**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure odors were not pervasive on the 300 Hall. The facility census was 89 residents. Review of the facility Resident Rights Policy dated 8/2020 showed: -All residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility including those specified in this policy. 1. During an interview on 6/16/25 at 3:18 P.M. Family Member A said: -He/She visited in the facility approximately five times over the last three months. -During the visits there was the presence of strong body odor smell of feces and urine. -The facility is unclean. -He/She was so overwhelmed with the smell he/she was unable to pay attention to anything else. -He/She was unable to stay and visit with his/her family member due to the smell. During an interview on 6/17/25 at 2:15 P.M. the Housekeeping Supervisor said: -If there are odors in the facility, it is not because of housekeeping, it is usually due to resident's medical conditions. -A resident on the 300 hall often has strong odors. -If he/she smell odors he/she will clean and deodorize the area. -Housekeeping staff can get more deodorizers if needed. Observation on 6/17/25 at 2:30 P.M. showed a strong odor around resident room [ROOM NUMBER]-308 and extended throughout the hallway to the activity room at the end of the hall. Observation on 6/18/25 at 1:41 P.M. showed the Regional Registered Nurse Consultant acknowledged the extremely strong odor throughout the 300 Hall. MO00255924

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the failed to ensure an allegation of possible misappropriation of resident's funds was investigated timely when on 5/23/25 Resident #2's family reported a $300 charge from the resident's CashApp on his/her phone out of 12 sampled residents. The facility census was 89 residents. Review of the facility Abuse and Prohibition Program policy dated 10/24/22 showed: -The purpose was to ensure the facility established, operationalized, and maintained an abuse prevention and prohibition program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting abuse, neglect, mistreatment, misappropriation, and crime in accordance with federal and state requirements. -Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. -The facility has a zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. -Staff must not permit anyone to engage in abuse, neglect, mistreatment, or misappropriation of resident property. -The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems. -Facility staff are mandatory reporters. -Facility owners, operators, employees, managers, agents, and contractors are obligated by the Elder Justice Act and any state specific regulations to report known or suspected instances of abuse of elder or dependent adults. -The facility will not impede or inhibit a facility staff member's reporting duties, nor will facility staff be reprimanded or disciplined for reporting abuse. -The facility has a strict non-retaliation policy for good faith reporting in compliance with the Elder Justice Act and any other state specific laws. -Failure to report suspected or known abuse may result in legal action against the individual(s) withholding such information. -In order to facilitate reporting, ensure confidentiality, and promote order at the facility, the administrator, or his/her designee, shall be the individual who reports known or suspected instances of abuse of residents at the facility to the proper authorities. -Facility staff will report known or suspected instances of abuse to the administrator, or his/her designee. -All mandated reporters will report reasonable suspicion of a crime against a resident when it is objectively reasonable for a person to entertain a suspicion of conduct that appears to be financial abuse, physical abuse, neglect, abandonment, isolation, abduction, or other treatment resulting in physical harm or pain or mental suffering, deprivation of goods or services that are necessary to avoid physical harm or mental suffering. -The facility will report allegations including misappropriation of resident property. --Immediately, but no later than two hours after forming the suspicion, if the alleged violation involves abuse or results in serious bodily injury to state survey agency, adult protective services, law enforcement, and the ombudsman. --No later than 24 hours after forming the suspicion, if the alleged violation does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement, and ombudsman. -Reporting requirements are based on real (clock) time, not business hours. -The administrator will provide the state survey agency, law enforcement and the ombudsman with copy of the investigative report within five days of the incident. -Failure to file a report within the required time frames may result in disciplinary action, up to and including termination. -If multiple staff become aware of the same incident, facility staff may choose to submit individual reports or submit a joint report containing each staff member's name and information about the suspected abuse from each staff person. -The facility will post a notice that informs facility staff of their reporting obligation and the right to file a complaint with the Department of Public Health if they feel that they facility has retaliated against them for making the report. -Anyone who fails to report within mandated timeframe's will be subject to a civil money penalty of not more than $200,000 and the covered individual who failed to report may be excluded from participation in any Federal health care program. 1. Review of Resident #2's admission Record showed the resident was admitted on [DATE] with diagnoses including legal blindness, muscle weakness and cognitive communication deficit. During an interview on 5/15/25 at 6:11 P.M. the Hospital Social Worker said: -There were concerns about a $300 charge from the resident's CashApp that was traced back to a nurse in the facility. -He/She was under the understanding law enforcement had been contacted related to the missing money. During an interview on 6/18/25 at 1:46 P.M. the Social Worker said: -He/She had the resident's phone when the family came to retrieved the phone. -The charge nurse had reported to him/her there was another resident going to Resident #2's room asking about the phone repeatedly. -The nurse took the phone and locked it up in the medication cart. -When he/she came into the facility the nurse brought him/her the phone. -The resident's spouse came for the phone. -The phone was dead and was charged in the facility. -When the family looked on the phone and the CashApp was reinstalled and reviewed by the family. -There was an allegation at that time of a transaction the family did not recognize. -The son of the resident stated him/her to find out who did it and to get law enforcement involved. -He/She did interview the nurse and the resident's spouse. -The spouse did not want to file a grievance. -He/She did suggest the spouse dispute the charges. -He/She brought up the allegations the following day in the morning meeting with department heads. -He/She did not contact law enforcement or participate in investigation. -He/She understood the phone was locked up by the nurse two days prior the being turned over to him/her. -He/She did not report the allegations to Department of Health and Senior Services or law enforcement. -He/She was told to complete a grievance about the phone. -He/She completed a grievance on 6/18/25 and gave it to the Administrator. -He/She was a mandated reporter and felt this was a reportable incident. -He/She did not report as the Administrator was aware and usually did the reporting in the facility. During an interview on 6/18/25 at 2:20 P.M. the Human Resource (HR) person said: -He/She was coming upstairs and noticed the family was upset as they came out of the Social Services office and recalled the allegation of misappropriation being discussed in morning meeting. -He/She was a mandated reporter and felt this was a reportable incident. -He/She did not report the allegation as the interim Administrator was aware and usually did the reporting in the facility. During an interview on 6/18/25 at 2:25 P.M. the Business Office Manager (BOM) said: -He/She did recall the allegations being brought up in morning meeting. -He/She was not aware if there was an investigation. -He/She was a mandated reporter and felt this was a reportable incident. -He/She did not report the allegation as the interim Administrator was aware and usually did the reporting in the facility. During an interview on 6/18/25 at 2:37 P.M. the Interim Administrator said: -He/She was filling in for the Administrator who was on medical leave through late April. -The Social Worker mentioned the allegations about the resident's money being taken through a CashApp. -He/She told the Social Worker to see if the family could bring proof of the money transaction. -There was no further information brought to him/her. -He/She asked the son to prove the transaction occurred. -He/She said the Administrator was responsible to investigate allegations of abuse and/or neglect. -He/She did not conduct an investigation because the family would not return his/her calls and no other information was brought to him/her. -He/She did not document his/her attempts to contact the family or the initial allegations. During an interview on 6/24/25 at 11:07 A.M. the Administrator said: -He/She has been in contact with the resident's spouse and has offered to replace the money. -He/She requested the screen shot of the transaction to continue his/her investigation. -He/She asked the Assistant Director of Nursing (ADON) to contact the spouse to obtain information. -The spouse has not provided any information from the resident's phone. -Allegations of misappropriation should be investigated and reported. MO00254321

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the toilets securely in place in the 100 and 300 Hall Spa Rooms, 200 Hall Spa Room toilet was blocked with equipment, 400 Hall Spa Room was inaccessible and the toilet in room [ROOM NUMBER] was inoperable. From 6/15/25 to 6/16/25 Resident #3 was unable to utilize his/her toilet and when using the 100 Hall Spa Room toilet it moved causing him/her to become unbalanced and fearful of using the toilet. Resident #3 then attempted to utilize the 300 Hall Spa Room toilet to find it was not secured. This practice potentially affected all residents who utilized the spa bathroom toilets. The facility census was 89 residents. 1. During an interview on 6/17/25 at 1:56 P.M. the Administrator said: -He/She was informed on 6/15/25 at approximately 4:00 P.M. about a toilet being clogged. -He/She contacted a plumber to fix the toilet. -The plumber was unable to get the toilet fixed and returned the next day. -The plumber was able to unclog the toilet on 6/16/25. During an interview on 6/17/25 at 1:59 P.M. the Maintenance Director said: -There had been no concerns about the shower/spa rooms or work orders for any of them. -There was a concern about a clogged toilet on 6/15/25 which was resolved on 6/16/25. -The resident had access to spa room toilets during the repair of his/her clogged toilet. Observation on 6/18/25 at 1:38 P.M. showed: -The 100 Hall spa (shower) room toilet was not bolted in place. -The toilet was moved easily 90 degrees. Review of Resident #3's admission Record showed the resident was admitted on /22/25 with diagnoses including hemiplegia and hemiparesis (total or partial paralysis of one side of the body that results from disease of or injury to the motor centers of the brain), following a cerebral infarction (stroke) affecting the right dominant side and asthma. During an interview on 6/18/25 at 1:39 P.M. Resident #3 said -He/She was unable to use his/her bathroom [ROOM NUMBER]/15/25 through 6/16/25. -When attempting to use the bathroom in the 100 Hall spa room, the toilet moved causing him/her to become unsteady and fearful of falling and/or injury. -He/She said there were other toilets that were not bolted down as well. Observation on 6/24/25 at 4:09 P.M. showed: -Spa room on 300 Hall, the toilet was not bolted down and moved 90 degrees. -Unable to access 400 Hall Spa room. -200 Hall Spa room filled with equipment, that blocked access to the toilet. During an interview on 6/24/25 at 4:10 P.M. the Assistant Director of Nursing (ADON) said: -He/She was not aware of the toilets not being bolted down in the 100 and 300 Hall spa rooms. -He/She was not able to access the 400 Hall Spa room and was not sure why the door would not open. -He/She was shocked he/she was able to move the toilet 90 degrees with no resistance. -He/She confirmed the toilets were not safe for use. During an interview on 6/24/25 at 4:35 P.M. the Maintenance Director said: -He/She has not received any concerns related to the toilets other than the clogged toilet. -He/She has not been informed of any safety concerns related to any toilets in the facility. -He/She said the 400 Hall Spa room door should open. -The 200 Hall Spa room was used to store extra equipment. -He/She denied knowledge of the 100 and 300 Hall Spa room toilets not being bolted down. -He/She said all toilets should be secured. -He/She will bolt the toilets down immediately. MO00254912

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent physical abuse for two sampled residents (Resident #3 and #4) out of nine sampled residents. The facility census was 94 residents. On 5/7/25, the Administrator was notified of the past non-compliance which occurred on 4/25/25. Facility staff were educated on the root-cause of the abuse and keeping the back patio doorway/area clear. Interventions were put into place to mitigate future occurrences. The deficiency was corrected on 4/26/25. Review of the facility's policy titled Abuse Prevention and Prohibition Program dated August 2020 showed each resident had the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. Review of the facility's policy titled Reporting Abuse showed: -Abuse meant the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -Physical abuse meant assault, battery, assault with a deadly weapon or force likely to produce great bodily injury, unreasonable physical constraint or prolonged or continual deprivation of food or water, sexual assault, use of a physical or chemical restraint or psychotropic medication for punishment or for beyond a period of time that was ordered by a licensed physician, or for any purpose not authorized by the physician. 1. Review of Resident #5's admission record showed he/she admitted to the facility 2/7/24 with the following diagnosis of bilateral amputations of his/her legs. Review of Resident #5's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 3/21/25 showed: -The resident had moderately impaired cognition. -The resident exhibited verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) one to three times within the seven days look back period. Review of Resident #4's Pre-admission Screening and Resident Review (PASRR- a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility regardless of source of payment) dated 9/15/23 showed: -The resident had a diagnosis of Schizophrenia. (a disorder that affects a person's ability to think, feel, and behave clearly). -The resident had an Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). -The resident had a Traumatic Brain Injury (TBI- brain dysfunction caused by an outside source). -The resident had minimal behavioral symptoms related to being withdrawn or depressed. Review of Resident #4's admission record showed he/she re-admitted to the facility 1/16/24 with the following diagnoses: -Paraplegia (the inability to voluntarily move the lower parts of the body). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Schizophrenia . Review of Resident #4's quarterly dated 2/03/25 showed the resident was cognitively intact. Review of video footage of the altercation dated 4/25/25 at 8:21 A.M. showed: -The footage had no sound. -The video footage was two minutes and eight seconds long. -Both residents can be seen outside on the patio. -Resident #4 wheeled up close to the back entrance door of the facility smoking a cigarette. -Resident #5 could be seen in the back area away from the door. -Approximately 20 seconds into the video, Resident #5 could be seen starting to propel his/her wheelchair towards the same door that Resident #4 was in proximity of. -Resident #5 continued towards the door and then became within arms distance of Resident #4 and appeared words were exchanged. -After possible words exchanged Resident #5 pushed Resident #4 out of the way to continue to try to get into the building. -That action caused Resident #4 to become visibly upset and Resident #4 wheeled his/her wheelchair back towards Resident #5. -Resident #5 responded to this by reaching out and grabbing Resident #4's sleeve. -Resident #5 continued to hold Resident #4's sleeve and started to shake Resident #4's arm around. -Resident #4 and Resident #5 also appeared to be exchanging words with each other. -Certified Medication Technician (CMT) A and Activity Assistant A could then be seen exiting the facility to respond to the incident. -At that same time Resident #5 continued to hold Resident #4's sleeve and punched Resident #4 twice in the face. -CMT A then separated the residents. -Resident #4 and Resident #5 continued to communicate with each other even though they had been physically separated. -CMT A then pulled Resident #4's wheelchair back, so Resident #5 could enter the building. -As Resident #5 entered the building he/she could be seen visibly upset by the altercation. -The video footage concluded once Resident #5 entered the building. Review of the facility Investigation Summary for the altercation dated 4/25/25 showed: -Resident #4 and Resident #5 were involved in an altercation. -Both residents had been outside in the back patio area. -Resident #5 had been attempting to get back into the facility and Resident #4 was blocking Resident #5's path. -Both residents became agitated and were bumping wheelchairs against each other. -Both residents were flinging their arms at each other. During an interview on 5/5/25 at 10:45 A.M. Resident #4 said: -He/She had been hit in the head and neck during the altercation. -He/She felt safe at the facility and was not afraid of Resident #5. -He/She had been outside in the smoking area. -Resident #5 hit him/her because he/she had been in the way and he/she needed to go back inside to use the bathroom. During an interview on 5/5/25 at 10:50 A.M. Resident #5 said: -Resident #4 had thrown a cigarette on him/her. -Resident #4 was not supposed to be smoking by the door. During an interview on 5/7/25 at 12:05 P.M. Resident #4 said he/she felt like he/she had not deserved to be hit. Review of a witness statement dated 4/25/25 completed by Activity Assistant A showed: -Resident #4 had been sitting in his/her wheelchair in the walkway area. -Resident #5 had been trying to get through. -Resident #4 continued to smoke his/her cigarette. -Resident #4 and Resident #5 began to argue and were bumping into each other. During an interview on 5/7/25 at 1:06 P.M. Activity Assistant A said: -He/She had been standing by the door to the back patio area. -Resident #4 and Resident #5 started bickering with each other about Resident #4 being in Resident #5's way. -He/She had seen Resident #5 punch Resident #4. During an interview on 5/7/25 at 4:12 P.M. the Assistant Director of Nursing (ADON) said: -He/She was aware that Resident #4 and Resident #5 had been in an altercation but had not seen the video footage. -He/She was unsure of what happened during Resident #4's and Resident #5's altercation. -The staff had been educated after the altercation about keeping the back patio doorway and area clear to prevent further issues. -That intervention seemed to be effective since being put in place. -Staff were responsible for intervening and attempting to re-direct residents when exhibiting verbal behaviors. -If a resident hits another resident it counted as physical abuse. During an interview on 5/7/25 at 4:55 P.M. the Director of Nursing (DON) and Regional Corporate Nurse A said: -Abuse had occurred during the altercation. -The abuse occurred when Resident #5 punched Resident #4. 2. Review of Resident #2's Pre-admission Screening and Resident Review dated 1/7/25 showed: -The resident had Schizophrenia. -The resident had Schizoaffective Disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania or depression). -The resident had an Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). -The resident had Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life. -The resident had Post-Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). -The resident had difficulty in adapting to change. Review of Resident #2's quarterly MDS dated [DATE] showed he/she was cognitively intact. Review of Resident #3's quarterly MDS dated [DATE] showed he/she was cognitively intact. Review of the facility's Investigation Summary dated 5/8/25 showed: -On 5/3/25 Resident #2 and Resident #3 were involved in an altercation with each other. -Resident #3 was sitting in the dining room in his/her wheelchair when Resident #2 approached Resident #3 and stated the resident owed him/her 20.00. -Resident #3 denied owing Resident #2 anything. -This caused Resident #2 to become agitated and allegedly pushed Resident #3 to the ground. -Staff then entered the dining room and noted that Resident #3 was on the ground. -Resident #2 and Resident #3 were separated at that time and told to stay away from each other. -Resident #3 then called the police and the police came to the facility to file a report. -Resident #2 and Resident #3 were also placed on 1:1 monitoring. -Skin assessments were completed for Resident #2 and Resident #3. -Resident #3 had noted injuries to his/her nose and left knee. During an interview on 5/5/25 at approximately 9:30 A.M. Resident #2 said: -He/She thought that Resident #3 was going to hit him/her with his/her cane and was defending himself/herself by deflecting the cane from hitting him/her which caused him/her fall to the ground. -The altercation had occurred in the dining room. -The altercation had started as an argument about money. During an interview on 5/5/25 at 11:50 A.M. Resident #3 said: -Resident #2 had owed him/her money. -He/She went into the dining room to confront Resident #2 about the money. -He/She had been trying to walk away from the incident with his/her cane when Resident #2 had swiped his/her legs from underneath him/her which caused him/her to fall on a table then to the floor. -He/She thought Resident #2 was going to hit him/her. During an interview on 5/7/25 at 4:12 P.M. the ADON said: -Resident #2 mostly exhibited verbal behaviors. -Resident #3 was not known for exhibiting any behaviors. -He/She was unsure of what happened in the altercation between Resident #2 and Resident #3. -He/She knew that the altercation occurred in the dining room and that there had been an argument. During an interview on 5/7/25 at 4:55 P.M. the DON and Regional Nurse Consultant A said: -Resident #2 liked to be noisy with other staff and residents. -Resident #2 should have behavioral monitoring in place prior to 5/7/25. -He/She was unsure why behavioral monitoring was not in place for Resident #2 prior to 5/7/25 and it was possible the incident could have been avoided. MO00253302 & MO00253688

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure written notification to the resident and/or family prior to transfer from the facility for one sampled resident (Resident #10) out of 18 sampled residents. The facility census was 92 residents. Review of the facility Transfer and Discharge policy dated June 2020 showed: -Facility staff will provide the resident with reasonable advance notice of the transfer or discharge before it occurs. 1. Review of Resident #10's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/8/24 showed the resident was moderately cognitively impaired. Review of the resident's Change of Condition progress note dated 12/20/24 showed: -He/She was leaning to his/her right side, his/her mouth also was sliding to his/her right side, he/she was unable to sit upright even after being repositioned and his/her pulse was 105 beats per minute. -His/Her physician was notified, and an order was received to send him/her to the emergency room for evaluation and treatment. -He/She left the facility at 10:30 A.M. in route to hospital emergency room. -There was no mention of written notification to the resident or the resident's family prior to the resident's transfer to hospital. Review of the resident's entire Electronic Medical Record (EMR) showed no written notification to the resident or the resident's family regarding his/her transfer to hospital on [DATE]. Review of the resident's Change in Condition progress note dated 12/23/24 showed during a telephone call, a facility licensed nurse informed the resident's family member that the resident had gone to an emergency room and was then admitted to the hospital. Review of the resident's annual Minimum Data Set (MDS - a federally mandated assessment tool required to be completed by facility staff for care planning) Dated 1/16/25 showed he/she was cognitively intact. During an interview on 2/20/25 the resident said: -He/She had been admitted to hospital a couple of times in the past couple of months. -He/She could not remember if the facility had given him/her written notification of the reason for his/her hospitalization and the name and address of the hospital. During an interview on 2/26/25 at 12:01 P.M. the facility social worker said: -He/She did not provide written notice to the resident or family when a resident was transferred to hospital. -That would be a licensed nurse responsibility since he/she was usually not in the facility when a resident was transferred to hospital. During an interview on 2/26/25 at 12:17 P.M. Licensed Practical Nurse (LPN) B said: -He/She had worked at the facility for over one year. -He/She had never given a resident or a resident's family a written transfer notification with information about the reason for and location of the resident's transfer prior to sending the resident to a hospital. During an interview on 2/26/25 at 12:15 P.M. the Director of Nursing (DON) said: -The licensed nurse on duty at the time of the resident's transfer was responsible for providing written notification regarding the resident's transfer, including the reason for the transfer and the location of the transfer. -He/She was responsible for monitoring to ensure transfer/discharge notices were given to residents/residents' family prior to a resident's transfer or discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure oxygen equipment such as tubing, nebulizer (a machine that converts liquid medication into a fine mist that could be inhaled through a mouthpiece or mask) and Bilevel Positive Airway Pressure machine (BiPAP- a non-invasive ventilator that helps patients breathe by providing two different air pressure levels for inhaling and exhaling) were stored in a clean plastic bag when not in use for two sampled resident's (Resident #55 and #57) and failed to have a physician's order for two sampled residents to use a nebulizer and/or BiPAP (Resident #55 and #57) out of 18 sampled residents. The facility census was 92 residents. Review of the facility's policy, BiPAP Support, revised 5/2015 showed: -A physician's order is required to initiate BiPAP support and should include BiPAP settings as prescribed. -All BiPAP equipment should be cleaned and stored per general cleaning storage guidelines. Review of the facility's policy, Oxygen Administration, dated 6/2020 showed: -A physician's order was required to initiate oxygen therapy. -All oxygen tubing, humidifiers, masks, and cannulas used to deliver oxygen would be changed weekly and when visibly soiled. -Oxygen items would have been stored in a plastic bag at the resident's bedside to protect the equipment from dust and dirt when not in use. 1. Review of Resident #55's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). -Obstructive Sleep Apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Review of the resident' care plan dated 1/27/25 showed: -He/She had COPD. -Staff was to administer oxygen as ordered if ordered, dated 8/28/23. -Staff was to give aerosol (treatment) as ordered, dated 8/28/23. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 2/3/25 showed: -He/She was cognitively intact. -He/She had COPD. -Respiratory treatment was not checked. Review of the resident's February 2025 Physician's Order Sheet (POS) did not show an order for a nebulizer treatment. Observation on 2/19/25 at 12:27 P.M. showed a nebulizer mouthpiece was sitting on the resident's night stand not in a bag. There was no bag to store the nebulizer mouthpiece in. Observation on 2/20/25 at 9:27 A.M. showed a nebulizer mouthpiece was sitting on the resident's night stand not in a bag. There was no bag to store the nebulizer mouthpiece in. Observation on 2/21/25 at 11:30 A.M. showed a nebulizer mouthpiece was hanging off the side of the resident's night stand not in a bag. There was no bag to store the nebulizer mouthpiece in. 4. Observation and interview on 2/26/25 11:46 A.M. with Licensed Practical Nurse (LPN) A showed: -The nebulizer was on the resident's nightstand and the mouthpiece was not in a bag. -The LPN A said he/she could not find an order for the nebulizer but the resident had COPD. -The nebulizer must have been the roommates. -The LPN A removed the nebulizer from the resident's room. During an interview on 2/24/25 at 1:30 P.M. the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) said: -A nebulizer pipe (mouthpiece) or oxygen equipment should have been in a bag with the date written on it showing when it was changed. -The nebulizer pipe (mouthpiece) should have been cleaned daily and then air dried then put into a bag to keep it clean. -There should have been an physician's order for any type of oxygen. -The nurse was responsible to ensure oxygen equipment was kept in a bag when not in use. During an interview on 2/26/25 at 9:37 A.M. LPN B said: -When oxygen equipment such as the nebulizer was not in use it should have been in a bag to ensure it was kept clean. -There should have been a date on the bag or the tubing indicating when it was changed, it should have been changed weekly. -The nebulizer pipe (mouthpiece) and tubing should not have been hanging off the side of the resident's nightstand. -Nursing was responsible to ensure the oxygen equipment was changed out weekly, kept in a bag with the date it had been changed written on it. During an interview on 2/26/25 at 12:10 P.M. the Director of Nursing (DON) said: -There should have been an order for a resident to have oxygen or oxygen equipment. -The resident did not have an order for the nebulizer. -The oxygen equipment should have been hanging off of the nightstand. -Nursing was responsible to ensure the oxygen equipment was kept in a sanitary condition. -The oxygen equipment when not in use should have been kept in a bag with the date it had been changed written on it. During an interview on 2/26/25 at 1:30 the resident said: -The staff did not put the nebulizer mouthpiece in a bag when not in use, there was no bag in the room. -Someone had stolen his/her nebulizer in the last hour or so. -The nebulizer was his/her personal machine. -He/She still used it. -The nursing staff provided the medication for the nebulizer machine. -He/She had a treatment the day before. -He/She did not know how they got the medication for the nebulizer if they did not have a physician's order for it. 2. Review of Resident #57's Face Sheet showed the resident was admitted to the facility on [DATE] with the following diagnoses: -Abnormalities of breathing. -Heart failure. Review of the resident's Electronic POS dated 2/2025 showed he/she had no orders for BiPAP. During an observation and interview on 2/19/25 at 9:46 A.M., showed: -The resident had a BiPAP at least a couple of weeks. -The resident had not seen staff clean or cover the mask. -The mask was observed in the resident's top dresser drawer uncovered. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She was not using BiPAP. Review of the resident's care plan on 2/25/25 showed: -His/Her care plan was last reviewed/revised on 12/19/24. --Note: The care plan had not addressed BiPAP. Review of the resident's Electronic Medical Record on 2/25/25 showed he/she had a physician consult sheet dated 1/15/25 that showed new BiPAP and pressure setting ordered by his/her physician. During an interview on 2/26/25 at 9:39 A.M., Certified Nursing Assistant (CNA) A said: -Resident masks should be placed in a plastic bag when not in use. -Charge nurses are responsible for resident BiPAP machines. -If a resident has a BiPAP it should be in his/her care plan that is located at the nursing station. -He/She was not aware that Resident #57 had a BiPAP. During an interview on 2/26/25 at 9:46 A.M., Certified Medication Technician (CMT) A said: -He/She has worked at the facility for three years. -Masked should be covered when not in use. -The charge nurse is responsible for the resident BiPAP machines. -BiPAP's should have orders. -The Unit Managers are responsible for updating resident care plans. During an interview on 2/26/25 at 10:07 A.M., LPN A said: -Residents who have BiPAP's should have physician orders for settings and care for the machine. -The charge nurses are responsible obtaining BiPAP orders. -The MDS nurse is responsible to update the resident care plans. -He/She is updated in daily nursing report of any resident changes. -He/She was not aware that Resident #57 had a BiPAP. During an interview on 2/26/25 at 10:12 A.M., the MDS nurse said: -He/She had worked at the facility for five years. -He/She was responsible for the resident care plans. -He/She reviews new orders and updates the care plans. -He/She was not aware that Resident #57 had a new order for BiPAP. -Physician consults are reviewed during morning meetings for any new orders. During an interview 2/26/25 at 12:10 P.M., the DON said: -He/She would expect there would be orders including care if the BiPAP. -All new orders are reviewed in morning meetings and care plans updated. -He/She is responsible that orders are written and the care plans are updated. -He/She was not aware that Resident #57 did not have BiPAP orders written related to a physician consult from 1/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure documentation related to attending the dialysis (a procedure that filters the blood when the kidneys were no longer able to do so) unit and coming back from the dialysis unit was completely filled out and accurate for four sampled dialysis residents, (Residents #10, #23, #32, and #33), and failed to document assessments in the computer in a consistent manner for two sampled resident, (Resident# 23, Resident #32) out of 19 sampled residents. The facility census was 92 residents. Review of the facility Dialysis Care policy dated June 2022 showed: -The facility was responsible for the overall care delivered to the resident, monitoring of the resident prior to and after the completion of each dialysis treatment, and providing for all non-dialysis needs off the residents including during the time period when the resident was receiving dialysis. -The facility maintained a contract with a dialysis service provider which addresses communications between the facility and the provider. -The facility would provide a method of communication between the dialysis provider and the facility. -Nursing staff would communicate pertinent information in writing to the Dialysis staff which might include medication changes, recent changes in condition and the resident's tolerance of dialysis. -The dialysis provider would communicate in writing to the facility the resident's current vital signs (temperature, heart rate, breathing rate, and blood pressure), pre and post dialysis weight and any problems encountered while the resident was at the dialysis provider. -The nursing staff would keep the resident's attending physician, the resident and the resident's family informed of any change in the resident's condition. -(The Facility) would inspect the shunt site (a surgical connection of an artery and a vein for dialysis) area for color, warmth, redness, tenderness, pain, edema, drainage, and bruit (the whooshing sound) one per shift. -(The Facility) would check for a bruit (a pulsation felt of blood flowing through the ateriovenous anastmomosis (shunt site). -Place your fingertip slightly over the vein and feel for the thrill. -Place the stethoscope over the vein and listen for the buzz or bruit. -Document the findings in the medical record. -The dialysis provider and the resident's attending practitioner (medical professional including physicians and nurse practitioner with advanced education and licensed to diagnose and treat health conditions) must be notified of a canceled or postponed dialysis treatment and responses to the change in treatment must be documented in the resident's medical record. -If dialysis was canceled or postponed, the nursing staff and dialysis provider should provide or obtain ongoing monitoring and medical management for changes such as fluid gain, respiratory issues, reviews of relevant lab results, and any other complications until dialysis can be rescheduled based on resident assessment, stability and need. -Nursing staff were to use the Nurses Dialysis Communication Record or comparable form to convey information to the dialysis provider. -All documentation concerning dialysis services and care of the dialysis resident would be maintained in the resident's medical record. Review of the facility Dialysis and Nursing Home Handoff Communication Tool, undated showed: -A section for Information to be completed by nursing home and sent with the resident for each dialysis treatment. -A section to be completed by dialysis and returned with the resident for each dialysis treatment that included pre-dialysis weight, post-dialysis weight, problems during dialysis, amount of fluid removed, post dialysis vitals, labs drawn yes/no, copy of lab results attached yes/no, updated physician (MD) orders attached yes/no. did dietitian make recommendations, did social worker make recommendations, food/fluid consumed during dialysis, percentage meal consumed, fluids consumed, medications given during dialysis - anemia (low red blood cell count) medications, other medications, vascular access (where the dialysis machine connects to the bloodstream during dialysis treatments) condition, dialysis nurse's signature and date. 1. Review of Resident # 10's electronic medical record on 2/19/25 through 2/26/25 showed: -He/She was admitted to the facility on [DATE]. -He/She had a physician's order for dialysis on Tuesday, Thursday and Saturday. -There were a total of four Dialysis and Nursing Home Handoff Communication Tools dated 1/30/24, 2/4/25, 2/8/25 and 2/11/25. Review of the resident's Dialysis and Nursing Home Handoff Communication Tool dated 1/30/25, 2/4/25 showed: -The section to be completed by dialysis had only the resident's pre-dialysis weight and a post-dialysis weight, pulse and blood pressure. -No additional information was documented by the dialysis staff and/or facility staff. Record review of the residents Dialysis and Nursing Home Handoff Communication Tool dated 2/11/25 showed: -The section to be completed by dialysis had only the resident's pre-dialysis but not the resident's post-dialysis weight, temperature, respiratory rate and blood pressure and the area for problems showed he/she was taken off dialysis early. -No additional information was documented by the dialysis staff and/or facility staff. Review of the resident's Nursing Progress Notes dated 1/1/25 through 2/26/25 showed: -No documentation of facility licensed nurse follow-up with dialysis regarding any missing dialysis communication forms. -No documentation of facility licensed nurse follow-up with dialysis regarding any missing information on the resident's 1/30/25 2/5/25, and 2/11/25 dialysis communication forms. During an interview on 2/25/25 at 3:55 P.M. the Director of Nursing (DON) said: -The resident had been going to dialysis three times a week, there should be more dialysis communication forms than the three in his/her EMR. -There might be more dialysis communication forms waiting to be uploaded to the resident's EMR. -He/She would check with medical records to see if there were additional dialysis communication forms not in the resident's medical record and would bring any dialysis communication forms found in medical records to the surveyor. -Note: At the time of the survey exit on 3/5/25 no additional dialysis communication forms for the resident were provided to the survey team. 2. Review of Resident #23's face sheet showed he/she was re-admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease (ESRD - a permanent condition in which the kidneys are no longer able to function), dated 6/26/24. Review of the resident's care plan dated 1/7/25 showed: -He/She received dialysis on Monday, Wednesday, and Friday. -Staff was to auscultate Bruit and palpate Thrill to fistula/shunt every shift. Notify physician of abnormalities or absence, dated 7/11/24. -Staff was to monitor site as ordered. Review of the Entry Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 1/21/25 showed: -He/She was moderately cognitively impaired. -He/She had ESRD. Review of the January 2025, Dialysis Communication Tool received by the facility on 2/21/25 at 8:37 A.M. showed: -No documentation before 1/17/25 was in the resident's chart. -The Communication Tool dated 1/17/25 showed: -The Pre dialysis weight was 81.1. -The Post dialysis weight was 81.1. -462 milliliters of fluid was removed. -No fluid was added. -There was no other Dialysis Communication Tools for January (missing 12). --NOTE: The facility did not have this documentation at the time of survey. The facility contacted the dialysis center for the information after it was requested during survey. Review of the resident's January Nurses' Administration Record showed: -Staff was to assess the resident's dialysis right arm shunt site every shift for signs/symptoms of infection, bleeding, pulsation or aneurysm dated 1/21/25. -Out of 30 opportunities the staff documented: -(n) 27 times. -(no/-) twice. -NA once. -None of the above were in the chart code (approved abbreviations to have been used by the nursing staff in documentation). Review of the resident's February 2025 Physician's Order Sheet (POS) showed the following orders: -Assess the resident's dialysis device graft/fistula in right arm. Monitor for bruit/thrill every shift related to ESRD, dated 1/22/25. -Assess dialysis right arm shunt site every shift for signs/symptoms of infection, bleeding, pulsation or aneurysm every shift, dated 1/22/25. -Dialysis treatment on Tuesday, Thursday, and Saturday. Review of the February Nurses' Administration Record showed: -Staff was to assess the resident's dialysis right arm shunt site every shift for signs/symptoms of infection, bleeding, pulsation or aneurysm dated 1/21/25. -Out of 61 opportunities the staff documented: -(n) 50 times. -(m) twice. -NA six times. -(no/-) three times. -None of the above were in the chart code. Review of the February 2025, Dialysis Communication Tools received by the facility on 2/21/25 at 8:37 A.M. showed: -No documentation for the following days; 2/3, 2/5, 2/14, and 2/19. -Documentation on 2/17 was not completed by dialysis unit. -There was no documentation the dialysis unit had been contacted to retrieve the information. --NOTE: The facility did not have this documentation at the time of survey. The facility contacted the dialysis center for the information after it was requested during survey. During an interview on 2/21/25 at 1:30 P.M. the DON said: -There was no Communication Tool from the Dialysis unit before 1/17/25 for this resident. -They must have done something different at the dialysis unit for the weight to have been the same before and after treatment. -He/She would not have expected the facility staff to have question the weight being the same before and after treatment. -Documentation from the dialysis unit did not show the resident had any extra treatments. -He/She would have expected there to have been a Communication Tool to have came back with the resident after every treatment and that it was completely filled out. -The Communication Tool should have been downloaded into the resident's chart every week. -He/She would have expected nursing staff to have ensured the Communication Tool came back with the resident and if that was not done staff should have called the dialysis unit to have them fax the document, this has not been done. 3. Review of Resident #32's face sheet showed he/she had been admitted to the facility on [DATE] with a diagnosis of Acute Kidney Failure. Review of the resident's January 2025, Dialysis Communication Tools received by the facility on 2/21/25 at 8:37 A.M. showed: -There were two Dialysis Communication Tools dated 1/1/25 by the facility. -(A) showed the date on the facility's section was 1/1/25. -The date on the dialysis section was 12/30/24. -(B) showed the date on the facility's section was 1/1/25. -The date on the dialysis section was 1/1/25. -Documentation on 1/8/25 did not show a code status (a person's predetermined medical instructions regarding the use of life-saving measures in the event they stop breathing) on the facility's section. -Documentation on 1/10/25 was a different form. The form did not have a place for the resident's code status, nor was it documented anywhere on the facility's section. -Documentation on 1/13/25 did not show a code status on the facility's section. -Documentation on 1/13/25 was a different form. The form did not have a place for the resident's code status, nor was it documented anywhere on the facility's section. -Documentation on 1/15/25 did not show a code status on the facility's section. -Documentation on 1/15/25 was a different form. The form did not have a place for the resident's code status, nor was it documented anywhere on the facility's section. --The pre dialysis weight was documented by the dialysis unit as 119/68. --The post dialysis weight was documented by the dialysis unit as 119/68. -Documentation on 1/17/25 did not show a code status on the facility's section. -Documentation on 1/17/25 was on a different form. The form did not have a place for the resident's code status, nor was it documented anywhere on the facility's section. -There was no documentation on 1/20/25. -Documentation on 1/27/25 was not completed by the facility or the dialysis unit. -There was no Dialysis Communication tool on 1/29/25. -There was no Dialysis Communication tool on 1/31/25. --NOTE: The facility did not have documentation from 1/1/25 -1/27/25 at the time of survey. The facility contacted the dialysis center for the information after it was requested during survey. Review of the resident's January 2025 Nurses' Administration Record showed: -Upon return from dialysis palpate the resident's right arm shunt for thrill and listen for the bruit. Repeat twice within eight hours post dialysis. -If either was absent notify the physician and document findings. -Check the bruit and thrill every shift routinely, every Monday, Wednesday, and Friday. -Document Y for audible bruit and thrill. -Document N if there were no audible sound and notify the physician immediately, dated 4/10/24. -Out of 93 opportunities (three times 31 days) there was no Y or N they were marked with an X. -X was not in the chart code. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She had ESRD. -He/She was on dialysis. Review of the resident's February 2025 Nurses' Administration Record showed: -Upon return from dialysis palpate the resident's right arm shunt for thrill and listen for the bruit. Repeat twice within eight hours post dialysis. -If either was absent notify the physician and document findings. -Check the bruit and thrill every shift routinely, every Monday, Wednesday, and Friday. -Document Y for audible bruit and thrill. -Document N if there were no audible sound and notify the physician immediately, dated 4/10/24. -Out of 70 opportunities (three times 31 days) 43 times they were marked with an X. -X was not in the chart code. -N was marked 23 times, there was no documentation the physician was notified. -There were four Vs. Review of the resident's February 2025 POS showed the following orders: -Dialysis on Monday, Wednesday, and Fridays, dated 7/1/24. -Upon return from dialysis palpate right arm shunt for thrill and listen for the bruit. Repeat twice within eight hours post dialysis. -If either was absent notify the physician and document findings. -Check the bruit and thrill every shift routinely, every Monday, Wednesday, and Friday. -Document Y for audible bruit and thrill. -Document N if there were no audible sound and notify the physician immediately, dated 4/10/24. Review of the resident's care plan dated 2/5/25 showed: -He/She was to receive dialysis three times a week on Monday, Wednesday, and Friday. -Staff was to Auscultate the Bruit and palpate the Thrill to the right arm shunt every shift. -Staff was to notify the physician of abnormalities or absence. -Monitor the dialysis site as ordered. -Monitor vital signs before and after Dialysis. Review of the resident's February 2025, Dialysis Communication Tools received by the facility on 2/21/25 at 8:37 A.M. showed: -There was no Dialysis Communication Tool on 2/3/25. -Documentation on 2/5/25 was blank (not completed by the dialysis unit). -Documentation on 2/7/25 was blank (not completed by the dialysis unit). -There was no Dialysis Communication tool on 2/10/25. -Documentation on 2/12/25 was blank (not completed by the dialysis unit). -Documentation on 2/14/25 did not include vital signs taken by the facility. --NOTE: The facility did not have this documentation at the time of survey. The facility contacted the dialysis center for the information after it was requested during survey. 4. Review of Resident #33's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of ESRD. Review of the resident's care plan dated 1/13/25 showed: -He/She had a behavior problem and would refuse to go to dialysis. -He/She received dialysis. Review of the quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She had ESRD. -He/She was on dialysis. Review of the resident's January 2025, Dialysis Communication Tools received by the facility on 2/21/25 at 9:37 AM. showed: -There was no documentation showing that the resident went to dialysis or refused to go to dialysis from 1/2/25 to 1/15/25, missing five dates. -Documentation on 1/17/25 was a different form. The form did not have a place for the resident's code status, nor was it documented anywhere on the facility's section. -There was no documentation showing that the resident went to dialysis or refused to go to dialysis from 1/18/25 to 1/31/25, missing six dates. --NOTE: The facility did not have this documentation at the time of survey. The facility contacted the dialysis center for the information after it was requested during survey. Review of the resident's February 2025, Dialysis Communication Tools received by the facility on 2/21/25 at 9:37 A.M. showed: -On 2/5/25 there was no documentation showing that the resident went to dialysis or refused to go to dialysis. -On 2/12/25 there was no code status on the facility's part of the Dialysis Communication Tool. -There was no post dialysis weight documented by the dialysis unit. -There was no documentation showing that the resident went to dialysis or refused to go to dialysis on 2/14/25 or 2/17/25. --NOTE: The facility did not have this documentation at the time of survey. The facility contacted the dialysis center for the information after it was requested during survey. Review of the resident's February 2025 POS showed a physician order for Dialysis three times a week on Monday, Wednesday, and Friday, dated 12/9/24. During an interview on 2/19/25 at 11:15 A.M. the resident said: -He/She has a Peripherally Inserted Central Catheter (PICC a long think flexible tube inserted into a person vein in the arm) line on his/her chest. -Staff did not look at the PICC site when he/she would return from dialysis. -The resident some times refuses dialysis. -The staff was supposed to have sent a sheet with his/her vitals on it to the dialysis unit and he/she was supposed to have brought the sheet back from the dialysis unit with the dialysis information on it. He/She would give the dialysis staff the notebook when he/she went to dialysis, but he/she did not look in the notebook. -He/She did not look in the notebook, so he/she may have taken an empty notebook back and forth. During an interview on 2/21/25 at 10:30 A. M .,Licensed Practical Nurse (LPN) A said: -The resident had a PICC line in her chest and they did dialysis through that line. -This resident was his/her own person and often refused to go to dialysis. -If the resident refused, they were to document on his/her medical record as well as the Dialysis Communication Record that the resident had refused. -He/She ensured the resident's refusal had been documented but did not think other staff did. -On the Dialysis Communication Record should have been completely filled out with the vital signs, code status and the other information on the sheet. -The dialysis unit was to completely and accurately complete their part of the Dialysis Communication Record. -The dialysis unit should have ensured the resident's pre and post weights as well as vital signs and any difficulties. -There should have been a Dialysis Communication Sheet filled out completely by the facility and the dialysis unit that was accurate every time the resident went to dialysis. -If a Dialysis Communication Sheet did not come back from the dialysis unit the receiving nurse should have called the dialysis unit to have it faxed back to the facility. -That did not always happen. -The receiving nurse should have seen that the resident's weight was the same before and after dialysis there might have been a reason but there was no not stating why the weight was the same. -The nursing staff should have documented the dialysis site assessment the same way and it was not being done. -He/She could not tell what the documentation concerning the dialysis site meant. -He/She said maybe they need some education. -The DON was ultimately responsible for ensure documentation was done correctly and accurately every time. -The resident had a dialysis notebook that he/she was to take to dialysis and had them fill out, bring it back and upload the information weekly. -They have called the dialysis center to notify them the notes have not been coming back with the residents and they were still not sending the notebook with documentation back as they should. 5. During an interview on 2/24/25 at 1:30 P.M. the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) said: -The receiving nurse should have looked at the dialysis notes from the dialysis unit to ensure that they were completely filled out and were accurate. -He/She could not think of a reason that the pre and post dialysis weights would have been the same. -If the dialysis unit did not send a note back or it was incomplete the nurse should have called the dialysis unit back to retrieve the note. -If a resident refused to go to dialysis then it should have been documented in the Nurses' Notes. -The assessment of the dialysis site on the Nurses' Administration record should have been recorded as Y (yes there was an infection or bleeding at the site) or N (no bleeding or infection) the staff has not been doing that. -The DON was ultimately responsible for ensuring there was complete and accurate documentation that went to the dialysis unit and came back from the dialysis unit every time. During an interview on 2/26/25 at 9:37 A.M. LPN C said: -There are several residents that go out to dialysis. -If a resident declined to go out to dialysis it should have been charted in the Nurses' Notes. -The resident should have received education and the physician should have been notified. -The note from the facility should have included vital signs and code status. -The note when it came back from dialysis should have been viewed by the receiving nurse to ensure it was filled out completely and correctly. -The note should have included pre and post weights and vital signs as well as anything unusual. -The dialysis unit did not always send the note back. -The receiving nurse would have then contacted the dialysis unit to retrieve the documentation. -It has been a struggle to get the note from the dialysis unit. -The weights should never have been the same as they take fluid off of the resident. -The dialysis shunt should always have been assessed to ensure there was not bleeding or infection. -The documentation would have been on the progress notes not the nurses' notes. -The thrill should have been document as (+) if it was felt. -If the thrill was not felt then it should have been documented as (-). -The staff was documenting the assessments many different ways and was not able to understand their documentation. -The DON was ultimately responsible for ensuring staff was documenting correctly and documentation came back from the dialysis unit every time a resident went to dialysis. During an interview on 2/26/25 at 12:10 P.M. the DON said: -The facility should have had written communication with the dialysis unit. -There was a sheet that was started at the facility then went to the dialysis unit in a binder with the resident. -The sheet should have been filled out by both the facility and the dialysis unit then it would have been sent to Medical Records to have been downloaded into the resident's medical record. -The sheet should have included vital signs and weights before and after dialysis. -The facility licensed nurse on duty at the time of the resident return from dialysis assesses the resident's vital signs and dialysis access and reviews the resident's dialysis communication form and if there is missing information, the licensed nurse should then contact the dialysis center and obtain the missing information and should confirm any information regarding the resident's pre and post-dialysis weights as needed. -The DON should have been notified if a resident did not have three completed sheets from dialysis every week. This has not been done. -If a resident refused to go to dialysis then it should have been document in their chart. -The sheet the facility filled out should have included a code status. -If the resident's weight was the same pre and post dialysis he/she would have expected the nurse to have called the dialysis unit to find out why. -They have had a lot of issues with the dialysis unit sending the sheets back with the resident. -Staff should have documented the shunt assessment in the same way not three or four different ways. They should have all charted the same way. -He/She was ultimately responsible for ensuring staff was documenting the same way. -He/She had not audited the dialysis notebooks or assessments.

