Based on interview and record review, the facility failed to ensure two sampled residents (Residents #40 and #55) out of three sampled residents, who were notified their Medicare Part A coverage would likely end and had benefit days remaining, were provided the Quality Improvement Organization (QIO) contact name and toll free phone number on their Notice of Medicare Non-Coverage (NOMNC), Centers for Medicare (CMS)-10123 form. On 1/31/25 the Administrator was notified of the past non-compliance which took place for a period of months that started on or before 7/9/24 and went through 12/31/24. On 1/2/25 the Social Services Director was given an updated Form CMS-10123 containing the QIO contact name and toll-free number so residents could appeal the decision to end services. On 1/2/25 the Social Services Director received education from Regional Nurse Consultant A on providing the QIO contact name and phone number to residents with benefit days remaining whose services were expected to end. The deficiency was corrected on 1/2/25. Review of the facility's Medicare Denial Process policy, dated April, 2024, showed: -The NOMNC, Form CMS-10123, is required to be delivered to the resident or his/her representative at least two calendar days before Medicare covered services end. -The beneficiary or representative will sign and date the notice acknowledging it was received. -Information provided must include the last covered day of service, the phone number of the QIO, and the time frame for appeal. 1. Review of Resident #40's Form CMS 10123 - NOMNC showed: -The resident started services on 7/5/24 and services were expected to end on 7/11/24. -The resident's representative acknowledged the notice on 7/9/24. -Under the section How to Ask for an Immediate Appeal the form showed the beneficiary must make request to the Quality Improvement Organization (QIO), the independent reviewer authorized by Medicare to review the decision to end services. The request for an appeal should be made no later than noon the day before the effective date of services ending. The beneficiary was to call his/her QIO to appeal or with questions. -Above the signature line was the sentence I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. -No QIO name or toll-free number was provided on the form for the beneficiary to use should he/she decide to appeal. 2. Review of Resident #55's Form CMS 10123 - NOMNC showed: -The resident's effective date of coverage started 9/3/24 and services were expected to end on 11/26/24. -The resident's representative acknowledged the notice on 11/23/24. -Under the section How to Ask for an Immediate Appeal the form showed the beneficiary must make request to the QIO. The request for an appeal should be made no later than noon the day before the effective date of services ending. The beneficiary was to call his/her QIO to appeal or with questions. -Above the signature line was the sentence I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. -No QIO name or toll-free number was provided on the form for the beneficiary to use for an appeal. During an interview on 1/31/25 at 10:09 A.M., the Social Services Director said: -He/She was unaware the QIO contact information was not on the NOMNC forms that were presented to Resident's #40 and #55. -On 1/2/25 Regional Nurse Consultant A provided an updated Form CMS-10123 that he/she could type on which contained the QIO contact name and toll-free number.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities to meet the needs of two sampled residents (Residents #49 and #176) who didn't like to go to group activities and were dependent upon staff to provide activities for mental, physical, and psychosocial stimulation out of 18 sampled residents. Additionally, the facility failed to ensure there was a way to easily access daily activity participation over time. The facility census was 74 residents. Review of the facility's Activities Program policy, revised 10/24/22, showed: -The purpose of the policy was to encourage resident participation to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable residents to maintain the highest attainable social, physical, and emotional functioning. -After completion of the initial Activity Assessment and the Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning), an Individualized Care Plan will be developed and implemented for each resident. -The Activity care plan will be reviewed and up-dated at least quarterly and with any change of condition. -Activities are tailored to meet the needs of residents with cognitive impairment or other special needs. -The facility will provide equipment and supplies for independent and group activities and for residents with special needs. -No less than quarterly the Director of Activities or designee will make a progress note as part of the resident's health record that includes the resident's level of participation, perceived benefit, response to interventions outlined in the Care Plan, progress made toward goals and recommendations for activities. -The Activity Department will maintain accurate records of each resident's participation in group, independent, and room visit involvement. Participation will be documented daily. 1. Review of Resident #49's admission MDS, dated [DATE], showed the resident: -Was diagnosed with non-traumatic brain dysfunction (a condition in which the brain is damaged by internal factors rather than external force to the head) and dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Had adequate hearing (could hear normal conversation) and adequate vision (could see fine detail such as newsprint). -Was severely cognitively impaired. -Had difficulty concentrating nearly every day. -Liked snacks. -Was unable to communicate what activities he/she liked. Review of the resident's Activity care plan, initiated 8/19/24 showed: -Encourage the resident's participation. -Allow the resident to leave activities at any time. -Provide assistance and escort to activity functions. Note: The care plan did not show activities that were meaningful for the resident. Review of the resident's quarterly Activity Interview for Daily Preferences, dated 10/14/24 showed the resident liked snacks but was unable to verbalize other activities of interest. Review of the resident's Activities Quarterly and Annual Participation Review, dated 1/2/25 showed the resident: -Enjoyed walking around, 1:1 visiting with staff, people-watching, sensory activities, listening to music, having snacks, reading, coloring, and bird watching. -Had good hearing and good vision with glasses. Review of the resident's annual MDS, dated [DATE] showed it was somewhat important for the resident to have magazines to read, listen to music, be around animals, and go outside for fresh air. It was very important to have snacks. Review on 1/30/25 of the resident's Activities care plan (initiated 8/19/24) showed it was never updated to include activities that were meaningful for the resident given he/she didn't like group activities. Review on 1/30/25 of the resident's progress notes for 10/1/25 through 1/29/25 showed no Activities progress notes. Daily participation documentation was not found in the resident's electronic record. Daily participation documentation was requested and not provided. Observation of the resident on the following dates and times showed: -On 1/27/25 between 7:20 A.M. and 8:00 A.M. and 8:45 A.M. and 9:20 A.M. the resident was in bed. There was no music or other stimulating activity on the resident's hall or in the resident's room. -On 1/28/25 from 10:05 A.M. to 10:30 A.M. the resident was in bed. At 12:30 P.M. the Activity Aide came on the unit and told staff he/she would take one of the residents to the bird cage while he/she cleaned the cage. The resident was in bed and wasn't asked if he/she would like to go. -On 1/29/25 at 10:15 A.M. residents were observed in the Day Services/Multipurpose Room while an outside entertainer was playing music. The resident was not at the activity. At 10:20 A.M. the Activity Aide said the resident was not at the music activity. At 10:25 P.M. the resident was observed in bed. No activity was taking place and music was not being played on the unit or in the resident's room. -Observation on 1/30/25 at 1:32 P.M. showed the resident in his/her room sitting on the side of his/her bed. There was no activity taking place or music playing on the living area or in the resident's room. During an attempt to interview on 1/30/25 at 1:35 P.M., when asked if he/she liked music, the resident said he/she didn't know. When asked if he/she liked to walk or be outside the resident did not respond. He/She nodded yes when asked if he/she liked activities on the unit where food was served. During an interview on 1/30/25 at 1:57 P.M. Certified Nursing Assistant (CNA) A said: -He/She had never seen the resident out of his/her room except at meal times. -The resident used to like a roommate, but that resident was no longer at the facility. -The resident might come out of his/her room for a food-related activity. Activities did not bring and Nursing did not pass juice or coffee mid-morning or mid-afternoon. The Activities Director had coffee and donuts sometimes in the activity room, but did not bring that to the resident halls. During an interview on 1/30/25 at 2:13 P.M. CNA B said: -The resident kept to himself/herself. -He/She didn't watch television. -He/She used to follow his/her former roommate around, but that resident was no longer at the facility. -He/She thought the resident would hover around if there was a birthday party or Valentine's Day party on the unit because he/she liked to eat. He/She was diabetic so he/she would need a sugar-free Kool-Aid or soda and a less-sweet snack. -When spoken to by familiar staff the resident would smile so he/she thought the resident would benefit from socials on the hall and 1:1 interaction. During an interview on 1/31/25 at 10:56 A.M. the Activities Director said: -He/She couldn't find daily documentation for the resident in his/her electronic record. Any activity the resident would have participated in would have been entered on the day he/she participated, but he/she wasn't able to see all daily activities for the entire week, month, or quarter. He/She could only enter the activity on the [NAME] for the day. -Activities the resident had participated in included going down the main hall to look at the bird cage and sitting in front of the television on his/her living hall during a [NAME] movie. -They had taken the resident to live music activities before and the resident left the area and needed staff to get back onto his/her hall. -The resident liked the Missouri Conservation magazine and would take it if handed to him/her, but would lose the magazine. The resident used to hunt and fish so he/she tried to find an article the resident would like to stimulate his/her interest. 2. Review of Resident #176's admission Activity Assessment, dated 12/27/24 showed the resident: -Was admitted to the facility on [DATE]. -Had adequate hearing and poor vision. -Had memories of hunting and fishing in the Ozarks. -Liked to be around animals and watch sports. Review of the resident's Activity Interview for Daily and Activity Preferences, dated 12/27/24 showed the resident's primary respondent said: -It was very important for the resident to have snacks between meals and to go outside for fresh air when the weather was good. -It was somewhat important for him/her to listen to music, be around animals and pets, and participate in religious services. Review of the resident's Comprehensive care plan, initiated 12/28/24 showed the resident had no Activities care plan. Review of the resident's admission MDS, dated [DATE] showed the resident: -Had a primary diagnosis of a stroke and had dementia. -Had continuous inattention and disorganized thinking. -Had adequate hearing and vision (this contrasted with the poor vision noted on the admission Activity Assessment.) -Found it very important to have snacks and be outside when the weather permitted and somewhat important to listen to music, be around animals, and attend religious services. Review on 1/30/25 of the resident's progress notes for 10/1/24 through 1/29/25 showed no Activities progress notes. Review on 1/30/25 of the resident's Comprehensive care plan showed no Activities care plan had been added after 12/28/24. Observation of the resident on the following dates and times showed: -On 1/27/25 between 7:20 A.M. and 8:00 A.M. the resident was at the dining room table. No stimulating activity such as soft background music was taking place during breakfast. Between 8:45 A.M. and 9:20 A.M. the resident was in bed with eyes closed. No activity was going on in the living area. -On 1/28/25 from 10:05 A.M. to 10:30 A.M. the resident was in bed with eyes closed. No activity was taking place on the living area. -On 1/29/25 at 10:15 A.M. residents were observed in the Day Services/Multipurpose Room where an outside entertainer was playing music. The resident was not at the activity. At 10:20 A.M. the Activity Aide said the resident was not at the music activity. At 10:27 P.M. the resident was observed in bed. No activity was taking place and no music was being played on the unit or in the resident's room. -Observation on 1/30/25 at 1:30 P.M. showed the resident was in bed with eyes closed. No activity was taking place on the living area. During an interview on 1/30/25 at 2:03 P.M. CNA A said: -Staff could get the resident to come out of his/her room as long as they offered the resident a coffee or Coca Cola. The resident would attend food-related activities on the living area. -The resident did sometimes read the Daily Chronicle newsletter and had watched part of a football game within the past month. -He/She didn't know if the resident liked music. During an interview on 1/30/25 at 2:11 P.M. CNA B said: -The resident liked to drink coffee. -There was no radio on the unit and nursing staff didn't play vintage music for the residents. He/She didn't know if the resident liked music. -The resident liked talking with staff and had funny sarcasm when he interacted. During an interview on 1/31/25 at 10:56 A.M. the Activities Director said: -He/She was still working on figuring the resident out. He/She spoke with a family member, but got little information about the resident's interests. -It was best to try to grab the resident right after a meal before he/she went back to bed. -The resident had watched a [NAME] movie on the resident hall and seemed to like that. 3. Review of the facility's Activity calendars for October, 2024 through January, 2025 showed: -In October one-to-one visits were listed for the five Tuesdays during the month. It didn't show which of the six halls the one-to-one visits took place on any given Tuesday. All other activities were group activities. -In November, 2024 and December, 2024 there were no one-to-one activities or room visits scheduled. -In January, 2025 room visits took place on Resident #49 and #176's hall on 1/6/25 and 1/22/25. -No scheduled activities were shown on the activity calendars for Saturdays or Sundays. Independent resident activities of choice and an activity cart were shown as available on weekends. During an interview on 1/27/25 at 9:35 A.M. the Activity Aide said: -They had Coffee Club scheduled in the Activity Room on 1/27/25 at 9:45 A.M. -Residents who wanted to attend came to the Activity Room. -There was no coffee and snack brought to the resident halls for residents who couldn't or didn't want to leave their living area. -Almost all the scheduled activities took place off the living halls. During an interview on 1/30/25 at 2:13 P.M. CNA A said: -The Activities Department encouraged residents to go to activities scheduled off the resident halls. -There were no activities done on the resident halls, except when Activities staff left printed coloring pictures and puzzles for residents to do on their own. -There was nothing for residents to do on the weekends except for coloring pictures and puzzles available on the activity cart. -He/She had never seen Activities do one-to-one activities with residents who couldn't or didn't want to leave their living area. -He/She wasn't sure if there were oldies music stations on the television so residents could listen to music on the living area. During an interview on 1/31/25 at 10:56 A.M. the Activities Director said: -Documentation of activity assessments and care plans were done through the resident's electronic record. He/She didn't do progress notes, but documented activity participation daily in the [NAME] and quarterly on review forms. They only documented when residents actively participated. They didn't record when residents were encouraged to participate, but refused. -Almost all activities reflected on the monthly calendars were done in the main hallway, the activity room, or the multipurpose room. Sometimes activities were brought to the halls. On Halloween staff dressed up and treats were brought to the resident halls. -Activities tried to do one-to-one activities on each hall twice monthly. -There were radios on the halls that could be used by nursing staff for resident activities. -There were no scheduled activities on the weekend. Each hall had an activity cart with coloring pictures and table activities and residents pursued activities on their own. During an interview on 1/31/25 at 12:51 P.M. the Director of Nursing (DON) said: -All activities should be documented in the resident's electronic record. -He/She thought they were documented in Activity progress notes. -Staff should have access to daily activity participation documentation either through the resident's electronic record or through paper charting. -For residents who don't go to group activities or don't initiate activities on their own, one-to-one activities of interest should be provided by either the Activities or the Nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document behaviors and develop a care plan that included target behaviors (specific behaviors of the resident), and relevant non-pharmacological approaches for one sampled resident (Residents #49) who was prescribed a psychotropic medication (a drug that affects brain activities associated with mental processes and behaviors). The facility census was 74 residents. Review of the facility's Behavior Management policy, undated, showed key components of behavior management included: -Identifying residents whose behaviors may pose a risk to self or others. -Develop individualized and practical care strategies based on assessed needs. -Implement a behavior management program. -Ongoing assessment, monitoring, and evaluation of the effectiveness of the behavior management program including effectiveness of psychoactive drugs. -Nursing staff will document the response to medication, including behaviors and the side effects on the Medication Administration Record (MAR). -The facility will re-asses continued use of psychotherapeutic drug interventions. 1. Review of Resident #49's admission Record showed: -The resident was admitted to the facility on [DATE] with a diagnosis of Dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). Review of the resident's Psychotropic Medication care plan, initiated 8/19/24 showed: -The resident used psychotropic medications. -Staff were to administer medications as ordered. -Every shift will monitor for side effects (unsteady gait, shuffling gait, ridged muscles, shaking, frequent falls, blurred vision, fatigue, loss of appetite, vomiting, and behavioral symptoms not usual for the resident). Note: The care plan did not mention resident target behaviors or symptoms indicating the need for the psychotropic medication. Review of the resident's Medication Review Report showed the physician ordered medication Quetiapine Fumarate oral tablet 25 milligrams (mg) at bedtime for mood disorder was started on 8/23/24. Review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff and used for care planning), dated 10/15/24, showed the resident: -Was severely cognitively impaired. -Had fluctuating inattention and continuous disorganization. -Felt down and depressed half or more days. -Had no verbal or physical behaviors directed toward others or other behaviors (e.g.: self-injurious behaviors, disrobing, smearing bodily wastes, making disturbing noises). -Was not diagnosed with a psychiatric or mood disorder such as anxiety, depression, schizophrenia, or psychotic disorder. -Was prescribed a routine antipsychotic medication. Review of the resident's Medication Administration Record (MAR) dated November 2024 behavioral documentation showed: -There were no behaviors on the day shift. -Behaviors occurred six times on the evening shift and twice on the night shift, including hitting, kicking, pushing, entering other residents' personal space, restlessness, and refusing cares. -Interventions used included redirection, removing from the situation, reapproaching, and offering food. Staff documented outcomes of behavioral interventions as either the behavior remained the same or staff were unable to determine if the behavior improved. Review of the resident's November 2024 progress notes showed there were no progress notes in November addressing details of any of the resident's behaviors such as the duration or intensity of the behaviors, possible predisposing causes of the behaviors, or details about the intervention effectiveness which could be helpful for future behavioral care planning and psychotropic medication adjustment. Review of the resident's MAR dated December 2024 showed: -There was one behavior on the day shift and four behaviors on the evening shift. Behaviors included grabbing, hitting, kicking, cursing at others, expressing frustration or anger, threatening others, entering other residents' space, and refusing cares. -Interventions included providing a calm environment, removing from the situation, engaging in a meaningful activity, and reapproaching. -The night shift documented RU thirteen times on the form. The form legend showed R stood for rummaging and U stood for Unable to determine if the intervention attempt was successful. Review of the resident's December 2024 progress notes showed: -A note was written on 12/18/24 at 8:19 P.M. showing the resident continued to remove clothing from his/her roommate's closet and wear them which greatly upset his/her roommate. Staff redirected the resident, but the behavior repeated soon after related to dementia. -No other progress notes in December addressed details of the resident's behaviors, possible predisposing causes of the behaviors, or details about each intervention's effectiveness. During an interview on 1/30/25 at 1:57 P.M. CNA A said: -He/She didn't know how the resident acted when his/her mood was down or what staff were to do to address that. -He/She had never seen the resident out of his/her room except for meals and didn't know if staying in his/her room related to his/her mood. -He/She hadn't seen any behaviors on the day shift. During an interview on 1/31/25 at 12:13 P.M. Licensed Practical Nurse (LPN) A said: -Everyone on a psychotropic medication should be monitored every shift for behaviors. -The resident's care plan should show the diagnosis, target behaviors, and symptoms related to the reason they are on a psychotropic medication. There should be non-pharmacological interventions to address the behavioral issues for all residents on a psychotropic medication such as redirection or whatever usually helped that resident. -Residents on psychotropic medications had a generic order to identify behaviors. -All behaviors should be documented on the MAR and documented in detail in the resident's progress notes. If a resident behavior was documented on the MAR, the resident's electronic record should trigger the charge nurse to write a detailed progress note. -The care plan should reflect target behaviors staff should be monitoring. -The resident used to have more episodes of resisting cares, combativeness, and arguing with a former roommate, but those behaviors had recently decreased while wandering had increased. -Justification for an antipsychotic medication should be documented on a care plan and include target behaviors and symptoms associated with the diagnosis for which the antipsychotic was ordered. During an interview on 1/31/25 at 12:37 P.M. the MDS Coordinator said: -The psychiatrist or psychiatric nurse practitioner saw all the residents who were on psychotropic medications. -If a resident was on a psychotropic medication nurses should chart behaviors on the MAR every shift and document details of behaviors in a progress note. -The care plan should explain why a resident was on an antipsychotic medication and describe target behaviors and symptoms the resident was having such as hallucinations (a perception of something that isn't actually there) or delusions (a belief that is persistently held despite evidence to the contrary). During an interview on 1/31/25 the Director of Nursing (DON) said: -The resident's target behaviors and symptoms should be identified on the care plan. -Psychotropic medications should relate to the resident's diagnosis, behaviors, and symptoms and be reviewed monthly by the pharmacist and physician. -The charge nurse should document behaviors on the resident's MAR and in their progress notes. -Behavioral documentation was used in deciding if psychotropic medications needed adjusting.

