident had no cognitive impairment. Record review of the resident's undated care plan showed: -No dates as to when goals were set, achieved or reviewed. -No focused activities or goals were noted on the care plan. During an interview on 6/2/22 at 9:05 A.M., the resident said: -He/she played bingo when offered. -He/she was unsure when the last time bingo was offered. -Before quarantine the facility took residents to the main street library. -This activity had not been offered since quarantine. -Sometimes the facility had movies and popcorn. Observation on 6/1/22 at 2:56 P.M., showed the resident was observed in the court yard moving around, looking like he/she was dancing. During an interview on 6/1/22 at 2:56 P.M. the receptionist said the resident went out there a lot and tried to catch butterflies. Observations conducted while on site 6/1/22 through 6/8/22 showed the resident was not involved in any activities. 5. Record review of Resident #2's face sheet, dated 10/4/19, showed: -The resident was admitted to the facility on [DATE]. -The resident did not have a legal Guardian. -The resident's diagnoses included epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) and major depressive disorder (a mental disorder characterized by a feeling of profound and persistent sadness or despair and is frequently accompanied by a loss of interest in things that were once pleasurable). Record review of the resident's Annual Participation Review (Activities), dated 5/19/21, showed: -The resident participated in activities of his/her choosing. -The resident enjoyed reading, watching TV and socializing with peers. -No changes were noted to activity level or preferences. Record review of the Activity Interview for daily and Activity Preferences, dated 5/19/21, showed it was somewhat important to have books, newspapers and magazines to read. Record review of the resident's care plan, revised on 5/28/21, showed: -The resident had nine focus areas revised on 5/28/21. -No further date entries noted. -The care plan did not address any of the resident's activity preferences. Record review of the resident's Quarterly Participation Review, dated 8/16/21, showed: -The resident participated in activities of his/her choosing. -The resident enjoyed reading, watching TV and socializing with peers. -No changes were noted to activity level or preferences. Record review of the resident's Quarterly Participation Review, dated 11/16/21, showed: -The resident participated in activities of his/her choosing. -The resident enjoyed reading, watching TV and socializing with peers. -No changes were noted to activity level or preferences. Record review of the residents Psychiatric Periodic Evaluation dated 2/7/22, showed to continue offering activities, social events and group initiatives as well as personal one on one time as staffing allows. Record review of the resident's Quarterly Participation Review, dated 2/16/22, showed: -The resident participated in activities of his/her choosing. -The resident enjoyed reading, watching TV and socializing with peers. -No changes were noted to activity level or preferences. Record review of the residents Psychiatric Periodic Evaluation dated 3/9/22, showed to continue offering activities, social events and group initiatives as well as personal one on one time as staffing allows. Record review of the residents Psychiatric Periodic Evaluation dated 4/6/22, showed to continue offering activities, social events and group initiatives as well as personal one on one time as staffing allows. Record review of the resident's annual MDS, dated [DATE], showed: -The resident scored a 15 on the BIMS. --This showed the resident had no cognitive impairment. -It was somewhat important to do things with groups of people. -It was somewhat important to listen to music. Record review of the resident's Social Service Progress Notes, dated 5/18/22 showed: -The resident's care plan meeting was today. -Continued to enjoy reading his/her books and smoking his/her pipe. During an interview on 6/1/22 at 2:57 P.M., the resident said: -He/she wanted to do activities like fishing and go to the library. -He/she wanted more activities to choose from. -He/she had some mobility issues so some activities he/she was unable to do. -He/she wanted to possibly go swimming. -He/she was bored a lot of the time. Observations conducted while on site 6/1/22 through 6/8/22 showed the resident was not involved in any activities. 6. Record review of Resident #34's admission Record showed he/she admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Dementia (a general term for a decline in mental ability resulting in memory loss, and other mental abilities severe enough to interfere with daily functioning) without behavioral disturbance. -Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side. -Alcohol abuse. -Muscle weakness. Record review of resident's Annual MDS dated [DATE] showed: -BIMS score of 3. -Activity preferences showed it was somewhat important to him/her to: --Read books, newspapers, and magazines. --Listen to music. --Be around animals such as pets. --Keep up with the news. --Do things with groups of people. --Do his/her favorite activities (it did not list what favorite activity was) --Go outside to get fresh air when the weather is good. --Participate in religious services or practices. Record review of resident's care plan dated as last reviewed 1/19/22 showed: -Resident had little or no activity involvement related to his low cognitive and physical disabilities. -Goal: --Will develop steady activity level next 3 months -Interventions: --Encourage to participate in all activities. --Invite to all scheduled activities. --Provide items for favorite activity. Record review of resident's Quarterly MDS dated [DATE] showed: -BIMS score of 3. -Cognition severely impaired. Observation on 6/1/22 at 10:00 A.M., showed the resident sleeping in a Broda chair in the hall near the nurses' station. Observation on 6/1/22 at 2:34 P.M., showed the resident was in his/her bed asleep. Observation on 6/6/22 at 9:59 A.M., showed the resident was in a Broda chair in the hall near the nurses' station, holding the strap of the lift sling that was in the chair. During an interview on 6/6/22 at 10:00 A.M. the resident said: -He/she did not like sitting in the chair in the hall. -He/she would like to watch TV -There were no activities to do. 7. Record review of Resident #56's admission Record showed he/she admitted on [DATE] with the following diagnoses: -Dysphagia (inability or difficulty swallowing). -Hearing loss, right ear. -Hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following Cerebrovascular Disease (CVA-stroke) affecting the left dominant side. -Major Depressive Disorder -Epileptic Seizures (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain), related to external causes, not intractable (not easily managed or relieved), without status epilepticus (a seizure lasting longer than five minutes). Record review of resident's admission MDS dated [DATE] showed: -BIMS score of 13 and cognition intact. -Activity preference showed it was somewhat important to him/her to: --Read books, newspapers, and magazines. --Listen to music. --Be around animals such as pets. --Keep up with the news. --Do things with groups of people. --Do his/her favorite activities (it did not list what favorite activity was) --Go outside to get fresh air when the weather is good. --Participate in religious services or practices. Record review of resident's care plan dated last reviewed 1/31/22 showed: -Limited physical mobility related to CVA with left side hemiparesis. -Interventions: --Activities, Invite resident to activity programs that encourage: --Physical activity. --physical mobility, such as exercise group, walking activities to promote mobility. --Provide gentle range of motion as tolerated with daily care. -Smoker. Record review of resident's Quarterly MDS dated [DATE] showed his/her BIMS score of 13 and cognition intact. During an interview on 6/1/22 at 2:51 P.M. the resident said: -He/she doesn't think there are any activities. -He/she goes to smoke and visits with other residents. During an interview on 6/6/22 at 12:27 P.M. the resident said: -Doesn't know if he/she would go to activities now if they have them. -Visits with others when smoking. -Watches TV. 8. Record review of Resident #60's admission Record showed he/she admitted on [DATE] with the following diagnoses: -Dementia without behavioral disturbance. -Intracranial (within the skull) injury without loss of consciousness, initial encounter. -Epilepsy, unspecified, not intractable, with status epilepticus. Record review of resident's Annual MDS dated [DATE] showed: -BIMS score of 3. -Cognition severely impaired. -Activity preferences showed it was somewhat important to him/her to: --Read books, newspapers, and magazines. --Listen to music. --Be around animals such as pets. --Keep up with the news. --Do things with groups of people. --Do his/her favorite activities (it did not list what favorite activity was) --Go outside to get fresh air when the weather is good. --Participate in religious services or practices. Record review of resident's Quarterly MDS dated [DATE] showed: -BIMS score of 3. -Cognition severely impaired. Record review of the resident's care plan dated last reviewed 5/11/22 showed: -Impaired social interaction related to use of profanity when conversing. -Goal: --Will interact with other residents, staff or visitors as evidenced by participating in activities of his/her choosing. -Interventions: --Encourage attendance and participation in interaction groups. --Involve in individual planned activity. --Plan for specific periods of planned diverse activity. Observation on 6/2/22 at 9:42 A.M., showed the resident was wandering around facility and would sit in the dining room and/or the hall. Observations during the survey from 6/1/22 through 6/6/22 showed: -The resident wandered in the halls to the nursing stations, a chair in the North hall way, the dining room and to his/her room. -Staff would acknowledge the resident as he/she passed by. -He/she did not have one on one activities with any staff. 9. Record review of Resident #65's admission Record showed he/she admitted on [DATE] with the following diagnoses: -Hemiplegia and Hemiparesis following cerebral infarction affecting unspecified side. -Epilepsy, unspecified, not intractable, without status epilepticus. -Major Depressive Disorder. Record review of resident's Annual MDS dated [DATE] showed: -BIMS score of 15 and cognition intact. -Activity preferences showed it was somewhat important to him/her to: --Read books, newspapers, and magazines. --Listen to music. --Be around animals such as pets. --Keep up with the news. --Do things with groups of people. --Do his/her favorite activities (it did not list what favorite activity was) --Go outside to get fresh air when the weather is good. --Participate in religious services or practices. Record review of the resident's Quarterly Activities participation Review dated 8/12/21 at 12:46 A.M. showed: -Resident's attendance preferences and participation level with activities: --Resident attends and participates in activities of his/her liking . --Resident enjoyed watching movies, listening to music, socializing with peers, and smoking his/her cigarettes. -Resident's activity-related focus(s) including needs, strengths and preferences: --Activity-related focuses remain appropriate/current as per current care plan. -Progress toward resident's activity goals: --Goals were met. -Activity-related interdisciplinary interventions/approaches: --Interventions/approaches have been effective in reaching goals. Record review of the resident's Quarterly Activities participation Review dated 11/16/21 at 9:36 A.M. showed: -Resident's attendance preferences and participation level with activities: --Resident attends and participates in activities of his/her liking. -Describe resident's favorite activities: --Resident enjoyed watching movies, listening to music, socializing with peers, listening to audible books and smoking his/her cigarettes. -Resident's activity-related focus(s) including needs, strengths and preferences: --Activity-related focuses remain appropriate/current as per current care plan. Record review of the resident's Quarterly Activities participation Review dated 2/16/22 at 3:24 P.M. showed: -Resident's attendance preferences and participation level with activities: --Resident attends and participates in activities of his/her liking. -Describe resident's favorite activities: --Resident enjoys socializing with peers and smoking his/her cigarettes. -Resident's activity-related focus(s) including needs, strengths and preferences: --Activity-related focuses remain appropriate/current as per current care plan. -Progress toward resident's activity goals: --Goals were met. -Activity-related interdisciplinary interventions/approaches: --Interventions/approaches have been effective in reaching goals. Record Review of the resident's care plan dated last reviewed 3/30/22 showed: -The resident had a high social and activity level. --Goal: ---Resident will maintain a high activity level during the next 3 months. --Interventions: ---All staff to converse with resident while providing care. ---Assist with planned activities. ---Invite the resident to scheduled activities ---Provide resident with activity supplies as needed. ---Thank resident for attendance at activity function. -The resident smoked. Record review of resident's Quarterly MDS dated [DATE] showed a BIMS score of 15 and cognition intact. During an interview on 6/1/22 at 2:00 P.M. the resident said: -There were no activities since COVID. -There used to be bingo. -He/She liked going to bingo. During an interview on 6/6/22 at 9:39 A.M., as the resident was coming out of the smoking room he/she said he/she: -Watched TV in the mornings. -Smoked several times during the day and visited with other residents there. -Visited other residents during the day. -Took a nap after lunch. -Smoked and watched TV in the afternoon. -Would like to play bingo. 10. Observations throughout the survey conducted from 6/1/22 to 6/8/22 showed: -No activities lead by staff. -No residents were engaged in group activities. -Televisions were on with no residents gathered around watching movies. No popcorn was served while the TV was on. -Residents were observed doing individual activities on their own such as watching TV in their room, reading in their room, etc. Observation on 6/3/22 at 7:59 A.M. showed: -A bulletin board was posted across from the south nurse's station. -No activities calendar displayed. 11. During an interview on 6/1/22 at 9:00 A.M., the Administrator said: -They have not had anyone working in the Activity Department since COVID-19 started (March 2020). -They were just now getting the Activity Department up and running again. -The Activity Assistant started working there yesterday (5/31/22). During an interview on 6/2/22 at 2:30 P.M., Licensed Practical Nurse (LPN) A said: -He/she came in once or twice a month on his/her day off and played music for the residents. -He/she did not have a lot of extra time to do activities but he/she does what he/she can when he/she can. -There has not been an Activities Coordinator at the facility for a long time. During an interview on 6/3/22 8:22 A.M., Certified Medication Technician (CMT) A said: -There was no activities calendar. -There was no activities person since March 2020. -They just hired a person for activities. -The nurses and aides have been doing activities as time allowed. During an interview on 6/3/22 at 10:45 A.M., the Social Services Designee (SSD) said: -There was an activity room in the basement. -The basement floor was being redone and residents were not having activities down there at the time being. -Residents did puzzles downstairs. -The facility hired a new activity director this week. -They facility was without an activities director or assistant since March 2020. During an interview on 6/6/22 at 9:44 A.M., the SSD said: -They just got a new activity staff member. -He/she didn't know how long it had been since they had an activities staff member. -The nurse sometimes helped do bingo with the residents, chair exercises and movies with popcorn. During an interview on 6/6/22 at 11:09 A.M., the Activities Aide said: -He/she started working there last week. -He/She would plan group activities and one-on-one activities. -He/She had been meeting with residents doing activities assessments. During an interview on 6/8/22 at 8:10 A.M., LPN A said: -Sometimes they did bingo or turned music on, sat and talked, did stretches or music. -They played music for the residents once or twice a week even if it was just turning music on during a meal. During an interview on 6/8/22 at 8:23 A.M., CMT B said: -He/she tried to do bingo a couple times a month. -He/she had gotten a birthday cake and played music for the residents. -LPN A did exercises with the residents sometimes. -They have not had activities or activities staff since COVID-19 started (March 2020). -The activity department had been shut down because of COVID-19. During an interview on 6/8/22 at 8:32 A.M., the MDS Coordinator said: -He/she, the Social Services Designee and the Administrator have been developing the activities care plans with input from a CMT or a nurse. -If they don't trigger for activities from the MDS, they generally don't do an activity care plan. -If activities was a problem for a resident, they would do a care plan. -They