Based on observation, interview and record review, the facility failed to post staffing information that consistently included the facility name, daily census, and the actual hours worked per shift for each of the three categories of nursing employees: Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs)/Certified Medication Technicians (CMTs) directly responsible for resident care. The facility census was 92 residents. Review of the facility's Nurse Staffing Posting Policy, revised June 2020 showed: -The facility would post the staffing on a daily basis and would have included: --Facility name. --The current date. --The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: ---RN's. ---LPN's. ---CNA's. --Resident Census -The facility would post the nursing data specified above, on a daily basis at the beginning of each shift. -Data must be posted in a clear and readable format and in a prominent place accessible to residents and visitors. 1. Observations on 2/19/25 at 11:15 A.M., 2/20/25 at 9:30 A.M., and 2/21/25 at 9:50 A.M., showed the posted staffing sheet did not show the total number worked for RN's, LPN's, or CNA's. During an interview on 2/24/25 at 1:16 P.M., Staffing Coordinator said: -He/She filled out the form the facility used for staffing. -The form did not have a space for actual hours worked for all staff by job title. -If the form had that spot he/she would have filled it in. -He/She did not know that he/she needed total hours worked per job title. During an interview on 2/26/25 at 11:05 A.M., the Administrator said: -He/She the Staffing Coordinator filled out and posted the form. -The Staffing Coordinator was responsible for filling out the staffing form. -He/She was unaware that the form needed total hours worked per job title. During an interview on 2/26/25 at 12:11 P.M., the (Director of Nursing) DON said: -He/She did not fill out the daily staffing form. -He/She did not verify that this was done. -It was his/her expectation that the staffing would be posted daily with the required information. -He/She did not realize the facility had been using the wrong form without all the required information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were not left at the bedside unattended for three sampled residents (Residents #53, #57, and #23), out of 19 sampled residents, failed to ensure medication carts were maintained and locked when unattended by staff, failed to maintain cleanliness in the medication room, and failed to maintain the medication refrigerator temperatures within recommended ranges. The facility census was 92 residents. Review of the facility's policy, Storage of Medications, dated 8/2020 showed: -Medications and biologicals were to have been stored safely, securely, and properly, following manufacturer's recommendations. -The medication supply was accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. -Medication rooms, carts, and medication supplies were to have been locked when they were not attended by persons with authorized access. -Medication storage areas were to have been kept clean, well-lit, and free of clutter and extreme temperatures and humidity. -Medication storage conditions were to have been monitored on a regular basis by the consultant pharmacist and corrective action was to have been taken if problems were identified. -All medications were to have been maintained within the temperature ranges noticed in the United States Pharmacopeia and by the Centers for Disease Control (CDC). -Refrigeration was to have been 36 degrees Fahrenheit (F) to 46 F degrees, with a thermometer to allow temperature monitoring. -The facility should have checked the refrigerator in which vaccines were stored at least two times a day, per CDC guideline. Policy for medication administration was requested and was not provided. Review of The Nursing Drug Handbook 2017 retrieved on 3/6/25 showed: -Insulins: Store unopened insulin lispro (a rapid acting insulin) pens between 36 degrees F to 46 degrees F. Do not freeze. Do not use if frozen. --Insulin Lispro pens included: Admelog and Humalog. -Insulins: Store unopened insulin glargine (a long acting insulin) pens between 36 degrees F to 46 degrees F. Do not freeze. Discard if frozen. --Insulin Glargine pens included: Semglee and Lantus. 1. Observation on 2/24/25 at 7:15 A.M. of the medication pass on the south hallway with Licensed Practical Nurse (LPN) A showed: -He/She went into a resident's room to wash his/her hands. -He/She had left the medication cart facing outward in the hall, unlocked while in the room. -An unidentified resident rolled by the unlocked medication cart in his/her wheelchair. Observation on 2/24/25 at 7:20 A.M. of the medication pass on the south hallway with LPN A showed: -He/She came out to the medication cart to obtain the equipment to check the resident's blood sugar. -He/She left the cart unlocked facing outward in the hall while he/she went into the room to take the resident's blood sugar. -An unidentified resident walked by the outward facing in the hall unlocked cart. Observation on 2/24/25 at 7:48 A.M. of the nurses' medication cart on the south hallway with LPN A showed: -There was a large pink stain in the bottom of the first drawer which contained residents prescribed medications. -There was one round pink pill loose in the bottom of the medication drawer. -There was one half of a round blue pill loose in the bottom of the medication drawer. -In the top drawer with resident's prescribed medication there were the following items: --A used hair clip. --A lighter. --Two sets of car fobs to an unknown person's car. --A pair of used tweezers. Observation and record review on 2/24/25 at 8:13 A.M. of the medication room on the south hallway with LPN A showed: -There was no documentation of the medication refrigerators temperature on the Temperature log for the last two days. -The temperature documented the previous six days was at 32 F degrees or lower. -The Temperature Log said to maintain refrigerator temperature at 36 to 41 degrees F. -In the medication refrigerator there were the following medications: -Three vials of Tuberculin (TB - a sterile liquid used in a skin test to help diagnose tuberculosis -a serious bacterial infection that infects the lungs). -On the TB box it showed to not freeze, and was to have been stored at 36 to 46 F degrees. -Five Semglee unopened insulin pens. -Five unopened Admelog solostar insulin pens. -Four unopened Humalog insulin pens. -Four unopened Lantus insulin pens. -There was one round tan pill on the floor. -The only sink in the medication room was dirty with rust. -There was no paper towels so staff could wash and dry their hands. During an interview on 2/24/25 8:15 A.M., LPN A said: -The medication carts should always have been locked if you were not in front of it using it. -There should not have been a pink stain in the drawer it was probably from an old medication that had spilled. -There should not have been any loose pills in the drawers or on the floor. -There should not have been any personal items in the medication cart. -Whoever had used the medication cart should have ensured it was cleaned at the end of their shift. -Dietary was in charge of checking the refrigerator temperatures. -The temperature of the medication refrigerator should have been checked daily by the night nurse. -The temperature of the medication refrigerator should not have been below freezing, 32 F degrees. -Pharmacy should have been notified that the medications had been stored at a temperature less than freezing to see what they recommended and that had not been done as far as he/she knew. -If the temperature was out of range maintenance should have been notified and that had not been done. -Housekeeping should have ensured the sink in the medication room was clean and that there were paper towels so nursing staff could wash their hands, they had been out of paper towels several days. -He/She did not think that the sink had been cleaned for a while. 2. Observation on 2/24/25 at 8:50 A.M. of the Certified Medication Technician (CMT) cart on the south hallway with CMT A showed: -The following loose pills were found in the drawers of the medication cart: -One white round pill. -One peach colored oblong pill. -One red capsule. -One white oblong pill. During an interview on 2/24/25 at 9:00 A.M. CMT A said: -Whoever was on the medication cart should have kept it clean. -There should not have been any loose pills in the drawers or on the floor. -Twice in the last month he/she had seen pills on the floor. -He/She would tell the nurse then pick up the pills from the floor and throw them away. -The medication carts should have been locked if you were not in front of it as there were some residents who would have tried to take something out of it. -There should not have been any personal items in the medication cart. -The housekeeper should have ensured the medication room sink was cleaned daily and that there were paper towels so you could have dried your hands after washing them. -The Unit Manager should have ensured the medication refrigerator was kept within the temperature range. During an interview on 2/24/25 at 1:30 P.M. the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) said: -There should not have been any loose pills or other objects in the medication cart with the residents medications. -There should not have been any pills on the floor. -The nurse was responsible for ensuring the temperature of the medication refrigerator was within range and checked every night. -If it was not within the range 36 to 46 degrees maintenance should have been notified. -The medication cart should not have been unlocked if he/she was not using it. -The nurse was responsible for ensuring the temperature of the medication refrigerator was within range and checked every night. -If it was not within the range 36 to 46 degrees maintenance should have been notified. -The medication cart should not have been unlocked if he/she was not using it. During an interview on 2/26/25 at 12:10 P.M. the Director of Nursing (DON) said: -There should not have been any medication found on the floor. -There should not have been any loose pills in the medication carts. -There should not have been any personal items in with the residents' medications. -The medication cart should have been cleaned after each shift by the staff member who used it. -The medication cart should have been locked if staff was not directly in front of it. -The nursing staff was responsible for ensuring the medication room was clean and that they had supplies such as the paper towels in it. -The nursing staff should have checked the medication refrigerator at least daily to ensure the temperature was within range and that none of the medications had been frozen. -The Charge Nurse was responsible for ensuring the medication refrigerator was checked to ensure it was within range and not below 32 degrees F. -If the medication refrigerator was out of range the DON should have been notified, he/she had not been told it had been out of range. -He/She could have readjusted the temperature and rechecked to ensure it was within range. -If medication such as insulin had been frozen it should have been thrown away and new insulin ordered from the pharmacy. 3. Observation on 2/26/25 at 9:45 A.M., north nursing station medication cart showed: -Left unlocked facing outwards toward the hallway and unattended by staff. -One resident observed to roll by in his/her wheelchair past the medication cart while unlocked. 4. Review of Resident #23's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Seizures (uncontrolled jerking, loss of consciousness, blank stares, or other symptoms caused by abnormal electrical activity in the brain). -Heart failure (a condition in which the heart does not pump blood as well as it should). -Hemiplegia and Hemiparesis following cerebral infarction affecting right non-dominate side (a condition that causes weakness or paralysis (loss of muscle function) on on side of the body after blood flow to the brain was reduced. -Dysphagia (a difficulty swallowing foods or liquids). -Altered mental status (a change in a person's level of consciousness, awareness, and cognitive function). -Muscle weakness. Review of the resident's care plan dated 1/7/25 showed: -He/She was able to feed self once the meal tray was set up. -There was nothing about the resident able to self administrate their own medications. Review of the resident's entry Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 1/21/25 showed: -He/She was moderately cognitively impaired. -He/She was impaired on one side. -He/She needed set up assistance to eat. Review of the February 2025 Physician's Order Sheet showed the following orders: -Crush oral medications or open capsules and mix all medications together for administration with medium of resident's choice, dated 12/4/24. -There was order to leave medications at bedside. Observation on 02/19/25 at 9:53 A.M. showed: -He/She was not in the room. -There was a pill cup toppled over on the resident's bedside tray table. -There were two white oblong pills and one round blue pill under the resident's bed. -The roommate was severely cognitively impaired. Observation on 2/21/25 at 12:28 P.M. showed: -The resident was not in the room. -There was a cup with four pills in it sitting on the resident's bedside tray table. -One tan oblong pill, one dark brown capsule, one round white pill, one round blue pill. During an interview on 2/24/25 at 8:13 A.M. LPN A said: -The resident was most likely at dialysis. -There should not have been any medications left at bedside. -None of the resident's had a physician's order stated that medications could have been left at bedside. -Nurses were responsible to ensure the residents took their medications and that the medication was not left at the bedside. -Staff was to watch to make sure the residents took the medication and did not choke. -The facility had provided education on ensuring residents took their medications and staff did not just leave the medications at bedside. -This resident did not have an order to leave any medications at bedside. -His/Her medications were to have been crushed and put in applesauce or pudding. 5. Review of Resident #57's quarterly MDS dated [DATE] showed the resident was cognitively intact. Observation and interview on 2/19/25 at 9:46 A.M., showed: -The resident was sitting on side of his/her bed. No facility staff present. -Showed he/she had a medication cup with pills inside not dated or marked on top of his/her dresser. -He/She said that it was his/her morning medication and staff had always left at his/her bedside before he/she took it. 6. Review of Resident #53's quarterly MDS dated [DATE] showed the resident was cognitively intact. Observation and interview on 2/25/25 at 10:10 A.M., showed: -The resident was in his/her bed asleep. His/Her breakfast tray on over the bed table with medication cup of pills on tray not marked or dated. No staff present. -He/She had woke up and said that it was his/her morning medication and had fallen back to sleep before taking. -He/She said that staff often left his/her medication on the meal tray. 7. During an interview on 2/24/25 at 8:00 A.M. CMT A said: -None of the residents had an order to leave medications at their bedside. -There would have had to had a physician's order to leave the medication at bedside. -He/She had seen pills left at the bedside from the previous shift twice this month. -He/She had told the nurse and then threw the pills away. -The Charge Nurse was responsible for ensuring medication were not left at bedside. -You need to watch the residents swallow the pills to ensure they don't choke. -He/She had seen other residents roam into other resident's rooms so you needed to ensure pills were not left at bedside because a different resident might have taken them. During an interview on 2/24/25 at 1:30 P.M. with the ADON said: -There should not have been any pills left at bedside or on the floor. -Staff needed to watch to ensure the residents took their medications. During an interview on 2/26/25 at 9:39 A.M., Certified Nursing Assistant (CNA) A said medication should not be left at resident bedside and if he/she saw them he/she would have thrown them in the trash and told the nurse. During an interview on 2/26/25 at 9:46 A.M., CMT A said medication should not be left at the bedside. He/She would take to the nurse if found. During an interview on 2/26/25 at 10:07 A.M., LPN A said: -Medication should not be left at bedside unless there is a physician order. -He/She would be responsible make sure staff are not leaving medication unattended. -Medication administration competencies are done yearly During an interview 2/26/25 at 12:10 P.M., the DON said: -He/She would expect medication not to be left at resident bedside if no physician orders. -He/She would be responsible for medication administration training and audits are completed. -Staff was to have watched the residents take their medications. -There should never have been any pills left at bedside or spilled on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three sampled dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidney were not functioning properly) residents (Resident #23, Resident #32, and Resident #33) and one supplemental resident who had a feeding tube (a medical device that delivers liquid nutrition directly to the stomach through a surgically created opening in the abdominal wall), (Resident #42) were on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) out of 18 sampled residents and one supplement resident, failed to adequately educate the staff about EBP, and failed to have EBP or isolation signs on the door and isolation carts (a container that contained Person Protective Equipment (PPE - clothing and other equipment designed to protect the wearer from the risk of injury of infection) at the resident's rooms or in the hallway. The facility census was 92 residents. Review of the facility's policy, Implementation of PPE Use in Nursing Homes to Prevent Spread of Multi-Drug Resistant Organisms (MDROS) dated July 12, 2022 showed: -EBP may be indicated for residents with any of the following: -Wounds or indwelling medical devices. -Infections. -Effective implementation of EBP requires staff training on the proper use of personal protective equipment and the availability of PPE and hand hygiene supplies at the point of care. 1. Observation on 2/19/25 at 9:30 A.M. of 300 and 400 hallways did not show: -Any signs on the following residents' doors (Resident #23, Resident #32, Resident #33 or Resident #42), which showed the staff was to use EBP when doing cares with the residents on those hallways. -Any isolation equipment at any of the residents' rooms or in the hallway. Observation on 2/19/25 at 1:30 P.M. of 300 and 400 hallways did not show: -Any signs on the following residents' doors (Resident #23, Resident #32, Resident #33 or Resident #42), which showed the staff was to use EBP when doing cares with the residents on those hallways. -Any isolation equipment at any of the residents' rooms or in the hallway. Observation on 2/20/25 at 9:15 A.M. of 300 and 400 hallways did not show: -Any signs on the following residents' doors (Resident #23, Resident #32, Resident #33 or Resident #42), which showed the staff was to use EBP when doing cares with the residents on those hallways. -Any isolation equipment at any of the residents' rooms or in the hallway. 2. Review of Resident #23's face sheet showed the resident was admitted to the facility on [DATE] with the following diagnosis: -End Stage Renal Disease (ESRD - the last stage of Kidney disease). -He/She resided on the 300 hallway. Review of the resident's care plan dated 1/7/25 showed: -Did not show the resident was to have been on EBP. -He/She required the assistance of one staff for personal hygiene. -He/She received dialysis Monday, Wednesday, and Friday. -Staff was to assess the dialysis shunt every shift and notify the physician of abnormalities or absence of thrill (the vibration when touching the dialysis shunt indicating a good blood flow) or bruit (a whooshing sound heard with a stethoscope over the dialysis shunt). Review of the resident's February 2025 Physician's Order Sheet (POS) showed the following order: -Dialysis treatment Tuesday, Thursday, and Saturday, dated 2/5/24. -EBP when dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting every shift for EBP, dated 2/14/25. -Assess dialysis right arm shunt site(a surgical connection between an artery and a vein in the arm or wrist to perform dialysis) every shift for signs and symptoms of infection, bleeding, pulsation or aneurysm (blood clot) every shift, dated 1/22/25. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning) dated 1/11/25 showed: -He/She was moderately cognitively impaired. -He/She was on dialysis Observation and interview on 2/19/25 at 2:00 P.M. showed: -Two Certified Nursing Assistants (CNA)s said they were going to change the resident's brief. -Observed the two CNAs as they entered the resident's room and closed the curtain around the resident to change the resident's brief without wearing a gown. -There was no sign on the resident's door indicating EBP precautions were to have been used with the resident. -There was no isolation cart with PPE in the hallway or in the resident's room. During an interview on 2/19/25 at 2:30 P.M. the resident said: -When the staff performed cares such as changing his/her brief or assessing his/her dialysis shunt, they wore gloves but no gown. -He/She had not seen a sign on his/her door about EBP or an isolation cart outside the room. 3. Review of Resident #33's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Periorbital cellulitis (infection of the skin surrounding the eye). -ESRD. -Other bacterial infections. -He/She resided on the 400 hallway. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She was occasionally incontinent of urine. -He/She was frequently incontinent of stool. -He/She was on dialysis. -Wound infections was not checked. Review of the resident's care plan dated 1/13/25 showed: -He/She needed the assistance of one staff member for bathing. -He/She had a genital infection. -Staff was to maintain universal precautions when providing resident care. -He/She received renal dialysis. -Staff was to auscultate Bruit and palpate Thrill to shunt every shift and notify physician of abnormalities or absence, dated 5/7/24. -Staff was to change dressing daily at access site as ordered, dated 5/7/24. -Did not show the resident was to have been on EBP. Review of the resident's February 2025 POS showed the following orders: -Assess dialysis shunt site (right chest) every shift for signs/symptoms of infection, bleeding, pulsation or aneurysm, dated 12/9/24. -Dialysis on Monday, Wednesday, and Fridays, dated 12/9/24. -EBP when dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting, dated 2/14/25. -Apply Vaseline or Aquaphor (an ointment that enhances skin healing) four times a day on eyelid until follow up appointment at the eye clinic, dated 2/27/24. -Cleanse legs with soap and water pat dry. Apply Calcium Alginate (a natural absorbent biodegradable substance used in wound dressings)to right lower leg. Cover with ABD (abdominal pads - used do help keep wounds dry) pads. Wrap and secure with kerlix (bandage rolls which provide absorbency). Dressing to have been changed twice a day for Osteomyelitis (a bone infection) dated 2/20/25. -Miconazole 7 Vaginal (used to treat vaginal infections) Cream 2% insert one application vaginally every 12 hours for Candida (a yeast infection), dated 12/7/24. -Nystatin (a powder used to treat yeast infections) External Powder 100000 unit/gram to apply to bilateral pannus folds (an abnormal extra layer of skin on the abdomen) topically every six hours as needed for skin condition, dated 12/7/24. -There was no order for the resident to have been on EBP. During an observation and interview with the resident on 2/20/25 at 9:10 A.M.: -He/She said: --The staff had not been using EBP (gown or gloves) when checking his/her dialysis site. --The staff did wear gloves but not a gown when they applied a cream to his/her genital area. --The staff did not wear a gown when they put an ointment on his/her eye. --The staff did not wear a gown or gloves when they bathed him/her. --He/She had the toes on both feet surgically removed in the fall of last year. --He/She was not able to see if the surgical sites had healed. --He/She said there was no sign on his/her door nor any isolation cart. --He/She had open areas on his/her legs that weeped from cellulitis (skin infection). --He/She had a surgical site on left eye was open to air (where they had surgically removed extra skin). --He/She had a dialysis access was a PICC (a Peripherally inserted central catheter, a thin flexible tube inserted into a vein and threaded into a large vein in the heart) line on the right side of his/her chest. -There was no sign outside of his/her door indicating staff was to wear PPE. -There was no isolation cart at the door of the resident's room. -Observation showed the resident had a surgical site under his/her left eye. -Observation showed the resident had a PICC line on the right side of his/her chest. -Observation showed the resident had several open areas on his/her legs that were weeping. -Observation showed an open area on both of the resident's feet from old surgery where his/her toes had been amputated. During an interview on 2/21/25 at 10:30 A.M. Licensed Practical Nurse (LPN) A said: -He/She knew the resident had a PICC line in her chest and they did dialysis through that line. -They check the site for redness or warmth or drainage every shift and is on the Treatment Administration Record (TAR). -He/She did not know what EBP was. -They just started to put signs on the doors saying to See Nurse and putting isolation containers on the doors since survey started. 4. Review of Resident #42's quarterly MDS dated [DATE] showed: -He/She was moderately cognitively impaired. -He/She had a feeding tube. -He/She resided on the 300 hallway. Review of the resident's February 2025 POS while on site showed the following orders: -Aquaphor (ointment used to apply to dry skin) to have been applied four times a day on the resident's left eyelid. -Staff was to follow EBP, dated 2/14/25. -Staff was to assess dialysis shunt site (PICC) right upper chest daily. Observation of tube feeding administration on 2/24/25 at 9:00 A.M. with LPN A showed: -The nurse entered the room set up supplies and started to flush the resident's feeding tube with water. -The nurse was stopped and asked twice if he/she had forgotten anything and he/she responded no. -The nurse was wearing gloves but not an isolation gown. -There was a sign on the resident's door that said See Nurse. -There was an isolation container with gowns and gloves hanging on the door to the resident's room. During an interview on 2/24/25 at 9:25 A.M. LPN A said: -They had just started using the isolation carts after survey started. -The ADON had talked about EBP a couple of weeks ago but he/she forgot what they were supposed to have done. -He/She did not know why a resident would have been on EBP. 5. Review of Resident #32's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnosis: -Acute kidney failure. -He/She resided on the 300 hallway. Review of the resident's quarterly MDS dated [DATE] showed: -He/She was cognitively intact. -He/She was on dialysis. Review of the resident's February 2025 POS showed the following orders: -Dialysis on Monday, Wednesday, and Friday. -EBP when dressing/bathing, showering/transferring in room or therapy gym/personal hygiene, changing linen, providing hygiene, changing briefs or assisting with toileting every shift, dated 2/14/25. -Upon return from dialysis palpate right arm shunt for thrill and bruit. Repeat twice within eight hours post dialysis. Check bruit and thrill every shift routinely. -May apply Barrier cream as needed to redness or excoriation (skin that has been scraped away which resulted in scratches or wounds) after incontinent episodes every morning and night for skin breakdown dated 11/30/23. Review of the resident's care plan dated 2/5/25 showed: -He/She needed the assistance of one staff member for bathing/showering and dressing. -He/She received dialysis three times a week. -Staff was to auscultate the Bruit and palpate Thrill to right arm shunt every shift. -The care plan did not include using EBP with the resident. During an interview on 2/20/25 at 1:59 P.M. the resident said: -He/She goes out to dialysis. -He/She declined allow wound care/dialysis shunt cares to be observed. -The staff did not always check his/her dialysis shunt like they were supposed to. -When they checked his/her dialysis shunt they did not wear a gown or gloves. -When they checked his/her heel they did not wear gloves or a gown, he/she frequently had open heel sores. -Staff had just put up a sign on his/her door which said to see Nurse. -Staff had just put a isolation station at his/her door today. -He/She had not received education from the nursing staff about why there was a sign on his/her door or why staff was wearing PPE. 6. During an interview on 2/24/25 at 1:30 P.M. LPN/Infection Preventionist (IP) said: -EBP had started in the building on 2/14/25. -He/She had provided education with the staff about EBP by doing 1:1 education. -There had not been signs which showed the staff or visitors were to see the nurse on the third or fourth hallways. -The nurse would have told the staff or visitors to wear EBP if doing cares with the residents. -The staff should have been told in report that EBP was needed on which residents and why. -There should have been an order for EBP from the physician. -It should have been in a resident's care plan that EBP was needed by the MDS Nurse. -If a resident had open areas on their skin, had a foley, a PICC line, dialysis shunt, or a feeding tube, they should have had EBP. -He/She did not put the isolation containers or signs on the door of the third and fourth hall until the second day of survey. -He/She was responsible for ensuring that staff were educated on EBP, that there were signs on the residents door for those who needed EBP, there were isolation containers at the residents door, and should have done spot checks to ensure staff was following EBP protocol. -There were many residents at the facility that were on EBP. During an interview on 2/26/25 at 9:37 A.M. LPN B said: -They had education provided by the ADON about two weeks ago but he/she could not recall what the education included. He/She did not know what PPE should be included for EBP or when to use EBP. -They just started to put signs on the resident's doors which said See Nurse, and have isolation containers on some of the residents doors on Tuesday after the survey started. -They were to wear gloves and gowns when working with a resident who had a foley (tube that goes into the bladder to drain urine), peg tube, open wound, dialysis shunt, or PICC line. During an interview on 2/26/25 at 10:25 A.M. Certified Medication Technician CMT B said: -There might have been education about a month ago that the ADON provided 1:1 with the staff about EBP, but he/she could not recall what the education included. He/She did not know what PPE should be included for EBP or when to use EBP. -They had just put out the signs and isolation carts after survey started. -He/She did not know why a resident would have been on EBP. During an interview on 2/26/25 at 12:10 P.M. the Director of Nursing (DON) said: -If staff were to use EBP on a resident there should have been a sign on the door stating staff was to wear PPE when working with the resident. -An isolation container with PPE was to have been available at the resident's doorway. -EBP was not put in place until after the start of survey. -Education about EBP had been provided by the IP maybe 2/14/25. -No education had been provided to the residents or family about EBP. -Any resident who had a foley, PICC line, Dialysis shunt, feeding tube, or an open wound should have been on EBP. -

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to properly secure one sampled resident (Resident #3) during transport in the facility van out of three sampled residents. The facility census was 91 residents. Review of the facility's Safe Transportation Unloading Procedure, undated, showed: -Always make sure the resident is secure with wheelchair locks engaged and tie down hooks secured to frame of wheelchair. -If transporting multiple residents, ensure other resident wheelchair(s) are fully secured (wheel locks engaged and tie down straps on wheels) until ready for unloading. -If for any reason you must step away from the resident reapply the wheel locks, hook straps and make sure the resident is fully secured. 1. Review of Resident #3's admission Record showed he/she was admitted to the facility on [DATE] with diagnoses that included: -Multiple Sclerosis (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve function, and in most cases some degree of disability). -Left knee contracture (a shortening of muscles and soft tissue often leading to deformity and rigidity). -Abnormal posture. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 11/14/24 showed the resident: -Was cognitively intact. -Had upper extremity impairments on both sides and lower extremity impairments on both sides. -Was dependent (helper does all the effort) for dressing, transfers, showers, toileting, and repositioning. -Used a motorized wheelchair. Review of the resident's Fall Risk care plan, dated 11/27/24 showed a goal for the resident to be free of falls and injuries. Review of the resident's internal Fall Report, dated 12/12/24 showed: -On 12/12/24 At 3:30 P.M. the resident reported he/she fell inside the van and hit his/her head when returning from an appointment. -Transportation Driver (TD) A's written statement showed he/she was bringing the resident and another resident back to the facility when he/she made a turn onto another street and the resident's chair tilted over and the resident said he/she hit his/her head. He/She didn't fall out of his/her seat. -Transportation Escort (TE) A's written statement showed the van turned a corner. The resident's chair was leaned back and he/she tilted over and said he/she hit his/her head. The resident never hit the floor. He/She and TD A tilted the chair back over and the resident rolled back into the facility. -There were no new interventions or plans mentioned in the Fall Report for preventing a similar future accident from happening. During an interview on 12/26/24 at 1:38 P.M. TD A said: -He/She was the driver to take residents to medical appointments. -Before he/she headed home he/she asked TE A if Resident #3 was strapped up and TE A said he/she strapped in Resident #3's wheelchair. -He/She was heading back to the facility from resident medical appointments when he/she made a turn and Resident #3's wheelchair tilted towards the van window. -He/She stopped the vehicle and the resident said he/she hit the right side of his/her head on the window during the turn. At the time the resident said his/her head hurt a little bit, but later told him/her he/she was OK. -The resident had a motorized wheelchair and the back of the wheelchair was found reclined instead of all the way up when they stopped. Another resident was in a manual wheelchair to Resident #3's right and the other resident's wheelchair stopped Resident #3 from falling to the van floor. Resident #3's wheelchair was leaning on the other resident's wheelchair when he/she stopped. Resident #3 didn't hit the other resident, just his/her wheelchair. -TE A strapped Resident #3 in on the day of the accident. He/She had shown TE A how to strap in wheelchairs using four straps per wheelchair, attaching them just under the resident's seat. -On the day of the accident they were transporting two residents. TE A had difficulty getting Resident #3 and the other passenger in because TE A's motorized wheelchair was so large. All the motorized wheelchairs tended to be larger than the manual wheelchairs. -He/She didn't know if TE A used all four straps, but TE A said he/she did. -When he/she stopped the van after Resident #3 tilted to his/her right he/she saw that the two straps on the left side of Resident #3's wheelchair were not attached. He/She had never known wheelchair straps to come off and out of the floor slot before. Either TE A didn't have the straps on securely or they weren't on right. -He/She thought Resident #3 was just so scrunched up with the other resident in the van TE A couldn't put the straps on like he/she normally did. -As the driver he/she was responsible for ensuring all wheelchairs were strapped down appropriately. He/She should have double checked the wheelchairs were strapped in correctly. During an interview on 12/26/24 at 3:30 P.M. Resident #3 said: -He/She was not strapped in correctly. They put straps on one side, but not the other so he/she was only half-way buckled in. -He/She tipped over while the van was in motion and the right side of his/her head hit the window hard. It really hurt at the time. -He/She called an ambulance when they got back to the facility and went to the hospital to have it checked out. He/She wanted to make sure he/she was alright. During an interview on 12/26/24 at 3:50 P.M. TE A said: -Resident #3 and another resident were in the back of the van. -He/She attached three straps onto Resident #3's wheelchair. He/She was supposed to put anywhere from two to four straps on the wheelchair. -The previous Transportation Driver, who was no longer working at the facility, had shown him/her how to attach the straps to the wheelchairs. -When he/she got the residents in the van the back of Resident #3's wheelchair was positioned upright. -On the way back from the medical appointments he/she heard a little scream. -The driver pulled over immediately. -They found Resident #3's wheelchair tipped over onto the back section of another resident's wheelchair and the back of Resident #3's wheelchair was reclined. Neither resident was hurt. -The front left strap that had been attached to Resident #3's wheelchair came up off the van floor. -Once before one of the wheelchair straps came up out of the van floor when they were transporting a different resident. That resident wasn't hurt either. -He/She wasn't aware of any protocol he/she needed to follow to prevent a similar accident from happening again. -It was fine to use anywhere from two to four straps to secure wheelchairs in the van. During an interview on 12/26/24 at 4:10 P.M. the MDS Coordinator said: -The resident used an outside transportation company as well as the facility van for appointments. -The driver should make sure the resident's wheelchair was locked and he/she was strapped down correctly before transporting. During an interview on 12/26/24 at 4:25 P.M. the Maintenance Director said: -He/She supervised the Transportation Driver. -He/She was told the resident tipped in his/her wheelchair during transport. -Without having seen it, he/she didn't know if the resident was strapped in correctly. -He/She had never been told straps had come up off the van floor. -He/She hadn't spoken to or provided education to TD A or TE A since the resident's accident. -The driver was always supposed to use four straps to secure each wheelchair. -After TD A was hired, he/she trained TD A to always use four straps to attach the front and back of each side of the wheelchair, and to ensure straps were securely latched. -Drivers were supposed to make sure straps were attached correctly. -TE A is the escort. He/She didn't train TE A because the driver was supposed to always secure the wheelchairs. During an interview on 12/26/24 at 4:33 P.M. the Administrator said: -Residents other than Resident #3 also have power (motorized) wheelchairs. -He/She re-educated the driver the day of the accident on making sure all strap latches were secure. He/She also told TD A and TE A to make sure all wheelchairs were in remained in an upright position. -The Maintenance Director was responsible for educating drivers on latching the straps to the wheelchairs. -He/She held the driver responsible for ensuring wheelchairs were secure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate three out of three sampled residents' (Residents # 1, #2, #3) preferences related to showering. The facility census was 91 residents. Review of the facility's Resident Rights - Accommodation of Needs policy, revised 8/2020 showed: -Residents' individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. -In order to accommodate residents' individual needs and preferences facility staff attitude and behavior are directed toward assisting the residents in maintaining independence, dignity, and well-being to the extent possible according to resident wishes. 1. Review of Resident #1's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), dated 10/22/24, showed the resident was: -Cognitively intact. -Dependent (helper does all effort) on staff for toileting hygiene, bathing/showering, and shower/tub transfers. -Incontinent of bowel. -Diagnosed with paraplegia (loss of movement of both legs and generally the lower trunk). Review of the resident's Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) care plan, revised 10/24/24 did not show any of the resident's bathing/showering needs or preferences. Review of the resident's shower sheets dated 12/2024 showed: -On 12/4/24, 12/11/24, 12/17/24, and 12/19/24 he/she received showers. -On 12/22/24 he/she refused a shower. The form did not document why the resident refused. During an interview on 12/26/24 at 11:20 A.M. Certified Medication Technician (CMT) A said: -The resident took showers whenever they were offered. -The resident would speak up if he/she had to go too long without a shower. -As far as he/she knew the resident was getting them. Observation on 12/26/24 at 11:35 A.M. showed the resident had what looked like crumbs and a few dots of stains on the lap area of his/her pants. During an interview on 12/26/24 at 11:35 A.M. the resident said: -There were times he/she had gone a couple of weeks before getting a shower. -He/She hadn't had a shower during the week of Christmas and would have liked to have had one because he/she wanted to feel clean, especially if visitors came. -A weekly shower wasn't enough to keep him/her feeling clean. He/She needed one at least every few days. During an interview on 12/26/24 at 12:42 P.M. Certified Nurse Assistant (CNA) A said the resident did not refuse showers when they were offered. During an interview on 12/26/24 at 2:14 P.M. Licensed Practical Nurse (LPN) A said: -The resident often needed a shower. Anytime they gave residents showers the resident was on the list for one. -He/She was always dropping something on himself/herself. -The resident got a shower at least once a week. 2. Review of Resident #2's quarterly MDS dated [DATE] showed the resident was: -Severely cognitively impaired. -Dependent upon staff for toileting hygiene, bathing/showering, and tub/shower transfers. -Always incontinent of bowel and bladder. -Diagnosed with Hemiplegia/hemiparesis (paralysis/weakness affecting one side of the body). Review of the resident's ADL care plan, revised 10/16/24, showed the resident was dependent on one staff for bathing/showering twice weekly and as needed. A sponge bath would be offered when a full bath or shower cannot be tolerated. Review of the resident's shower sheets dated 12/2024 showed: -On 12/6/24 he/she refused a shower. There was no documentation as to why. -On 12/20/24 and 12/16/4 he/she had a shower. -On 12/20/24 he/she refused a shower. There was no documentation as to why. During an interview on 12/26/24 at 12:00 P.M. the resident said he/she: -Didn't always get to have showers every week. -Wanted more showers than what he/she was getting because he/she felt dirty and thought others could smell him/her. -Would like to get at least a couple of showers a week. 3. Review of Resident #3's quarterly MDS, dated [DATE] showed the resident was: -Cognitively intact. -Dependent on staff for toileting hygiene, bathing/showering, and tub/shower transfers. -Always incontinent of bowel and bladder. -Diagnosed with multiple sclerosis (MS, a neurological disease that attacks the protective covering of the nerves, leading to impaired sensory and motor nerve function, and in most cases some degree of disability) and had upper and lower extremity impairments on both sides of his/her body. Review of the resident's ADL care plan, revised 12/5/24, showed the resident required assistance of two staff for bathing/showering as necessary. It did not mention the resident's bathing/showering preferences related to frequency or time of day. Review of the resident's shower sheets dated 12/2024 showed he/she had showers on 12/2/24, 12/9/24, 12/14/24, and 12/18/24. Observation on 12/26/24 at 12:25 P.M. showed the resident had a body odor. During an interview on 12/26/24 at 12:25 P.M. the resident said: -He/She wasn't getting showers as often as he/she wanted. Sometimes it was only once every two weeks. -He/She had always liked to shower daily, but in the facility setting that probably wasn't possible. -At the very minimum he/she would like to shower at least two or three times a week. -He/She didn't feel clean which affected his/her mood. He/She felt better when he/she was clean. -He/She didn't have any set days of the week for showering and didn't think there was a shower schedule. -He/She was often told there weren't enough staff to shower him/her. -Today he/she asked one of the CNAs for a shower and was told to wait until Saturday (two more days) because staff were too busy. During an interview on 12/26/24 at 12:42 P.M. CNA A said the resident did not refuse showers when they were offered. During an interview on 12/26/24 at 2:14 P.M. LPN A said: -The resident never mentioned to him/her that he/she wanted a shower. -There were four CNAs assigned to the halls on his/her side of the building so a CNA should have been available to give the resident a shower if he/she asked for one. He/she had not heard the resident had refused any shower. 4. During an interview on 12/26/24 at 12:42 P.M. CNA A said: -Residents had scheduled shower days. Lately the nurse just told the CNAs when a resident needed a shower. They hadn't been going by the shower schedule. -Resident showers were documented on shower sheets. During an interview on 12/26/24 at 2:14 P.M. LPN A said: -He/She determined if a resident needed a shower by looking at them. -There was a bathing schedule, and all residents were scheduled to receive two showers a week, but the nurse just determined by looking at residents who actually needed one. -They didn't necessarily get two showers a week since the shower aide had been working as a CNA. During an interview on 12/26/24 at 4:45 P.M. the Acting Director of Nursing (DON)/Regional Nurse Manager said: -Residents should be offered a shower on their scheduled shower days. -If a resident refused a regular bath or shower staff should offer a sponge bath. If they refuse that staff should get the nurse involved to see why the resident was refusing. -If there are four CNAs working on one side of the building staff should shower everyone who is scheduled to get a shower. They can give extra showers as they have time or see if the next shift can get the resident showered. MO00246401