Based on observation, interview and record review, the facility failed to post the actual hours worked for Registered Nurses (RN's), Licensed Practical Nurses (LPNs), Certified Medication Technicians (CMTs) and Certified Nursing Assistants (CNAs) directly responsible for resident care per shift in locations throughout the facility for view by residents, family members and visitors. The facility census was 74 residents. Record review of the facility Staffing, Schedule and Postings policy dated 10/24/2022 showed: -The facility would post the current date, the total number and the actual hours worked by licensed (RNs and LPNs) and unlicensed (CNAs) nursing staff directly responsible for resident care per shift, and the facility resident census. 1. Record review of the Staffing Ratio and Census Reports dated 12/27/24 through 1/27/25 showed: -The number of RNs, LPNs, CNAs and CMTs for each 24 hour period, rather than for each eight hour shift. -The staffing sheets did not show the total number of hours for RNs, LPNs, CNAs and CMTs for each eight hour shift. Observation of the posted Staffing Ratio and Census Report on 1/28/25 at 11:45 A.M. showed: -The number of RNs, LPNs, CNAs and CMTs for each 24 hour period, rather than for each eight hour shift. -The staffing sheets did not show the total number of hours for RNs, LPNs, CNAs and CMTs for each eight hour shift. -The date of the form was 1/27/25. During an interview on 1/28/25 at 1:35 P.M. the facility Staffing Coordinator said: -The posted staffing sheets showed the number of nurses, CNAs and CMTs for one 24 hour period. -It did not show the hours worked. -He/she was responsible for completing and posting the facility staffing sheets. During an interview on 1/31/25 at 12:00 P.M. the Director of Nursing (DON) said: -Up until 1/28/24 the total hours worked for licensed and unlicensed staff was not included on staffing sheets and the staffing sheets covered a 24 hour period rather than each eight hour shift. -After a meeting on 1/28/25 and going forward the total hours for each category of licensed and unlicensed staff for each shift would be included on staffing sheets. -The Staffing Coordinator was responsible for posting of staffing. -He/she and the Administrator were responsible for monitoring the posting of staffing. -Staffing sheets were posted at the reception desk and on the resident living units at the nurse's stations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to assess a resident who had fallen before moving him/her and did not call Emergency Medical Services (EMS) in a timely manner for one sampled resident (Resident #1) out of four sampled residents. The facility census was 77 residents. The Administrator was notified on 8/26/24 of Past Non-Compliance (PNC) which occurred on 8/20/24. On 8/20/24 facility administration identified the resident was moved after a fall prior to being assessed by a licensed nurse and the delay in emergency services being notified to transfer the resident to the hospital. The facility completed the investigation, and the facility staff were in-serviced by 8/21/24. Review of the facility's policy, Response to Falls, dated October 24, 2022 showed: -Residents who have experienced a fall would have been promptly assessed and treated for injuries. -After each fall, a Licensed Nurse would have completed a Post-Fall Assessment and Investigation. -Immediate Post Fall Response: -Upon finding a resident in a position indicating a fall, stay with the resident and send another staff member to notify a Licensed Nurse if the first responder was not licensed personnel. -Do not move the resident initially until after an assessment was completed. -Call for assistance. -The Licensed Nurse should have assessed the resident and taken the resident's vitals. -Assess the resident's level of consciousness, position, possible injuries, head injuries, pain, tenderness, swelling, bruising, alignment and range of motion. -If the Licensed Nurse suspects a fractured hip, back or other injury, the Licensed Nurse should have made the resident comfortable until emergency medical services arrived. -The Licensed Nurse would have also completed the Neurological Flow Sheet for any un-witnessed fall, or witnessed fall with known head injury for 72 hours following the fall. 1. Review of Resident #1's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). -Dementia (a group of thinking and social symptoms that interferes with daily functioning). -Spinal Stenosis (when the spaces inside the bones of the spine get too small). -Lumbago with Sciatica, left side (anything that causes narrowing of the spinal canal has the potential to compress nerve roots and cause a bulging disc). -Muscle weakness. -Lack of coordination. -Cognitive communication deficit (having trouble reasoning and making decisions while communicating). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility for care planning), dated 6/21/24 showed: -He/She was moderately cognitively impaired. -He/She did not have any impairment to lower extremities (hip, knee, leg, or foot). -He/She used a walker. -He/She used a cane or crutch. -He/She had prior falls with no major injury. Review of the resident's undated Care Plan showed: -He/She had a self-care performance deficit, required supervision to limited assistance by staff for transfer as necessary. -He/She had impaired cognitive function. -He/She has had actual falls related to poor balance and unsteady gaits; 6/5/24, 6/10/24, 8/5/24, and 8/20/24 (fall with hip fracture). -He/She was at risk for falls and staff needed to follow facility fall protocol. Review of the Nurses Progress Notes dated 8/20/24 at 6:47 A.M. written by Licensed Practical Nurse (LPN) A showed: -He/She was notified by a staff member of the resident sitting on the floor next to a chair. -He/She arrived to room to see the resident sitting on the floor next to a chair. -Upon assessing the resident he/she noticed there was no bruising but his/her left leg had pain when moving it. -The resident stated he/she had lost his/her balance, fell and hurt his/her leg. -He/She did a full body assessment, gathered vital signs (blood pressure, pulse, respirations,neurological assessment). -The resident was experiencing left leg pain. -An X-ray was ordered for the resident's left leg. -He/She notified the Director of Nursing (DON), Assistant Director of Nursing (ADON), Physician, and Durable Power of Attorney (DPOA -legal statement authorizing another person to make decisions for someone who mentally was not able to). -There was no documentation showing a Certified Nurses Assistant (CNA) moved the resident prior to being assessed by a licensed nurse Review of the facility's undated fall investigation showed: -Statement from CNA D on 8/20/24 showed: -He/She was notified by the resident's roommate that Resident #1 needed help. -He/She entered the resident's room and observed the resident laying on the floor. -He/She asked the resident if he/she was hurt. -The resident responded yes, his/her leg was hurt. -The resident reached out to him/her and grabbed his/her hand to sit up. -Additional staff entered the room to assist with the fall so he/she stepped out. -Review of the witness statement dated 8/20/24 written by Restorative Aide/CNA A on 8/20/24 showed: -A night shift CNA approached him/her stating the resident had fallen. (The RA did not know the CNAs name). -When he/she entered the room, the resident was in a seated position with his/her legs in front of him/her. -Several other staff members responded to the room. -The resident complained of leg pain. -He/She assisted the resident to a nearby chair for his/her comfort. -Review of the witness statement dated 8/20/24 written by LPN A showed: -A CNA notified him/her the resident had fallen in his/her room. -Several staff had responded to the room. -He/She had completed an initial assessment and initiated fall procedures. -The resident's family was notified. -The family had requested the resident be sent to the hospital. -Review of the witness statement dated 8/20/24 written by LPN B showed: -When he/she had arrived to work he/she had received a report from the off-going shift that the resident had fallen. -The resident's family would like him/her sent to the hospital. -He/She entered the resident's room and observed him/her sitting up in a chair. -An assessment revealed the resident had pain in his/her left shoulder and hip. -The Paramedics arrived and transported the resident to a nearby hospital. -Review of the Investigation Summary dated 8/20/24 showed: -At about 6:20 A.M. CNA D was informed the resident had an unwitnessed fall in his/her room. -The resident was attempting to get up off the floor independently while awaiting clinical assessment secondary to impaired mentation and impulsivity related to a dementia diagnosis. -Clinical staff assisted the resident to a nearby chair to prevent greater potential injury. -The Nurse was informed of the incident and a complete head to toe assessment with no visualized injuries noted. -The resident complained of left hip and shoulder pain. -The resident's Physician was notified of the fall and an order was received for a STAT (immediate) X-ray. -The DON was notified. -The DPOA was notified via phone and requested the resident be sent to the hospital and not to wait for an in house radiology (X-ray). -911 was called. -Paramedics arrived at the facility. -The resident was taken to the nearby hospital. Review of the video of the resident's fall on on 8/20/24 showed: -At 6:17 A.M. on 8/20/24 the resident was walking in his/her room toward the bathroom when he/she fell backwards into his/her left side. -His/Her roommate was in the room at the time and went to find a staff member to help. -At 6:22 A.M. CNA D entered the room. -The CNA asked if the resident was OK. -CNA D then sat the resident up on the floor as he/she had been laying flat on the floor. -The resident groaned and said he/she was in pain as he/she was moved to a sitting position on the floor. -He/She left the room to find the nurse. -He/She came right back to the resident and asked the resident if his/her leg was ok. -The resident said, No it's not ok. -At 6:23 A.M. Restorative Aide (RA)/CNA A and three other staff members entered the room. -The RA/CNA A asked the resident if he/she was ok, was he/she hurt. -The resident said, I'm hurt alright, my hip and my arm. -The RA/CNA A put a gait belt (a safety assistance device used to help transfer a person) around the resident's waist and with the assistance of one other staff member they assisted the resident up and into a chair. -One of the CNAs put shoes on the resident. -The RA/CNA A put a sweat shirt on the resident and told the resident they will go get some coffee and wait for breakfast. -The RA/CNA A said they would see how well he/she was walking. -At 6:26 A.M. RA/CNA A assisted the resident up with the gait belt and gave the resident his/her walker to walk him/her into the dining room. -The resident was not able to take more than a step and sat the resident back down into the chair. -The RA/CNA A pushed the chair the resident was sitting in forward and the resident's left leg didn't move, it was dragged under the chair. -The RA/CNA A left the resident sitting up in the chair and left the room with the door shut. -At 6:36 A.M. a CNA came into the room to make the bed, he/she did not speak to the resident. -At 6:38 A.M. a male staff member walked in and looked at the resident, went to walk out then turned around and asked the resident if he/she fell. -The resident said yeah I fell. -The male staff member walked out of the room and shut the door. -At 7:49 A.M. the door opened and the roommate left the room. -The LPN B came into the room and assessed the resident. -LPN B asked the resident how he/she was doing, are you hurt? -The resident said yes on his/her left side. -LPN B did a full head to toe assessment. -LPN B looked at the resident's arms and left shoulder. -The resident said it hurts (left shoulder). -LPN B assessed the resident's left leg. -The resident said it's real sore (left leg). -LPN B assessed the residents blood pressure and vital signs. -LPN B left the room. -At 8:03 A.M. EMS were seen in the resident's room taking him/her out to the hospital. During an interview on 8/26/24 at 9:10 A.M. CNA B said: -He/She would notify the nurse if he/she had found a resident on the floor. -He/She would not move the resident. -The Nurse would have done an assessment then he/she would do a set of vital signs. -The Administrator and DON have done education on not moving a resident until they were assessed by a Nurse in the last 30 days. During an interview on 8/26/24 at 9:20 A.M. LPN B said: -If a resident was on the floor staff should have contacted a nurse. -The nurse would have done a head to toe assessment and neuro checks on the resident. -If a resident was in pain he/she would have notified the physician. -The physician would have given an order for an X-ray or to have sent the resident to the hospital. -He/She was scheduled to work the day shift on 8/20/24. -The night shift CNA told him/her that the resident had fallen. -The night shift nurse called him/her and gave report. -The night shift nurse had called the physician and had received orders for a portable X-ray. -The family member had called him/her and requested that the resident to go to the hospital. -The family member called him/her and requested the resident go to the hospital. -He/She went to see the resident. -The resident was sitting in a chair. -The resident had a flat affect, (no emotion) on his/her face. -The resident appeared to be in pain. -He/She did a range of motion evaluation on the resident's left shoulder, which was painful (resident verbalized). -He/She was unable to extend the resident's left leg out straight. -The resident said it hurt to move his/her leg. -He/She called the resident's Nurse Practitioner to get an order to send the resident to the hospital, which he/she received. -He/She called 911 to activate Emergency Services (EMS- Emergency Medical Services). -EMS arrived and took the resident to the hospital. -The reporter was notified the resident had been sent out to the hospital. -The night nurse should have stayed with the resident. -He/She did not think the night nurse had called 911. During an interview on 8/26/24 at 10:00 A.M. CNA C said: -During report at the change of shift at 7:00 A.M., the night CNA (name unknown) reported to him/her that the resident had fallen. -If a resident was on the floor you should get the nurse. -The nurse would do an assessment on the resident. -He/She would not move the resident until the nurse told him/her to. -When he/she first came to work he/she saw the resident sitting in a chair with LPN B doing an assessment on him/her. During an interview on 8/26/24 at 10:10 A.M. the family member said: -The family has a video camera in the resident's room. -At 6:30 A.M. the camera dinged notifying him/her that the resident was moving in the room. -He/She reviewed the video which showed the resident laying on the floor. -He/She reviewed the video at an earlier time which showed at 6:17 A.M. the resident got up and was walking to the bathroom without his/her walker when he/she stumbled over his/her own feet and fell to the floor. -At 7:07 A.M. a nurse(night shift) called him/her and told him/her they were going to do an in-house X-ray. -He/She told the nurse to call an ambulance and send the resident to the hospital. -He/She called the nurse a second time and told him/her to send the resident to the hospital. -At 7:45 A.M. he/she called and talked to (LPN) B and asked him/her to open the resident's door which had been closed. -LPN B said he/she was going to call for an in-house X-ray. -The family member asked the day nurse to call an ambulance to send the resident to the hospital. -At 7:50 A.M. LPN B went into the resident's room to assess him/her. -The resident said it was sore. -At 8:03 A.M. the EMS arrived and took the resident to the hospital. -The resident had previous falls. -The resident was taken to a nearby hospital where he/she had surgery the next morning to repair his/her broken hip. -He/She was very upset because he/she had told the nurses three different times to call EMS to transfer the resident to the hospital. -It was almost two hours after the fall before EMS came to transport the resident to the hospital. -The staff sat the resident up before he/she was assessed by a nurse. -The staff had attempted to walk the resident to breakfast before he/she was assessed by a nurse then sat him/her in a chair with the door closed. -He/She had showed the video to the DON and Administrator. During a telephone interview at 12:35 P.M. on 8/26/24 LPN A said: -He/She was the night nurse when the resident fell. -The resident fell between 6:00 A.M. and 7:00 A.M. on 8/20/24. -A CNA notified him/her that the resident had fallen. -He/She had went into the resident's room and completed an assessment. -The resident said he/she had hip pain. -He/She had documented the assessment on the computer system. -He/She had called the family and the physician to let them know about the fall. -The physician had ordered an X-ray. -The family member wanted the resident to go to the hospital. -He/She did not call 911, but passed it onto the day shift nurse in report. -He/She did not move the resident. -The facility has provided education before and after the fall, not to move the resident until a nurse completes an assessment. -He/She was the only nurse in the building at the time of the fall. During a telephone interview at 2:05 P.M. on 8/26/24 RA/CNA A said: -His/Her shift starts at 6:00 A.M. and he/she was there at that time. -Night shift staff asked him/her if he/she could help with the resident as he/she had fallen. -CNA D asked him/her to help get the resident up into a chair, which he/she did. -He/She was not sure what was wrong with the resident. -He/She was not sure if a nurse had assessed the resident before he/she was moved. -The resident did not have any signs of pain when he/she moved him/her. -He/She saw the nurse when he/she left the room but did not talk to him/her. -He/She knew that the resident went out to the hospital. During an interview on 8/26/24 the DON said: -If a CNA found a resident on the floor (unwitnessed fall) he/she would have expected him/her to go get help from a nurse and then stay with the resident. -The nurse should have done an assessment prior to moving the resident to determine injuries. -He/She would have expected the nurse to have done an assessment before staff moved the resident. MO00240919