lost their activity coordinator during COVID-19. During an interview on 6/8/22 at 1:32 P.M., the MDS Coordinator said: -They have had some activities since COVID-19. -LPN A and CMT B did bingo. -He/she didn't know how often they did bingo. -He/she talked and visited with the residents. -He/she took residents up to the nurse's station. -The residents watched football games together. -LPN A would take some of the residents in for relaxation exercises at least once a week. -LPN A came in on his/her days off and did activities with the residents. During an interview on 6/8/22 at 2:31 P.M. the SSD said: -Announcements were made over the intercom system for resident activities. -Being able to hear the intercom varied from room to room. -LPN A and CMT B did bingo, chair exercises and movies and popcorn. -LPN A and CMT B conducted activities as they had time. -LPN A and CMT B also did birthday parties at the end of the month. -CMT B did birthdays a couple of times. Based on observation, interview and record review, the facility failed to provide an ongoing activity program based on a comprehensive assessment and care plan of each resident's interests for nine sampled residents (Resident's #13 #58, #41, #45, #2, #34, #56, #60, and #65) out of 17 sampled residents. The facility census was 66 residents. Record review of the facility's Activity Policy dated 2000 showed: -Activities were any activity other than Activities of Daily Living (ADLs-dressing, grooming, bathing, eating, and toileting) that a resident pursued in order to enhance a sense of well-being. -The activity program should be revised, reviewed often and tailored to each resident's individual needs. -Activities provide increased self-esteem, pleasure, comfort, education, creativity, success and financial or emotional independence. -Activities can provide stimulation or solace. -Activities can provide spiritual well-being. -Activities promote physical, cognitive and/or emotional health. -Activities enhance physical and emotional status. -All residents should be included in some form of activity. -Examples of services provided include birthday parties, holiday celebrations, games, exercise fun, religious services, arts and crafts, beauty program, movie/theater, getting together group, and one-on-one visits. -The admission activity assessment should identify choices, preferences and life style of each resident. -Progress notes should be written quarterly, with a significant change, reflect how the resident spends the day, reflect the implementation of the activity care plan and monitor the residents' involvement with and response to the care plan. -The activity assessment should identify residents who attend activities independently, have their own interests they pursue, need gender specific activities, always refuse, have special physical or cognitive needs and those who require one-on-one programming. Record review of Centers for Medicare and Medicaid Services (CMS) guidance for activities showed: -August 31, 2020: --Phase 1: Restrict group activities, but some activities may be conducted (for COVID-19 (a new disease caused by a novel (new) coronavirus that emerged in December 2019, led to severe social restrictions beginning in March 2020 and led to a pandemic) negative or asymptomatic residents only) with social distancing, hand hygiene, and use of a cloth face covering or facemask. --Phase 2: Group activities, including outings, limited (for asymptomatic or COVID-19 negative residents only) with no more than 10 people and social distancing among residents, appropriate hand hygiene, and use of a cloth face covering or facemask. --Phase 3: Group activities. including outings, allowed (for asymptomatic or COVID-19 negative residents only) with no more than the number of people where social distancing among residents can be maintained, appropriate hand hygiene, and use of a cloth face covering or facemask. -September 17, 2020 (Quality Safety & Oversight (QSO) memoranda 20-39 NH): Communal Activities and Dining: While adhering to the core principles of COVID-19 infection prevention, communal activities may occur. Facilities should consider additional limitations based on status of COVID-19 infections in the facility. Additionally, group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, or with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering. Facilities may be able to offer a variety of activities while also taking necessary precautions. For example, book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. -March 24, 2021: Communal Dining and Group Activities: Group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, or with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering (except while eating). -April 27, 2021 (QSO 20-39 revised): Communal Activities and Dining: While adhering to the core principles of COVID-19 infection prevention, communal activities may occur. Book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. The Centers for Disease Control and Prevention (CDC) has provided additional guidance on activities and dining based on resident vaccination status. For example, residents who are fully vaccinated may participate in activities without face coverings or social distancing if all participating residents are fully vaccinated; if unvaccinated residents are present during communal dining or activities, then all residents should use face coverings when not eating and unvaccinated residents should physically distance from others. -November 12, 2021 (QSO 20-39 revised): Communal Activities, Dining and Resident Outings: While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. Book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. The safest approach is for everyone, regardless of vaccination status, to wear a face covering or mask while in communal areas of the facility. -March 10, 2022 and still current (QSO 20-39 revised): Communal Activities, Dining and Resident Outings: While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur. Book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission. The safest approach is for everyone, regardless of vaccination status, to wear a face covering or mask while on in communal areas of the facility. 1. Record review of Resident #13's face sheet showed he/she moved into the facility on 2/14/20 and some of his/her diagnoses included: -Osteoarthritis (a degenerative disease of the bones and joints). -Depression (a mood disorder that consists of intense sadness and a loss of interest or loss of pleasure in activities and/or life). Record review of the resident's undated activity evaluation showed the resident's current interests included cards, games, crafts/arts/hobbies, music, outdoors, TV/radio, movies, talking, parties/socials, news, community outings and groups/organizations (no details were documented as to what kind of cards, music, etc.). Record review of the resident's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff and used for care planning) dated 2/28/22 showed the following staff assessment of the resident: -Reading, listening to music, being around pets, keeping up with the news, group activities, doing his/her favorite activities, being outside and religious activities were all somewhat important to the resident. -Was cognitively intact. -Was independent with all ADLs except required supervision and/or set-up assistance for eating and bathing. -Did not use a mobility device. -Had a diagnosis of depression. Record review of the resident's activities annual participation review dated 3/2/22 showed: -He/she participated in activities of his/her choosing with peers. -He/she enjoyed playing cards, reading books and socializing with peers. -His/her activity-related focuses remained appropriate/current as per current care plan. -The resident's goals were met. -The activity interventions were effective. Record review of the resident's care plan revised 3/30/22 showed nothing regarding activities was included in the care plan. Observation on 6/1/22 at 10:10 A.M., showed the resident lying in bed. During an interview on 6/2/22 at 9:14 A.M., the resident said: -They do almost nothing for activities. -Once in a while they have bingo. -They can get books from the library. -He/she watched TV in his/her room. -The only excitement around the facility was when another resident acted out. Observation on 6/2/22 at 3:30 P.M. showed: -The resident was lying in bed, covered with multiple blankets and said it was too cold (the thermostat read 72 degrees Fahrenheit in the room) to do anything. -The resident was reading on a kindle and his/her TV was on in his/her room as well. Observation on 6/3/22 at 6:11 A.M. showed the resident was asleep in bed. During an interview on 6/6/22 at 9:38 A.M., Nursing Assistant (NA) A said the resident read books. During an interview on 6/6/22 at 9:44 A.M., the Social Services Designee said the resident reads and sits out on the courtyard when he/she smokes. Observation on 6/7/22 at 9:33 A.M. showed the resident was asleep in bed. During an interview on 6/7/22 at 10:12 A.M., the resident said: -He/she missed bingo the most. -The last time they played bingo was on Mother's day (5/8/22) weekend. -They have not done activities that he/she enjoyed since then. -The facility staff mostly just played movies for them. -The new activity staff member had not come to resident to assess his/her activity interests. During an interview on 6/8/22 at 8:32 A.M., the MDS Coordinator said the resident sat in his/her room a lot and watched TV, went out to smoke and liked to talk with others. 2. Record review of Resident #58's face sheet showed he/she moved into the facility on [DATE] and some of his/her diagnoses included heart failure and major depressive disorder. Record review of the resident's undated activity evaluation showed the resident's current interests included cards, games, arts and crafts, exercise, sports, music, reading, writing, baking/cooking, religious, trips/shopping, outdoors, TV, radio, movies, gardening, plants, talking, volunteer, parties, social events and keeping up with the news (no details were documented as to what kind of cards, music, etc.). Record review of the resident's annual MDS dated [DATE] showed reading, listening to music, being around pets, keeping up with the news, group activities, doing his/her favorite activities, being outside and religious activities were all somewhat important to the resident. Record review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Was cognitively intact. -Was independent with all ADLs except required supervision and/or set-up assistance for eating, hygiene and bathing. -Did not use a mobility device. -Some of his/her diagnoses included heart failure, depression a

Based on observation, interview and record review, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors of the daily resident census, or the number of nursing staff for each shift. This practice had the potential to affect residents and visitors who were inquiring about the facility staffing hours. The facility census was 66 residents. A copy of the facility staffing policy was requested. The facility provided a copy of the Facility Assessment only. Record review of the Facility assessment dated 2022 showed: -The Facility Wide Assessment helps to make decisions about the facility's capacity and needs to provide services to residents. -Resources to provide care included staffing plan and staff types. -The Assessment did not include any information on posting of staffing on a daily basis with the resident census or the number of nursing staff for each shift. 1. Observations from 6/1/22 to 6/8/22 showed: -No nursing staffing sheet posted at main reception desk. -No nursing staffing sheet posted at the main dining room. -No nursing staffing sheet posted at nurses station on North Hall. -No nursing staffing sheet posted at nurses station on South Hall. -There was a monthly nursing staff schedule at both the North and South hall nursing stations. During an interview on 6/8/22 at 9:05 A.M., Licensed Practical Nurse (LPN) A said the only staffing schedule he/she is aware of was the monthly schedule at both nurses' stations. During an interview on 6/8/22 at 1:32 P.M., Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) Coordinator filling in for the Director of nursing (DON) said: -The monthly nursing staff schedule was at each nursing station. -They did not have a daily staffing sheet showing the resident census and the number of nursing staff for each shift posted in prominent places in the facility for residents and visitors to see.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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, resulting in an error in the count for one resident (Resident #53). The facility census was 66 residents. Record review of the facility Policy for Management of Schedule II medication (medications with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) dated 2010 showed: -All controlled medications shall be checked and counted each shift by two licensed nurses. -The counting record shall be kept separately from other medication records. -The licensed nurse will count the medications with the on-coming shift licensed nurse and document on the provided sheet with both licensed signatures. -A missing or discrepancy in counting shall be notified immediately to the Director of Nursing (DON) or the Administrator. -The DON and the Administrator shall initiate the investigation immediately. -Upon investigation, any serious violation (stealing) against the Missouri State board of Nursing and/or regulatory requirements shall be reported to the appropriate agency. -Errors in documentation shall be investigated by the DON and Administrator -The DON or designated licensed staff shall perform weekly checking and audit the controlled medications cart and records. 1a. Record review of Resident #53's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Osteoarthritis (inflammation of the bone with progressive cartilage deterioration). -Migraine (a recurrent throbbing headache that typically affects one side of the head and is often accompanied by nausea and disturbed vision), unspecified, not intractable (typically lasts up to 72 hours and can be treated with migraine medications), without status migrainosus (a type of migraine that is considered dangerous and requires emergency medical care). Record review of the resident's Physician's Order Sheet (POS) dated 6/1/22 to 6/30/22 showed: -Tramadol HCl(Ultram- a controlled opioid used to treat moderate to severe pain in adults) 50 milligram (mg) tablet. Take one tablet by mouth (PO) every six hours as needed (PRN) for pain. --Ordered 11/30/21. Record review of the resident's Shift Change controlled Substance Check Sheet for Tramadol showed: -On 6/3/22 at 5:00 A.M., 32 tablets of Tramadol HCL 50 mg were remaining. -Licensed Practical Nurse (LPN) D (the night shift charge nurse) pre signed the off going nurse 7:00 A.M., spot without completing the shift change narcotic count with the oncoming nurse. Record review of the resident's Controlled Drug Record for Tramadol HCL 50 mg tablet showed: -90 tablets were received on 5/10/22 with the order to take one tablet PO every six hours PRN for pain. The resident received the following: -On 6/3/22 at 5:00 A.M. --One tablet was given with a remaining count of 32 tablets. -On 6/3/22 at 8:05 A.M. --Two day shift nurses doing the South Side Narcotic medication count. ---There were 31 tablets of Tramadol HCL 50 mg tablets remaining. ---There was one tablet of Tramadol HCL 50 mg tablets missing. -At 8:06 A.M. The DON was notified of the missing Tramadol HCl 50 mg tablet. -At 8:10 A.M. The DON and the two licensed nurses recounted the residents Tramadol HCl 50 mg tablets. --There was one tablet of Tramadol HCL 50 mg missing. During an interview on 6/3/22 at 8:10 A.M., the DON said he/she would check with the night shift nurse to see if he/she gave the medication and did not chart it. During an interview on 6/3/22 at 10:58 A.M., LPN B said: -He/she floated between the North and South sides. -He/she signed the narcotic count sheet after counting the medications. -Nurses should not sign the narcotic count sheet ahead of time before doing the count. -When a nurse signed the narcotic count sheet it was verification that the count was correct. -If the count was off both the oncoming and off going nurses recounted to see if someone miscounted. -If the count was off one of the nurses would call the DON to notify him/her, and the DON would take care of the situation. -There was usually two night nurses working one each side of facility. -Each shift nurse going off counts with the oncoming nurse and signed the narcotic count sheet as accurate. -Last night there was only one nurse on for the facility. -The off going nurse should have counted both North and South side medication carts for the narcotic count. -The night nurse did not do the narcotic count for the south side with him/her on the morning of 6/3/22. -He/She did the South side narcotic count on the morning of 6/3/22 with the MDS nurse. -Today he/she was the only day shift nurse scheduled, he/she had two Certified Medication Technician (CMT)'s passing non narcotic medications. -He/She passed the narcotic medications, checked resident's blood sugars, and gave insulin injections. -The MDS nurse covered and helped when needed. During an interview on 6/3/22 at 11:33 A.M., the DON said: -He/she had not called the night shift nurse yet. -He/she was training a new employee. -He/she