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to provide ordered pressure ulcer wound dressing changes on a consistent basis for two sampled residents (Resident #5 and #8), and failed to prevent an acquired pressure injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for one sampled resident (Resident #2) who was at high risk out of nine sampled residents. The facility census was 86 residents. Review of the facility Wound Management Policy, updated 6/2020 showed: -The purpose of the policy was to provide a system for the treatment and management of residents with wounds including pressure ulcers. -Any resident who had a wound was to have received the necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. -Treatment of a pressure injury should include minimizing pressure and/or tension on the wound, maintaining moisture balance while controlling drainage and protecting the surrounding skin to avoid deteriorating wound edges. -A licensed nurse was to perform a skin assessment upon admission, readmission, weekly and as needed for each resident. -The assessment of the wound care needed for pressure injuries was to emphasize, identifying risk factors, treatment, mechanical offloading, pressure reducing devices, reducing skin friction, sheer and moisture, proper nutrition, and evaluating and modifying interventions for residents with existing pressure injuries. -The physician was to have been notified of any new pressure injuries, those wounds that were not responding to treatment, any wounds that worsened, any complaints of pain or decrease in mobility by a resident, signs of infection, and any residents refusing treatment. -Wound documentation was to have occurred at a minimum of weekly until the wound was healed. Documentation was to have included: --Location of the wound. --Length, width, and depth measurements recorded in centimeters (cm's). -Direction and length of any tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound), undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure is larger at its base than at the skin surface. Undermining often develops from shearing forces and is differentiated from tunneling by the larger extent of the wound edge involved in undermining and the absence of a channel or tract extending from the pressure ulcer under the adjacent intact skin), if applicable. -Appearance of the wound base. --Drainage amount and characteristics including color, consistency and odor. --Appearance of the wound's edges. --Description of the peri-wound (the skin surrounding the wound) or evaluation of the skin adjacent to the wound. --Presence or absence of new hearing at the wound rim. --Presence of pain. -Licensed Nurses were to have documented effectiveness of current treatment in the resident's medical record on a weekly basis. Review of the Facility Assessment Tool dated 11/19/24 showed: -The facility was able to meet the needs of residents with skin ulcers and injuries. -One of the services the facility provided was pressure injury prevention and care, skin care, wound care including pressure injuries. -The facility resources necessary to provide competent care and support for residents included administration, a treatment/wound nurse, food and nutrition services, rehabilitation services, physicians, nurse practitioners, pharmacists, and outside providers as needed. -One of the competencies necessary for nursing staff was specialized care including wound care and dressing changes. -The facility was to develop, implement and maintain an effective training program for all new and existing nursing staff, consistent with their expected roles. 1. Review of Resident #5's Facility admission Record showed the resident was admitted on [DATE] with the following diagnoses: -Osteomyelitis of the spine. -Paraplegia (loss of movement of both legs and generally the lower trunk). Review of the resident's quarterly Minimum Data Set ((MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 10/25/24 showed he/she: -Was cognitively intact. -Bilateral lower extremities were impaired. -Used a wheelchair. -Was totally dependent on facility staff for- --Dressing, showering/bathing, lower body dressing, and applying footwear. --Sitting to standing and standing to sitting. Sitting to lying and lying to sitting. --Bed to chair and chair to bed transfers. --Tub/shower transfers. --Had two stage IV pressure injuries (most severe stage of pressure ulcer where there is a full thickness tissue loss exposing underlying structures like bone, tendon, or muscle) with one of them present upon admission. --Was at risk for skin breakdown. --Had a wound infection. Review of the resident's Nursing Care Plan dated 10/30/24 showed: -He/she had pressure injuries which he/she was admitted with and became infected. -The wounds were to show signs of healing by the next review date. -The facility staff was to administer medications and complete the wound care treatments per the physician's orders. -The facility staff was to assess, record and monitor the wound healing weekly and report improvements and declines to the physician. -The facility staff was to follow the policies and protocols for the prevention of further skin breakdown. -Weekly treatment documentation was to include the measurement of each wound including length, width depth, type of tissue and drainage present. -The resident had a history of noncompliance with wound care, refusing at times to have the wounds treated and refusing to stay in bed when needed for wound off-loading. -The facility staff was to re-educate the resident on the importance of having the wounds treated per the physician's orders. -The facility staff was to re-educate him/her on the need to off load the areas where the wounds were present which meant spending some time up and other times in the bed. Review of the resident's Physician Order Sheet (POS) dated 11/4/24 showed: -The resident's left lateral foot pressure injury was to have been cleaned with wound cleanser or normal saline, packed with Dakins 0.125% (diluted bleach used to treat wounds and prevent or treat infections) moistened gauze, cover with an ABD (a large, thick wound covering) dressing, wrap with kerlix (rolled gauze used to cover a dressing), secured with and ACE (a stretchy tight bandage) bandage every day and as needed for soiling. Review of the Outside Certified Wound Care Provider Physician's Assistant's Progress Note dated 11/5/24 at 10:27 A.M., showed: -The resident's Stage IV sacral wound measured 8.5 cm X 6.8 cm x 1.7 cm with 75% granulation tissue (any soft pink fleshy projections that form during the healing process in a wound that does not heal by first intention) and 25% slough (nonviable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed) present. -The wound was malodorous (had odor) with heavy drainage and there was exposed muscle. -At this point, the resident had a Negative Pressure Device (a type of wound care treatment device that pulls fluid and bacteria out of a wound to promote healing) he/she was not appropriately utilizing. -The wound was documented as stable. -The resident's left lateral foot pressure injury measured 3.0 x cm x 3.1 cm x 0.7 cm with 90% granulation and 10% slough present. -There was exposed muscle and bone present, and the wound was documented as worsening. Review of the Outside Certified Wound Care Provider Physician's Assistant's Progress Note dated 11/12/24 at 10:57 A.M., showed the resident refused to be assessed or treated. Review of the resident's facility wound note dated 11/12/24 at 9:22 A.M. showed: -Wound Nurse A walked into the facility and the resident was seen sitting outside on the patio in his/her wheelchair. -Wound Nurse A asked the resident if he/she was going to see the provider for wound care that day. -Wound Nurse A also reminded the resident that wound care was every Tuesday stating at 9:24 A.M. to 11:30 A.M. -The resident stated that he/she forgot and asked what he/she needed to do. -Wound Nurse A informed the resident that he/she would need to have the staff return him/her to bed for wound care to occur. -The resident then stated he/she did not want to do that because he/she did not know when he/she would be gotten back up into the chair again. -Wound Nurse A then informed the resident that his/her refusal of wound care would have to be documented to which the resident just shrugged his/her shoulders. -Wound Nurse A then walked into the facility and clocked in for work. Review of the resident's facility wound note dated 11/13/24 at 11:01 A.M., showed: -Wound Nurse A noted the resident was sitting up in his/her wheelchair as the nurse was rounding for wound care. -The resident had begun asking to get up at 8:00 A.M., with anxiousness and frustration. -The staff encouraged the resident to remain in bed until his/her wound care was completed. -The resident refused however since the resident had the right to get up, the resident was gotten up into his/her chair shortly after he/she asked. -Wound Nurse A asked resident if he/she would allow his/her wound care to be completed to which the resident asked if he/she could stay in his/her chair to have the dressing changed. -Wound Nurse A explained to the resident that with the wound on his/her sacrum, it was not possible to have the dressing changed. -The resident then rolled his/her wheelchair away and did not get his/her dressing changed. Review of the resident's Wound Care noted dated 11/13/24 at 6:38 P.M., showed: -The resident was in bed at the time after having been up in his/her wheelchair for more than 11 hours. -The resident had not had any wound care completed since 11/9/24 due to refusal and upon removing the dressing, the wound showed malodorous slough and necrotic (dead) tissue. -The resident agreed to have the dressing changed on his/her sacrum and left foot. -The dressings were changed. -His/her left lower leg showed some signs of swelling from the mid-calf to the toes. -The resident had no fever and was currently receiving intravenous (IV) antibiotics. Review of the resident's Wound Note dated 11/13/24 at 8:00 P.M., showed Wound Nurse A reported the change in the resident's condition to the provider who ordered the resident sent to the hospital for evaluation and treatment. Review of the resident's POS dated 11/18/24 showed the sacral wound was to have been cleaned with wound cleanser of Normal Saline, pat dry, lightly pack with Dakins 0.125% strength without packing too tightly, cover with a foam dressing daily and as needed for soiling. Review of the resident Treatment Administration Record (TAR) dated November 2024 showed: -No would care/dressing change was completed for the resident's left lateral foot pressure injury on 11/1/24, 114/24, 11/6/24, 11/7/24, 11/8/24, 11/9/24, 11/10/24, 11/11/24, 11/17/24, 11/18/24, 11/19/24, 11/20/24, 11/22/24, 11/23/24 and 11/24/24. -No wound care/dressing change was not completed for the resident's sacral wound on 11/19/24, 11/22/24, 11/23/24 and 11/24/24. -There was no documentation on why the wound care was not done. Review of the resident's Outside Certified Wound Care Provider Physician's Assistant's Progress Note dated 11/21/24 at 10:14 A.M., showed: -The resident's sacral pressure injury measured 9.6 cm x 7.0 cm x 2.0 cm with 80% granulation and 20% slough present. -The wound was malodorous and showed as worsening. -He/she remained non-compliant with wound care and dressing changes. -The resident's left lateral foot pressure injury measured 2.3 cm x 2.5 cm x 0.7 cm with 90% granulation and 10 % slough present. -There was muscle and bone exposed and was documented as improving. Review of the resident's Wound Care note dated 11/28/2411/27/24 at 9:33 A.M., showed: -He/she was up in his/her wheelchair at the time of Wound Nurse A's arrival to complete his/her wound care. -The resident had a handwritten note in his/her room on the wall that instructs the resident on when wound care was to be performed so he/she would remain in bed until the wound dressings were changed. -The resident refused to have his/her dressings changed. Review of the resident's Wound Care note dated 11/28/24 at 9:54 A.M., showed: -The resident was observed by Wound Nurse A up in his/her wheelchair. -Wound Nurse A asked the resident if he/she was going to get his/her dressings changed to which the resident stated he/she thought they had already been changed. -He/she refused to have his/her dressings changed. Review of the resident's Outside Certified Wound Care Provider Physician's Assistant's Progress Noted dated 12/3/24 at 10:36 A.M., showed: -The resident's sacral pressure injury measured 9.6 cm x 7.3 cm x 2.2 cm with 70% granulation and 30% slough. -There was heavy drainage and the wound was malodorous with muscle exposed. -The wound was documented as worsening. -The resident remained non-compliant with wound care and dressing changes. -The resident's left later foot pressure injury measured 2.3 cm x 2.6 cm x 0.8 cm with 90% granulation and 10% slough present. -There was muscle and bone exposed and the wound was listed as worsening. During an interview on 12/4/24 at 2:45 P.M., Wound Nurse A said: -The resident was very non-compliant. -He/she had placed a sign in his/her room reminding him/her not to get up until his/her dressing changes were completed but he/she frequently insists on getting up early in the morning. -He/she has a lot of issues with the nursing staff not doing the resident's dressing changes when he/she is not in the building. -He/she keeps his/her treatment cart unlocked in a locked room and all the nurses have a key to get in so there should be no issue with not having supplies to do the resident's dressing changes. -He/she consults with the outside wound care company if he/she feels it to be necessary. -He/she know that he/she was not good at always documenting the dressing changes or reasoning behind dressing change refusals and he/she planned to work on doing a better job of documentation. During an interview on 12/4/24 at 3:24 P.M., Licensed Practical Nurse (LPN) A said: -The resident was very non-compliant with his/her wound care and dressing changes. -He/she wanted to be up in his/her wheelchair all day, every day which was not good for his/her sacral pressure injury. -The resident had an agreement with Wound Nurse A, to be in his/her bed at the times his/her dressing changes were completed, however, he/she frequently did not abide by that request and would insist on getting up early to go outside and smoke. -When Wound Nurse A was off or on weekends, the nursing staff assigned to the resident was to have completed his/her wound care/dressing changes. -Whomever does the dressing change should have documented in detail if the resident refused to have the dressing changes completed after continuing to encourage the resident and re-educate him/her on the importance of getting the dressing changed, getting into the bed to offload his/her sacrum. During an interview on 12/5/24 at 10:50 A.M., the Outside Certified Wound Care Provider Physician's Assistant said: -He/she had a hard time getting the resident to understand that he/she needed to spend some time in bed and that it would be helpful if he/she stayed in bed on the days of his/her consulting days until the dressing changes were completed. -The resident was very non-compliant, however, he/she also had concerns regarding the lack of wound care when Wound Nurse A was not in the building. -He/she frequently came into the facility and found the resident's dressings that were outdated, saturated with drainage or soiled. -He/she had even come in when Wound Nurse A was on vacation to find the same dressing on that he/she had placed on the wound the week prior. -The resident's initial treatment plan was a negative pressure device, however, he/she would remove it, the staff would not keep it charged, and rarely was another dressing placed on the resident's sacral wound. During an interview on 12/5/24 at 11:22 A.M., the Director of Rehabilitation said: -He/she had worked with the resident to get a good off-loading device for his/her wheelchair, but the resident still spent too much time up and not off-loading the sacrum. -He/she saw a real problem with the resident's dressings not getting changed per the physician orders. During an interview on 12/5/24 at 3:00 P.M., the resident said: -He/she thought he/she was getting dressing changes completed appropriately. -He/she did not always want to wait until later in the morning to get up so sometimes he/she got up before his/her dressing change was completed. -When he/she was already up, he/she did not like to have to go back to bed for a dressing change. -He/she knew he/she should have his/her dressings changed daily but did not always like to have them changed so sometimes he/she said no when asked. During an interview on 12/20/24 at 3:10 P.M., the facility Medical Director said: -He/she would have expected that all ordered treatments have been provided by the facility nursing staff or the facility Wound Nurse and that those wound treatments have been documented as completed. -He/she would have expected that all completed treatments have been documented by the nurse who completed the treatment. -He/she would have expected thorough documentation of the resident refusal for the wound treatment, including further attempts to encourage the resident to comply with wound care, education and re-education provided by the nurse attempting to provide the wound care. -He/she would have expected the continuing refusals by the resident to have been reported to the attending physician as well as facility administration. 2. Review of Resident #8's Facility admission Record showed the resident was admitted on [DATE] with a diagnosis of pressure injury to his/her coccyx (tailbone). Review of the resident's POS dated 5/23/24 showed: -The resident's wound was to have been cleaned with wound cleanser, patted dry before applying nickel thick amount of Santyl (an ointment used for the debridement of pressure ulcers) to the necrotic area, covered with Calcium Alginate (a natural fibrous substance used in wound dressings) followed by a foam dressing daily and as needed for soiling. Review of the resident's Nursing Care Plan dated 6/4/24 showed: -He/she was admitted with an unstageable pressure injury on his/her coccyx. -The pressure injury was to have shown signs of healing and remain free from infection by the review date. -The facility staff was to have been administered per the physician's orders. -The facility staff was to have completed wound treatments per the physician's orders. -The facility staff was to have followed the facility policies and protocols for the prevention/treatment of skin breakdown. -The facility staff was to have monitored/documented/reported any changes in skin status, appearance, color, wound healing, signs/symptoms of infection, wound size (length, width, depth), and stage weekly and as needed. Review of the resident's POS dated 6/11/24 showed to treat the resident's coccyx was to clean with wound cleanser, patted dry before applying Dakins 0.125% moistened gauze before covering the wound with a foam dressing, daily and as needed for soiling. Review of the resident's POS dated 9/28/24 showed to clean the wound with wound cleanser, pat dry, apply collagen sprinkles to the wound bed, cover with a foam dressing daily and as needed for soiling. Review of the resident's admission MDS dated [DATE] showed he/she: -Was cognitively intact. -Required supervision for rolling, sitting to standing, standing to sitting, and transferring from the bed to the chair. -Required partial to moderate assistance for toileting, personal hygiene and lying to sitting edge of bed. -Was able to ambulate ten to 50 feet with partial to moderate assistance. -Was dependent for bathing and showering. -Was admitted with one Stage IV pressure injury and three unstageable pressure injuries. Review of the resident's POS dated 11/13/24 showed: -The resident was to receive a pressure relieving mattress. -The resident's sacral wound was to have been cleaned with would cleanser or Normal Saline, patted dry, lightly packed with quarter strength Dakins solution and covered with a foam dressing daily and as needed for soiling. -The resident's left ankle, right ankle and left heel was to have been cleaned with wound cleanser, patted dry, apply Betadine paint to eschar (dead tissue) and Calcium Alginate to the open area before covering with a Silicone dressing daily and as needed for soiling. Review of the resident's November 2024 TAR showed: -No wound care/dressing change for his/her coccyx wound was completed on 11/1/24, 11/4/24, 11/6/24, 11/7/24, 11/8/24, 11/9/24, 11/10/24, 11/11/24, 11/12/24, 11/17/24, 11/18/24, 11/19/24, 11/22/24, 11/23/24, and 11/24/24. -No wound care/dressing changes for his/her left ankle, left heel or right heel wounds were completed for-11/17/24, 11/18/24, 11/19/24, 11/22/24, 11/23/24, and 11/24/24. -No documentation was recorded as the reason why the wound care was not done. Review of the resident's Facility Weekly Pressure Injury Trend for the month of November 2024 showed he/she was admitted with the following pressure injuries: -Week one he/she had: -One Stage III pressure injury (a full thickness tissue loss where subcutaneous fat is visible within the wound, but bone, tendon, or muscle are no exposed) on his/her left heel measuring 4.6 cm x 4,7 cm x 0.4 cm. -One Stage IV pressure injury on his/her left ankle measuring 2.4 cm x 2.0 cm x 0.4 cm. -One unstageable pressure injury on his/her right heel measuring 3.1 cm x 3.0 cm x 0.3 cm. -One Stage IV pressure injury on his/her coccyx measuring 3.1 cm x 2.7 cm x 0.5 cm. -Week two he/she had: -One Stage III pressure injury on his/her left heel measuring 3.7 cm x 4.1 cm x 0.4 cm. -One Stage IV pressure injury on his/her left ankle measuring 2.2 cm x 2.0 cm x 0.4 cm. -One unstageable pressure injury on his/her right heel measuring 3.2 cm x 3.0 cm x 0.3 cm. -One Stage IV pressure injury on his/her coccyx measuring 3.6 cm x 2.8 cm x 0.6 cm. -Week three he/she had: -One Stage III pressure injury on his/her left heel measuring 3.5 cm x 4.0 cm x 0.4 cm. -One Stage IV pressure injury on his/her left ankle measuring 1.1 cm x 1.1 cm x 0.4 cm. -One unstageable pressure injury on his/her right heel measuring 3.3 cm x 2.9 cm x 0.3 cm. -One Stage IV pressure injury on his/her coccyx measuring 3.6 cm x 2.8 cm x 0.6 cm. -Week four he/she had: -One Stage III pressure injury on his/her left heel measuring 3.7 cm x 3.8 cm x 0.3 cm. -One Stage IV pressure injury on his/her left ankle measuring 1.3 cm x 1.3 cm x 0.3 cm. -One unstageable pressure injury on his/her right heel measuring 3.2 cm x 2.2 cm x 0.3 cm. -One Stage IV pressure injury on his/her coccyx measuring 3.5 cm x 2.8 cm x 0.6 cm. Review of the resident's Outside Certified Wound Care Provider Physician's Assistant's Progress Note dated 12/3/24 at 11:35 A.M., showed: -The resident's Stage IV coccyx pressure injury measured 2.9 cm x 3.0 cm x 0.6 cm with undermining of 3.3 cm from 12:00 to 1:00 with 90% granulation and 10% slough. -The wound showed muscle exposure, no drainage and was noted as stable. -The resident Stage III left lateral ankle pressure injury measured 1.0 cm x 1.0 cm x 0.3 cm with 95% granulation and 5% slough, no drainage and improving. -The resident's Unstageable right heel pressure injury measured 3.4 cm x 1.6 cm x 0.3 cm with 10% granulation and 90% eschar, light drainage and improving. -The resident's Stage IV left heel pressure injury measured 4.2 cm x 4.1 cm x 0.4 cm with 25% granulation and 75% slough, muscle exposure, moderate drainage and improving. During an interview on 12/4/24 at 2:45 P.M., Wound Nurse A said: -The resident never got out of bed so was on a low air-loss mattress for pressure reduction. -The staff attempted to keep his/her feet off the bed by using pillows. -He/she was being seen by the outside wound care company. During an interview on 12/4/24 at 3:24 P.M., Licensed Practical Nurse (LPN) A said: -The resident never wanted to get out of bed, so the staff tried to keep his/her feet off the bed. -He/she could turn himself/herself but spent a lot of time on his/her back. During an interview on 12/5/24 at 10:50 A.M., the Outside Certified Wound Care Provider Physician's Assistant said: -He/she had never seen the resident out of his/her bed before. -The staff stated they try to get him/her to get up into the chair but the resident refuses. -The staff had him/her on a low air-loss mattress and attempted to keep his/her heels off the bed. 3. Review of Resident #2's Facility admission Record showed the resident was admitted on [DATE] with the following diagnoses: -Osteomyelitis of the spine (infection of the bone). -Sepsis (a blood stream infection). -Diabetes type 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 POS dated 6/14/24 showed Physical Therapy (PT) and Occupational Therapy (OT) was to evaluate and treat the resident to address his/her deceased strength, decreased self-care skills and decreased overall functional ability. Review of the resident's wound note dated 11/5/24 at 4:25 P.M., showed: -The resident developed a dark circular hardened area to his/her left heel measuring 3.5 cm x 3.5 cm. -Betadine Paint (a topical antiseptic used the help prevent infection in wounds) was ordered. Review of the resident's POS dated 11/5/24 showed the resident's left heel pressure injury was to have been cleaned with wound cleanser, patted dry before applying Betadine Paint then covering with a dry dressing every other day and as needed. Note: The resident's left heel pressure injury had not yet been care planned before the resident left the facility, went to the hospital and was discharged home from the hospital, not returning to the facility. Review of the resident's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact. -Had impairment of his/her upper extremity (shoulder, elbow, wrist, hand). -Used a wheelchair. -Was totally dependent on facility staff for- --Dressing, showering/bathing, lower body dressing, applying footwear, and personal hygiene. --Rolling right and left. --Sitting to standing and standing to sitting. Sitting to lying and lying to sitting. --Bed to chair and chair to bed transfers. --Tub/shower transfers. --Had one stage III pressure injury, not present on admission. --Had an unstageable pressure injury, not present on admission. --Was at risk for skin breakdown. During an interview on 12/4/24 at 2:45 P.M. Wound Nurse A said: -The resident laid in his/her bed partially on his/her right side primarily, with his/her left foot against the bed. -He/she had severe spasms of his/her left leg causing almost constant back and forth movement of his/her left foot. -This constant movement of the inside portion of his/her left foot caused added pressure to that area which in turn, caused a pressure injury to develop. -He/she did not believe that anything could have been done to prevent the pressure injury to the resident's foot. -He/she did not try any padding to that portion of the resident's foot and the resident refused to wear off-loading booties while in bed. -The resident was on a low air-loss mattress. During an interview on 12/4/24 at 3:24 P.M. LPN A said: -The resident frequently complained of severe leg spasms and was on muscle relaxants for them. -He/she did not like to be in bed and when he/she was up, he/she insisted on wearing tennis shoes. -He/she refused to wear off-loading booties, but he/she did not believe that any padding of his/her foot was ever attempted, or any other off-loading devices were tried. During an interview on 12/5/24 at 3:15 P.M., the resident said: -He/she liked to stay in bed. -He/she did not think his/her dressing always got changed when they were supposed to. -Sometimes they put pillows under his/her feet but not always. During an interview on 12/6/24 at 10:50 A.M. the Outside Certified Wound Care Provider Physician's Assistant said: -He/she was never asked to see the resident. -He/she felt as though he/she was not always appropriately consulted on residents who would benefit from being evaluated and treated. -He/she would have expected to have been consulted on the resident as soon as the necrotic area was discovered on the resident's foot. During an interview on 12/6/24 at 11:22 A.M., the Director for Rehabilitation Services said: -He/she had been seeing the resident since admission for overall strengthening. -He/she was the one who discovered the new necrotic pressure injury on the resident on 11/5/24 and reported it to the Wound Nurse. -Since finding the new pressure injury, he/she had been working to get appropriate off-loading devices in place and a better wheelchair for the resident that would better off-load the resident's feet. -The resident did have severe muscle spasms involving his/her left foot. During an interview on 12/20/24 at 3:10 P.M., the Facility Medical Director said: -The resident should have been seen by the Outside Wound Care Provider. -He/she would have expected the facility Wound Nurse to appropriately refer the resident who was in need of further wound care evaluation and treatment. -He/she would have expected the facility Wound Nurse appropriately off-load and/or pad the resident's foot where there was extra pressure due to the resident's left/foot spasms to prevent the acquired pressure injury. -He/she would have expected the area of breakdown on the resident's foot to have been found before that area became necrotic. 4. During an interview on 12/5/24 at 1:06 P.M., Registered Nurse (RN) A said: -He/she worked primarily on the night shift but did pick up some day shifts if needed. -If there was a dressing that needed to be changed and Wound Nurse A was not in the building, he/she would always do the dressing change. -If a resident refused a dressing change, he/she would attempt more than once and if the dressing did not get changed, he/she would document everything he/she did and the refusal. During an interview on 12/5/24 at 2:21 P.M., LPN B said: -If a dressing needed to be changed and Wound Nurse A was not at the facility, he/she had no problem changing the dressing. -He/she noticed dressings that were overdue to be changed even when Wound Nurse A was in the building. -He/she believed that sometimes the dressing just did not get changed or documented. During an interview on 12/6/24 at 10:30 A.M., the Administrator, Director of Nursing (DON) and the Regional Nurse Consultant said: -Wound Nurse A had been with the facility for about a year and a half and was hired as an LPN wound nurse with w