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure parameters were in place for the nursing staff to safely administer Metoprolol (a medication used to treat high blood pressure) and other blood pressure medications for three supplemental residents, (Resident #44, Resident #74, and Resident #10), and to ensure parameters were in place for the nursing staff to safely administer Digoxin (a medication used to treat heart failure and heart rhythm problems) for one supplemental resident (Resident #44) out of three supplemental residents for medication pass. The facility census was 76 residents. Review of the Mayo Clinic precautions for Digoxin (Oral Route Precautions), dated 5/1/23 showed: -Side effects include; dizziness, fainting, fast, pounding or irregular pulse, or slow heartbeat. -The nurse should take an apical (a measurement that takes place when a person is sitting or lying down by placing a stethoscope (a medical instrument used to listen to sounds produced within the body) on the left side of the breastbone over the apex (the tip of the heart that faces the left arm) of the heart) pulse for a full minute before administering Digoxin as it could decrease the heart rate. Review of the Mayo Clinic's precautions for Metoprolol, Medical Education and Research, dated 2023 showed: -Before administering Metoprolol the nurse should always assess the patient's blood pressure and pulse. -The medication should have been held when the patient's heart rate was less than 60 beats per minute. -The medication should have been held when the patient's blood pressure was less than 100 systolic (the measurement of the pressure in your arteries when your heart beats. Review of the facility's policy, Medication - Administration, dated October 24, 2022 showed: -Medication would be administered by a Licensed Nurse per the order of an Attending Physician or licensed independent practitioner. -Testing and taking of vital signs, upon which administration of medications were conditioned, may be performed and the results recorded. -When administration of the drug was dependent upon vital signs or testing, the vital signs or testing would have been completed prior to administration of the medication and recorded in the medical record. The Physician's standing order was requested and not supplied by the end of survey. 1. Review of Resident #44's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -High blood pressure. -Paroxysmal Atrial Fibrillation (An irregular often rapid heart rate that commonly caused poor blood flow). Review of the resident's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by the facility staff for care planning) dated 4/28/23 showed: -He/she had a Brief Interview for Mental Status (BIMS) score of one out of 15 indicating he/she was severely cognitively impaired. -He/she had high blood pressure. -Atrial Fibrillation was not marked. Review of the resident's Physician's Order Sheet (POS) dated May 2023 showed: -Digox (Digoxin) tablet 0.125 microgram (mcg) one tablet by mouth in the morning for irregular heartbeat related to Paroxysmal Atrial Fibrillation, dated 7/12/22. --There were no parameters for checking the resident's heart rate before administering the medication. --There were no parameters to indicate when the medication was to be held for a slow heart rate. -Metoprolol Tartrate tablet 100 milligrams (mg) one tablet by mouth in the morning for high blood pressure. --There were no parameters for checking the resident's heart rate or blood pressure before administering the medication. --There were no parameters to indicate when the medication was to be held for a slow heart rate or low blood pressure. Observation on 5/17/23 at 9:18 A.M. of the medication pass with Licensed Practical Nurse (LPN) C showed: -LPN C administered Digoxin 0.125 mcg to the resident without checking the resident's pulse. -LPN C administered Metoprolol 100 mg tablet to the resident without checking the resident's blood pressure or pulse. 2. Review of Resident #74's face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Bradycardia (slow heart rate less than 60 beats per minute). -High blood pressure. Review of the resident's admission MDS assessment dated [DATE] showed: -The resident's BIMS score was four out of 15 indicating he/she was severely cognitively impaired. -He/she had high blood pressure. Review of the resident's POS dated May 2023 showed: -Metoprolol Succinate Extended Release (ER) 24 hour 25 MG, one tablet by mouth in the morning related to high blood pressure, dated 4/14/23. --There were no parameters to check the blood pressure before administering the medication. 3. Review of Resident #10's face sheet showed he/she admitted to the facility on [DATE] with the following diagnosis of high blood pressure. Review of the resident's POS dated May 2023 showed: -Lisinopril (a medication to treat high blood pressure) tablet 2.5 mg one tablet by mouth one time a day related to high blood pressure, dated 4/19/23. --There were no parameters to check the blood pressure before administering the medication. 4. During an interview on 5/17/23 at 9:30 A.M., LPN C said: -He/she should have checked the residents pulse before administering Digoxin. -There were no parameters in the physician's order to check the pulse before administering the medication. -If the resident's pulse was less than 60 beats per minute, Digoxin should have been held. -He/she should have checked the residents blood pressure before administering Metoprolol or other blood pressure medications. -If the systolic number was less than 100 it should have been held. -There were no parameters in the physician's order to check the blood pressure before administering the medication. -One resident had been at the facility since 2022 and parameters for checking the blood pressure before administering Metoprolol should have been in the physician's order so it would automatically pop up on the computer screen. -The parameter for Digoxin (hold if pulse was under 60 beats per minute) should have been in the Physician's order so it would automatically pop up on the computer screen. -The nurse who did the resident's admission and checked the orders for the medications should have noticed there were no parameters and clarified the order with the physician so there were parameters for staff to follow before administering the medications. -He/she did not know if anyone checked the orders. -There were at least four other residents that were on blood pressure or heart medications that the pulse or blood pressure should have been checked before administering the medications. -The computer system should have prompted him/her to check the blood pressure or pulse. -Staff had not checked the pulse or blood pressures before administering the medications like they were taught in nursing school. During an interview on 5/18/23 at 12:50 P.M. the Nurse Practitioner (NP) said: -There should have been parameters for administering Digoxin, Metoprolol, and other blood pressure medications. -The nurse should have checked the parameters before administering the medications. -The nurse who received the order should have ensured there were parameters for administering Digoxin, Metoprolol, and other blood pressure medications. -Metoprolol and other blood pressure medications should have been held if the resident's blood pressure was less 100/60. -Digoxin should have been held if the resident's pulse was less than 60. -He/She had written the parameters in other facilities but did not do that at this facility. During an interview on 5/18/23 at 1:30 P.M. the Director of Nursing (DON) said: -Staff had a standing order to check the pulse before administering Digoxin. -Staff should have checked the blood pressure before administering a blood pressure medication such as Metoprolol. -Checking the parameters was a professional standard taught in nursing school. -The parameters should pop up on the computer program. -The NP had ordered parameters at other facilities he/she did not know why he/she did not order it here. -The nurse who admitted the resident reviewed the medications and should have caught that there were no parameters for Metoprolol, other blood pressure medications, and Digoxin. -The Pharmacy reviewed the medications monthly. -Pharmacy should have caught that there were no parameters set for Metoprolol, other blood pressure medications and Digoxin before administering the medications. -If the nurse knew the residents were on these medications they should have checked and documented the blood pressure and pulse and ensured it was on the computer program.

Based on interview and record review, the facility failed to provide restorative care (a program to maintain a person's highest level of physical, mental, and psychosocial function in order to prevent declines that impact quality of life) following discharge from therapy services for one sampled resident (Resident #8) out of 18 sampled residents. This deficient practice had the potential to effect all residents who were discharged from therapy services to a restorative program. The facility census was 76 residents. Review of the facility's Restorative Nursing Program Guidelines policy, dated 10/24/2022, showed: -The program focused on achieving and maintaining physical, mental and psychosocial functioning. -A resident started the Restorative Nursing Program when a resident was discharged from formalized physical, occupational or speech rehabilitation therapy. -The Director of Nursing Services (DSN) managed and directed the Restorative Nursing Program. -General restorative nursing care did not require the use of qualified professional therapists to render such care. The basic restorative nursing categories included, but not limited to: --Active range of motion (AROM). --Walking. -The Licensed Therapist documented whether the resident may benefit from a more detailed rehabilitation evaluation or from unskilled therapy (restorative nursing services that can be provided by caregivers). -An order was obtained from the attending physician as indicated for participation in the Restorative Nursing Program. -The care plan will reflect restorative needs of each resident. 1. Review of Resident #8's quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning) dated 5/12/23, showed: -The resident scored a 13 on the Brief Interview for Mental Status (BIMS an assessment tool that shows a score between 3 of 15 which shows the resident's mental status. This tool helps determine the resident's attention, orientation and ability to register and recall new information. These items are crucial factors in care planning decisions). --The resident's score indicated the resident was cognitively intact. -The resident's diagnoses included kidney failure (a condition in which the kidneys stop working and are not able to remove waste and extra water from the blood or keep body chemicals in balance) and dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses). -The resident was discharged from Occupational Therapy (OT) and Physical Therapy (PT) on 5/13/23. Review of the resident's care plan, undated, showed: -The resident had a restorative care program. -The resident would maintain current level of mobility through review date. -Interventions included: --Bi-lateral Upper Extremities (BUE) strength all planes, AROM 2 x 10. --Bi-lateral Lower Extremities (BLE) strength all plans, against gravity 2 x 20. --Ambulation with four wheeled walker x 250 feet twice as tolerated. Review of the resident's Nursing Restorative Care Program/Functional Maintenance Plan, dated 5/12/23, showed: -Goals/Approaches: --BUE strength: All planes, AROM 2x10. --Environmental engagement: Promote participation in facility activities. --BLE strength: All planes against gravity 20 x 2. --Ambulation: With four wheeled walker x 250 feet, twice as tolerated. Review of the resident's Physician Orders, dated 5/22/23, showed: -Restorative Care Program: --BUE strength: All planes, AROM 2x10. --BLE strength, all planes against gravity 20 x 2. --Ambulation with four wheeled walker x 250 feet twice, as tolerated. During an interview on 5/22/23 at 9:11 A.M., Certified Nursing Assistant (CNA) A said: -The resident had restorative with the Restorative Aide (RA) and had seen the resident walking with the RA. -The resident was discharged from therapy. During an interview on 5/22/23 at 9:53 A.M., the RA said: -The resident discharged from therapy two weeks ago. -He/she did not have an order yet to do restorative care with the resident. During an interview on 5/22/23 at 10:21 A.M., Licensed Practical Nurse (LPN) A said: -The resident was pulled off of skilled therapy a couple of weeks ago. -He/she had not seen orders for restorative therapy yet. During an interview on 5/22/23 at 10:52 A.M., the Director of Rehab said: -The resident was discharged from therapy due to meeting goals and exhausting the Medicare part A. -He/she wrote a restorative plan for the resident and gave it to the MDS Coordinator. -The resident should have already started the restorative care program. During an interview on 5/23/23 at 1:05 P.M., the Director of Nursing (DON) said: -The MDS Coordinator was out of the building for an emergency and not able to be interviewed. -After the resident was discharged from therapy the therapist wrote an order for restorative care. -The order went to the MDS Coordinator who input the information in the care plan and made sure the order was in place then reviewed it with the RA who would initiate the program. -The therapist wrote the order for restorative care within a couple of days of being discharged from therapy. -Ideally it would be written upon discharge to avoid a lapse in care. -He/she would have expected less time to have lapsed from 5/13/23, the date when the resident was discharged from therapy to the time the order was written on 5/22/23. -The orders went into place yesterday on 5/22/23.

Based on interview and record review, the facility failed to follow their policy to complete a Criminal Background Check (CBC) for 10 out of 10 sampled new staff and to follow their policy to check the Nurse Aide (NA) Registry to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prior to hire for seven out of 10 sampled new staff. The facility census was 76 residents. Review of the facility's undated Onboarding Standard Operating Procedure showed: -Instructions to run all necessary background checks (Family Care Safety Registry (FCSR-helps to protect long-term care residents by providing background information on employees or prospective employees)) while a new hire was completing their onboarding. -The NA registry check and the FCSR were some of the required checks under the background checks bullet point. Review of the facility's Staff Screening policy dated 10/24/22 showed: -Prior to employment, the facility would verify and document a CBC and state exclusion screening. -The facility would not employ any individual who had been found guilty of abuse, neglect, exploitation or mistreatment or misappropriation of property or who has a finding in the state NA registry. 1. Review of the facility's list of employees hired since their last annual survey showed: -Employee A was hired on 3/4/23. -Employee B was hired on 4/10/23. -Employee C was hired on 1/23/23. -Employee D was hired on 2/25/23. -Employee E was hired on 4/1/23. -Employee F was hired on 12/21/22. -Employee G was hired on 1/27/23. -Employee H was hired on 3/20/23. -Employee J was hired on 4/15/23. -Employee K was hired on 4/13/23. Record review of employees A, B, C, D, E, F, G, H, J and K's employee files showed: -A CBC was not requested or received for any of the employees. -The FCSR checks showed all the sampled employees were registered with the FCSR (The law requires that every elder care worker hired on or after January 1, 2001 to register). -All of the sampled employees' FCSR forms printed out stated on the form that the form was not a background check (requesting the background checks was a separate process). During an interview on 5/23/23 at 10:06 A.M., the Human Resources Director (HR) said: -He/she thought when he/she was checking the FCSR website that it included a CBC (he/she was only checking the section that indicated if the employee was registered or not). -He/she was doing CBCs through the highway patrol previously but stopped because he/she thought the FCSR registration check covered it. During an interview on 5/23/23 at 1:31 P.M., the Administrator said he/she was aware the CBC should be requested prior to hire and would expect it to be done prior to hire. 2. Review of the facility's list of employees hired since their last annual survey showed: -Employee C was hired on 1/23/23. -Employee D was hired on 2/25/23. -Employee E was hired on 4/1/23. -Employee G was hired on 1/27/23. -Employee H was hired on 3/20/23. -Employee J was hired on 4/15/23. -Employee K was hired on 4/13/23. Review of employees C, D, E, G, H, J and K's employee files showed NA registry checks were not conducted on them. During an interview on 5/23/23 at 10:06 A.M., the HR Director said he/she did NA registry checks on Certified Nursing Assistants (CNAs) only and did not know he/she needed to do a NA registry check on all other staff. During an interview on 5/23/23 at 1:31 P.M., the Administrator said he/she expected the NA registry check to be done on all employees prior to hire.