would contact the night shift nurse (LPN D). During an interview on 6/3/22 at 11:45 A.M., the DON said: -He/She had not contacted LPN D about the missing Tramadol. -He/She had been busy training a new employee. -He/She would contact LPN D. -LPN D probably just forgot to sign that he/she gave the Tramadol. During a phone interview on 6/3/22 at 11:33 P.M., LPN D said: -He/she was not sure if he/she worked on 6/2/22 to 6/3/22 11:00 P.M. to 7:00 A.M., night shift. -He/She would have to look at the schedule. -LPN D was reminded that he/she spoke with him/her (the surveyor) upon entering the facility at 6:05 A.M., on 6/3/22. -LPN D said yes, he/she did work last night. -He/She was the only nurse and worked both North and South sides of the facility. -He/She was not sure what time he/she left the facility in the morning on 6/3/22. -He/She counted the narcotic medications with the day nurse (LPN E) for both sides of the facility. -LPN D was reminded that two day shift nurses MDS Coordinator and LPN B did the South side narcotic medication count since he/she had left the facility. -He/She does the narcotic medication count when he/she comes on to the night shift with the off going nurse and signs the narcotic count sheet in the oncoming spot. -He/She does the narcotic medication count when going off shift with the day nurse and signs the narcotic count sheet in the off going spot. -He/she is supposed to do the narcotic medication count with both the North and South side on coming nurses before leaving the building when he/she was the only nurse. -When he/she was the only nurse working he/she would sometimes sign the oncoming spot on the narcotic count sheet and the off going spot at the same time. -He/She was not sure if he/she signed the off going 7:00 A.M., spot for 6/3/22 when he/she came on at 11:00 P.M., on 6/2/22 night shift. -There were two residents on the South side of the facility that got upset if they did not get Tramadol first thing in the morning. --NOTE: Resident #53 was one of those residents. -He/she did give those two residents Tramadol on 6/3/22 at 5:00 A.M. -He/she was not sure if he/she signed off on both resident's Tramadol for 5:00 A.M., on 6/3/22, it was very busy being the only nurse. -He/She knows he/she signed off resident #53's Tramadol for 5:00 A.M., on 6/3/22. -He/She said the Tramadol count was correct when he/she signed on shift on 6/2/22 at 11:00 P.M. -It was his/her mistake for signing the narcotic count off going spot for 7:00 A.M., on 6/3/22 when he/she came on shift at 11:00 P.M. on 6/2/22. -It was his/her mistake for not counting with the oncoming day nurse for the South side on 6/3/22. -He/She counted twice with the oncoming day nurse (LPN E) on the North side and a surveyor was watching the count. -He/She was not aware that the Tramadol narcotic count was off for any residents on the South side on the morning of 6/3/22. -He/She did not know why there was missing Tramadol for any resident on the South side. -He/She did not take pain medications due to being allergic to them. -If the narcotic count sheet was off during the count he/she would notify the DON. -The DON has not contacted him/her about any missing medication or the narcotic count being incorrect. 1b. Record review of the resident's Shift Change Controlled Substance Check Sheet for Tramadol HCL with a starting date of 5/26/22 and an ending date of 6/3/22 showed: -5/26/22 3:00 P.M., no oncoming or off going signatures. -5/26/22 11:00 P.M., no off going signature. -5/27/22 3:00 P.M., no oncoming signature. -5/27/22 11:00 PM. no off going signature. -5/28/22 3:00 P.M., no oncoming or off going actual signature just hash marks under names from the previous shift. -5/28/22 11:00 P.M., no oncoming signature. -5/29/22 7:00 A.M., no sign off -5/29/22 3:00 P.M., no on and off actual signatures just hash marks under names from the previous shifts. -5/30/22 3:00 P.M., no oncoming signature. -5/30/22 11:00 P.M., no off going signature. -5/31/22 3:00 P.M., no oncoming or off going signatures. -5/31/22 11:00 P.M., no off going signature. -6/2/22 3:00 P.M., no oncoming signature. -6/2/22 11:00 P.M. no off going signature. -6/3/22 7:00 A.M., no oncoming signature. -6/3/22 7:00 A.M., the off going spot signed prior to the nurse going off shift. During an interview on 6/7/22 at 2:04 P.M., LPN C said: -Not all nurses sign the Shift Change controlled Substance Check Sheet. -The nurses should do the med count and sign the sheet when coming on shift that the count is correct. -The nurses should do the med count and sign the sheet when going off the shift that the count is correct. -If the narcotic medication count is off the two nurses do a recount. -If the narcotic medication count is still off the two nurses notify the DON. -If the error is found the nurse would circle the correct count indicating the count is correct. During an interview on 6/8/22 at 1:32 P.M., the MDS Coordinator who was filling for the DON said: -The shift change controlled substance check sheets were to be signed by two nurses at the beginning and the end of each shift. -The oncoming and the off going nurses' sign the shift change controlled substance check sheets when they do the narcotic medication count or whenever the narcotic lock box keys are exchanged for the shift. -The nurse should not sign the shift change controlled substance check sheet in off going spot at the beginning of his/her shift. -When the nurse signs the oncoming or the off going spots on the shift change controlled substance check sheet he/she was verifying the narcotic medication count was correct. -If the narcotic medication count was off the nurse was to notify the DON and/or the Administrator. -The DON would do a recount of the medication with the two nurses. -If the count was not rectified the DON and the Administrator would start an investigation before the staff leave the building.

Based on observation, interview, and record review, the facility failed to ensure medication refrigerators which held residents' insulin pens and stock vaccines were checked by the nursing staff to ensure the temperature was within range: to ensure the medication refrigerator was clean; to ensure the sink in the medication room was clean; to ensure staff was not pre setting medications prior to medication pass, and to ensure the medication carts were kept locked when staff were not actively working with the mediation cart and did not have direct eyesight of the cart. The facility census was 66 residents. Record review of facility's policy Medication Storage, Handling and labeling Daily Practice Standards dated 3/13 showed: -The medication room was to have been kept clean. -The medication refrigerator temperature was to register between 36 degrees Fahrenheit (F) to 46 degrees F and was to be noted daily on the Refrigerator temperature daily log. -The medication and treatment carts were to be locked when not in use. Record review of a notice to all Nurses and Certified Medication Technicians (CMT's) dated 4/3/13 showed: -The medication refrigerator was to be clean, organized, and free of soiling or spills. -The refrigerator temperature should have registered between 36 to 46 degrees F. -The temperature was to be noted on the Refrigerator Temperature Daily Log. -If the temperature was below 36 degrees or above 46 degrees the medication should be removed from the current refrigerator and moved to the to the opposite Nurse's station refrigerator. -Failure to comply with this policy would result in disciplinary action. -Was signed by the Director of Nursing (DON). Record review of the manufacture's instruction sheet for Lantus Prefilled Pens dated December 2020 showed: -Keep the insulin pen in cool storage 36 degrees to 46 degrees F until first dose. -Do not allow it to freeze. -Do not put it next to the freezer compartment of your refrigerator or next to a freezer pack. Record review of the manufacturer's instruction sheet for Novolog Flexpen dated 3/21 showed: -DO NOT freeze Novolog. -DO NOT use Novolog if it has been frozen. -Until the first use store unused Novolog Flexpen in the refrigerator at 36 degrees to 46 degrees F. The policy for medication administration was not provided. 1. Observation on 6/3/22 at 8:44 A.M. of the Medication room on the north side with Licensed Practical Nurse (LPN) B showed: -There was no sheet that verified the temperature of the medication refrigerator. -There was three inches of ice built up in the freezer. -The temperature was 32 degrees F. -There was a red colored substance on the walls of the refrigerator. -The sink in the medication room had a rust colored stain in it that was approximately four inches long. During an interview on 6/3/22 at 8:50 A.M. LPN B said: -The refrigerator temperature was 32 degrees F. -The refrigerator temperature should be checked on each of the three shifts. -The nurse should have signed it verifying the temperature was within range. -There was no temperature log for the month of June so no one had been doing it. -The temperature range was correct between 32 degrees and 40 degrees. -The third shift was responsible for cleaning out the refrigerator and ensuring it was de-iced. -He/she did not know who was supposed to clean the sink, it was very dirty. -The refrigerator should not have had a red substance on the walls. -There were a lot of medications in the refrigerator. -There was more than three vials of insulin. -There was more than five insulin pens. -He/she did not know what to do about it, maybe someone should clean it up. -The refrigerator temperature was ok at 32 degrees. Observation on 6/3/22 at 11:15 A.M. of the medication refrigerator on the north side showed: -Haloperidol (medication used to treat mental disorders) two mililiters (ml) - two vials. -Lantus (a type of insulin used to treat high blood sugars) 20 ml - two vials. -Latanoprost eye drops (medication used to treat high blood pressure in the eye so a person's eye sight does not get worse) 2.5 ml - three unopened boxes. -Timolol eye drops (medication used to treat high blood pressure in the eye so a person's eye sight does not get worse) five ml - one unopened box. -Bisacodyl (a medication used to treat constipation) 10 mg suppository - one. -Tylenol (mild pain medication) 650 mg suppository - four. -Novolog (a type of insulin) vials - two. -Tuberculin (used to test for Tuberculosis) one ml vial - two, the box said DO NOT FREEZE. -Novolog (Type of insulin) pen 15 ml - five. -Victozapen (type of insulin) pen three ml - two. -Lantus pen 15 ml - one, the package said DO NOT FREEZE. -The temperature was 28 degrees F. Observation on 6/6/22 at 9:27 A.M. of the North side medication room with LPN B showed: -The temperature was 30 degrees. -There was no temperature log. -The sink was still dirty. -There was still three inches of ice build-up in the freezer area. -The same medications were still in the refrigerator. During an interview on 6/6/22 at 9:27 A.M. LPN B said: -The temperature was supposed to be more than 32 degrees. -He/she did not know what to do about the medications. During an interview on 6/6/22 at 9:30 A.M. the Corporate Maintenance Supervisor (CMS) said: -There should have been a log to check the medication refrigerator's temperature. -There was not one there for the month of June 2022. -The nurses were responsible to check the temperature and record it every shift. -The temperature should be between 38 degrees and 41 degrees F. -The temperature was 32 degrees F. Observation on 6/7/22 at 11:29 A.M. with the CMS showed: -He/she put a new temperature log out on top of the North side medication refrigerator. -The medication room on the South side also did not have a temperature log so he/she had put a new one there. -June first through the fifth 2022 did not have any signatures by the nurses indicating they had been checking the temperature of the medication refrigerator. During an interview on 6/7/22 at 11:29 A.M. the CMS said: -The nurses had not been checking the temperature of the medication refrigerators. -The nurses were responsible for checking the temperatures every shift and it should have been charted on the temperature log. -He/she just put a temperature log and thermometer for each refrigerator on both medication refrigerators. -There were two thermometers in the refrigerator the original thermometer read 30 degrees F. -The other one the maintenance supervisor had just put in the medication refrigerator read 40 degrees F. -The ice had not melted in the freezer area nor was there any moisture underneath it. -The medication vials with liquid medication was solid, there was no movement showing they were in liquid form. -He/she thought the new thermometer was correct. 2. Observation and interview on 6/1/22 at 11:00 A.M. of CMT C showed: -He/she was taking medication cups with medications in them out of the drawer of the medication cart. -He/she passed the medications to three different residents. -He/she said he/she would not have done anything differently. Observation on 6/1/22 at 11:39 A.M. of the North CMT medication cart showed: -There were two cups with three pills in each, in a drawer. -There was no name on the cups, they were locked in the cart. During an interview on 6/1/22 at 11:39 A.M. CMT C said: -The cups with the medications were left over from night shift. -They should have been disposed of. -The night shift should not have left the pills. -He/she threw the pills away. Observation on 6/3/22 at 6:00 A.M. showed: -LPN D removed two cups from the drawer of the medication cart that had medication in them. -LPN D place one cup on top of the medication cart. -LPN D took one cup with him/her as he/she walked down the hallway and gave a resident the medication. -LPN D did not lock the medication cart before walking down the hallway. -LPN D left the medication cup on top of the medication cart unattended while taking the medication to a resident. -There was a resident sitting within three feet of the unlocked and unattended medication cart for more than three minutes. During an interview on 6/3/22 at 6:10 A.M. LPN D said: -The medication in the cups was Synthroid (a thyroid medicine that replaces a hormone normally produced by your thyroid gland to regulate the body's energy and metabolism). -He/she pre-set all the resident's Synthroid at the same time. 3. Observation on 6/1/22 at 11:00 A.M. showed: -CMT C had left the medication cart unlocked as he/she walked down to the end of the hall to deliver a medication to a resident. -CMT C left the unlocked cart unattended for more than three minutes. -Two residents passed within two feet of the unlocked, unattended medication cart. Observation on 6/3/2022 at 6:00 A.M. showed: -LPN D left the medication cart open for more than three minutes while delivering medications to a resident. -A resident was sitting within three feet of the unlocked, unattended medication cart. 4. During an interview on 6/7/22 at 10:48 A.M. LPN C said: -No one was assigned to clean the medication room or check the temperatures of the refrigerators. -Anyone could check the temperature of the medication refrigerators. -The temperature should have been charted on the paper. -He/she had not documented temperatures in a while. -He/she did not know what the temperature of the medication refrigerator should be. -He/she did not know who to tell if he/she thought the temperature was out of range. -The medication cart should not be unlocked unless he/she was in front of it. -Medications should not be pre-popped. -Medications should be removed, given and charted one at a time. During an interview on 6/7/22 at 1:30 P.M. the Minimum Data Set (MDS a federally mandated assessment tool completed by facility staff for care planning) Coordinator said: -The DON was on vacation. -The nurses and the CMT's were responsible for checking the temperature of the medication refrigerators. -Temperatures should be checked daily and charted on the sheet on top of the refrigerator. -He/she did not know what the temperature range of the refrigerator was supposed to be. -He/she was not aware the temperature was out of range. -The staff should move the medication to the other refrigerator and find out what the problem was. -It was up to the DON or Maintenance Supervisor to ensure the medication refrigerator was working. -The staff should not pre pop medications. -The staff know better than to leave a medication cart unlocked. 5. Observation on 6/3/22 at 6:09 A.M., of the south side medication cart showed: -The medication cart was at the nurses' station and was unlocked. -Five pre-popped pills were in a medication cup in the top drawer of the unlocked medication cart. -There was one resident sitting across from the medication cart in a chair with a small folding table in front of him/her. Observation on 6/3/22 6:17 A.M., showed: -The medication cart was still unlocked. -The resident was still sitting across from the unlocked medication cart. -An unknown staff member walked past the unlocked cart. -Three other residents walked past the unlocked medication cart. Observation on 6/3/22 at 8:30 A.M., showed a nurse walking past the unlocked medication cart and locked the cart. Observation on 6/3/22 at 9:30 A.M., showed: -LPN B opened the South Side Medication Cart. -The medication cup with the pre-popped pills was no longer in the top drawer. During an interview on 6/3/22 at 9:30 A.M. LPN B said: -The medication carts should be locked whenever the nurse steps away from it. -Medications should never be pre-popped and left in a medication cup in a unlock medication cart.