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate staffing for residents needing a mechanical lift for transfers so they could get out of bed as desired for six sampled residents (Residents #4, #5, #12, #13, #16, #17) out of 23 sampled residents. Additionally, staff reported shifts weren't covered as reflected by the Daily Staffing Sheets and Time Card Records. The facility census was 89 residents. Review of the facility's Nursing Department Staffing, Scheduling and Postings policy, dated 10/22/24 showed: -The facility will employ sufficient nursing staff on a 24-hour basis to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident. -In staffing an adequate number of nursing personnel, scheduling will be done as needed to meet resident needs and will account for the resident population census, diagnoses, and acuity (measures care need based on severity of resident illness or condition. Resident acuity can determine the staffing level required to provide services to residents). Review of the Facility Assessment Tool, dated 12/29/23 showed: -The facility would provide resources necessary to meet the various resident medical condition and psychiatric/behavioral health needs. Specialized treatments and cares included intravenous (IV) medications, oxygen therapy, ostomy, and hospice care. -Over half of the population required assistance of one to two staff or were totally dependent upon staff for dressing bathing, transfers, and toileting. -The facility's staffing plan included: --A full-time Director of Nursing (DON) daily. --An Assistant Director of Nursing (ADON)/Infection Preventionist. --A Treatment/Wound nurse. --A Minimal Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) Nurse. --Two Registered Nurses or Licensed Practical/Vocational Nurses per each shift. --Two Medication Technicians (CMT) on the Day and Evening shifts. --At least four Certified Nurse Assistants (CNAs) on each shift. Review of the facility's list of residents requiring Activities of Daily Living (ADL - dressing, grooming, bathing, eating, and toileting) cares showed: -Nineteen current residents required two-staff transfer assistance for full-body mechanical lifts. Twelve of the residents who required a mechanical lift were on the north side of the building and seven were on the south side. -Twenty-six residents required one-staff transfer assistance. Nine of the residents were on the north side and seventeen were on the south side. -One resident on the north side and one on the south side required the help of one to two staff for transfers. -One resident on the south side required the help of two staff (without a mechanical lift). -One additional resident on the north side sometimes required help with transfers. -Twenty-one residents required total cares for toileting, including twelve residents on the north side and nine on the south side. -One resident on the north side and two residents on the south side had to be fed their meals. Review of the facility Census Sheet for 10/16/24 showed forty-one residents were on the north side of the building and forty-eight residents were on the south side. 1. Review of the facility Staffing Sheet for 10/3/24 showed: -On the north side of the building on the night shift one nurse and three CNAs were originally scheduled to work, but the three CNAs called in. CMT A was scheduled to fill in as the CNA. -On the south side one nurse and two CNAs were scheduled on the night shift. One of the two CNAs worked a partial shift from 10:37 P.M. to 3:13 A.M. Review of the facility Staffing Sheet for 10/5/24 showed: -On the night shift on the north side one nurse and one CNA worked the full shift. One CNA called in and a third CNA left at 10:00 P.M. -On the night shift on the south side a nurse and one CNA worked. A second CNA called in. Review of the facility Time Card Report for 10/5/24 showed the CNA on the north side shown on the Staffing Sheet left at 10:00 P.M. clocked in at 3:10 P.M. and out at 10:00 P.M. and clocked back in at 10:30 P.M. and out at 4:00 A.M. the following morning. Review of the facility Staffing Sheets for 10/10/24 showed: -On the night shift one nurse and three CNAs were scheduled for the north side of the building. One of the CNAs had been moved from the south side to the north side. One of the three CNAs working on the night shift left at 5:30 A.M. -On the south side one nurse and one CNA were shown as working the night shift. One CNA was shown to have walked out at 11:15 P.M. and one did not show up for work. Review of the facility Time Care Record for 10/10/24 showed: -One CNA on the north side clocked in at 9:51 P.M. and out at 6:59 A.M. the following morning. One CNA clocked in at 3:41 P.M. and out at 5:06 A.M. and one CNA clocked in at 9:06 P.M. and out at 5:38 A.M. -The CNA on the south side clocked in at 10:20 P.M. and out at 7:00 A.M. the following morning. Review of the facility staffing sheet for 10/11/24 showed: -One nurse, one CMT and two CNAs worked the day shift on the north side. A third CNA called in. -On the south side a nurse, a CMT and four CNAs were shown as scheduled and working on the day shift. Review of the facility Time Card Report for 10/11/24 showed: -One CNA shown scheduled on the north side worked 6:43 A.M. to 10:14 A.M. The other scheduled CNA did not work. -One CNA shown scheduled on the south side worked 6:59 A.M. to 2:30 P.M. One CNA worked 7:00 A.M. to 12:33 P.M. One worked 7:49 A.M. to 3:34 P.M. and the fourth CNA shown on the schedule did not work. Review of the facility Staffing Sheets for the day shift on 10/12/24 showed: -A nurse, one CMT, and three aides (one was CMT A who worked the shift as a CNA) were scheduled for the day shift on the north side (100 and 200 Halls). -A nurse, a CMT, and four CNAs were scheduled on the south side (300 and 400 Halls). One CNA on the south side was being oriented as a new employee. Review of the facility Time Card Report for 10/12/24 showed: -On the north side of the building one of the CNAs shown on the 10/12/24 staffing schedule worked 6:43 A.M. to 10:14 A.M. instead of the full eight-hour shift. Another CNA worked 8:50 A.M. until 2:20 P.M. CMT A, worked 7:49 A.M. to 3:34 P.M. -On the south side of the building one CNA worked 6:59 A.M. to 2:30 P.M., one worked 7:00 A.M. to 12:33 P.M., one worked 7:29 A.M. to 12:00 P.M. and 2:41 P.M. to 10:01 P.M., and the CNA in orientation worked 7:02 A.M. to 2:30 P.M. Review of the facility Staffing Sheets for the day shift on 10/13/24 showed: -A nurse, a CMT, and CMT A, who was scheduled as a CNA, was on the schedule for the north side. Two other CNAs called in and one did not call or show up. -A nurse, a CMT, and four CNAs, one of which was being oriented, were scheduled on the south side of the building. Review of the facility Time Card Report for 10/13/24 showed: -CMT A clocked in at 8:25 A.M. and out at 2:20 P.M. -One CNA scheduled to work the south side worked 7:28 A.M. to 2:45 P.M. One CNA worked 7:39 A.M. to 2:31 P.M. The CNA in orientation worked 7:15 A.M. to 2:31 P.M. One CNA shown as working on the south side did not clock in. 2. Review of Resident #4's admission MDS, dated [DATE], showed the resident: -Was cognitively intact. -It was very important he/she do things with a group of other people and go outside to get fresh air. -Had upper and lower extremity impairments on both sides. -Was totally dependent on staff for transferring from one surface to another (such as from the bed to a wheelchair), dressing, bathing, incontinence cares, and rolling from side to side. Review of the resident's Comprehensive Care Plan, dated 9/4/24 showed the resident required total assistance of two staff for transfers and repositioning, total assistance of one staff for dressing and incontinence cares, extensive assistance (staff does over 50 percent of the effort) of two staff for bathing, and extensive assistance of one staff for personal hygiene. Review of the resident's grievance for 10/12/24 and 10/13/24 showed: -The resident did not get out of bed the weekend of 10/12/24 and 10/13/24 and did not receive care from staff. -A grievance response dated 10/16/24 showed nursing was to educate staff on getting the resident up timely and providing cares and rounds every two hours. -Attached to the grievance was a statement by CMT A showing he/she was the only aide working the day shift on 10/13/24 on the north side of the building. The resident asked to be gotten up and was a two-person transfer. He/She made sure the resident was clean and dry and the resident didn't ask to get up any more throughout the shift. During an interview on 10/16/24 at 1:30 P.M. the Social Services Designee said: -The resident filed a grievance because nobody on the day shift got him/her up over the weekend of 10/12/24 and 10/13/24. He/She stayed in bed the entire weekend. -The resident liked to sleep in and have breakfast in his/her room and wanted to get up before lunch. During an interview on 10/16/24 CMT B said: -On 10/13/24 CMT A was the only staff working as a CNA on the north side. The south side had three staff working as CNAs. He/She didn't know why one wasn't pulled to help CMT A on the north side. -The resident was not up at any time on the day shift on 10/12/24 and 10/13/24. He/She was in the resident's room multiple times on those dates, but didn't recall if the resident mentioned why he/she wasn't out of bed. He/She normally got out of bed during the day. -CMT A never asked him/her to help get the resident up on 10/13/24. He/She wasn't asked to get anyone up and didn't get anyone up. -On 10/13/24 he/she helped pass trays, helped feed residents in the dining room and answered call lights. During an interview on 10/16/24 at 2:47 P.M. Licensed Practical Nurse (LPN) A said: -There were only two CNAs working the north side on 10/12/24 and one of the two CNAs on the north side left before residents were served lunch. -CMT A, who was working as a CNA, was asked to work on the south side on 10/12/24 because they were short staffed. -On 10/12/24 Resident #4 didn't get out of bed, but normally does get up. Two staff were needed to get the resident up because he/she was transferred with a full body mechanical lift. The CNA never asked him/her (LPN A) to help get the resident out of bed and didn't know if he/she asked the CMT for help. -The resident asked CNA G to get him/her up. At the time CMT B was at lunch and CNA G said he/she would ask CMT B to help get him/her up after CMT A finished his/her break. By the time CMT A finished his/her break at around 1:00 P.M. trays were being passed to the rooms. Room trays were being picked up right before the evening shift started at 2:30 P.M. -He/She didn't realize until 1:00 P.M. the resident hadn't gotten out of bed before lunch. -There needed to be at least three CNAs on the north side during the day shift because there were several residents who had to be transferred with the mechanical lift. Several residents also needed incontinence cares and help getting dressed. During an interview on 10/21/24 at 10:30 A.M. LPN B said: -He/She worked as the nurse on the south end on 10/12/24 and 10/13/24. -He/She wasn't sure about the staffing on the north side of the building on 10/12/24. -On 10/13/24 the south end had two CNAs and a CMT. There was a third CNA who was in orientation and could help with resident cares but couldn't be left alone with residents. -On 10/13/24 CMT A was acting as the CNA on the north side. He/She was the only CNA scheduled for the north side who showed up. -The Weekend Nurse Supervisor was calling the Staffing Coordinator to try to get someone in, but wasn't able to find anyone. He/She thought the CMT from the south side helped CMT A a short while on the north side, but he/she could only do that while working around his/her medication pass times. -Nurses and CMTs can help with cares but must work around their medication passes and the CNA has to tell them they need help. -The north side nurse was responsible for contacting the Staffing Coordinator if his/her side was short staffed. During an interview on 10/21/24 at 12:55 P.M. LPN C said: -He/She worked on the north side of the building on 10/13/24. -CMT A was the only staff working as a CNA. -He/She and CMT B helped CMT A answer call lights and pass meal trays. -He/She didn't help anyone out of bed. No residents asked him/her to assist them out of bed and CMT A didn't ask for help in getting anyone up. -Sometimes only one CNA shows up for a shift. It makes for poor resident care. It takes longer to do everything like getting everyone up, cleaned, and dressed. -There were several residents on the north side that needed two staff for mechanical lift transfers so it makes it very difficult to meet their needs when only one CNA shows up and medications have to be passed. During an interview on 10/21/24 at 2:09 P.M. CMT A said: -On 10/12/24 he/she was on the schedule to work the north side, but ended up working on the south side because he/she was asked to do so. -On 10/13/24 he/she worked by himself/herself on the north side. He/She didn't get anyone up that needed a mechanical lift transfer because he/she was by himself/herself. In the early morning before the day shift started on 10/13/24 the night shift got a few people up, but he/she didn't get anyone up who needed a mechanical lift transfer. They didn't send anyone over from the south side to help him/her. There were two CNAs and a newer CNA who was orienting on the south side on 10/13/24. -The north side nurse and CMT did not offer to help get anyone up. They helped with meal trays. The call lights were going crazy all day and the north side nurse and CMT helped answer lights. They didn't help get anyone up or provide incontinence cares. He/She didn't think they had time to help with that. They looked busy all day. -He/She had to keep all the incontinent residents clean and dry on the north side. -Resident #4 asked to get up on 10/13/24. The resident normally gets up every day. He/She told the resident he/she would try to get someone to help get him/her up, but wasn't able to find anyone to help. By the time he/she finished changing the incontinent residents the shift was over. During an interview on 10/21/24 at 3:58 P.M. the resident said: -On the weekend of 10/12/24 and 10/13/24 the day shift would pass meal trays and leave and not come back until the next shift. He/She didn't get up at all either of the two days and wanted up on both days. -He/She was told there wasn't enough staff to get him/her up. He/She knew the CMT and nurse were working both days on the north side and they could have helped the CNA get him/her up or the CNA could have gotten an aide from the south side to help. -The weekend before (10/5/24 and 10/6/24) he/she got up one of the weekend days but not the other. He/She pushed the call light between breakfast and lunch and told the staff he/she wanted up. They said OK and left the room and never came back the rest of the shift. The evening shift told him/her they didn't want to get him/her up just to have to put him/her back to bed, so he/she never got up that day. -When he/she was up and out of bed staff don't want to change his/her brief because they have to put him/her back to bed to change him/her and then get him/her back up again. He/She needed two staff for every transfer. For that reason, he/she stayed soiled most days. 3. Review of the Resident #5's admission MDS, dated [DATE] showed the resident: -Was cognitively intact. -It was very important he/she do things with a group of people and go outside for fresh air. -Had upper and lower extremity impairments on both sides. -Was totally dependent on staff for transfers, dressing, bathing, incontinence cares, and rolling from side to side. Review of the resident's Comprehensive Care Plan, dated 8/30/24 showed the resident required total assistance of two staff for transfers, repositioning, and bathing and total assistance of one staff for dressing and incontinence cares. During an interview on 10/21/24 at 1:15 P.M. the resident said: -He/She never got out of bed on 10/12/24 or 10/13/24. They told him/her there was not enough staff to get him/her up. That's no fun to stay in bed. He/She stayed in bed all day and didn't get up at all on any shift on 10/12/24 and 10/13/24. -It was the same way the weekend before (10/5/24 and 10/6/24). One of those days he/she didn't get up. -It had been bad for about a month or more. That was his/her only complaint. -If it didn't get better, he/she would have to move, but he/she didn't want to move to another place. During an interview on 10/21/24 at 2:09 P.M. CMT A said: -Resident #5 was in bed when he/she told his/her roommate, Resident #4, he/she wasn't able to find anyone to help get him/her up. -Resident #5 normally gets up every day, on both weekends and weekdays. During an interview on 10/22/24 at 1:07 P.M. LPN A said Resident #5 stayed in bed all day on 10/12/24. It was 1:00 P.M. before he/she realized the resident was still in bed and too late to call the Staffing Coordinator. 4. Review of Resident #12's Comprehensive Care Plan, dated 8/22/24 showed the resident: -Required total assistance of two staff for transfers with a mechanical lift, toileting, and bathing and maximal assistance of one staff for repositioning and dressing. -Preferred to get up between 9:00 A.M. and 9:30 A.M. Review of the resident's Annual MDS, dated [DATE] showed the resident: -Was cognitively intact. -It was very important he/she do things with a group of people and it was somewhat important to go outside for fresh air. -Had upper and lower extremity impairments on both sides. -Was totally dependent on staff for transfers, dressing, bathing, incontinence cares, and needed partial/moderate assistance (staff does less than half the effort) for rolling from side to side. During an interview on 10/21/24 at 12:00 P.M. the resident said: -He/She didn't get out of bed at all Friday, Saturday or Sunday (10/11/24 - 10/13/24). He/She really wanted up on Friday and Sunday. -On Friday he/she put his/her call light on before lunch. They didn't come to his/her room until they brought lunch. They never gave him/her a chance to get up. -He/She had to have the mechanical lift to get up. Nurses, except for the wound nurse, won't help get him/her up. -On 10/13/24 he/she put his/her light on at 11:00 A.M. Someone turned it off at 11:30 A.M. and said he/she would tell the aide. The aide didn't come until 1:30 P.M. to change him/her. The CNA didn't offer to get him/her up after lunch. That was too late anyway because he/she wanted up before lunch. -He/She didn't know if they really tell aides when he/she needs help or if they forget. -There were many days he/she missed getting out of bed because staff don't get him/her up. He/She didn't keep track of the dates. During an interview on 10/21/24 at 2:09 P.M. CMT A said Resident #12 normally gets up during the day, but he/she didn't have help to get the resident up on 10/13/24. During an interview on 10/22/24 at 1:07 P.M. LPN A said Resident #12 stayed in bed all day on 10/12/24. It was 1:00 P.M. before he/she realized the resident was still in bed and too late to call the staffing coordinator for more staff. 5. Review of Resident #13's Annual MDS, dated [DATE] showed it was very important to the resident he/she do things with other people and go outside for fresh air. Review of the resident's Quarterly MDS, dated [DATE] showed the resident: -Was cognitively intact. -Was totally dependent on staff for transfers with a mechanical lift and repositioning and required maximal assistance with bathing and dressing his/her lower extremities. Review of the resident's Comprehensive Care Plan, dated 9/24/24 showed the resident required total assistance of two staff for transfers; total assistance of one staff for incontinence cares, repositioning and dressing; and extensive assistance of one staff for bathing. Review of staffing for 10/21/24 showed an LPN, a CMT, and two CNAs were scheduled on the north side. During interview on 10/21/24 at 12:17 P.M. the resident said: -There were lots of times he/she wanted out of bed and couldn't get up because there weren't enough aides. Today was one of those days. -He/She told an aide around 7:00 A.M. he/she wanted up. They said they would get him/her up but nobody has gotten him/her up. -He/She couldn't stay in the bed all day. He/She had a sore on his/her left foot and his/her backside was broken down. He/She was paralyzed and couldn't move himself/herself. -A lot of times when he/she put the call light on he/she waits over an hour for help. During an interview on 10/21/24 at 2:09 P.M. CMT A said: -Resident #13 got up every day, but he/she didn't have help to get him/her up on 10/13/24. -His/Her shift ended at 2:30 P.M. He/She hadn't had time to get the resident up yet. 6. Review of Resident #16's Annual MDS, dated [DATE] showed it was very important to the resident to do things with other people and go outside for fresh air. Review of the resident's Comprehensive Care Plan, dated 8/6/24 showed the resident required total assistance of two staff for transfers with a full body mechanical lift, bathing, dressing, and repositioning and total assistance with incontinence cares. Occasionally the resident needed extensive assistance to eat if he/she was weak or tired. Review of the resident's Quarterly MDS, dated [DATE] showed the resident: -Was severely cognitively impaired. -Was totally dependent on staff for transfers, repositioning, bathing, dressing and incontinence cares and required maximal assistance for eating. During an interview on 10/21/24 at 2:09 P.M. CMT A said Resident #16 gets up every day, but he/she didn't get up on 10/13/24 because he/she didn't have help to get him/her up. During an interview on 10/22/24 at 1:07 P.M. LPN A said the resident stayed in bed all day on 10/12/24 because they were short staffed. 7. Review of Resident #17's Comprehensive Care Plan, dated 8/5/24 showed the resident required total assistance of two staff for transfers with a full body mechanical lift, bathing, and dressing and was dependent upon one staff for repositioning and incontinence cares. Review of the resident's Annual MDS, dated [DATE] showed the resident: -Was moderately cognitively impaired. -Thought it was very important to do things with other people and go outside for fresh air. -Was totally dependent on staff for transfers, dressing and incontinence cares. During an interview on 10/21/24 at 2:09 P.M. CMT A said Resident #17 didn't get out of bed on 10/13/24 because nobody helped him/her get the resident up. 8. During an interview on 10/21/24 at 1:05 P.M. CMT B said: -It was difficult to get everyone up who wanted up when there was only one CNA on a side. -They might want up in the morning, but it might be later in the day before staff have time to get them up. During an interview on 10/21/24 at 1:09 P.M. CNA B said: -Normally there were two CNAs working on the north side of the building. -He/She wouldn't be able to get everyone up who wanted up if he/she was the only CNA. He/She would need assistance. -If only a nurse and CMT was working with him/her he/she would have to wait for them to finish passing medications for them to help with mechanical lift transfers and there wouldn't be time to get everyone up with all the incontinence cares needed as well. -Two CNAs working the north side was doable, but three CNAs was what was really needed for the day shift. It got very busy with just two staff trying to answer all the lights. -If he/she was the only CNA on a side he/she would have to do what he/she could and tell the charge nurse he/she couldn't do all the cares needed and the charge nurse would need to notify the DON to try to get staff to come in. During an interview on 10/21/24 at 2:35 P.M. CNA C said: -He/She worked on the south side of the building on 10/13/24 with CNA D and CNA E who was in orientation. They didn't have time to help CMT A on the north side because they had to get the south side residents to the dining room and didn't have time to help get north side residents up before lunch. -LPN B, who was the charge nurse on the south side, never asked the south side CNAs to help on the north side. -CMT A came over a few times during the shift and asked for the south side CNAs' help, but they didn't have time to help. It was all they could do to take care of the residents on their own side. -CNAs were supposed to ask their own charge nurse for help. The nurse and CMT on that side would have to help outside of medication pass times. Residents who were transferred by mechanical lifts would have to wait until the CNA could get help. During an interview on 10/21/24 at 2:45 P.M. CNA F said he/she would not be able to provide cares by himself/herself on any shift on either side of the building due to the high numbers of residents who needed help getting up and who need incontinence cares. Note: At this point CNA F looked over the list of residents needing various types of ADL assistance and said it looked accurate to him/her. During an interview on 10/21/24 at 4:15 P.M. LPN C said: -It was the Registered Nurse (RN) Supervisor's duty to get needed staff on the weekends. He/She told the RN Supervisor there was only one aide who showed up on the north side on 10/13/24. -He/She didn't realize so many residents were still in bed on 10/13/24 or he/she would have asked the RN Supervisor for help. During an interview on 10/22/24 at 9:50 A.M. LPN D said: -Multiple CNAs had been clocking in and leaving the building and coming back before the end of the shift to clock out. They would be gone for hours and residents weren't receiving the cares they needed. The DON was made aware of the problem by multiple nurses. -Sometimes the DON or LPN E would call CNAs to bring up the staffing numbers. They put them in for a body count, but CNAs would refuse to help on another side when staff were short. During an interview on 10/22/24 at 1:07 P.M. LPN A said: -On 10/12/24 CNA H arrived to work around 6:45 A.M. and about 10:15 suddenly announced he/she was leaving. He/She couldn't tell the CNA not to go. He/She would have left anyway. -Before lunch he/she was busy giving insulin and administering medications and the CMT was also giving medications. -He/She was supposed to call the Staffing Coordinator if there were not enough staff. That day he/she didn't call because it was 10:15 A.M. before he/she realized the CNA was leaving and staff weren't going to be able to get everyone up. -By 1:00 P.M. he/she realized they hadn't gotten several residents up and by then it was so late he/she didn't call the staffing coordinator for more staff. -He/She never knew who would show up on the weekends. They had more call-ins on the weekend. -Three CNAs were enough to get everyone up and keep them clean and dry. If only two CNAs show up they were constantly working and trying to keep up with the work. During an interview on 10/22/24 at 1:30 P.M. CNA E said: -On 10/13/24 he/she was in orientation due to being new. He/She already had a current CNA certification and knew how to do resident cares. -During orientation he/she was allowed to assist with mechanical lift transfers, get people up and dressed, provide incontinence cares, and do everything any other CNA did. During orientation he/she just had to be with another CNA for all resident cares. -He/She and either of the two aides he/she worked with on 10/13/24 on the south side could have assisted CMT A on the north side had any of them been assigned or told to do so. During an interview on 10/22/24 at 1:45 P.M. CNA J said: -He/She had worked alone the night of 10/5/24 and 10/10/24 on the south side of the building and had done so about three times within the past month. -He/She tried to keep up with the incontinence cares as best he/she could. It helped a lot to have a second person to work with. -Sometimes a second aide will leave early and he/she would be left alone for the remainder of the shift. That happened on 10/3/24 and at other times. -On the south side approximately 10 residents were incontinent of bladder on the 400 hall and six or seven were incontinent on the 300 hall. He/She also had to empty three catheter bags on the 400 hall and two on the 300 hall. -There were five residents in particular who were very difficult for one person to turn from side to side to change and reposition in bed. One was on the 400 Hall and four were on the 300 Hall. They were either very heavy, very stiff, or weak and unable to help much with turning. -The facility expected the night shift to get a few residents from the south side up in the morning. That was very difficult to do when there was only one CNA working the morning hours. He/She couldn't always get them up when working by himself/herself. During an interview on 10/22/24 at 2:20 P.M. CMT A said: -He/She has had to work the night shift alone. That happened on 10/3/24. -It was much easier to keep up with incontinence cares when there were two CNAs. -He/She worked mostly on the day shift and on the north side of the building. -There were too many mechanical lift transfers and incontinence cares to do during the day for two CNAs. -Three CNAs were needed on the north side on the day and evening shifts. Two were needed on the night shift to get all the incontinence cares and repositioning done. During an interview on 10/22/24 at 2:42 P.M. CNA K said: -He/She has had to work alone before. He/She tried to get everyone changed at least once or twice throughout the night when working alone. -When there were two CNAs he/she could check everyone every two hours. -When he/she worked the evening shift the nurse and CMT had to pass medications between 7:00 P.M. and 9:00 P.M. -Most of the residents want to go to bed during that time so they had to wait to be transferred to bed. -When there were at least two CNAs it was better, but they really needed three CNAs per side on the evening shift. It went more smoothly when there were three CNAs. -About three or four weeks ago he/she was the only CNA on the evening shift on the south side after 7:00 P.M. when the other CNA left. They tried to get as many residents to bed as possible before 7:00 P.M., but residents were just finishing supper. -Nobody from the north side helped out after the second CNA left. He/She just did what he/she could. During an interview on 10/22/24 at 3:10 P.M. the RN Supervisor said: -He/She had been newly hired at the facility and didn't know most resident or staff names. -He/She recalled the CNA working by himself/herself on 10/13/24. The LPN on the south end didn't want the south side CNAs going to the north side to help. -He/She texted the DON to get staff to help on the north side and waited quite a while to hear back. They were unable to find a CNA to come in. He/She helped on the north side with meal trays and answering call lights. -Nobody reported to him/her there were residents who didn't have the opportunity to get up the weekends of 10/5/24 to 10/6/24 and 10/12/24 to 10/13/24. -They should report to him/her if they can't get everyone up or can't get all their work done. The charge nurses should be watching to make sure everyone gets up who wants up. -He/She expected the CNAs, CMTs, charges nurses and the shift supervisor to work as a team and pitch in and help with resident cares as needed. -He/She gave both sides of the building his/her number to contact him/her with any emergencies or concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe and home like environment when multiple leaks occurred in the facility on 1/18/24 affecting two sampled residents (Resident #2 and Resident #3) out of 14 sampled residents; the facility also failed to ensure the floors of rooms of three sampled residents (Residents #10, #6 and #4) were maintained, free of a buildup of grime and debris. The facility census was 82 residents. Review of the Facility's undated policy titled Rapid Response Guide: Flood showed the first initial action would be to rescue anyone in immediate danger. NOTE: There was no specific policy or guideline related to water leaks in resident rooms. 1. Review of Resident #3's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Other Acute Osteomyelitis (a serious infection of the bone), left ankle and foot. -Diabetes Mellitus (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). -Chronic Obstructive Pulmonary Disorder (COPD- a disease process that decreases the ability of the lungs to perform ventilation). Review of Resident #3's Quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 12/8/23 showed: -The resident was cognitively intact. -The resident used a wheelchair and/or walker for mobility. -The resident was independent for most care except for needing Setup or clean-up assistance (helper sets up or cleans up, resident completes activity) when putting on/taking off footwear (the ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable). 2. Review of Resident #2's Face Sheet showed he/she admitted to the facility with the following diagnoses: -Pneumonia (lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid). -Unspecified Psychosis (when there is some loss of contact with reality) not Due to a Substance Abuse or Known Physiological Condition. Review of Resident #2's admission MDS dated [DATE] showed: -The resident was cognitively intact. -The resident did not have any verbal behavioral symptoms directed towards other (e.g., threatening others, screaming at others, cursing at others) within the seven day look back period. -The resident needed supervision or touching assistance (helper provides verbal cues or touching/steadying assistance as the resident completes activity) when going from a sit to lying position. -The resident needed supervision or touching assistance when lying to sitting on the side of the bed. -The resident needed supervision or touching assistance when sitting to standing. -The resident used a wheelchair for mobility. 3. During an interview on 1/18/24 at 9:37 A.M. the Administrator said there was a leak in the center of room [ROOM NUMBER]. Observation on 1/18/24 at 9:50 A.M. of room [ROOM NUMBER] showed: -An active leak in the center of room. -Resident #2's bed had been moved and was turned at an angle towards the entrance of the room and away from the center of the room. -A 32-gallon bucket in the center of the room collecting the leaking water. -Wet bath blankets (a multi-purpose product that can have many uses throughout the facility, commonly used during bed baths for warmth and privacy) around the 32-gallon bucket. -Standing water around the bath blankets on the floor. -Resident #2 was sitting in his/her bed and watching television. -Resident #3 was sitting in his/her wheelchair near the door to the bathroom watching television. During an interview on 1/18/24 at 10:34 A.M. Resident #3 said: -He/She was currently being moved out of his/her room. -He/She thought the leak had started around 4:00 A.M. -He/She thought he/she told Registered Nurse (RN) A about the leak around 5:00 A.M. that morning. -The reason why he/she told the staff about the leak when he/she did was because the leak had worsened. -The facility had not done anything with the leak except putting towels on the floor and placing a bucket underneath the leak. -He/She was really upset about the leak and was afraid that the ceiling may fall on him/her especially once the leak worsened. During an interview on 1/18/24 at 10:47 A.M. Resident #2 said: -He/She did not want to move out of his/her room because he/she was concerned about his/her belongings going missing. -He/She was upset about the leak causing him/her to be uncomfortable especially because the water leaked on him/her and his/her bed. -He/She was unsure of the exact time in which the leak had started, but thought it was around 3:00 A.M. -He/She had told staff about the leak but could not remember the exact time. -He/She thought the leak had worsened around 7:30 A.M. and the facility had not done anything to fix the leak up until that time. -He/She had wanted to change his/her bedding due to the sheets getting wet from the leak. Observation on 1/18/24 at 10:47 A.M. showed the presence of water on the floor at the left side of and close to the foot of Resident #2's bed and the presence of moist sheets on the resident's bed. During an interview on 1/18/24 at 12:47 P.M. the Administrator said: -The facility had started leak audits in all the resident rooms. -He/She thought the residents from that room would be moved into the conference room. -If any other leaks occurred in resident rooms, then the facility would have to start moving residents to other facilities. During an interview on 1/18/24 at 1:09 P.M. Licensed Practical Nurse (LPN) A said: -He/She informed the Director of Nursing (DON) about the leak once he/she saw the DON that morning. -He/She was unsure of when he/she told the DON, but the night nurse was still in the building at that time. During an interview on 1/18/24 at 1:41 P.M. LPN A said: -Resident #2's bed had already been moved away from the leak. -He/She asked Resident #2 and Resident #3 to sit in the dining room for breakfast. -He/She had not told the Maintenance Director about the leak in 307 because there were previous leaks in the building that he/she had been fixing. -It would have been night shift's responsibility to inform management and the Maintenance Director of the leak in room [ROOM NUMBER] because it occurred on night shift. During an interview on 1/18/24 at 1:46 P.M. Resident #2 said: -He/She had moved his/her bed over out of the leak area once the leak had started. -The sheets that were on his/her bed at 10:47 A.M. were the same sheets that were on his/her bed at the time of the leak. During an interview on 1/18/24 at 1:51 P.M. the DON said: -He/She had been made aware of the leak in room [ROOM NUMBER] around 7:45 A.M. that morning. -He/She had been in the building since 6:30 A.M. but had been on the other halls until that time. -He/She was new to the building and was unsure of what needed to happen, so he/she sent out a group text. -He/She was unsure if the group text that had been sent out included the Maintenance Director. During an interview on 1/18/24 at 2:55 P.M. the Administrator said: -He/She was unaware of the leak in room [ROOM NUMBER] until he/she received the group text from the DON. -He/She would have expected staff to notify him/her, the DON, or the Maintenance Director as soon as the staff were aware of the leak in room [ROOM NUMBER], especially because it had been actively leaking. During a phone interview on 1/18/24 at 2:37 P.M. Certified Nursing Assistant (CNA) B said: -Resident #2 and Resident #3 did not need a lot of care. -Resident #2 had not complained of his/her sheets being wet during his/her shift prior to moving rooms. -Resident #2's bed was made when he/she came on shift and had not changed the sheets during his/her shift. -The Maintenance Director and management had already been aware of the leak in room [ROOM NUMBER] by the time he/she knew there was a leak in 307. During a phone interview on 1/18/24 at 2:44 P.M. Registered Nurse (RN) A said: -He/She was unsure of when the leak started in room [ROOM NUMBER]. -He/She had been notified of the leak by one of the Residents around 5:50 A.M. -Once he/she was made aware of the leak, he/she went down to room [ROOM NUMBER] and saw an active leak in the middle of the room. -Resident #2 would be capable of moving his/her own bed and moved his/her bed frequently. -He/She had moved Resident #2's bed more so he/she could put the bath blankets on the floor due to the standing water that was on the floor. -He/She had discussed moving to a new room with Resident #2 and Resident #3, but they had both refused at that time. -He/She tried to call the DON about the leak in room [ROOM NUMBER], but the call would not go through. -Once he/she had finished his/her nursing duties and gave report to LPN A, he/she then told the DON verbally about the leak in room [ROOM NUMBER]. -He/She had informed the DON around 7:30 A.M. that morning. -Resident #2 did not appear wet when he/she went into the room once notified of the leak in room [ROOM NUMBER]. During a phone interview on 1/18/24 at 6:00 P.M. CNA A said: -Resident #2 and Resident #3 had not informed him/her of a leak at any time during his/her shift. -He/She was only made aware of the leak when the surveyor left a voicemail on his/her phone. -The last time he/she had seen Resident #2 and Resident #3 had been around dinner time while he/she was passing out dinner trays. -He/She had not gone back into room [ROOM NUMBER] because Resident #2 had cursed at him/her, and he/she felt threatened. -Resident #2 had also asked him/her to not come back into the room. -room [ROOM NUMBER]'s door was open and had seen a bath sheet on the floor before leaving the facility. -He/She must have been doing his/her last rounds of the shift during the time the leak occurred. -He/She had left the facility around 7:10 A.M. that morning. During a phone interview on 1/19/24 at 7:21 A.M. CNA A said: -He/She had charted Resident #2's behaviors and told the charge nurse. -Resident #2 had not exhibited any verbal behaviors towards him/her before that shift. -He/She thought Resident #2 was going to hit him/her and was really scared. During an interview on 1/19/24 at 9:28 A.M. RN B said: -All residents should be rounded on every two hours at the minimum for safety concerns. -Resident #2 had not exhibited any verbal behaviors towards him/her and would notify the DON of any behavioral issues. -The only behavior he/she had seen from Resident #2 was pacing around his room. -He/She would still have expected the CNA A or a different CNA to have rounded on Resident #2 and Resident #3 regardless of their behavioral issues. During an interview on 1/19/24 at 9:49 A.M. CNA A said: -He/She was unaware of any past behavioral issues from Resident #2 prior to that shift. -Resident #2 and Resident #3 are independent with all care. -The rounds should have been delegated to someone else because he/she had not completed them. During an interview on 1/19/24 at 12:10 P.M. Resident #3 said: -He/She never refused to change rooms once the leak occurred in his/her room. -He/She was never made aware of any plan for a room change prior to surveyor arrival to the facility. During an interview on 1/19/24 at 12:15 P.M. the Administrator and The DON said: -The DON had asked Resident #2 and Resident #3 to come out of the room once he/she was made aware of the leak in room [ROOM NUMBER]. -He/She told Resident #2 that it would be safer for him/her to move out of the room, but Resident #2 had stated that he/she would not move to a different room without knowing where his belongings were going. -By the time the DON had finished speaking with Resident #2 and Resident #3 the Maintenance Director was in the building and provided no further intervention. -The Administrator had arrived to the facility around 8:30 A.M. on 1/18/24 and had sent a message to the Maintenance Director about the leak in 307 around that time. -There was not a discussion of what happened or what was going to happen with room [ROOM NUMBER] prior to morning meeting. -The morning meeting started around 9:00 A.M. on 1/18/24 and was adjourned once management was made aware of surveyor being in the facility which was around 9:30 A.M. 4. Review of Resident #10's medical record who was admitted to the facility on [DATE] and his/her admission MDS was not completed as yet. Observations on 1/19/24 at 1:45 P.M., showed the presence of a brown colored grime on floor of the resident's room and at the entrance of his/her room. Further observation showed the resident was sleeping, so he/she was not interviewed. Observation on 1/19/24 at 1:50 P.M., showed the presence of debris on the floor and a large red stain behind the bed in the resident's room. 5. Review of Resident #6's face Sheet dated 1/10/24, showed diagnoses which include quadriplegia (paralysis of the legs and arms) neuromuscular dysfunction of bladder, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest which can affects how a person feel, think and behave and can lead to a variety of emotional and physical problems). During an interview on 1/19/24 at 1:52 P.M. the resident said the housekeepers had not been to his/her room yet. Observation on 1/19/24 at 1:50 P.M., showed the presence of debris on floor and red stains behind the resident's bed. 6. Review of Resident #4's annual MDS dated [DATE], showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. Observation on 1/19/24 at 1:56 P.M. showed a heavy buildup of debris between bed and wall in the resident's room. During an interview on 1/19/24 at 1:57 P.M., the resident said the housekeepers did not pull his/her bed out for cleaning and everyone can do a little bit better job. During an interview on 1/19/24 at 2:33 P.M., the Housekeeping Supervisor said he/she expected the housekeepers to clean the debris from under the beds and at the entrance to room, after he/she observed Resident #10's room. Observation on 1/19/24 at 2:36 P.M., with the Housekeeping Supervisor, showed the buildup of debris between Resident #4's bed and the wall. During an interview on 1/19/24 at :40 P.M., the Housekeeping Supervisor said: -He/she looked at 4-5 rooms for cleanliness, at the end of the day. -He/she noticed some of these issues with lack of cleanliness in the past. MO 00229207 and MO 00230452.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to document wound care orders and treatment for one sampled resident (Resident #3) out of five sampled residents. The facility census was 83 residents. Review of the facility Wound Management Policy dated 6/20 showed: -Purpose: -To provide a system for the treatment and management of residents with wounds including pressure -Policy: -A resident who has a wound will receive necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing. -Procedure: -Assessment: --A licensed nurse will perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. -Upon identification of a new wound the licensed nurse will ---Measure the wound (length, width, depth. ---Initiate a wound monitoring record sheet for each wound. ---Implement a wound treatment per physician's order. -Wound management: --Rehabilitation services will be contacted for appropriate devices or pressure redistribution devices. --A licensed nurse will develop a care plan for the resident based on recommendations from dietary, rehabilitation and the attending physician. -Documentation: -Wound documentation will occur at a minimum of weekly until the wound is healed. --Documentation will include: ---Location of wound. ---Length, width, and depth measurements recorded in centimeters. ---direction and length of tunneling and undermining (if applicable). ---Appearance of the wound base. ---Drainage amount and characteristics including color, consistency, and odor. ---Appearance of the wound base. ---Description of the peri-wound (skin around the wound) condition. ---Presence or absence of new skin at wound rim. ---Presence of pain. --Licensed nurse will document effectiveness of current treatment in the resident's medical record on a weekly basis. --Update the resident's care plan as necessary. 1. Review of Resident #3's admission Record showed he/she was admitted on [DATE] with the diagnoses of Diabetes Type 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), Hemiplegia and Hemiparesis (paralysis/weakness affecting one side of the body) following a stroke affecting the right dominant side, and history of falling. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/10/23 showed the resident: -Was cognitively intact. -Was totally dependent on staff for assistance with Activities of Daily Living (ADL). -Required maximal assistance with toileting hygiene. -No skin conditions assessed. Review of the Resident's undated Care Plan showed the resident: -Had a self-care performance deficit. --Staff assistance to the extent needed to accomplish task. (Note: no care plan was developed for skin issues or wounds) Review of the resident's admission assessment dated [DATE] showed he/she had a scab to his/her right heel. Review of the resident's Skin Only Evaluation dated 9/16/23 showed: -Stage 1 pressure injury to the right heel. (Observable, pressure-related alteration of intact skin with non-blanchable redness of a localized area usually over a bony prominence; may include changes in skin temperature, tissue consistency and/or sensation). --No treatment indicated. --No pain indicated. -No care planning indicated for wound management and documented pressure ulcer (pressure injury). Review of the resident's Medication Review Report printed on 9/27/23 showed: -To cleanse his/her right heel deep tissue injury (DTI - an injury to a patients underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) wound with wound cleaner, pat dry, skin prep on peri wound (skin surrounding the wound), apply nickel thick Santyl (an ointment used for the debridement of pressure ulcers) on center of wound and cover with dry dressing. Change every day shift Monday, Wednesday, Friday and as needed with an order date of 9/27/23. -Heel boot at all times to his/her right foot with a order date of 9/27/23. -Wound care consult with an order date of 9/27/23. (Note: No wound care, wound prevention or wound consultations prior to 9/27/23. There were two discontinued wound care orders back dated to 9/5/23.) Review of the resident's medical records showed no wound assessment or wound tracking before 10/4/23. During an interview and observation on 9/27/23 at 11:07 A.M., of the resident showed: -He/she thought there was also an open area on his/her right heel due to not being put to bed at his/her request. -He/she rated the pain to his/her heel 8-9 on a scale of 0-10 (0 = no pain, 10 = the worst pain). -Observation of the resident's right heel showed a dark black colored area approximately the size of a half dollar. During an interview on 9/27/23 at 11:47 A.M. Certified Nurses Aide (CNA) A said he/she was not aware of the area on the resident's right heel. During an interview on 9/27/23 at 12:02 P.M. the Nurse Practitioner said: -He/she was not aware of the area on the resident's right heel. -He/she verified in the electronic record that there were no current orders for wound care, wound prevention or a wound consultation. -He/she assured that a treatment would be started for the resident as soon as possible. -He/she expects all wounds to be assessed and the physician and/or Nurse Practitioner to be notified immediately. During an interview on 9/27/23 at 12:29 P.M. Licensed Practical Nurse (LPN) A said: -Resident skin assessments are to include heels. -Skin assessments were done weekly and documented in the resident chart. -He/she was not the nurse for the resident and had not assessed the resident. -If wounds were assessed the doctor should be contacted for a treatment order. During an interview on 9/27/23 at 12:54 P.M. LPN B said: -Skin assessments were done by the nurse weekly. -If a black spot or any kind of wound was noticed, he/she would notify the doctor and start the treatment. -He/she was unaware of any wounds for the resident. During an interview on 9/27/23 at 1:00 P.M. the Physician said: -He/she was aware of the DTI. -The resident was being seen by the wound care team. During an interview on 9/27/23 at 1:10 P.M. Regional Registered Nurse (RN) A said: -He/she confirmed there were no treatment orders for the resident's wounds to his/her right heel since admission. -There were orders put in on 9/27/23 that had been back dated to 9/5/23. -He/she instructed the Director of Nursing (DON) to correct the error immediately. During an interview on 9/27/23 at 2:26 P.M. the DON said: -He/she expects all wounds to be assessed, treatment initiated and risk management completed. -If resident admitted with a wound, staff should check for treatment orders. -If there are no treatment orders, the nurse should contact the physician for treatment orders. -The resident should have a wound consult for follow up and ongoing treatment. -The resident had not been seen by wound care since admission. -Skin assessments were done weekly and documented in the resident chart. -Wound care was being done by the wound nurse. -Since the wound care nurse was not longer there, the DON was responsible to ensure wound care and a assessments were being done. During an interview on 9/27/23 at 2:53 P.M. the Administrator said: -He/she expected wounds to be assessed, measured and treated per regulatory standards. -He/she was not aware of the resident's untreated heel wound. MO00224076

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for three sampled residents (Resident #3, #4, and #5) out of five sampled residents. The facility census was 83 residents. Review of the facility Care and Services Policy dated 6/20 showed: -Residents are provided with the necessary care and services to maintain the highest practicable physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of long-term care facility. -Care and services are provided in a manner that consistently enhances self-esteem and self-worth. Review of the facility Communication-Call System Policy dated 10/24/22 showed: -Purpose: To provide a mechanism for residents to promptly communicate with nursing staff. -Policy: --The facility will provide a call system to enable resident to alert the nursing staff from their beds and toileting/bathing facilities. ---The call system should be accessible to a resident lying on the floor in toileting and bathing facilities. -Procedure: --Call cords will be placed within the resident's reach in the resident's room. --Nursing staff will answer call bells promptly, in a courteous manner. 1. Review of Resident #3's admission Record showed He/She was admitted on [DATE] with the diagnoses of Diabetes Type 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), Hemiplegia and Hemiparesis (paralysis/weakness affecting one side of the body) following a stroke affecting the right dominant side, and history of falling. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 9/10/23 showed the resident: -Was cognitively intact. -Was totally dependent on staff for assistance with Activities of Daily Living (ADL). -Required maximal assistance with toileting hygiene. -Was frequently incontinent. Review of the resident's undated Care Plan showed: -He/She had a self-care performance deficit. --He/She needed staff assistance to the extent needed to accomplish task. --He/She needed staff assistance with getting on and off toilet. --He/She required staff assistance to move between surfaces. --To encourage use of the call bell for assistance. -At risk for falls. --Needed safety movement with a working and reachable call light. --Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. --The resident needed prompt response to all requests for assistance. Review of the resident's Grievance/Complaint report dated 9/11/23 showed He/She complained that his/her call light was on and it went unanswered for most of the night on 9/10/23 which resulted in him/her being left in his/her own waste for most of the night. During an interview on 9/27/23 at 10:16 AM, the Social Services Director said the grievance for the call lights was related to clinical services so it was given to the Director of Nursing (DON) to handle but as of now the grievance was unresolved. During an interview on 9/27/23 at 11:47 A.M., Certified Nurses Aide (CNA) A said: -The last time He/She checked on the resident was after breakfast. -It should only take a couple of minutes to answer a call light, if He/She is working on the floor. -35 to 40 minutes is too long for a call light to go unanswered. -He/She left for break at around 10:50 A.M. and was back just after 11:00 A.M. -He/She did not answer the resident's call light from 11:07 A.M. through 11:47 A.M. because He/She was on break. During an interview and observation of the resident on 9/27/23 from 11:07 A.M. through 12:01 P.M. showed: -The resident's call light had been activated. -The resident was waiting for staff to assist him/her to the bathroom. -He/She thought the light had already been on for about 10 - 15 minutes. -He/She recalled making a complaint to the facility about not being able to get assistance to the bathroom and getting clean and dry when He/She has been incontinent. -He/She was normally able to control his/her bowel and bladder, but getting assistance to the bathroom sometimes took to long resulting in him/her becoming incontinent. -The staff get frustrated with him/her when He/She was incontinent. -Once staff put him/her to bed, He/She would have to wait until the follow morning to be clean up. -He/She laid in his/her diarrhea up to his/her shoulders for most of one night. -He/She did not have any skin problems prior to being admitted , but He/She believes there is an open area on his/her bottom now. -He/She rated the pain to his/her bottom 8-9 on a scale of 0-10 (0 = no pain, 10 = the worst pain). -He/She felt if the call light was answered timely, He/She could of make it to the bathroom and He/She would not be having the pain to his/her bottom. -At 11:47 A.M., CNA A opened and shut the door without making contact with the resident. -The resident had not been able to maintain control of his/her bowels and was incontinent. -He/She was upset and said I was a CNA when younger and would never treat someone this way. 2. Review of Resident #4's admission Record showed He/She had been admitted on [DATE] with the diagnoses of Diabetes Type II, Hemiplegia and Hemiparesis following a stroke affecting the right dominant side, and unsteadiness on feet. Review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was cognitively intact. -Totally dependent on staff for ADLs. -Was wheelchair bound. -Was incontinent of bowel and bladder. Review of the resident's undated Care Plan showed: -He/She had an ADL self-care performance deficit related to stoke. -He/She required staff assistance with toileting and was to be clean and dry. -He/She was to checked and changed every two hours. Review of the resident's Grievance/Complaint report dated 9/26/23 showed the resident complained that he/she had thrown up and had a bowel movement on 9/22/23 when the CNA did not assist him/her to the bathroom after waiting over an hour. During an interview on 9/27/23 at 12:16 P.M., the resident said: -He/She had made a complaint to social services about not getting assistance from the staff. -He/She had been incontinent of bowel and had turned his/her call light on. -He/She was in need of assistance and went into the hall. - An unknown CNA said he/she was not responsible for him/her and went to the other hall. -The resident had not been able to get assistance from staff using the call light to go to the bathroom or to be put to bed when the resident was ready. -When he/she was dismissed by the CNA he/she was so upset he/she vomited on him/herself and was crying. 3. Review of Resident #5's admission Record showed He/She was admitted on [DATE], and readmitted on [DATE] with the diagnoses of Diabetes Type II, Hemiplegia and Hemiparesis, following a stroke affecting the left non-dominant side, and contracture of the left upper arm and left lower leg. Review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was cognitively intact. -Was totally dependent on staff for all cares. -Was wheelchair bound. -Was incontinent. Review of the resident's undated Care Plan showed the resident: -Had a self-care deficit related to stroke. -Required total assistance from staff for toileting. -Required staff to check every two hours and change to make sure the resident is clean and dry. -Was incontinent of bowel and bladder. -Skin should be kept clean and dry. Review of the resident's Grievance/Complaint report dated 9/26/23 showed He/She complained that He/She was not changed for an entire shift on 9/25/23. During an interview on 9/27/23 at 12:46 P.M. the resident said: -It takes 30 minutes to an hour for a call light to be answered. -He/She had trouble getting incontinent cares done. -There were times when the staff would take the call light from him/her because He/She uses it too much. -He/She had been told to not use the call light unless He/She was dying or on the floor by staff. -He/She had bumps and itching in perineal area due to not being able to be clean and dry. -He/She had made a grievance to social services and nothing had been done. 4. During an interview on 9/27/23 at 12:02 P.M., the Nurse Practitioner said he/she expects residents to not have to wait for 35 to 40 minutes for a call light to be answered. During an interview on 9/27/23 at 12:29 P.M., Licensed Practical Nurse (LPN) A said: -He/She expected call lights to be answered within three to five minutes. -35 to 40 minutes was not acceptable for a resident to wait for a call light to be answered. During an interview on 9/27/23 at 12:54 P.M., LPN B said: -It was not acceptable for a resident to be incontinent due to not being taken to the bathroom. -He/She expected call lights to be answered in five minutes or less, unless the aides were busy. -If staff were busy, they should answer the call light and let the resident know they will return as soon as possible. -35 to 40 minutes was too long for a call light to go unanswered. -He/She was responsible to ensure call lights were being answered in a timely manner on 9/27/23 from 11:07 A.M. to 11:47 A.M. -He/She was not on the hall during the time the call light was not answered for approximately 40 minutes. -It was not uncommon for him/her to be off the hall for 40 minutes. -Unknown why the call light was not answered for approximately 40 minutes. During an interview on 9/27/23 at 2:26 P.M., the DON said: -He/She expected call lights to be answered in three to five minutes. -35 to 40 minutes was not an acceptable time for a call light to go unanswered. -It was unacceptable for a resident to be incontinent due to not being taken to the bathroom timely. -He/She was unaware of Resident #3 being incontinent or having skin issues due to waiting too long to be taken to the bathroom. -There should be no reason a resident was left all night in urine or fecal matter all night. -Residents should be checked after being put to bed and before getting up in the morning. During an interview on 9/27/23 at 2:53 P.M., the Administrator said: -He/She expected call lights to be answered immediately if possible. -35 to 40 minutes was not acceptable for a call light to go unanswered under normal circumstances. -He/She was not aware a call light went unanswered on 9/27/23 from 11:07 A.M. to 11:47 A.M. -There could have been a good reason the call light was unanswered for approximately 40 minutes that he/she was not aware of. -The nurse being off the unit to make copies and staff being on break, leaving the hall unattended, could be okay. -Residents should never be told not to use their call light. During an interview on 10/4/23 at 11:01 A.M., CNA C said: -He/She was assigned to the residents on the other hall on 9/27/23. -When CNA A went on break He/She was responsible for call lights as long as He/She was not in a room taking care of his/her own residents. -Call lights should be answered within three to five minutes. -40 minutes was not acceptable for a call light to go unanswered. -On 9/27/23 from 11:07 A.M. to 11:47 A.M. he/she was in another resident's room with one resident for approximately 10 to 15 minutes. -It was not uncommon for him/her to be alone on the hall, especially if the facility was short staffed. During an interview on 10/4/23 at 11:35 A.M., the Certified Medication Technician (CMT) said: -Everyone was responsible for answering call lights. -He/She had answered call lights and had done what he/she could for the residents. -On 9/27/23 from 11:07 A.M. to 11:47 A.M. he/she was passing his/her noon medications on the opposite hall and did not see/hear the call light going off. -Call lights should be answered within two to three minutes. -40 minutes was an unacceptable time for a call light to go unanswered. During an interview on 10/4/23 at 1:54 P.M., Regional Registered Nurse (RN) B said: -It was never appropriate for a call light to go unanswered for 40 minutes. -There were direct care staff, ancillary staff and administrative staff that could have answered the call light. During an interview on 10/4/23 at 2:00 P.M., the Regional Director said it was everyone's responsibility to answer call lights, including him/her. MO00224076

Based on interview and record review, the facility failed to ensure resident dignity was maintained for one sampled resident (Resident #1) when on 8/31/23 there was an allegation that Certified Medication Technician (CMT) A threw water on the resident, out of three sampled residents. The facility census was 78 residents. On 9/1/23 the Administrator was notified of the past noncompliance which occurred on 8/31/23. On 8/31/23 the facility administration was notified of the incident and the investigation was started. CMT A was suspended on 8/31/23 and later terminated. No employees were allowed to work prior to reeducation completed 8/31/23. The deficiency was corrected on 8/31/23. Review of the facility's policy titled Privacy and Dignity dated June 2020 showed: -The staff assist residents in maintaining self-esteem and self-worth. -Staff treat residents with respect including respecting their social status, speaking respectfully, and listening carefully. 1. Review of Resident #1's face sheet showed he/she admitted to the facility with the following diagnoses: -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). -Peripheral Vascular Disease (PVD- inadequate blood flow to the extremities). -Congestive Heart Failure (a weakness of the heart that leads to the build-up of fluid in the lungs and surrounding tissues). Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 7/20/23 showed the resident was cognitively intact. Review of the facility's investigation report dated 8/31/23 showed: -The incident occurred just before 12:00 P.M. on 8/31/23. -The resident stated the staff member would not tell him/her what his/her medications were used for and then threw water at him/her. -CMT A stated that he/she had explained the medication to the resident and had not thrown water on the resident. -CMT A stated that the resident had made a gesture like he/she did not wanted to take the medication and bumped the water cup, spilling the water onto him/herself. -The charge nurse for the hall stated that the resident had told him/her the same story. -In conclusion, the alleged incident could not be verified and it was determined that the issue was related to customer service/dignity rather than abuse. During an interview on 9/1/23 at 10:07 A.M. the resident said: -CMT A gave him/her six to eight pills to take. -He/she had asked CMT A about the medication. -CMT A told the resident he/she would not understand and would not explain what the medication was for. -CMT A then started to backed away from his/her bed and called him/her a bitch. -When CMT A got to the end of his/her bed he/she threw the water that was for him/her to take his/her medications. -The water landed on the wall, his/her monitor by his/her bedside, all-over him/her, and his/her face. -CMT A then left the his/her room. -There were no witnesses to the altercation. During an interview on 9/1/23 at 11:50 A.M. the Director of Nursing (DON) said: -All staff were expected to treat each resident with respect and dignity. -CMT A had not given the resident appropriate customer service or care. During an interview on 9/1/23 at 1:09 P.M. the resident said: -He/she felt shocked and outraged by the altercation. -He/she received his/her medications and his/her linens had been changed after the altercation occurred. During an interview on 9/1/23 at 1:30 P.M. the Admissions Coordinator said: -A staff person, maybe a housekeeper had called him/her over to the resident's room after the altercation occurred. -He/she observed the resident wet from the chest down, with some water on the top of the resident's head. -There had also been water on the resident's mattress. During interview on 9/1/23 at 1:33 P.M. CMT A said: -He/she was not normally assigned to the hall that the resident was on. -He/she had explained all of the resident's medications to the resident. -The resident had made a gesture towards him/her like he/she did not wanted the medication and then the resident bumped the cup of water and it spilled on him/herself. -The water spilled all over the resident, but could not describe specifically where the water had landed on the resident. -The resident had told him/her to get out if his/her room. During an interview on 9/1/23 at 1:54 P.M. Certified Nurses Aide (CNA) B said: -He/she had been working on the resident's hall when the altercation occurred. -He/she had gone into the resident's room to do a normal check of the resident. -He/she had not been asked by CMT A to assist the resident in getting changed. -Once he/she entered the room the resident reported the incident to him her. -He/she observed the resident and it had looked like water had been thrown at the resident. -The bottom of the resident's bed, the wedge pillow, and the resident's knees were wet. -He/she then reported the incident to the Admissions Coordinator and stayed with the resident. -The Admissions Coordinator, the charge nurse, and the DON all came in to the room, so he/she left the room to get supplies to change the resident and resident's bed linens. -He/she performed a full bed change and the rest of the shift went on as normal. MO00223816

Based on observation, interview, and record review, the facility failed to ensure resident's preferences were assessed and honored for one resident (Resident #41) out of 23 sampled residents. The facility census was 74 residents. 1. Record review of Resident #41's face sheet showed he/she was admitted with: -Chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). -Unsteadiness on feet. Record review of the resident's Care Plan, revised 1/13/23, showed: -Staff assistance was required for the resident to bathe, perform personal hygiene, and for oral care. -Staff did not address resident preferences. Record review of the resident's Minimum Data Set (MDS-a federally mandated tool used for assessments) 5 Day PPS Assessment, completed 2/10/23, showed: -The resident was totally dependent on staff for toileting, personal hygiene, and bathing. -The resident was always incontinent of bladder. -The resident was always incontinent of bladder. -The resident had a Brief Interview for Mental Status (BIMS) of 11 out of 15 which showed the resident was moderately cognitively intact. During an interview on 2/27/23 at 12:48 P.M., the resident said: -Staff told him/her what to do and when to do it. -Staff did not give him/her a choice on when they wake, get out of bed, eat, or with clothing choices. Continuous observation on 3/2/23 from 8:27 A.M. to 10:11 A.M. showed: -The resident's call light was on. -Staff had entered and exited the resident's room, turning off the resident's call light telling the resident they would be back to assist the resident to get dressed and get to therapy. Staff did not return to assist the resident and he/she would turn the call light back on several times during the continuous observation. -The resident was wearing a brief and shirt while lying in bed. Observation on 3/2/23 at 10:12 A.M. showed: -Certified Nursing Assistant (CNA) A and CNA C entered the resident's room. -CNA A brought clothing into the resident's room with him/her. -CNA A and CNA C put the pants, brought in by CNA A, on the resident. -CNA C attempted to assist the resident from his/her bed to his/her wheelchair. -The resident refused to transfer until staff changed his/her shirt. -CNA A and CNA C changed the resident's shirt and CNA C took the resident, via his/her wheelchair, to therapy. During an interview on 3/2/23 at 12:10 P.M., CNA C said: -Staff should address any resident request for cares within 10-15 minutes. -Residents waiting over an hour for requested care was inappropriate. During an interview on 3/2/23 at 12:52 P.M., CNA A said: -He/she would tell a resident if they could not assist them at that time but would let other staff know the resident's request. -If a resident asked to get out of bed they shouldn't have to wait for an hour. -He/she generally picked out all residents' clothing but would get something different if the resident said they didn't like it. During an interview on 3/3/23 at 8:57 A.M., the resident said: -He/she had been upset about having to wait so long on 3/2/23 to get out of bed. -He/she was frequently left in dirty briefs. -He/she used his/her call light when he/she needed his/her brief changed but it takes them forever to assist. -He/she felt very uncomfortable with the lack of choices he/she was allowed to make. During an interview on 3/3/23 at 10:22 A.M., Licensed Practical Nurse (LPN) A said: -Staff should address any resident request for cares within 10-15 minutes. -One hour was too long for a resident to wait for their requested care to be performed. During an interview on 3/3/23 at 2:40 P.M., the Director of Nursing (DON) said: -Staff were to honor the residents' choices by following the care plan. -Staff should discuss decisions with residents to ensure their choices are honored. -He/she expected staff to assist a resident with any requested cares within 30 minutes of the request. -If staff were not able to perform the resident's requested care within 30 minutes, staff were to notify the resident of a time frame when they would be available to assist or have another staff member provide the care. -Staff were to ask other staff members for assistance when a resident has used their call light multiple times for the same care request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure notification of the facility bed hold policy for one sampled resident (Resident #326) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy titled Bed Hold dated June 2020 showed the facility notifies the resident or his/her representative, in writing, of the bed hold policy any time the resident is transferred to general acute care hospital even if the facility has not met the occupancy requirements. 1. Record review of Resident #326's undated face sheet showed he/she was admitted to the facility on [DATE] with the diagnosis of unspecified Atrial Fibrillation (an irregular heart beat). Record review of the resident's Electronic Medical Record (EMR) dated February 2023 showed: -The resident was sent to the hospital on 2/7/23, 2/10/23, and 2/12/23. -The resident was sent to the hospital on 2/7/23 for a family initiated hospitalization. -The resident was sent to the hospital on 2/10/23 for increased edema (swelling). -The resident was sent to the hospital on 2/12/23 for complaints of chest pain. -The resident had not returned to the facility at time of exit. -No record or documentation that a bed hold notice was sent with the resident or given to the resident's representative. The resident's bed hold notices for all three hospitalizations were requested and not received at the time of exit. During an interview on 3/3/23 at 3:22 P.M., Licensed Practical Nurse (LPN) A said: -He/she did not normally send out bed hold notices for the residents who get sent to the hospital. -He/she thought it would be the responsibility of the person in charge of admissions to send out all bed hold notices. During an interview on 3/3/23 at 3:47 P.M., the Director of Nursing (DON) said: -A bed hold notice needed to be sent out with each resident who was transferred to the hospital. -He/she expected the nurse that was sending the resident to the hospital to give the resident the bed hold notice and the Social Service's Director would be the one to follow up to make sure the resident received the notice.