Based on observation, interview, and record review, the facility failed to keep the walk-in refrigerator floor clean; to maintain sanitary utensils and food preparation equipment; to safeguard against foreign material possibly getting into food and/or beverages; to properly document food temperatures to ensure they were suitably cooked to lessen the chance of bacterial contamination; to maintain plastic cutting boards and utensils and to ensure the proper refrigeration, and/or disposal of foodstuffs, in accordance with professional standards for food service safety. These deficient practices had the potential to affect all residents, visitors, volunteers, or staff who ate food from the kitchen. The facility's census was 76 residents with a licensed capacity for 78 residents at the time of the survey. 1. Observations during the initial kitchen inspection on 5/17/23 between 8:56 A.M. and 12:19 P.M. showed the following: -There was a wooden rolling pin in the center food preparation table drawer that had food residue on it. -The gasket on the door to the reach-in refrigerator was detached and torn. -In a utensil drawer a wood handled spatula's plastic red blade was chipped. -The manual can opener had paper on its blade. -The brown, red, yellow, and blue cutting boards had excessive scoring to the point of plastic bits flaking off. -In the Dry Storage room, on the bottom shelf of a rack by the door, there was a 1 gallon (gal.) jug of soy sauce approximately (appx.) 1/2 full, with a best by date (BBD) of 1/2/23 stamped on it and a label which read Refrigerate After Opening. -On the same shelf was another jug of the same kind of soy sauce, appx. 1/8 full, with no lid on it. -On the large can dispenser rack there was a 6 pound (lb.) 3 ounce (oz.) can of shredded sauerkraut that was dented on its bottom rim, and a 6 lb. 10 oz. can of mandarin orange segments that was dented on its top rim. -On the bottom shelf of the south wall rack in the Dry Storage room was an opened 138 oz. jug of salsa with a label that read Refrigerate After Opening. -There was a 4 oz. pod of strawberry yogurt, onion peels, and paper scraps under the racks in the walk-in refrigerator. -A large floor stand fan had a heavy accumulation of lint on its blades and blade guard. -There was paint peeling off of the underside of the range hood over the deep fryer and the stove. -A rubber gasket on the inside rim of the garbage disposal was torn and incomplete. -When that day's lunch was being taken from the oven to the steam table, the top tray of chicken measured at 138.7 degrees Fahrenheit (F). Record review of the kitchen food temperature log sheet for 5/17/23, taped onto the side of the reach-in refrigerator by itself, showed the hot and cold food temperatures were recorded for that day's lunch, but the previous breakfast foods' temperatures were left blank. During an interview on 5/22/23 at 12:50 P.M., the Dietary Manager said the following: -The dietary aides were responsible for cleaning the kitchen and walk-in floors every night before they leave. -He/she would expect any food stuffs that should be refrigerated would be. -Damaged food items are to be sent back to the vendor. -Any damaged food preparation items should be thrown in the trash as soon as they are noticed. -He/she would expect food to be free of foreign substances. -The dietary aides are to clean food preparation items as needed. -The cooks are to fill out the food temperature logs for each meal but they only do it occasionally.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's policy titled Medication-Administration dated 10/24/22 showed: -The licensed Medical or Nursing Staff must wash hands before and after medication administration. -Gloves will be worn to administer medications when contact with blood or potentially infectious bodily fluid is anticipated. Review of the facility's policy titled Eye Drops dated May 2016 showed: -Staff must perform hand hygiene before the procedure and put on gloves. -When the administration was complete the person administering should remove his/her gloves and either wash or sanitize his/her hands. Review of the facility's policy titled Medication Administration Nebulizer (Updraft) dated September 2010 showed: -Staff must perform hand hygiene before the procedure. -Once the procedure was completed staff should wash hands thoroughly. Review of the facility's policy titled Hand Hygiene dated 10/24/22 showed: -Facility staff, visitors, and volunteers must wash their hands in the following circumstances: --After unprotected (ungloved and damaged gloves) contact with blood, other body fluids, secretions, excretions, mucous membranes, non-intact skin, intact skin soiled with blood and other bodily fluids, wound drainage and soiled dressings. --In between glove changes. -Alcohol-based hand hygiene products can and should be used to decontaminate hands: --Immediately upon entering a resident occupied area. --Immediately upon exiting a resident occupied area. -Hand hygiene was always the final step after removing and disposing of personal protective equipment. Review of Resident #8's undated face sheet showed he/she admitted to the facility with the following diagnoses: -Chronic Obstructive Pulmonary Disease (COPD- a disease process that decreases the ability of the lungs to perform ventilation). -Diabetes Mellitus (DMII- a complex disorder of carbohydrate, fat, protein metabolism that is primarily a result of a deficiency or complete lack of insulin secretion in the pancreas or resistance to insulin). -End Stage Renal Disease (ESRD- a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis). -Unspecified Glaucoma (a group of eye diseases that can cause vision loss or blindness by damaging the optic nerve). Observation of the resident's medication pass on 5/17/23 at 12:16 P.M. completed by Licensed Practical Nurse (LPN) A showed: -He/she sanitized his/her hands, put on gloves, and administered the resident's eye drops, removed his/her gloves, but did not wash/sanitize his/her hands afterwards. -He/she then went back to the medication cart and did not wash/sanitize his/her hands while prepping or giving the resident his/her oral medication. -He/she did not wash/sanitize his/her hands after giving the medication to the resident or before starting the preparation of the nebulizer (a device that produces fine mist for inhaling medication) treatment. -After the nebulizer treatment was started on the resident, he/she walked back to the medication cart and sanitized his/her hands. During an interview on 5/17/23 at 12:24 P.M. LPN A said: -He/she felt the medication pass went okay. -He/she was unsure if the nebulizer treatment was performed correctly. Observation on 5/17/23 at 12:28 A.M. showed the nebulizer mask was not working and the treatment needed to be re-done. Observation on 5/17/23 at 12:37 P.M. of the nebulizer treatment completed by LPN A showed: -He/she sanitized his/her hands and put on gloves. -He/she turned off the treatment and replaced the resident's treatment mask. -He/she then took off his/her gloves, placed a new vial of treatment in the replaced mask, and started the treatment again. -He/she went back to the medication cart and sanitized his/her hands. -After completion of the treatment he/she did not sanitize his/her hands before entering the resident's room, and put on gloves. -He/she then removed the mask from the resident, rinsed the mask off in the resident's sink, dried the mask with a paper towel, and placed the mask in a designated bag for the mask. -He/she removed his/her gloves and returned to the medication cart without washing/sanitizing his/her hands before the next medication pass. During an interview on 5/17/23 at 2:17 P.M. LPN A said: -He/she did not think that his/her hand hygiene was correct during Resident #8's medication pass. -He/she should have washed/sanitized his/her hands between each part of the medication pass: --Before and after the eye drops. --Before and after the oral medication --Before and after both attempts of the nebulizer treatment. -He/she should have washed his/her hands before administering the resident's eye drops and before the nebulizer treatment. -He/she should have sanitized his/her hands every time he/she removed his/her gloves. During an interview on 5/18/23 at 11:54 A.M. LPN B said hand hygiene during medication pass should happen before and after each resident. During an interview on 5/18/23 at 12:07 P.M. the DON said: -Before administration of eye drops he/she would expect staff to wash their hands. -He/She would also expect hand hygiene during medication pass to be completed when: --Gloves were removed. --Going from treatment to treatment on a single resident. --Going from resident to resident. -LPN A did not perform hand hygiene correctly during medication pass. -He/She expected staff to sanitize their hands before a nebulizer treatment was given and to wash their hands afterwards. Based on observation, interview, and record review, the facility failed to meet all the requirements for a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of water-borne pathogens (a bacterium, virus, or other microorganism that can cause disease), including documented assessments for such an outbreak and a plan to deal with them, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. The facility failed to follow their policy to complete testing to screen new employees for tuberculosis (TB- a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for four out of ten sampled new employees sampled for TB screening. These deficient practices had the potential to affect all residents, visitors, volunteers, and staff who resided, visited, used, or worked in the facility and the facility failed to ensure proper hand hygiene was completed during medication pass for one sampled resident (Resident #8) out of 18 sampled residents. The facility census was 76 residents. 1. Review of the facility's water management program documents provided by the Assistant Director of Nursing (ADON) from their Infection Control binder, showed the following: -There was a copy of the 31 page Centers for Disease Control (CDC) toolkit issued 6/24/21 and entitled Developing a Water Management Program to Reduce Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) Growth & Spread in Buildings, which outlined what needed to be done to develop such a program, but nothing facility-specific, and an unanswered set of eight questions on page 2. -There was a two page policy dated 10/24/22 entitled Legionella which cited the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standard #188 and the CDC toolkit as sources, but did not include the two forms referenced for developing a program and identifying Legionnaires Disease. Review of the facility's two generic water-borne pathogen program assessments provided by the Administrator, a 27 page form dated 7/22/21 and a 22 page form dated 4/4/23, both entitled Legionella Environmental Assessment Form, with an educational section which outlined how to implement such a prevention program and mentioned some CMS requirements, showed the following: -There was no actual facility-specific risk assessment that considered the ASHRAE industry standard #188. -The diagram of the facility's complete water system was an altered generic diagram that did not match their written explanation of the water flow throughout the facility. -There was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. -There was no program and/or flow chart that identified and indicated facility-specific potential risk areas of growth within the building with assessments of each individual area's potential risk level. -There were no written facility-specific interventions or action plans for when testing protocols and acceptable ranges for control limits were not met. -There was no documentation of any site log book being maintained with any dated cleanings, sanitizings, descalings, and inspections mentioned. Review of the facility's emergency preparedness program binder entitled Disaster Manual, last reviewed on 6/10/22 and obtained from the 400 Hall nurse station, showed the following: -There was a copy of the CDC toolkit issued 6/5/17 and entitled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, with a set of eight unanswered questions on page 2. -There were copies of the two generic water-borne pathogen program assessments provided by the Administrator and mentioned above. Observations during the kitchen inspection on 5/17/23 between 8:56 A.M. and 12:19 P.M. showed a three-sink area, a wall-mounted sink for hand washing, a chemical dish-washing machine, and an ice machine and sink in the adjacent kitchenette. Observations during the facility Life Safety Code (LSC) room-by-room inspection with the Director of Maintenance (DOM) on 5/22/23 between 9:25 A.M. and 11:22 A.M. showed the following: -There were 40 resident rooms with private and/or adjoining bathrooms. -There was a Laundry room at the western end of the building and numerous closets with water heaters throughout the facility. -There was a bathing room and two restrooms on the main center hallway. -In the main center hall's Soiled Utility closet there was a floor mounted mop hopper sink with brown residue around the water line and in the trap at the bottom indicating it had not been flushed in a while, and a sign posted above it that read, Please Flush. -In the main center hall's Janitor's Closet was a square floor mop hopper sink filled with water that was so murky the bottom could not be seen. -There were two sprinkler systems with a main drain and auxiliary drains throughout the facility. -There two restrooms in the eastern administrative section of the building. Record review of the facility's 2-page educational document provided by the Administrator entitled Legionella Water Management, with the effective date of 10/26/2018 but no review or revision dates written in, it listed the DOM as being part of the water management team at point 2.d. During an interview on 5/23/23 at 9:39 A.M. the DOM said the following: -Testing the water for chloramine (which is a secondary disinfectant most commonly formed when ammonia is added to chlorine to treat drinking water to provide longer-lasting disinfection as the water moves through pipes to consumers) levels was all he/she had been instructed to do. -He/she thought the purpose was to control listeria (Listeriosis is a serious infection caused by the germ Listeria monocytogenes which can make people become ill after eating contaminated food). During an interview on 5/23/23 at 11:07 A.M. the Administrator said that he/she had been educated on the water-borne pathogen prevention program by reading the materials he/she provided earlier. 2. Review of the facility's Tuberculosis Screening policy dated 10/24/22 showed: -Facility staff were screened for TB as part of the requisite employee health examination. -There were no specific instructions on the procedure of TB screening. Review of the facility's Administration and Interpretation of TB Skin Tests (TST) policy dated 10/24/22 showed: -Screening of facility staff for TB was done upon hire. -A licensed nurse or healthcare practitioner interpreted the TST 48 to 72 hours after administration. Review of the facility's undated Onboarding Standard Operating Procedure showed: -A TST must be read and documented within 48-72 hours from when it was administered. -No employee could start working prior to the reading of the first TST. Review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A was hired on 3/4/23. -Employee B was hired on 4/10/23. -Employee C was hired on 1/21/23. -Employee E was hired on 4/1/23. -Employee G was hired on 1/27/23. Review of the above employees' TB testing forms showed: -Employee A's first TST was administered on 3/9/23, which was five days after date of hire and was read on 3/12/23, which was eight days after hire (instead of prior to hire) and the results were negative (0 millimeters (mm)). -Employee B's first TST was administered on 4/7/23 and read on 4/10/23 and the results were negative (0 mm). -Employee B's second TST was administered on 4/14/23, which was four days after the first TST instead of seven to 21 days after the first TST. -Employee C's first TST was administered on 1/22/23, which was one day after date of hire and was read on 1/24/23, which was three days after hire and the results were negative (0 mm). -Employee E's first TST was administered on 4/1/23, which was the date of hire and the results were read on 4/3/23, which was two days after date of hire and the results were negative (0 mm). -Employee G's first TST was administered on 4/2/23, which was over two months after the date of hire and was read on 4/4/23 and the results were negative (0 mm). During an interview on 5/23/23 at 10:06 A.M., the Human Resources Director said: -One of the charge nurses or the Assistant Director of Nursing (ADON) administer and interpret the employee TSTs. -He/she takes the onboarding employee to one of the charge nurses or the ADON to take their TST and then they come back in two days for the TST to be read. -The ADON was responsible for making sure the second TST was completed. -He/she did not think employee A and C were scheduled to work until their first TST was completed. -Employee A never worked a shift. -Employee C worked on 1/21/23 which was three days prior to the completion of his/her first TST. -It was an error on their part that Employee G's TST was not done prior to hire. Employee G was just missed somehow. During an interview on 5/23/23 at 12:10 P.M., the ADON said: -He/she tries to make sure the first TSTs are done before the employee's first day working. -The Human Resources Director lets him/her know they are hiring a new employee. -The nurses do the TSTs for the new employees. -Once the first TST is completed on an employee, he/she puts the TB screening document on a clipboard in order to track when to do the second TST. -There should be seven days between the first TST and the second TST. During an interview on 5/23/23 at 1:05 P.M., the Director of Nursing (DON) said: -The ADON does all of the employee TB screening oversight. -He/she would expect the 1st TST to be done prior to hire. -The second TST should be done seven to 21 days after the first TST was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress setting following manufacturer's guidelines and to ensure a Broda chair (a specialized tilt in space wheelchair used for comfort and positioning) was the appropriate size for one sampled resident (Resident #21) out of 18 sampled residents. The facility census was 73 residents. 1. Record review of Resident #21's undated face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Unspecified dementia (a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgment, and impulses). -Cerebral Infarction (stroke occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). -Rheumatoid Arthritis with rheumatoid factors (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility, especially in the fingers, wrists, feet, and ankles). -Spinal stenosis (a narrowing of the spaces within your spine, which can put pressure on the nerves that travel through the spine). -Edema (swelling caused by excess fluid trapped in your body's tissues). Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment instrument completed by facility staff for care planning) dated 4/1/21 showed the resident: -Had a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. -Had a pressure relieving device in his/her chair. -Had a pressure reducing bed. -Had a risk for skin breakdown. Observation on 6/23/21 at 10:00 A.M., of the resident showed: -His/her knees were bent due to his/her feet being against the footboard. -His/her low air loss mattress was set to over 400 pounds (lbs.) -He/she weighed 189 lbs. -The mattress did not fit in the bed frame. There was approximately 14 inches of bed frame exposed. -His/her last height was documented at 69 inches. During an interview on 6/23/21 at 10:00 A.M., the resident said: -The bed was very uncomfortable and he/she did not like it. -He/she had to bend his/her knees because there is no room to stretch out. During an interview on 6/23/21 at 10:01 A.M., Certified Nursing Assistant (CNA) C said: -He/she had not been educated on how to adjust the airflow mattress. -He/she thought the low air loss mattress was for the comfort of the resident. During an interview on 6/23/21 at 10:15 A.M., Restorative Aide (RA) A said he/she had not been educated on how to adjust the low air loss mattress and would let the nurse know. Observation on 6/23/21 at 10:20 A.M., showed CNA C and RA A transferred the resident from his/her bed to his/her Broda wheelchair using a full body mechanical lift: -Both CNA C and RA A washed his/her hands, put on gloves, positioned the lift pad, and positioned the chair. -The resident's right knee was bent and his/her left foot was past the foot rest of the chair. -The resident said he/she was not comfortable. -RA A extended the foot rest of the chair so the residents right leg could be straight and the left foot was on the foot rest. -The resident said he/she was comfortable. During an interview on 6/23/21 at 10:25 A.M. CNA C said he/she was not aware that the foot rest could be adjusted. During an interview on 6/23/21 at 10:30 A.M., Hospice (end of life care) nurse A said: -He/she was one of several hospice care staff for the resident. -The company that brought in the low air loss mattress usually adjusted the settings when the mattress was installed. -He/she did not know how or when the setting had been changed. -The mattress was an older version and had a dial versus an electronic setting. -He/she changed the setting of the mattress to ensure it was correct for the resident's weight. -He/she would ensure that the bed would be the appropriate length to accommodate the height of the resident. -When a Broda chair was obtained for a resident, it was usually measured by the company to ensure it was the right fit for the resident. The foot rest could be adjusted to provide comfort to the resident. During an interview on 6/24/21 at 1:05 P.M., the Director of Nursing (DON) said: -He/she was aware training was needed for nursing staff regarding the determination of the appropriate size bed and chair for residents. -Resident's should have a bed that is long enough for them. -Resident's should have a chair that fits them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately document the wishes of a resident to be a Do Not Resuscitate (DNR a legal order indicating that a person does not want to receive cardiopulmonary resuscitation (CPR an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person) if that person's heart stops beating) for one sampled resident (Resident#44) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's policy titled Cardio-Pulmonary Resuscitation (CPR) dated [DATE] showed: -Residents may elect to execute an advanced directive to have CPR withheld in the event of a cardiac or respiratory arrest. -CPR may be withheld or stopped once it has been determined the resident had such an order. -Residents without an executed advanced directive or who had elected a full code status would receive CPR until ordered to stop by a higher trained first responder or physician. -CPR would continue until Emergency Medical Services (EMS) arrived or a valid advanced directive/DNR order for no CPR was presented to the rescuers. 