Based on observation, interview and record review, the facility failed to ensure one Nursing Assistant (NA) (Employee K) completed the Certified Nurse Assistant (CNA) training program within four months of his/her employment in the facility. The facility census was 66 residents. 1. During an interview on 6/6/22 at 11:37 A.M., Employee K said he/She had taken some CNA training and needs to finish. Record review of the facility staffing roster on 6/7/22 showed: -Employee K's date of hire was 5/15/20. -He/she worked on the following days: --6/1/22 day shift. --6/2/22 day shift. --6/3/22 day shift. --6/6/22 day shift. --6/7/22 day shift. Observations from 6/1/22 to 6/7/22 of Employee K showed: -He/she was going in and out of resident's rooms. -He/she would take clean briefs (underwear for incontinence) into resident's rooms. -He/she was assisting resident's in wheelchairs to and from the dining room. During an interview on 6/8/22 at 11:20 A.M., the Administrator said: -Employee K was hired on 5/15/20. -As of 6/8/22 he/she had not completed a CNA training program. During an interview on 6/8/22 at 1:32 P.M., the Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) Coordinator filling in for the Director of Nursing (DON) said: -NA's should obtain certification as a CNA within four months of hire. -During COVID-19 there was an exemption for NA's to work longer than four months without obtaining certification as a CNA. -The facility had three NA's in an online class for CNA training at this time. -The facility had one NA who had worked past the time period of four months for being certified and had not completed the training yet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the annual 12 hours of in-service training and staff competencies for the nursing staff including the Certified Nurse Assistant's (CNA) required 12 hours of in-service education and based on performance reviews annually. The facility census was 66 residents. Requested the facility policy for In-services and at the time of exit had not received it. 1. Record review of the facility's Facility assessment dated 2022 showed: -To determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. -The Assessment helped to make the decisions about the facility's capacity and needs to provide services to residents, including the staff competencies (specific training). -Resources to provide care include staff competencies to continue training staff and assess for educational needs. Record review of in-services staff received in the last 12 months showed: -[DATE]th, 2021: Abuse & Neglect; Geri Chair vs lounge chair; broken equipment. -[DATE]: N-95 masks; visitor screening; side rails; report maintenance repair. -[DATE]: none given. -[DATE]: Caring for combative residents; tools to use; safety #1 concern, always. -No in-services were held for the following months in 2021: --August. --September. --October. --November. --December. -[DATE]: nursing-blood borne pathogens; transmission, type of Personal Protective Equipment (PPE) and what they were used for. -Jan. 16, 17,18 and 19th 2022: Amended Policy for COVID tests; Policy for resident's returning to facility; The COVID infected or exposed employee; New 2022 monitoring form for resident's with COVID symptoms; Resident's COVID-19 cohorting and transitional policy. -Feb. 2022: hand hygiene with a check off and blood sugars. -Mar. 2022: how to write orders on POS & MAR; proper nursing & CNA guidance on cares; addressing residents in a timely manner; New Director of Nursing (DON); TB: Transition & monitoring. -[DATE]: Hand washing; assessed knowledge of infection control techniques. -[DATE]: None. Record review of the last 12 months in-services for Licensed Practical Nurse (LPN) B showed: -He/she received a total of eight hours of in-services. -Two in [DATE]. -One in [DATE]. -Two in [DATE]. -One in February 2022 and was checked off on hand hygiene and infection control. -One in [DATE]. -One in [DATE]. Record review of the last 12 months in-services for CNA B showed: -He/she received a total of five hours of in-services. -Two in [DATE]. -One in [DATE]. -One in February 2022 and was checked off on hand hygiene and infection control. -One in [DATE]. Record review of the last 12 months in-services for Nursing Assistant (NA) A showed: -He/she received a total of seven hours of in-services. -Two in [DATE]. -One in [DATE]. -One in [DATE]. -One in February 2022 and was checked off on hand hygiene and infection control. -One in [DATE]. -One in [DATE]. During an interview on [DATE] at 9:51 A.M., Certified Medication Technician (CMT) C said: -He/She only worked part time. -He/she gets in-services every now and then. During an interview on [DATE] at 10:33 A.M., CNA B said: -He/she started working at the facility in [DATE]. -He/she had been a CNA for 40 years. -Received monthly in-services on various topics. -Has had Cardiopulmonary Resuscitation (CPR) training. -Has not had behavioral health training. During an interview on [DATE] at 10:42 A.M., Registered Nurse (RN) A said: -He/she just started on [DATE]. -Had read the facility policies on things like Infection Control, behaviors and a lot of other things. During an interview on [DATE] at 11:20 A.M., the Administrator said: -There have been some months since COVID-19 that have not had in-services. -They have done Abuse and Neglect in-services and behavioral as caring for combative residents. -About 75% of residents have had some type of behavioral issues, feels facility has been able to turn some of behaviors around through staff in-services. -NA A was hired on [DATE], he/she just finished the CNA training and was waiting to take the CNA testing. -CNA B was hired on [DATE]. -LPN B was hired on [DATE]. During an interview on [DATE] at 1:32 P.M., Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) Coordinator filling in for the DON said: -He/she and the former DON did the in-services. -In-services were held monthly and sometimes twice a month. -In-services were held on an individual basis when COVID-19 hit due to not being able to gather as a group. -The Administrator kept track of the staff in-services. -The last in-service was in [DATE] by the DON on hand washing and assessed knowledge of hand washing and infection control techniques.

Based on observation, interview, and record review, the facility failed to keep the kitchen, Dry Storage, and walk-in refrigerator floors clean; failed to retain operable thermometers in all refrigerators/freezers to confirm adequate temperature ranges; failed to maintain sanitary utensils and food preparation equipment; and failed to keep trash and garbage receptacles lidded. These deficient practices potentially affected all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 66 residents with a licensed capacity for 84 residents. 1. Observations during the initial kitchen inspection on 6/1/22 between 9:00 A.M. and 11:56 A.M. showed the following: -The walk-in refrigerator off the Dry Storage room had onion peels, dried food debris, and a bread wrapper clip on the floor. -The Dry Storage room had scraps of paper and a bread wrapper clip under the racks. -An unlidded 5-gallon bucket next to the tilt-skillet was almost full with a dark liquid, trash, and food scraps inside, and an abundance of dried liquid splatters on the outside. -The food preparation table under the wall-mounted magnetic knife holder had paper debris and a bread wrapper clip underneath. -The reach-in refrigerator across from the tilt-skillet had a thermometer inside that had its red liquid in a glass tube separated with numerous air bubbles. -The reach-in freezer by the double exit doors had no thermometer inside. -Four large metal cooking sheet pans under the food preparation table across from the 3-sink area had large amounts of black residue built up on their underside edges and around their upper edges. -A metal frying pan was completely covered on the bottom by a thick black residue that was also around the top rim inside. -A pair of oven mitts on top of the conveyor-toaster had numerous stains, food residue, and rips and tears. Observations during the follow-up kitchen inspection on 6/2/22 at 9:59 A.M. showed the following: -An unlidded 5-gallon bucket next to the tilt-skillet was approximately 1/5 full with a dark liquid, trash, and food scraps inside, and an abundance of dried liquid splatters on the outside. -The reach-in refrigerator across from the tilt-skillet had a thermometer inside that had its red liquid in a glass tube separated with numerous air bubbles. -The reach-in freezer by the double exit doors had no thermometer inside. -Four large metal cooking sheet pans under the food preparation table across from the 3-sink area had large amounts of black residue built up on their underside edges and around their upper edges. -A metal frying pan was completely covered on the bottom by a thick black residue that was also around the top rim inside. -A pair of oven mitts on top of the conveyor-toaster had numerous stains, food residue, and rips and tears. During an interview on 6/3/22 at 9:39 A.M. the Dietary Manager said the following: -The dietary aides and the cooks were responsible for cleaning the kitchen, Dry Storage, and walk-in floors at least twice a week. -Food preparation utensils and equipment should be replaced when they start getting rough around the edges or damaged. -The thermometers inside refrigerators and freezers should be present and working. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: -Chapter 4-101.11: Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated wear washing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. -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.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of the facility's undated policy Hand Washing, showed: -Hands should be thoroughly washed before and after providing resident care. -Proper hand washing techniques must be followed at all times. Record review of facility staff inservices showed: -In February 2022 hand washing audits were done with the staff. -Certified Medication Technician (CMT) A was observed during the audits on 2/10/22. -Hand hygiene was completed at appropriate times. -The staff member demonstrated the proper procedure. -The staff member was able to identify when to use alcohol based hand rub (ABHR). -The staff member was able to identify when to wash hands with soap and water. During an interview on 6/3/22 at 6:50 A.M. (CMT) A said: -He/she had to wear copper fingerless gloves due to his/her arthritis. -He/she would just take the gloves off to cleanse his/her fingers during medication pass. Observation of the medication pass on 6/3/22 at 7:00 A.M. with CMT A showed he/she: -Was wearing copper fingerless gloves. -Had ABHR was on his/her medication cart. -Did not cleanse his/her hands before starting the medication pass. -Had passed medications to three residents which included an inhaler and eye drops, without cleansing his/her hands in between passing medications to each resident. -Put on a pair of disposable gloves over the copper gloves he/she was wearing before administering the eye drops to the resident. -After administering the eye drops he/she took off one glove and it dropped on the floor. -Bent down and picked the glove up off of the floor with his/her bare hand then threw both gloves into the trash. -Left the resident's room then went into another resident's room to administer medication without cleansing his/her hands. During an interview on 6/3/22 at 7:20 A.M., CMT A said: -The facility had given the staff education on hand hygiene. -He/she would not have done anything different during medication pass. During a follow up interview 6/7/22 at 12:27 P.M., CMT A said staff should wash their hands between each resident when giving medications. During an interview on 6/7/22 at 10:48 A.M., Licensed Practical Nurse (LPN) C said: -The facility had provided the staff with education on hand hygiene. -During medication pass you should cleanse your hands before you start the medication pass. -Should cleanse your hands between residents. -Should cleanse your hands after completing the medication pass. -Should wash your hands if you pick anything up off of the floor. -Should wash your hands before and after putting on gloves. During an interview on 6/8/22 at 1:30 P.M., the Infection Preventionist said: -The Director of Nursing (DON) was on vacation and he/she was acting in his/her place. -Staff was expected to use ABHR after each resident. -Staff was expected to wash their hands with soap and water after administering medications to five residents. -If a staff member picked anything up off of the floor he/she would expect them to cleanse their hands. -The staff has had hand hygiene education. -The DON had done audits on hand hygiene. 3. Record review of the facility's policy Policy for Tuberculosis (TB - a bacteria that can spread when an infected person coughs or sneezes)- Resident Version, dated 2013, showed: -The record of TB administration was to be kept by the Administrator and DON. -All residents shall be asked to participate in TB test or chest X-ray for possible tuberculosis. -The chest X-ray can be arranged by the facility. Record review of Resident #12's face sheet showed he/she was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the resident's immunization record, dated 4/22, showed: -The box that showed the resident had signs or symptoms of TB was blank. -The box that showed the resident did not have signs of TB was blank. Record review of the resident's June 2022 Physician's Order Sheet (POS) showed an order dated 4/15/17 that the resident was to be assessed annually for signs and symptoms of TB. During an interview on 6/3/22 at 7:00 A.M. Licensed Practical Nurse (LPN) B said: -They had a pharmacy come in to do the immunizations. -The DON would be responsible for ensuring the immunizations and TB tests were done. -If the physician ordered it, it should have been done and documented. During an interview on 6/7/22 at 10:48 A.M., LPN C said: -The Infection Preventionist would be in charge of the TB tests. -If a resident was assessed for signs and symptoms it should have been documented completely on the immunization record. During an interview on 6/8/22 at 1:30 P.M., the Infection Preventionist said: -The DON was on vacation and he/she was acting in his/her place. -If a resident was assessed for TB it should have been documented completely on the immunization log. -The DON was responsible for ensuring it was done. Based on observation, interview, and record review, the facility failed to meet the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, volunteers, and staff who reside, visit, use, or work in the facility; to ensure staff used proper hand hygiene techniques during medication pass; failed to document whether a resident had signs or symptoms of tuberculosis for one sampled resident (Resident #12) out 17 sampled residents; and to ensure staff followed source control measures to help mitigate the spread of COVID-19 when 29 facility staff and one contract staff, including seven unvaccinated staff, did not wear masks in resident common areas. The facility census was 66 with a licensed capacity for 84. 