Based on interview, and record review, the facility failed to ensure care plans were updated to accurately reflect the resident's condition for one sampled resident (Resident #41) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy Care Planning dated 10/24/22 showed staff were to: -Include services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Update a resident's care plan per the Resident Assessment Instrument (RAI-used in conjunction with Minimum Data Set [MDS-a federally mandated tool used for care planning]) schedule. -Update a resident's care plan as dictated by changes in the resident's condition. -Update a resident's care plan to address changes in behavior and cares. 1. Record review of Resident #41's face sheet showed he/she was admitted with the following diagnoses: -Chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). -Unsteadiness on feet. Record review of the resident's Care Plan, last revised 1/13/23, showed: -The resident was independent with transfers. -Fall interventions had not been updated since 3/3/22. -The resident was on a mechanical soft diet with nectar thick liquids. -The resident no longer used his/her enteral feeding tube and it was to be discontinued in December 2022. Record review of the facility's fall investigation for this resident showed he/she had a fall with no injury on 1/5/23 with no new interventions related to the fall. Record review of the resident's Physician Order Sheet, dated 3/1/23, showed: -The physician ordered the resident be NPO (nothing by mouth) on 1/23/23. -The physician ordered enteral feedings and water flushes through enteral feeding tube on 1/23/23. During an interview on 3/1/23 at 8:47 A.M., the Social Services Designee (SSD) said: -The resident was currently NPO and receiving tube feedings. -The Registered Dietitian (RD) was supposed to come to the care plan meetings but he/she did not know who the RD was at that time. -Care plans were to be updated immediately if incorrect. -He/she was responsible for developing and updated care plans at the facility. -This resident's care plan was out of date and not applicable to the resident at the current time. During an interview on 3/2/23 at 12:52 P.M., Certified Nursing Assistant (CNA) A said: -He/she was not sure what was in any resident's care plan. -He/she provided cares based on verbal report from other staff. -He/she did not know how to find a resident's care plan. During an interview on 3/3/23 at 9:08 A.M., the SSD said: -He/she expected NPO status to be listed on the resident's care plan. -He/she expected any resident with NPO status to have nutrition and hydration addressed in the care plan. -He/she expected enteral feeding tubes to be addressed with appropriate interventions for each resident that had a feeding tube. -He/she was unsure what, if any, interventions were put in place for Resident #41 after his/her past fall. -He/she agreed Resident #41's care plan should have been updated after his/her fall. -The charge nurse is responsible for relaying the resident's needs to the staff. -He/she was unsure if CNAs had access to resident care plans. During an interview on 3/3/23 at 10:22 A.M., Licensed Practical Nurse (LPN) A said: -He/she did not know who was responsible for updating care plans and stated, he/she was not involved in that process. -He/she agreed the resident's care plan did not reflect the resident's current condition. -Resident #41 had a fall in January 2023 but he/she was not sure what new interventions were put in place. During an interview on 3/3/23 at 2:40 P.M., the Director of Nursing (DON) said: -Any resident that is NPO should have had that addressed in their care plan. -Staff should include hydration on all care plans for residents that are NPO. -Staff educated Resident #41 after his/her fall in January 2023 but the care plan should have been updated. -Care plans were to be updated quarterly or if there's a change in the resident's condition.

Based on interview and record review, the facility failed to ensure pain medication was available as ordered and documentation of control substance medication, reordering medication in timely manner and provide ongoing pain management for one sampled resident (Resident #50) out of 23 sampled resident. The facility census was 74 residents. Record review of the facility's policy and procedure undated for Medication Administration showed: -The nursing staff will document each medication given with time and initial of nurse who gave the medication. -For as needed medication the nurse will document the reason for the medication, name of the medication, time given and effect. 1. Record review of Resident #50's admission Face-Sheet showed he/she had a diagnosis of chronic pain, Multiple Sclerosis (MS, is a potentially disabling disease of the brain and spinal cord). Record review of the resident's hospice (end of life care) pharmacy signed delivery manifest receipt dated 1/21/23 showed the facility nurse had received the resident's Fentanyl (control substance used for severe pain) 50 micrograms (mcg)/hour (hr) patch for total of 10 patches. Record review of the resident's hospice pharmacy signed delivery receipt dated 1/26/23 showed: -The facility nurse had received the resident's Fentanyl 75 mcg/hr patch for total of five patches. -The facility were not able to find the control substance record sheet for this medication. (The control substance record sheet shows the beginning and ending totals and each time the medication was pulled from stock for administration). Record review of resident's discontinued physician order sheet dated 1/26/23 at 11:06 P.M. showed: -Fentanyl patch 50 mcg/hr, apply one patch transdermal (on skin) every 72 hours for pain. Rotate site and remove per schedule, was stopped on 1/26/23 due to an increase in the dosage. -Was signed by physician on 2/12/23 at 8:27 P.M. Record review of the resident's Treatment Administration Record (TAR) for 1/2023 showed: -On 1/27/23 the resident reported pain scale level of 8 out of 10. -Fentanyl 75 mcg was applied per physician's order on 1/27/23 and 1/30/23. Record review of the resident Pain Care plan was updated on 2/7/23 showed: -The resident had pain related to diagnosis of MS. -Administer analgesia oxycodone (a narcotic pain medication) 10 milligrams (mg) as per ordered. Give 1/2 hour before any treatment or care dated 7/2/21. -Facility nursing staff were to respond immediately to any resident complaint of pain. Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 2/9/23, and showed the resident: -Had a Brief Interview for Mental Status (BIMS) of 14 out 15. -Was cognitively intact and was able to make his/her needs known. -Needed extensive to total assistance of one staff member for bathing, dressing, mobility and toileting. -Had frequent pain with pain scale of 5 out 10 with 10 being the worst pain. -Received a controlled substance pain medication during the lookback time. -Received both scheduled and as needed pain medication. Record review of the resident's Physician Order Sheet (POS) 2/2023 showed: -Assess pain level every shift. -Gabapentin (a medication used for nerve pain) 600 milligram (mg) by mouth at bedtime for pain. -Fentanyl patch 75 mcg/hr, apply one patch transdermal every 72 hours for pain. Rotate site and remove per schedule dated 1/27/23. -Oxycodone HCI 10 mg give one tab by mouth every four hours, given as needed for severe pain dated 7/7/21. Review of the resident's TAR for 2/2023 showed: -Fentanyl patch 75 mcg/hour apply one patch transdermal every 72 hours for pain. Rotate site and remove per schedule, had a start date of 1/27/23. -No documentation by facility staff Fentanyl 75 mcg/hr patch for pain was given or not available on 2/17/23 and 2/20/23. No documentation the resident's physician was notified the medication was not available or administered. -No valid physician's order for Fentanyl patch 50 mcg/hr due to the order was discontinued on 1/26/23. --No documentation staff administered Fentanyl patch 50 mcg/hr in error on 2/11/23. No documentation the resident and/or representative or the resident's physician was notified of this medication error. -Had a physician order for Oxycodone HCI 10 mg give one tab by mouth every four hours, given as needed for severe pain. --No administration of the as needed pain medication was given on 2/18/23 or on 2/20/23. -Assess the resident's pain every shift for pain monitoring. --On 2/17/23 pain level of 9 out scale of 10 for the day shift. --On 2/20/23 pain level of 0 out scale of 10 for the day shift, the evening and night shift assessment. Record review of the resident's Fentanyl 50 mcg control substance log sheet showed: -The starting count of 10 patches was dated 1/20/23. -One patch was removed and applied on the resident's left chest on 2/11/23 leaving nine patches remaining. -The patch was removed from the resident on 2/14/23. --NOTE: The order for Fentanyl 50 mcg/hr patches were discontinued on 1/26/23. Record review of the resident's nursing note dated 2/20/23 at 9:27 A.M. showed: -The pharmacy was contacted regarding delivering resident's Oxycodone. -Resident needs a physician signed script. -Pharmacy staff will contact the resident physician to send script. -The resident was notified of the delay in medication. --NOTE: No documentation the pharmacy was contacted regarding the resident's Fentanyl patches 75 mcg/hr. During an interview on 2/27/23 at 10:37 A.M., the resident said: -He/she was having concerns with his/her medication being late or the facility was running out of his/her medication. -He/she was on schedule narcotic pain medication and as needed pain medication. -He/she was sent to hospital last week due to the facility not having his/her pain medication as ordered. During an interview on 3/2/23 at 8:28 A.M., Licensed Practical Nurse (LPN) C said: -The resident had transitioned from hospice medication to facility purchased medication. -On 2/17/23 to 2/20/23 the facility were waiting on pharmacy to deliver the medication. During an interview on 3/2/23 at 8:29 A.M., LPN D said: -The control substance medication should been documented on the resident TAR and control substances record sheet. -Medical record would have the resident old control substance record sheet, -He/she had dose change to his/her Fentanyl and was started on 2/23/23. -He/she unsure about missing documentation from 2/17/23 to 2/20/23. During an interview on 3/3/23 at 3:49 P.M., the Director of Nursing (DON) said: -He/she expected staff to administer the dose of medication ordered. -He/she expected staff to document on the resident's TAR each time an as needed medication and scheduled medication were administered. -If staff remove a medication from the resident's Controlled Substance Log, that medication should be documented on the resident's MAR as well; -He/she does not compare the Controlled Substance Log with the TAR to ensure accuracy of the medication count. -He/she performs spot checks for monitor of nursing staff signatures. Complaint # MO 2014989

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the pharmacist's recommendations were received from the pharmacist and addressed by the physician for one sampled resident (Resident #41) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy Drug Regimen Review dated June 2020 showed: -The pharmacist was to review each resident's medication regimen at least once a month. -The pharmacist was to report any irregularities to the attending physician, the medical director, and the Director of Nursing (DON), and the reports must be acted upon. -The physician must document his/her rationale if the pharmacist's recommendations were not acted upon. -The DON was responsible for ensuring the physician followed up on all pharmacy recommendations. Record review of Mayoclinic.org's article Lacosamide dated February 2023 showed: -This medication, in tablet form, must be taken whole and could not be crushed. -For enteral feeding tubes, a liquid version of this medication was to be given. 1. Record review of Resident #41's face sheet showed he/she was admitted with the following diagnoses: -Chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). -Unsteadiness on feet. Record review of the resident's Medication Regimen Review, dated 9/27/22, showed: -The pharmacist stated the resident was receiving Lacosamide (a medication for seizures) 100 milligram (mg) tablets and that the medication should not crushed. -Pharmacist suggested changing the order to Lacosamide 10 mg per milliliter (ml) oral solution to allow administration through the resident's feeding tube. -No response was documented on the form. Record review of the resident's Progress Note, dated 11/23/22, showed: -The Registered Dietitian (RD) noted the resident received 100% of nutrition via enteral feeding tube(enteral feeding tubes allow liquid food to enter your stomach or intestine through a tube). -The RD noted the resident's nutritional needs, including hydration, were met via enteral feeding tube. Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated tool used for care planning), dated 12/10/22, showed: -The resident's drug regimen review (N2001) was left blank. -The resident's medication follow up (N2003) was marked as not assessed. -The resident's medication intervention (N2005) was left blank, which showed no clinically significant medication issues had been identified. Record review of the resident's PPS 5 Day Assessment MDS, dated [DATE], showed: -The resident had an enteral feeding tube prior to admission to the facility. -The resident received 51% or more of his/her nutrition via the enteral feeding tube. -The resident received 501 ml of water per day via enteral feeding tube. -Staff marked that there were no issues upon the resident's drug regimen review (N2001). Record review of the resident's Medication Review Report, dated 3/1/23, showed: -The resident was nil per os (NPO-Latin for nothing by mouth). -The physician ordered medications to be crushed when crushable, unless contraindicated. -The physician entered an order on 1/23/23 for Lacosamide oral tablet 200 mg to be given twice a day via feeding tube. Record review of the resident's Medication Administration Record (MAR), dated 3/2/23, showed: -Staff documented giving the resident Lacosamide 200 mg every morning for the month of February 2023. -Staff documented giving the resident Lacosamide 200 mg 25 out of 28 evenings for the month of February 2023. During an interview on 3/2/23 at 8:49 A.M., Licensed Practical Nurse (LPN) A said: -He/she gave all the resident's medications through his/her feeding tube. -Staff crushed all meds for this resident because he/she was NPO. During an interview on 3/3/23 at 10:22 A.M., LPN A said: -He/she gave this resident his/her lacosamide crushed and through his/her feeding tube. -He/she was not aware the medication was not to be crushed. -He/she did not have any involvement in the monthly medication review or the pharmacist's recommendation. Observation on 3/3/23 at 12:00 P.M. showed the resident's lacosamide medication card contained large blue tablets. During an interview on 3/3/23 at 2:40 P.M., the DON said: -He/she received the pharmacist's month recommendations via email, which he/she printed out and gave to the nurse managers and/or physician's, depending on the request. -Pharmacy recommendations that required a physician's order were printed and placed in the physician's mail box. -Once the physician had addressed the pharmacists' recommendations, he/she would return them to him/her. -If he/she were the one reviewing the pharmacists' recommendations, he/she would compare what he/she gave to the physician to what was received from the pharmacist to ensure all recommendations were addressed. -He/she did not work at the facility in September 2022 and did not know why that pharmacy recommendation was not addressed.

Based on observation, interview and record review, the facility failed to have recipes available for the chicken alfredo sauce over pasta, pureed (cooked food that has been ground pressed, blended or sieved to the consistency of a creamy paste or liquid) chicken alfredo sauce over pasta and the pureed season cauliflower in the recipe books. This practice potentially affected residents who ate pureed food from the kitchen. The facility census was 74 residents. 1. Record review of the Week at a Glance menu for Week 2 on 2/27/23 showed the following for the lunch meal hearty meat sauce over mostaccioli (a smooth textured pasta in the form of a short tube with oblique ends), seasoned broccoli and seasonal fruit cup. During an interview on 2/27/23 at 9:35 A.M., Dietary [NAME] (DC) A said: - The dietary department changed the menu from a hearty meat sauce to a chicken alfredo sauce over pasta on that day because they felt the residents had too many red sauce dishes, and so the residents would not have to continue to eat the same stuff. - Cauliflower would be served on the side instead of broccoli. During an interview on 2/27/23 at 10:15 A.M., DC B said there was not a recipe for the chicken alfredo sauce over pasta. Observation on 2/27/23 from 10:56 A.M. through 11:01 A.M., showed: - DC A made pureed chicken alfredo sauce over pasta. - There was no recipe book open. - The pureed chicken alfredo tasted grainy and was not smooth. During an interview on 2/27/23 at 11:06 A.M., DC B said he/she did not taste test the pureed foods. Observation on 2/27/23 at 11:13 A.M. DC B made pureed cauliflower with no recipe book opened. Record review of the recipe books showed the absence of a recipe for chicken alfredo sauce over pasta, pureed chicken alfredo sauce over pasta and pureed seasoned cauliflower. During an interview on 2/27/23 at 1:22 P.M., the DM said the dietary department did not have a recipe for the pureed cauliflower, the regular chicken alfredo and the pureed chicken alfredo. During a phone interview on 3/14/23 at 9:35 A.M., the current Consultant Registered Dietitian (RD) said: - The dietary staff should have recipes for everything available. - The dietary staff could call the menu company if there were missing recipes. - The dietary staff have a sheet that they are supposed to write the substitutions on the sheet and he/she would sign off on when he/she goes to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure hot foods (cauliflower and chicken alfredo sauce over pasta) were served at or close to a temperature at 120 degrees Fahrenheit (ºF) at the time of service to the residents in who received room tray in the 200 Hall. This practice potentially affected at least five residents whose trays were delivered towards the end of the delivery session. The facility census was 74 residents. 1. Record review of the minutes from the resident food council meeting dated 2/21/23 showed the residents said meals that were being received for lunch and dinner are sometimes cold. Observation on 2/27/23, of the delivery of room trays to the 200 Hall, showed: - At 12:30 P.M., the Dietary Department delivered the cart for the 200 Hall residents. - From 12:32 P.M. through 12:51 P.M., room trays were delivered to rooms in the 200 Hall. - At 12:56 P.M., a temperature check of the test tray was done with Certified Nurse's Assistant (CNA) B as a witness and the following was found: -- The seasoned cauliflower was 103.2 ºF and the pasta dish was 115.0 ºF 2. Record review of Resident #20's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 2/13/23, showed he/she was cognitively intact with a Brief Interview for Mental Status (BIMS-an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions.) of 15 out of 15 (indicating he/she was cognitively intact). During an interview on 2/28/23 at 10:54 A.M., Resident #20 said: - He/she ate meals in his/her room. - When he/she gets cold food, he/she does not feel like eating it, so he/she stays hungry. 3. Record review of Resident #44's quarterly MDS, dated [DATE], showed he/she had a BIMS score of 9 out of 15, which showed the resident's mental status as Moderate Cognitive Impairment. During an interview on 3/2/23 at 12:21 P.M., Resident #44 said the food was cold when it was delivered to him/hewer and he/she has heard of other residents who also received cold food. 4. During an interview on 2/27/23 at 12:57 P.M., CNA B said he/she had not seen anyone form the dietary department check the temperatures of hot foods on room trays. During an interview on 2/27/23 at 1:09 P.M., Dietary [NAME] (DC) B said: - That day was his/her second week at the facility. - He/she has not sent anyone to check the temperatures of hot foods. During an interview on 2/27/23 at 1:10 P.M., the Dietary Manager (DM) said the dietary department has not sent anyone to look at the system of delivering food on the hallways. During a phone interview on 3/14/23 at 9:38 A.M., the current Consultant Registered Dietitian (RD) said in order to monitor food temperatures, the dietary staff should measure the temperatures of sample trays on each hall to make sure that hot foods stay hot and cold foods stay cold. MO00213935

Based on observation, interview and record review, the facility failed to ensure food in the resident use refrigerators were labeled with the date and the name of the resident, the food was for. This practice potentially affected an unknown number of residents for whom, food was stored in the South and North Unit resident use refrigerators. The facility census was 74 residents. 1. Record review of the facility's policy entitled Food Brought in by Visitors and revised on 2/2021, showed: - Purpose: To provide residents with the option of having food prepared by the resident's family brought into the facility. - Policy: Food may be brought to a resident by the family members, the resident's responsible party, or friends (visitors) if the food is compatible with the physician's diet order. - If the resident desires to have food brought in by visitors, the Food and Nutrition Services Staff will review the resident's diet with the visitor, and provide education regarding the resident's diet orders and safe food handling practices. - Food from outside sources should be stored in a sealable container with the resident's name and date it as brought to the facility. - Perishable food requiring refrigeration will be discarded after two hours at bedside, and if refrigerated it will be then labeled, dated, and discarded after 48 hours. Observation on 2/27/23 at 2:55 P.M., of the South Unit resident use refrigerator showed one bag with food in it which was not labeled with a resident's name or a date and 6 ½ pint containers which were not labeled. Observation on 2/27/23 at 2:59 P.M., of the North Unit resident use refrigerator showed one bag with food in it which was not labeled with a resident's name or a date . During an interview on 2/27/23 at 3:02 P.M., Licensed Practical Nurse (LPN) C said he/she expected food for a specific resident to be labeled.

Based on observation and interview, the facility failed to place a cover on the trash container located in the kitchen, before and during meal preparation on 2/27/23. This practice potentially affected at least 70 residents who ate food from the kitchen. The facility census was 74 residents. 1. Observations on 2/27/23 at 9:07 A.M., 9:31 A.M., 9:52 A.M. 10:16 A.M., and 11:22 A.M., showed an uncovered trash container open during the lunch meal preparation. During an interview on 2/27/23 at 11:25 A.M., the Dietary Manager (DM) said he/she was not sure where the cover was located.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain tube feeding poles in resident rooms [ROOM NUMBERS] free of grime; to maintain wheelchairs in resident rooms 308, 211 and 302 free of debris in and on the wheelchairs; to maintain the floors of resident rooms 413, 412, 411, 408, 309, 304, 102, 215, 211, 208 and 204, free from a heavy buildup of dust and debris; to maintain the sprinkler heads in the main dining room (MDR) free from a dust buildup; to maintain the blue shower pads in the 100 Hall spa room and the South Side soiled utility room, free from damaged areas which rendered the blue shower pads as not easily cleanable; to maintain the knee rest of the standup lift on the south side free of a tear that made the knee rest not easily cleanable. This practice potentially affected at least 60 residents who used or resided in those areas. The facility census was 74 residents. 1. Observation on 2/27/23 at 2:00 P.M., and on 3/1/23 at 1:39 P.M., showed a layer of yellow substances on the tube feeding pole in resident room [ROOM NUMBER]. Observation on 3/1/23 at 1:10 P.M., showed a layer of yellow grime on the tube feeding pole in resident room [ROOM NUMBER]. During an interview on 3/2/23 at 3:07 P.M., Certified Nurse's Assistant (CNA) E said nurses are supposed to clean the tube feeding poles. During an interview on 3/2/23 at 3:13 P.M., Licensed practical Nurse (LPN) C said the night shift nurses are supposed to clean the tube feeding poles. 2. Observations with the Administrator and the Maintenance Director on 3/1/23, showed: - At 11:34 A.M., there was a heavy buildup of dust on the wheelchair in resident room [ROOM NUMBER]. - At 1:28 P.M., there was a buildup of dirt and hair on the wheels of the wheelchair in resident room [ROOM NUMBER]. During an interview on 3/2/23 at 3:04 P.m., CNA G said the night shift staff are supposed to clean the wheelchairs. During an interview on 3/3/23 at 9:27 A.M., the Social Service Designee (SSD) said the staff on 11:00 P.M.-7:00 A.M., shift, are supposed to clean the wheelchairs, but anyone can clean the wheelchairs, if they notice them. Observations with CNA C on 3/3/23 at 9:31 A.M., showed the presence of food crumbs in the seat part of the resident's wheelchair in resident room [ROOM NUMBER]. During an interview on 3/3/23 at 9:33 A.M., CNA C said: - The CNA's are supposed to check the wheelchairs for cleanliness. - The CNA's have to do a glance over because they do not enough time or staff look at the wheelchairs more closely. 3. Observations with the Administrator and the Maintenance Director on 3/1/23, showed: - At 10:58 A.M., a heavy buildup of dust and cobwebs on the floor under the bed in resident room [ROOM NUMBER]. - At 11:01 A.M., a heavy buildup of dust was under the bed in resident room [ROOM NUMBER]. - At 11:02 A.M., a heavy buildup of dust was under the bed in resident room [ROOM NUMBER]. - At 11:08 A.M., a heavy buildup of dust and debris, were under the bed in resident room [ROOM NUMBER]. - At 11:28 A.M., a heavy buildup of dust and debris, were under the bed in resident room [ROOM NUMBER] - At 11:40 A.M., there was a heavy buildup of dust and debris under the bed in resident room [ROOM NUMBER]. - At 12:52 P.M., there was a buildup of dust on the sprinkler heads in the MDR. - At 1:06 P.M., a heavy buildup of dust and debris, were under the bed in resident room [ROOM NUMBER]. - At 1:20 P.M., a heavy buildup of dust and debris including pieces of candy, were under the bed in resident room [ROOM NUMBER]. - At 1:28 P.M., there was a buildup of dirt and hair on the wheels of the wheelchair in resident room [ROOM NUMBER]. - At 1:30 P.M., there was a buildup of dust and debris along the wall where the TV was located, in Resident room [ROOM NUMBER]. - At 1:36 P.M., there was dust and grime behind the drawer in resident room [ROOM NUMBER]. and During an interview on 3/1/23 at 11:53 A.M., Housekeeper A said the following after looking at the dust buildup under the beds in resident room [ROOM NUMBER]: - To clean that area properly, he/she would take a cloth wipe that area under the beds and pull the beds out. - He/she tried to clean under the beds two to three times per week. During an interview on 3/3/23 at 9:06 A.M., the Housekeeping Supervisor said: -The housekeepers are supposed to use the dusters and they are supposed to sweep. - When he/she saw the dust buildup under the various beds, he/she realized the housekeepers were not dusting as much as they should. - Two rooms are supposed to be deep cleaned each day - The housekeepers are supposed to get into the corners on a regular basis. - He/she would make sure that he housekeepers sweep under the beds in resident room [ROOM NUMBER]. 4. Observations on 3/1/23 at 11:19 A.M. and on 3/2/23 at 12:12 P.M., showed a blue shower pad with numerous areas of damage in it located in the South Unit soiled utility room. During an interview on 3/2/23 at 12:14 P.M., the Assistant Director of Nursing (ADON) said he/she saw the damaged blue shower pad and had not seen it used since he/she started employment at the facility back in February 2023. Observations on 3/3/23 at 10:17 A.M., showed a blue shower pad in the 100 Hall shower room with numerous areas of damage. 5. Observation on 3/1/23 at 1:13 P.M., showed a rip that was 3 inches (in.) long, in the knee ret of a stand-up (a specifically designed to secure patients during transfers from a seated position to a standing position, enabling quicker, easier, and safer patient lifting) lift in the 200 Hall Shower room. During an interview on 3/3/23 at 10:02 A.M., the Central Supply Coordinator said it was during that observation, was the first time he/she knew about the stand-up lift located in the 200 Hall shower room. During an interview on 3/3/23 at 10:10 A.M., CNA E said he/she did not notice the rip in the knee rest of the stand-up lift when he/she used the lift earlier that day. During an interview on 3/3/23 at 10:12 A.M., the Director of nursing (DON) said that facility staff should inform the Central Supply Coordinator and any appliance that should be out of commission, should be told to the Maintenance Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident's care plan accurately reflected the resident's condition upon admission for three sampled residents (Resident #6, #19, and #4) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy titled Care Planning dated 10/24/22 showed: -Each resident's comprehensive care plan will describe the following: -Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. -Any specialized services including rehabilitative service as a result of the Pre admission Screening and Resident Review (PASARR) recommendations. 1. Record review of Resident #6's undated face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Major Depressive Disorder (MDD- A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). Record review of the resident's care plan dated 11/4/22 showed no focus or interventions in place for the diagnoses of MDD or Anxiety Disorder. Record review of the resident's Minimum Data Set (MDS- A federally mandated assessment instrument completed by facility staff for care planning) dated 12/16/22 showed the resident had active diagnoses of MDD and Anxiety Disorder. 2. Record review of Resident #19's undated face sheet showed he/she admitted to the facility on [DATE] with the diagnosis of Acute Respiratory Failure (impairment of gas exchange between the lungs and the blood causing a lack of oxygen in the blood). Record review of the resident's care plan dated 12/6/22 showed no focus or interventions in place for the use of oxygen. Record review of the resident's MDS dated [DATE] showed: -The resident had an active diagnosis of Respiratory Failure. -The resident received oxygen therapy. Observation on 2/27/23 at 10:47 A.M. showed the resident was receiving oxygen therapy via nasal cannula and oxygen tank. During an interview on 2/28/23 at 2:04 P.M. the resident said he/she used an oxygen tank attached to his/her wheelchair during the day and at night he/she used an oxygen concentrator by his/her bedside. 3. Record review of Resident #4's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Encephalopathy (a broad term for any brain disease that alters brain function or structure). -Cognitive Communication Deficit (an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). Record review of the resident's admission MDS dated [DATE], showed: -The resident had an enteral feeding tube (surgical creation of a permanent opening into the stomach through the skin for the introduction of nourishment and fluids through a tube) prior to admission to the facility. -The resident received 51 percent (%)or more of his/her nutrition via the enteral feeding tube. -The resident received 501 milliliters (ml) of water per day via enteral feeding tube. Record review of the undated Physician's Order Sheet showed: -The resident was NPO (nothing by mouth). -The resident had orders for water boluses to be given through the enteral feeding tube. Record review of the resident's Progress Note, dated 11/23/22, showed: -The Registered Dietitian (RD) noted the resident received 100% of nutrition via enteral feeding tube. -The RD noted the resident's nutritional needs, including hydration, were met via enteral feeding tube. Record review of the resident's Treatment Administration Record (TAR), dated 2/1/23-2/28/23, showed: -The resident was NPO. -The physician ordered the feeding tube be flushed with 100 ml every four hours for hydration. Record review of the resident's Care Plan, last revised 2/28/23, showed: -Staff did not indicate the resident's NPO status. -Staff did not address the resident's water bolus for hydration. During an interview on 3/2/23 at 12:52 P.M., Certified Nursing Assistant (CNA) A said: -He/she was not sure what was in any resident's care plan. -He/she provided cares based on verbal report from other staff. -He/she did not know how to find a resident's care plan. During an interview on 3/3/23 at 9:08 A.M., the Social Services Designee (SSD) said: -He/she expected NPO status to be listed on the resident's care plan. -He/she expected any resident with NPO status to have nutrition and hydration addressed in their care plan. -The charge nurse is responsible for relaying the resident's needs to the staff. -He/she created and updated the care plans. -He/she was unsure if CNAs had access to resident care plans. 4. During an interview on 3/3/23 at 2:40 P.M., the Director of Nursing (DON) said: -Staff should include hydration on all care plans for residents that are NPO. -Care plans should reflect each resident's current status. -Diagnosis of depression and anxiety should be included on care plan. -Oxygen therapy should be included in care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Record review of Resident #37's undated face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation). -Chronic Pain Syndrome (pain that lasts weeks to years). -Generalized Muscle Weakness. Record review of the resident's MDS dated [DATE] showed: -The resident had a BIMS score of 15/15 indicating the resident was cognitively intact. -The resident needed extensive assistance to maintain personal hygiene including shaving. -The resident was fully dependent on staff for bathing/showering. Record review of the resident's care plan dated 12/14/22 showed: -The resident had an ADL self-care deficit and that he/she required extensive assistance by staff with showering/bathing. -The resident preferred showers on Wednesdays. Record review of the facility's undated shower schedule showed the resident was to receive baths/showers every Tuesday and Friday evening. Record review of the facility's undated shower sheet binder showed no record of the resident's shower sheets. The resident's shower sheets were requested and not received at the time of exit. Observation on 2/27/23 at 10:28 A.M. showed the resident had facial hair growing on his/her chin and his/her hair was frizzy and braided out of the resident's face. During an interview on 2/27/23 at 10:28 A.M. the resident said: -Baths and showers were inconsistent. -He/she had only been wiped down with perineal area wipes last week and could not remember when his/her last bath was given. Observation on 2/28/23 at 10:28 A.M. showed the resident still had the facial hair on his/her chin and his/her hair was braided out of the resident's face. During an interview on 2/28/23 at 10:28 A.M. the resident said: -He/she was dependent on staff for his/her hair care. -He/she could shave his/her face, but the staff do not provide the materials for him/her to be able to shave. -His/her family braided his/her hair back in December and the facility had not taken the braids out. Observation on 3/1/23 at 8:36 A.M. showed the resident still had facial hair on his/her chin and his/her hair was braided out of the resident's face. During an interview on 3/1/23 at 8:36 A.M. the resident said the care staff were going to bath him/her on 2/28/23, but the staff were unable to give him/her one. Observation on 3/2/23 at 9:13 A.M. showed the resident had his/her braids taken down, but the facial hair still remained on his/her chin. During an interview on 3/2/23 at 9:13 A.M. the resident said: -He/she received a bath on 3/1/23 in the afternoon. -He/she would have liked to have the opportunity to shave him/herself yesterday. Observation on 3/3/23 at 10:56 A.M. showed the resident still had facial hair on his/her chin. 6. Record review of Resident #6's undated face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Hemiplegia (paralysis of one side of the body) following unspecified Cerebrovascular (blood vessels in the brain) disease affecting left non-dominant side. -Contracture (a condition of shortening and hardening of muscles, tendons, and other tissue, often leading to deformity and rigidity of joints), left ankle. -Generalized Muscle Weakness. Record review of the resident's care plan dated 11/4/22 showed: -The resident had a self-care deficit related to Cerebrovascular Accident (CVA- damage to the brain from interruption of its blood supply also known as a stroke). -The resident required extensive assistance for his/her ADL care in bathing/showering. Record review of the resident's MDS dated [DATE] showed: -The resident had a BIMS score of 13 out of 15 indicating the resident was cognitively intact. -The resident was fully dependent on staff for baths/showers. Record review of the facility's undated shower schedule showed the resident did not have a shower schedule. Record review of the facility's undated shower sheet binder showed no record of the resident's shower sheets. The resident's shower sheets were requested and not received at the time of exit. During an interview on 2/27/23 at 1:25 P.M. the resident said the staff do not wash or do his/her hair and they do not give him/her showers/baths. During an interview on 3/1/23 at 8:34 A.M. the resident said he/she had not received a bath yet this week. During an interview on 3/2/23 at 8:27 A.M. the resident stated that he/she had received a bath from CNA C on 3/1/23. Based on observation, interview, and record review, the facility failed to provide baths for six sampled residents (Resident #41, #15, #31, #58, #37 and #6); to provide oral care for one sampled resident (Resident #4), and to provide timely incontinence care for one sampled resident (Resident #41) out of 23 sampled residents. The facility census was 74 residents. The following policies were requested and not received at the time of exit: -Oral care. -Bathing. -Incontinence care. -Activities of Daily Living (ADL) assistance. 1. Record review of Resident #4's face sheet showed he/she was admitted with the following diagnoses: -Encephalopathy (a broad term for any brain disease that alters brain function or structure). -Cognitive Communication Deficit (an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). Record review of the resident's care plan, last revised 2/14/23, showed: -Total assistance from staff was required for bathing. -Staff were to provide frequent oral care to keep the resident's mouth clean. Record review of the resident's Medication Administration Record (MAR), dated 2/28/23, showed the resident NPO (nothing by mouth). Record review of the resident's Treatment Administration Record (TAR), dated 2/28/23, showed oral care was not listed as a task. Observation on 2/27/23 at 2:09 P.M. showed: -The resident had white crusting on his/her lips and around his/her mouth. -No oral swabs were present in the resident's room. Record review of the resident's hospice (end of life care) visits for 2023 showed oral care was provided by hospice on the following dates: -1/3/23, 1/6/23, 1/10/23, 1/13/23, 1/17/23, 1/20/23, 1/24/23, 1/31/23, 2/7/23, 2/10/23, 2/14/23, 2/21/23, 2/24/23, and 2/28/23. During an interview on 3/2/23 at 12:10 P.M., Certified Nursing Assistant (CNA) C said: -He/she did not perform oral care for the resident. -He/she believed hospice provided all the cares for the resident. During an interview on 3/2/23 at 12:52 P.M., CNA A said: -He/she provided oral care for the resident. -Hospice was responsible for the resident's cares. 2. Record review of Resident #41's face sheet showed he/she was admitted with the following diagnoses: -Chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). -Unsteadiness on feet. Record review of the resident's Care Plan, revised 1/13/23, showed staff assistance was required for the resident to bathe, perform personal hygiene, and for oral care. Record review of the resident's Minimum Data Set (MDS-a federally mandated tool used for assessments) 5 Day PPS Assessment, completed 2/10/23, showed: -The resident had a Brief Interview for Mental Status (BIMS) of 11 out of 15 indicating the resident was moderately cognitively impaired. -The resident was totally dependent on staff for toileting, personal hygiene, and bathing. -The resident was always incontinent of bladder. -The resident was always incontinent of stool. Record review of the facility's undated bathing schedule showed staff had scheduled this resident for bathing every Wednesday and Saturday evening. Observation on 2/27/23 at 9:09 A.M. showed the resident's face was shiny and his/her hair was disheveled. During an interview on 2/27/23 at 12:57 P.M., the resident said he/she needed help for showering and dressing. Observation on 3/1/23 at 8:35 A.M. showed: -The resident's face was shiny and his/her hair was disheveled. -He/she was wearing the same clothing he/she had been wearing on 2/27/23. During an interview on 3/1/23 at 8:38 A.M., the resident said: -His/her last bath was five days prior. -He/she wanted a bath but no staff had offered. -He/she hated when he/she did not get a bath, made him/her want to stay in his/her room. Record review of bath sheets from 2023, received from the Director of Nursing (DON) on 03/01/23 at 10:24 A.M., showed the resident received a bath on 1/4/23, 1/21/23, 2/18/23, and 2/25/23. Observation on 3/1/23 at 11:22 A.M. showed: -The resident's face was shiny and his/her hair was disheveled. -The resident's shirt had been changed but the new shirt was crusted with an unidentified yellow substance. During an interview on 3/1/23 at 11:22 A.M., the resident said: -Staff had changed his/her shirt. -He/she had not received a shower before having his/her clothes changed. Observation on 3/2/23 at 8:28 A.M. showed: -The resident's face and hair were shiny and slick, hair remained uncombed. -He/she was wearing the same clothing with the yellow, crusted stain on his/her shirt he/she had been wearing on 3/1/23. During an interview on 3/2/23 at 8:28 A.M., the resident said he/she still had not received a bath. Continuous observation on 3/2/23 from 8:27 A.M. to 10:11 A.M. showed: -The resident's call light was on. -Staff had entered and exited the resident's room, turning off the resident's call light telling the resident they would be back to assist the resident. Staff did not return to assist the resident and he/she would turn the call light back on several times during the continuous observation. -The resident was wearing a brief and lying in bed. -The resident had asked staff to get out of bed to go to therapy. Observation on 3/2/23 at 10:12 A.M. showed: -CNA C and CNA A entered the room to assist the resident. -With the resident still laying in the bed, CNA A removed the resident's brief and the resident said he/she had waiting a long time for assistance. -CNA A found a large piece of feces molded into the resident's gluteal fold. -CNA A attempted to remove stool but crusting was still present on resident's buttocks. -CNA C got a bottle of peri-cleanser (a perineal cleanser that gently and effectively cleans urine, emesis and fecal matter) and poured it directly onto the resident's buttocks and into the package of wet wipes being used to clean the resident. -CNA C wiped with great effort to remove all dried feces. During an interview on 3/3/23 at 8:57 A.M., the resident said: -He/she was upset about waiting so long to get out of bed and dressed. -He/she was frequently left in dirty briefs. -He/she would use the call light when he/she needed his/her brief changed but it takes staff forever to assist. -It made him/her very uncomfortable to be left in a dirty brief. Observation on 3/3/23 at 10:53 A.M. showed the resident's face and hair were shiny and slick. During an interview on 3/3/23 at 10:53 A.M., the resident said he/she still had not been bathed. 3. Record review of Resident #58's face sheet showed he/she was admitted with: -Muscle Weakness. -Unsteadiness on feet. -Pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral region (large, triangular bone at the base of the spine and at the upper and back part of the pelvic cavity). Record review of the resident's Annual MDS Assessment, dated 2/8/23, showed: -The resident had a BIMS of 14 out of 15 indicating the resident was cognitively intact. -The resident required physical help during bathing. During an interview on 2/27/23 at 1:40 P.M., the resident said: -Staff were not bathing residents like they were supposed to. -He/she had not had a bath for three weeks. Record review of the resident's bath sheets in bathing binder showed: -Staff had last bathed the resident 1/11/23. -NOTE: At this time, requested additional/missing bath sheets from DON. Observation on 3/1/23 at 8:16 A.M. showed the resident's face was shiny. During an interview on 3/1/23 at 8:16 A.M., the resident said: -He/she was upset he/she had not received a bath in so long. -He/she felt gross. During an interview on 3/2/23 at 12:42 P.M., the resident said: -He/she still had not had a bath. -He/she didn't want to leave his/her room because of lack of bathing. -He/she only left his/her room to smoke. Record review of the facility's undated bathing schedule showed staff had scheduled this resident for bathing every Wednesday and Saturday mornings. Observation on 3/3/23 at 10:57 A.M. showed the resident's face was shiny. During an interview on 3/3/23 at 10:57 A.M., the resident said he/she still had not received a bath. 4. Record review of Resident #15's face sheet showed he/she was admitted with the following diagnoses: -Muscle weakness. -Unsteadiness on feet. Record review of the resident's Annual MDS, dated [DATE], showed: -The resident had a BIMS of 11 out of 15 indicating he/she was moderately cognitively intact. -The resident required one personal physical assistance for bathing. Record review of the resident's care plan, revised 2/3/23, showed: -Staff were required to assist the resident with bathing/showering twice a week. -Staff were required to assist resident to dress. Observation on 2/27/23 at 9:09 A.M. showed: -The resident was in a hospital gown and disheveled. -The resident's room smelled strongly of urine. During an interview on 2/27/23 at 12:31 A.M., the resident said he/she needed staff to assist with bathing. Record review of the resident's bath sheets for 2023, received from the DON on 3/1/23 at 10:20 A.M., showed staff had bathed the resident 1/16/23 and 2/3/23. Observation on 3/1/23 at 11:26 A.M. showed the resident's face was shiny and his/her hair was not brushed. 7. Record review of Resident #31's Face Sheet showed he/she was admitted to the facility on [DATE] with diagnoses including diabetes, high blood pressure, high cholesterol and indigestion. Record review of the resident's quarterly MDS dated [DATE], showed the resident: -Had a cognition score of 9 (showing the resident had confusion on a range from 0 to 15) and short term memory loss. -Had no limitations with range of motion. -Had unsteady standing balance and needed assistance to stabilize. -Needed physical assistance of one person for bathing, limited assistance with dressing and supervision only for hygiene. Record review of the resident's Nursing Notes from 12/2022 to 3/1/23 showed there was no documentation showing the resident refused bathing or showers. There was no documentation to show when showers were attempted or given to the resident. Record review of the resident's Care Plan updated 10/14/22, showed the resident had a self-care performance deficit and needed assistance with all ADL care (bathing, dressing, toileting, grooming) except toileting and transfers. It showed staff would: -Allow the resident sufficient time for dressing and undressing. -Would provide staff assistance with help picking out clothes. -Would provide staff setup assist with personal hygiene and observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. -Encourage the resident to participate to the fullest extent possible with each interaction. -Encourage the resident to use bell to call for assistance. -Praise all efforts at self-care. -The care plan did not show the type of assistance the resident needed with bathing. It did not show that the resident refused bathing. Record review of the Facility Shower Schedule showed the resident was to receive showers in the evening (on the evening shift) weekly on Tuesday and Friday. Record review of the resident's CNA Task Sheet regarding the Bathing Task showed there was no documentation during 2/2023 that showed the resident had a bath/shower. On 2/2/23 and 2/24/23 it showed not applicable when identifying if the resident had a shower/bath, whether it was refused or if the resident was independent or needed assistance on those dates. Record review of the monthly Bath Sheets showed the resident did not have any bath sheets documented. During an interview on 2/27/23 at 12:45 P.M., Licensed Practical Nurse (LPN) A said: -The resident could do some of his/her own care, but bathing and continence care were done by staff. -The resident was alert with some confusion, but was able to make his/her needs known. During an observation and interview on 2/28/23 at 2:30 P.M., showed the resident was fully dressed and sitting in his/her wheelchair watching tv. He/she was alert and oriented. His/her fingernails were a little long with dirt underneath them. The resident said: -He/she had been cleaning himself/herself at the sink in the bathroom, but he/she had not had a shower in quite a while (he/she did not know the exact date his/her last shower was). -He/She had not refused any showers and if staff were going to take him/her to get a shower, he/she would like to have one. -He/She did not remember the last time he/she had a shower but he/she thought he/she had one or two showers in February. -He/She would like to have a shower at least weekly. 8. During an interview on 2/28/23 at 1:33 P.M., CNA C said bath sheets were filled out by the CNAs and given to the charge nurse to review; they were then placed in the binder on the nurse's desk. During an interview on 3/1/23 at 11:07 A.M. CNA C said: -The facility has a bath aide. -The bath aide usually gets pulled to work on the floor instead of being able to give baths. -All CNAs can give baths, but the bath aide is the one that usually does them. -No residents had complained to him/her about not receiving baths/showers. -If a resident said to him/her that they had not received a bath in a while then he/she would attempt to give a bath as long another CNA was available to watch his/her residents. -He/she did not think that the facility had a shower schedule for the residents. During an interview on 3/1/23 at 11:30 A.M., Restorative Aide (RA) said: -He/she completed restorative services with all residents on his/her caseload but he/she also completes showers/baths for the residents when he/she has time. -He/she was not the only person who completes resident baths/showers, all of the CNA staff are able to give baths. -He/she will sometimes get pulled to work as a CNA and give baths all day when they get behind. -He/she completed the bath sheet with every bath/shower and provided it to the charge nurse. During an interview on 3/2/23 at 10:40 A.M., LPN A said: -The bath aide is not the only aide that was able to do baths, all CNAs could give baths. -If a resident were to refuse a bath he/she would ask why the resident did not want one and schedule a new time for the bath if that was the reason the resident did not want a bath. -There was a shower book with all of the residents scheduled times to get bathed. -The CNAs would complete a shower sheet and give it to him/her once a bath was completed. -When a resident refuses a bath it would need to be documented in that resident's chart. -If a resident told him/her that they had not received a bath in a while he/she would look for documentation of a bath and then give the resident a bath. -Getting shaved is a part of getting a shower. -CNAs should be able to recognize when a resident needs to be shaved. -CNAs should help residents with shaving regardless if the residents can do it themselves. -There are hospitality aides that ensure residents look the way the residents want to look. During an interview on 3/2/23 at 12:10 P.M., CNA C said: -The facility had a bath aide that was responsible for bathing the residents. -If the bath aide was not available, he/she wasn't sure who was responsible for completing resident baths. -He/she had not bathed any residents. During an interview on 3/2/23 at 12:22 P.M., CNA G said: -The CNAs complete bathing for the residents in addition to the bath aide. -The residents were supposed to get baths twice weekly but they don't always get them done, some residents also refuse. -They try to re-schedule the baths, but it does not always occur. -They were supposed to document on the bath sheets that the bath was given and then they put the bath sheet under the DON's door when they complete it. -Sometimes they don't always get the bath sheets completed if it's a really hectic day, and sometimes the DON will remind them they need to complete the bath sheet for the resident. During an interview on 3/2/23 at 12:52 P.M., CNA A said: -He/she was unsure of the facility's bathing schedule. -The facility did not currently have a bath aide. -He/she did not follow the bathing schedule, he/she only bathed residents if they requested it. -Staff were required to fill out a bath sheet for a resident, even if the resident refused, and place it in the bath sheet binder. -Staff were to change a dirty brief when the resident requested, an hour wait was inappropriate. During an interview on 3/2/23 at 2:40 P.M., CNA F said: -He/she said she works evening shift and sometimes works the day shift. -Residents were supposed to receive two showers weekly and most of the showers were supposed to be given during the day, but some were given on the evening shift. -Most of the time, if a shower is not given it is due to resident refusal or they are out of the building. -If a resident refuses a shower/bath, he/she will leave and come back and see if they want to take it later, and then will give the shower. If the resident refuses again, he/she will ask a third time with a witness present. -They will try to give the shower on a different day if the resident does not receive their shower day. -They are supposed to document whether they give the shower/bath or any refusals on the bath sheet each time they give a shower or make an attempt to give the shower. -The bath sheet is the proof of whether they gave a shower or whether the resident refused it. -They usually don't give as many showers on evening shift because most of the showers were given during the day. -Resident #31 does not refuse cares and he/she had never seen the resident refuse any showers. During an interview on 3/2/23 at 2:58 P.M., LPN D said: -The residents were supposed to receive two showers weekly and some of the residents refuse or don't want the shower at the time it is offered. -They try to re-schedule the shower at another time and if they have extra staff, they will designate one staff to just give showers all day. -If they cannot give the shower in the morning, they will inform the evening shift that the shower needs to be given on the evening shift. -All of the nursing assistants were supposed to fill out the bath sheets and give them to either the nurse or the DON, so they can track who had received a shower and who has not. -All of the bath sheets eventually go to the DON and are placed in the bath sheet book. -He/she did not know who monitored to ensure resident baths were actually given twice weekly. During an interview on 3/3/23 at 10:22 A.M., LPN A said: -Staff should provide oral care to any NPO resident every shift. -CNAs were responsible for providing oral care and documenting in the electronic health record. -Staff were to bathe residents at least twice a week. -The bath aide performed showers but if the aide was unavailable it was the responsibility of the CNAs. -Staff were to document a bath refusal on the bath sheets. -Staff should address a resident's desire to have their brief changed within 10-15 minutes. During an interview on 3/3/23 at 2:40 P.M., the DON said: -Staff were to bathe all residents at least once a week. -Staff were to document any attempt at bathing on the bath sheets, even if the resident refused. -Staff were to provide oral care to any resident that was NPO at least once per shift. -All care staff were responsible for completing oral care. -Staff were to document oral care completion on the TAR. -Staff were expected to provide oral care regardless if hospice is also providing oral care. -He/she had notified all the CNAs upon his/her hire that there was not a bath aide and the CNAs were now responsible for bathing residents. -He/she would expect staff to give or offer a resident a bath immediately if that resident complained of not receiving a bath. -He/she would expect to determine why the resident had not been receiving baths. -He/she would expect to assist ant resident with shaving if the resident had unwanted facial hair. MO00213935, MO00214413, MO00213706