1. Record review of Resident #44's undated face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Dementia (a group of thinking and social symptoms that interferes with daily functioning) without behaviors. -Mild cognitive impairment (an early stage of memory loss). -Chronic kidney disease stage 3 (kidney damage with moderate to severe loss of kidney function). -Dilated cardiomyopathy (a condition in which the heart becomes enlarged and cannot pump blood effectively). -The resident had a guardian for financial matters. -There was no code status on the face sheet. Record review of the resident's care plan dated [DATE] showed the resident and his/her family had chosen to have DNR as his/her code status. Record review of the resident's Physician's Order Sheet (POS) dated [DATE] showed there was no physician's order for the DNR code status. During an interview on [DATE] at 10:45 A.M. Licensed Practical Nurse (LPN) B said: -He/she could not find the resident's code status on his/her face sheet. -He/she could not find the physician's order for the code status. -If there were a code the staff would look on the resident's face sheet or in the Code notebook at the nurse's station. -He/she was not able to find the resident's face sheet or code status (purple sheet) in the Code notebook. -He/she said it must have been missed because the resident had been transferred from a different hallway. -He/she said it was his/her responsibility to ensure this was done and he/she should have ensured it was done. -The resident had a Purple code sheet signed for DNR status in the chart. Observation on [DATE] at 10:45 A.M. showed LPN B put the code status on the resident's face sheet, printed the purple sheet for the Code notebook, and put in a physician's order for DNR status. During an interview on [DATE] at 11:00 A.M. Certified Nursing Assistant (CNA) A said: -He/she would ask the nurse what the resident's code status was. -He/she would be able to find the resident's code status in the Code notebook behind the nurse's station. -The nurses would keep the Code notebook up to date. During an interview on [DATE] at 11:14 A.M. LPN A said: -Most of the time the resident would come from the hospital with a code status (the purple sheet) saying if they were a DNR or a full code. -The code status would be put in the computer. -The code status would be on the face sheet or profile page. -The code status would also be in the Code notebook kept at the nurse's station. -The Code notebook would have a copy of the resident's face sheet and the purple DNR sheet. -Sometimes Social Services would the resident's code status. -Everyone was responsible for ensuring the resident's code status was done. -There would be a physician's order for the resident's code status. During an interview on [DATE] at 2:01 P.M. the Director of Nursing (DON) said: -The staff would find a resident's advance directive in the Code notebook at the Nurse's station. -There would be a physician's order for the advance directive. -The physician's order should have matched what was documented in the resident's care plan. -The Social Worker was responsible for ensuring the Advance Directive was done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain one sampled resident's (Resident #219) dignity by allowing the bottom half of the resident to be exposed during cares and to attempt to provide privacy for one sampled resident (Resident #50) who had removed his/her shirt in the day area of the unit out of 18 sampled residents. The facility census was 73 residents. Note: A policy related to resident dignity was requested from the facility Director of Nursing (DON) on 6/28/21 and he/she reported that the facility had no such policy. 1. Record review of Resident #219's undated face sheet showed the resident had the following diagnoses: -Dementia without behaviors (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). -Malignant neoplasm of female genital organs (cancer of female genital organs excluding the uterus and ovary). -Malignant neoplasm of vulva (cancer that occurs on the outer surface of female genitals). -Pressure ulcer of sacral region, stage IV (a wound that has reached all the way through the skin to the muscle, bone, or tendon of the tailbone area). -Pressure ulcer of left buttocks, Stage II (partial thickness loss presenting as a shallow open ulcer with a red or pink wound bed. It may also present as an intact or open/ruptured blister). -The resident had a guardian. Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 5/8/21 showed: -The resident needed extensive assistance with activities of daily living (ADL) including getting dressed. -The resident was totally dependent on staff for transfers from his/her bed to wheelchair. Record review of the resident's Care Plan dated 5/20/19 showed: -The resident required extensive assistance with bed mobility, dressing, toileting, and hygiene. -The resident was at risk for alteration in skin integrity related to bowel incontinence and impaired mobility. Observation on 6/23/21 at 11:49 A.M. of wound care showed: -Licensed Practical Nurse (LPN) B and Certified Nursing Assistant (CNA) A took the resident's pants and disposable brief off. -The resident's genitalia was exposed. -The staff did not shut the blinds to the outside window. -The resident's room shared an adjoining bathroom with the room next door. -The staff did not close the bathroom door. -The staff did not close the privacy curtain between the resident and his/her roommate. -The roommate was in the room with the door open and the roommate left the room during the cares. -Anyone walking by the doorway could have seen the resident. -A staff member came through the bathroom from the adjoining room to see if the staff needed any help. -The resident was on a memory care unit with other residents who would wander into the wrong rooms. During an interview on 6/23/21 at 11:55 A.M. LPN B said: -He/she has had education on dignity. -The curtain between the roommates should have been totally closed. -The bathroom door should have been closed. -The blinds on the outside window should have been closed. -Anyone walking by could have seen into the resident's room and seen the exposed resident. During an interview on 6/23/21 at 12:00 P.M. CNA A said: -He/she had education on dignity during orientation. -The curtain between the roommates should have been totally closed. -The bathroom door should have been closed. -The outside window should have been closed. -Anyone walking by could have seen into the resident's room and seen the exposed resident. During an interview on 6/28/21 at 11:14 A.M. LPN A said: -He/she has had education on how to provide dignity to the residents. -During cares the staff should close the door to the bathroom, close the blinds on the window, and close the curtain between the residents. During an interview on 6/28/21 at 2:01 P.M. the Director of Nursing (DON) said: -He/she would expect the staff to close the curtains between residents, the doors should have been closed, and the blinds to the outside should have been closed. -The staff has had education on providing dignity to the residents. 2. Record review of Resident #50's nurse's note dated 4/23/21 showed the resident removed his/her clothing and his/her brief. Record review of the resident's nurse's note dated 4/30/21 showed the resident repeatedly removed his/her clothing and his/her brief. Record review of the resident's nurse's note dated 5/4/21 showed the resident attempted to tear off his/her brief. Record review of the resident's quarterly MDS dated [DATE] showed the following assessment of the resident: -Had short-term and long-term memory impairment. -Had severely impaired cognitive skills for decision-making. -Was totally dependent on two or more persons for locomotion off the unit, dressing, toileting and bathing. -Was totally dependent on one person for personal hygiene. -Required extensive assistance of two people for bed mobility, when transferring between surfaces (such as from a chair to a bed), and locomotion on the unit. -Used a wheelchair. -Did not walk. -Displayed physical behaviors one to three days out of the past seven days. -Displayed verbal behaviors one to three days out of the past seven days. -Displayed other behaviors not directed toward others one to three days out of the past seven days. -Rejected cares one to three days out of the past seven days. -Some of his/her diagnoses included Alzheimer's Disease (a progressive loss of brain cells that leads to memory loss and the decline of other thinking skills), dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes), anxiety disorder (a psychiatric disorder that involve extreme fear, worry and nervousness), 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) and bipolar disorder (a disorder characterized by extreme mood swings from depression to mania). Record review of the resident's nurse's note dated 5/17/21 showed the resident removed his/her clothes. Record review of the resident's nurse's note dated 5/18/21 at 2:29 P.M. showed the resident undressed himself/herself. Record review of the resident's nurse's note dated 5/18/2021 at 8:28 P.M. showed the resident was resistive to cares and repeatedly removed his/her clothing. Record review of the resident's care plan dated 5/21/21 showed: -The resident was dependent on staff for physical and emotional needs. -The resident had a self-care performance deficit related to dementia. -The resident required extensive assistance of one staff to get dressed. -The resident was verbally and physically aggressive. -There were no specific interventions related to the resident removing his/her clothes and/or briefs. Record review of the resident's nurse's note dated 5/28/21 showed the resident made multiple attempts to remove his/her clothing. Record review of the resident's nurse's note dated 6/7/21 showed the resident removed his/her clothing and brief repeatedly. Record review of the resident's nurse's note dated 6/9/21 showed: -The resident attempted multiple times to remove his/her clothing. -The resident was assisted into bed and removed his/her clothes and brief repeatedly. Record review of the resident's nurse's note dated 6/9/21 at 11:07 P.M. showed: -The resident took his/her brief off. -The resident was assisted onto his/her mattress. -The resident promptly removed the blanket and tore off his/her brief. Record review of the resident's nurse's note dated 6/10/21 showed the resident removed his/her clothes and brief right after staff changed him/her. Record review of the resident's nurse's note dated 6/15/21 showed: -The resident removed his/her shirt repeatedly. -Staff placed the resident's brief and pajamas on and the resident immediately removed them. Record review of the resident's behavior note dated 6/23/21 at 4:26 A.M. showed the resident repeatedly removed his/her brief throughout the night. Continuous observation on 6/23/21 showed: -At 10:21 A.M., the resident was asleep in his/her Broda chair (a specialized wheelchair used for comfort and positioning) facing the nurses' station. -At 10:31 A.M., the resident was in the same place asking if someone could help him/her. -The resident took his/her shirt off and did not have anything on underneath his/her shirt. -LPN C was in a resident's room. -CNA B was in the area where the resident was with his/her back to the resident. -The state surveyor informed staff that the resident had taken off his/her shirt. -CNA B and LPN C pushed the resident in his/her Broda chair into the doorway of his/her room with his/her shirt still off and left the resident sitting in the doorway. During an interview on 6/28/21 at 11:01 A.M., LPN C said: -They could have re-dressed the resident after he/she took off his/her shirt. -Sometimes the resident takes his/her clothes off immediately after just putting them back on. -They tried putting a gown on in the past and he/she took that off. -They tried putting a blanket over his/her bottom half in the past and he/she took that off. During an interview on 6/28/21 at 2:01 P.M., the DON said: -They should have put his/her clothes back on the resident, tried a gown or asked him/her what he/she wanted. -The resident can say what he/she wants to wear. -The staff have had education on providing dignity for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to adequately prepare one resident for a planned surgery by not ensuring the resident was kept Nothing by Mouth (NPO) which resulted in the surgery having to be rescheduled for one sampled resident (Resident #44) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's policy, titled Physician Orders, dated 10/28/15 showed: -Physician orders were obtained and carried out in a systematic, organized fashion so resident care could be provided in a safe and consistent manner. -Once an order was received, it must be carried out as soon as possible. -Carrying out the order consisted of, but was not limited to, transcribing the order and notifying other applicable departments. 1. Record review of Resident's #44 face sheet showed the resident was readmitted to the facility on [DATE] with the following diagnoses: -Dementia without behaviors (a group of thinking and social symptoms that interferes with daily functioning. -Mild cognitive impairment (an early stage of memory loss). -Chronic kidney disease stage 3 (long standing disease of the kidneys leading to renal failure). -The resident had a guardian for financial decisions. Record review of the resident's Physician's Notes dated 4/23/21 showed: -The resident had been admitted to the hospital on [DATE]. -The resident had abdominal pain, nausea, and dark urine. -The resident had a kidney stone. -The resident was returned to the facility on 4/23/21. -The resident was scheduled to have the kidney stone removed on 5/12/21. Record review of the resident's Quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility staff for care planning) dated 5/8/21 showed: -The resident needed extensive assistance for activities of daily living like getting dressed. -The resident was totally dependent on staff to transfer from his/her bed to his/her wheelchair. -The resident's Brief Interview for Mental Status (BIMS) was 9 (moderately impaired cognition). -The resident needed only setup help for eating. Record review of the resident's Nurse's Notes dated 5/12/21 at 6:24 A.M. showed: -The resident had remained NPO after midnight per orders for his/her scheduled appointment. -The resident was tolerating being NPO well. Record review of the resident's Nurse's Notes dated 5/12/21 showed: -The nurse had observed the resident with his/her breakfast tray. -The nurse immediately removed the food from the resident as he/she was to be NPO for surgery. -The resident was re-educated of what was to take place. -The resident stated understanding. -The nurse spoke with the nurse at the hospital at approximately 12:45 P.M. -The nurse explained to the nurse at the hospital that the resident had only taken a few bites of his/her food and discussed the resident had held the resident's blood thinner medication but gave the resident of his/her morning medications with only a sip of water. -The hospital nurse stated that was all he/she needed and the conversation ended. -The resident had returned from the hospital without having the scheduled surgery due to having a few bites of breakfast the morning of surgery at 8:00 A.M. -The resident was given lunch when he/she returned to the facility. -The date and time for the rescheduled surgery was not yet determined. Record review of the resident's Nurse's Notes dated 5/26/21 showed the resident had returned to the facility after having the kidney stone removed. Record review of the resident's June 2021 Care Plan showed: -The resident had impaired cognitive function related to Dementia. -The staff was to cue, reorient, and supervise the resident as needed. During an interview on 6/24/21 at 9:30 P.M. Licensed Practical Nurse (LPN) B said: -There should have been an order for the resident to be NPO the night before surgery. -The order should have come in the discharge order from the hospital. -The order should have been written by the physician. -The nurse could not find the order on the physician's order sheet. -The NPO order would also have been nurse's judgement as the resident was to have surgery. -The NPO order would have been passed from one nurse to the next nurse during report. -The kitchen should also have been called so the resident did not receive a morning tray. -Some how the resident got a morning tray, and it was given to the resident by staff who should have known the resident was NPO. -The resident ate a few bites. -The resident was sent to the hospital for surgery. -The hospital found out the resident had not been NPO and was sent back to the facility. -The surgery had to be rescheduled because the resident had not been NPO. During an interview on 6/24/21 at 1:01 P.M. the Director of Nursing (DON) said: -The resident was to have kidney stone removal on 5/12/21. -The resident ate some breakfast and this was a problem. -The surgery was rescheduled because the resident had eaten. -The nurse should have sent a memo or electronic message to the kitchen so the resident would not have received a morning tray. -The nursing staff should have ensured the resident did not eat before surgery. -The nurse and the Certified Nursing Assistant (CNA) both should have caught the mistake. -There should have been an order from the hospital when the resident was discharged back to the facility or the resident's physician should have wrote an order for the resident to be NPO. During an interview on 6/28/21 at 11:42 A.M. the Day [NAME] said: -The nurses would call them or sometimes send a note to the kitchen to notify the kitchen staff if a resident was not to receive a tray because the resident could not eat before a procedure. -Residents had received a tray a couple of times when the residents had been NPO and should not have eaten. -This had happened a couple of times that he/she knew of. During an interview on 6/28/21 at 2:01 P.M. the DON said he/she would have expected the staff to follow the physician's order in relation to the resident going to the hospital for surgery.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete weekly weights as ordered for one sampled resident (Resident #5) and to schedule a Computed Tomography scan (CT-provides detailed images of internal organs) as ordered for one sampled resident (Resident #6) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's physician orders policy dated 10/28/15 showed: -All general guidelines for obtaining physician orders applied to nutritional/dietary and diagnostic testing orders. -The nurse was responsible for contacting the provider who will be performing the diagnostic test to make an appointment. 1. Record review of Resident #6's care plan dated 12/31/20 showed the resident: -Required assistance with his/her daily cares related to impaired cognition due to Alzheimer's disease (a progressive loss of brain cells that leads to memory loss and the decline of other thinking skills). -Had high blood pressure. -Was at risk for falls. Record review of the resident's most recent neurocheck (neurological checkpoints to monitor level of consciousness, ability to move extremities, eye responses and change in pupils and vital signs) dated 3/4/21 showed the resident's pupils were both equal, reactive to light, both 3 millimeters (mm) in size and the resident could follow the employee's finger. Record review of the resident's primary care physician's note dated 5/24/21 showed: -The resident presented with agitation. -Staff stated resident was more confused than usual and refusing cares. -The resident was alert, refusing to take a shower and yelling at the physician. -The resident had a diagnosis of dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes) with behavioral disturbance. Record review of the resident's primary care physician's progress notes dated 5/26/21 for 5/25/21 showed the resident complained of behavior change, confusion and dementia. Record review of the resident's primary care physician's progress note dated 6/3/21 showed: -Present Illness: Resident had noted unequal pupils with the right pupil slightly bigger than the left. -The resident denied headaches or other neurological deficits. -His/her right pupil measured about 2 mm while his/her left pupil measured about 1 mm, equally reactive and without any other focal deficits. -Plan: CT of head with contrast. Record review of the resident's nursing noted dated 6/3/21 by Registered Nurse (RN) B showed the resident was seen by the resident's primary care physician and a new order was received for a CT scan with contrast due to the resident with pupils uneven in size. Record review of the resident's nurse's notes dated 6/4/20 showed: -Licensed Practical Nurse (LPN) C called the hospital to schedule a CT scan. -The scheduler stated they needed a written script from the physician. -LPN C notified the physician that they needed a written script for the CT scan. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 6/19/21 showed the following staff assessment of the resident: -Severely cognitively impaired. -Walked independently. -Transferred from one surface to another independently. -Some of his/her diagnoses included high blood pressure and Alzheimer's disease . -Had no falls since last MDS (3/19/21). During an interview on 6/22/21 at 12:34 P.M., the Director of Nursing (DON) said: -He/she could not find any CT results for the resident. -He/she asked LPN C about the resident's CT scan. -LPN C said he/she called and followed-up on it yesterday and was told they had a lot of orders to go through. -They will need to follow-up more today and see if they got it. Record review of the resident's nurse's note dated 6/22/21 at 12:35 P.M. showed: -LPN C called the resident's primary care physician regarding the written script for the resident's CT scan. -LPN C informed the resident's primary care physician that a call was placed to the hospital and the scheduler stated they had not received the script for the CT. -The resident's primary care physician stated he/she would drop off the script that day. Observation on 6/25/21 at 10:17 A.M. showed the resident's left pupil was pin point and his/her right pupil was slightly larger. During an interview on 6/25/21 at 10:23 A.M., LPN C said he/she called the doctor earlier this week and he/she was supposed to drop off a script so the facility could fax it. During an interview on 6/25/21 at 10:36 A.M., the DON said: -He/she didn't know about the CT scan. -He/she needed to follow up with LPN C. -The physician supposedly dropped off a paper script either Tuesday or Wednesday. -He/she's tried to call LPN C a couple of times. -He/she would have to ask LPN C. -They need a paper script for things like a CT scan order. 2. Record review of Resident #5's weights showed the following resident weights: -12/4/2020: 124.6 pounds (Lbs) -1/12/21: 126.2 Lbs -2/3/21: 117.0 Lbs -3/5/21: 111.2 Lbs -3/5/21: 111.2 Lbs -4/5/21: 110.6 Lbs -5/4/21: 109.8 Lbs -6/1/21: 107.0 Lbs (14% weight loss since December 2020) Record review of the resident's Nutrition/Dietary Note dated 3/19/21 showed a recommendation to give Med Pass (a supplement) in between meals and increase to three times a day due to significant weight loss. Record review of the resident's quarterly MDS dated [DATE] showed the following staff assessment of the resident: -Had short-term and long-term memory impairment. -Had severely impaired cognitive skills for decision-making. -Required supervision (oversight, encouragement or cueing) with setup help only for eating. -Some of his/her diagnoses included anemia (when one doesn't have enough healthy red blood cells to carry adequate oxygen to the body's tissues), Alzheimer's disease, dementia, 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) and psychotic disorder (a mental disorder in which there is a severe loss of contact with reality). -Height was 5'4. -Weight was 107 Lbs. -Had a significant weight loss and was not on a physician-prescribed weight loss regimen. Record review of the resident's June 2021 Physician's Order Sheet (POS) showed the following orders: -9/24/20 weekly weights. -10/9/21 Mirtazapine 15 milligrams (mg) at bedtime (an antidepressant that can be used as an appetite stimulant). -3/20/21 Med pass after meals and at bedtime related to Alzheimer's disease, give 120 milliliters (ml) between meals and at bedtime. -Regular diet with regular texture and consistency. -Add fortified foods and finger foods as tolerated but no fortified milk according to the resident's preference. -Divided plate for meals. Record review of the resident's care plan dated 6/8/2021 showed: -The resident was dependent on staff for meeting his/her needs related to cognitive deficits due to Alzheimer's disease and dementia. -The resident had an activities of daily living (ADL - dressing, grooming, bathing, eating, and toileting) self-care performance deficit related to cognitive deficits due to Alzheimer's disease and dementia. -The resident was able to feed himself/herself independently after staff set up with supervision. -The resident had potential for impaired nutritional status related to Alzheimer's disease and dementia. -Instructions to: --Administer medications as ordered and to monitor and document for side effects and effectiveness. --Allow ample time to eat. --Do not rush resident while eating. --Offer snacks between meals. --Provide finger foods as tolerated. --Invite the resident to activities that promote additional intake. --Monitor any problems the resident has while eating. --Monitor for signs and symptoms of malnutrition. --Monitor for significant weight loss: 3 lbs in one week, greater than (>) 5% in one month, >7.5% in three months, >10% in six months. --Obtain and monitor lab/diagnostic work as ordered, report the results to the physician and follow up as indicated. --Provide and serve diet as ordered (regular diet with fortified foods). --Monitor intake and record every meal. --Registered Dietitian to evaluate and make diet change recommendations as needed. --Weights as ordered (weekly weight in am on Thursdays). Record review of the Registered Dietitian (RN) assessment dated [DATE] showed: -Most Recent Weight: 107.0 (Lbs) Date: 6/1/21. -Most Recent Height: 64.0 (Inches) Date: 7/11/16. -Med Pass 120 ml three times a day and at bedtime. -Mirtazapine is administered as an appetite stimulant. -Regular diet with fortified foods (started 10/19/20) . -Consuming 26-100% of meals independently sometimes with supervision. -Weights: 6/1/21 107 Lbs, 5/4/21 109.8 Lbs, (April 2021 was not included), 3/5/21 111.2 Lbs, 12/4/20 124.6 Lbs. -Weight stable over the past three months. -Significant weight loss over the last six months of 17.6 lbs which is a 14.1% weight loss. -Body mass index was underweight at 18.4 (BMI - a number calculated from one's height and weight to determine one's amount of body fat. According to the American Dietetic Association, a BMI of less than 18.5 is underweight and a normal BMI range is 18.5-24.9). -Med Pass 120 ml three times a day and at bed time started on 3/19/21. -No new recommendations at this time. Observation on 6/21/21 showed: -At 12:27 P.M., the resident was in the dining room holding an empty ice cream or supplement container. -At 12:59 P.M., the resident was served beverages. -At 1:28 P.M., --The resident wheeled away from the table. --LPN C pushed the resident in his/her wheelchair back to his/her dining room table and Certified Nursing Assistant (CNA) B served the resident his/her food. --LPN C fed the resident a few bites. --LPN C gave the resident his/her fork and walked away from the table. --The resident put his/her hands on the dessert of the resident sitting next to him/her. --The resident put his/her dessert on top of his/her plate. --The resident stuck both of his/her hands on the food on his/her plate. --The resident ate about 25%, of his/her food. Observation on 6/22/21 at 9:37 A.M. showed the resident was sitting at the dining room table and had drank all of his/her beverages. During an interview on 6/25/21 at 10:36 A.M., the DON said he/she saw there was an order for weekly weights back in September or October 2020 or some time around then but they had not been doing the weekly weights. During an interview on 6/28/21 at 11:01 A.M., LPN C said the restorative aide was responsible for weighing the residents. During an interview on 6/28/21 at 11:11 A.M., the Restorative Aide said: -He/she started working at the facility 4/6/21. -He/she was responsible for weighing the residents. -He/she weighed residents who were newly admitted , returned from the hospital or had weight loss weekly for four weeks. -He/she was not aware the resident needed to be weighed weekly. During an interview on 6/28/21 at 2:01 P.M., the DON said: -The resident's weekly weights order was put in their electronic health records system sometime around September or October 2020. -The nurse who entered the weekly weights order did not enter it correctly so it didn't populate to the nurses' Medication Administration Record and therefore was not communicated to the restorative therapy aide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review of Resident #319's undated face sheet showed he/she was admitted on [DATE] with the following diagnoses: -Major Depressive disorder (disease with certain characteristic signs and symptoms that interferes with the ability to work, sleep, eat, and enjoy once pleasurable activities). -Type 2 Diabetes Mellitus (an impairment in the way the body regulates and uses sugar as a fuel. This long-term condition results in too much sugar circulating in the bloodstream). -Pure Hypercholesterolemia (a condition in which a genetic anomaly causes high cholesterol levels). -Glaucoma (caused by damage in the optic nerve and causes irreversible loss of vision). -High blood pressure. -Dementia without Behavioral Disturbance (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). Observation on 6/28/21 at 11:25 A.M., showed: -CNA D was cleaning out the resident's walker due to excessive items and found a medication cup with 10 pills in it. -CNA D gave the medication cup with the pills in it to LPN A. -The pills found did not show any indication that they had been broken down by saliva. During an interview on 6/28/21 at 11:25 A.M., CNA D said: -He/she would check the resident's walker about 3-4 times a week due to residents taking things and putting them inside. -Staff would get complaints from some of the residents that someone has taken things out of their room. -Sometimes the walkers were full of items, it could fall out and the resident may trip over them and fall. During an interview on 6/28/21 at 12:00 P.M., LPN A said: -When administering medications, he/she always checked to ensure the resident had swallowed all medications. -He/she compared the cup of medications to the resident's Medication Administration Record (MAR) and verified all were morning medications. Observation on 6/28/21 at 12:00 P.M. showed LPN A verified the following medications were found in the resident's walker: -Ferrous Sulfate Tablet 325 milligram (mg) (Iron supplement) Give 1 tablet by mouth one time a day. -Amlodipine Besylate Tablet 2.5 mg (used to treat high blood pressure) Give 2.5 mg by mouth one time a day. -Losartan Potassium Tablet 100 mg (used to treat high blood pressure) Give 1 tablet by mouth one time a day. -ICaps Capsule (Multiple Vitamins-Minerals used to help treat glaucoma) Give 1 tablet by mouth two times a day. -Carvedilol Tablet 25 mg (used to treat high blood pressure) Give 1 tablet by mouth two times a day. -Citalopram Hydrobromide Tablet 10 mg (Celexa an antidepressant used to treat depression) Give 1 tablet by mouth one time a day. -Apixaban Tablet 5 mg (Eliquis a blood thinner used to treat stroke) Give 5 mg by mouth two times a day. -Namenda Tablet 10 mg (used to treat severe dementia) Give 1 tablet by mouth two times a day. -Docusate Sodium Capsule (Colace a stool softener used to treat constipation) Give 100 mg by mouth two times a day. -Depakote Tablet Delayed Release 125 mg (an anticonvulsant used to treat seizures and also used to treat dementia) Give 1 tablet by mouth two times a day. During an interview on 6/28/21 at 1:03 P.M., LPN B said: -Upon administration of oral medications, the residents were watched to ensure that pills had been swallowed. -Staff would check for cheeking or pocketing of medications. -Some residents had a difficult time swallowing but staff should not leave the resident until the pills had been swallowed and verified as swallowed. -If the resident continued to have difficulty swallowing pills, the physician would be notified for a change in pill form to be crushed or changed to a liquid. -He/she was not aware of any residents that had kept pills. Record review of the resident's Dementia Care Plan dated 6/24/21 showed the following interventions: -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Explain all procedures to the resident before starting and allow the resident to adjust to changes. -Intervene as necessary to protect the rights and safety of others. -Approach and speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. -Monitor behavior episodes and attempt to determine underlying cause. -There was no mention of watching the resident swallow his/her pills. During an interview on 6/28/21 at 2:02 P.M., the DON said: -He/she expected nursing staff who was giving medications to check they had been swallowed by the resident. If necessary check mouth to ensure it was swallowed. -He/she would not expect to find a cup of medication among residents belongings. -If medications were found, he/she expected medications be given to the charge nurse and to be notified. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent three near falls for one sampled resident (Resident #50); and to ensure one sampled resident (Resident #319) received his/her morning medications out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's Accidents and Incidents policy dated 2/13/20 showed: -The facility should assess each resident's risk of an accident including the need for supervision. -Interventions should be implemented to prevent accidents including adequate supervision. 1. Record review of Resident #50's skin note dated 3/31/21 showed: -The resident rolled out of his/her bed and onto his/her fall mattress. -It was care planned that the resident would lie on the mattress on the floor at his/her will. Record review of the resident's nurse's note dated 4/13/21 showed the resident was on the floor in the dining room, on his/her right side next to his/her Broda chair (a wheelchair that can recline that is specialized for the resident's comfort) and the dining room table. Record review of the resident's nurse's note dated 4/23/21 showed the resident was rolling around on the floor mattress, removed his/her clothing and his/her brief, and rolled onto the floor. Record review of the resident's nurse's note dated 4/30/21 showed: -The resident was yelling and cursing at staff. -The resident attempted to grab peers as they walked by. -The resident was in his/her Broda chair and repeatedly attempted to slide out of the chair onto the floor. -The resident repeatedly removed his/her clothing and his/her brief. -The resident attempted to hit and pinch the nurse. Record review of the resident's behavior note dated 4/30/21 showed: -At the onset of the shift, the resident was on the floor close to his/her door. -15 minutes prior, the resident was on the floor mattress resting quietly. -Two staff members assisted the resident in getting dressed and placed him/her in his/her Broda chair. -The resident yelled profanities and was verbally and physically aggressive during cares. -The resident was placed in the dining room for breakfast. -The resident tried to slide out of his/her chair. -The nurse attempted to prevent the resident from falling. -The resident struck out, kicked and pinched at the nurse. Record review of the resident's nurse's note dated 5/4/21 showed: -The resident was at the dining room table and repeatedly attempted to get out of his/her Broda chair. -The resident repeatedly attempted to grab art work from the wall. -The resident attempted to grab peers as they walked by. -The resident yelled and cursed at staff. -The resident was assisted into bed and changed. -The resident attempted to bite staff and attempted to tear off his/her brief. Record review of the resident's quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by facility staff for care planning) dated 5/11/21 showed the following assessment of the resident: -Had short-term and long-term memory impairment. -Had severely impaired cognitive skills for decision-making. -Had two or more non-injury falls. -Was totally dependent on two or more persons for locomotion off the unit, dressing, toileting and bathing. -Was totally dependent on one person for personal hygiene. -Required extensive assistance of two people for bed mobility, when transferring between surfaces (such as from a chair to a bed), and locomotion on the unit. -Required extensive assistance of one person for eating. -Used a wheelchair. -Did not walk. -Had two or more non-injury falls since the last assessment dated [DATE]. -Had one minor injury fall since the last assessment dated [DATE]. -Displayed physical behaviors one to three days out of the past seven days. -Displayed verbal behaviors one to three days out of the past seven days. -Displayed other behaviors not directed toward others one to three days out of the past seven days. -Rejected cares one to three days out of the past seven days. -Some of his/her diagnoses included Alzheimer's Disease (a progressive loss of brain cells that leads to memory loss and the decline of other thinking skills), dementia (a progressive mental disorder characterized by memory problems, impaired reasoning and personality changes), anxiety disorder (a psychiatric disorder that involve extreme fear, worry and nervousness), 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) and bipolar disorder (a disorder characterized by extreme mood swings from depression to mania). Record review of the resident's nurse's note dated 5/16/21 showed: -The resident was up in his/her Broda chair at the dining table for breakfast. -The resident yelled and was restless. -The resident needed a lot of repositioning in his/her Broda chair due to the resident moving self around in his/her chair so much. -The resident then scooted too close to edge of chair and slid out of the chair landing on his/her bottom. Record review of the resident's nurse's note dated 5/17/21 showed: -The resident was resting on his/her floor mattress. -The resident yelled out frequently, removed his/her clothes and rolled around on the floor. Record review of the resident's nurse's note dated 5/17/21 showed: -The resident repeatedly removed his/her clothes, screamed, yelled and cursed. -The resident refused to sleep in bed and rolled himself/herself onto the floor mattress and mat. Record review of the resident's nurse's note dated 5/18/21 at 2:29 P.M. showed: -The resident was up in his/her Broda chair with staff assistance. -The resident attempted to get out of his/her Broda chair. -Staff repositioned the resident several times and attempted to redirect the resident, requiring staff observation while up in chair. -The resident yelled out, struck out at staff, pinched at staff, kicked at staff, yelled out profanities and undressed himself/herself. Record review of the resident's nurse's note dated 5/18/2021 at 8:28 P.M. showed: -The resident repeatedly attempted to pull himself/herself out of his/her Broda chair and onto the floor. -The resident repeatedly removed his/her clothing. -The resident screamed, yelled, and cursed at staff. -The resident was resistive to cares and attempted to pinch, hit, and scratch staff. -The resident was assisted to bed and immediately pulled himself/herself out of bed and onto the floor mattress, onto the floor mat and rolled around on the floor multiple times. Record review of the resident's care plan dated 5/21/21 showed: -The resident was at risk for falls related to lack of safety awareness, dementia, and behaviors. -The goal was that the resident would be free of injury related to falls -Interventions included: --Anticipate and meet the resident's needs. --Use bed alarm while in bed. --Ensure the resident's call light was within reach and encourage the resident to use it for assistance as needed. --The resident would use a wheelchair for mobility. --When resident appeared agitated, provide calm conversation to redirect. --Floor mat at bedside while in bed. --11/27/20-Dycem (a non-slip material used to help prevent sliding) in wheelchair to prevent sliding forward in wheelchair. --11/29/20-Chair alarm. --12/5/20-Hipsters (adult briefs that have hip pads that are impact absorbing to help prevent injury to the hip area) to be worn while awake. --12/11/20-Offer toileting upon waking. --12/26/20-Push resident up to the table when in wheelchair. --12/27/20-Provide frequent supervision while in recliner. --12/29/20-Assess Dycem in wheelchair for effectiveness and placement. --1/3/21-Continue effective use of bed alarm and fall mat. --1/18/21-Ensure bed is in lowest position when in use. --1/26/21-Arrange sleeping area with mattress on floor (per resident request). Record review of the resident's nurse's note dated 5/28/21 showed: -The resident continued yelling and screaming at staff. -The resident made multiple attempts to remove his/her clothing. -The resident attempted to reach out and grab peers as they walked by. -The resident repeatedly attempted to pull himself/herself from his/her Broda chair and onto the floor. Record review of the resident's primary care physician's progress note dated 6/3/21 showed: -The resident had been hollering out, resisted care and rolled off his/her mattresses frequently. -The resident had a diagnosis of senile dementia with psychosis and aggressive behaviors. -A medication change was ordered. Record review of the resident's nurse's note dated 6/6/21 at 6:42 A.M. showed: -The resident was in bed with his/her eyes closed. -The resident remained on the floor mattresses throughout most of the shift. Record review of the resident's nurse's note dated 6/7/21 showed: -The resident yelled out repeatedly at staff. -The resident removed his/her clothing and brief repeatedly. Record review of the resident's nurse's note dated 6/9/21 showed: -The resident repeatedly yelled at staff. -The resident was up in in his/her Broda chair. -The resident attempted multiple times to pull himself/herself out of his/her Broda chair. -The resident attempted multiple times to remove his/her clothing. -The resident was assisted into bed and pulled himself/herself onto the floor mattress, removed his/her clothes and brief repeatedly. Record review of the resident's nurse's note dated 6/9/21 at 11:07 P.M. showed: -The resident would not sleep in his/her bed and rolled himself/herself from floor mattress onto the floor. -The resident took his/her brief off. -The resident was assisted onto the mattress. -The resident promptly removed the blanket and tore his/her brief off. Record review of the resident's nurse's note dated 6/10/21 showed: -The resident continued to yell repeatedly. -The resident removed his/her clothes and brief right after staff changed him/her. Record review of the resident's nurse's note dated 6/15/21 showed: -The resident repeatedly yelled at staff. -The resident removed his/her shirt repeatedly. -The resident would not sleep in his/her bed and was on the floor mattress. -Staff placed the resident's brief and pajamas on and the resident immediately removed them. Observation on 6/21/21 at 10:44 A.M., showed the resident was lying on a mattress on the floor in his/her room. Record review of the resident's behavior note dated 6/23/21 at 4:26 A.M. showed: -The resident was up in the middle of the night rolling on his/her floor mats. -The resident repeatedly removed his/her brief. Continuous observation on 6/23/21 showed: -At 10:21 A.M., the resident was asleep in his/her Broda chair facing the nurses' station. -At 10:31 A.M., the resident was in the same place asking if someone could help him/her. -The resident took his/her shirt off. -Licensed Practical Nurse (LPN) C was in a resident's room. -Certified Nursing Assistant (CNA) B was in the area where the resident was with his/her back to the resident. -The state surveyor informed staff that the resident had taken off his/her shirt. -CNA B and LPN C pushed the resident in his/her Broda chair into the doorway of his/her room with his/her shirt still off. -Both LPN C and CNA B left the resident's room and left the resident in the doorway. -LPN B went into the resident's room and pushed the resident further into his/her room. -LPN B left the room. -The state surveyor went into the resident's room and observed the resident with his/her shirt off and depends down with his/her feet tangled in the Broda chair falling out of his/her Broda chair and the state surveyor had to hold on to the resident's arm to prevent him/her from falling out of the Broda chair. -The state surveyor went and told LPN C the resident almost fell and was still about to fall. -CNA B was in another resident's room. -LPN C went to the resident's room. -LPN C left the room. -The state surveyor observed the resident starting to roll off the bed which was not in the low position and his/her upper body was headed toward the hard floor as the resident's floor mattress was not next to the bed. -The resident's floor mattress was near the foot of the bed. -The state surveyor had to grab onto the resident's arm to prevent him/her from falling out of the bed. -The state surveyor informed LPN C that the resident almost fell out of the bed. -LPN C went to the resident's room. -At 10:47 A.M., LPN C came out of the resident's room and said to CNA B that he/she was ready to get the resident back in his/her chair. -At 10:57 A.M., the resident was out by the nurse's station facing his/her room in his/her Broda chair. -The resident said he/she was hungry. -At 11:00 A.M., CNA B told LPN C the resident said he/she was hungry. -LPN C said he/she would call dietary and see if they had a snack for the resident -At 11:02 A.M., LPN C called dietary and asked if they had any snacks for the resident. -CNA B told LPN C he/she was leaving the unit. -At 11:09 A.M., LPN C was on the phone and said that CNA B went to lunch so he/she didn't have anyone to watch the residents on the unit. -At 11:12 A.M., dietary staff brought a snack for the resident and the resident ate the food independently. -At 11:19 A.M., the resident knocked on the glass window of the nurses' station and said to LPN C that he/she had eaten all of his/her snack. LPN C threw away the resident's trash and gave the resident some water. -At 11:40 A.M., LPN C left the unit. -At 11:54 A.M., the resident repeatedly said he/she had to go to the bathroom. The resident pounded on the wall and said, I gotta go to the bathroom! Does anybody care? The resident pounded on the wall again and said, I gotta go to the bathroom! -LPN C was not on unit. -CNA B was not visible on the unit. -At 12:02 P.M., CNA B came out of another resident's room and told the resident he/she would take him/her to the bathroom. -At 12:03 P.M., CNA B took the resident into his/her room. -At 12:04 P.M., LPN C returned to the unit and went into the resident's bathroom where the resident and CNA B were and then went back to the nurses' station. -At 12:07 P.M., LPN C went into the resident's bathroom. -At 12:13 P.M., CNA B brought the resident out of his/her room in his/her Broda chair and placed the resident in front of the nurses' station, facing the nurses' station. -At 12:16 P.M., the resident asked for milk twice and something to drink once. -At 12:17 P.M., LPN C gave the resident a cup of water. -At 12:24 P.M., the resident was asking for ice cream but no staff were visible on the unit. -The resident started scooting down in his/her Broda chair, almost falling out of chair. -The resident continued to scoot down the Broda chair while no staff were visible on the unit. -The state surveyor yelled for staff assistance repeatedly as the resident got closer and closer to the end of the Broda chair. -CNA B and a housekeeper came out of two different rooms on the unit. -LPN C came over to the middle of the hall from another unit. During an interview on 6/23/21 at 12:43 P.M., CNA B said when the nurse passes medications on the other unit, he/she is the only one on the unit to take care of residents. During an interview on 6/23/21 at 1:57 P.M., CNA B said: -He/she tried to watch the residents in the day area. -It was pretty common for the resident to try to get out of his/her chair. -He/she always tried to put the resident right out in front of him/her so he/she could keep an eye on him/her. -They have to make sure the resident's foot rest is extended, his/her seat is tilted back, things are out of his/her reach, they tend to his/her needs and give him/her what he/she wants. -The resident is always asking for food and drink. -The resident isn't always like that. -The resident is relaxed some days. During an interview on 6/23/21 2:02 P.M., LPN C said: -There is one CNA per hall and one nurse for the two halls that he/she works on. -It would be optimal to have a third CNA to help when the other CNA's were on break. -They place the resident right in front of the nurses' station window. -The resident tries to get up out of his/her chair a lot of the time. -The resident had quite a few falls when he/she first moved to the facility. -They put the resident on the mattresses on the floor in the resident's room and he/she hasn't had many falls since sleeping on the mattress on the floor. -The resident just moves off the mattress and onto the floor. -They have tried several medications and interventions such as music, food, drink, conversation, magazines, one-on-ones and some things work for a short period of time but they have to keep trying different things. -The resident just scoots the Dycem right off the chair. -The bed and chair alarms weren't helpful because the resident moves around so much so they were constantly going off. During an interview on 6/28/21 at 11:01 A.M., LPN C said: -Staff should check the residents in the day/dining area before going on a break or helping a resident in their room. -They should not leave the resident unsupervised when he/she is agitated. -They need to be right by the resident when he/she's agitated. During an interview on 6/28/21 at 2:01 P.M., the Director of Nursing (DON) said: -There has to be one staff member person on each unit at all times. -The staff were educated that if they are going in to do something that will take a while in another resident's room that they need to make sure another staff member is there at all times. -The staff can go get someone else from another unit if they need another person to monitor the residents. -Someone should observe the resident when he/she is agitated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident received proper treatment and care by not obtaining physician ordered laboratory tests for one sampled resident (Resident #44) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's policy titled Physician Orders, dated 10/28/15 showed: -Physician's orders were to be obtained and carried out in a systematic, organized fashion so that resident care could be provided in a safe and consistent manner. -Once obtained the order must be carried out as soon as possible. -In the event an order could not be implemented the nursing staff must notify the physician who wrote the order to discuss care alternatives. 1. Record review of Resident #44's face sheet showed the resident was admitted on [DATE] then readmitted on [DATE] with the following diagnoses: -Dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). -Chronic kidney disease stage 3 (moderate kidney damage). Record review of the resident's care plan dated 4/16/21 showed the resident had impaired cognitive function related to Dementia. Record review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 4/28/21 showed: -The resident's Brief Interview for Mental Status (BIMS a screening tool used to assist with identifying a resident's current cognition) score was 9 (moderately impaired cognition). -The resident was independent with activities of daily living. -The resident was continent of urine. -The resident had renal failure. Record review of the resident's medical record did not show any results from the Urinalysis with Culture and Sensitivity (a urine test to check for bacteria in the urine) (UA with C&S) test dated 6/20/21. Record review of the resident's Physician's Orders Sheet (POS) did not show an order for the the UA with C&S test dated 6/20/21. Record review of the POS dated 6/23/21 showed the physician had ordered a Basic Metabolic panel (BMP- a group of eight tests that measure several substances in the blood) related to hypokalemia (a low level of potassium in the blood) and dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake) following intravenous (IV into the vein) fluids. Record review of the resident's medical record did not show any results from the BMP dated 6/23/21. Record review of the resident's Nurse's Notes dated 6/24/21 at 2:05 P.M. showed: -The BMP was not completed on 6/23/21. -The nurse placed a call to the Physician and received new orders for STAT (immediate) BMP related to hypokalemia and dehydration following IV fluids. -The nurse entered the physician's order into the electronic laboratory system (lab). -The nurse placed a call to the lab. -The lab said they would be in that day. Record review of the Nurse's Notes dated 6/24/21 at 9:55 P.M. showed: -The physician was notified of the BMP results. -The physician did not state any new orders. Record review of the Nurse's Notes dated 6/25/21 showed: -The nurse placed a call to the Nurse Practitioner (NP) regarding the unobtained UA with C&S. -The NP reviewed the labs and discontinued the order. -The nurse was to push fluids (make sure the resident drinks fluids). During an interview on 6/25/21 at 10:09 A.M. Licensed Practical Nurse (LPN) B said: -He/she had received an order for a UA with C & S on 6/20/21. -He/she could not find the physician's order in the resident's chart. -The facility did not have any specimen cups so he/she did not get the urine sample. -He/she told the Director of Nursing (DON) the facility was out of specimen cups. -He/she said the DON obtained the specimen cups on 6/23. -He/she had still not obtained the urine sample. -He/she had not told the physician it had not been done. -He/she could not say why he/she had not obtained the urine sample. -He/she should have called the physician to let him/her know it had not been obtained. -He/she could not say why the BMP had not been done. -The staff was to put the order in the electronic system that went to the lab. -He/she had put the STAT order in and called the lab, the lab said they had not received the order for a BMP. -The nurse who took the order should have recorded the order on the POS During an interview on 6/28/21 at 11:14 A.M. LPN A said: -There would be an order from the physician for any lab work that need to be done. -If for any reason the lab work could not be done, the nurse would make a note of it in the Nurse's Notes. -The nurse would call the physician to let him/her know. -If the facility was out of specimen cups he/she would have called the lab and the lab would have brought some to the facility. -There should always be an order on the POS for any labs. During an interview on 6/28/21 at 2:01 P.M. the DON said: -There should always be supplies available to obtain labs. -The physician should have been notified if the labs could not have been obtained such as the resident refused to allow staff to obtain them. -There should have been a physician's order for the lab.

Based on interview and record review, the facility failed to check the Nurse Aide (NA) Registry for two out of ten sampled employees to ensure they did not have a Federal Indicator (a marker given to a potential employee who has committed abuse, neglect, or misappropriation of property against residents) prohibiting them to work in a certified facility. The facility's census was 73 residents. 1. Record review of the facility's list of employees hired since the facility's last annual survey showed: -Employee A, a housekeeping supervisor, was hired on 12/21/20. -Employee C, a dietary worker, was hired on 2/22/21. Record review of the above employees' employee files showed no check of the NA Registry to ensure they did not have a Federal Indicator prohibiting them to work in a certified facility. During an interview on 6/28/21 at 10:00 A.M., the Administrator said: -The Human Resources employee was responsible for completing the NA registry checks. -He/she didn't know NA registry checks were required on non-nursing staff. During an interview on 6/28/21 at 10:11 A.M., the Human Resources employee said he/she didn't know NA registry checks were required on non-nursing staff.

5. Observation on 6/24/21 at 6:55 A.M., of the 500/600 hallway Licensed Nurses medication cart showed: -There was a red pill crusher that had pill residue in the bottom and top of the container. -The pill splitter had a piece of pink pill in it. -There was an uncapped razor and an open large nail clipper in the top drawer. -There was a small nail clipper in the open position in the second drawer. -There was a red pill, two pink pills, and half a white pill loose in drawer four. During an interview on 6/24/21 at 6:55 A.M. LPN A said: -The medication cart should be clean and the pill crusher and pill splitter should not have residue on or in them. -There should not be loose pills in the medication cart. -There should not be nail clippers in the medication cart in the open position as no one would know who they were for and should not be used on multiple residents. -There should not be an uncapped razor in the medication cart. -He/she has not had time to clean the medication cart. 6. Observation on 6/24/21 at 6:55 A.M. of the 500/600 Licensed Nurses medication cart showed: -There were multiple medications that were brought from home for a resident (Resident #500) -One of the medications was Donepezil HCl 10 milligram (mg) (Aricept used to treat dementia and is given at night because of its side effects of low heart rate and possible fainting and when given at night, patients were able to sleep through the side effects without difficulty) give one tablet at bedtime was printed on the medication label. -The word bedtime had a line drawn through it and the word morning was hand-written on the label. Record review of the resident's Physician's Orders dated June 2021 showed Donepezil HCl 10 mg give one tablet by mouth at bedtime. During an interview on 6/24/21 at 6:55 A.M., LPN A said: -The medication bottle was from the resident's home. -Nursing would only follow what was on the resident's Medication Administration Record (MAR) and review the physicians order. -Staff would not follow what was written on the label. -It was possible that the family had written the change of time on the bottle. During an interview on 6/24/21 at 1:05 P.M., the Director of Nursing (DON) said: -There was no defined schedule for cleaning medication carts. -He/she expected staff to clean the medication carts as they go. -Any medication that was not labeled properly should be removed from the medication cart and a new order should be written. -Occasionally when a new resident came in to the facility, the use of home medications may be needed until pharmacy delivered the medication. 7. During an interview on 6/28/21 at 11:14 A.M. LPN A said: -The Nurse or the Certified Medication Technician (CMT) was responsible for keeping the medication carts and medication room clean. -The medications that were expired should have been thrown away. -If a medication had been opened it should have had the date it was opened written on the container. -There should not have been anything like candy or teeth in the medication carts. -The bleach wipes should not have been in the drawer with the resident's medications. -The medication carts, treatment carts, and medication rooms were to be locked at all times. During an interview on 6/28/21 at 2:01 P.M. the DON said: -There should not have been expired medications on the medication carts or in the medication room. -There should have been an opened date on the medications that had been opened. -The sink in the medication room should have been cleaned by staff. -There should not have been anything extra in with the medications. Based on observation, interview, and record review, the facility failed to ensure the resident's medications were kept in a clean, sanitary, and secured medication cart or medication room, to ensure expired medications were destroyed/discarded, to ensure opened medications had the date they were opened written on the container, failed to ensure there was no food stored in with the medications, to ensure there were no cleaning supplies being stored/kept in the medication drawer, to ensure medications were removed from the medication cart when a resident discharged from the facility in two out of four medication carts, one treatment cart, and one medication room, and failed to ensure medications were labeled and matched the physician's order for one resident (Resident #500) out of 18 sampled residents. The facility census was 73 residents. Record review of the facility's policy titled Medication Storage in the Facility, dated 11/18 showed: -Medications and biologicals were stored safely, securely, and followed the manufacturer's recommendations or those of the supplier. -Potentially harmful substances such as cleaning supplies or disinfectants would be stored in a locked area separately from medications. -Outdated, contaminated, or deteriorated medications and those in containers that were soiled or without secure closures were immediately removed from inventory, disposed of according to procedures for medication disposal. -Medication storage areas were kept clean and free of clutter. -Medication storage conditions were monitored at least quarterly. -When the original seal of a manufacturer's container or vial was initially broken, it was recommended that a nurse write the date opened on the medication container or vial. -The nurse would check the expiration date of each medication before administering it. -No expired medication would be administered to a resident. -All expired medications would be removed from the active supply and destroyed in the facility, regardless of the amount remaining. 1. Observation on 6/23/21 at 8:30 A.M. of the medication room with Licensed Practical Nurse (LPN) B showed: -There were two vials of Influenza vaccine type A and B, in the refrigerator that had expired on 5/4/21. -There was one container of stock control solution (Ultra Trak) (a control solution for a blood sugar monitoring device) a 4 milliliter (ml) box that had expired 11/18. -There was one container of stock control solution (Ultra Trak) a 4 ml box that had expired 11/24/19. -There was a case of stock control solution (Ultra Trak) that had expired 3/31/20. -There was a case of stock control solution (Ultra Trak) that had expired 8/31/20. -The only handwashing sink in the medication room was dirty with brown colored rust around the drain. 2. Observation on 6/23/21 at 10:10 A.M. of the 300/400 hall medication cart with LPN B showed: -A resident's bottle of liquid Morphine (a narcotic used to treat severe pain) 30 ml prescribed by a physician was opened without an opened date written on it. -A resident's Polyethylene Glycol (laxative) 510 grams (g) prescribed by a physician was opened without an opened date written on it. -A resident's Geri Tussin (cough syrup) 473 ml bottle prescribed by a physician was opened without an opened date written on it. The bottle was sticky. The medication had expired 2/21. -There was a resident's half eaten chocolate bar in with the medications. -One of the drawers in the medication cart was sticky with an orange colored substance. -One of the drawers had a brown melted substance in it. -One of the drawers had bleach wipes in with the medications. 3. Observation on 6/23/21 at 10:20 A.M. of the 300/400 hall treatment cart with LPN B showed: -One of the drawers had a set of dentures from one of the residents (not in a bag). -There was a container of Lidocaine Pixie Dust powder (a numbing medication) a prescription medication for a resident not in a bag. -The treatment cart was not locked. 4. During an interview on 6/23/21 at 10:30 A.M. LPN B said: -There should not have been any expired medications in the medication carts. -The expired medications should have been discarded. -The sink in the medications room should have been cleaned. -The nurse did not know who was responsible for cleaning the sink. -There should not have been candy in the medication cart. -Medications that had been opened should have had an opened date written on the container. -The medication containers should have been clean not sticky. -There should not have been bleach wipes in with the medications. -The drawers should be kept clean. -The treatment cart should have been locked. -There was no reason to have a resident's dentures in the cart. -The nurses were responsible for cleaning and checking the medication carts and the medication room.