1. Record review of the Centers for Disease Control (CDC) paperwork completed and provided by the Corporate Maintenance Director (CMD) entitled Legionella Environmental Assessment Form, showed a 23-page assessment designed to help enable public health officials to gain a thorough understanding of a facility's water systems which can be used to develop a water management program, but failed to include any documentation that followed CMS's requirements for a waterborne pathogen program such as, but not limited to: -A facility-specific risk assessment that considers the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard. -A completed Centers for Disease Control (CDC) toolkit assessment including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -A schematic or diagram of the facility's water system with a written explanation of the water flow throughout the facility. -A facility-specific infection prevention program or plan to deal with outbreaks of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other waterborne pathogens. -A program and/or flowchart that identified and indicated specific potential risk areas of growth within the building. -Assessments of each individual area's potential risk level. -Testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility. -Facility-specific interventions or action plans for when control limits are not met. -Documentation of any site log book being maintained with any dated cleanings, sanitizings, descalings, and inspections mentioned. Record review of the facility's disaster manual entitled Southside Disaster Information Book obtained from the south nurse's station, on page #114, Legionaire Disease Prevention Policy, showed a 3-page document, last dated as revised in 2019, that only explained the purpose of developing a water-borne pathogen prevention program with references for guidelines to follow and recommendations for water systems, but nothing showing any implementation was done. Observations during the Life Safety Code (LSC) room inspections with the CMD on 6/2/22 between 1:13 P.M. and 2:59 P.M., showed the following: -Most resident rooms had their own, or an adjoining, bathroom with a sink and toilet. -There were bath houses located on both the North and South Halls. -There were at least two water heaters for the facility. -There were at least two janitor's closets in the facility with a place to rinse out mops. -The kitchen had sinks and a dishwashing area with a low-temperature dish washing machine. -There were public restrooms near the front lobby,the nurse's stations, and individual restrooms in a rear conference room and an adjacent office. -The basement had two restrooms. During an interview on 6/7/22 at 9:34 A.M., the CMD said that he/she was unaware of all the requirements for a water-borne pathogen prevention program such as a completed CDC Toolkit, a written explanation of the facility's water flow, any type of log book, or a plan to manage any outbreaks. 4. Record review of the facility's Mandatory Vaccination Policy, dated 11/8/21, showed: -CMS is requiring workers at health care facilities participating in Medicare or Medicaid to have received the necessary shots to be fully vaccinated by January 4. -Employees are informed that they may be legally entitled to a reasonable accommodation if they cannot be vaccinated and/or wear a face covering because of a disability, or if provisions in this policy for vaccination, and/or testing for COVID-19, and/or wearing a face covering conflict with a sincerely held religious belief, practice, or observance. -NOTE: The policy did not include a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated for COVID-19. Record review of the facility's undated Policy for Infection Control Practice During the Crisis showed: -The purpose was to be compliant with CDC guidance and CMS instruction during the pandemic and to ensure the proper infection control practices to protect residents and staff during the crisis. -The facility will remind all staff about proper hand hygiene and infection control practices through the facility via posters and verbal reminders. -The facility will continue reinforcing the daily infection control practices to staff and residents. Record review of the facility's undated Policy for Personal Protective Equipment (PPE) showed: -The purpose was to ensure respiratory protection to staff and residents. -PPE included face masks. -The PPE user is responsible for properly wearing PPE as required. -The procedure for face masks included: --Implement extended use of facemasks. Wear the same facemask for repeated close contact encounters with several different patients, without removing the facemask between patient encounters. --The facemask should be removed and discarded if soiled, damaged, or hard to breathe through. --Staff should leave the patient/resident care area if they need to remove the facemask. Record review of the updated guidance for healthcare workers from the CDC titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic, updated on 02/22/2022, showed the following: -Implement source control refers to use of well-fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing; -Source control options for Health Care Providers (HCP) include a NIOSH-approved N95 or equivalent or higher-level respirator filtering facepiece respirators or a well-fitting mask; -Health Care Providers (HCP) should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers; -Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. This is particularly important for individuals, regardless of their vaccination status, who live or work in counties with substantial to high community transmission; or if they are not up to date with all recommended COVID-19 vaccine doses; or Have moderate to severe immunocompromise; or have otherwise had source control and physical distancing recommended by public health authorities. Observations of staff on 6/1/22 between 8:30 A.M. - 3:00 P.M., showed: -16 staff were observed throughout the day not wearing a mask, including one staff who was wearing a mask removing his/her mask to talk to residents throughout the day. -Of the 16 staff observed either not wearing a mask or removing his/her mask to speak to residents, four were unvaccinated. -One vaccinated contract staff was observed throughout the day in resident common areas not wearing a mask. -Two signs across from the North Hall Nurse's Station and two signs across from the South Hall Nurse's Station said to wear face masks at all times. Observations of staff on 6/2/22 between 8:30 A.M. - 3:00 P.M., showed: -20 staff were observed throughout the day not wearing a mask, including one staff who was wearing a mask removing his/her mask to talk to residents throughout the day. -Of the 20 staff observed either not wearing a mask or removing his/her mask to speak to residents, seven were unvaccinated. -Two signs across from the North Hall Nurse's Station and two signs across from the South Hall Nurse's Station said to wear face masks at all times. Observations of staff on 6/3/22 between 6:00 A.M. - 12:30 P.M. showed: -14 staff were observed throughout the day not wearing a mask, including one staff who was wearing a mask removing his/her mask to talk to residents throughout the day. -Of the 14 staff observed either not wearing a mask or removing his/her mask to speak to residents, four were unvaccinated. -Two signs across from the North Hall Nurse's Station and two signs across from the South Hall Nurse's Station said to wear face masks at all times. 5. During an interview on 6/3/22 at 6:55 A.M., CNA A said: -He/she was not wearing a face mask. -He/she did not think staff were required to wear face masks anymore. -He/she was not sure if staff were supposed to wear masks anymore or not. -He/she thought face masks were optional and it depended on if a person needed to wear the face mask to feel safe. During an interview on 6/3/22 at 7:00 A.M., CMT A said: -He/she was not wearing a face mask. -It was not required to wear a face mask anymore, it was up to the individual if they wanted to wear a face mask or not. During an interview on 6/3/22 at 7:53 A.M., the Laundry Aide said: -He/she does not wear a face mask, because of a medical condition. -He/she did not think staff had to wear masks anymore and asked if he/she needed to wear one. -He/she thought everyone at the facility had been vaccinated from COVID-19. During an interview on 6/3/22 at 8:12 A.M., Housekeeper A said: -He/she was not wearing a face mask and was not told he/she needed to wear a face mask at the facility. -He/she asked if he/she needed to wear a face mask. During an interview on 6/3/22 at 10:59 A.M., the Infection Control Nurse said: -He/she was not wearing a face mask. -He/she did not wear a face mask at the facility, because he/she believed in natural immunity. -When asked if facility staff were required to wear a face mask, he/she called for the Administrator. During an interview on 6/3/22 at 11:02 A.M., the Administrator said: -He/she was not wearing a face mask. -He/she did not know why staff should have to wear a face mask while in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow standard trash and garbage disposal practices to mitigate the presence of common household pests (for example, bed bugs, lice, roaches, ants, mosquitoes, flies/gnats, mice, and/or rats), and to maintain an effective pest control program with adequate measures to eradicate those pests when present. These deficient practices potentially affected all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility. The facility's census was 66 residents with a licensed capacity for 84 residents. 1. Record review of the last three exterminator's invoices to the facility provided by the Corporate Maintenance Director (CMD), showed the following: -The treatment dates were 3/22/22, 4/20/22, and 5/11/22. -The invoice for 3/22/22 listed the service as Monthly Pest Control. -The areas treated were listed as the exterior of the building, interior common areas, restrooms, the kitchen, resident rooms on both the north and south sides, the basement, and the dining room. -Targeted pests were listed as ants, German roaches, flying occasional invaders, and house mice. -Conditions that needed to be addressed were Gaps around pipes and/or fixtures - Bugs entering through unsealed areas, and Weeds overgrow around the perimeter of the building - Dead leaves and moisture creating breeding and harborage. **Note: At the start of survey the conditions that needed to be addressed were still noted as areas of concern and as the survey went on brush outside of the building was being cleared and removed. Observations in resident room N-11-12 on 6/1/22 at 11:39 A.M., showed the following: -There were cockroaches in a dresser drawer. -When the top sheet on resident bed N-11 was pulled back there were cockroaches crawling on the bed sheet underneath. Observations in resident room N-13-14 on 6/6/22 at 8:56 A.M., showed the following: -A resident was lying in bed N-13 with 3-4 small blood streaks on his/her sheets. -When the top sheet was pulled back there was a live bed bug underneath. Observations in resident room N-11-12 on 6/6/22 at 9:05 A.M., showed the following: -There was a cockroach on the top of a dresser. -When the top sheet was pulled back from resident bed N-11, there were 10 cockroaches crawling on the bed sheet underneath. Observations outside the Resident Smoke Room on 6/6/22 at 9:23 A.M., showed a live centipede dropped out of the ceiling. 2. Observations during the Life Safety Code (LSC) facility outer perimeter inspection with the CMD on 6/2/22 at 11:45 A.M. showed the dumpster by the loading dock was filled with so many trash bags that both lids were propped open by them approximately 3 to 4 feet. Observations on 6/6/22 at 8:31 A.M. showed the right lid of the dumpster by the loading dock was left open. 3. Record review of Resident #58's Quarterly Minimum Data Set (MDS- a federally mandated assessment tool required to be completed by facility staff for care planning) dated 5/3/22, showed the resident was able to make himself/herself understood, was able to understand others, had no swallowing disorders, and was assessed as a resident who was alert and oriented as evidenced by the resident having a Brief Interview for Mental Status (BIMS)(A screen used to assist with identifying a resident ' s current cognition and to help determine if any interventions need to occur.) score of 15 indicating he/she was cognitive intact. During an interview in resident room S-31 on 6/1/22 at 10:00 A.M., Resident #58 said the following: -He/She had been at the facility for about five years. -They had seen mice and roaches, but were afraid to tell the Administrator. -The mice and bugs were always in their bedrooms and everywhere else, too. 4. Observations in resident room S-33-36 on 6/1/22 at 12:14 P.M., showed ants crawling along the window sill. Record review of Resident #65's Quarterly MDS dated [DATE], showed the resident was able to usually make himself/herself understood, was able to understand others, had no swallowing disorders, and was assessed as a resident who was alert and oriented as evidenced by the resident having a BIMS score of 15 indicating he/she was cognitive intact. During an interview in resident room S-33-36 on 6/1/22 at 12:16 P.M., Resident #65 said the ants were always there. Observations during the LSC facility room inspections with the CMD on 6/2/22 at 1:43 P.M. showed ants on the window sill of resident room S-33-36. 5. Record review of Resident #57's Quarterly MDS dated [DATE], showed the resident was able to make himself/herself understood, was able to understand others, had no swallowing disorders, and was assessed as a resident who was alert and oriented as evidenced by the resident having a BIMS score of 15 indicating he/she was cognitive intact. During an interview in resident room N-13-14 on 6/6/22 at 8:59 A.M., Resident #57 said the following: -He/She had bed bugs in his/her sheets. -There were a couple bed bugs on him/her this morning and he/she killed them. -That is what the blood streaks were from. Observation in room N-13-14 on 6/1/22 at 2:43 P.M. showed resident bed sheets had multiple blood streaks. Resident reported they were from killing bugs in his/her bed. Observation in room N-13-14 on 6/6/22 at 8:56 A.M. showed multiple live bed bugs crawling on the resident's sheets wadded up at the foot of his/her bed. 6. Observations in the laundry area on 6/6/22 at 9:31 A.M., showed the Laundry Aide was putting resident #45's (reside's in room N-11) bed blankets in the washing machine. During an interview in the laundry area on 6/6/22 at 9:33 A.M., the Laundry Aide said the following: -He/She does the laundry every day. -On Mondays the beds are stripped down and the bed linens are brought to the laundry area; the nursing staff changes the linens -During the week the nursing staff bring the residents' clothing to be washed. -There is a problem with bugs in the facility that is now worse than ever. -They sprayed for bugs a couple of weeks ago. -When a particular room is infested everything is taken out of the room, washed, folded, and put away. -He/She occasionally sees bugs in the laundry area prior to washing things, but they do not see any bugs afterward. -He/She has had no training on how to clean clothing and linens for bed bugs. -The CMD is supposed to treat them before bringing to him/her to wash. During an interview on 6/7/22 at 9:34 A.M. the CMD said the following: -He/She oversaw the maintenance needs for the company's four facilities. -The exterminator came about once a month, but more frequently if there was a problem. -He/She was unaware of the extent of the infestation at this facility. MO-00201223

Based on interview and record review, the facility failed to ensure documentation was included in the resident's medical record regarding the resident being sent to the hospital and whether the resident's physician was notified for one sampled closed record resident (Resident #61) out of two closed records sampled. The facility census was 57 residents. A policy for documentation required when sending a resident to the hospital was requested but not received. 1. Record review of Resident #61's nurses' notes from 4/4/19 to 5/23/19 showed no documentation regarding the resident being discharged to the hospital on 5/21/19, whether the physician was notified or that notification was received that the resident would not be returning to the facility. Record review of the resident's discharge Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/21/19 showed the resident was discharged and his/her return was not anticipated. Record review of the outside of one of four manila folders that were the resident's closed records showed the resident left against medical advice on 5/23/19. During an interview on 7/24/19 at 12:54 P.M., the Social Services Director and the Administrator In Training said: -The resident went to the hospital on 5/21/19. -The hospital called on 5/23/19 and said the resident wasn't coming back to the facility. -The resident's family took the resident from the hospital to another long-term care facility. -The resident's family never came back to get his/her belongings or medications. The charting regarding the resident's discharge to the hospital was requested from the facility on 7/24/19 at 1:45 P.M. and on 7/25/19 at 1:13 P.M. and was not received. During an interview on 7/26/19 at 12:34 P.M., the Director of Nursing said the charge nurse should document on the chart that the resident was sent out to the hospital, why they were sent and that the physician was notified.