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a comprehensive skin assessment that showed the location, measurement, and description of all pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) upon admission and weekly and to treat and cover pressure ulcers after removing the dressings for three sampled residents (Residents # 4, #8 and #38) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy Wound Management dated June 2020 showed: -Staff were to ensure wounds maintained moisture. -Staff were to protect the skin surrounding the wound from moisture. -A licensed nurse was to perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. -A licensed nurse, upon identifying a new wound, was to measure the wound. -Documentation of new wounds were to include the location, measurements recorded in centimeters (cm), direction and length of tunneling if present, appearance of wound base, drainage amount and characteristics, appearance of wound edges, evaluation of the skin adjacent to the wound, presence of absence of new tissue at wound rim, and presence of pain. 1. Record review of the Resident #4's face sheet showed he/she was admitted [DATE] with the following diagnoses: -Encephalopathy (a broad term for any brain disease that alters brain function or structure). -Cognitive Communication Deficit (an impairment in organization/ thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). Record review of the resident's medical record from 11/16/22 - 3/3/23 showed no documentation by the facility staff of a comprehensive skin/wound assessment upon admission to the facility and no detailed weekly skin/wound assessments. Record review of the resident's Initial admission Skin Assessment, dated 11/16/22, showed: -Staff had marked the resident had a pressure related skin condition. -Staff had documented right foot and upper leg above ankle with no documentation on size, if tunneling was present, presence of drainage, appearance of wound base, or wound edges. -No documentation of a detailed description and assessment of all the pressure wounds. Record review of the resident's Inter-disciplinary Team (IDT) Progress Note, dated 11/17/22, showed: -Staff documented the resident admitted to the facility with a wound on his/her right foot, left leg, and left foot. -No documentation of a detailed description of the wounds, including if the wounds were pressure or non-pressure, the stage, measurements, or descriptions of the drainage, wound base, and wound edges. -No documentation of a detailed description and assessment of all the pressure wounds. Record review of the resident's Physician's Progress Note, dated 11/18/22, showed: -The physician did not note any wounds or accompanying information for the resident's lower body. -The resident was to continue on hospice (end of life) care. Record review of the resident's Annual Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/22/22 showed: -The resident was at risk for pressure ulcers. -The resident had two Stage III pressure ulcers (a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling). Record review of the resident's Physician's Progress Note, dated 11/22/22, showed a Wound Care Consultant: -Documented the resident had unstageable pressure ulcers (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) to his/her right ankle, right lateral foot, right heel, left lateral leg that contained moderate nonviable tissue. -Identified wounds to the resident's right ankle, right lateral (away from middle) foot, and right heel, with orders to paint with betadine (a topical antiseptic) daily and leave open to air. No measurements, staging, or appearance noted. -Identified a wound to the resident's left lateral leg that was to be covered with adhesive foam daily. -Noted that the wounds will take months to resolve and may require imaging in the future if the wounds did not improve. -No documentation of a detailed description and assessment of all the pressure wounds. Record review of the resident's Dietary Note, dated 11/23/22, showed: -The Registered Dietitian noted the resident had multiple wounds on his/her right foot, left foot, and his/her leg was scarred from old wounds. -Caloric and hydration needs were identified and monitored. Record review of the Physician's Progress Note, dated 12/6/22, showed: -The physician noted the resident had unstageable pressure ulcers to his/her right ankle, right lateral foot, right heel, and left lateral leg. -No documentation of a detailed description and assessment of all the pressure wounds. -The physician noted the wounds would take months to resolve and may need imaging if the wounds did not improve. Record review of the Physician's Progress Note, dated 12/8/22, showed the physician noted the resident was to continue on hospice. Record review of the resident's Hospice Comprehensive Assessment, dated 1/6/23, showed the resident was started on hospice care 10/27/22, prior to admission to the facility. Record review of the Physician's Progress Note, dated 12/13/22, showed the Wound Care Consult documented: -The resident had faint pulses in both lower extremities. -The resident had unstable pressure ulcers to his/her right ankle, right lateral foot, right heel, and right lower extremity with mild drainage but no sign of infection. -The resident had an unstable pressure ulcer to his/her left later leg with mixed moderate nonviable tissue and small drainage, with no signs of infection. -No documentation of a detailed description and assessment of all the pressure wounds. -The resident was on hospice at the time. -The resident's family had stated to the wound care consultant that he/she did not want aggressive measures for wound care. -The wounds would take months to years to resolve. Record review of the resident's Physician's Progress Note, dated 1/10/23, showed the first documentation of any wound measurements, description, drainage, and wound base descriptions. Record review of the resident's contracted Wound Nurse note, dated 2/23/23, showed: -An unstageable pressure ulcer on his/her right heel measuring 6 centimeters (cm) in length by 6 cm in width by 0.4 cm in depth. Treat with calcium alginate (a highly absorbent wound dressing), ABD (a thick wound dressing), and Kerlix (woven gauze that is non-adhesive used to wrap wounds and burns) daily. -A Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) on his/her left lower leg measuring 18 cm in length by 5 cm in width by 0.4 cm in depth. Treat with calcium alginate, ABD, and Kerlix daily. -A Stage III pressure ulcer to his/her left lateral (outside)foot measuring 1.5 cm in length by 1.5 cm in width by 0.3 in depth. Treat with calcium alginate, foam, and Kerlix daily. -A Deep Tissue Injury (DTI - Deep tissue injury may be characterized by a purple or maroon localized area of discolored intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Presentation may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue) to his/her left dorsal (top) foot measuring 3 cm in length by 1.5 cm in width by 0.1 cm in depth. Apply Skin Prep (a topical barrier between skin and adhesives) daily. -An unstageable pressure ulcer to his/her right lateral lower leg measuring 34 cm in length by 14 cm in width by 0.6 cm in depth. Treat with calcium alginate, ABD, and Kerlix daily. Record review of the resident's care plan, last revised 2/28/23, showed: -The resident was on hospice. -The resident had multiple wounds. The wounds were not identified as pressure or non-pressure. -Staff were to document treatments weekly, to include location, measurements of each area of skin breakdown, type of tissue and exudate (any fluid that filters from the circulatory system into lesions or areas of inflammation), and any other changes. Observation on 3/2/23 at 10:45 A.M. showed: -A contracted Wound Nurse had cut all the wound dressings open to expose the wounds. -The contracted Wound Nurse was measuring all the wounds. -NOTE: No dressing or cover was placed over wounds, all were left open to air when the contract Wound Nurse and facility nurse left the resident's room. -The resident's right heel wound was not clearly visible but moderate serosanginous drainage was noted on the bed under the resident's right heel. -The resident's left lower leg wound contained approximately 30% slough, granulation tissue observed in wound bed. -The resident's left lateral foot wound contained granulation tissue and approximately 20% slough, no drainage observed. -The resident left dorsal foot wound had viable granulation tissue present, no drainage observed. -The resident's right lower leg consisted of approximately 30% eschar, slough covering approximately 20% of the wound, moderate serosanginous drainage which had soaked the bottom third of the resident's underpad, and bone and tendon were visible. The skin surrounding the wound was macerated. During an interview on 3/2/23 at 10:45 A.M., a contracted Wound Nurse said: -He/she had been contracted at this facility for two weeks. -He/she gave the facility a paper record of his/her visit. Observation on 3/2/23 at 1:47 P.M. showed the resident's wounds remained open to air while the soiled dressings that were cut remained under the resident's legs. 3. Record review of Resident #8's Face Sheet showed the resident was admitted on [DATE] with diagnoses including of a Stroke and Diabetes. Record review of the resident's care plan for Diabetes was updated on 11/2/22 showed: -Facility care staff were to inspect the resident feet daily for any open areas or sores, pressure areas, redness, blister and edema. -The resident did not have care plan documented for at risk for pressure ulcer or had current pressure ulcer on left outer foot. Record review of the resident's significant change MDS dated [DATE], and showed the resident: -Was not able to answer any of the Brief Interview for Mental Status (BIMS) questions and showed he/she had a memory problem. -Needed extensive to total assistance with bathing, dressing, mobility, eating, and toileting. -Was at risk for developing pressure ulcer. Record review of the resident's nursing note dated 2/26/23 at 9:57 A.M. showed: The resident had a pressure ulcer on his/her left outer foot. -The wound was cleaned with wound cleanser, pat dry and covered with dry dressing. -The nurse had left a note for Nurse Practitioner, Director of Nursing (DON). -The resident's family member was notified. -An order to treat the wound was obtained. -Did not include a detail description and comprehensive assessment of the pressure wound. Record review of the resident's Nurse Practitioner visit progress notes dated 2/27/23 showed: -Had no detail description or measurement of the resident's left outer foot wound. -Skin assessment had documented the resident had a wound to his/her left outer foot. -He/she had a pressure ulcer to his/her right outer foot (wrong foot noted, has a right blow the knee amputee,). -Verbal order given to wound nurse for wound treatment with Santyl (an ointment used for the debridement of pressure ulcers), Vaseline gauze dressing (is a pad that remains moist and nontoxic while clinging and conforming to all body contours) and to change daily. -Order for the resident to be seen by wound team. -He/she had a history of osteomyelitis (bone infection). Record review of the resident's POS sheet dated 2/27/23 showed: -He/she had new physician order to clean wound to his/her left outer foot with wound cleanser and pat dry with gauze, then apply Santyl and cover with Vaseline gauze and secure with Mepilex (an absorbent dressing). -Dressing change schedule for the day shift on Monday, Wednesday and Friday or as needed. ( active as of 3/1/23). -The wound measurement was 2 cm length by 1 cm width. -Did not include a detail description and assessment of the pressure wound. Record review of the resident nursing note dated 2/28/23 at 2:03 P.M. showed: -The resident was seen by Nurse Practitioner regarding a new pressure wound on his/her left outer foot. -An physician order was received to stop previous order and start new treatment of Santyl and Vaseline gauze daily. -Did not include a detail description and comprehensive assessment of the pressure wound. Record review of the resident's weekly skin assessment dated [DATE] showed: - Documented the resident having a pressure ulcer on his/her left lateral foot. -Had no documentation of a detail comprehensive assessment of his/her new pressure wound. Record review of the resident's care plan as of 3/1/23 showed the resident did not have care plan documented for at risk for pressure ulcer or had any current pressure ulcer on his/her left outer foot. Observation on 3/1/23 at 9:15 A.M., the resident had an undated dressing on his/her left foot. No drainage noted. Record review of the resident TAR dated 3/1/23 showed he/she had wound care treatment on left outer ankle that day. Record review resident's Wound Consult Report dated 3/2/23 showed the resident: -Had an unstageable pressure wound to his/her left foot. -Measure 2.5 cm L by 1.7 cm W by 0.3 cm D. -Had slough of 80%, granulation of 20%, maceration, friable and had moderate drainage. -Pressure precaution was for facility care staff to ensure off-loading of the lateral foot. -Had an order for treatment with Santyl and covered with foam dressing. dressing to be change every day. Observation on 3/2/23 at 2:53 P.M., resident's left foot with CNA G showed: -Could not see any open areas to left heel or foot at that time. -The resident left lower leg was contracted and were unable to position to see the area at that time. -Had no dressing on his/her left foot. During an interview on 3/3/23 at 12:02 P.M., LPN D said: -He/she was not aware of any change in the resident's foot, until the hospice shower aide informed the nurse. -He/she was not made aware the resident's wound care had not been completed on 3/2/23 and that the resident was without dressing from the afternoon on 3/2/23 to the morning on 3/3/23. -The facility had a wound nurse who would be responsible for weekly wound care and detail documentation for the resident's wound. -The charge nurse would be responsible for daily wound care and document the care on the resident's TAR. During an interview and observation of the resident on 3/3/23 at 9:00 A.M., LPN B said: -Resident #8 had been assessed by the contracted wound Nurse Practitioner the afternoon of 3/2/23. -Contracted wound nurse would assess, measure the wounds and then order wound care treatments. -Nurse Practitioner normally does not provide hands on wound care for the resident while his/her is at the facility. -He/she was not able to complete the wound care treatment for Resident #8 on 3/2/23 after the Nurse Practitioner left the facility. -He/she was pulled to be a charge nurse on the south side and he/she said had informed the ADON that he/she had not completed the wound care for Resident #8 and another resident on that hallway. -He/she was not aware that the wound care was not completed for Resident #8 or he/she was without a dressing from later afternoon on 3/2/23 to morning on 3/3/23. -After he/she had assisted the wound Nurse Practitioner with rounding on the facility's wounds, then he/she had to go back to finish any wound care treatments for all residents that had been seen on 3/2/23. -He/she had left all the residents wounds open to air and not treated until later on that day. -Observation showed he/she had no dressing in place. The resident's left outer foot had half dollar size open area. His/her heel protective boot had a reddish-brown drainage spot. -LPN B said the resident did not have a dressing on the pressure wound overnight to the present time. -The resident had treatment orders of cleaning the wound and then apply Santyl and cover with a dressing. -He/she did not communicate with the charge nurse or DON related to wound care not completed on 3/2/23. During an interview on 3/3/23 at 10:22 A.M., LPN A said: -Staff should redress a wound within 15-20 minutes after it is uncovered. -He/she felt it very inappropriate for a Stage 3 pressure ulcer to be left open to air for three hours. During an interview on 3/3/23 11:30 A.M. ADON said: -He/she had just started working on wound reports and tracking of all wounds in the facility. -He/she was not made aware that LPN B had not completed the wound care for Resident #8. -LPN B should have reported to DON, him/her and the charge nurse that wound care needed to be completed for that resident. -All nursing staff were responsible for completing the resident's wound care. -He/she would expect wound care to be documented in the resident's electronic record, located nursing notes and on the TAR. -Staff should notify the doctor of any changes, detail note with descriptive of the wound and changes. -Weekly skin assessment should been completed by the facility Wound Nurse. --He/she would expect to have detailed assessments of the wound to include weekly measurements. -Regarding Resident # 8, the CNA would be responsible to notify the charge nurse of any skin changes found, and nursing staff would be responsible for assessing and documentation findings. should assess the area one document. During an interview on 3/3/23 at 12:11 P.M., LPN D said: -The resident was admitted from the hospital with all of the wounds. -The nurse who admitted the resident was supposed to complete the full body assessment and document the location of each wound and document a description of each wound but they do not measure them. -When they received treatment orders, they began treating the wounds. -The wound care consultant actually documented the wound measurements, staged the wounds and ordered treatments upon seeing the resident initially last week. -Up until the time the wound care consultant came, the floor nurses were completing the resident's wound care treatments as ordered. -They were treating the wounds on the resident's bottom, leg and back. -The wound under the resident's breast developed at the facility and they started treating that one also. -LPN B said he/she rounds with the wound care nurse on Thursdays and completes all of the wound care treatments on Thursday. -On all other days, the floor nurses completed wound care treatments and it varied depending on who was the charge nurse on any given day. During an interview on 3/3/23 at 12:34 P.M., the ADON said: -The initial wound assessment is completed by the charge nurse on duty upon admission. -The charge nurse completing the assessment was supposed to document a description of the wound, location, whether there is drainage and try to give a size of the wound if they can. They are not allowed to stage but they can measure it. -The description should be good enough that by the time the wound care consultant sees it, they would have something to compare their assessment to. -The charge nurse also obtains the treatment orders for the wound care and documents it on the physician's orders. -The wound care consultant actually stages wounds, determines the type of wound each one is and determines the treatment orders. -Until the wound care consultant comes in to see the resident, the nurse should document the location and description of the wounds when they provide the treatments. -When the wound care consultant comes in, they have LPN B complete rounds with him/her to see all of the wounds. -LPN B was supposed to undress the wounds while the wound care consultant assessed the wounds, measured them, staged them (identified the wound) and determined the treatment orders. -The wound care consultant was supposed to provide any treatments he/she felt necessary at that time and then LPN B was supposed to complete the treatment of each wound before they moved to the next resident. -If they undress the wound and do not complete the treatment at that time, they should at least cover the wound with a dry, sterile dressing until they can treat it. -Yesterday, LPN B was asked to work as the charge nurse and he/she provided all of the wound care documentation to him/her but he/she was not aware that he/she had not finished all of his/her treatments. -If he/she had known there were two residents that had not received wound care treatments, he/she either would have told LPN B to finish the treatments or let another nurse know so they could have been completed. -He/she did not know if LPN B was wound care certified. -His/her expectation is that since the CNAs go in to check the residents for incontinence, if they see any wounds that were uncovered, they would let the charge nurse know and the nurse should immediately check the resident's wound care orders and then provide the treatment. -They should not have left the wounds open and undressed overnight. -He/she found out this morning that wounds were not being treated at the time the wound care consultant was in the building because he/she was in a hurry to get done, and that was not how the wound care process was supposed to be done. -He/she said he/she would round with the wound care consultant on his/her next visit. During an interview on 3/3/23 at 2:40 P.M., the DON said: -Staff were to perform a full body skin assessment immediately upon a resident's admission. -The skin assessment was expected to include the wound size and location. -He/she expected the staff to document any wound location but did not expect his/her staff to measure wounds. -The contracted wound care company was responsible for measuring each wound weekly. -Once staff removed a wound dressing, he/she expected staff to follow the physician's order in completion, which would include applying a new dressing immediately. -He/she found it unacceptable for a wound to be open to air, without an order, for more than three hours. During an interview on 3/3/23 at 3:27 P.M., Physician A said he/she expected staff, upon a resident's admission, to document where the wounds were located, measurements, and a description of each wound. During an interview on 3/3/23 at 3:49 P.M., DON said; -LPN D had reported to physician and documented on the weekly skin assessment the resident's new wound. -Nursing staff are responsible for completing daily wound care and documented treatment on the resident TAR. -The facility nursing staff have not been trained on staging or to document detail of the resident with wounds. -He/she would expect the nursing staff to description what they see in the resident nursing notes and on skin assessment. MO00214413 2. Record review of Resident #38's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including urinary tract infection, pressure sores, dementia, anxiety, muscle weakness, sepsis (a serious condition in which the body responds improperly to an infection) and cognitive communication deficit. Record review of the resident's Skilled Nursing assessment dated [DATE], showed: -In the section titled skin observation it showed the resident's skin was dry, with multiple wounds that were pressure and non-pressure wounds. It showed the resident had one open right buttock pressure wound, two left buttock open pressure wounds, a lower left leg deep tissue injury, a mid-back right gluteal fold open area, and a left toe deep tissue injury. There was no further description, or size/measurements of the wounds or pressure sores documented. Record review of the resident's All Inclusive Nursing assessment dated [DATE], showed he/she was wheelchair bound with limited mobility, requiring moderate to maximum assistance with movement, likely nutritionally inadequate, required a full body transfer and mobility assistance and his/her skin was very moist. The assessment showed the resident had skin issues but did not show any descriptions of the resident's wounds or pressure sores that included the location, description or measurement of each pressure sore. Record review of the resident's Physician's Order Sheet (POS) dated 2/2023, showed physician's orders to: -Cleanse his/her mid back wound with wound cleanser, pat dry, apply calcium alginate, cover with a dry dressing and tape. Change daily and as needed every day shift (2/1/23). -Cleanse his/her right buttocks wounds with wound cleanser, pat dry, apply collagen, cover with a four by four gauze and tape. Change daily and as needed every day shift 2/1/23. -Cleanse his/her left buttocks wounds with wound cleanser, pat dry, apply collagen, cover with a four by four gauze and tape. Change daily and as needed every day shift 2/1/23. -Complete a weekly skin assessment, perform skin assessments weekly every Wednesday on the day shift (2/1/23). -May apply barrier cream as needed to redness or excoriation and/or after incontinent episodes (2/1/23). -Provide a Registered Dietitian consult as needed (2/1/23). -Cleanse his/her lower leg DTI (deep tissue injury) wound with wound cleanser, pat dry, apply skin prep daily and as needed every day shift (2/2/23). Record review of the resident's Nursing Notes showed: -On 2/1/23, the resident was admitted to the facility from the hospital for sepsis (serious infection), urinary tract infection and pressure ulcers. The resident was alert with confusion, was incontinent of bowel and bladder and had several wounds on both his/her buttocks, back folds and left lower extremity. The resident denied pain or discomfort at this time. -On 2/2/23, documentation showed the nursing staff documented the following measurements: --Mid back wound measurement was 4 cm length (L) by 2 cm width (W). --Right buttock measurement was 4 cm L by 1.5 cm W. --Left Lower leg measurement was 6.2 cm L by 4.3 cm W. -There was no description of the wounds (to include what each wound looked like, if there were any odors or drainage). -There were no additional wounds/pressure ulcers documented. There was no staging (process to determine the deterioration of a pressure sore) of any of the wounds or identification of the wounds as pressure sores. Record review of the resident's admission MDS 2/6/23, showed the resident: -Was severely cognitively impaired. -Needed total assistance with bed mobility, transfers, toileting, bathing, dressing, grooming and was incontinent of bowel and bladder. -Had lower extremity range of motion impairment. -Was at risk for developing pressure ulcers and had one or more unhealed pressure sores that were at a Stage I pressure ulcer (Intact skin with non-blanchable redness of a localized area usually over a bony prominence) or higher. -Had three stage III pressure ulcers. -Had moisture associated skin damage (MASD). -Received pressure sore treatments and application of ointments and dressings on areas other that to his/her feet. -Received pressure reliving devices in his/her bed and wheelchair. Record review of the resident's POS dated 2/2023, showed physician's orders for: -The Wound team to manage wounds (2/6/23). -Low air loss mattress (2/6/23). -Ascorbic Acid Tablet 500 milligrams (mg) two times a day for wound healing (2/7/23). -Multiple Vitamin one time a day for wound healing (2/7/23). Record review of the resident's Braden Scale (pressure sore risk tool) dated 2/7/23, showed a risk score of 11 indicating he/she was at high risk for developing pressure ulcers. Record review of the resident's Weekly Skin Assessments showed there were skin assessments completed on 2/7/23, 2/14/23 and 2/21/23. None of the skin assessments showed measurements or descriptions of each of the resident's pressure ulcers or deep tissue injuries. The body diagrams did not show where the pressure ulcers and deep tissue injuries were located. There was no documentation showing the facility was monitoring the pressure ulcers or deep tissue injuries. Record review of the resident's Physician's Progress Note dated 2/13/23 showed the resident was seen for follow up medical management and noted the resident had a recent hospitalization for wounds and foot pain. The physician documented: -The hospitalization course showed the resident had pressure ulcers to his/her left fifth toe and heel. -He/she saw the resident and documented the resident had wound to (his/her) right lower extremity that was a deep tissue injury with eschar (dead tissue) and buttocks. -The resident had multiple chronic leg and foot wounds in various stages of healing and his/her left fifth digit had necrosis (the death of all or most of the cells in an organ or tissue due to disease or lack of blood supply). -He/she consulted podiatry and an arterial Doppler (an ultrasound that checks the circulation in the upper and lower extremities) was ordered. Record review of the resident's Care Plan dated 2/14/23, showed the resident was at risk for pain and discomfort related to wounds and was admitted to the facility with four Stage III wounds to his/her mid-back measuring 4 cm L by 2 cm W; right buttock measuring 4 cm L by 1.5 cm W; left buttock measuring 2.5 cm L by 2.5 cm W; and left leg 6.2 cm L by 4.3 cm W. Interventions showed: -Encourage good nutrition and hydration in order to promote healthier skin. -Follow facility protocols for treatment of injury. -Provide a pressure relieving/reducing mattress. -Keep his/her skin clean and dry. Use lotion on dry skin. -Monitor and document the location, size and treatment of skin injuries. Report abnormalities, failure to heal, signs and symptoms of infection, changes to the physician. -Obtain blood work such as blood chemistry lab, blood cultures and the wound culture of any open wounds as ordered by the physician. -Weekly skin assessment done by a licensed nurse. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Record review of the resident's POS dated 2/2023, showed physician's orders for: -An arterial doppler of the resident's bilateral legs for non-healing wound (2/20/23). -Wounds to be managed by wound team or wound clinic weekly (2/20/23). -Clean wound to right breast with wound cleanser. Pat dry with gauze. Apply triple antibiotic ointment and cover with bordered gauze, every day shift on Mon, Wed, Fri for wound care (2/20/23). Record review of the resident's Radiology Report dated 2/21/23 showed the resident had a non-pressure chronic ulcer of his/her left ankle. A bilateral arterial Doppler of his/her lower left extremity with unspecified severity was completed. The result showed the resident had significant arterial disease (plaque build-up in an artery causing blockage) with 50 to 75 percent blockage. Record review of [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review of Resident #19's undated face sheet showed he/she admitted to the facility on [DATE] with the diagnosis of Acute Respiratory Failure with Hypoxia (impairment of gas exchange between the lungs and the blood causing a lack of oxygen in the blood). Record review of the resident's care plan dated 12/6/22 showed no focus or intervention indicating the resident was on oxygen. Record review of the resident's POS dated March 2023 showed no orders in place for oxygen or oxygen tubing. Record review of the resident's MDS dated [DATE] showed the resident received oxygen therapy. During an observation and interview on 2/28/23 at 2:04 P.M. the resident said: -He/she uses two different nasal cannulas, one during the day attached to his/her portable oxygen tank and the other nasal cannula at night attached to the concentrator. -He/she was receiving oxygen through a nasal cannula. During an interview on 3/2/23 at 11:01 A.M., LPN A said: -There should be an oxygen order in place for residents who receive oxygen. -The order should include the amount, when to check the oxygen, and when the tubing should be changed. -He/She would contact the doctor if there was no order in place for a resident who receives oxygen. During an interview on 3/3/23 at 3:47 P.M. the DON said: -A resident should have an order in place for oxygen therapy. -The order should include: -- The amount of oxygen. --The diagnosis for why the resident is on oxygen. --When the oxygen needs to be administered. --The method to be used for administration. -He/She would expect the staff to get an order for oxygen if there was not one in place. 2. Record review of Resident #41's face sheet showed he/she was admitted with diagnoses: -Chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). -Unsteadiness on feet. Record review of the resident's MDS completed 2/10/23, showed: -The resident had a Brief Interview for Mental Status (BIMS) of eleven indicating he/she was moderately cognitively impaired. -He/she received oxygen therapy. Record review of the resident's POS, dated 3/1/23, showed the physician ordered oxygen tubing to be changed weekly with each component dated and initialed for infection control. Observation on 2/27/23 at 9:09 A.M. showed: -The resident was in his/her room wearing his/her nasal cannula with the oxygen concentrator on. -There was no bag available for the nasal cannula tubing present in the room. Observation on 2/27/23 at 1:04 P.M. showed: -The resident was in his/her wheelchair using an oxygen tank attached to the wheelchair. -The nasal cannula attached to the oxygen tank did not have a date or bag available for the cannula to be placed in when not in use. -The resident's nasal cannula, connected to the not-currently-in-use oxygen concentrator, was lying on the floor, undated, and with no barrier. Observation on 2/28/23 at 12:21 P.M. showed: -The resident's nasal cannula, attached to the oxygen concentrator, was lying on the floor. -A plastic bag, which was dated, was now attached to the oxygen concentrator but remained empty. During an interview on 2/28/23 at 12:21 P.M., the resident said staff removed his/her nasal cannula when moving to another oxygen source, he/she did not remove it from his/her nose. Observation on 3/1/23 at 11:02 A.M. showed: -The resident was not in his/her room. -The resident's nasal cannula, connected to the oxygen concentrator, was in the resident's bedside drawer with various other items, and remain uncovered. Observation on 3/1/23 at 11:52 A.M. showed: -The Assistant Director of Nursing (ADON) was providing a treatment for the resident. -The resident's oxygen cannula remained in the resident's bedside drawer, uncovered. -ADON did not address the resident's nasal cannula being uncovered. Observation on 3/2/23 at 8:27 A.M. showed: -The resident was in bed with a nasal cannula on, connected to the oxygen concentrator. -The nasal cannula tubing for the oxygen tank on his/her wheelchair was in a bag but the nasal cannula prongs (the portion that is placed directly into the nostrils) were sitting underneath one wheel of the wheelchair. Observation at 3/2/23 at 8:55 A.M. showed Licensed Practical Nurse (LPN) A entered the resident's room to perform a procedure, walked past the wheelchair with the nasal cannula prongs under one wheel two times, and did not address the nasal cannula on the floor/under the wheel. Observation on 3/2/23 at 10:12 A.M. showed: -Certified Nursing Assistant (CNA) A and CNA C entered the resident's room to provide cares. -While CNA A and CNA C were preparing to transfer the resident, CNA C pulled the oxygen tubing connected to the oxygen tank out of the plastic bag on the wheelchair but was unable to get to the nasal cannula prongs, so he/she lifted the wheelchair off the nasal cannula. -CNA A removed the nasal cannula, connected to the oxygen concentrator, from the resident and placed it on the floor. -CNA C placed the nasal cannula, connected to the wheelchair oxygen tank, that he/she had found under the resident's wheelchair wheel on the resident. -CNA A and CNA A attempted to transfer the resident but the resident refused to transfer until his/her shirt was changed. -CNA C then removed the resident's nasal cannula and again placed it the floor, changed the resident's shirt, picked up the nasal cannula from the floor, and placed back on the resident. During an interview on 3/3/23 at 10:12 A.M., CNA A said he/she wouldn't have done anything differently. 3. During an interview on 3/02/23 at 11:06 A.M., CNA E said: -When the resident is not using their oxygen, it should be in a plastic bag and there should be a plastic bag in the resident's room to place it in. -They usually change the oxygen tubing weekly or as needed. -If the oxygen tubing was on the floor, they should replace it. During an interview on 3/2/23 at 12:10 P.M., CNA C said: -Oxygen tubing was to be wrapped up and put in a bag on top of the resident's machine. -Oxygen tubing should never be on the floor and should always have a barrier under it. -If he/she found oxygen tubing on the floor, he she would throw it away and get a new one because it would be contaminated. -He/she didn't know why he/she didn't do that for Resident #41. During an interview on 3/2/23 at 12:52 P.M., CNA A said: -All oxygen tubing was to be left on the resident's chair. -Oxygen tubing in a resident's room was to be placed in the resident's bedside drawer. -He/she would throw away any nasal cannula found on the floor. -He/she would never put a nasal cannula that was on the floor on a resident. -He/she didn't change the nasal cannula during the cares on 3/2/23 at 10:12 A.M. for Resident #41 because he/she was in a rush. During an interview on 3/3/23 at 10:22 A.M., LPN A said: -Oxygen tubing was to be stored in a plastic bag that was dated. -He/she would immediately replace any oxygen tubing he/she found on the floor. -Staff were not to put a nasal cannula on a resident after it had touched the floor. During an interview on 3/03/23 at 11:28 A.M., LPN A said: -The charge nurses keep the plastic bags for storage of oxygen equipment on the medication cart. -The CNA can also get the bags from central supply. -Everyone should be checking to ensure the plastic bags are available and obtain one when they see the resident does not have a bag in their room for their oxygen supplies. -All oxygen supplies should be stored in a plastic bag when they are not being used. During an interview on 3/3/23 at 2:40 P.M., the Director of Nursing (DON) said: -Nasal cannulas were to be stored in a bag when not in use. -The nurses were responsible for ensuring oxygen tubing was stored correctly. -He/she expected any staff that found oxygen tubing on the floor to throw it away and replace it. -All care staff were responsible for monitoring to ensure oxygen tubing was properly covered. Based on observation, interview and record review, the facility failed to ensure oxygen orders were transcribed and in place for one sampled resident (Resident #19); to ensure oxygen nasal cannulas (a medical device used to deliver supplemental oxygen to people who have lower oxygen levels or respiratory difficulty) and tubing were kept covered when not in use for two sampled residents (Resident #47 and #41) and to care plan the resident's need for oxygen for one sampled resident (Resident #47) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy titled Oxygen Administration dated June 2020 showed: -A physician's order is required to initiate oxygen therapy, except in an emergency situation. -The physician's order for oxygen should include: --Oxygen flow rate. --Method of administration. --Usage of therapy. --Titration instructions if indicated. --Indication for use. -Oxygen items were to be stored in a plastic bag at the resident's bedside to protect the equipment from dirt and dust when not in use. 1. Record review of Resident #47's Face Sheet showed he/she was admitted on [DATE], with diagnoses including dyspnea (labored breathing), muscle weakness, cirrhosis (a condition in which your liver is scarred and permanently damaged), cognitive communication deficit and anemia (low iron level). Record review of the resident's Comprehensive Care Plan dated 1/5/23, showed his/her care plan did not identify that he/she was to receive oxygen, at what amount, why he/she was to receive oxygen and interventions for use. Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool to be completed by facility staff for care planning) dated 2/22/23, showed the resident had received oxygen treatments during the look back period. Record review of the resident's Physician's Order Sheet (POS) dated 2/2023 showed physician's orders for: -Complete oxygen saturation and pulse every shift and as needed for dyspnea (2/3/23). -Oxygen at 4 liters per minute via nasal cannula, continuously or as needed to keep oxygen saturation levels greater than 90 percent every day and night shift (2/3/23). -Cleaning the oxygen filter weekly on night shift every night shift weekly (2/3/23). -Oxygen tubing: change weekly, label each component with date and initials every night shift on Sunday (2/5/23). Observation on 2/28/23 at 10:23 A.M., showed the resident was fully dressed laying in his/her bed resting with his/her eyes closed. He/she was not wearing oxygen. There was an oxygen concentrator (a medical device that takes in air from the room and filters out nitrogen) with tubing and a nasal cannula that was not stored in a plastic bag. There was no plastic bag in his/her room for storage. Observation on 3/1/23 at 12:01 P.M., showed the resident was laying in his/her bed with his/her eyes closed resting comfortably. His/her oxygen concentrator was beside his/her bed and was on and running at 2 liters per minute. The nasal cannula and tubing was coiled around the concentrator beside the humidifier bottle with the nasal cannula touching the floor. Observation on 3/01/23 at 2:21 P.M., showed the resident was sitting up in his/her wheelchair. He/she was not wearing his/her oxygen, but the oxygen concentrator was on and running and the nasal cannula and tubing was still wrapped around the humidifier bottle. At 2:22 P.M., nursing staff went into the resident's room to check the resident for incontinence. Upon exiting the resident's room, the resident's oxygen concentrator was still on and running and was not in use. The nasal cannula was still coiled around the humidifier bottle, uncovered. Nursing staff left the resident's room without either placing the resident's oxygen on or turning it off and placing the nasal cannula and tubing in a bag. There was no bag in the resident's room. Observation on 3/2/23 at 8:28 A.M., showed the resident was not in his/her room. His/her oxygen concentrator was in the middle of the room with the oxygen tubing and nasal cannula coiled around the concentrator, uncovered. The concentrator was not on. There was no bag in the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 74 residents. Record review of the facility's policy titled Nursing Department-Staffing, Scheduling, and Postings dated [DATE] showed: -The facility will post the following information on a daily basis: --Facility name. --The current date. --The total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift including Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Licensed Vocational Nurses (LVNs), and Certified Nursing Assistants (CNAs). --Resident Census. -Posting Requirements: --The facility will post the nurse staffing data specified above, on a daily basis at the beginning of each shift. --Data must be posted in a clear and readable format and in a prominent place readily accessible to residents and visitors. -The facility will complete all applicable staffing and census forms when applicable, as determined by state law indicating the Director of Nursing (DON) or designee is responsible for validating the accuracy of the data on such staffing and census forms. 1. Observation on [DATE] at 12:28 P.M. showed the staffing was posted inside a bulletin board by the front desk, but did not show the facility census, total number of care staff on each shift, and actual hours of work by certified staff. Observation on [DATE] at 8:24 A.M. showed staffing for the day had not been posted. Observation on [DATE] at 11:17 A.M. showed: -The staffing had been posted for that day and for [DATE]. -The staffing on both sheets did not have the facility census or actual hours worked. -The total number of staff was hidden behind the first page. Observation on [DATE] at 9:05 A.M. showed staffing had not been posted. During an interview on [DATE] at 3:47 P.M. the DON said: -Staffing should be posted each day including all care staff who are Cardiopulmonary Resuscitation (CPR) certified, the total hours of certified staff and the amount of certified staff, and the census. -All of the information should be visible for anyone to see.