Based on observation, interview, and record review, the facility failed to keep the walk-in refrigerator floor clean; to retain a thermometer in the walk-in freezer to confirm correct temperatures; to safeguard plastic cutting boards were in good condition to avoid food safety hazards; to separate damaged food stuffs; and to ensure the proper refrigeration or disposal of food products. These deficient practices potentially affected all residents who ate food from the kitchen. The skilled nursing facility census was 73 residents with a licensed capacity for 78. 1. Observations during the initial Kitchen inspection on 6/21/21 between 9:05 A.M. and 1:31 P.M. showed the following: -On a large can dispenser rack in the Dry Storage room there was a 6 pound (lb.) 6 ounce (oz.) can of white diced potatoes dented on the bottom rim and a 7 lb. 5 oz. can of baked beans dented on a lower back side. -In the walk-in refrigerator, there was a plastic lid under a rack. -There was no thermometer in the walk-in freezer. -The brown, red, white, and green cutting boards heavily scored to the point of plastic bits hanging off. -There was an open, nearly empty 1-gallon jug of soy sauce on a shelf under a side table next to the sugar and flour bins that read refrigerate after opening on the label. -On the same shelf there was a 1-quart (qt.) bottle of egg shade (yellow) food coloring that read Best By 12/9/19 on the label. During interview on 6/21/21 between 9:49 A.M. and 1:35 P.M. the Dietary Manager said the following: -They would have to get a thermometer for the freezer because they sure don't see it, it's usually hanging right there, pointing to an upper rack by the door. -He/She saw the cutting boards being examined so they changed them out with new ones. -The jug of soy sauce was disposed of for the same reason. 2. Observations during the follow-up Kitchen inspection on 6/22/21 at 10:34 A.M. showed the following: -On a large can dispenser rack in the Dry Storage room there was a 6 lb. 6 oz. can of white diced potatoes dented on the bottom rim and a 7 lb. 5 oz. can of baked beans dented on a lower back side. -In the walk-in refrigerator, there was a plastic lid under a rack. -On a shelf under a side table next to sugar and flour bins there was a 1 qt. bottle of egg shade food coloring that read Best By 12/9/19 on the label. During an interview on 6/23/21 at 2:17 P.M., the Dietary Manager said: -The cutting boards were thrown out because they were too heavily scored. -The jug of soy sauce was disposed of because it was supposed to have been refrigerated. -He/She tries to have the cooks keep an eye out for those sorts of things. -If foodstuffs have a Best By date, they need to be discarded after then. -He/She puts away deliveries from their food vendor for the Dry Storage room and the walk-in freezer and the Day [NAME] does the walk-in refrigerator. -There is an area set aside in the Dry Storage room for any damaged foodstuffs. Record review of the 1999 and 2009 Food and Drug Administration (FDA) Food Code and Missouri Food Codes, showed: -Chapter 4-101.11: Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: (A) Safe; (B) Durable, corrosion-resistant, and nonabsorbent; (C) Sufficient in weight and thickness to withstand repeated wear washing; (D) Finished to have a smooth, easily cleanable surface; and (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. -In Chapter 4-501.12, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were tested and/or screened for tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) for five sampled residents (Residents #14, #21, #27, #55 and #56) out of five residents sampled and to wash or sanitize hands between glove changes during wound care for one sampled resident (Resident #50) out of 18 sampled residents. Additionally, the facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to help prevent the development and transmission of waterborne pathogens (a bacterium, virus, or other microorganism that can cause disease), and failed to provide documented assessments for such an outbreak, in accordance with Centers for Medicare and Medicaid Services (CMS) guidelines. This deficient practice had the potential to affect all residents, visitors, and staff who reside in, visit, use, or work in the facility. The facility census was 73 residents. Record review of the facility's Policy for Tuberculosis Screening-Residents, dated June 2017, showed: -All new residents who were admitted from home would receive a two-step Tuberculin Skin Test (TST used to screen for TB) within seven days of their admission. -A TB screening (signs and symptoms review) only would be required for those who had documentation of a previous two-step TST with negative results. -Residents would be screened annually in October. 1. Record review of Resident #56's entry tracking form showed the resident was admitted to the facility on [DATE]. Record review of the resident's Annual Tuberculosis Screening Questionnaire, dated 10/16/19, showed: -The resident was screened for TB on 10/16/19. -The resident screening result was no active TB suspected. Further review of the resident's record showed no Annual Tuberculosis screening Questionnaire since 10/16/19. During an interview on 6/22/21 at 10:50 A.M., the Director of Nursing (DON) said he/she contacted corporate and was unable to locate a TB screening form since 10/16/19. 2. Record review of Resident #21's entry tracking form showed the resident was admitted to the facility on [DATE]. Record review of the resident's Annual Tuberculosis Screening Questionnaire, dated 10/16/19, showed: -The resident was screened for TB on 10/16/19. -The resident had no symptoms checked. -The resident screening result was not marked. Further review of the resident's record showed no Annual Tuberculosis screening Questionnaire since 10/16/19. During an interview on 6/22/21 at 10:50 A.M., the DON said he/she contacted corporate and was unable to locate a TB screening form since 10/16/19. 3. Record review of Resident #55's entry tracking form showed the resident was admitted to the facility on [DATE]. Record review of the resident's Annual Tuberculosis Screening Questionnaire, dated 10/16/19, showed: -The resident was screened for TB on 10/16/19. -The resident screening result was no active TB suspected. Further review of the resident's record showed no Annual Tuberculosis screening Questionnaire since 10/16/19. During an interview on 6/22/21 at 10:50 A.M., the DON said he/she contacted corporate and was unable to locate a TB screening form since 10/16/19. 4. Record review of Resident #14's entry tracking form showed the resident was admitted to the facility on [DATE]. Record review of the resident's Immunization tab in the facility's electronic health records system showed there was no record of a TB test and/or screening for the resident. During an interview on 6/22/21 at 10:50 A.M., the DON said he/she contacted corporate and was unable to locate a TB screening form or testing for the resident. 5. Record review of Resident #27's entry tracking form showed the resident was admitted to the facility on [DATE]. Record review of the resident's immunization tab in the facility's electronic health records system showed: -Step one of a TST was administered on 3/14/2021 with a negative result (date of result was not documented). -No other information was recorded. During an interview on 6/22/21 at 10:50 A.M., the DON said: -He/she can only assume the second step was not completed. -He/she contacted corporate and was unable to locate a TB screening form for this resident. 6. During an interview on 6/28/21 at 11:36 A.M., Licensed Practical Nurse (LPN) C said: -The nurse admitting the resident to the facility is supposed to administer a TST for the resident. -A nurse is supposed to read the TST three days later. -The order for the administration and reading of TST's is supposed to be on the Medication Administration Record (MAR). -The second TST is also supposed to be included in the orders on the MAR. -TB screenings for residents are supposed to be done yearly. During an interview on 6/28/21 at 2:01 P.M., the DON said: -They did the annual screening for the residents in 2020. -The Assistant Director of Nursing (ADON) said they did the annual resident TB screenings in 2020 and gave them to the previous medical records associate who no longer works there and they cannot find them. -The admitting nurse administers the first TST and enters it into the MAR. -The second TST would be administered by the nurse working when due and he/she would enter it into the MAR. 7. Record review of the facility's Hand Hygiene policy, dated September 2017, showed: -Employees must wash their hands for 10-15 seconds using soap and water after contact with blood, body fluids, secretions, mucous membranes or non-intact skin. -If hands are not visibly soiled, employees must use an alcohol based hand rub/gel: --Before direct care with residents. --Before putting on gloves. --Before handling clean or soiled dressings, gauze pads, etc. --Before moving from a contaminated body site to a clean body site during resident care. --After contact with a resident's intact skin. --After handling used dressings, contaminated equipment, etc. --After removing gloves. -The use of gloves does not replace handwashing/hand hygiene. Record review of Resident #50's quarterly Minimum Data Set (MDS-a federally mandated assessment tool used for care planning) dated 5/11/21, showed the following staff assessment of the resident: -Had short-term and long-term memory impairment. -Had severely impaired cognitive skills for decision-making. -Had two stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough (nonviable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) 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). Record review of the resident's care plan, dated 5/21/21, showed the resident had a stage II pressure ulcer on his/her sacrum (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 June 2021 Treatment Administration Record (TAR) showed: -6/8/21 Cleanse coccyx (tailbone) wound with normal saline, apply Triad cream (a zinc oxide-based hydrophilic paste that absorbs moderate levels of wound exudate) to granulation (new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process) and cover with foam dressing. -Change every three days every day shift every Tuesday, Friday, and Sunday and as needed when soiled or missing for coccyx wound. -1/16/21 Apply Calmoseptine (a multipurpose moisture barrier) to buttock every shift and as needed for soiling until resolved. Observation on 6/23/21 at 10:45 A.M., of the resident's wound care with LPN C showed: -LPN C removed his/her gloves after removing the old dressing. LPN C did not perform hand hygiene. -LPN C applied new gloves, applied the Triad cream and took his/her gloves off. LPN C did not perform hand hygiene. -LPN C applied new gloves, applied Calmoseptine lotion and took his/her gloves off. LPN C did not perform hand hygiene. -LPN C put the resident's disposable brief and pants on and washed his/her hands. During an interview on 6/23/21 at 11:00 A.M., LPN C said he/she should have washed his/her hands when he/she changed gloves. During an interview on 6/28/21 at 11:14 A.M., LPN A said: -They should wash or sanitize their hands after each glove change. -They have received education on hand hygiene. During an interview on 6/28/21 at 2:01 P.M., the DON said: -There has been education provided to the staff about hand hygiene. -He/she would expect staff to wash or sanitize hands after glove changes. 8. The Centers for Disease Control (CDC) Toolkit for Legionella (which is officially titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings) showed that healthcare facilities need to actively identify and manage hazardous conditions that support growth and spread of Legionella by: -Identifying building water systems for which Legionella control measures are needed; -Assess how much risk the hazardous conditions in those water systems pose; -Apply control measures to reduce the hazardous conditions, whenever possible, to prevent Legionella growth and spread; -Make sure the program is running as designed and is effective; -Legionella grows best at 77-108 degrees Fahrenheit (F); -Disinfectants (one way to prevent Legionella) are only effective in certain pH levels (usually 6.5 - 8.5); -How often to check depends on several factors (which should be determined by the facility from its Water Management Program); -The water temperatures and pH levels should be checked at regular intervals. Record review of the facility's Emergency Preparedness (EP) plan binders entitled Disaster Manual, last reviewed and updated on 8/13/19 and obtained from the old nurse station room and the 200 hall nurse station, showed there was no section covering waterborne pathogens such as Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever). Record review of the undated Facility Needs Assessment binder provided by the Administrator, under Addendum G: Infection Control Check List, showed the following: -A 5-page document that included the subheadings Policy Requirement and Outcome Measures to Be Developed or Reviewed. -Four pages all included the facility's name, but the dates of any assessments or points and standards having been Reviewed in Place on each page were left blank. -Each page carried a disclaimer at the bottom that Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance. Record review of the facility's undated binder entitled Legionella, provided by the Administrator, showed the following: -A copy of the Centers for Disease Control (CDC) toolkit outlining what needs to be done to develop a water management program to reduce Legionella growth and spread. -There was an absence of any of the requirements for a waterborne pathogen program including: -A completed Centers for Disease Control (CDC) toolkit including control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and environmental testing for pathogens. -A schematic or diagram of the facility's water system. -A facility-specific infection prevention program or plan to deal with outbreaks of Legionella (A [NAME] of pathogenic Gram-negative bacteria that includes the species L. pneumophila, causing legionellosis (all illnesses caused by Legionella) including a pneumonia-type illness called Legionnaires' disease and a mild flu-like illness called Pontiac fever) and/or other waterborne pathogens. -A program and flowchart that identifies and indicates specific potential risk areas of growth within the building. -Assessments of each individual potential risk level. -Testing protocols and acceptable ranges for control measures with a method of monitoring them specifically at this facility. -Facility-specific interventions or action plans for when control limits are not met. -Documentation of any site log book being maintained with any cleanings, sanitizing, descalings, and inspections mentioned. -A flow chart of the facility's water system. -A written description of the facility's water system. -Explanatory guidance from a United [NAME] agency. -General recommendations and information on Legionella and Pontiac fever. -A 2-page Legionella - What You Need to Do document. -There was no facility-specific risk assessment that considered the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) industry standards. -There was no facility-specific infection prevention program or plan to deal with outbreaks of Legionella and/or other waterborne pathogens. -There was no program and flowchart that identified and indicated specific potential risk areas of growth within the building with assessments of each individual potential risk level. -There were no facility-specific interventions or action plans for when control measure limits are not met. -There was no documentation of any site log book being maintained with any cleanings, sanitizings, descalings, and inspections mentioned. Observations during the facility Life Safety Code (LSC) room-by-room inspection with the Maintenance Director on 6/21/21 through 6/24/21 showed the following: -There were approximately 40 resident rooms with private and/or adjoining bathrooms. -There was a laundry room at the western end of the building and numerous rooms with water heaters throughout the facility. -There was a bathing room and two restrooms on the center main hallway. -There were two sprinkler systems with a main drain and auxiliary drains throughout the facility. -There was a kitchen and two restrooms in the eastern section of the building. During an interview on 6/23/21 at 1:34 P.M., the Maintenance Director said his/her only role in the Legionella program was to do monthly checks of Chloramines (also known as secondary disinfection, are disinfectants used to treat drinking water and they: are most commonly formed when ammonia is added to chlorine to treat drinking water. They can provide longer-lasting disinfection as the water moves through pipes to consumers.) in the water system. During an interview on 6/24/21 at 1:05 P.M., the Administrator said the following: -He/She was instructed to implement the Legionella program by telling the department heads what to look for. -Maintenance was also to check the water monthly.