Based on interview and record review, the facility failed to ensure a discharge Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) was completed and/or submitted for two supplemental residents (Residents #1 and #2). The facility census was 57 residents. A policy for submitting discharge MDS's was requested but not received. 1. Record review of the facility's MDS's and submission logs showed Resident #1 had a discharge MDS for 4/12/19 but there was no record that the discharge MDS was submitted. 2. Record review of the facility's MDS's and submission log showed Resident #2 had a discharge MDS for 3/21/19 but it was submitted on 3/14/19 which was seven days prior to the resident being discharged . The discharge MDS was accepted but reflected an error that resident information did not match (Warning #1031). 3. During an interview on 7/25/19 at 1:13 P.M., the MDS Coordinator said: -Resident #1 was discharged on 4/12/19 and there's no record of submission in the submission log book. -Resident #2 was discharged on 3/21/19 and there's a discharge MDS that was submitted but he/she doesn't know how it could have been submitted 3/14/19 since the submission date was before the resident was discharged and in the submission log book shows it was accepted but it had an error and -He/she will look for the information to see if she/he can find out what happened. During an interview on 7/26/19 at 12:34 P.M., the Director of Nursing said: -He/she would expect the discharge MDS to be completed and submitted timely and in chronological order and -The MDS Coordinator is responsible for submitting the discharge MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #49's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Mild intellectual disabilities. -Paranoid schizophrenia (a mental illness with delusions). -Anxiety; and -Insomnia (inability to sleep). Record review of the resident's PASRR showed: -The PASRR I had been done and -The resident had triggered for a PASRR II to be done. Record review of referral assessment letter dated 12/03/15 showed a level II screening was done and the following services were recommended to be provided at the nursing facility: -Individual and group psychotherapy. -Drug therapy and monitoring of drug therapy. -Structured socialization activities. -Development and maintenance of daily living skills. -Development of personal support networks. -Provision of a structured environment. -Physician services. -Dietary services. -Dental services; and -Regional office referral/continues services. Record review of the annual MDS dated [DATE] showed he/she did not trigger for a Level II screening. During an interview on 7/26/19 at 8:00 A.M. the MDS Coordinator said: -The Social Services Designee (SSD) sends the information to Centers for Medicare/Medicaid (CMS). -He/she is just learning this job. -It was done before he/she started this job and -The information should have been sent to CMS. During an interview on 7/26/19 at 8:20 A.M. The SSD said: -He/she gets the information from the MDS coordinator. -He/she sends the information to CMS. -Unless it is less than the first 14 days the information should be on the MDS. -The resident who triggered for a PASRR II should have had the information on the MDS and -It must have been missed. During an interview on 7/26/19 at 12:34 P.M. the DON said: -The PASRR should be accurate; and -It should have been sent to CMS. Based on interview and record review, the facility failed to accurately reflect the resident's weight on the Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) for one sampled resident (Resident #44) and to accurately reflect a PASRR (Preadmission screening and resident review) assessment on the MDS for one sampled resident (Resident #49) out of 15 sampled residents. The facility census was 57 residents. Record review of the facility's undated policy titled RAI (Resident Assessment Instrument) Process Protocol, showed: -The purpose was to ensure the accuracy. -The purpose was to ensure the timeliness of all MDS (Minimum Data Set) assessments. -The purpose was to be compliant with regulatory requirement for certifying the accurate assessment; and -The MDS coordinator was to transmit the MDS to the state database every month on the first week of the month. Record review of the facility's undated policy, Myers Convalescent Center-PASRR Policy, showed: -The PASRR is a federally mandated screening process for individuals with a serious mental illness or mentally retarded or developmental disability related diagnosis who reside in a Medicaid Certified bed in a nursing facility. -The screening assures appropriate placement of persons known or suspected of having a mental impairment. -The individual needs of mentally impaired persons can be met in the appropriate placement environment. -The purpose is to ensure compliance with rules and law requirements by the state of Missouri. -Any person for whom placement in a Medicaid certified bed was to be screened for a Level I screening. -A level II screening is completed on those persons identified at a Level I screening who were known to have a serious mental illness or mental retardation and -The screening should be done prior to admission. 1. Record review of Resident #44's weights log showed: -The resident weighed 130.2 pounds on 12/18/18. -There was no weight for January or February 2019. -The resident weighed 140 pounds in March 2019. -The resident weighed 126.4 pounds in April 2019 and -There were no weights for May, June or July 2019. Record review of the resident's weights listed on his/her MDS's showed: -The resident weighed 121 pounds on 1/4/19. -The resident weighed 180 pounds on 3/29/19 and -The resident weighed 143 pounds on 6/21/19. During an interview on 7/26/19 at 12:34 P.M., the Director of Nursing (DON) said: -The Certified Medication Technicians (CMT)s weigh the residents. -The CMTs document the weights on a sheet that they use for tracking weights. -The CMTs give the weights to the charge nurse once they are completed. -If anyone refuses to be weighed, the CMT should let the charge nurse know that they refused and -He/she would expect the weights to be correct on the MDS and on the weight record and for the residents to be weighed monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a fall comprehensive care plan was developed and implemented for one sampled resident (Resident #26) out of 15 sampled residents. The facility census was 57 residents. Record review of the facility's undated Interdisciplinary Plan of Care Policy showed: -The development, implementation, and maintenance of a patient's pan of care is an interdisciplinary process. -Patients receive care and treatment based on an assessment of their needs, the severity of their disease, condition, impairment, or disability. -The data obtained from the assessment is used to determine and prioritize the patient's plan of care. -The patient's progress will be evaluated as necessary and the plan of care will be revised as indicated. -Documentation for the Interdisciplinary Plan of Care will include a minimum of: --Actual and potential patient/family/significant other health care concerns; --Patient goals/measurable outcomes; --Plan of action; --The date plan was initiated --The date plan was revised; --The dated plan was completed or discontinued; --Follow-up care required; and --Discharge planning. -The patient goal/measurable outcome and plan of action is updated by: --The individual who identified the problem; or --By other healthcare team members according to their expertise and credentials. 1. Record Review of Resident #26's admission Record Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -Cardiac arrhythmia (Occurs when electrical impulses in the heart don't work properly, causing improper heat beat, whether irregular, too fast, or too slow) and -Hypertension (high blood pressure). Record review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 3/1/19 showed he/she: -Had no falls since previous assessment and -The falls were not charted under the Care Area Assessment (CAA) summary. Record review of the resident's Nurses Notes dated 4/8/19 for the 11:00 P.M. to 7:00 A.M. shift showed: -The nurse was called to the resident's room by another resident. -The resident was on the floor on his/her stomach. -There was no bleeding or anything else noted. -The nurse called the resident's Physician and left a message that the facility was sending the resident to the hospital to get checked out and -The resident was in his/her room in bed and tried to get up with walker and fell. Record review of the resident's Nurses Notes dated 4/8/19 at 6:15 P.M., showed: -The resident was found lying between the two beds in his/her room on the floor facing up. -The resident said I rolled out of bed, I did not hit my head. I'm ok. I'm not hurting anywhere. -No apparent injuries noted and -The resident got himself/herself up and was able to move all extremities. Record review of the resident's Nurses Notes dated 4/9/19 at 1:15 P.M., showed: -The resident was laying in the hallway. -The nurse called 911 and -The resident was sent to the hospital for evaluation and treatment. Record review of the resident's Care Plans showed no care plans were written or implemented for the resident's falls or for being at risk for falls. During an interview on 7/23/19 at 9:59 A.M., the resident said: -He/she has had several falls. -He/she had fallen out of bed and -He/she had fallen while walking with his/her walker. During an interview on 7/26/19 at 12:34 P.M., the Director of Nursing (DON) said: -Each resident should have care plans written for each of their individual needs. -The Interdisciplinary Team (IDT-consisting of the DON, Social Service Director, MDS Coordinator, Activities Director and Dietary Manager, Physical Therapy Director, and any department head) are responsible for writing the care plans and -The IDT is responsible for updating a resident's care plan.

2. Observation on 7/24/19 at 6:45 A.M., of the North Hall medication storage room showed: -Two bottles of Calcium (A mineral found mainly in the hard part of bones) 600 milligram (mg) with Vitamin D expired on 5/18. -Certified Medication Technician (CMT) B remove the expired medication bottles. -CMT B disposed of the expired medications by flushing them down the soiled utility hopper and -CMT B did not chart the disposition of the expired medications after the disposal of them. During an interview on 7/26/19 at 12:34 P.M., the DON said: -The charge nurses are responsible for checking for expired medications. -Medications in the medication storage rooms should be checked at least monthly. -Over the counter expired medications may be flushed down the soiled utility hopper. -Central supply should be notified when expired medications are removed and disposed of from the medication storage rooms and -He/she would notify central supply that the two bottles of Calcium 600 mg with Vitamin D expired on 5/18 and were disposed of. Based on observation, interview and record review, the facility failed to ensure documentation was completed that included the disposition of the resident's medications for one sampled resident (Resident #61) who went to the hospital and did not return out of two closed records sampled, and to remove in a timely manner two bottles of over the counter supplements that had expired from the medication storage room. The facility census was 57 residents. The policy for disposition of medications after a resident is discharged was requested but not received. Record review of the facility's Medication Storage, Handling and Labeling Policy dated 3/13 showed expired medications were to be destroyed within 30 days. Record review of the facility's Medication distribution System Policy dated 5/1/08 showed outdated medications shall be removed from stock by nursing. 1. Record review of Resident #61's nurses' notes from 4/4/19 to 5/23/19 showed no documentation regarding the resident being discharged to the hospital on 5/21/19 or that notification was received that the resident would not be returning to the facility. Record review of the resident's discharge Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/21/19 showed the resident was discharged and his/her return was not anticipated. Record review of the outside of one of four manila folders that were the resident's closed records showed the resident left against medical advice on 5/23/19. During an interview on 7/24/19 at 12:54 P.M., the Social Services Director and the Administrator In Training said: -The resident went to the hospital on 5/21/19. -The hospital called on 5/23/19 and said the resident wasn't coming back to the facility. -The resident's family took the resident from the hospital to another long-term care facility. -The resident's family never came back to get his/her belongings or medications. The charting regarding the disposition of the resident's medications was requested from the facility on 7/24/19 at 1:45 P.M. and on 7/25/19 at 1:13 P.M. and was not received During an interview on 7/26/19 at 12:34 P.M., the Director of Nursing (DON) said: -Medications are sent back to the pharmacy after a resident is discharged from the skilled nursing facility and -The charge nurse should write on the physician's order sheet that the medications were sent back to the pharmacy.