Based on observation, interview, and record review, the facility failed to ensure medications were stored in a locked compartment, that medications were labeled, and that medications stored in a refrigerator were monitored for temperature. The facility census was 74 residents. Record review of the facility's policy, dated November 2020, and titled Storage of Medications showed: -Drugs used in the facility were to be stored in locked compartments under proper temperature. -Drugs were to be stored in the packaging in which they were received. -Compartments (including carts, rooms, and refrigerators) that contained drugs were to be locked when not in use. 1. Observation on 2/27/23 at 8:49 A.M. showed a treatment cart containing scissors and medications was unlocked on the north hall. Observation on 2/27/23 at 9:06 A.M. showed a treatment cart containing scissors and medications was unlocked on the north hall. -Licensed Practical Nurse (LPN) D approached cart and examined supplies, then walked away without locking the cart. Observation on 2/27/23 at 9:08 A.M. showed a medication cart on the south hall was unlocked and unattended. Observation on 2/27/23 at 9:54 A.M. showed: -A medication cart on the south hall was unlocked and unattended. -Multiple staff members walked past the cart at various time but none locked it. Observation on 2/27/23 at 12:19 P.M. showed: -A medication cart on the south hall unlocked, no staff at desk or visible in halls. -A visitor was able to go through all the drawers in the south hall medication cart which contained needles and multiple residents' medications. Observation on 2/27/23 at 12:20 P.M. showed a treatment cart containing scissors and medications was unlocked on the south hall. Observation on 2/27/23 at 1:06 P.M. showed a treatment cart in the south hall was in the hallway unlocked with no staff visible. Observation on 2/27/23 at 2:22 P.M. showed a treatment cart on the north hall was unlocked with no staff visible. Observation on 2/27/23 at 2:56 P.M. showed: -The south hall medication room door had a napkin placed in the strike plate (a metal plate affixed to a doorjamb that holds the door closed), which prevented the door from locking. -Staff attempted to close the door three times unsuccessfully. During an interview on 2/28/23 at 9:21 A.M., LPN A said: -He/she noticed the napkin in the door frame late in the day on 2/27/23 and removed it. -He/she had no idea which facility employee may have placed a napkin in the door frame to keep it from latching. Observation on 3/1/23 at 9:15 A.M. showed a treatment cart on the north hall was unlocked and unattended. Observation on 3/1/23 at 10:49 A.M. showed LPN D removed a plastic bag from the strike plate of the north hall medication room, which had prevented the door from locking. During an interview on 3/2/23 at 11:52 A.M., LPN D said: -He/she did not remember removing any items from the strike plate of either medication room. -The medication room doors were always closed and locked. During an interview on 3/2/23 at 11:56 A.M., the Assistant Director of Nursing (ADON) said the doors to the medication rooms were to be closed completely and locked at all times. During an interview on 3/2/23 at 12:10 P.M., Certified Nursing Assistant (CNA) C said: -The medication room doors should be locked at all times. -He/she was unaware of anyone placing items in the strike plate to prevent the doors from closing and/or locking. Observation on 3/2/23 at 12:59 P.M. showed: -A medication cart on the south hall was unlocked with no staff visible. -Two residents in the hall near the unlocked medication cart with no staff present. -A resident opened a drawer on the medication cart and removed a pen. -LPN A walked by the unlocked medication cart but did not lock it. Observation on 3/2/23 at 2:10 P.M. showed: -A treatment cart on the south hall unlocked and unattended while residents were in the hall. -Multiple staff walked by the unattended cart and did not lock it. Observation on 3/3/23 at 8:55 A.M. showed a medication cart on the south hall was unlocked and unattended; staff at desk but not within reach of medication carts. Observation on 3/3/23 at 9:03 A.M. showed a treatment cart on the south hall was unlocked and unattended. Observation on 3/3/23 at 12:25 P.M. showed a medication cart and treatment cart in the north hall was unlocked and unattended; staff at desk but not within reach of medication carts. 2. Observation on 2/28/23 at 1:40 P.M. showed a medication cart on the north hall contained 2 white circular pills marked with TCL 272 in a medication cup. The cup was not labeled with the name of the resident or the medication. During an interview on 2/28/23 at 1:47 P.M., LPN D said staff were to throw away any medications that had been removed from their original packaging and not given. During an interview on 3/1/23 at 9:53 A.M., Certified Medication Technician (CMT) A said staff were to discard any medications taken out of the package and not given. 3. Observation on 2/28/23 at 12:11 P.M. showed the medication room on the south hall had a temperature log hung by the medication refrigerator for the month of December 2022. No other temperature logs were present. Record review of the medication refrigerator logs received from the Director of Nursing (DON) on 3/1/23 at 10:47 A.M. showed: -Every day for the past six months was signed by the same staff member. -A missing temperature log for October 2022. -A temperature log, completed, for October 2023. During an interview on 3/1/23 at 10:55 A.M., the DON said: -He/she was unsure how temperature logs could have be completed for dates that had yet to occur. -He/she did not know of any process in the facility that including auditing temperature logs. -The staff member that filled out the temperature logs had not worked every day for the past six months. -The staff member that filled out the temperature logs must have made up the readings. 4. During an interview on 3/2/23 at 12:52 P.M., Certified Nursing Assistant (CNA) A said: -The medication room doors were normally locked. -He/she had never seen anyone place an item in the strike plate of the medication room door to prevent it from closing. -He/she did not know who was responsible for monitoring the medication refrigerators or how often they were to be checked. -If he/she found a medicine cup with pills in it, he/she would tell the resident to take their medication. -Medication and treatment carts were always to be locked when unattended because the residents roam in the hall. -Nurses were responsible for ensuring their medication and/or treatment cart was locked when not in use. During an interview on 3/3/23 at 10:22 A.M., LPN A said: -The medication rooms were to be locked at all times. -He/she had removed items from the medication room strike plate on multiple occasions because other staff were stuffing things in it to prevent the door from locking. -Medication refrigerator temperatures should be checked and documented at least daily. -He/she was unsure who was responsible for monitoring and documenting medication refrigerator temperatures. -If he/she found a medication cup with unlabeled pills, he/she would throw it away immediately. -Medication and treatment carts were to be locked when unattended. During an interview on 3/3/23 at 2:40 P.M., the DON said: -The medication rooms were to be locked at all times. -He/she had found multiple instances where staff had put something in the strike plate of the medication room doors to prevent them from locking and had educated the staff. -The medication refrigerator temperatures were to be checked nightly by the nurse. -A medication cup with loose pills should be destroyed. No pills out of their packaging were to be in the medication cart. -Medication and treatment carts were to be locked at all times when not in use, even if staff were present at the nurse's desk. -The staff member that used a medication and/or treatment cart was responsible for ensuring it was locked, but all staff should be monitoring and were to lock the carts if noted to be unlocked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Registered Dietitian (RD) was in the facility to perform dietary assessments and to consult with dietary staff in the kitchen. This practice affected two sampled residents (Residents #8 and #18) who needed dietary assessments during the time span there was not an RD coming to the facility. This practice also affected all residents because dietary staff did not get dietary consultation. The facility census was 74 residents. 1. During an interview on 2/27/23 at 1:50 P.M., the Administrator said he/she started at the facility on 2/6/23 and there has not been an RD at the facility during that time. During a phone interview on 2/27/23 at 2:03 P.M., the Chief Operating Officer (COO) from the former RD consult Company A said: -12/27/22 was the last time an RD from his/her company was last in the facility. -The contract the facility had with his/her company was not renewed after it was ended between the facility and his/her company. - He/she was not sure why the contract was not renewed. Record review of Resident #8's Progress Notes showed he/she had diagnoses which included dysphagia (swallowing difficulties with certain foods or liquids) following cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it),Chronic Obstructive Pulmonary Disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems). -Chronic kidney disease. Record review of the resident's Nutrition Dietary Note dated 10/5/22, showed: -The resident with an average intake on a mechanical soft diet and a gastrostomy tube (GT-a tube inserted through the wall of the abdomen directly into the stomach which allowed air and fluid to leave the stomach and can be used to give drugs and liquids, including liquid food, to the patient) in which the resident was fed glucerna (nutritional supplement) at 60 cubic centimeter (ccs) per hour and flushed at 150 ccs of water. -The resident had previously been stable recent increase likely related to continued increase in oral intake no edema (swelling) noted. - Combined oral and GT intake feeding providing adequate nutrition to meet needs. -Monitor nutrition parameters. Record review of the resident's Progress Notes showed nutritional notes dated 9/28/22, 10/13/22, 11/4/22, 11/8/22, 11/11/22, 11/23/22, and 11/27/2 by the RD from RD Consultant Company A; and no RD notes or assessments from 11/28/22 through 3/1/23. Record review of the resident's Nurse's Note dated 2/27/23, showed he/she was seen by a Nurse Practitioner (NP) regarding a new pressure wound (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) on his/her left outer foot. Record review of the resident's Nurse's Note dated 2/26/2023, showed he/she had a a pressure ulcer on his/her left outer foot. Record review of the resident's medical record showed the absence of any RD assessments or notes regarding his/her pressure ulcer. Record review of Resident #18's admission Face sheet showed: - The resident was admitted on [DATE]. - The resident had diagnosis of end stage renal disease (inability of the kidneys to excrete wastes, concentrate urine, and conserve electrolytes), Protein calorie malnutrition (A disparity between the amount of food and other nutrients that the body needs and the amount that it is receiving), and diabetes (primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). Record review of the resident's POS dated 3/1/23 showed: - A physician's order dated 10/22/22,a regular mechanical soft texture diet, large portions, encourage resident to avoid oranges, orange juice, and tomatoes. - A physician's order dated 10/24/22, to limit potatoes and dairy products to one serving per day (ordered on 10/24/22). - A physician order dated 10/24/22, for Hemodialysis (a treatment to filter wastes and water from a patient's blood, as their kidneys did when they were healthy in order to control the patient's blood pressure and balance important minerals, such as potassium, sodium, and calcium, in a patient's blood) on Tuesdays, Thursdays and Saturdays. Record review of the Resident's medical record showed the absence of any Dietitian notes by a facility's consultant RD. During an interview on 3/3/23 at 11:08 A.M., the Director of Nursing (DON) said: - The last time there was a RD assessment was 12/7/22. - Any concerns related to weight loss or skin breakdown was referred to the physician. - The RD consults were not getting done during the period of time after 12/7/22. During a phone interview on 3/14/23 at 9:33 A.M., the Current Consultant RD said: - When he/she started consulting at the facility on 3/2/23, he/she knew the facility did not have a consultant RD for 86 days. - There were no dietary admission assessments, dietary assessments of residents wounds or any dietary assessments of tube feedings. Record review of the Week at a Glance menu for Week 2 on 2/27/23 showed the following for the lunch meal hearty meat sauce over mostaccioli (a smooth textured pasta in the form of a short tube with oblique ends); seasoned broccoli and seasonal fruit cup. During an interview on 2/27/23 at 9:35 A.M., Dietary [NAME] (DC) B said: - The dietary department changed the menu from a hearty meat sauce to a chicken alfredo sauce over pasta on that day because they felt the residents had too many red sauce dishes, and so the residents would not have to continue to eat the same stuff. - Cauliflower will be served on the side instead of broccoli. During an interview on 2/27/23 at 9:38 A.M., DC B said he/she could not consult with the RD about the menu change because there was not an RD for dietary staff consult with at that time. During an interview on 2/28/23 at 11:13 A.M., the Regional Dietary Manager (DM) said without a an RD, dietary staff are expected to fill in substitutions in the substitution book; so an RD could sign off on those substitutions when and if one started to consult with the facility. Record review of the substitution book with the Regional DM on 2/28/23 at 11:15 A.M., showed the substitutions for hearty meat Sauce to alfredo sauce and the substitution of broccoli to to cauliflower were not filled out in the substitution log. During a phone interview on 3/14/23 at 9:35 A.M., the current Consultant RD said the dietary staff have a sheet that they are supposed to write the substitutions on the sheet and he/she would sign off on, when he/she goes to the facility.

Based on observation and interview, the facility failed to ensure molded green peppers were not stored in the walk-in fridge; to label containers with the name of the substances that were in those containers; to ensure paper towels were located at the hand washing station close to the south exit door of the kitchen; to remove burnt on debris from the top of the six burner stove; to ensure the maintain the gasket (a mechanical seal which fills the space between two or more mating surfaces, generally to prevent leakage from or into the joined objects) in the fridge labeled old; to place items which required refrigeration in the fridge; to maintain two fans free of a heavy dust buildup; and to clean the nozzle of the hose from the soft drink dispenser. This practice potentially affected at least 70 residents who ate food from the kitchen. The facility census was 74 residents. 1. Observations on 2/27/23 from 9:09 A.M. through 1:18 P.M., showed: - Eight molded green peppers in boxes in a refrigerator. - A white powdery substance that as in a container that was not labeled and a grainy brown colored substance that was in a container that was labeled with what was in the container. - The lack of paper towels at the handwashing station close to the south exit door of kitchen. - A buildup of debris on the gas lines behind six burner stove. - A rip in the gasket on a fridge labeled OLD. - A container of chopped garlic and lemon juice which were not refrigerated with the words refrigerate after opening on the containers. - A buildup of dust on the wall mounted fan and on the black pedestal mounted fan close to the dishwashing station. - A buildup of soft drink debris on the nozzle of the soft drink dispenser. During an interview on 2/27/23 at 9:45 A.M., Dietary [NAME] (DC) A said there were bread crumbs in one container and flour in the other and he/she understood a label needed to be placed on those containers. During an interview on 2/27/23 at 10:31 A.M., Dietary Aide (DA) A said he/she did not know the last time, the fan was cleaned. During an interview on 2/27/23 11:19 A.M., DC A said he/she placed the unrefrigerated items in the fridge. During an interview on 2/27/23 at 1:16 P.M., the Dietary Manager (DM) said: -They did not have paper towels for the hand washing station located close to the south exit door of the kitchen, and the paper towels were supposed to be delivered on Wednesday of that week. - The dietary staff have not removed the grease from the gas lines as yet. -He/she has only been working three days and he has not asked dietary staff to clean the soft drink nozzle as yet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure they developed and implemented a Quality Assurance and Performance Improvement (QAPI) Plan pertaining to on-going systemic issues regarding residents not receiving showers on a regular basis. The facility also failed to implement a QAPI program to ensure skin assessments and assessments of pressure ulcers were obtained on regular basis. The facility census was 74 residents. 1. Record review of a book showed a plan to address the shower issue December 2022. Record review of an in-service training report dated 12/21/22 showed only nine employees received training on topics which include showers, shower sheets, shower documentation and refusals. During an interview on 3/3/23 at 2:29 P.M., the Director of Nursing (DON) stated that training was started by an Administrator who was at the facility back in December 2022. During a phone interview on 3/2/23 at 8:35 P.M., Former Employee E said: -He/she worked at the facility until a few months ago. -Some of the Certified Nurse's Assistants (CNAs) did not care to give showers as much. -When he/she worked there it was difficult even then, for charge nurses to get the CNA's to give showers. -If everything was going well, the residents would get a shower twice per week. -He/she often heard from residents that they (the residents) were not getting showers. During an interview on 3/3/23 at 9:33 A.M. CNA C said -The CNAs did not have enough time to give the residents two showers per week. -There were former employees who walked out of the facility in the past. During an interview on 3/3/23 at 10:27 A.M., CNA B said: -He/she used to be a full time shower aide. -When he/she gave showers full time the process was decent. -Some residents refused showers -The CNA's are supposed to document the showers on the Bath sheets. -He/she went from full time to part time since the first week of December 2022. -The facility has not hired any full time shower aides after he/she went part time. -He/she did not think the shower situation was going well for the residents. During an interview on 3/3/23 at 11:40 A.M., the DON said: -The last time they had a Quality Assurance (QA) meeting was before Christmas of 2022. -A big part of the reason for them not having meetings was the facility was on its third Administrator since that time. -One of the CNA's who used to give showers, CNA H, has been on light duty for several months. -One of the former shower aides, CNA J, resigned. -A list of residents that need to be showered is supposed to be given to the CNA's daily. -It will be difficult for the aides to give showers with all the duties they already have. During an interview on 3/3/23 at 11:46 A.M. the Administrator said: -The facility needed to hire a bath aide for each side (the South and the North) of the facility. -It is the lack of dedicated staff that would contribute to the residents not getting their showers in a timely manner. During an interview on 3/3/23 at 12:20 P.M., the DON said there would be room for improvement in looking at the lack of a dedicated shower aide on each side could affect the residents not getting showers. During an interview on 3/3/23 at 2:26 P.M., the DON said: -The only evidence that the facility staff had followed up on giving showers in a timely manner is the shower sheets but he/she realized that many shower sheets were not completed and he/she would expect that the facility staff would fill out shower sheets even if the resident refused. -He/she would review the plan in the future and the current plan was not working. -He/she said they (the leadership at the facility) would have to develop a plan, implement a plan, monitor the plan. -He/she has not had a process to assess if the plan for showers are working. 2. Record review of the facility's policy Wound Management dated June 2020 showed: -A licensed nurse was to perform a skin assessment upon admission, readmission, weekly, and as needed for each resident. -Documentation of new wounds were to include the location, measurements recorded in centimeters (cm), direction and length of tunneling (a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) if present, appearance of wound base, drainage amount and characteristics, appearance of wound edges, evaluation of the skin adjacent to the wound, presence of absence of new tissue at wound rim, and presence of pain. Record review of Resident #4's medical record showed no weekly documentation by the facility staff of a comprehensive skin/wound assessment upon admission to the facility and no detailed weekly skin/wound assessments. Record review of Resident #38's Weekly Skin Assessments showed: -There were skin assessments completed on 2/7/23, 2/14/23 and 2/21/23. -None of the skin assessments showed measurements or descriptions of each of the resident's pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) or deep tissue injuries. -The body diagrams did not show where the pressure ulcers and deep tissue injuries were located. -There was no documentation showing the facility was monitoring the pressure ulcers or deep tissue injuries. Record review of Resident #8's nursing note dated 2/28/23 showed: -The resident was seen by Nurse Practitioner (NP) regarding new pressure wound on his/her left outer foot. -A physician order was received to stop previous order and start new treatment of Santyl (an ointment used for the debridement of pressure ulcers) and Vaseline gauze daily. -Did not include a detailed description and comprehensive assessment of the pressure wound. Record review of the Resident #8's weekly skin assessment dated [DATE], showed: -He/she had documented the resident having a pressure ulcer on his/her left lateral foot. -Had no documentation of a detail comprehensive assessment of his/her new pressure wound. During an interview on 3/3/23 at 11:59 A.M., the DON said: -In the past (before the new agreement with Wound Care Organization A), the physician for that company, placed notes in the medical record. -Facility staff took those notes and transcribed them into treatment orders. -The physician or the former company preferred to have one person measure the pressure ulcers. -The physician for the former company, did not document measurements when his/her company first came in. -He/she (the DON) contacted the facility's corporate office to influence the former company to document measurements. -As of 1/25/23, there was a new wound assessment company, which assessed the resident's pressure ulcers. -He/she (the DON) did not see the contract before the former company brought in the former company. -The former company started servicing the facility in July 2022. -He/she (the DON) started in June 2022 -The former company serviced the facility until January 2023. -There were a few weeks between when the former company stopped servicing the facility, and when Wound Care Organization A started to service the facility. -During that time, he/she (the DON) set up an appointment for four residents to go to the wound clinic of a local medical center. -Of four residents scheduled, only one resident went to the appointment. During an interview on 3/15/23 at 9:36 A.M., the Nurse Practitioner (NP) A with the former wound care company said: -There was a verbal agreement which pertained to his/her organization would get a plan together for the facility's residents with wounds. -Their organization started serving the facility in July 2022. -The process of documenting wound measurements involved a person from the facility who would measure pressure ulcers on the residents and do rounds with his/her organization and the staff member form the facility would do the actual measuring. -Six weeks into their service they (wound care company staff) were told they (wound care company staff) would have to measure the pressure ulcers, but that was not told to them at the beginning. -He/she (NP A) only measured when the appropriate supplies needed to measure, were available. -He/she said they were only able to measure about one out of every four weeks within a month. -They depended on the facility have its own supplies. -He/she was disappointed when supplies were not available at times. -He/she spoke about his/her concerns with the DON. -He/she voiced concerns three and six weeks after he/she started servicing the facility. -The DON said they were going to hire a wound care nurse and that someone would be dedicated to wound care. -A dedicated wound care nurse was hired around the end of September 2022. -He/she (NP A) was only able to make rounds with that dedicated wound care nurse the first week of October. -In subsequent weeks, when his/her organization went to the facility on Tuesdays, he/she was not able to make rounds with that dedicated wound care nurse because that person was asked to work on the floor. During a phone interview on 3/15/22 at 9:52 A.M., the DON said that wound care nurse was originally hired as a wound care nurse, but because the facility census was low, the nursing department was directed to place that nurse as an LPN floor nurse. During a phone interview on 3/15/22 at 10:13 A.M., the Human Resources Officer said: -A nurse was hired as a dedicated wound care nurse on 9/22/22. -On 9/26/22 that nurse's position was changed from wound nurse to floor nurse, because the census was low at that time. During an interview on 3/15/22 at 10:50 A.M., the Physician with the former wound care company said: -His/her organization did not have a written agreement with the facility. -The facility did not have a consistent person for his/her organization to round with, when they were there. -He/she preferred to have one person dedicated to wound care at the facility, to round with, so the measurements could be consistent. -About six weeks into their service to the facility, the facility started to expect that their organization would measure the dimensions of the wounds. -Sometimes the facility did not have adequate supplies for measuring the wounds. -If supplies were not available, he/she did not measure wounds. -Sometimes, the facility staff had difficulty with dressing changes because the daily dressing changes were not being done; sometimes his/her organization would go to the facility on a Tuesday and a dated dressing from the previous Friday would still be applied on a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Record review of Resident #19's undated face sheet showed he/she admitted to the facility on [DATE] with the following diagnoses: -Acute Respiratory Failure with Hypoxia (impairment of gas exchange between the lungs and the blood causing a lack of oxygen in the blood). -Acute Kidney Failure (a condition in which the kidneys suddenly cannot filter out waste from the blood). -Diabetes Mellitus (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). Observation on 3/2/23 at 3:34 P.M., during a wound dressing change showed Licensed Practical Nurse (LPN) A: -Sanitized his/her hands, gathered the wound care supplies, placed a clean barrier on the resident's bed, and put his/her initials and date on the wound bandages. -He/she then re-sanitized his/her hands and put on gloves. -He/she cleansed the resident's left lower calf surgical wound, wiped the wound clean, placed the Aquacel Silver (Ag) dressing (a moisture retention dressing that consists of non-woven fibers integrated with ionic silver which forms a gel on contact with the wound) and placed a bandage overtop without changing his/her gloves and washing/sanitizing his/her hands between cleaning the wound and placing a new dressing on. -He/she then moved onto the resident's right lower calf surgical wound without taking off his/her gloves or washing/sanitizing his/her hands. -He/she cleansed the resident's right lower calf surgical wound, wiped the wound clean, placed the Aquacel Ag dressing and placed a bandage overtop without changing his/her gloves and washing/sanitizing his/her hands between cleaning the wound and placing a new dressing on. -He/she then took his/her gloves off, placed them in the trash with the rest of the used supplies and washed his/her hands before exiting the resident's room. During an interview on 3/2/23 at 3:41 P.M., LPN A said: -He/she knew that he/she needed to take off his/her gloves, wash/sanitize his/her hands after cleansing the resident's wounds, and put clean gloves on before placing a clean dressing on the resident's wound. -He/she knew that he/she needed to take off his/her gloves, wash/sanitize his/her hands, and put on new gloves in between each wound. -He/She normally would do that, but did not during this wound dressing change. 5. Record review of Resident #41's face sheet showed he/she was admitted with: -Chronic Respiratory Failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body). -Fracture of left radius (broken bone in the arm). Record review of the resident's Minimum Data Set (MDS-a federally mandated tool used for assessments) 5 Day PPS Assessment, completed 2/10/23, showed: -The resident had a Brief Interview for Mental Status (BIMS) of 11 out of 15 indicating the resident was moderately cognitively impaired. -The resident was totally dependent on staff for toileting, personal hygiene, and bathing. -The resident was always incontinent of bladder. -The resident was always incontinent of stool. Observation on 3/2/23 at 10:12 A.M., showed: -CNA A entered the resident's room without washing or sanitizing his/her hands or applying gloves and made the resident's roommate's bed. -CNA A did not perform hand hygiene, put on gloves, and began preparing supplies for perineal care for this resident. -CNA C entered the room and put on gloves without performing hand hygiene. -CNA C removed feces from the resident's bottom, then used his/her gloved hands to remove more supplies from packaging. -CNA C finished cleaning the feces from the resident, with the same gloved hands, he/she touched the resident's hip to roll the resident over in bed, and began cleaning pubic area with the same gloves. -CNA A and CNA C removed used gloves and put on new gloves prior to placing new brief under the resident. Neither performed hand hygiene. -CNA A and CNA C then used the same gloves to dress the resident and assist him/her to his/her wheelchair. -CNA C removed his/her gloves and wheeled the resident to therapy without performing hand hygiene. -CNA A removed his/her gloves, gathered trash and dirty linens, and left the room without performing hand hygiene. -CNA A opened the dirty utility room door with his/her unwashed hands to dispose of the trash and dirty linens. During an interview on 3/2/23 at 10:12 A.M., CNA A said he/she should have performed hand hygiene between glove removals. During an interview on 3/2/23 at 12:10 P.M., CNA C said: -Staff were to perform hand hygiene upon entering and leaving a resident room, and after each glove removal. -Staff should never go from a dirty activity, like pericare, to a clean activity, like dressing a resident, without performing hand hygiene. -He/she was aware CNA A and he/she had not performed hand hygiene or changed gloves appropriately while providing the resident's care. 6. Record review of Resident #4's face sheet showed he/she was admitted with: -Encephalopathy (a broad term for any brain disease that alters brain function or structure). -Communication Deficit. Observation on 3/2/23 at 2:30 P.M., showed: -LPN B was in the resident's room starting wound care with gloved hands. All dressings had already been cut away, but not removed and were laying under the resident and LPN B had already started wound care on the first wound at the time of the observation. -LPN B pressed calcium alginate (highly absorptive, non-occlusive dressings made of soft, non-woven calcium alginate fibers derived from brown seaweed or kelp) into the resident's left leg wound. -LPN B placed an abdominal pad (ABD-used to absorb discharges from abdominal and other heavily draining wounds) around the resident's wound, then wrapped in Kerlix (a roll of white gauze). -With the same gloved hands, LPN B went to the treatment cart located in the resident's doorway, opened a drawer, reached inside and removed tape, closed the drawer, returned to the resident, and secured the Kerlix with the tape. -With the same gloved hands, LPN B reached in his/her inner shirt pocket and removed a marker, used the marker to write the date and his/her initials on the dressing, and returned the marker to his/her pocket. -With the same gloved hands, LPN B opened a new ABD and laid the new ABD on its packaging. -With the same gloved hands, LPN B removed a pillow from under the resident's right knee and placed the newly opened ABD under the resident's right calf. -With the same gloved hands, LPN B reached into a gauze packet sitting on the bedside table and removed more gauze, grabbed a bottle of wound cleanser from the bedside table and soaked the gauze with the cleanser. -With the same gloved hands, LPN B began cleaning the resident's posterior right lower leg wound with the soaked gauze. -With the same gloved hands, LPN B reached into the gauze packet and removed more gauze and continued removing debris from the wound. -With the same gloved hands, LPN B went to the treatment cart at the resident's doorway, opened the drawer, removed a box, opened the box and removed calcium alginate, closed the box, returned the box to the cart, and closed the drawer. -With the same gloved hands, LPN B opened one package of calcium alginate and pressed it into the wound. -LPN B returned to treatment cart and with the same gloved hands, opened the drawer, and removed more Kerlix, closed the drawer, returned to the resident, wrapped the ABD around the wound and then wrapped Kerlix around the resident's right calf, approximately half way down the leg, to keep the ABD in place. -With the same gloved hands, LPN B opened another package of calcium alginate and placed on top of the packaging, then placed it into the wound on the back side of the resident's right leg just above the ankle. -LPN B repositioned the ABD previously placed to cover both wounds and wrapped with the remaining Kerlix. -With the same gloved hands, LPN B returned to the treatment cart, opened multiple drawers, removed an additional ABD, and closed the drawers. -With the same gloved hands, LPN B opened the package and placed the new ABD on top of its packaging, lifted the resident's right leg, and placed the ABD under the resident's ankle and bottom of leg. -LPN B removed the trash bag with old dressings and used dressing supplies from the trash can and sat the bag on the floor. -With the same gloved hands, LPN B reached into the gauze package again and removed more gauze, soaked with wound cleanser, and removed debris from the resident's right heel wound. -With the same gloved hands, LPN B used new gauze to clean the wound on the outer side of the resident's foot. -LPN B returned to the treatment cart, and with the same gloved hands,opened a drawer and removed a box, again removed calcium alginate from the box, closed the box, returned it to the cart, and closed the drawer. -With the same gloved hands, LPN B opened the calcium alginate and held it up to the wound on the outside of the right heel, removed a pair of scissors from the bedside table to cut the calcium alginate to size, put the scissors into his/her pocket without sanitizing them, and pressed the calcium alginate into the wound. -With the same gloved hands, LPN B repositioned the ABD to cover all the wounds and wrapped with remaining Kerlix. -LPN B tied the trash bag with used wound care supplies and placed it on top of the treatment cart without a barrier, and with the same gloved hands, opened a drawer of the cart, removed tape, cut the tape with scissors he/she removed from his/her pocket, replaced the scissors in his/her pocket, and closed the drawer. -With the same gloved hands, LPN B used the tape to secure the Kerlix wrapped around the resident's right leg/foot. -With the same gloved hands, LPN B reached into his/her inner shirt pocket and removed a marker which he/she used to date and initial the dressing, and returned the marker to his/her inner pocket. -LPN B picked up additional dirty wound supplies on the resident's bed and placed them in the trash can. -With the same gloved hands, LPN B picked up the resident's pillow and replaced under his/her right knee, covered the resident with a blanket, pushed back the privacy curtain, returned to the treatment cart and removed his/her gloves and without washing or sanitizing his/her hands, exited the resident's room. -Without washing or sanitizing his/her hands, LPN B pushed the treatment cart (with the closed trash bag still on top) to the nurse's desk and began shuffling papers on top of the cart. -LPN B removed trash from treatment cart and took into the dirty utility room, returned to the cart and sanitized his/her hands. He/She did not sanitize the top of the treatment cart after he/she removed the trash bag. During an interview on 3/2/23 at 2:30 P.M., LPN B said he/she normally changed gloves between wounds. 7. Record review of Resident #33's face sheet showed he/she was admitted with Type 2 Diabetes Mellitus. Observation on 2/28/23 at 12:05 P.M., showed: -LPN A placed all gathered supplies directly on the resident's bedside table without a barrier and without sanitizing the top of the bedside table. -LPN A placed a blood sample on the test strip of the glucometer and sat on the resident's bedside table without a barrier. -LPN A then took the glucometer (with blood strip removed) and placed on top of medication cart without a barrier, then placed back in the medication cart without cleaning the device. 8. During an interview on 3/2/23 at 12:52 P.M., CNA A said: -Staff were to perform hand hygiene before and after providing any cares to a resident and between each glove removal. -Staff were to change gloves and perform hand hygiene when going from a dirty task to a clean task. During an interview on 3/3/23 at 10:22 A.M., LPN A said: -Staff were to perform hand hygiene before and after leaving a resident's room. -Staff were to perform hand hygiene between each glove change. -Staff were to change gloves and perform hand hygiene after each wound, regardless if moving to another wound on the same resident. -Staff were to remove gloves and sanitize before touching clean supplies or reaching into a treatment cart. -Glucometers could be sat on a resident's bedside table without a barrier. During an interview on 3/3/23 at 2:40 P.M., the DON said: -Staff were to perform hand hygiene when entering and leaving a resident's room, and also between all glove changes. -Staff were to change gloves, if feces was cleaned before pubic area, before starting to clean the resident's pubic area. -Staff were not allowed to place glucometers directly on a resident's table, the device must always be placed on a barrier. -Staff were to change gloves when moving from one wound to another, even if the same resident. -Staff were to change gloves after cleaning a wound, before applying the new/clean dressing. -Staff should not touch any reusable supplies with dirty gloves on. -Staff should not reach into a supply cart with gloves used to provide wound care. Based on observation, interview, and record review, the facility failed to ensure an on-going monitoring facility-wide Infection Prevention Control Program (IPCP) was established and to ensure surveillance logs were maintained for 11 months out of 12 months surveillance to include but not limited to: monitor, track, and identify trends of infections in the facility. The facility failed to ensure proper hand hygiene during wound care for two sampled residents (Resident #19 and #4), during perineal care for two residents (Resident #8 and Resident #41); during transfers for one sampled resident (Resident #54); failed to ensure reusable supplies for multiple residents were sanitized before or after use for one resident (Resident #4); and failed to ensure a barrier was used during blood sugar testing for one sampled resident (Resident #33) out of 23 sampled residents. The facility census was 74 residents. Record review of the facility's policy titled Hand Hygiene, dated June 2020, showed: -The facility staff and volunteers must perform hand hygiene with soap and water in the following circumstances but not limited too: --After unprotected (un-gloved and damaged gloves) contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, and intact skin soiled with blood and other body fluids, wound drainage and soiled dressings. -The facility staff and volunteers must perform hand hygiene with alcohol based hand hygiene products when: -Before moving from a procedure area regardless of glove use. -Staff were to perform hand hygiene upon entering, and again when leaving, a resident's room. -Staff were to perform hand hygiene before moving from one resident to another in a multiple-bed room, regardless of glove use. Record review of the facility's policy and procedure titled Perineal Care, dated 6/2020, showed: -Perineal care was provided as port of resident hygienic program, a minimum of once daily and per resident request. -Staff were to wash hands as enter the resident room. -Gather supplies needed and then place gloves on hands. -Staff were to clean the resident's pubic area first using a clean wipe each time, then turn the resident to the side. -Staff were to wash, rinse and dry buttocks and peri-anal area without contamination perineal area. -Remove wet linen. -Place dry linens or brief or both underneath resident and reposition the resident. -After performing care, staff were to remove their gloves, and wash hands or use alcohol -based hand sanitizer. -Staff were not to touch anything with soiled gloves after performing this task (i.e. curtain, side rails, call bells). -Put on new gloves and clean and return all equipment to proper place. -Place soiled linens in proper container and remove their gloves. -Wash their hands after completed all task. -Did not indicate to perform hand hygiene and change gloves from a dirty to clean process. The following facility policies were requested and not received at the time of exit: -Infection Control Prevention Program/Infection Control Surveillance. -Glucometer (a machine used to test blood sugar levels) care. -Wound care. 1. Requested the facility documentation for their Infection Control Surveillance from 1/1/22 to 1/31/23 showed the Infection Control Preventionist (ICP) and Director of Nursing (DON) were not able provide 12 months of infection control surveillance monitoring by the end of survey. Record review of the facility Infection Control Surveillance for 12 months of surveillance showed: -Had one out of 12 months of infection control surveillance log sheets from 1/2022 to 2/2023. -2/2023 had the facility antibiotic tracking sheet and list of residents positive with COVID-19 (a new disease caused by a novel (new) coronavirus) for that month. --Had mapping of the type of infection and highlight by color the rooms and units on a facility map. During an interview on 3/2/23 at 11:25 A.M., the ICP said: -He/she had requested the facility infection control surveillance binder or documentation for the past year. -He/she had just started at the facility and recently started tracking all infections on 2/6/23. -He/she would have to find the facility infection control surveillance binder and any monthly reports for infections for the past year. During an interview on 3/3/23 at 11:30 A.M., the ICP said: -He/she began employment around end of 1/2023. -He/she starting tracking and trending infections 2/2023. -At that time the facility administration were unable to find the infection control surveillance binder for the past year of surveillance. -He/she had been tracking and trending for the spread of COVID and testing residents and staff for COVID by using the testing record sheet and map them out by rooms and units. -The facility had no formal documentation of tracking and trending for COVID-19 in place at that time. -He/she would be responsible for the facility monitoring, tracking and trending of all infection control surveillance, -He/she would have expected the facility to have an infection control surveillance system in place to include documentation, tracking and trending of all infections in the building. -He/she would expect to have completed a monthly infection control report for Quality Assurance to review. During an interview on 3/3/23 at 3:49 P.M., the DON said: -The facility had switched management in 12/22 and at that time the facility had an Infection Control Surveillance binder for the previous months. -The documentation in the missing Infection Control Surveillance binder, included all infections for the last 12 months. -The ICP would be responsible for ongoing documentation of all Infection Control monitoring, which would include tracking, monitoring of all resident and staff with infections, reviewing lab and pharmacy reports and document tracking findings on a line list form and trending by mapping out infections in the building. -He/she would expect the facility to have an Infection Control Surveillance binder with monthly documentation of tracking and trending of all infections and illnesses in the building for each month and to include the monthly Infection Control summary report. -He/she would expect to have an end of a month report for all infection surveillance to be presented during the Quality Assurance team meetings. 2. Record review of Resident #8's Face Sheet showed the resident was admitted on [DATE] with diagnosis of a stroke. Record review of the resident's significant change Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning), dated 12/9/22, showed the resident: -Was not able to answer any of the Brief Interview for Mental Status (BIMS) questions and showed he/she had a memory problem. -Needed extensive to total assistance with bathing, dressing, mobility, eating, and toileting. Observation on 3/1/23 at 9:15 A.M., of the resident's personal care and transfer by Certified Nursing Assistant (CNA) G and CNA A showed: -CNA A enter the resident's room and without washing or sanitizing his/her hands, put on gloves. -CNA A began to unfasten the resident's wet and soiled brief and pushed down the brief inbetween the resident's legs. -CNA A without discarding his/her gloves and washing or sanitizing his/her hands, touched the resident's blankets and bed control. -CNA G pulled the incontinence wipes and handed them to CNA A who cleaned the resident's front peri-area from front to back and discarded the wipes in the trash. -CNA G rolled the resident to the opposite side and CNA A cleaned the resident's soiled bottom then disposed of the wipes in the trash. -CNA A removed soiled gloves that had brown substance on them each time he/she wiped the resident's bottom and without washing or sanitizing his/her hands each time would place new gloves on his/her hands. -After CNA A completed the final wipe of the resident's soiled bottom, without discarding his/her gloves and washing or sanitizing his/her hands, he/she placed a new clean brief under the resident. -CNA A discarded his/her gloves and without washing or sanitizing his/her hands, placed new gloves on his/her hands, then placed mechanical lift sling under the resident. -CNA G discarded his/her gloves and without washing or sanitizing his/her hands opened the door and exited the resident's room to obtain the mechanical lift. -CNA G returned to the resident's room and washed his/her hands with soap and water. -CNA G and CNA A with gloved hands proceeded to transfer the resident to his/her wheelchair. -CNA A and CNA G removed and discarded their gloves, and washed their hands prior to exiting the resident's room. During an interview on 3/1/23 at 10:57 A.M., CNA A said: -He/she should have washed his/her hands upon entering and exiting the resident's room and between a dirty to clean process. -He/she should have washed his/her hands between glove changes. During interview on 03/2/23 at 2:07 P.M., CNA G said: -He/she could have been more prepared for care supplies and should have washed his/her hands more often. -He/she should have washed or sanitize his/her hands as he/she entered the resident's room and before exiting the resident's room, between a dirty and clean process and between gloves changes. -He/she should not be touching a resident's personal items with soiled gloved hands. During an interview on 3/3/23 at 11:30 A.M., the ICP said: -He/she would expect facility care staff to wash their hands or to use hand sanitizer between each glove change, upon entering the resident's room and before exiting the resident's room. -He/she would expect facility care staff to wash their hands from a dirty process to a clean process, and should not touch the resident's personal items with unclean gloves. 4. Record review of Resident #54's Face Sheet showed he/she was admitted to the facility on [DATE], with diagnoses including stroke, diabetes, high blood pressure, high cholesterol, unsteadiness on his/her feet, abnormal mobility, and difficulty in walking. Record review of the resident's quarterly MDS, dated [DATE], showed the resident: -Was alert and oriented with no cognitive deficiencies. -Needed maximum assistance with transfers. Observation on 02/27/23 at 10:18 A.M., showed: -CNA D came into the resident's room with the full body mechanical lift and did not wash, sanitize or put gloves on his/her hands. -The resident was laying in his/her bed, fully dressed. CNA D asked the resident if he/she was ready to get up and the resident said he/she was. CNA D positioned the lift over the resident's bed and began to attach the sling to the lift. -LPN C entered the resident's room and put on gloves without washing or sanitizing his/her hands. -LPN C took the controller and used it to lift the resident while CNA D assisted to move the resident to his/her wheelchair and position him/her while LPN C lowered the resident into his/her wheelchair. -CNA D pulled the privacy curtain around the resident, put on gloves without washing or sanitizing his/her hands, removed the resident's shirt, took a cleansing wipe and wiped around his/her neck. -CNA D then, with the same gloved hands, gave the resident deodorant and assisted him/her to put on a clean sweatshirt. -CNA D gave the resident a bag of personal items that he/she requested and then removed and discarded his/her gloves. -CNA D did not wash or sanitize his/her hands before leaving the resident's room. During an interview on 3/2/23 at 2:36 P.M., CNA F said: -Upon entering the resident's room, he/she should wash hands and put on gloves before doing anything in the resident's room or touching the resident. -After transferring the resident, he/she should wash or sanitize hands, then re-glove and begin any cares needed. -He/She was supposed to wash or sanitize his/her hands after completing any dirty tasks and then re-glove. -Once he/she was finished with cares, he/she should wash hands prior to leaving the resident's room. During an interview on 3/3/23 at 9:06 A.M., LPN D said: -Nursing staff should wash their hands when they walk into the resident's room, before gloving. -After they transfer the resident they should wash or sanitize their hands. -If they start assisting with any resident care or grooming, they should wash or sanitize their hands before providing care and then once they have completed care, they should wash or sanitize their hands before leaving the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that an individual with a current Administrators license issued by the state of Missouri (MO) was employed by the facility between [DATE] and [DATE]. This deficient practice had the potential to affect all residents residing in the facility and employees working in the facility. The facility census was 65 residents. Record review of the Temporary Emergency License (TEL) Application Checklist dated [DATE] showed: -The Board may grant a TEL for a period not to exceed 120 days to a person that has met the TEL criteria established by the Board to serve as an acting Administrator, provided such person is replacing a licensed Administrator who has died, has been removed or has vacated the administrator position. No extensions are granted. -Please be advised that section 344.020, Revised Statutes of Missouri (RSMo), prohibits an unlicensed person from acting or serving in the capacity of a licensed Administrator without first securing a license from this office. -To do so is a violation of the Board's statute and can be grounds to deny licensure. -Applicants cannot begin working as a temporary licensed Administrator of the facility until the TEL has been approved and a temporary Administrator license has been issued to the applicant. 1. Record review of the facility's TEL Application showed: -The previous Administrator (Administrator A) vacated his/her position on [DATE]. -The information field regarding why the previous Administrator left his/her position was blank. -The current Administrator (Administrator B) was requesting the TEL. -The date the TEL was requested was [DATE]. Record review of the undated Change of Administrator/Manager in Long-Term Care Facility form showed: -The facility name and address. -Effective Date Change [DATE]. -Administrator A's last day of employment was [DATE]. -No other information was completed on the form. Record review of the Assistant Administrator's previous TEL showed: -The TEL was effective from [DATE] through [DATE]. -The TEL was issued to the Assistant Administrator. During an interview on [DATE] at 2:15 P.M. the Assistant Administrator said: -He/she had a TEL which had expired in [DATE]. -Administrator A left his/her position on [DATE]. -Administrator A had given notice about two weeks prior to leaving his/her position. -Administrator A was supposed to complete the Change of Administrator form. -Administrator B applied for another TEL and sent it in yesterday or today. During an interview on [DATE] at 2:35 P.M. the Business Office Manager (BOM) said: -He/she had only been at the facility for two weeks. -He/she was aware that Administrator A was leaving his/her position. -He/she did not have the letter of resignation. -The Human Resources (HR) director may have it. During an interview on [DATE] at 2:43 P.M. the HR director said: -He/she had been out of the office. -He/she found out Administrator A was leaving the day he/she left the position. -He/she did not have a copy of the resignation letter. During an interview on [DATE] at 2:48 P.M. Administrator B said: -He/she applied for another TEL today and was waiting to hear back. -Administrator A did put in a letter of resignation prior to leaving his/her position. -He/she was unaware of the exact date of the letter of resignation but was sure it was a least a couple weeks prior to his/her last day. During an phone interview on [DATE] at 1:52 P.M. the Assistant Board Coordinator for the Board of Nursing Home Administrators said: -The TEL for Administrator B was not approved as there was information missing. -The Assistant Administrator only had an expired TEL and was not qualified to be the Administrator. -There was no licensed Administrator from [DATE] to [DATE]. MO00212058