Based on observation and interview, 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 57 residents with a licensed capacity of 84 residents. 1. During an interview on 7/22/19 at 9:05 A.M., the Dietary Supervisor said the following: -The facility did not have an actual outside food policy. -Families usually give the food straight to a resident, and -Two or three residents have their own refrigerators. During an interview on 7/23/19 at 9:11 A.M., the Director of Nursing (DON) said the following: -If food was brought in by a family member or friend for a resident it is taken to one of the nurse's stations where there are refrigerators specifically for residents' foods. -It is checked with their diet to ensure it is the correct texture. -If the food would be difficult for the resident to chew or swallow the family would be told it was inappropriate, and -He/she did not learn the procedure anywhere, it was just common sense. During an interview on 7/23/19 at 9:17 A.M., Licensed Practical Nurse (LPN) A said the following: -If food was brought in by a family member or friend for a resident it would be put in a refrigerator until asked for. -It would be heated up for the resident if needed. -He/she had worked at this facility off and on since 1991, and -He/she had not seen the process written down anywhere, it was just something everyone knew. 2. Observations during the room-by-room facility inspection with the Corporate Maintenance Director on 7/23/19 between 11:05 A.M. and 12:37 P.M. showed a refrigerator for residents' foods in each of the two nurse's stations' Medication Rooms. During an interview on 7/23/19 at 3:57 P.M., a request was made to the Administrator for the facility's outside food brought in by family policy, but none was forthcoming for the remainder of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #39's immunization record dated 2018 showed: -The pneumonia vaccination was left blank and -Nothing was documented for 2019. Record review of the resident's annual MDS dated [DATE] showed the resident was admitted on [DATE]. Record review of the resident's medical records showed no documentation regarding the resident receiving or declining the pneumonia vaccination. Record review of the resident's July 2019 Physician's Order Sheet (POS) showed: -The resident had an order to have the Pneumovax dated 6/26/18 and -The date the Pneumovax was given was blank. 3. Record review of Resident #3's immunization record dated 2017 showed: -The resident signed to get the Pneumovax vaccine; and -The was no documentation that he/she received the vaccine. Record review of the resident's quarterly MDS dated [DATE] showed the resident was admitted on [DATE]. Record review of the resident's POS dated July 2019 showed: -The resident had an order to have the Pneumovax vaccine; and -The date the Pneumovax was given was blank. 4. During an interview on 7/26/19 at 10:00 A.M. Licensed Practical Nurse (LPN) A said: -He/she has a book for the immunizations. -He/she monitors the new residents for vaccines. -Vaccines are offered to all the residents. -He/she will educate the resident if they don't want the vaccines. -He/she will have the resident sign a refusal form. -Each resident should have the date the vaccines were given. -Each resident should have a refusal form if they decline to have the vaccines with the education on the sheet. -The nurse who admits the resident should give the resident the vaccines; and -He/she was the one who is responsible to make sure the paperwork was done. During an interview on 7/26/19 at 12:34 P.M. the DON said: -The vaccines are offered to each resident. -If the resident declines they have a refusal sheet they must sign. -The charge nurse is responsible for administering the vaccines; and -The DON was ultimately responsible to make sure the vaccines have been done. Based on interview and record review, the facility failed to offer the pneumococcal (pneumonia-lung infection) vaccination to three sampled residents (Resident #33, #39, and #3) out of 15 sampled residents. The facility census was 57 residents. Record review of the facility's Pneumonia Immunization policy dated 2006 showed: -Residents or their family/legal representatives will be provided educational instructions regarding the benefits of immunization as well as the potential for side effects prior consenting to receive the immunizations. -All newly admitted residents will be offered to receive the pneumonia immunization in the facility. -The Director of Nursing (DON) keeps the record for residents who receive pneumonia immunizations. -The Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff completed by facility staff for care planning) Coordinator will ensure the documentation is included in the resident's MDS and -All immunization injections shall be consulted and ordered by the physician prior to offering to avoid medical contraindications. 1. Record review of Resident #33's immunization record dated 2018 showed: -The pneumonia vaccination was left blank and -Nothing was documented for 2019. Record review of the resident's MDS showed on the annual MDS dated [DATE] and the quarterly MDS dated [DATE]: -The resident was admitted to the facility on [DATE] and -The pneumonia vaccination boxes that asked if the resident's pneumonia vaccination was up to date or if the resident refused were left blank. Record review of the resident's medical records showed no documentation regarding the resident receiving or declining the pneumonia vaccination. During an interview on 7/24/19 at 11:14 A.M., the Administrator said: -He/she didn't know if the resident had received a pneumonia vaccination. -The resident did not receive the pneumonia vaccination at the facility. -They did not offer the pneumonia vaccination to the resident and -They only give the pneumonia vaccination if the resident's doctor orders it or if the family requests it. During an interview on 7/26/19 at 12:34 P.M., the DON said: -The nurses should offer pneumonia vaccinations upon admission. -If the resident declines, they have them sign that they refused and -He/she is responsible for the immunizations overall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) a copy of transfers to a hospital for four sampled residents (Residents #26, #28, #34, and #48) out of 15 sampled residents. The facility census was 57 residents. 1. Record Review of Resident #26's admission Record Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD - a disease process that decreases the ability of the lungs to perform ventilation). -Cardiac arrhythmia (Occurs when electrical impulses in the heart don't work properly, causing improper heat beat, whether irregular, too fast, or too slow) and -Hypertension (high blood pressure). Record review of the resident's Nurses Notes dated 4/9/19 at 1:15 P.M., showed: -The resident was laying in the hallway. -The nurse called 911 and -The resident was sent to the hospital for evaluation and treatment. Record review of the resident's medical record showed no notification sent to the Ombudsman. 2. Record Review of Resident #28's admission Record Face Sheet showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Absence of right leg above the knee and -Polyneuropathy (damage or disease affecting nerves in the same areas on both sides of the body, causing weakness, numbness, and or burning pain). Record review of the resident's Nurses Notes dated 1/16/19 No time noted showed: -The resident went to the hospital for wound on his/her right foot and toes and -The resident was admitted to the hospital. Record review of the resident's Nurses Notes dated 1/22/19 at 11:25 P.M., showed the resident returned to facility with a right above the knee amputation stump. Record review of the resident's medical record showed no notification sent to the Ombudsman. 3. Record Review of Resident #34's admission Record Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) and -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 Nurses Notes dated 11/1/18 no time noted showed: -The resident was walking to the bus stop. -He/she lost his/her balance in the parking lot and fell. -This resident complained of left hip pain with palpation and range of motion (ROM the range on which a joint can move). -The resident was covered with a blanket until the ambulance arrived and -The resident was transported to the hospital. Record review of the resident's Nurses Notes dated 11/16/18 at 2:00 P.M., showed that the resident returned to facility from hospital. Record review of the resident's medical record showed no notification sent to the Ombudsman. 4. Record Review of Resident #48's admission Record Face Sheet showed he/she was admitted on [DATE] with the following diagnoses: -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others) and -Cirrhosis of liver (chronic liver damage from a variety of causes leading to scarring and liver failure). Record review of the resident's Nurses Notes dated 6/13/19 at 9:40 P.M., showed: -The resident fell by a closet and hit his/her head and -The resident was sent to the hospital. Record review of the resident's Nurses Notes dated 6/18/19 at 5:30 P.M., showed the resident returned to facility at 5:20 P.M. Record review of the resident's medical record showed no notification sent to the Ombudsman. 5. During an interview on 7/26/19 at 11:20 A.M., the Social Service Director (SSD) said: -He/She does not notify the Ombudsman when residents transfer to the hospital and -He/She only notifies the Ombudsman when a resident discharges from the facility. During an interview on 7/26/19 at 1:34 P.M., the Director of Nursing (DON) said the Ombudsman should be notified when residents are transferred to the hospital by the SSD.

Based on observation, interview, and record review, the facility failed to minimize loss or diversion of the resident's medication by allowing the staff to keep purses in the locked medication room; to ensure the sharps containers (a container to put used needles in) on two sampled medication carts were locked of five sampled medication carts; to ensure medications were stored correctly by storing food and cleaning supplies in with the medication and medication supplies in one sampled medication rooms of two sampled medication rooms; to date an opened bottle of medication that had been opened, and to keep the medication room clean for one sampled medication room of two sampled medication rooms. The facility census was 57 residents. Record review of the facility's policy, Medication Storage, Handling and Labeling, dated 3/13 showed: -The medication storage space is to be kept clean. -The staff do not store personal items in the medication storage area. -The storage space under the sink is designated for hazardous chemicals or cleansers only. -Expired medications were to be destroyed within 30 days and -The drawers in the medication carts are to be be cleaned as needed to remove loose pills. Record review of the facility's policy, Medication distribution system, dated 05/01/08 showed: -Medications should be stored in locked cabinets, rooms or carts. -Medications should be inaccessible to residents and visitors and -Outdated medications shall be removed from stock by the nursing staff. 1. Observation on 7/24/19 at 6:45 A.M. with Licensed Practical Nurse (LPN) C of the Medication/treatment/narcotics cart showed: -The sharps container at the side of the cart was not locked and -The sharps container was full of used sharps some with medications in them. Observation on 7/24/19 at 7:00 A.M. with LPN C of the Day medication cart showed: -The sharps container at the side of the cart was not locked. -The sharps container was full of used sharps some with medications in them. -In the bottom of one of the medication drawers there was 1/2 of a unidentified loose white pill. -In the bottom of one of the medication drawers there was one unidentified loose oblong orange pill. -A wristwatch was in one of the medication drawers sitting on top of medications and -A remote control (for the room air conditioner) was in the locked Narcotics drawer (All the other remote controls for the room air conditioners were on a rack on the wall in the medication room). Observation on 7/24/19 at 7:20 A.M. with LPN C of the South Hall medication room showed: -The only sink in the medication room was dirty. -The only sink in the medication room had a dental pick (a device to clean between teeth) in it. -A resident's Gabapentin (medication for nerve pain) 250 milligrams (mg)/5 milliliters (ml) 180 ml bottle was opened without an opened date on it. -The syringes were stored under the sink in an opened box. -There was an opened bottle of Louisiana Hot Sauce under the sink with the box of syringes. -There was an opened bottle of cleaning detergent with the box of syringes and -There were two black staff purses in the medication room. During an interview on 7/24/19 at 7:25 A.M., LPN C said: -He/she did not know why the sharps containers were not locked. -He/she did not know who was responsible for cleaning the medication room. -He/she did not know how often the medication room was cleaned. -When a housekeeper cleans the medication room a nurse has to be with them. -He/she did not know why there was hot sauce under the sink. -He/she did not know why there was an opened box of syringes under the sink. -The opened medications should have an opened date written on the bottle. -The pills just fell out during administration. -The watch and remote control were in the medication cart for safe keeping and -The facility doesn't have a policy about personal belongings in the medication room. During an interview on 7/24/19 at 8:03 A.M. LPN B said: -There should not be any open pills in the bottom of the drawer. -The sharps containers should be locked. -There should not be food in with the syringes. -There should not be personal belongs in the medication cart. -It is OK to have purses in medication room. -He/she did not know when or how the sink was cleaned and -Housekeeping should do it. Observation on 7/26/19 at 9:32 A.M. showed a tan purse in the medication room. During an interview on 7/26/19 at 12:34 P.M. the Director of Nursing (DON) said: -He/she would expect the sharps containers on the medication carts to be locked. -He/she would not expect there to be any loose pills in the medication drawers. -He/she would not expect there to be any personal belongings in the medication room. -He/she would not expect there to be any personal belongings in the medication carts. -He/she would expect that medications that have been opened have the date they were opened written on the bottle. -He/she would not expect there to be opened foods in with the syringes. -He/she would expect housekeeping to clean the sink in the medication room with a nurse watching them; and -He/she would expect the sink in the medication room to be cleaned.

Based on interview and record review, the facility failed to establish and maintain annual competencies and skill sets of at least 12 hours of education in-services/training of facility licensed nursing staff, Certified Medication Technicians (CMTs), and Certified Nursing Assistants (CNAs) that included Abuse, Neglect, and Dementia training. This has the potential to effect all residents. The facility census was 57 residents. 1. Record review of staff in-services/training records from August 2018 through June 2019 showed: -No in-services/training for Abuse, Neglect, and Dementia. -Behavioral in-service/training were done. -No type of in-services/training for the months of: --September 2018; --October 2018; --November 2018; --December 2018 and --May 2019. -One hour of in-services/training each month for the following months: --August 2018; --January 2019; --February 2019; --March 2019; --April 2019 and --June 2019. -In-service/training hours only totaled six hours. During an interview on 7/26/19 at 11:52 A.M., the Administrator said: -He/she keeps the in-service/training records. -He/she did not have the in-service/training records for the months of: --September 2018; --October 2018; --November 2018; --December 2018 and --May 2019. During an interview on 7/26/19 at 12:15 P.M., CNA A said: -He/she has worked at the facility for four years. -He/she should have 12 hours of in-service/training a year. -He/she had 12 hours of in-service/training over the last year. -He/she signed in for each of the in-services/training he/she attended. -He/she had abuse, neglect, and dementia training, this last year and -The Administrator or the Director of Nursing (DON) does the training. During an interview on 7/26/19 at 12:23 P.M., Licensed Practical Nurse (LPN) A said: -The In-services are on the last payday of the month. -The In-services usually last an hour, sometimes longer. -He/she usually works the day of the in-services and gets a printed copy of what was covered. -The last in-service was about: --Handwashing; --Verbal abuse; --How to talk to the residents and privacy. -In-services include things that have happened in other places, from the news, and how to address that situation if it were to come up or happen here. -In-services have also covered: --Behaviors, and what to do if a resident becomes irate or too physical; --When to call the police if needed and --Falls. During an interview on 7/26/19 at 12:30 P.M., CMT A said: -The facility has in-services at the staff meetings. -The staff meetings are at the end of the month and last two hours. -He/she signs in every time he/she attends an in-service. -He/she had abuse, neglect and dementia care in-services and -He/she had 24 hours of in-services over the last year. During an interview on 7/26/19 at 12:34 P.M., the DON said: -In-services are held monthly usually on payday. -The Administrator does the in-services. -Some of the in-services include: --Handwashing; --Perineal care (care to the area between the anus and the exterior genitalia); --Monitoring resident meals for the right diet and consistency for each resident; --Abuse, neglect, behavior, and dementia training; -Every staff member should be receiving in-services and training no matter what shift they work or when their day off is; -Abuse, neglect, behavior, and dementia training are done yearly; -He/she believes prior to his/her coming to the facility that abuse, neglect, behavior, and dementia were done twice a year and -The Administrator will do the abuse, neglect, behavior, and dementia training more than once a year if there is a need for it. During an interview on 7/26/19 at 1:42 P.M., the Administrator said: -He/she has not done any competency checks on staff since about the last state survey. -The DON has only been at the facility since about April or May of this year and -He/she is waiting for the DON to become more oriented to his/her job before having him/her do the competency checks of the staff.