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect one sampled resident (Resident #1) from abuse when Resident #2 struck Resident #1 on his/her left shoulder out of three sampled residents. The facility census was 65 residents. On 12/6/22 the Administrator was notified of the past noncompliance which occurred on 11/18/22. On 11/18/22 the facility administration was notified of the incident and the investigation was started. Staff had been educated on the resident behaviors, interventions were in place at the time of the resident to resident incident. The facility staff immediately separated Resident #1 and Resident #2. Resident #2 was discovered to have a UTI (urinary tract infection) and was treated. The deficiency was corrected on 11/23/22. Record review of the facility policy titled Abuse, Neglect and Exploitation with a copyright 2022 showed: -It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedure that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. -Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Physical abuse includes, but is not limited to hitting, slapping, punching, biting and kicking. -The facility will develop and implement written policies and procedures that: -Prohibit and prevent abuse, -Establish policies and procedures to investigate any such allegations, and -Include training for new and existing staff on activities that constitute abuse, reporting procedures and resident abuse prevention. -New employees will be educated on abuse, -Existing staff will receive annual education through planned in-services and as needed. -The facility will make efforts to ensure all resident are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. 1. Record review of the Resident #1's admission Record showed he/she was admitted on [DATE], and readmitted on [DATE] with diagnosis that include: -Weakness. -Difficulty walking. -End stage renal disease. Record review of the Resident #1's Annual Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 9/20/22 showed the resident to be cognitive intact and able to communicate. Record review of Resident #2's admission Record showed he/she was admitted on [DATE], readmitted on [DATE] with diagnosis that include: -Muscle weakness. -Unsteadiness on feet. -Cognitive communication deficit. Record review of Resident #2's Quarterly MDS dated [DATE] showed the resident to be cognitive intact and able to communicate. Record review of the facility Incident Report dated 11/18/22 showed: -Resident #2 made contact with Resident #1's back with an open hand in the dining room. -Resident #2 and Resident #1 were separated immediately. -Both residents were interviewed and there were no injuries observed. -Resident #2 was found to be positive for a UTI. Record review of Resident #1's written statement dated 11/18/22 showed he/she reported being hit on his/her back and reported tenderness to the area. Record review of Resident #2's written statement dated 11/18/22 showed: -He/she thought the other resident was going to hit him/her, so he/she the other resident first. -He/she said the other resident was in a wheelchair facing away from him/her. -He/she admitted hitting the other resident in the back. Record review of Resident #2's nurses notes dated 11/18/22 showed he/she was afraid Resident #1 was going to hit him/her, so he/she hit the resident first. During an interview on 12/6/22 at 12:53 P.M., Resident #1 said: -He/she was hit by Resident #2 on his/her left shoulder. -He/she did not see Resident #2 strike him/her, but it felt like Resident #2 used his/her fist. -He/she complained of soreness to his/her left shoulder. During an interview on 12/6/22 at 1:05 P.M., the Unit Manager said: -He/she expected staff to de-escalate and immediately separate residents if an altercation of any kind occurred. -The staff should report the incident immediately and begin first aid, if indicated. -The staff should make observations of altered mental status, pain and behaviors after an incident occurred. During an interview on 12/6/22 at 1:20 P.M., Resident #2 said: -He/she admitted there was an incident between him/her and Resident #1. -He/she denied striking the Resident #1, but demonstrated a strike motion. -He/she thought the other resident was going to hit him/her first. During an interview on 12/6/22 at 1:40 P.M., the with the Director of Nursing (DON) said: -The definition of abuse was infliction of willful harm to a resident. -If the resident felt uncomfortable, it was worth investigating. During an interview on 12/6/22 at 1:45 P.M., the Administrator said: -There were five forms of abuse. -There was no way to prevent abuse 100%, especially when there were no indicators before the incident. MO00210093

Based on interview and record review, the facility management company failed to ensure payments were issued or issued in a timely manner, to the facility's electric, gas, and water companies who provide services for the needs of residents. The facility census was 66 residents. 1. Record review of Vendor A's invoice and facility payment information, provided on 11/14/22 at 10:30 A.M., showed: -Invoice, dated 10/5/22, current amount due $6,386.82. -Invoice, dated 10/5/22, previous balance due $34,625.74 -Invoice, dated 10/5/22, total amount due by 10/26/22, $41,012.57 and after 10/26/22, amount due $41,391.36. -Facility did not provide any other invoices for Vendor A. -No payments issued to vendor for the invoice dated 10/5/22. Record review of the facility e-mailed Vendor A's payment confirmation on 11/14/22 at 2:28 P.M., showed: -Confirmation Number 1624055, payment amount of $12,774.36, paid 11/14/22. -Confirmation Number 1624056, payment amount of $15,094.76, paid 11/14/22. -Confirmation Number 1624058, payment amount of $13,143.45, paid 11/14/22. During an interview on 11/15/22 at 9:24 A.M., Vendor A said: -The total amount due 11/23/22 was $45,233.39 and was eligible for shut off. -Last payment was made on 3/8/22 in the amount of $2,290.91. 2. Record review of Vendor B's invoice and facility payment information, provided 11/14/22 at 10:30 A.M., showed: -Invoice, dated 11/1/22, current amount due $5,145.03. -Invoice, dated 11/1/22, previous balance due $20,827.50. -Invoice, dated 11/1/22, total amount due by 11/16/22, $25972.53. -Facility did not provide any other invoices for Vendor B. -No payments issued to vendor for the invoice dated 11/1/22. Record review of the facility e-mailed Vendor B's payment confirmation on 11/14/22 at 2:28 P.M., showed: -Confirmation Number 76984357993510, payment amount of $20,827.50, paid 11/14/22. -Remaining balance due 11/16/22 of $5,145.03. During an interview on 11/15/22 at 8:16 A.M., Vendor B said: -The vendor had received a payment on 11/14/22 of $20,827.50. -Last payment was made on 8/11/22 in the amount of $7,596.15. -The facility still owed Vendor B $5,145.03, due on 11/16/22. 3. Record review of Vendor C's invoice and facility payment information, provided 11/14/22 at 10:30 A.M., showed: -Invoice, dated 10/19/22, current amount due $1,071.52. -Invoice, dated 10/19/22, previous balance due $3,582.94. -Invoice, dated 10/19/22, payment made of $1,285.16. -Facility did not provide any other invoices for Vendor C. Record review of the facility e-mailed Vendor C's payment confirmation on 11/14/22 at 2:28 P.M., showed Confirmation Number 121739273699, payment amount of $2,297.78, paid 11/14/22. During an interview on 11/15/22 at 8:19 A.M., Vendor C said: -The vendor had received a payment on 11/14/22 for the amount of $2,297.78. -Last payment was made on 9/29/22 in the amount of $1,285.16. -The facility still owed Vender C $1,122.06, due 11/17/22. 4. During an interview on 11/14/22 at 11:35 A.M., the Administrator said: -Vendor A, B or C mailed their invoices directly to the corporate office to be paid. -The facility had not received any shut off notices for Vendor A, B or C. -The residents had not been affective in anyway. -The facility still had water, lights, and gas. -He/she was unaware the invoices for Vendor A, B or C were not paid. -He/she did not control what was paid at the corporate office. MO00209856

**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 #8) and one supplemental resident (Resident #24) who required mechanical lifts and assistance of two people were gotten out of bed when requested out of 19 sampled residents. The facility census was 70 residents. 1. Record review of Resident #8's care plan dated 4/18/17 showed the resident required assistance with activities of daily living (ADL's-such as grooming, hygiene, etc.) and transferred from one surface to another with the use of a full body mechanical lift. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/21/21 showed the following staff assessment of the resident: -Was cognitively intact. -Displayed no altered mood symptoms or behaviors. -Was totally dependent upon two or more people for transferring from one surface to another (such as from the bed to a wheelchair). -Was totally dependent upon one person for dressing. -Used a wheelchair for mobility. -Was independent with locomotion on and off the unit. -Some of his/her diagnoses included cerebral palsy (a disability resulting from damage to the brain before, during, or shortly after birth and outwardly manifested by muscular incoordination and speech disturbances) and depression (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). Observation and interview on 4/26/21 at 2:02 P.M. showed: -The resident was lying in bed. -The resident said: --He/she likes to get up out of bed and go outside in the spring and when there's good weather. --He/she did not get up this past Saturday and Sunday because there was no one to put him/her to bed. --An aide told him/her that because he/she required extensive help that they wouldn't be able to get him/her up. --He/she knows he/she can't get up on the weekends. --The staff may not always say it but he/she knows they won't get him/her up on the weekends. --It's been happening since about January 2021. --He/she required a mechanical, stand up lift to get in and out of bed and it takes two people to get him/her up and there weren't two people to help him/her. -This past Saturday there was one aide on the day shift and one aide on the evening shift on his/her hall. -This past Sunday there were two aides in the afternoon and one aide in the evening on his/her hall. 2. Record review of Resident #24's care plan dated 5/25/17 showed: -The resident required assistance with ADL's. -Instructions for staff to assist the resident with transfer in and out of chair with full body mechanical lift and two staff members. -The resident used an electric wheelchair for locomotion. Record review of the resident's annual MDS dated [DATE] showed the following staff assessment of the resident: -Was cognitively intact. -Displayed no altered mood symptoms or behaviors. -Was totally dependent upon two or more people for transferring from one surface to another. -Required extensive assistance of two or more people for dressing. -Used a wheelchair for mobility. -Was independent with locomotion on and off the unit. -Some of his/her diagnoses included depression and rheumatoid arthritis (an inflammatory disease that may lead to serious joint damage and disability). Observation and interview on 4/27/21 at 12:12 P.M. showed: -The resident was sitting on the patio. -He/she said: --He/she required a lift to get up out of bed. --Staff don't always get him/her up out of bed. --Staff usually don't get him/her up out of bed on the weekends. --He/she has to stay in bed on Saturdays and Sundays. --The staff either come in and tell him/her that they don't have enough staff to get him/her up out of bed or they just don't ever come to get him/her up. --It happened almost every weekend for the past few months 3. Record review of the facility's staffing schedule for Saturday, 4/24/21 showed: -One nurse, one Certified Medication Technician (CMT) and two Certified Nursing Assistants (CNA)'s on the day shift for the two halls on the side of the building where Residents #8 and #24 resided (for 33 residents which included the transition hall for new admissions and residents returning from the hospital, requiring staff to wear full personal protective equipment (PPE-such as respirators/masks, gloves and gown going into each room). -One nurse, one CMT and one CNA on the evening shift for the two halls on the side of the building where Residents #8 and #24 resided (for 33 residents). Record review of the facility's staffing schedule for Sunday, 4/25/21 showed: -One nurse, one CMT and two CNA's on the day shift for the two halls on the side where Residents #8 and #24 resided (33 residents). -One nurse, one CMT and two CNA's on the evening shift for the two halls on the side of the building where Residents #8 and #24 resided (33 residents). During an interview on 4/26/21 at 2:39 P.M., the Social Services Director said: -Some of the residents have complained about weekend staffing. -They have hired some new staff but they didn't come back. -They were working on hiring more staff. During an interview on 4/27/21 at 12:50 P.M., CNA E said: -He/she worked on weekends, usually 6:30 A.M. to 2:30 P.M. -They were often short staffed on weekends. -He/she was the only CNA for the day shift recently. -They can't get the residents up who require a lift to get up because they don't have enough staff. -The residents who require a lift want to get up. During an interview on 4/27/21 at 1:55 P.M. Registered Nurse (RN) B said: -They focus on keeping residents clean and dry. -It takes two people to get the residents up who require a mechanical lift so there were weekends when those residents don't get up because they didn't have two people available. During an interview on 4/27/21 at 1:55 P.M. Licensed Practical Nurse (LPN) A said: -There were times when they couldn't get the residents who required a lift up out of bed because they didn't have enough staff available to help. During an interview on 4/27/21 at 2:28 P.M., the Director of Nursing (DON) said: -He/she expected staff to offer residents the opportunity to get up out of bed. -He/she was aware of one time when Resident #24 told him/her that he/she was not gotten up out of bed and he/she took care of it. He/she gave Resident #24 his/her business card so the resident could call him/her on the weekends but the resident has not called him/her on a weekend. -Resident #8 talked to him/her all the time and he/she has not told him/her that he/she had issues with staff not getting him/her up out of bed. -They had to let some staff go. -They have a new Human Resources person and a new process for pulling applications and getting them in for interviews. -Their nurse managers and RN's come in on the weekends. -They were working on hiring staff. -They do have a contract with a staffing agency if it ever came to that. -The issue was staff not showing up for scheduled shifts. -When they have staff call-in for their shift, they ask people who were off if they would come in, they ask those working to stay longer and nurse managers fill in as well.

**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 #27) out of 19 sampled residents (five of the 19 residents smoked) wore a smoking apron and was supervised while smoking. The facility identified 19 residents as residents who smoke. The facility census was 70 residents. Record review of the facility's Smoking by Residents policy dated June 2020 showed: -Instructions to ensure residents who chose to smoke, to do so safely. -Resident who wanted to smoke would be assessed for their ability to smoke safely prior to being allowed to smoke. -Residents who were not able to smoke safely would be accompanied by facility staff while smoking. -Residents who smoke should wear a smoking apron if they were found not to be safe. -All smoking sessions were to be supervised by facility staff members. 1. Record review of Resident #27's annual Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff used for care planning) dated 8/20/20 showed the resident used tobacco. Record review of the resident's quarterly smoking assessment dated [DATE] showed: -The resident was safe to smoke with supervision and a smoking apron. -The resident was non-compliant with use of a smoking apron. Record review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Was cognitively intact. -Had adequate vision. -Had no behaviors. -Walked with supervision. -Transferred with supervision (such as from a standing position to a seated position in a chair). -Did not use an assistive device. -Had a diagnosis of legal blindness. Record review of the resident's care plan updated 2/26/21 showed: -The resident smoked. -Due to the resident's lack of vision, he/she was supposed to wear a smoking apron. -The resident was educated on the requirement of the use of a smoking apron but the resident was non-compliant with the use of a smoking apron. -Instructions to educate the resident regarding the facility policy on smoking such as the locations, times and safety concerns. -The resident could smoke with supervision. -A goal for the resident was that the resident would not smoke without supervision. -The resident was able to keep his/her cigarettes and lighter at bedside. -Instructions to notify the charge nurse immediately if it was suspected that the resident violated the facility smoking policy. Record review of the resident's interdisciplinary note dated 4/7/21 showed: -The interdisciplinary team met with the resident to review his/her plan of care and educate the resident related to non-compliance with his/her plan of care. -The resident was blind and he/she smoked. -The resident continued to refuse to wear the smoking apron and got angry if staff tried to educate him/her. -The resident required staff supervision when smoking. Record review of the undated facility list of residents who smoke received during the annual survey showed: -15 residents smoked independently. -Four residents required supervision, including Resident #27. -The resident required a smoking apron and one-on-one assistance. -The resident was non-compliant with wearing a smoking apron. Observation on 4/19/21 at 8:28 A.M. showed the resident sitting on the back patio smoking with no smoking apron on, ashes on his/her clothes and no staff member present. Observation on 4/20/21 at 10:24 A.M. showed the resident walking down the hall using a white cane (used by individuals who are blind or visually impaired). Observation on 4/26/21 at 8:30 A.M. showed the resident and two other residents on the patio smoking. The resident was not wearing a smoking apron and no staff members were present. During an interview on 4/26/21 at 8:35 A.M., Hospitality Aide A said: -He/she sometimes watched the residents who were outside smoking. -The Maintenance Assistant was out on the patio earlier. -A staff member was supposed to be on the patio supervising residents who needed supervision while smoking. During an interview on 4/26/21 at 10:47 A.M., Registered Nurse (RN) B said: -The resident was non-compliant with a lot of stuff. -He/she didn't know if he/she needed staff to go with him/her to smoke. -If he/she saw the resident going out to smoke, he/she took him/her out and/or brought him/her back because the resident was blind. -No one was assigned specifically to go out with residents who smoke that required supervision. During an interview on 4/26/21 at 10:53 A.M., the Social Services Director said: -The resident was non-complaint with smoking. -The resident doesn't cooperate with wearing an apron and cussed at staff. -Usually a staff member went out with the resident to smoke. -The resident liked it when the Maintenance Assistant went out to smoke with him/her. -Certified Nursing Assistants (CNA) and hospitality aides were supposed to help the residents smoke and go out there with the ones that need supervision. -He/she sometimes went out to monitor residents smoking. During an interview on 4/26/21 at 11:57 A.M., Certified Medication Technician (CMT) A said: -Every resident should be supervised when smoking and should wear a smoking apron. -The resident was stubborn and cussed staff out regarding wearing a smoking apron. -There was no one specifically scheduled to supervise residents while they smoked. -The Maintenance Assistant was supervising the residents' smoking that day. During an interview on 4/26/21 at 12:17 P.M., the Maintenance Assistant said: -He/she monitored the residents as much as needed throughout the day and helped with the smoking aprons. -Hospitality aides helped with smoking supervision too. -Other staff helped supervise residents while smoking. -Some residents could smoke without supervision. -Management provided him/her a list of residents who smoke and whether they needed supervision and/or a smoking apron. -The resident needed supervision and a smoking apron. -He/she arrived today a little after 8:00 A.M. -The resident was outside around 8:00 A.M. and said he/she wasn't going to smoke until staff was there to supervise. -There was a toilet that was flooded so he/she had to go take care of that. -He/she helped the resident with smoking when he/she came back. -He/she was asked to supervise smoking a lot more over the past couple of weeks than he/she had in the past. -The resident was cooperative with him/her but was not for some of the staff. During an interview on 4/27/21 at 3:20 P.M., the resident said: -When he/she started to head out to the patio, somebody lets him/her out to the patio to smoke. -He/she waits for the Maintenance Assistant or whoever to come out and smoke with him/her. -He/she tried to abide by the rules. -The staff put the smoking apron on him/her. -He/she smoked for 40 years independently and feels he/she doesn't need supervision but he/she knows they want him/her to have supervision. During an interview on 4/27/21 at 2:28 P.M., the Director of Nursing (DON) said: -Smoking assessments were done upon admission. -During the smoking assessment, it was determined if the residents could smoke independently or not. -The residents were observed smoking to determine if they were safe or unsafe while smoking. -The interdisciplinary team determined what interventions the residents needed to smoke safely. -Education was provided to the residents regarding their interventions required for safe smoking. -The hospitality aides were usually the ones who assist the residents with smoking and they were made aware of which residents needed assistance and what assistance they needed. -The resident should be supervised while smoking and should have on a smoking apron. -The resident knows he's/she's not supposed to be smoking outside by himself/herself. -The staff usually walk the resident outside. -The screener at the door would be the last employee who would see the resident before going out the door to the patio and would be responsible for getting an employee to go out to supervise the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Record review of Resident #61's Quarterly MDS dated [DATE] showed: -The resident was admitted on [DATE]. -The resident needed the assistance of two staff members to move from the wheelchair to his/her bed. -The resident was able to understand other people. -The resident was able to make self understood. -The resident's BIMS score was 15 (cognitively intact). -The resident was a Paraplegic (loss of muscle function in the lower half of the body). During an interview on 4/19/21 at 8:50 A.M. the resident said: -The staff had to use the Hoyer (mechanical lift) to move him/her in and out of bed. -He/she would like to stay up past 9:00 P.M. but there isn't enough staff so they have to put him/her in bed before the night shift comes on. -He/she only had one bath a week and would have liked two baths. 5. Record review of Resident #15's admission record showed he/she was admitted on [DATE] and readmitted on [DATE] with the following diagnoses: -Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body) following unspecified Cerebrovascular Disease (heart conditions that include diseased vessels, structural problems, and blood clots) affecting left non-dominant side. -Contracture (deformity and rigidity of joints) of left hand and ankle. Record review of the resident's Quarterly MDS dated [DATE] showed the resident: -Was always incontinent. -Was a two person assist for bed mobility and transfers Observation on 4/19/21 at 10:30 A.M., of the resident showed: -He/she was sitting up in bed. -A protective boot on the his/her left foot and a protective hand grip on left hand. During an interview on 4/19/21 at 10:35 A.M., the resident said: -It took at least two hours sometimes to get changed. -Some staff have told him/her they only have to change him/her every two hours. 6. During an interview on 4/22/21 at 5:37 A.M., CNA D said: -There were three CNA's working on 4/21/21. -Each CNA had 13 residents for a total of 39 residents. -Usually there were only two CNA's. -He/She felt that two CNA's could handle the 39 residents. -The charge nurse also helped if needed. -Worked the past weekend with two CNA's on Saturday and three CNA's on Sunday. -He/She worked every other weekend. -Night shift got several residents up in the morning starting about 5:00 A.M During an interview on 4/27/21 at 3:00 P.M., the DON said: -Staffing was done based on the acuity of residents in the building depending on census, no specific number. -Acuity was the level of care of resident's. --They do it each day for the next day. --You may have 30 residents that are all independent and only need one nurse and one CNA . --0r all 30 residents were high acuity and needed more help and may need more than one nurse and several CNA's. -There was always an RN on duty for each 8 hour shift, seven days a week. -Monday through Friday there were: --Two to three LPN's for direct care. --Wound nurse. --Assistant Director of Nursing (ADON). -Seven days a week: --One RN for each eight hours shift. --If an RN was not scheduled due to vacation or illness then the DON comes in. -Day shift: --Two direct care LPN's or RN's (licensed staff) not including wound nurse or ADON. --Two CMT's. -Five days per week: --One restorative aide --One bath aide -Minimum of five CNA's for day shift 7:00 A.M. - 3:00 P.M. -Evening shift: --Two licensed staff, Two CMT's, four to six CNA's depending on census. --The last six month census has been running 68-74 residents. -Night shift and weekends: --Two licensed staff, three to five CNA's. --Weekend supervisor LPN 7A.M.-7 P.M. -There are four hospitality aides (uncertified assistive personnel, employed by the facility). -Hospitality Aides work seven days a week. --Tasks included monitor smoking, answering call lights, getting resident's water or ice, hand them remote to the TV. -Staffing was decent. -When short CNA's a nurse manager would step to the floor. -A nurse manager was on seven days a week. -A lot of CMT's would step into CNA spots. -Planning an in-service on answering call lights. During an interview on 4/27/21 at 3:20 P.M., the Regional Director of Operations said: -The facility doesn't staff by a certain number on individualized basis. -They staff by acuity with the amount of staff needed to meet the level of care that the residents need each day. Based on observation, interview and record review, the facility failed to ensure adequate staffing to provide cares needed for three sampled residents (Residents #8, #15, and #61) and one supplemental resident (Resident #24) out of 19 sampled residents. The facility census was 70 residents. 1. Record review of Resident #8's care plan dated 4/18/17 showed the resident required assistance with activities of daily living (ADL's-such as grooming, hygiene, etc.) and transferred from one surface to another with the use of a full body mechanical lift. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 4/21/21 showed the following staff assessment of the resident: -Was cognitively intact. -Displayed no altered mood symptoms or behaviors. -Was totally dependent upon two or more people for transferring from one surface to another (such as from the bed to a wheelchair). -Was totally dependent upon one person for dressing. -Used a wheelchair for mobility. -Was independent with locomotion on and off the unit. -Some of his/her diagnoses included cerebral palsy (a disability resulting from damage to the brain before, during, or shortly after birth and outwardly manifested by muscular incoordination and speech disturbances) and depression (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). Observation and interview on 4/26/21 at 2:02 P.M. showed: -The resident was lying in bed. -The resident said: --He/she likes to get up out of bed and go outside in the spring and when there's good weather. --He/she did not get up this past Saturday and Sunday because there was no one to put him/her to bed. --An aide told him/her that because he/she required extensive help that they wouldn't be able to get him/her up. --He/she knows he/she can't get up on the weekends. --The staff may not always say it but he/she knows they won't get him/her up on the weekends. --It's been happening since about January 2021. --He/she required a mechanical, stand up lift to get in and out of bed and it takes two people to get him/her up and there weren't two people to help him/her. -This past Saturday there was one aide on the day shift and one aide on the evening shift on his/her hall. -This past Sunday there were two aides in the afternoon and one aide in the evening on his/her hall. 2. Record review of Resident #24's care plan dated 5/25/17 showed: -The resident required assistance with ADL's. -Instructions for staff to assist the resident with transfer in and out of chair with full body mechanical lift and two staff members. -The resident used an electric wheelchair for locomotion. Record review of the resident's annual MDS dated [DATE] showed the following staff assessment of the resident: -Was cognitively intact. -Displayed no altered mood symptoms or behaviors. -Was totally dependent upon two or more people for transferring from one surface to another. -Required extensive assistance of two or more people for dressing. -Used a wheelchair for mobility. -Was independent with locomotion on and off the unit. -Some of his/her diagnoses included depression and rheumatoid arthritis (an inflammatory disease that may lead to serious joint damage and disability). Observation and interview on 4/27/21 at 12:12 P.M. showed: -The resident was sitting on the patio. -He/she said: --He/she required a lift to get up out of bed. --Staff don't always get him/her up out of bed. --Staff usually don't get him/her up out of bed on the weekends. --He/she has to stay in bed on Saturdays and Sundays. --The staff either come in and tell him/her that they don't have enough staff to get him/her up out of bed or they just don't ever come to get him/her up. --It happened almost every weekend for the past few months 3. Record review of the facility's staffing schedule for Saturday, 4/24/21 showed: -One nurse, one Certified Medication Technician (CMT) and two Certified Nursing Assistants (CNA)'s on the day shift for the two halls on the side of the building where Residents #8 and #24 resided (for 33 residents which included the transition hall for new admissions and residents returning from the hospital, requiring staff to wear full personal protective equipment (PPE-such as respirators/masks, gloves and gown going into each room). -One nurse, one CMT and one CNA on the evening shift for the two halls on the side of the building where Residents #8 and #24 resided (for 33 residents). -One nurse and one CNA on each side of the building. Record review of the facility's staffing schedule for Sunday, 4/25/21 showed: -One nurse, one CMT and two CNA's on the day shift for the two halls on the side where Residents #8 and #24 resided (33 residents). -One nurse, one CMT and two CNA's on the evening shift for the two halls on the side of the building where Residents #8 and #24 resided (33 residents). 4. During an interview on 4/26/21 at 12:45 P.M., CNA G said: -He/she worked Saturday night, 4/24/21 on the north side of the building with one nurse on the north side of the building. -He/she was the only CNA for over 30 residents. -The bathroom flooded in a resident room and covered the floor in water and feces. -He/she had to pass out all the drinks, all the meal trays, answer all of the call lights, clean the flooded water and feces and shower the resident who was in the room where the bathroom flooded. During an interview on 4/26/21 at 1:50 P.M., Licensed Practical Nurse (LPN) B said: -He/she worked Saturday night, 4/24/21, on the south night shift with one CNA. -They focused on making sure all the residents were dry and passing ice water to all the residents. During an interview on 4/26/21 at 2:39 P.M., the Social Services Director said: -Some of the residents have complained about weekend staffing. -They have hired some new staff but they didn't come back. -They were working on hiring more staff. During an interview on 4/27/21 at 12:50 P.M., CNA E said: -He/she worked on weekends, usually 6:30 A.M. to 2:30 P.M. -They were often short staffed on weekends. -He/she was the only CNA for the day shift recently. -They can't get the residents up who require a lift to get up because they don't have enough staff. -The residents who require a lift want to get up. During an interview on 4/27/21 at 1:55 P.M. Registered Nurse (RN) B said: -They focus on keeping residents clean and dry. -It takes two people to get the residents up who require a mechanical lift so there were weekends when those residents don't get up because they didn't have two people available. During an interview on 4/27/21 at 1:55 P.M. LPN A said: -There were times when they couldn't get the residents who required a lift up out of bed because they didn't have enough staff available to help. During an interview on 4/27/21 at 2:28 P.M., the Director of Nursing (DON) said: -He/she expected staff to offer residents the opportunity to get up out of bed. -He/she was aware of one time when Resident #24 told him/her that he/she was not gotten up out of bed and he/she took care of it. He/she gave Resident #24 his/her business card so the resident could call him/her on the weekends but the resident has not called him/her on a weekend. -Resident #8 talked to him/her all the time and he/she has not told him/her that he/she had issues with staff not getting him/her up out of bed. -They had to let some staff go. -They have a new Human Resources person and a new process for pulling applications and getting them in for interviews. -Their nurse managers and RN's come in on the weekends. -They were working on hiring staff. -They do have a contract with a staffing agency if it ever came to that. -The issue was staff not showing up for scheduled shifts. -When they have staff call-in for their shift, they ask people who are off if they would come in, they ask those working to stay longer and nurse managers fill in as well.

Based on observation, interview and record review, the facility failed to properly store food in the refrigerated walk-in unit and failed to practice sanitary procedures before food preparation tasks. These practices potentially affected the residents and staff who received and ate their meals from the facility's kitchen. The facility census was 70 residents. 1. Observations and interviews on 4/20/21 between 6:05 A.M. and 8:23 A.M. in the kitchen showed the following: -At 6:13 A.M. The refrigerated walk-in unit that stored fruits, produce, eggs and meat had a portable thermometer on its shelf displaying a temperature of 50 degrees Fahrenheit (ºF). -At 6:15 A.M. a second digital thermometer was placed side-by-side to the shelf thermometer to determine the accuracy of the walk-in refrigerated unit and its thermometer. -At 6:16 A.M., Dietary [NAME] (DC) A said he had not been in the kitchen's refrigerated walk-in unit early that morning and was unaware that the food storing temperature was out of range and too warm in the unit. -At 6:22 A.M. the second digital thermometer in the refrigerated walk-in unit read 49.8ºF, an inappropriate and unacceptable temperature range deviating from the acceptable temperature range of 33.0ºF - 41.0ºF. -There was a juice dispensing machine with one nozzle connected to and dispensing several different beverages of lemonade, cranberry juice and fruit punch. These nozzles were sticky with multi-colored debris on the inside and outside of the nozzles. -A gray-colored, trashcan contained sticky, red debris on the outer sides of the container and its lid was off the trashcan and located partially behind a refrigerated reach-in unit. -The gray-colored trashcan and lid located in the rehabilitation dining room under the big clock contained sticky, red debris on the outer sides of the container and its lid. -The spice containers were dirty, grimy and greasy to the touch. -The top of the stove, its backsplash and sides and, grill were black in color and had burnt on grease and food debris on top of the stove grates. -At 8:03 A.M. Dietary [NAME] (DC) A tested the sanitizing solution mixture with the incorrect test strips, using chlorinated-base test strips instead of chemical pHydrion Papers (chemical test strips used to measure the appropriate bio-chemical strength levels of the sanitizing solution) test strips. -At 8:11 A.M. the Dietary Manager (DMgr) brought the correct test strips from another area of the kitchen and tested the sanitizing solution mixture, which tested in the appropriate and effective bio-chemical strength and range level. During an interview on 4/20/21 at 8:15 A.M., the Dietary Manager said: -He/she was unaware that the walk-in refrigerated unit's temperature was out of range and would contact the facility's vendor to service the unit. -He/she did not know for how long the walk-in refrigerated unit's temperature was out of range, but thought that it was only for a day. -He/she located the chemical testing strips in another area of the kitchen. -The last chemical test one week ago indicated the sanitizing solution mixture was between 200 - 300 parts per million (ppm - a chemical solution measurement indicating a strength level for a sanitizing concentration and water solution mixture). -He/she tested the sanitizing solution mixture and, it was in the appropriate sanitizing range of 200 - 300 parts per million indicated by the color change of the test strips. -The nozzles of the juice and beverage dispensing equipment and spice containers were not listed on any cleaning schedules, but would be placed on one. -The gray-colored, 55-gallon trashcans and their lids were on weekly and monthly cleaning schedules, but did not think that they were cleaned in the previous week. -The dietary staff would be in-serviced on hand-washing techniques after handling trash discarded in the gray-colored trashcans. -The facility would be purchasing new step-on trashcans with an automatic trashcan lid closures for the kitchen. -He/she would in-service the dietary staff of when and how to use and test the sanitizing solution mixture, as well as cleaning the spice containers and the juice machine nozzles. Record review of the facility's kitchen equipment cleaning schedule (undated), showed: -The nozzles of the juice and beverage dispensing equipment and spice containers were not listed on the cleaning schedules. -The gray-colored, 55-gallon trashcans and their lids were cleaned on a weekly and monthly basis or as needed. Record review of the 2013 edition of the U.S. Food and Drug Administration (FDA) Food Code Chapter 2-301.14, showed, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under §(Section) 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in (paragraph) 2-403.11(B); (D) Except as specified in (paragraph) 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating, or drinking; (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. Record review of the 2013 edition of the FDA Food Code Chapter 4-601.11, showed, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. Record review of the 2013 edition of the FDA Food Code Chapter 4-602.11, showed, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (1) Except as specified in [paragraph] (B) of this section, before each use with a different type of raw animal FOOD such as beef, FISH, lamb, pork, or POULTRY; (2) Each time there is a change from working with raw FOODS to working with READY-TO-EAT FOODS; (3) Between uses with raw fruits and vegetables and with TIME/TEMPERATURE CONTROL FOR SAFETY FOOD; (4) Before using or storing a FOOD TEMPERATURE MEASURING DEVICE; and (5) At any time during the operation when contamination may have occurred. Record review of the 2013 edition of the FDA Food Code Chapter 4-602.11, showed, Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

Based on observation, interview and record review, the facility failed to maintain an essential piece of kitchen equipment - the refrigerated walk-in unit - for properly storing food at the acceptable temperature ranges. This situation potentially affected the residents and staff who received and ate their meals from the facility's kitchen. The facility census was 70 residents. 1. Observations and interviews on 4/20/21 between 6:05 A.M. and 8:23 A.M. in the kitchen showed the following: -At 6:13 A.M. The refrigerated walk-in unit that stored fruits, produce, eggs and meat had a portable thermometer on its shelf displaying a temperature of 50 degrees Fahrenheit (ºF). -At 6:15 A.M. a second digital thermometer was placed side-by-side to the shelf thermometer to determine the accuracy of the walk-in refrigerated unit and its thermometer. -At 6:16 A.M., Dietary [NAME] (DC) A said he/she had not been in the kitchen's refrigerated walk-in unit early that morning and was unaware that the food storing temperature was out of range and too warm in the unit. -At 6:22 A.M. the second digital thermometer in the refrigerated walk-in unit read 49.8ºF, an inappropriate and unacceptable temperature range deviating from the acceptable temperature range of 33.0ºF - 41.0ºF. During an interview on 4/20/21 at 8:15 A.M., the Dietary Manager said: -He/she was unaware that the walk-in refrigerated unit's temperature was out of range but would contact the facility's vendor to service the unit. -He/she did not know for how long the walk-in refrigerated unit's temperature was out of range, but thought that it was only for a day. During an interview on 4/20/21 at 1:35 P.M., the Dietary Manager said that the Maintenance Director (MD) contacted the facility's heating and air conditioning vendor and the vendor would be there, onsite, later in the afternoon. During an interview on 4/20/21 at 3:35 P.M., the MD said the vendor had serviced the refrigerated walk-in unit and added some Freon gas mixture (a common component in the modern refrigerator. This compound is used for heat transfer to keep the internal compartment of your refrigerator cool and ensure that your food is kept at the proper temperature) to the unit's compressor unit to increase and stabilize the unit's temperature. The MD said the refrigerated walk-in unit was low on Freon. Record review of the 2013 edition of the Food and Drug Administration (FDA) Food Code, Chapter 2-103.11, showed, The person in charge shall ensure that: (G) Employees are properly cooking [potentially hazardous food] time/temperature control for safety food, being particularly careful in cooking those foods known to cause severe foodborne illness and death, such as eggs and comminuted meats, through daily oversight of the employees' routine monitoring of the cooking temperatures using appropriate temperature measuring devices properly scaled and calibrated as specified under Section 4-203.11 and Paragraph 4-502.11(B). Record review of the 2013 edition of the FDA Food Code Chapter 3-501.16, showed, (B) EGGS that have not been treated to destroy all viable Salmonellae shall be stored in refrigerated EQUIPMENT that maintains an ambient air temperature of 7°C (45°F) or less. Review of the 2013 edition of the Food and Drug Administration (FDA) Food Code, Chapter 4-201.11, showed, EQUIPMENT and UTENSILS shall be designed and constructed to be durable and to retain their characteristic qualities under normal use conditions. Review of the 2013 edition of the Food and Drug Administration (FDA) Food Code, Chapter 4-501.11, showed, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.