Based on interview and record review, the facility failed to have a system in place to ensure Certified Nurse Assistant (CNA's) received the required 12 hours in-service education based on performance reviews annually. The facility census was 57 residents. 1. Record review of staff in-services/training records from August 2018 through June 2019 showed: -No in-services/trainings for Abuse, Neglect, and Dementia; -No type of in-services/trainings for the months of: --September 2018; --October 2018; --November 2018; --December 2018; --May 2019; -One hour of in-services/training each month for the following months: --August 2018; --January 2019; --February 2019; --March 2019; --April 2019; --June 2019. -In-service/training hours only totaled six hours. During an interview on 7/26/19 at 11:52 A.M., the Administrator said: -He/She keeps the in-service/training records; -He/She did not have the in-service/training records for the months of: --September 2018; --October 2018; --November 2018; --December 2018; --May 2019. During an interview on 7/26/19 at 12:15 P.M., Certified Nursing Assistant (CNA) A said: -He/She has worked at the facility for four years; -He/She should have 12 hours of in-service/training a year; -He/She had 12 hours of in-service/training over the last year; -He/She signed in for each of the in-services/trainings he/she attended; -He/She had abuse, neglect, and dementia training, this last year; -The Administrator or the Director of Nursing (DON) does the training. During an interview on 7/26/19 at 12:23 P.M., Licensed Practical Nurse (LPN) A said: -The In-services are on the last payday of the month; -The In-services usually last an hour, sometimes longer; -He/She usually works the day of the in-services and gets a printed copy of what was covered; -The last in-service was about: --Handwashing; --Verbal abuse; --How to talk to the residents; --And privacy. -In-services include things that have happened in other places, from the news, and how to address that situation if it were to come up or happen here; -In-services have also covered: --behaviors, and what to do if a resident becomes irate or too physical; --When to call the police if needed; --And falls. During an interview on 7/26/19 at 12:30 P.M., Certified Medication Technician (CMT) A said: -The facility has in-services at the staff meetings; -The staff meetings are at the end of the month and last two hours; -He/She signs in every time he/she attends an in-service; -He/she had abuse, neglect and dementia care in-services; -He/she had 24 hours of in-services over the last year. During an interview on 7/26/19 at 12:34 P.M., the DON said: -In-services are held monthly usually on payday; -The Administrator does the in-services. -Some of the in-services include: --Handwashing; --Perineal care (care to the area between the anus and the exterior genitalia); --Monitoring resident meals for the right diet and consistency for each resident; --Abuse, neglect, behavior, and dementia training; -Every staff member should be receiving in-services and trainings no matter what shift they work or when their day off is; -Abuse, neglect, behavior, and dementia trainings are done yearly; -He/she believes prior to his/her coming to the facility that abuse, neglect, behavior, and dementia were done twice a year; -The Administrator will do the abuse, neglect, behavior, and dementia training more than once a year if there is a need for it. During an interview on 7/26/19 at 1:42 P.M., the Administrator said: -He/She has not done any competency checks on staff since the last state survey; -The DON has only been at the facility since April or May of this year; -He/she is waiting for the DON to become more oriented to his/her job before having him/her do the competency checks of the staff.

Based on observation and interview, the facility failed to dispose of spoiled foods to reduce contamination risks; to keep food can labels legible; to maintain sanitary food preparation utensils; to ensure cutting boards were in good condition to avoid food safety hazards; to adequately control pests; and to make sure proper hair hygiene practices were followed to prevent foodborne illness. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 57 residents with a licensed capacity for 84 residents. 1. Observation during the kitchen inspection on 7/22/19 between 8:38 A.M. and 12:59 P.M., showed the following: -There was a wilted head of lettuce in a box on an upper rack in the basement dry storage room. -A 6-pound can of food on the bottom shelf of a cart by the tilt-skillet was missing its entire label. -A white cutting board was scored to the point of having bits of plastic hanging off. -A ladle and slotted spoon in an upright seven-drawer utensil cart had food residue on them. -Two of the seven drawers in the utensil cart had crumbs in the bottoms of them. -A full-grown roach was seen skittering under the toaster on a food preparation table. -Sugar and flour were kept in separate 20-gallon waste containers that had streaks on their insides. -There was a hairnet instruction sheet over a mixer on a food preparation table that stated A hairnet covering all portions of the hair shall be the standard against which less restrictive alternatives are judged, and -Three of four servers at lunchtime had hairnets that did not completely cover their hairlines. During an interview on 7/24/19 at 2:43 P.M., the Dietary Supervisor said the following: -Fruits or vegetables that have gone bad should be disposed of. -Canned foods should have clearly readable labels on them. -Cutting boards are checked as used, cleaned, and changed about every two months. -Whoever uses the food preparation utensils are to clean them. -An exterminator treats the kitchen at least twice a month and as needed. -The sugar and flour containers are cleaned every other week, and -The dietary staff are reminded daily about proper hair hygiene.

Based on interview and record review, the facility failed to provide a Facility Assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and in emergencies as required by 11/28/17. The lack of a Facility Assessment has the potential to affect the entire resident population. The facility census was 57 residents. Record review of the State Operations Manual appendix PP, section 483.70(e) revised 11/22/17, Facility Assessment showed: -An assessment of the resident population is the foundation of the facility assessment and determination of the level of sufficient staff needed; -It must include the number of residents and the facility's resident capacity; -It must include an evaluation of: -- Diseases. --Conditions. --Physical, functional or cognitive limitations of the resident population's. --Acuity (the level of severity of residents' illnesses, physical, mental and cognitive limitations and conditions). --And any other pertinent information about the residents that may affect the services the facility must provide. -The assessment of the resident population should drive staffing decisions. -Inform the facility about what skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. -The facility's assessment must address/include: --An evaluation of staff competencies that are necessary to provide the level and types of care needed for the resident population. --Additionally, staff are expected to demonstrate competency with the activities listed in the training requirements per §483.95, such as: ---Preventing and reporting abuse, neglect. ---Exploitation. ---Dementia management. ---And infection control. --Also, nurse aides are expected to demonstrate competency with the activities and components that are required to be part of an approved nurse aide training and competency evaluation program. - Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: --Resident Rights. --Person centered care. --Communication. --Basic nursing skills. --Basic restorative services. --Skin and wound care. --Medication management. --Pain management. --Infection control. --Identification of changes in condition. --Cultural competency. -The facility must review and update the assessment, as necessary, and at least annually and -The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. 1. Record review of staff in-services/training records from August 2018 through June 2019 showed: -No in-services/training's for Abuse, Neglect, and Dementia. -No type of in-services/training's for the months of: --September 2018; --October 2018; --November 2018; --December 2018 and --May 2019; During an interview on 7/26/19 at 12:15 P.M., Certified Nursing Assistant (CNA) A said: -He/she has worked at the facility for four years. -He/she should have 12 hours of in-service/training a year. -He/she had 12 hours of in-service/training over the last year. -He/she signed in for each of the in-services/training's he/she attended. -He/she had abuse, neglect, and dementia training, this last year and -The Administrator or the Director of Nursing (DON) does the training. During an interview on 7/26/19 at 12:23 P.M., Licensed Practical Nurse (LPN) A said: -The In-services are on the last payday of the month. -The In-services usually last an hour, sometimes longer. -He/she usually works the day of the in-services and gets a printed copy of what was covered. -The last in-service was about: --Handwashing. --Verbal abuse. --How to talk to the residents and --Privacy. -In-services include things that have happened in other places, from the news, and how to address that situation if it were to come up or happen here. -In-services have also covered: --behaviors, and what to do if a resident becomes irate or too physical. --When to call the police if needed and --Falls. During an interview on 7/26/19 at 12:30 P.M., Certified Medication Technician (CMT) A said: -The facility has in-services at the staff meetings. -The staff meetings are at the end of the month and last two hours. -He/she signs in every time he/she attends an in-service. -He/she had abuse, neglect and dementia care in-services and -He/she had 24 hours of in-services over the last year. During an interview on 7/26/19 at 12:34 P.M., the DON said: -He/she didn't know if there was a Facility Assessment and would check with the Administrator. -In-services are held monthly usually on payday. -The Administrator does the in-services. -Some of the in-services include: --Handwashing. --Perineal care. --Monitoring resident meals for the right diet and consistency for each resident. --Abuse, neglect, behavior, and dementia training. -Every staff member should be receiving in-services and training's no matter what shift they work or when their day off is. -Abuse, neglect, behavior, and dementia training's are done yearly. -He/she believes prior to his/her coming to the facility that abuse, neglect, behavior, and dementia were done twice a year. -The Administrator will do the abuse, neglect, behavior, and dementia training more than once a year if there is a need for it and -He/she has not done any staff competency checks since he/she has been here. During an interview on 7/26/19 at 1:42 P.M., the Administrator said: -He/she was not sure where the Facility Assessment would be. -He/she has not done any competency checks on staff since the last state survey. -The DON has only been here since April or May of 2019. -He/she is waiting for the DON to become more oriented to his/her job before having him/her do the competency checks of the staff. -He/she keeps the in-service/training records. -He/she did not have the in-service/training records for the months of: --September 2018; --October 2018; --November 2018; --December 2018 and --May 2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record reviews with the Corporate Maintenance Director (CMD) on 7/24/19 at 8:12 A.M. of the facility's EP plan binder entitled Southside Disaster Information Book, obtained from the South Nurse's Station, and the copy from the Maintenance Office, showed a three page document that did not include the following: -A facility-specific risk assessment that considers the ASHRAE (American Society of Heating, Refrigerating, and Air Conditioning Engineers) industry standard. -A completed CDC (Centers for Disease Control) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -A schematic or diagram of the facility's water system. -A facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other water borne pathogens. -A program and flowchart that identifies and indicates specific potential risk areas of growth within the building. -Assessments of each individual potential risk level. -Testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility. -Facility specific interventions or action plans for when control limits are not met, and -Documentation of any site log book being maintained with any cleanings, sanitizing, descalings, and inspections mentioned. During an interview on 7/24/19 at 9:13 A.M., the CMD said that he/she was unaware of these particular requirements and no risk assessments had been performed. Based on observation, interview and record review, the facility failed to ensure infection control practices were implemented when one staff member failed to properly wash their hands, put on gloves, and sanitize equipment during wound care for one sampled resident (Resident #28); to establish and maintain a comprehensive infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), and to provide documented assessments for such an outbreak out of 15 sampled residents. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility. The facility census was 57 residents. 1. Record review of Resident #28's admission Record face Sheet showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Absence of right leg above the knee and -Polyneuropathy (damage or disease affecting nerves in the same areas on both sides of the body, causing weakness, numbness, and or burning pain). Record review of the resident's Physicians Order Sheet (POS) dated July 2019 showed: -Cymbalta (medication used to treat depression, and pain associated with neuropathy) 60 milligram (mg) by mouth (PO) daily for polyneuropathy start date 5/24/16. -Gabapentin (nerve pain medication) 200 mg PO three times a day (TID) for polyneuropathy start date 8/31/18 and -Silver Nitrate [inorganic chemical with antiseptic activity often used in wound care to help remove and debride hyper-granulation (scar) tissue or calloused rolled edges in wounds] to right above the knee amputation (AKA) and cover with dressing twice a week on Tuesday and Friday start date 4/19/19. Record review of the resident's undated Care Plan showed: -Medication observations for significant side effects dated 11/11/13 and -Physical immobility related to new AKA dated 1/22/19. Record review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 3/8/19 showed he/she had a surgical wound. Observation of the resident's wound care on 7/26/19 at 10:16 A.M., showed Licensed Practical Nurse (LPN) A: -Did not wash his/her hands before setting up wound care supplies. -Removed a pair of scissors from the treatment cart. -Did not clean/sanitize the scissors. -Did not put on gloves. -Opened a package containing an antibiotic foam pad. -Cut a piece of the antibiotic foam pad with the un-clean scissors. -Placed the scissors back into the treatment cart. -Entered the resident's room. -Did not wash hands. -Put on gloves. -Cleaned the small area of keloid (scar tissue) on the right AKA stump with wound cleanser soaked gauze. -Applied the ordered pre-packaged on a swab silver nitrate. -Placed the cut antibiotic foam pad on the keloid(is a type of raised scar. Unlike other raised scars, keloids grow much larger than the wound that caused the scar area). -Covered the resident's leg stump with a dressing and secured with tape. -Removed gloves and placed in a plastic bag with used supplies. -Placed the plastic bag into the trash can in room and -Left the room without washing his/her hands. During an interview on 7/26/19 at 10:30 A.M., LPN A said: -The resident does not have an opened wound. -The resident has keloid tissue on his/her stump that the Physician is treating and -The resident does not have any infection going on with his/her stump. During an interview on 7/26/19 at 10:30 A.M., the Director of Nursing (DON) said: -He/she would expect a nurse to wash hands and put on gloves before setting up dressing change supplies. -He/she would expect a nurse to clean scissors before using them and after using them. -He/she would expect a nurse to wash hands when entering a room. -He/she would expect a nurse to wash hands or sanitize them before putting on gloves. -He/she would expect a nurse to change gloves, wash/sanitize hands and put on new gloves when going from a soiled area to a clean area and -He/she would expect a nurse to remove gloves and wash hands before leaving a room.